Force Science News #295:

Sudden cardiac death: Mysteries persist despite new study



I. Sudden cardiac death: Mysteries persist despite new study

II. Top attorneys for DHS's agencies get Force Science briefing

III. Free: New online course that could help save lives & beat lawsuits

IV. A chance to turn your violent attack into a training aid

V. Quotable quote: A reporter's ah-ha moment


I. Sudden cardiac death: Mysteries persist despite new study


Results of a new study of sudden cardiac death suggest that some of the mysteries surrounding arrest-related fatalities are likely to remain unanswered for the foreseeable future and perhaps should simply be accepted as falling among unfortunate medical occurrences that often have no ready explanations.


"Cases of SCD [sudden cardiac death] associated with altercation and restraint receive mass media attention especially when police [or] other governmental bodies are involved," the research team notes.


But their findings about this phenomenon beg the question posed by one independent expert: Is it fair to hold law enforcement to unrealistic standards of prevention when there are so few certainties about how and why sudden deaths occur proximate to arrest?


PUZZLE OF YOUTH. The new study, reported in the journal Medicine, Science and Law, was conducted by four researchers associated with the medical school at Aristotle University in Greece and St. George's Medical School in London. Their aim was to further clarify the "well-established association" between both chronic and acute psychological stress and heart problems that may contribute to SCD.


In older subjects, they explain, underlying coronary artery disease is often identified as an influential factor. But SCD "is becoming increasingly recognized" among younger subjects, including those in the age range most commonly associated with police encounters. And in this group there "mainly [seems to be an] absence of coronary artery disease."


So what "associations and causes" may be driving stress-related SCD in this population? The researchers hoped to find out.


SUBJECT PARTICULARS. From a database of 2,400 SCD cases maintained at a cardiac pathology center in England, they thoroughly examined 110 instances of sudden death. The majority (over 80%) of subjects were male, the more vulnerable and combative gender, and nearly 60% were under age 35. Findings:


• Overall, about six in 10 "died instantaneously during [a] stressful event." The rest succumbed within 30 minutes after the event, with their stressed condition noticeable in the interim.


• "The main circumstances of SCD," the team found, were altercation (over 45%), struggling during restraint (31%), and merely being in police custody (10%). Lesser stressors included "receiving bad news," "exams/school/job stress," and "collapsing after a minor car accident."


• In nearly half the cases, restraint was imposed by LEOs. But at about the same collective rate, restraint was applied by non-LE personnel: psychiatric staff, security staff, or friends.


• For the most part (90%), toxicology reports for drugs and/or alcohol were negative.


WHY'D THEY DIE? The researchers report that 20% of the victims "had a psychiatric history and were on psychotropic drugs, and it is well established that such patients have a higher incidence of sudden death." Indeed, psychiatric patients are believed to be five times more likely to experience SCD than people generally, and "exposure to antipsychotic drugs further exacerbates this risk even at low doses."


Still, specific causation, especially among younger victims, seems to remain unclear. One member of the team performed a pathological analysis of each subject's heart. "The single most common finding": 60% had a heart that was "normal," including the majority of those younger than 35. Where abnormality of the heart muscle was discovered, this defect was concentrated predominately in older subjects. Similarly, all cases of coronary artery disease were in older subjects, with an average age of 60.


Without drawing specific conclusions, the researchers describe several possible influences among youthful victims with normal hearts, including a genetic predisposition to disrupted heart rhythm in the presence of "intense adrenalin activation" and an overwhelmingly negative "connection between the heart and the brain" incited by a psychological reaction to acute stress (being "scared to death," in effect).


As to definitive cause, though, the researchers report only vaguely: "[T]he mechanism of sudden death under stress may be multifactorial, resulting from a cascade of predisposing risk factors, including underlying cardiac disease, obesity, mental health, alcohol and/or drug use as well as physical exertion."


In high-profile cases, they recommend a "thorough autopsy with toxicology" conducted by an expert in cardiac pathology as the best hope of establishing "the correct cause of death" and shielding police and/or medical personnel from unwarranted blame.


