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TR - 01 - 2007 National Study On Neck Restraint In Policing Date: 2007 - January Prepared for the Canadian Police Research Centre Authors: Christine Hall, MD MSc FRCPC Department of Emergency Medicine Vancouver Island Health Authority Sergeant Chris Butler Calgary Police Service © HER MAJESTY THE QUEEN IN RIGHT OF CANADA (2005) © SA MAJESTÉ LA REINE DU CHEF DU CANADA (2005) As represented by the Solicitor General of Canada. représentée par le Solliciteur général du Canada. Foreword Law enforcement officers in Canada are encountering an increasing number of subjects that are not responsive to standard arrest and restraint tactics. Typically, the individuals who are not responsive to traditional restraint techniques are under the influence of central nervous system stimulants or hallucinogens, suffering acute psychosis, or both; all of which present a challenging restraint and control problem for the responding officers. The frequency of officers encountering these subjects in an altered state of cognition, whose actions are typified by episodes of unpredictable, frenzied and violent behaviour is anticipated to continue to increase as cocaine and methamphetamine use grows on a national scale. The inclusion of the latest less lethal technologies, such as the conducted energy device (Taser®), has not eliminated the requirement for officers to utilize physical control tactics to take these subjects into custody. The vascular neck restraint is one of the physical control techniques that officers frequently utilize to restrain these types of individuals. Many police agencies in Canada have included the neck restraint in their use of force paradigm for many years, some agencies have recently adopted or readopted the vascular neck restraint (VNR) and others yet are investigating whether the neck restraint is an appropriate technique to add to the training regimen. There has been little consensus among police professionals and medical investigators regarding the risk of neck restraints applied by police personnel when restraining subjects of police interest. Many medical opinions, coroners’ findings and legal reviews do not reflect the body of knowledge at the time. There are multiple techniques available in the spectrum of neck holds, with little information available regarding potential risks of various techniques. Each technique is different from the other and carries with it a different risk profile. In order to investigate the medical, legal and expert trainer evidence surrounding use of neck restraints, the Canadian Police Research Centre (CPRC) facilitated the following review, which is entitled the National Study on Neck Restraints in Policing. The intent of this review is to provide a multi disciplinary report evaluating police use of neck restraint, with specific attention to vascular neck restraint. The report began with extensive expert medical review of the body of medical evidence and case law surrounding application of neck restraint. The neck restraint was evaluated with focus directed to the various types of neck restraints, the risk of injury from application of the restraint, medical implications and any collateral issues pertaining to case law and training. Recommendations for future evaluations were also generated. Ultimately, the final report on neck restraints in policing provides a framework around which administrators can make informed decisions regarding the following: x Whether or not to teach / authorize the vascular neck restraint, x Development of course training standards and lesson plans, x Application threshold within the use of force continuum, x Training and recertification recommendations, x Policy development, x Risk management 2 The Canadian Police Research Centre and the report’s authors are proud to have contributed to furthering the knowledge, understanding and research of police practices in Canada and abroad. 3 Table of Contents Executive Summary……………………………………………………. 5 Declaration of Conflict of Interests…………………………............ 12 Research Methodology Evidence Based Approach…………………………………….. 13 Discussion of Causation……………………………………….. 14 Literature Search……………………………………………….. 15 Expert Medical Consultation…………………………………… 16 Introduction……………………………………………………………… 19 History of Neck Restraints…………………………………………… 20 Types of Neck Restraints Types of Vascular Neck Restraints…………………………… 22 Vascular Neck Restraint Physiology………………………….. 25 Terminology…………………………………………………………….. 27 Medical Implications of the Vascular Neck Restraint Neurology.............................................................................. 28 Cardiology……………………………………………………….. 34 Respiratory……………………………………………………… 38 Specific Risk Groups…………………………………………... 39 Excited Delirium……………………………………………………….. 43 Legal Review Summary ……………………………………………… 49 Applying Medical Principles – Sample Case Study……………... 57 Discussion of Research Questions………………………………… 66 Report Recommendations…………………………………………… . 76 Glossary of Terms……………………………………………………… 81 Appendix A – Law Enforcement / Medical Team Members…….. 86 Appendix B – Bibliography……………………………….….………. 92 Appendix C – Legal Cases Reviewed………………………………. 100 Appendix D – Medical Reports Neurology.............................................................................. 102 Cardiology……………………………………………………….. 105 Appendix E – Levels of Evidence…………………………………… 109 4 Executive Summary Summary of Report Recommendations: 1. Nomenclature For ongoing implementation and evaluation of vascular neck restraint, it is highly recommended that consistent and definable nomenclature for vascular neck restraint is used. The term vascular neck restraint, or its abbreviation, VNR, should be used. Agencies implementing the copyrighted LVNR® should adhere to that specific terminology1. Police applications of restraint technology such as the vascular neck restraint are deserving of a professional and consistent nomenclature to separate use of this restraint technique from the variable, inconsistent and often incorrect attempts at restraint of a person’s neck by untrained and non-police persons. There is a distinct and definable difference in application technique, physiology of effect and anticipated outcome between a vascular neck restraint and other types of holds involving the neck. Appropriate and consistent nomenclature assists in clarifying those differences. The term “carotid sleeper hold” should be abandoned. 2. Injury Potential / Medical Considerations This report finds that, while no restraint methodology is completely risk free, there is not medical reason to routinely expect grievous bodily harm or death following the correct application of the vascular neck restraint in the general population by professional police officers with standardized training and technique. The medical ramifications of application of various and sundry neck holds by untrained individuals and non police personnel cannot be evaluated or anticipated in detail except to say that a lack of a standard approach changes the risk profile of the technique for the worse. Professional application of the standardized vascular neck restraint should not be governed by the medical implications of lay person attempts at “neck holds” as the medical implications are likely to be vastly different. Most police officers have no formal medical training and must anticipate that subjects fall under the normal physiologic and medical characteristics of the general population unless overwhelming evidence or clues presented to the officer suggest otherwise. Good policy guidelines will enable officers to apply appropriate techniques with appropriate discretion, thereby minimizing risk. In the general population the medical implications of the application of vascular neck restraint are detailed in the sections that follow. Full discussion of the physiology of each body system as it responds to VNR application can be found in the body of this report under relevant section headings. 1 The LVNR® is a registered trademark of the National Law Enforcement Training Center (NLETC), Kansas City, Missouri. 5 Specific risk groups for adverse outcomes following application of VNR by appropriately trained individuals: While