How to document and report misconduct

3 EMS lessons from Minneapolis: EMS duty to the patient, even in uncomfortable situations


By Matthew Konya

By now, almost everyone has seen the senseless death of George Floyd. The video shows Mr. Floyd in the prone position with his hands cuffed behind his back, being pinned to the ground by a knee on the back of his neck from a Minneapolis police officer. For nearly 9 minutes, Floyd pleads for his life, repeatedly stating, "I can't breathe ... please stop" and asks for his mother.

Your documentation should never purposefully support one side of events over another. You cannot change how the events unfurled, but your accurate documentation can help ensure that the truth can be known.
Your documentation should never purposefully support one side of events over another. You cannot change how the events unfurled, but your accurate documentation can help ensure that the truth can be known. (Photo/EMS1)

The actions of the Minneapolis police officers on scene are a matter for the criminal courts of Minnesota and the court of public opinion. There are, however, three critically important lessons EMS professionals can learn in the aftermath of the tragic and needless death:

  1. Never restrain a patient in a prone position
  2. Speak up and attempt to intervene when you observe misconduct of police or any other responders at the scene
  3. Neutrally record the facts through clear documentation and reporting

1. The dangers of the prone position

In the video, Floyd is in the prone position, with his hands cuffed behind his back. This has been known to be a dangerous position for decades. Restraining an individual in this position increases the risk of death by positional asphyxiation [1]. Positional asphyxia occurs when the position of the body interferes with the person’s ability to breathe [1]. A patient can die from positional asphyxiation without warning. In a 1996 article for the FBI Law Enforcement Bulletin, Donald T. Reay, MD, then chief medical examiner for King County, Seattle, noted:

The process of hypoxia is insidious, and subjects might not exhibit any clear symptoms before they simply stop breathing. Generally, it takes several minutes for significant hypoxia to occur, but it can happen more quickly if the subject has been violently active and is already out of breath. If the subject experiences extreme difficulty breathing or stops breathing altogether, officers must take steps to resuscitate the subject and obtain medical care immediately [1].

EMS professionals should be vigilant of the risk factors associated with positional asphyxiation and how to mitigate those risks.

Positional asphyxiation risk factors. Certain individuals are at higher risk of death by positional asphyxia [2]. Along with being placed in the prone position, with hands behind their back, individuals that were recently involved in a violent struggle, individuals experiencing excited delirium, and individuals under the influence of drugs and alcohol are at higher risk of positional asphyxiation [2]. EMS professionals must be aware of these risk factors, especially when dealing with a patient who has been restrained after a violent interaction with the police.

Mitigating the risk of positional asphyxiation. Several steps can be taken by EMS professionals to mitigate the risk of positional asphyxiation [2]. While placing a patient in the prone position, with hands behind their back may help gain control of an out of control patient, it should only be used when other de-escalation and restrain techniques have failed. If a patient must be placed in this position to gain control of a situation, the patient should be moved into another position immediately; ideally sitting upright. Under no circumstance should weight be applied to the patient's back or neck when they are in a prone position.

Patients who have been restrained in the prone position should be monitored for any respiratory difficulty or cardiac compromise. EMS professionals should inquire about any recent drug or alcohol use by a patient who was restrained in the prone position. Finally, protocols and policies should be developed that encompass these principles. These polices should be reviewed and approved by your medical director, and then carefully monitored for compliance.

2. Speak up against misconduct and mistreatment

The second important lesson for EMS professionals in the wake of Mr. Floyd’s death is how EMS professionals should handle observed misconduct directed toward a patient by police or other responders. This would include any case where a detainee or patient is being physically mistreated. Police and EMS are often intertwined, as both are routinely present at the same scene. Being an active EMS professional myself, I understand the close relationship that can form between police officers and EMS professionals. However, this relationship cannot obstruct an EMS professional’s obligation to the patient.

The purpose of EMS is to ensure that all patients receive high-quality medical care, and part of this care requires EMS professionals to be patient advocates. Being a patient advocate may demand EMS professionals to step in and prevent additional harm to a patient, even if the perpetrators are police officers. In many instances, police officers only receive basic medical training, and may be unaware of all the risks and warning signs associated with positional asphyxiation. I am not advocating that EMS professionals should become aggressive towards police officers, but simply saying, “Hey! He is saying he cannot breathe; we need to check him out” may be enough to save someone’s life. It is my experience that police officers respect the opinion of EMS professionals they work alongside.

3. Reporting and documenting a charged situation

While it may be necessary to intervene in situations of misconduct involving patients, EMS professionals should also thoroughly document the interaction.

Every EMS agency should have a policy for reporting misconduct of others, and ways to keep these reports anonymous. These policies should not be limited to misconduct by police officers, but also by EMS professionals within the EMS agency, other EMS agencies, and fire departments.

As with all documentation, incidents like this one should be thoroughly documented. Documentation includes the PCR, and any other incidents reports deem appropriate by your EMS agency. Your documentation must remain neutral, no matter the circumstances that are surrounding the incident, which is often an emotionally charged situation. Your job as an EMS professional is to record the facts of an event accurately, objectively, and not to take sides. Your documentation should never purposefully support one side of events over another. You cannot change how the events unfurled, but your accurate documentation can help ensure that the truth can be known.

The duty to the patient

The final words of George Floyd were, "I can't breathe." These are precisely the words spoken by Eric Garner almost 6-years ago in an eerily similar situation. EMS professionals must remember they owe the highest duty to the patient, which is even true in cases where it may be uncomfortable to perform those duties or when other professionals are not treating the patient appropriately.

EMS professionals should speak up if they witness misconduct by anyone, attempt to intervene if necessary, and document this misconduct appropriately and accurately. In the often-misquoted words of philosopher George Santayana, those who cannot remember the past are condemned to repeat it.

Read next: Asphyxia by any other name is just as deadly

About the author

Matthew Konya, EMT Esq., is an associate attorney with Page, Wolfberg & Wirth, LLC and is an active EMS practitioner. He can be reached at mkonya@pwwemslaw.com.  

References

  1. Reay, D.T. (1996) Suspect Restraint and Sudden Death. Law Enforcement Bulletin. Quantico, Virginia: Federal Bureau of Investigation.
  2. Heiskell, L.E. (2019) How to Prevent Positional Asphyxia. Police Magazine.

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