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Restraint Techniques, Injuries, and Death: Use of Force Techniques
Restraint Techniques, Injuries, and Death: Use of Force Techniques GM Vilke and EM Castillo, University of California San Diego, San Diego, CA, USA r 2016 Elsevier Ltd. All rights reserved.
Abstract Use of force has been a part of policing since the beginning. Techniques and devices have evolved over the years as well as policies and protocols with much of the change based on research, outcomes, case reports, and litigation in the courts. This chapter will review the various components of law enforcement’s continuum of use of force. Specific detail will be given to the less lethal methods, including the use of riot control agents, such as tear gas and pepper spray, neck holds, and impact weapons such as blunt ballistics and conductive energy devices including TASERs.
Introduction Use of force in law enforcement has a very broad definition and ranges from verbal commands and openhanded techniques used to get subjects to follow orders, extending all the way to the deadly force of firearms. Most lay people think of the use of less lethal weapons when they think of use of force and this is accurate. But the range of items in the continuum of the use of force is much broader. A partial list of uses of force is found in Table 1. Less lethal weapons have become increasingly popular for law enforcement use when confronting dangerous, combative individuals in the field. On the use of force continuum, these technologies occupy an intermediate level between verbal and physical control methods and lethal force such as actual firearms. Less lethal weapons include riot control agents, electric stun devices such as TASERs electronic control devices (ECD) or electronic shields, and other blunt projectile weapons. Use of these less lethal weapons has been felt to increase both the safety of the subject by giving additional options instead of having to use lethal force, as well as of the user by controlling and subduing combative individuals while at times being able to maintain some safer distances. However, injuries and deaths have occurred in individuals following the use of all aspects of the use of force continuum with the exception of verbal commands (Reay, 1998; Strote et al., 2010; McEwen and Frank, 1994). This chapter will discuss the history of the various uses of force and some of the controversy and human effects of these forces.
Riot Control Agents Riot control agents included a variety of substances that can be used to control individuals as well as crowds of people. These agents include 1-chloroacetphenone (CN), o-chlorobenzylidene malononitrile (CS), and Oleoresin capsicum (OC). Typically these agents are dispersed as
Encyclopedia of Forensic and Legal Medicine, Volume 4
gases, smoke, or aerosols against individuals or large gatherings and, as such, may have the unintended effect of affecting or incapacitating the user as well as the subject. CN, 1-chloroacetphenone, also known as Mace, was first synthesized in 1871 by Graebe, and used in World War I and was the primary tear gas used by law enforcement and the military up through the 1950s (Figure 1). CN is a colorless crystalline substance that can be disseminated in a smoke form from an explosive device, such as a grenade, or propelled as a liquid or powder. CS, o-chlorobenzylidene malononitrile, is a riot control agent first synthesized in 1928 by Corson and Stoughton (hence code name CS). CS replaced CN as the standard riot control irritant agent in the US Army in 1959, as well as most law enforcement agencies as well Table 1
Use of force techniques
Verbal commands Empty hand control Contacts Grab, push, or pull Control hold Pressure point Strike Takedown Carotid restraint Weapons Pepper ball launcher with OC powder or water 37 mm rifle with standard or low energy 40 mm rifle with beanbag or sponge rounds TASER® brandished, sparked or used in probe or drive-stun mode OC agent Stingball grenade Impact weapon Sound/light device 12-gauge super sock Canine with presence or bite on Ultron/NOVA shield Vehicle/forcible stop Remote activated custody control belt Firearm pointed or fired at subject
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because of the improved effectiveness. CS is a white, crystalline solid that is insoluble in water and only partially soluble in ethyl alcohol. Because it has a low vapor pressure, CS is typically disseminated by dispersion of the powder or solution by explosion, spray, or smoke (Figure 2). Because it is relatively insoluble, decontamination of buildings or other items after use is difficult. CS also has a high flammability rating and has caused some structure fires.
Figure 1 Tear gas in World War I.
Figure 2 Riot control agent being dispersed by smoke.