AN EXPERT'S OBSERVATIONS. This study was brought to the attention of Force Science News by Dr. Mark Kroll, adjunct professor of biomedical engineering at the University of Minnesota and Cal Poly University in California, who lectured on the science of arrest-related deaths at the latest ILEETA annual training conference. Kroll offers some pertinent observations for law enforcement:


• "Being arrested is a highly emotional event, and the exertion of a struggle is several fold greater than that seen with normal exercise. To drive home the ability of extreme emotional stress to cause sudden death, consider that 4% of the deaths studied were caused by receiving news of a loved one's death, 7% were due to stress from examinations or a job, and 4% were from the stress of a minor car accident without major injuries"--events unrelated to any law enforcement involvement.


• "Annually, there are about 800,000 cases in which force is used by law enforcement in North America and approximately 800 arrest-related deaths (ARDs), yielding a mortality rate of about 1:1000--remarkably low, given the risks and stress involved. This can be compared to an in-hospital death rate of 1:232 for treatment of a common heart disorder [ablation for atrial fibrillation] by medical professionals--far higher than that for ARDs."


• "No matter how careful LEOs are, there will continue to be occasional ARDs. It is not clear that anything can be done to significantly reduce the risk of this below the present low rate. Is it even fair to expect law enforcement to achieve mortality rates even further below those of common hospital procedures when dealing with subjects who are often violent, disturbed, and intoxicated?"


• "An autopsy report by a medical examiner is often the primary factor in LEO discipline, termination, civil lawsuits, and criminal prosecutions. An individual ME will see an ARD every 10 years on average. Yet society expects MEs and coroners to always reach a cause and contribution to death conclusively.


"This is impossible since numerous studies find that 25-53% of sudden deaths in children, military recruits, and athletes cannot be explained. As this new study shows, this syndrome often has no clear pathological mechanism or no obvious anatomical or toxicological basis.


"Hopefully, someday society will accept the diagnosis of 'arrest-related death syndrome' without forcing the medical examiner to always find some deadly condition which is not necessarily there to be found."


FALSE THEORY CORRECTED. Kroll cites a "small weakness" in the new paper: The researchers mention "so-called compression/positional asphyxia as possibly contributing to restraint deaths." This "dying, unscientific theory" has been thoroughly discredited by "a substantial number of peer-reviewed studies" showing that positioning of arrestees has little or no impact on a suspect's ability to breathe, Kroll states. He and two colleagues have published a letter of correction in the journal.


A free abstract of the study, "Sudden cardiac death with stress and restraint," can be accessed by clicking here The full study is available for a fee by clicking here The letter disputing the validity of so-called positional asphyxia is available without charge by clicking here


II. Top attorneys for DHS's agencies get Force Science briefing


Twice a year, attorneys for the 22 federal agencies and departments involved in antiterrorist activities under the US Dept. of Homeland Security get together for special legal briefings and educational instruction.


At the gathering earlier this month at the DHS training center in Alexandria, VA, a featured speaker was Dr. Bill Lewinski, executive director of the Force Science Institute.


For a lively 90 minutes, Lewinski offered the 40 attorneys present an overview of Force Science research and its application to deadly force encounters. "It's important that these attorneys understand the realities of use of force because they review shootings and other major force events that occur in their agencies," says Robert Marohn, director of specialized and advanced training for the Federal Protective Service and a certified Force Science graduate, who organized the program.


Among agencies represented were the Federal Law Enforcement Training Center, the US Secret Service, the US Coast Guard, US Customs and Border Protection, the Transportation Security Administration, and US Citizenship & Immigration Services.


Stevan Bunnell, general counsel for DHS who hosted the meeting, reported "lots of positive feedback" from those attending. Lewinski's presentation, along with weapons demonstrations coordinated by Marohn, "were an excellent way for our group to gain a deeper appreciation of the difficult, split-second decisions law enforcement officers must make," he said.


