A Medical Perspective on the Garner Tragedy

When the initial news of the death of Eric Garner occurred, it seemed a minor occurrence – very important to Mr. Garner and his family, but not a major national event.  Now it has become the genesis of nationwide mindless protests, over the supposedly lethal and irresponsible actions of a New York policeman and the subsequent decision of a Grand Jury to decline an indictment.

Having reviewed the video several times now, and being a physician who specialized in the surgery of the very obese, I believe that the cause of Mr. Garner's death was not "police brutality" or negligence, but rather the unfortunate synergy between his disease of morbid obesity and actions most police perform countless times with only transient discomfort to the arrestee.  The decision of the Grand Jury was reasonable.

Mr. Garner's demise was the consequence of a confluence of many factors, most of which were beyond the ken of a policeman, and which occurred in devastatingly rapid sequence.

Eric Garner was very obese, said to weigh at least 350 pounds.  In fact, based upon his height and appearance, he very likely weighed more than that, but very few bathroom scales read high enough to accurately measure weight of that magnitude.  By simple observation, one could see that his abdomen was very large and protuberant.  His chest was similarly blanketed with a heavy layer of fat, and he had no visible neck – no indentation under his jaw, typically present in non-obese persons, which permits application of a "chokehold," to briefly arrest the carotid circulation to render him unconscious and manageable.  The chokehold was ineffective as a control, but it served to take him to the ground by leverage.

Medically, he was said to suffer from sleep apnea, and he may well also have Pickwickian Syndrome (less picturesquely, "Obesity-hypoventilation syndrome"), which can cause resting hypoxia; low blood oxygen levels, even at rest; and altered physiological responses to high levels of carbon dioxide in the blood.  These conditions in turn lead to congestive heart failure and to sporadic loss of consciousness.  Yet another diagnosis was acute and chronic bronchial asthma, which can be activated by any acute stress, and which would further impair his respiration.

An obese male of Mr. Garner's size has enormously powerful muscle strength.  Just lifting himself out of a chair requires pressing 350 lbs.!  His legs each lift at least 350 lbs. with every step.  He was almost certainly far stronger than any of the officers attempting  to arrest him, and that required that they exert significant force to subdue him.

The tragedy developed as follows:

  • The squad of officers who sought to arrest Garner was under the supervision of a sergeant who was black and female, and was therefore very unlikely to be racially motivated.
  • Mr. Garner was being placed under arrest for a tax law violation related to the sale of untaxed cigarettes – a trivial offense.
  • However, Mr. Garner actively resisted arrest, and that criminal offense forces the police to assert their authority, regardless of the gravity of the original crime  (next time you get a traffic ticket, refuse to sign it, and see what happens to you).
  • Officer Pantaleo can be seen in the video placing his left arm alongside Mr. Garner's neck, and encircling his neck with his right arm.  However, there is no impression of Pantaleo's arm under Garner's chin, as is necessary for an effective carotid occlusion.
  • The effect of Pantaleo's effort was to unbalance Garner, causing him to fall to the ground, with Pantaleo winding up on top of him.  At this point, Pantaleo can clearly be seen to release his ineffectual "chokehold" and to (roughly) hold Garner's head to the pavement while the other officers subdue him.
  • It was after Pantaleo had released his hold that Garner uttered, "I can't breathe!" several times.  Garner was still alive and conscious after Pantaleo released him from the "chokehold" that supposedly (by overwhelming popular opinion) was responsible for his death!
  • Mr. Garner was subdued by other officers who placed their weight on his body in order to wrest his arms behind him to apply handcuffs.
  • Mr. Garner's chest capacity (vital capacity) was already seriously compromised by his obesity.  An officer's weight on his chest would further diminish his lung capacities.
  • Pressure on Mr. Garner's abdomen, also exerted to subdue him, forced the enormous fatty contents of his abdomen to be pushed upward toward his chest, restricting his diaphragmatic motion, adding another factor that reduced his ability to breathe.  He was barely able to inhale enough air to gasp, "I can't breathe!"
  • A normal and healthy male would have been transiently distressed by the actions of the arresting officers.  Mr. Garner had no margin of safety, no reserve at all, and was precariously unstable even before he was accosted.  The actions of the arresting officers, undoubtedly used many times before without significant ill effect, combined with Garner's pathophysiology to rapidly produce hypoxia, very likely aggravated by carbon dioxide retention and narcosis, which suppresses the normal reflex to breathe.  This was rapidly followed by cardiac arrhythmia and death.

Unfortunately, when Mr. Garner became unconscious from hypoxia and carbon dioxide narcosis, the officers appeared bewildered and evidently did not realize that Mr. Garner was rapidly dying from cessation of his breathing and then of his cardiac activity. 

The subsequent post-mortem examination is said to have shown no evidence of injury to either the larynx or the hyoid bone, which is almost always fractured in cases of strangulation.  Mr. Garner is said to have died from "chest compression" and associated heart disease.

Few persons, undoubtedly including most police officers and even Mr. Garner, would understand the gravity and complex pathophysiology of this condition, and the rapidity with which it can become irreversible, unless an airway and mechanical ventilation can be quickly administered – and establishing an airway in a very obese person is itself extremely challenging even under ideal conditions, such as in an operating room, let alone on the sidewalk. 

Eric Garner's death had essentially nothing to do with racism or racial animosity, particularly when one can see an African-American female sergeant, in charge at the scene, standing and observing the arrest in the background.  Ultimately, as the senior officer on the scene, she was responsible for Mr. Garner's safety, although it would be unreasonable to incriminate her, either, given the obscure physiology of the chain of events that led to his unfortunate demise. 

Needless to say, the facts will have little influence on racial demagogues, such as Al Sharpton and President Obama, as they seek to racially divide our nation and generate racial hatred.