CN and CS are similar and act as an irritant smoke when in contact with skin or mucous membrane tissues such as the eyes, nasal passages, oral cavity, and airway. Symptoms of exposure include coughing, sneezing, and increased airway secretions, as well as rhinorrhea and burning of the nasal passages and airways. Oral cavity and gastrointestinal exposure can result in the sensation of burning in the mouth, increased salivation, gagging, nausea, and vomiting. Ocular exposure to CN causes a burning sensation in the eye, injection of the conjunctiva, eye irritation, photophobia, and tearing. Similarly, skin contact can result in burning, irrigation, and erythema. The degree of symptoms is typically based on concentration and duration of exposure as well as environmental factors. Effects improve after removal of the exposure and gradually resolve over 30–60 min, but some symptoms such as skin erythema may last up to several hours. CS has direct irritating properties to the skin. After minutes of exposure, a burning sensation may be noted, particularly over moistened or freshly shaven areas. This may lead to erythema that typically resolves in a couple of hours. However, high concentration exposures under high temperatures or humid environmental conditions can result in severe erythema along with edema and vesication, with the development of vesicles typically occurring within the first hour or so, but can be delayed up to several hours (Danto, 1987; Punte et al., 1963; Thomas et al., 2002). OC spray, also known as pepper spray, is derived from the natural oily extract of pepper plants in the genus Capsicum. In the 1980s, the use of OC spray by law enforcement agencies increased and by the 1990s the majority of states in the United States had legalized the use of OC spray by the public. OC is made up of a mixture of fat soluble phenols called capsinoids with capsaicin making up to 80–90% of these capsinoids which acts both as a stimulant for the release of
Restraint Techniques, Injuries, and Death: Use of Force Techniques
peripheral neuropeptides and direct irritant to nerve endings as well. OC concentrations range from 1% to 15%, is not considered flammable and is delivered as a liquid stream spray, aerosol spray, and powder delivered as a projectile, such as OC powder-filled projectile ball (Pepperballs) that is fired from a specialized launcher with a target range of 0–30 feet. Biochemically, OC spray causes immediate pain and burning sensation over exposed areas of the skin, ocular, nasal, and oropharyngeal tissues. Ocular symptoms include burning and tearing of the eyes, as well as blepharospasm ranging from involuntary blinking to sustained closure of the eyelids. Cutaneous symptoms may include tingling, flushing, and intense burning sensation of the skin, particularly over recently shaved or abraded areas. Exposure of the airway and respiratory tract may cause coughing, gagging, and shortness of breath. Some reports of a transient laryngeal paralysis with associated temporary inability to speak have also been reported. Deaths have been reported using riot control agents, but typically are related to high concentrations in enclosed spaces. An example of this is the case of a prisoner who was found dead under his bunk in his cell with closed windows and doors and no ventilation after a prolonged gassing using six thermal grenades, fourteen 100 g projectiles, and more than 500 ml of 8% CS solution. Acute ventilatory complaints have been reported, including the case series of nine marines who were exposed to CS during strenuous exercise and developed cough, shortness of breath, and hemoptysis and hypoxia in several of those exposed. Although a few required close monitoring and treatment for hypoxia, all demonstrated normal lung function within a week after the exposure (Smith and Greaves, 2002). As OC spray is commonly used by many law enforcement agencies, there are a number of cases reported of deaths and injuries following with OC use. However, a causal connection between OC exposure and death remains controversial. One report of 30 cases of incustody death following OC exposure noted that drugs and underlying natural diseases were a significant factor in a majority of these cases. Other reports had similar findings with OC determined to not have been the cause of death in most cases. In only one case was OC implicated on autopsy which was a person who had a history of asthma and was sprayed with OC spray 10–15 times and then suffered a sudden cardiorespiratory arrest. Autopsy revealed severe epithelial lung damage with the cause of death noted to be severe bronchospasm probably precipitated by the use of pepper spray (Steffee et al., 1995). A few observational reports have been published assessing safety of OC spray use, including a joint study by the US Army and the FBI that reported OC spray was not associated with any long-term health risks. The California State Attorney General reported that no fatal consequences occurred in over 23 000 exposures to OC
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spray and another study reviewed 908 exposures to OC spray and found fewer than 10% of subjects exposed required any medical attention, and none of these were determined to be significant. There were no deaths reported in either of these studies (Granfield et al., 1994; Lundgren, 1996; Onnen, 1993). One randomized, cross-over controlled trial evaluating pulmonary function in 35 volunteer human subjects who were exposed to either OC spray or placebo propellant without OC concluded that OC spray did not result in any evidence of respiratory compromise with and without restraint that would make OC inherently lethal (Chan et al., 2000).
Neck Holds Neck holds have been on continuum of the use of force progression used by law enforcement agencies for decades. Two basic types of neck holds typically trained and utilized are both forms of lateral vascular neck restraint (LVNR) and include the carotid sleeper hold (carotid restraint) and the shoulder pin restraint. These holds are often erroneously called ‘choke holds,’ which is a term reserved for a specific type of hold that is not trained to be used by law enforcement. Choking is a more vague term and refers to the violent act of strangulation, or aspiration of an object (Iserson, 1984). ‘Choking out’ or ‘choked out’ is a term often used by law enforcement and medical care givers when a subject has had a neck hold placed, but not specific to any particular hold and does not even mean that the subject even lost consciousness. The carotid sleeper hold, also known as the sleeper hold or carotid restraint, and the shoulder pin restraint, are both forms of LVNR in which tightening of the hold compresses the sides of the neck, compressing the carotid arteries, and diminishing cerebral blood flow resulting in loss of consciousness. When appropriately placed, these holds will cause loss of consciousness within 10–20 s. At that point, the hold should be released and the unconscious period typically lasts up to 30 s or so after release. Theoretically, there should be no permanent sequelae after appropriate use of this hold. A number of case series have reviewed deaths that occurred following the use of a neck hold (Kornblum, 1986a,b). In most cases, the deaths were related to improperly placed LVNR or placement of a bar hold, a hold in which the forearm or a flashlight or other device is held across the anterior aspect of the neck often occluding and injuring the airway. Several other deaths involved prolonged carotid restraint, from 1.5 to 3 min after the loss of consciousness. One review of 14 fatalities in which the autopsy findings determined that the death was caused by the use of neck holds found that all patients had evidence of injury to the neck, including bruises, ecchymosis, and hemorrhages on autopsy with
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five patients suffering fractures of neck bones or cartilage. These fractures all occurred in subjects who died after a bar hold. Other deaths in this series were attributed to asphyxia from prolonged holds after loss of consciousness (Reay and Eisele, 1982). Shime-waza, a term for the sleeper hold in judo, has been used in the sport since its founding in 1882 (Barquin, 1979). Although there have been 19 reported judo fatalities, none have been found to be due to shime-waza (Koiwai, 1981; Koiwai, 1987; Tezuka, 1978). Based on 12-month records from the International Judo Federation, World Class Championships, Olympics and Junior World Judo Championships, there were no reported deaths from the 2198 different techniques used to score, 97 of which involved the use of shime-waza. Overall, the LVNR has a good safety profile with no deaths reported when appropriately and correctly utilized.
