What EMS providers can learn from Eric Garner's death

Assessment and care of patients in police custody requires advanced preparation, vigilant assessment, and an open mind to the nature of illness

On July 17 2014 Eric Garner died after briefly resisting arrest. The most glaring mistake was the failure of both EMS and law enforcement to recognize a life threatening situation and take immediate action.

Video of the incident has been seen by thousands of people. In the footage, EMS providers arrive and appear to do nothing more than check a pulse and eventually place the patient on their stretcher. Bystanders are angry, police are unsure what to do, and even the EMTs are indecisive in their actions. The footage was bound to go viral.

I’m sure you have a pet peeve when EMS providers are shown inaccurately on TV or in movies. One of my major irritations is when EMS is depicted as doing nothing more than placing an oxygen mask and driving the patient to the hospital (where presumably the real medical care occurs). I'm sure you know that our role is so much more than that. We bring high quality medical care to wherever the patient is. We are more than an expensive taxi ride. In this case, the failure of EMS to immediately provide quality medical care is disappointing.

Cause of death

In August, a New York City medical examiner found that pressure on the chest and neck caused the death of Garner. Notwithstanding this finding, death as a result of positional asphyxia is a relatively common phenomenon.

First coined in the 1970s by a King County Seattle medical examiner, positional asphyxia and the exact way in which it causes death has been debated ever since. Several studies on the effects of being restrained while prone have been conducted. Some show a 25 percent reduction in forced vital capacity, the amount one is able to forcefully exhale after maximum inhalation, and used to measure the maximum volume in the subject’s lungs.[1]

Several other studies evaluated the immediate metabolic effects one may experience as a result of lying prone after a short period of anaerobic exercise. Those studies found no significant effect to the end tidal CO2, stroke volume, or blood pressure. One should quickly note that all of these studies were done using young healthy subjects with no know health risks. Obviously more research on the subject is needed. In either case, the effect of violent restraint and the weight of several people on the back of a subject, even for a brief period, should not be underestimated. EMS providers need to be vigilant and rapidly assess any person for which law enforcement summons our services.

In this unfortunate event there is plenty of blame to go around, but rather than placing the majority of the blame on individual providers, let's evaluate the system as a whole to determine what actions need to be taken. What can we learn? What can be improved? From simply viewing the footage[1] , I think we can identify several potential areas of improvement.

Public safety relationships

In some locations the relationship between different branches of public safety is a tense one. EMS providers may want to avoid a confrontation, and in so doing, they may not adequately assess the patient. In other cases, EMS providers may be intimidated by law enforcement. This is particularly common with newer EMTs. EMS providers need to be confident and kind enough to seamlessly work with law enforcement to avoid making a bad situation worse. Working at the management level to improve inter-agency relationships should be a priority.

Provider safety

EMS providers may feel uncomfortable if there are loud or angry bystanders. In this case, bystanders were frustrated with law enforcement. In the end, they also became frustrated by the apparent failure of EMS to intervene. Plenty of law enforcement officers were on scene, and when the scene is as safe as it can be, it's time for us to go to work. If EMS provides quality care, it will often further de-escalate the situation.

Respiratory assessment

It is unclear from the cellphone video footage if Garner was breathing. Some of the law enforcement officers can be heard saying that he was, but of course there is a difference between gasping, agonal respirations and normal breathing. Rapidly distinguishing between the two is important, and should be repeatedly practiced.

Pulse assessment

We've all felt our own pulse pounding during a stressful event. Attempting to palpate the presence or absence of a faint pulse can be difficult, but it should be done in a rapid manner taking no longer than 10 seconds. If you are unsure if you are feeling your patient’s pulse, consider attaching a pulse oximeter with plethysmographic waveform which can provide objective proof that the patient does indeed have a pulse.

Of course one should be able to assess the patient’s pulse with no more than their fingers, but it is good to be aware of all the tools at your disposal. In any case, if you are unsure if a pulse is present or not, immediately begin CPR and apply defibrillation pads.

Patient positioning

When caring for pediatric patients, we know that a quality assessment means removing, or at minimum looking, under their clothes. In the case of Garner, his position on the ground facing away from the provider could have had a negative impact on the assessment. Level of consciousness can be difficult to assess when you are not able to clearly view the patient's face. Position yourself or your patient in a manner that allows a quality assessment. If this means removing handcuffs, quickly do so with the assistance of law enforcement.

Bring your tools to the patient

The ability of EMS to deliver medical care to the location of the patient is arguably the reason for our existence. In this case, no obvious medical care was provided until the patient was moved from the scene. After speaking with a source close to the event, EMTs moved Garner to the ambulance where paramedics were called and care was rendered. In a field where we are fond of saying 'seconds count,' the failure of EMTs to rapidly render aid is concerning. Make sure when you arrive at the patient's side, you are able to provide at least basic medical care. Bring your equipment with you.

EMS provider bias

Preparing yourself for a patient based on dispatch information can predispose you to look for whatever it is you thought you’d find. Often EMS providers expect to find a patient in police custody to be looking for an escape from an immediate trip to jail. Don’t allow your preconceptions to cause you to see only what you want to see. Evaluate every patient as if there is almost no chance they are lying to you.

The goal

When a mistake occurs, there are always many contributing factors. Taking a hard look at the system design and process leading up to the incident has the potential to ensure the mistake does not happen again. Often managers take a punitive approach, which of course doesn’t actually solve the problem. Through dissecting the mistakes contributing to the death of Garner, we as a profession can better ourselves. We should never miss an opportunity to learn, and let’s not allow the lessons from this unfortunate incident to pass us by. Let’s learn what we can, change what we can, and emerge better for it.

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