ABSTRACT:

Emergency responders often encounter agitated and violent individuals. To ensure victim and responder safety, and to facilitate thorough medical examination and care, violent individuals require restraint. However, using any form of forceful-prone-restraint (or prone "hogtie" restraint) is not appropriate to emergency care provision. In addition to interfering with examination and care access, such manners of restraint have caused "Restraint Asphyxia" death. Alternative methods of restraint are available to every emergency responder – methods that are easily employed and equally as immobilizing as hobble or prone restraints, yet allow full access to the victim.

Charly's exciting and informative presentation begins with two physical exercises that assist participants to (safely!) experience how a "position" can significantly interfere with breathing. Next, "Positional Asphyxia" and "Restraint Asphyxia" are clearly identified. The anatomy and physiology of normal respiration is discussed. Then, the pathophysiology of restraint asphyxia is thoroughly explored: what causes it, and why. Lastly (depending upon the amount of time allotted), Charly leads participants in a discussion of safer strategies for restraining even the most violent individuals.

This presentation offers information – In ENGLISH! – that is invaluable to ANY care provider who is authorized to employ restraints: Prehospital EMS providers, Emergency Department and Inhospital staff, Psychiatric Hospital staff, care providers for developmentally-disabled or mentally ill individuals, residential facility or school employees, law enforcement and correctional personnel. (When law enforcement and correctional personnel are the "majority" of the audience, a program specifically geared to their special interests and issues is presented.)

LEARNING OBJECTIVES:
After attending this presentation, participants will

1. have personally experienced restraint positions that restrict respiration,
   developing a kinesthetic (physical) understanding of the relationship
   between forceful-prone-restraint and Restraint Asphyxia.
   
2. understand the physiology of normal breathing.
   
3. understand the pathophysiology of positional asphyxia and restraint asphyxia.
   
4. recognize the lethal dangers of forceful-prone-restraint (with or without "hogtie")
   and recognize other forms of restraint that interfere with breathing.
   
5. recognize the variety of safe and effective alternative restraint methods available.
   
6. know how to entirely avoid employing asphyxial manners of restraint in the future.
   
7. understand how to immediately intervene when other responders have
   employed forceful-prone-restraint or prone hobble restraint.

Several Presentation-Length Options are Available:

1. The briefest possible presentation runs 1 hour & 45 minutes,
   but allows no time for participant questions and discussions.

2. A very good Restraint Asphyxia – Silent Killer presentation requires 3 hours:
   • 1.5 hour presentation
     
   • 15 minute break
     
   • 1.25 hour presentation
   
   This presentation includes more in-depth instruction,
   and allows time for questions and problem-solving discussions.

3. The best possible Restraint Asphyxia – Silent Killer presentation requires 4 ½ hours:
   
   • 1.5 hour presentation
     
   • 15 minute break
     
   • 1.25 hour presentation
     
   • 15 minute break
     
   • 1.25 hour presentation
   
   This presentation includes more in-depth instruction in all aspects of this subject,
   additional time for questions and problem-solving discussions, and includes
   real-life CASE REVIEWS of several restraint asphyxia incidents
   I've personally evaluated as an "Expert Witness."

The "handout" for this presentation is Charly's article,
"RESTRAINT ASPHYXIA – SILENT KILLER"
Participants do not need this article during the presentation, and it is 25 pages long. So, it should not be printed and provided to them. Instead, they will be provided with the Internet address for the article. If they want the written material, they can read it online, or print it for themselves.

1. INTRODUCTION

2. All participants are lead through two physical exercises involving positions that interfere with breathing. A physical experience is one of the most effective educational tools any instructor can employ, especially regarding this subject. To read the "directions" for these entirely safe exercises, go to "Assume the Position!"

3. Definitions and explanation of "Positional Asphyxia" and "Restraint Asphyxia" are provided – including discussion of the three key elements required for forensic pronouncement of death by restraint asphyxia.

4. Review of the anatomy and physiology of normal respiration.

5. Explanation of how forceful-prone-restraint (and other forms of asphyxial restraint) interferes with respiration and leads to death.

6. Identification of restraint-related breathing-interference being THE FINAL ASPECT of a cascade of events that lead to Restraint Asphyxia: discussion of the three phases of restraint-asphyxia-related activities:
   • PHASE 1: ALTERED LEVEL OF CONSCIOUSNESS ONSET.
     The individual exhibits irrational, violent behavior with aggressive and/or paranoid features, resulting in hyperactivity and extreme physical exertion – something called, "excited delirium." Causes of excited delirium are explained, and the physiologic and pathologic effects of Phase 1 are explored.
     
   • PHASE 2: INTERVENTION INITIATION.
     Intervenors arrive, recognize the need for restraint, and a moderate or "medium" amount of restraint is initiated. The individual experiences additional extreme energy expenditure while running from or wrestling with intervenors. Physiologic and pathologic effects of Phase 2 are explored.
   • PHASE 3: CONTINUED STRUGGLE.
     The medium-restrained individual persists in extremely forceful attempts to defeat and escape restraint, and maximum restraint (total body restraint) is employed. Physiologic and pathologic effects of Phase 3 are explored.

7. The full spectrum of pathophysiological effects occurring during these three phases are explained and summarized, allowing participants to gain a complete understanding of precisely why restraint asphyxia occurs.

8. The "time" factors associated with restraint-related respiratory arrest, and restraint-related cardiopulmonary arrest, are identified and discussed (answering he age-old question, "How long can we 'safely' keep someone in a prone position?").

9. The historic FAILURE OF RESUSCITATION MEASURES is discussed, identifying current hypotheses as to why restraint asphyxia victims cannot be resuscitated.

10. Alternative methods of restraint (methods that AVOID threat of Restraint Asphyxia) are examined and discussed.

11. Means of intervening when other emergency responders are employing forceful-prone-restraint (or other lethal restraint methods) are identified and discussed.

12. SUMMARY

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"