Figure 3 Nightstick.
Impact Weapons Impact weapons are an intermediate use of force step between hands on techniques and firearms and consist of various types of tools such as a flashlight, nightstick, and batons (Figures 3 and 4). They are commonly available tools that can be used for subject compliance and selfdefense by law enforcement personnel, but they are not often utilized in use of force events. Although impact weapons are traditionally too short to be tactical weapons, they can be successful as they are readily available and can give heavy blows to disarm or help subdue a combative subject when the use of other more lethal tactics are not warranted or easily accessible and can also be used to push back or block a subject in certain situations. The majority of subject injuries as a result from impact weapon are minor, but they can be severe and result in death. Cases of death or disability typically involve head strikes resulting in subdural hematomas or other intracranial pathology. These types of injuries can be minimized with proper training though not eliminated, as field situations are fluid and unpredictable.
Electronic Control Devices Use of ECDs, such as the TASERs, includes delivery of a series of brief electrical pulses that result in rapid muscular contractions. Depending on the device, the pulses may be delivered via a pair of metal probes fired from the weapon, commonly referred to as ‘probe mode,’ or by direct contact utilizing conducting points. When the contact points have enough separation, the subject will have multiple muscle groups that can cause a form or neuromuscular incapacitation. There are a number of ECDs on the market and range from
Figure 4 Telescoping nightstick.
TASERs devices (both for law enforcement and personal security), stun guns, electronic control shields, and remote activated custody control belts. Specific to the TASERs, there is often lay press focus on the concern of electrocution based on the reported 50 000 V (V) peak open arcing voltage. However, TASERs handheld ECDs actually only deliver a fraction of the 50 000 V to the body. In the case of the TASERs X26, the mean delivered pulse voltage is 580 V. Although this may sound concerning, it is not the voltage, but the delivered electrical charge (Amperage), that actually creates a risk for cardiac effects. For example, the static electricity from walking across a carpet can generate 30 000–100 000 V. However, the average, aggregate, and actual delivered electrical current of the TASERs X26 ECD is only about 1.9 mA (mA) (or, 0.0019 A (A)) and the peak current is only about 3 A. By way of comparison, a TASERs M26™ ECD has a peak current of about 17 A; an International Electrotechnical Commission (IEC) Level IV static electricity shock has a
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Figure 5 TASER® X26.
peak current of 30 A; a Christmas tree light string will have on average current of 0.4 A or 400 mA, which is about 200 times the average (or actual or aggregate) delivered current of the TASERs X26 ECD (Figure 5). The stored energy in the TASERs X26 ECD is about 0.36 J per pulse, and the delivered energy is about 0.1 J per pulse, with the comparison of an automatic external cardiac defibrillator (AED) used many times per day by paramedics using 360 J, over 3000 times greater than the X26 ECD. Or, if one thinks about it, this limited amount of delivered electrical energy able to be transferred to a person makes sense as the TASERs X26 ECD is only powered by a battery of two 3 V cells (Duracells CR123s), commonly used in some small digital cameras (such as the Nikon F6). It is the TASERs ECD’s rapid cycling that can cause the subjects’ muscles to contract at about 19 times a second that can offer the effective incapacitation of the subject in probe mode, or painful compliance in drive-stun mode, while still offering a reported significant safety margin from electrical injury. Once the energy from an ECD is turned off, the subject is back to his physical baseline. Details of the history, epidemiology, and research involving the TASERs and other ECD are covered in more detail elsewhere in the encyclopedia and thus will not be further elaborated on in this chapter.
Blunt Projectiles Blunt projectiles were first used during the Hong Kong Riots of the 1950s and 1960s, with the initial projectiles being made of wood. Similar devices were also used during the Israeli-Palestinian and Northern Ireland conflicts in the 1970s and 1980s. Early devices included hard, rubber missile-shaped projectiles that were so inaccurate that hits to the head, face, and chest could not be avoided and were not uncommon. Later versions evolved into PVC-type bullets, modern-day blunt rubber bullets, and beanbag rounds, which are currently in use by various law enforcement agencies in the United States. Blunt projectiles involve being fired from a weapon, often a shotgun, that can impart energies on the
Figure 6 Rubber bullet.
order of 100–200 J depending on the type of round and the distance from firing at impact. As an alternative to regular firearms, blunt projectiles have been used when trying to disperse a crowd from a distance or when trying to subdue or incapacitate a combative, violent individual without utilizing lethal force. The action of the blunt projectile is to induce pain and distraction while local minimal incapacitation from injury to the subject without causing any life-threatening injuries that can occur with the use of lethal force (Figure 6). The physiologic effects of blunt projectiles are directly related to anatomic location where the projectile strikes the subject and induces its trauma to the individual. The association of blunt projectiles and sudden death syndrome mainly stem from risk of a direct blow to the chest inducing a cardiac dysrhythmia such as ventricular fibrillation. Commotio cordis, a rare syndrome in which young healthy individuals suddenly suffer cardiac arrest after blunt chest trauma traditionally related to a sports activity such as baseball, hockey, or lacrosse, is characterized by a sudden disruption of cardiac rhythm in the absence of demonstrable signs of significant heart injury that is induced by a direct blow to the chest. This is separate from direct injury to the heart leading to myocardial contusion, valvular disruption, or pericardial effusion. The energies involved in the use of less lethal projectiles are on the order of the same energies that are involved in some of these different sporting events. Therefore, one could speculate that these devices would have the same risk of causing VF. One specific case report of a death following use of the devices was published in 1998. A 61-year-old woman was facing police in a threatening manner brandishing a butcher knife. After two unsuccessful deployments of an ECD, she was shot in the chest using a plastic bullet (AR-1 baton round). She stumbled back and collapsed, had labored breathing and subsequently suffered cardiac
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appropriate by using less lethal tools such as ECD’s. The most common type of firearm use is the handgun, but other types such as shotguns and various types of rifles for specific situations. Law enforcement agencies require ongoing training on the operation and policies regarding the use of firearms. Although they are used to protect themselves, their partners, and the public, they are much more often used as a deterrent to gain control of a subject by simply having it at the ready or pointing it.
