The prone position paradox

Letter

Dr Steinberg presented a passionate critique of the prone-restraint position but did not present an alternative approach for positioning of the resistant subject.^1,2 Considering the comorbidities, the mortality rate of non-firearm arrest-related death (ARD) of 1:1000 is impressive compared to 1:232 for elective ablation of atrial fibrillation.^3,4 About 82% of the subjects involved in use-of-force events are affected by alcohol, drugs, or emotional disturbance. ⁵ Significant heart disease is found in 55% of ARDs. ⁶

In media discussions, an important subtlety is usually missed: there is little choice for the positioning before and during handcuffing. The prone position allows for sufficient control of the body and all extremities to apply handcuffs to the resistant subject compared to, say, the supine position and reduces the risk of injury to officers.

There are many reasons that modern policing has adopted prone restraint for handcuffing the uncooperative subject. These include (1) best core control for kinesiological stability, (2) restriction of hip flexors to reduce subject metabolic demands (and acidosis) and protect officers from kicks, ⁷ (3) restriction of shoulder and elbow flexors to reduce metabolic demands and protect officers from punches, ⁷ (4) prevention of occipital head-banging injury and bites to officers, (5) officer tactical visual advantage to accelerate the cuffing process, and (6) better gas exchange as seen in COVID patients.^8–12

Well-meaning experts can debate the optimal post-cuffing position but there are no practical restraint options while handcuffing the resistant subject. Steinberg's review is silent on this critical distinction.

The real-world field experience strongly supports the safety of prone positioning for the immediate management of combative subjects after handcuffing. In total, three large prospective studies found zero (0) deaths in 4288 cases left in the prone position and a single (1) death in 3601 cases left in other positions after handcuffing.^5,13,14

In his discussion of the Hall and Ross studies, Dr Steinberg neglected to note that the only death was in the non-prone group.^5,13 He neglected to mention the Lasoff study involving 2431 restraints. ¹⁴ With zero (0) deaths out of 4288 prone restraints it is hard to imagine what positioning crisis Dr Steinberg is attempting to address.

In his discussion of mechanical ventilation, Dr Steinberg makes a surprising comment which is curious in view of the dramatic recent data from COVID trials:

In other words, while prone positioning may serve to improve oxygenation of mechanically ventilated ARDS patients, these findings are not relevant to healthy unsedated subjects placed in prone restraint.

Numerous studies have confirmed the value of prone positioning for gas exchange in non-sedated awake and alert patients.^8–12

In blaming prone restraint for ARDs, Steinberg makes the implicit assumption that the cause of a sudden death can always be diagnosed.

In an autopsy study of 110 sudden unexpected cardiac deaths, after extreme physical or psychological stress, Krexi found that 53% had a “negative” autopsy and a morphologically normal heart. ¹⁵ Other plausible ARD mechanisms are often not revealed without genetic testing in the case of an otherwise negative autopsy.^4,15,16

Multiple studies show that 30–50% of sudden death in young people remains unexplained by a conventional autopsy.^17,18 In these cases, a genetic abnormality is later seen ∼27% of the time. ¹⁹ Eckart found that 35% of military recruit non-traumatic training deaths were unexplained. ²⁰

Dr Steinberg correctly pointed out that the majority of ARD cases present with non-shockable rhythms of asystole or pulseless electrical activity and argues that this finding tends to eliminate cardiac causes for ARDs. While it is true that cardiogenic arrests are more likely to result in a shockable rhythm, the vast majority of out-of-hospital cardiac arrests, regardless of etiology, tend to present in non-shockable rhythms. ²¹

Dr Steinberg closes with recommendations that sedation should be promoted for agitated subjects. We strongly agree that immediate sedation, especially with ketamine, can be life-saving for highly agitated individuals.^22–25 However, at least in the United States, the current politics are making this very difficult. Just this year, the American Medical Association resolved against using ketamine in the law enforcement setting. Their president, Dr Gerald Harmon, stated

For far too long, sedatives like ketamine and misapplied diagnoses like “excited delirium” have been misused during law enforcement interactions and outside of medical settings—a manifestation of systemic racism that has unnecessarily dangerous and deadly consequences for our Black and Brown patients.

Dr Steinberg concludes by citing a 2020 ARD as an example of a “catastrophic event that could have been prevented” if his recommendations were followed. While Dr Steinberg's passion is admirable, it does not match the facts of that case. The autopsy found severe multifocal coronary artery disease and cardiomegaly (540 g heart). ²⁶ The criminal allegation—against the officer—was suffocation via the sustained application of the lower leg across the trachea for over 9 min. Tracheal occlusion should not be conflated with prone restraint.