Background: Inappropriate Response to Seizures

Misinterpretation of Seizures

A common type of seizure (complex partial seizures) may cloud awareness, block normal communication and produce a variety of undirected, involuntary and unorganized movements. It is this type of seizure that is associated with symptoms that may be erroneously perceived as combativeness. These symptoms may include screaming, running, flailing or unnatural looking movements of the arms or legs, spitting, shouting and abusive statements. Again, all of these are involuntary and unconscious manifestations of seizures.

Following a seizure (referred to as postictal or post-ictal), a person typically is fatigued and dazed before he or she becomes more aware of surroundings, as normal brain function returns. It is during this period, which may last for an hour or more, that one may become belligerent or aggressive, especially when approached or threatened; one is also easily frightened or upset and unable to communicate. Accordingly, restraint of persons soon after a seizure may exacerbate or precipitate combativeness – the opposite of the intended result. As one's resistance to restraint increases, the threat to his or her life similarly increases. The Epilepsy Foundation's Take Another Look brochure and training materials discuss these issues in more depth.

Regulation of Restraint Use by First Responders

Law Enforcement Officers

The use of restraint by first responders is not regulated at the national level, and it is unclear to what extent it is governed by state or local law. There are no national reporting requirements on injuries or deaths associated with restraint in this situation. Accordingly, there is a lack of national data in this area. By contrast, the U.S. Centers for Medicare and Medicaid Services has issued detailed standards and reporting requirements concerning "behavioral" restraint use in mental health facilities, hospitals and other healthcare facilities. These rules were issued in the wake of media coverage documenting many deaths in these facilities resulting from widespread unregulated physical and chemical restraint and isolation practices used to control patients with mental and developmental disabilities when exhibiting combative behaviors as a result of their conditions.

Recommendations Against use of Prone Restraint

The National Association of EMS Physicians has published a position paper, "Patient Restraint in Emergency Medical Services Systems." The paper states that all EMS systems should adopt a protocol to minimize the use of restraint and ensure the safest practices possible. For instance, the paper states that "Patients should never be transported while hobbled, ‘hog-tied,' or restrained in a prone position with hands and feet behind the back."

The fact that prone restraint may lead to death is well-documented in the law enforcement and mental health fields. See in particular the excellent study prepared by Disability Rights CA (formerly Protection and Advocacy, Inc.), "The Lethal Hazards of Prone Restraint: Positional Asphyxiation" (2002), available at http://www.disabilityrightsca.org/pubs/701801.pdf. The study notes (p. 17-23) that restraining a person face-down may cause positional asphyxia, that is, compromising one's breathing by compressing the chest, which prevents sufficient oxygen content in the blood; in turn, a disturbed heart rhythm (cardiac arrhythmia) results. Importantly, the study finds (p.18) that:

There is even a graver risk of causing respiratory compromise during the process of subduing or restraining an uncooperative individual . . . . Agitation or an aggressive struggle further increases the body's demand for oxygen. . . .

Furthermore, during such a struggle, there is the potential for further compression and restriction of the chest by those executing the restraint. To gain physical control of a struggling person, a knee or hand may be pressed into the back of the individual in prone position or staff may use their weight to lean into the individual's back or thorax . . . .

Handcuffs in front

Also, the study observes (p. 20) that hog-tying, or binding the individual's hands behind the back (as in the use of handcuffs), places the individual in further danger. This position further compresses the movement of the chest, particularly if the hands are pulled firmly behind the back or if weight is applied to the individual's chest or back.