Conclusions The Use of Force continuum has changed over time, with certain tools and techniques having been added and others fallen out of favor, but the expectation is that the breath of use of force will always be the same, ranging from verbal to deadly force, but the methods and tools in between will continue to evolve. Figure 7 Injuries from blunt projectiles.
arrest. Autopsy showed she had sustained multiple rib fractures to the left chest, an underlying lung laceration, and heart lacerations that led to significant bleeding into the chest cavity with the cause of death certified as blunt force injuries of chest due to plastic bullet wound (Figure 7). Several studies have looked at the injury patterns from the use of plastic and rubber bullets and all conclude that while generally regarded as less lethal weapons, significant injuries including death can occur when the weapons strike the chest, abdomen, or head. One review evaluated 90 patients who had sustained various bodily injuries, concluded that the eyes, face, skull, bones, and brain are at greatest risk of injury from rubber bullets with the distance at which the rubber bullets resulted in serious injury ranged from 17 to 25 m. Another study reviewing 80 subjects injured by rubber bullets reported that of the four that died, three were from ventricular dysrhythmias secondary to cardiac contusion and one was from a hemopneumothorax. Nineteen other patients who required hospitalization had serious chest wounds. Numerous case reports have reported and documented the hazards and injuries, including deaths, caused by beanbag rounds and other blunt projectiles, like the super sock and 40 mm sponge rounds (Charles et al., 2002; Chute and Smialek, 1998; de Brito et al., 2001; Drazin et al., 2012; Grange et al., 2002; Millar et al., 1975).
Firearms Firearms continue to be a common and important law enforcement tool in the United States. In many agencies, there is a move to decrease the use of deadly force when
See also: Mortality: Statistics. Restraint Techniques, Injuries, and Death: Conducted Energy Devices
References Barquin, R.C., 1979. Handbook of the International Judo Federation. 29–39. de Brito, D., Challoner, K.R., Sehgal, A., Mallon, W., 2001. The injury pattern of a new law enforcement weapon: The police bean bag. Annals of Emergency Medicine 38 (4), 383–390. Chan, T.C., Vilke, G.M., Clausen, J., et al., 2000. The Impact of Oleoresin Capsicum Spray on Respiratory Function in Human Subjects in the Sitting and Prone Maximal Restraint Positions, Final Report. NCJ 182433. Washington, DC: United States Department of Justice, National Institute of Justice, 68 p. Charles, A., Asensio, J., Forno, W., et al., 2002. Penetrating bean bag injury: Intrathoracic complication of a nonlethal weapon. Journal of Trauma 53 (5), 997–1000. Chute, D.J., Smialek, J.E., 1998. Injury patterns in a plastic (AR-1) Baton fatality. American Journal of Forensic Medicine and Pathology 19 (3), 226–229. Danto, B.L., 1987. Medical problems and criteria regarding the use of tear gas by police. American Journal of Forensic Medicine and Pathology 8, 317–322. Drazin, D., Shirzadi, A., Hanna, G., Jeswani, S., Ozgur, B., 2012. Epidural hematoma and surgical evacuation from a bean bag weapon. American Surgeon 78 (1), E33–E35. Granfield, J., Onnen, J., Petty, C.S., 1994. Pepper Spray and in Custody Deaths: International Association of Chiefs of Police Executive Brief. Alexandria, VA: International Association of Chiefs of Police. Grange, J.T., Kozak, R., Gonzalez, J., 2002. Penetrating injury from a less-lethal bean bag gun. Journal of Trauma 52 (3), 576–578. Iserson, K., 1984. Strangulation: A review of ligature, manual and postural compression injuries. Annals of Emergency Medicine 13, 179–185. Koiwai, E.K., 1981. Fatalities associate with judo. Physician and Sportsmedicine 9, 61–66. Koiwai, E.K., 1987. Deaths allegedly caused by the use of “choke holds” (shimewaza). Journal of Forensic Sciences 32, 419–432. Kornblum, R.N., 1986a. Medical analysis of police choke holds and general neck trauma (part 2). Trauma 28, 13–64. Kornblum, R.N., 1986b. Medical analysis of police choke holds and general neck trauma (part 1). Trauma 27, 7–60. Lundgren, D.E., 1996. Oleoresin capsicum (OC) usage reports: Summary information. Report of the California State Attorney General. Sacramento, CA: California Department of Justice.
Restraint Techniques, Injuries, and Death: Use of Force Techniques
McEwen, T.O.M., Frank, L., 1994. Final Report: Less than Lethal Force Technologies in Law Enforcement and Correctional Agencies. Washington, DC: National Institute of Justice. Millar, R., Rutherford, W.H., Jonston, S., Malhotra, V.J., 1975. Injuries caused by rubber bullets: A report on 90 patients. British Journal of Surgery 62, 480–486. Onnen, J., 1993. Oleoresin Capsicum. Executive Brief, 1. Alexandria, VA: International Association of Chiefs of Police. Punte, C.L., Owens, E.J., Gutentag, P.J., 1963. Exposures to ortho-chlorobenzylidene malononitrile. Archives of Environmental Health 6, 72–80. Reay, D.T., 1998. Death in custody. Clinics in Laboratory Medicine 18, 1–22. Reay, D.T., Eisele, J.W., 1982. Death from law enforcement neck holds. American Journal of Forensic Medicine and Pathology 3, 253–258. Smith, J., Greaves, I., 2002. The use of chemical incapacitant sprays: A review. Journal of Trauma 52 (3), 595–600.