III. Free: New online course that could help save lives & beat lawsuits


After struggling furiously with Kentucky officers during his arrest and restraint, the suspect seemed to be snoring peacefully in the back of a patrol vehicle en route to booking. But when he arrived at the jail, he was, in fact, dead.


His "snoring" had been "agonal breathing," the pattern of shallow, sporadic respiration that is commonly accompanied by sounds of "gasping, gurgling, and moaning" and typically signals that death is imminent.


This "snoring" case and similar others he has investigated has led Dr. John Peters Jr., founder of the Institute for the Prevention of In-Custody Deaths, to launch a free, online instructional program designed to help LEOs detect the onset of ominous breathing and, where possible, do something about it.


The easy-to-follow, layman-oriented, five-lesson course, titled "One Breath: The Importance of Recognizing Agonal & Other Breathing Problems," can be accessed by clicking here. Peters estimates that 600 officers in the US and abroad already have participated in this unique training, and he says some administrators intend to mandate it department-wide.


The program developed from a dual concern, Peters told Force Science News: 1) the need to "minimize growing litigation about 'failure to train' and/or 'negligent training' of officers regarding breathing problems, especially agonal respiration, and 2) the need to correct a misconception often voiced by LEOs in the media and misunderstood on the street, the assertion that if a subject is talking, he's breathing. "That statement," Peters says, "is a dangerous myth that gets officers and their agencies in trouble."


In designing an accurate course, Peters collaborated with Brian Casey, an officer and paramedic in St. Paul, MN, and had their program vetted by two physicians. The sequence of succinct lessons covers the difference between mere ventilation and genuine respiration and between normal and abnormal breathing, the indicators of agonal breathing, and "best practices" for dealing with and possibly saving a subject in respiration crisis.


The course includes a downloadable, 36-page study guide, case studies, videos, graphics, optional narration, and, at the end, a 20-question exam. Successful completion yields a certificate that can be entered in a personnel file. In all, the program takes about two hours, which can be broken down as convenient for the student.


Peters says the program is appropriate for street officers, 911 call-takers, dispatchers, investigators, prosecutors--anyone interacting with the public and potentially involved in potentially fatal encounters. "Officers generally get good training on how to contain, capture, control, and restrain people, but receive little, if any, specialized training on post-restraining issued, such as how to identify breathing difficulties. This course can help close that gap.


"Together," he says, "we can save lives, save careers, and save taxpayer money."


IV. A chance to turn your violent attack into a training aid


If you have a story of a violent encounter, the US Dept. of Justice wants to hear from you.


The DOJ's Bureau of Justice Assistance, through its VALOR Initiative for officer safety training, is updating and expanding information included in three landmark studies of attacks on LEOs published between 1992 and 2006 by the FBI. (Two emeritus faculty members of the Force Science Institute, Dr. Anthony Pinizzotto and Ed Davis, were instrumental in conducting those groundbreaking research projects, Killed in the Line of Duty, In the Line of Fire, and Violent Encounters.)


Now the BJA wants to identify fresh cases that can be evaluated for training in how a "deadly mix" of officers, offenders, and circumstances might be avoided before they come together in tragedy. They want cases where:


• Officers were assaulted with a firearm, cutting instrument, or other weapon(s), including hands and feet


• Interaction occurred between officer and offender before the assault


• The offender has been identified, arrested, tried, and convicted or pleaded guilty and appeals have been exhausted


• Both the officer and the offender will likely cooperate in talking with interviewers. If you have an attack experience that fits those criteria and might help other officers, click here or go to:


There you can fill out a brief questionnaire about the case. You'll need to give your contact information, but no names will be used in the published reports. For further information, email Dennis Williamson at:


Our thanks to Lt. Glen Mills of the Burlington (MA) PD for alerting us to this effort.


V. Quotable quote: A reporter's ah-ha moment


"What quickly becomes clear [during patrol encounters] is how much a second can matter."


--Time Magazine correspondent Karl Vick, reflecting on his ride-along experience with Philadelphia PD








© 2017 Force Science Institute Ltd.