Screaming Their Last Breath
Why first responders must never ignore the words "I can't breathe"By Steve Cole, NRP, FTO | Dec 10, 2015
Every officer has heard “I can’t breathe!” yelled at the top of a subject’s lungs, usually as they are being handcuffed and detained after a vigorous struggle. I certainly know that I, as a paramedic responding to those calls to “check the subject” out, have heard it too. After a while, we all become a bit cavalier to the condition known as “jail-itis” or “allergic response to handcuffs,” or simply put: the subject maybe faking a medical emergency to get out of jail. Invariably someone will say, “If you can talk, you’re breathing.” I have said it. And, sadly, I have been wrong.
Let me say that I understand that a substantial majority of these patients are likely exaggerating their discomfort or trying to manipulate the situation. But the cost of assuming that’s the case is also unacceptably high. One case in a thousand is still one case that can result in a million-dollar lawsuit, criminal prosecution, loss of your job, and seeing your name all over CNN.
I want to share with you why the words “I can’t breathe” should be a red flag to the officer, just as much as the subject who has a clenched fist, or who is pacing a room erratically.
A major misconception is: if he can say that he can’t breathe, he can speak; and if he can speak then he has to be breathing. This is both true, and horribly wrong. This is perhaps one of the most lethal misconceptions in both EMS and law enforcement. To understand this, a little bit of boring physiology is needed. We must understand that respiration (breathing) is different than phonation (speaking).
A “breath” is a single inspiration and exhalation, and in medicine this is typically called a normal tidal breath. The amount/volume of this breath is called the tidal volume. The typical tidal volume for an adult male is typically 10-15 cc/kg, or about 500 – 700 cc total each breath (just over half a liter bottle of coke). I know this may be boring, but bear with me.
Now this tidal volume is total air movement with a normal resting breath. If you force yourself to take a deeper breath, it will of course be more, and visa versa. This breath is the volume to move air not only in the business-end of the lungs (the aveoli) but also the “airways” in between your lips/nose and the lungs.
This is important: The airways involve everything from the tip of your mouth, down your throat, through your larynx (voice box) and trachea, and down and down further through increasingly small tubes to the outside of the aveoli where actual breathing (cellular respiration: gas exchange of oxygen and carbon dioxide) takes place.
These passages are called “dead air” space, because no actual gas exchange occurs. It’s best to think of this space as “highway” and the alveoli as the actual destination. The volume of this space is typically about 150 cc in the adult male (give or take). In other words, of the 500 – 700 cc typically required to breath, the first 150 cc are required to move air before the first cc of air reaches the first aveoli.
Now let’s look at phonation (making sounds; speaking). The larynx, where sound is produced, only requires about 50 – 100 cc of air movement to produce sound. And the volume produced is related to the speed and force of air moving through the larynx, rather than the volume of air that reaches the alveoli. Therefore, phonation and respiration are two separate processes.
Why is this important? Most officers know that when a patient is prone, their respirations may be impeded. To be precise, the tidal volume may be reduced, sometimes significantly. A tidal volume breath in some circumstances may be decreased by up to 40%, and the work the subject must do to get that remaining 60% is much higher. At the same time that their tidal volume is reduced, their need for oxygen is dramatically increased because of their muscle activity (fighting, drugs, etc).
Finally, let’s look at oxygen demand. Oxygen demand is the amount of oxygen the body needs for the activity it is undertaking. If the subject does not have enough oxygen to meet this demand, they function at an oxygen deficit. Even if the subject is getting good airflow to the aveoli, are they getting enough to meet their needs? We all have run laps and found ourselves having to breath heavily to “catch our breath” afterward. This is because our oxygen demand exceeded our ability to meet that need.
We have all done this and our bodies have an ability to tolerate this for short periods. But add restraints, drugs, poor health, pre-existing medical conditions, obesity, and position to the mix, and bad things can happen. This results in an internal homeostasis (physiological state) that is thrown horribly out of balance, and in some cases may push subjects over the cliff into cardiac arrest.
In short, they literally cannot breathe (enough) despite moving air in and out. So when they say can’t breath, in a very real sense—they can’t.
Past the Point of No Return
Because they are moving at least 100 cc of air across their vocal chords, the subject can speak/scream/etc. Because they are working real hard at breathing, they are often yelling. The officer and/or paramedic may assume the subject is just fine. They will continue to yell and scream, until they don’t. By then its almost too late to recover.
Now this pertains to the concepts of excited delirium and positional asphyxia, both of which most LEOs are familiar with. But it also applies to a subject having an asthma attack and other medical emergencies as well. In other words, it doesn’t have to be drug related. This is a physiologic issue.
Yes, subjects are manipulative. Yes, they are “subjects” and being detained for a reason, and often they are restrained in the best way officers can in the circumstances of the moment. But every time an officer or paramedic passes on the myth that if they are speaking, they are breathing, I resist the urge rip out their lungs and show them why they are wrong. Because the reality is some of these patients may be speaking the truth with their last breath.
What actions should an officer take when this happens? Well, that’s a complex question dependent on the circumstances. I offer the following suggestions.
Never ignore the statement. One should treat it like a “medical threat cue,” sometimes serious and sometimes not, but always considered.
Make sure the subject is in a position to maximize his tidal volume. Is he sitting up or on his side? A subject should never be left prone.
Strongly consider having the patient checked out by your local EMS. Decrease his stress, struggle, and oxygen demand by allowing/coaching him to calm down while you wait.
What does your agency policy say? Does it address this?
Please do not pass on this myth to your trainees. It’s a flawed assumption that, while rare, can have potentially life threatening and career ending results.
Understanding a little bit of respiratory physiology will help you, the LEO, avoid potentially catastrophic pitfalls, and help you have a long career in this field. It will also benefit your agency. The subject, while he or she may not thank you, will certainly appreciate it as well.
I know that LEO’s do a difficult job, and I hope this article provides you with a few tools to do that job a little bit better.