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Steffee, C.H., Lantz, P.E., Flannagan, L.M., Thompson, R.L., Jason, D.R., 1995. Oleoresin capsicum (pepper) spray and “in-custody deaths”. American Journal of Forensic Medicine and Pathology 16 (3), 185–192. Strote, J., Verzemnieks, E., Walsh, M., Hutson, H.R., 2010. Use of force by law enforcement: An evaluation of safety and injury. Journal of Trauma Injury, Infection, and Critical Care 69 (5), 1288–1293. Tezuka, M., 1978. Physiological studies of the Ochi (unconsciousness) resulting from shime-waza (strangle-hold) in judo. Bulletin of the Association for Scientific Studies on Judo, Kodokan Report V, pp. 71−73. Thomas, R.J., Smith, P.A., Rascona, D.A., Louthan, J.D., Gumpert, B., 2002. Acute pulmonary effects from o-chlorobenzylidenemalontrile ‘tear gas’: A unique exposure outcome unmasked by strenuous exercise after a military training event. Military Medicine 167, 136–139.
Abstract Use of force has been a part of policing since the beginning. Techniques and devices have evolved over the years as well as policies and protocols with much of the change based on research, outcomes, case reports, and litigation in the courts. This chapter will review the various components of law enforcement’s continuum of use of force. Specific detail will be given to the less lethal methods, including the use of riot control agents, such as tear gas and pepper spray, neck holds, and impact weapons such as blunt ballistics and conductive energy devices including TASERs.
Introduction Use of force in law enforcement has a very broad definition and ranges from verbal commands and openhanded techniques used to get subjects to follow orders, extending all the way to the deadly force of firearms. Most lay people think of the use of less lethal weapons when they think of use of force and this is accurate. But the range of items in the continuum of the use of force is much broader. A partial list of uses of force is found in Table 1. Less lethal weapons have become increasingly popular for law enforcement use when confronting dangerous, combative individuals in the field. On the use of force continuum, these technologies occupy an intermediate level between verbal and physical control methods and lethal force such as actual firearms. Less lethal weapons include riot control agents, electric stun devices such as TASERs electronic control devices (ECD) or electronic shields, and other blunt projectile weapons. Use of these less lethal weapons has been felt to increase both the safety of the subject by giving additional options instead of having to use lethal force, as well as of the user by controlling and subduing combative individuals while at times being able to maintain some safer distances. However, injuries and deaths have occurred in individuals following the use of all aspects of the use of force continuum with the exception of verbal commands (Reay, 1998; Strote et al., 2010; McEwen and Frank, 1994). This chapter will discuss the history of the various uses of force and some of the controversy and human effects of these forces.
Riot Control Agents Riot control agents included a variety of substances that can be used to control individuals as well as crowds of people. These agents include 1-chloroacetphenone (CN), o-chlorobenzylidene malononitrile (CS), and Oleoresin capsicum (OC). Typically these agents are dispersed as
Encyclopedia of Forensic and Legal Medicine, Volume 4
gases, smoke, or aerosols against individuals or large gatherings and, as such, may have the unintended effect of affecting or incapacitating the user as well as the subject. CN, 1-chloroacetphenone, also known as Mace, was first synthesized in 1871 by Graebe, and used in World War I and was the primary tear gas used by law enforcement and the military up through the 1950s (Figure 1). CN is a colorless crystalline substance that can be disseminated in a smoke form from an explosive device, such as a grenade, or propelled as a liquid or powder. CS, o-chlorobenzylidene malononitrile, is a riot control agent first synthesized in 1928 by Corson and Stoughton (hence code name CS). CS replaced CN as the standard riot control irritant agent in the US Army in 1959, as well as most law enforcement agencies as well Table 1
Use of force techniques
Verbal commands Empty hand control Contacts Grab, push, or pull Control hold Pressure point Strike Takedown Carotid restraint Weapons Pepper ball launcher with OC powder or water 37 mm rifle with standard or low energy 40 mm rifle with beanbag or sponge rounds TASER® brandished, sparked or used in probe or drive-stun mode OC agent Stingball grenade Impact weapon Sound/light device 12-gauge super sock Canine with presence or bite on Ultron/NOVA shield Vehicle/forcible stop Remote activated custody control belt Firearm pointed or fired at subject
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because of the improved effectiveness. CS is a white, crystalline solid that is insoluble in water and only partially soluble in ethyl alcohol. Because it has a low vapor pressure, CS is typically disseminated by dispersion of the powder or solution by explosion, spray, or smoke (Figure 2). Because it is relatively insoluble, decontamination of buildings or other items after use is difficult. CS also has a high flammability rating and has caused some structure fires.
Figure 1 Tear gas in World War I.
Figure 2 Riot control agent being dispersed by smoke.
