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Pictures of Fatal Bedrail Entrapment

TO THE EDITOR: Bedrails are widely used in the care of patients staying in hospitals and nursing homes. It is not known whether bedrails decrease the patient's risk of falling or whether they increase the patient's chance of injury from falling over or through them.¹ It is known that entrapment in bedrails can lead to death, but such deaths have been difficult to study. Sketches of lethal bedrail entrapments have been based on brief written reports.

FIGURE 1A. The patient's leg is moving off the bed into the space between the upper and lower bedrails.

FIGURE 1B. The patient is sliding into the space between the upper and lower bedrails.

We are not aware of published photographs that could help physicians, bed manufacturers and policymakers understand how these deaths occur or how to prevent them. Decedents are often moved before their deaths can be photographed. We report here two cases of death by bedrail entrapment. In the first case, a video camera mounted on the ceiling with a digital clock inset inadvertently taped the death of the patient. In the second case, the death was documented by a coroner's photograph. Line drawings accompanying these case reports depict the scenario of these deaths, based on the videotape and the coroner's photograph.

In Case 1, an obtunded patient with a traumatic head injury died of asphyxiation. Videotape frames show two phases of movement: the patient leaving the bed and the patient becoming entrapped in the bedrail. Figure 1a shows the patient's left leg moving off the bed and into the space between the upper and lower bedrails. Figure 1b shows the patient's torso sliding into the slot between the upper and lower bedrails. The tape shows that once the patient's legs were in the slot, the raised head of the bed allowed the patient to slide into the slot. After the patient's pelvis moved off the bed, his weight pulled him into the space between the upper bedrail and the mattress frame.

Figure 1c shows the final position of the patient, in which the patient is suspended with his thorax lodged and compressed in a 6-inch gap between the upper bedrail and the mattress frame. Ten minutes elapsed between the time that the nurse last centered the patient on the bed and the time that the patient became positioned as shown in Figure 1a. Two more minutes passed from the time the patient was in the position in Figure 1a to the time that he was in the position shown in Figure 1c. The patient was found asphyxiated 14 minutes after reaching the position in Figure 1c, and resuscitation efforts failed.

Case 2 involved a confused, agitated, small elderly person who died afer sliding between the mattress and the bedrail. Figure 2 shows the patient's torso compressed in the space between the bedrail and the mattress, with the buttocks hanging above the floor. With the mattress pressed against the opposite bedrail, the space was only 4 inches wide.

FIGURE 1C. The patient is suspended with the thorax lodged and compressed in a 6-inch gap between the upper bedrail and the mattress frame.

FIGURE 2. The patient is found asphyxiated. Her torso is compressed between the bedrail and the mattress.

The patient in Case 2 had fallen from her bed on several previous occasions. On two occasions shortly before her death, the patient was found trapped by the bedrail. The patient had been monitored with a string-type position alarm that sounds when a patient moves out of position and pulls a cord out of an alarm box. The alarm did not sound during her death because the string was not pulled out of the alarm box. The alarm failed during a previous bedrail entrapment when the alarm box was pulled from the headboard and dragged across the mattress. The patient did not use the nurse call signal (seen hanging over the bedrail) before this or previous falls.

These cases illuminate how bedrail deaths occur. The U.S. Food and Drug Administration, along with studies of bedrail and restraint deaths, emphasizes that confused, agitated people who behave impulsively are at an especially high risk of entrapment.^2-4 The patient in Case 1 was semiconscious; the patient in Case 2 was confused. Both were impulsive and actively mobile. Both had experienced "rehearsal incidents" with nonlethal bedrail entrapments shortly before their deaths. These are very common occurrences before deaths that are related to physical restraints³ and should prompt swift, fundamental modification of the bed environment for the patient's safety.

These events show that the ability to prevent such deaths, given the present design of beds, is limited. Restraints may cause asphyxiation by themselves and do not prevent lethal entrapment in bedrails.^3-5 Lethal entrapment can occur with a single half-bedrail, split bedrails or a full-length rail. The string alarm in Case 2 did not alert medical staff to the entrapment. It is very difficult to gauge the safety of bed proportions. The space between the bedrails and the bed frame in these cases was 6 and 4 inches. Regular monitoring will not prevent these deaths as evidenced by the rapidity of events in Case 2. Neither bed had a weight-position sensor; perhaps rapid response to such alarms may prevent some deaths.