When the initial news of the death of Eric Garner occurred, it seemed a minor occurrence – very important to Mr. Garner and his family, but not a major national event.  Now it has become the genesis of nationwide mindless protests, over the supposedly lethal and irresponsible actions of a New York policeman and the subsequent decision of a Grand Jury to decline an indictment.

Having reviewed the video several times now, and being a physician who specialized in the surgery of the very obese, I believe that the cause of Mr. Garner's death was not "police brutality" or negligence, but rather the unfortunate synergy between his disease of morbid obesity and actions most police perform countless times with only transient discomfort to the arrestee.  The decision of the Grand Jury was reasonable.

Mr. Garner's demise was the consequence of a confluence of many factors, most of which were beyond the ken of a policeman, and which occurred in devastatingly rapid sequence.

Eric Garner was very obese, said to weigh at least 350 pounds.  In fact, based upon his height and appearance, he very likely weighed more than that, but very few bathroom scales read high enough to accurately measure weight of that magnitude.  By simple observation, one could see that his abdomen was very large and protuberant.  His chest was similarly blanketed with a heavy layer of fat, and he had no visible neck – no indentation under his jaw, typically present in non-obese persons, which permits application of a "chokehold," to briefly arrest the carotid circulation to render him unconscious and manageable.  The chokehold was ineffective as a control, but it served to take him to the ground by leverage.

Medically, he was said to suffer from sleep apnea, and he may well also have Pickwickian Syndrome (less picturesquely, "Obesity-hypoventilation syndrome"), which can cause resting hypoxia; low blood oxygen levels, even at rest; and altered physiological responses to high levels of carbon dioxide in the blood.  These conditions in turn lead to congestive heart failure and to sporadic loss of consciousness.  Yet another diagnosis was acute and chronic bronchial asthma, which can be activated by any acute stress, and which would further impair his respiration.

An obese male of Mr. Garner's size has enormously powerful muscle strength.  Just lifting himself out of a chair requires pressing 350 lbs.!  His legs each lift at least 350 lbs. with every step.  He was almost certainly far stronger than any of the officers attempting  to arrest him, and that required that they exert significant force to subdue him.

The tragedy developed as follows:

  • The squad of officers who sought to arrest Garner was under the supervision of a sergeant who was black and female, and was therefore very unlikely to be racially motivated.
  • Mr. Garner was being placed under arrest for a tax law violation related to the sale of untaxed cigarettes – a trivial offense.
  • However, Mr. Garner actively resisted arrest, and that criminal offense forces the police to assert their authority, regardless of the gravity of the original crime  (next time you get a traffic ticket, refuse to sign it, and see what happens to you).
  • Officer Pantaleo can be seen in the video placing his left arm alongside Mr. Garner's neck, and encircling his neck with his right arm.  However, there is no impression of Pantaleo's arm under Garner's chin, as is necessary for an effective carotid occlusion.
  • The effect of Pantaleo's effort was to unbalance Garner, causing him to fall to the ground, with Pantaleo winding up on top of him.  At this point, Pantaleo can clearly be seen to release his ineffectual "chokehold" and to (roughly) hold Garner's head to the pavement while the other officers subdue him.
  • It was after Pantaleo had released his hold that Garner uttered, "I can't breathe!" several times.  Garner was still alive and conscious after Pantaleo released him from the "chokehold" that supposedly (by overwhelming popular opinion) was responsible for his death!
  • Mr. Garner was subdued by other officers who placed their weight on his body in order to wrest his arms behind him to apply handcuffs.
  • Mr. Garner's chest capacity (vital capacity) was already seriously compromised by his obesity.  An officer's weight on his chest would further diminish his lung capacities.
  • Pressure on Mr. Garner's abdomen, also exerted to subdue him, forced the enormous fatty contents of his abdomen to be pushed upward toward his chest, restricting his diaphragmatic motion, adding another factor that reduced his ability to breathe.  He was barely able to inhale enough air to gasp, "I can't breathe!"
  • A normal and healthy male would have been transiently distressed by the actions of the arresting officers.  Mr. Garner had no margin of safety, no reserve at all, and was precariously unstable even before he was accosted.  The actions of the arresting officers, undoubtedly used many times before without significant ill effect, combined with Garner's pathophysiology to rapidly produce hypoxia, very likely aggravated by carbon dioxide retention and narcosis, which suppresses the normal reflex to breathe.  This was rapidly followed by cardiac arrhythmia and death.

Unfortunately, when Mr. Garner became unconscious from hypoxia and carbon dioxide narcosis, the officers appeared bewildered and evidently did not realize that Mr. Garner was rapidly dying from cessation of his breathing and then of his cardiac activity. 

The subsequent post-mortem examination is said to have shown no evidence of injury to either the larynx or the hyoid bone, which is almost always fractured in cases of strangulation.  Mr. Garner is said to have died from "chest compression" and associated heart disease.

Few persons, undoubtedly including most police officers and even Mr. Garner, would understand the gravity and complex pathophysiology of this condition, and the rapidity with which it can become irreversible, unless an airway and mechanical ventilation can be quickly administered – and establishing an airway in a very obese person is itself extremely challenging even under ideal conditions, such as in an operating room, let alone on the sidewalk. 

Eric Garner's death had essentially nothing to do with racism or racial animosity, particularly when one can see an African-American female sergeant, in charge at the scene, standing and observing the arrest in the background.  Ultimately, as the senior officer on the scene, she was responsible for Mr. Garner's safety, although it would be unreasonable to incriminate her, either, given the obscure physiology of the chain of events that led to his unfortunate demise. 

Needless to say, the facts will have little influence on racial demagogues, such as Al Sharpton and President Obama, as they seek to racially divide our nation and generate racial hatred.