CN and CS are similar and act as an irritant smoke when in contact with skin or mucous membrane tissues such as the eyes, nasal passages, oral cavity, and airway. Symptoms of exposure include coughing, sneezing, and increased airway secretions, as well as rhinorrhea and burning of the nasal passages and airways. Oral cavity and gastrointestinal exposure can result in the sensation of burning in the mouth, increased salivation, gagging, nausea, and vomiting. Ocular exposure to CN causes a burning sensation in the eye, injection of the conjunctiva, eye irritation, photophobia, and tearing. Similarly, skin contact can result in burning, irrigation, and erythema. The degree of symptoms is typically based on concentration and duration of exposure as well as environmental factors. Effects improve after removal of the exposure and gradually resolve over 30–60 min, but some symptoms such as skin erythema may last up to several hours. CS has direct irritating properties to the skin. After minutes of exposure, a burning sensation may be noted, particularly over moistened or freshly shaven areas. This may lead to erythema that typically resolves in a couple of hours. However, high concentration exposures under high temperatures or humid environmental conditions can result in severe erythema along with edema and vesication, with the development of vesicles typically occurring within the first hour or so, but can be delayed up to several hours (Danto, 1987; Punte et al., 1963; Thomas et al., 2002). OC spray, also known as pepper spray, is derived from the natural oily extract of pepper plants in the genus Capsicum. In the 1980s, the use of OC spray by law enforcement agencies increased and by the 1990s the majority of states in the United States had legalized the use of OC spray by the public. OC is made up of a mixture of fat soluble phenols called capsinoids with capsaicin making up to 80–90% of these capsinoids which acts both as a stimulant for the release of
Restraint Techniques, Injuries, and Death: Use of Force Techniques
peripheral neuropeptides and direct irritant to nerve endings as well. OC concentrations range from 1% to 15%, is not considered flammable and is delivered as a liquid stream spray, aerosol spray, and powder delivered as a projectile, such as OC powder-filled projectile ball (Pepperballs) that is fired from a specialized launcher with a target range of 0–30 feet. Biochemically, OC spray causes immediate pain and burning sensation over exposed areas of the skin, ocular, nasal, and oropharyngeal tissues. Ocular symptoms include burning and tearing of the eyes, as well as blepharospasm ranging from involuntary blinking to sustained closure of the eyelids. Cutaneous symptoms may include tingling, flushing, and intense burning sensation of the skin, particularly over recently shaved or abraded areas. Exposure of the airway and respiratory tract may cause coughing, gagging, and shortness of breath. Some reports of a transient laryngeal paralysis with associated temporary inability to speak have also been reported. Deaths have been reported using riot control agents, but typically are related to high concentrations in enclosed spaces. An example of this is the case of a prisoner who was found dead under his bunk in his cell with closed windows and doors and no ventilation after a prolonged gassing using six thermal grenades, fourteen 100 g projectiles, and more than 500 ml of 8% CS solution. Acute ventilatory complaints have been reported, including the case series of nine marines who were exposed to CS during strenuous exercise and developed cough, shortness of breath, and hemoptysis and hypoxia in several of those exposed. Although a few required close monitoring and treatment for hypoxia, all demonstrated normal lung function within a week after the exposure (Smith and Greaves, 2002). As OC spray is commonly used by many law enforcement agencies, there are a number of cases reported of deaths and injuries following with OC use. However, a causal connection between OC exposure and death remains controversial. One report of 30 cases of incustody death following OC exposure noted that drugs and underlying natural diseases were a significant factor in a majority of these cases. Other reports had similar findings with OC determined to not have been the cause of death in most cases. In only one case was OC implicated on autopsy which was a person who had a history of asthma and was sprayed with OC spray 10–15 times and then suffered a sudden cardiorespiratory arrest. Autopsy revealed severe epithelial lung damage with the cause of death noted to be severe bronchospasm probably precipitated by the use of pepper spray (Steffee et al., 1995). A few observational reports have been published assessing safety of OC spray use, including a joint study by the US Army and the FBI that reported OC spray was not associated with any long-term health risks. The California State Attorney General reported that no fatal consequences occurred in over 23 000 exposures to OC
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spray and another study reviewed 908 exposures to OC spray and found fewer than 10% of subjects exposed required any medical attention, and none of these were determined to be significant. There were no deaths reported in either of these studies (Granfield et al., 1994; Lundgren, 1996; Onnen, 1993). One randomized, cross-over controlled trial evaluating pulmonary function in 35 volunteer human subjects who were exposed to either OC spray or placebo propellant without OC concluded that OC spray did not result in any evidence of respiratory compromise with and without restraint that would make OC inherently lethal (Chan et al., 2000).
Neck Holds Neck holds have been on continuum of the use of force progression used by law enforcement agencies for decades. Two basic types of neck holds typically trained and utilized are both forms of lateral vascular neck restraint (LVNR) and include the carotid sleeper hold (carotid restraint) and the shoulder pin restraint. These holds are often erroneously called ‘choke holds,’ which is a term reserved for a specific type of hold that is not trained to be used by law enforcement. Choking is a more vague term and refers to the violent act of strangulation, or aspiration of an object (Iserson, 1984). ‘Choking out’ or ‘choked out’ is a term often used by law enforcement and medical care givers when a subject has had a neck hold placed, but not specific to any particular hold and does not even mean that the subject even lost consciousness. The carotid sleeper hold, also known as the sleeper hold or carotid restraint, and the shoulder pin restraint, are both forms of LVNR in which tightening of the hold compresses the sides of the neck, compressing the carotid arteries, and diminishing cerebral blood flow resulting in loss of consciousness. When appropriately placed, these holds will cause loss of consciousness within 10–20 s. At that point, the hold should be released and the unconscious period typically lasts up to 30 s or so after release. Theoretically, there should be no permanent sequelae after appropriate use of this hold. A number of case series have reviewed deaths that occurred following the use of a neck hold (Kornblum, 1986a,b). In most cases, the deaths were related to improperly placed LVNR or placement of a bar hold, a hold in which the forearm or a flashlight or other device is held across the anterior aspect of the neck often occluding and injuring the airway. Several other deaths involved prolonged carotid restraint, from 1.5 to 3 min after the loss of consciousness. One review of 14 fatalities in which the autopsy findings determined that the death was caused by the use of neck holds found that all patients had evidence of injury to the neck, including bruises, ecchymosis, and hemorrhages on autopsy with
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five patients suffering fractures of neck bones or cartilage. These fractures all occurred in subjects who died after a bar hold. Other deaths in this series were attributed to asphyxia from prolonged holds after loss of consciousness (Reay and Eisele, 1982). Shime-waza, a term for the sleeper hold in judo, has been used in the sport since its founding in 1882 (Barquin, 1979). Although there have been 19 reported judo fatalities, none have been found to be due to shime-waza (Koiwai, 1981; Koiwai, 1987; Tezuka, 1978). Based on 12-month records from the International Judo Federation, World Class Championships, Olympics and Junior World Judo Championships, there were no reported deaths from the 2198 different techniques used to score, 97 of which involved the use of shime-waza. Overall, the LVNR has a good safety profile with no deaths reported when appropriately and correctly utilized.