Overall, prevention of these types of deaths will require much more judicious use of bedrails, swift and effective changes for patients at high risk of entrapment, and fundamental changes in the design of the bed environment.

STEVEN MILES, M.D. KARA PARKER
University of Minnesota
Center for Bioethics
Ste. N504 Boynton
410 Church St. SE
Minneapolis, MN 55455-0346

REFERENCES

1. Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797-802.
2. Center for Devices and Radiological Health. FDA safety alert: entrapment hazards with hospital bed side rails. August 23, 1995. http://www.fda.gov/cdrh/bedrails.html.
3. Miles S. A case of death by physical restraint: new lessons from a photograph. J Am Geriatr Soc 1996; 44:291-2.
4. Miles SH, Irvine P. Deaths caused by physical restraints. Gerontologist 1992;32:762-6.
5. Rubin BS, Dube AH, Mitchell EK. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993;2:405-8.

Figures 1 and 2 were supplied by Media Productions, 125 SE Main St., Minneapolis, MN 55414. Graphics work supported by a grant from Untie the Elderly®, a program of the Kendal Corporation, P.O. Box 100, Kennett Square, PA 19348. Dr. Miles is supported as an Open Society Institute Faculty Scholar for the Project on Death in America.

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Sickle Cell Trait and Sudden Death in Athletes

TO THE EDITOR: I would like to commend Dr. O'Connor and colleagues on an excellent review of sudden death in athletes.¹ The authors point out the importance of preparticipation cardiovascular screening in young athletes. However, the association between sudden death and sickle cell trait² is not addressed in this article.

The prevalence of sickle cell trait is 8 percent in blacks.³ In one study,³ a 50 percent prevalence of sickle cell trait was found among black military basic trainees with exertional sudden death. Risk factors for sudden death associated with sickle cell trait include heavy exercise with poor physical conditioning, dehydration, increased ambient temperature and training at high altitudes.³

No specific recommendations exist for screening of the general population or for limitation of activities in athletes. The American College of Sports Medicine and the National Collegiate Athletic Association have published guidelines on the screening and counseling of individuals who may have sickle cell trait.⁴ They recommend that team physicians and athletic trainers familiarize themselves with the literature on sickle cell trait, as well as counsel patients with sickle cell trait on dehydration, acclimatization, physical conditioning, training at high altitudes and exercise during acute illness.⁴ Screening for sickle cell trait has additional relevance in family planning and genetic counseling. The association between sickle cell trait and sudden death might also be considered by physicians performing preparticipation physical examinations and managing athletes with exertional collapse.

P. SHAWN HOLMES, D.O.
KAREN K. KERLE, M.D.
CRAIG K. SETO, M.D.
Fort Benning Heat Emergencies in Army Troops (H.E.A.T.) Research Group
Martin Army Community Hospital
Fort Benning, GA 31907

REFERENCES

1. O'Connor FG, Kugler JP, Oriscello RG. Sudden death in young athletes: screening for the needle in a haystack. Am Fam Physician 1998;57:2763-70.
2. Kerle KK, Nishimura KD. Exertional collapse and sudden death associated with sickle cell trait. Am Fam Physician 1996;54:237-40.
3. Kark JA, Posey DM, Schumacher HR, Ruehle CJ. Sickle-cell trait as a risk factor for sudden death in physical training. N Engl J Med 1987;317:781-7.
4. American College of Sports Medicine. Active individuals with sickle cell trait. Current Comments October 1997.

IN REPLY: We would like to thank Drs. Holmes, Kerle and Seto for their kind comments, as well as for addressing an important omission in our article.

We are currently working with Dr. Kark to review 20 years of nontraumatic sudden deaths in military basic training. Our preliminary review, which is unpublished, demonstrates that heat stroke, not hypertrophic cardiomyopathy, appears to be the principal cause of death in this population.

The issue of screening for sickle cell trait, as was pointed out by Drs. Holmes, Kerle and Seto, is controversial. The ramifications of screening on participation in athletics or military service raise even more questions.

We feel that "universal precautions" should be applied to all soldiers and athletes, regardless of their sickle cell trait status. We agree with Drs. Holmes, Kerle and Seto that these precautions should include careful attention to acclimatization, proper hydration and modification of exercise with altitude and illness.

FRANCIS G. O'CONNOR, M.D.
JOHN P. KUGLER, M.D.
RALPH G. ORISCELLO, M.D.
Department of Family Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Rd.
Bethesda, MD 20814-4799

Copyright 1998 by the American Academy of Family Physicians.
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