Figure 3 Nightstick.
Impact Weapons Impact weapons are an intermediate use of force step between hands on techniques and firearms and consist of various types of tools such as a flashlight, nightstick, and batons (Figures 3 and 4). They are commonly available tools that can be used for subject compliance and selfdefense by law enforcement personnel, but they are not often utilized in use of force events. Although impact weapons are traditionally too short to be tactical weapons, they can be successful as they are readily available and can give heavy blows to disarm or help subdue a combative subject when the use of other more lethal tactics are not warranted or easily accessible and can also be used to push back or block a subject in certain situations. The majority of subject injuries as a result from impact weapon are minor, but they can be severe and result in death. Cases of death or disability typically involve head strikes resulting in subdural hematomas or other intracranial pathology. These types of injuries can be minimized with proper training though not eliminated, as field situations are fluid and unpredictable.
Electronic Control Devices Use of ECDs, such as the TASERs, includes delivery of a series of brief electrical pulses that result in rapid muscular contractions. Depending on the device, the pulses may be delivered via a pair of metal probes fired from the weapon, commonly referred to as ‘probe mode,’ or by direct contact utilizing conducting points. When the contact points have enough separation, the subject will have multiple muscle groups that can cause a form or neuromuscular incapacitation. There are a number of ECDs on the market and range from
Figure 4 Telescoping nightstick.
TASERs devices (both for law enforcement and personal security), stun guns, electronic control shields, and remote activated custody control belts. Specific to the TASERs, there is often lay press focus on the concern of electrocution based on the reported 50 000 V (V) peak open arcing voltage. However, TASERs handheld ECDs actually only deliver a fraction of the 50 000 V to the body. In the case of the TASERs X26, the mean delivered pulse voltage is 580 V. Although this may sound concerning, it is not the voltage, but the delivered electrical charge (Amperage), that actually creates a risk for cardiac effects. For example, the static electricity from walking across a carpet can generate 30 000–100 000 V. However, the average, aggregate, and actual delivered electrical current of the TASERs X26 ECD is only about 1.9 mA (mA) (or, 0.0019 A (A)) and the peak current is only about 3 A. By way of comparison, a TASERs M26™ ECD has a peak current of about 17 A; an International Electrotechnical Commission (IEC) Level IV static electricity shock has a
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Figure 5 TASER® X26.
peak current of 30 A; a Christmas tree light string will have on average current of 0.4 A or 400 mA, which is about 200 times the average (or actual or aggregate) delivered current of the TASERs X26 ECD (Figure 5). The stored energy in the TASERs X26 ECD is about 0.36 J per pulse, and the delivered energy is about 0.1 J per pulse, with the comparison of an automatic external cardiac defibrillator (AED) used many times per day by paramedics using 360 J, over 3000 times greater than the X26 ECD. Or, if one thinks about it, this limited amount of delivered electrical energy able to be transferred to a person makes sense as the TASERs X26 ECD is only powered by a battery of two 3 V cells (Duracells CR123s), commonly used in some small digital cameras (such as the Nikon F6). It is the TASERs ECD’s rapid cycling that can cause the subjects’ muscles to contract at about 19 times a second that can offer the effective incapacitation of the subject in probe mode, or painful compliance in drive-stun mode, while still offering a reported significant safety margin from electrical injury. Once the energy from an ECD is turned off, the subject is back to his physical baseline. Details of the history, epidemiology, and research involving the TASERs and other ECD are covered in more detail elsewhere in the encyclopedia and thus will not be further elaborated on in this chapter.
Blunt Projectiles Blunt projectiles were first used during the Hong Kong Riots of the 1950s and 1960s, with the initial projectiles being made of wood. Similar devices were also used during the Israeli-Palestinian and Northern Ireland conflicts in the 1970s and 1980s. Early devices included hard, rubber missile-shaped projectiles that were so inaccurate that hits to the head, face, and chest could not be avoided and were not uncommon. Later versions evolved into PVC-type bullets, modern-day blunt rubber bullets, and beanbag rounds, which are currently in use by various law enforcement agencies in the United States. Blunt projectiles involve being fired from a weapon, often a shotgun, that can impart energies on the
Figure 6 Rubber bullet.
order of 100–200 J depending on the type of round and the distance from firing at impact. As an alternative to regular firearms, blunt projectiles have been used when trying to disperse a crowd from a distance or when trying to subdue or incapacitate a combative, violent individual without utilizing lethal force. The action of the blunt projectile is to induce pain and distraction while local minimal incapacitation from injury to the subject without causing any life-threatening injuries that can occur with the use of lethal force (Figure 6). The physiologic effects of blunt projectiles are directly related to anatomic location where the projectile strikes the subject and induces its trauma to the individual. The association of blunt projectiles and sudden death syndrome mainly stem from risk of a direct blow to the chest inducing a cardiac dysrhythmia such as ventricular fibrillation. Commotio cordis, a rare syndrome in which young healthy individuals suddenly suffer cardiac arrest after blunt chest trauma traditionally related to a sports activity such as baseball, hockey, or lacrosse, is characterized by a sudden disruption of cardiac rhythm in the absence of demonstrable signs of significant heart injury that is induced by a direct blow to the chest. This is separate from direct injury to the heart leading to myocardial contusion, valvular disruption, or pericardial effusion. The energies involved in the use of less lethal projectiles are on the order of the same energies that are involved in some of these different sporting events. Therefore, one could speculate that these devices would have the same risk of causing VF. One specific case report of a death following use of the devices was published in 1998. A 61-year-old woman was facing police in a threatening manner brandishing a butcher knife. After two unsuccessful deployments of an ECD, she was shot in the chest using a plastic bullet (AR-1 baton round). She stumbled back and collapsed, had labored breathing and subsequently suffered cardiac
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appropriate by using less lethal tools such as ECD’s. The most common type of firearm use is the handgun, but other types such as shotguns and various types of rifles for specific situations. Law enforcement agencies require ongoing training on the operation and policies regarding the use of firearms. Although they are used to protect themselves, their partners, and the public, they are much more often used as a deterrent to gain control of a subject by simply having it at the ready or pointing it.
Conclusions The Use of Force continuum has changed over time, with certain tools and techniques having been added and others fallen out of favor, but the expectation is that the breath of use of force will always be the same, ranging from verbal to deadly force, but the methods and tools in between will continue to evolve. Figure 7 Injuries from blunt projectiles.
arrest. Autopsy showed she had sustained multiple rib fractures to the left chest, an underlying lung laceration, and heart lacerations that led to significant bleeding into the chest cavity with the cause of death certified as blunt force injuries of chest due to plastic bullet wound (Figure 7). Several studies have looked at the injury patterns from the use of plastic and rubber bullets and all conclude that while generally regarded as less lethal weapons, significant injuries including death can occur when the weapons strike the chest, abdomen, or head. One review evaluated 90 patients who had sustained various bodily injuries, concluded that the eyes, face, skull, bones, and brain are at greatest risk of injury from rubber bullets with the distance at which the rubber bullets resulted in serious injury ranged from 17 to 25 m. Another study reviewing 80 subjects injured by rubber bullets reported that of the four that died, three were from ventricular dysrhythmias secondary to cardiac contusion and one was from a hemopneumothorax. Nineteen other patients who required hospitalization had serious chest wounds. Numerous case reports have reported and documented the hazards and injuries, including deaths, caused by beanbag rounds and other blunt projectiles, like the super sock and 40 mm sponge rounds (Charles et al., 2002; Chute and Smialek, 1998; de Brito et al., 2001; Drazin et al., 2012; Grange et al., 2002; Millar et al., 1975).
Firearms Firearms continue to be a common and important law enforcement tool in the United States. In many agencies, there is a move to decrease the use of deadly force when
See also: Mortality: Statistics. Restraint Techniques, Injuries, and Death: Conducted Energy Devices
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McEwen, T.O.M., Frank, L., 1994. Final Report: Less than Lethal Force Technologies in Law Enforcement and Correctional Agencies. Washington, DC: National Institute of Justice. Millar, R., Rutherford, W.H., Jonston, S., Malhotra, V.J., 1975. Injuries caused by rubber bullets: A report on 90 patients. British Journal of Surgery 62, 480–486. Onnen, J., 1993. Oleoresin Capsicum. Executive Brief, 1. Alexandria, VA: International Association of Chiefs of Police. Punte, C.L., Owens, E.J., Gutentag, P.J., 1963. Exposures to ortho-chlorobenzylidene malononitrile. Archives of Environmental Health 6, 72–80. Reay, D.T., 1998. Death in custody. Clinics in Laboratory Medicine 18, 1–22. Reay, D.T., Eisele, J.W., 1982. Death from law enforcement neck holds. American Journal of Forensic Medicine and Pathology 3, 253–258. Smith, J., Greaves, I., 2002. The use of chemical incapacitant sprays: A review. Journal of Trauma 52 (3), 595–600.
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Steffee, C.H., Lantz, P.E., Flannagan, L.M., Thompson, R.L., Jason, D.R., 1995. Oleoresin capsicum (pepper) spray and “in-custody deaths”. American Journal of Forensic Medicine and Pathology 16 (3), 185–192. Strote, J., Verzemnieks, E., Walsh, M., Hutson, H.R., 2010. Use of force by law enforcement: An evaluation of safety and injury. Journal of Trauma Injury, Infection, and Critical Care 69 (5), 1288–1293. Tezuka, M., 1978. Physiological studies of the Ochi (unconsciousness) resulting from shime-waza (strangle-hold) in judo. Bulletin of the Association for Scientific Studies on Judo, Kodokan Report V, pp. 71−73. Thomas, R.J., Smith, P.A., Rascona, D.A., Louthan, J.D., Gumpert, B., 2002. Acute pulmonary effects from o-chlorobenzylidenemalontrile ‘tear gas’: A unique exposure outcome unmasked by strenuous exercise after a military training event. Military Medicine 167, 136–139.