For many years in emergency medical services (EMS), the treatment of choice for unconscious patients that are breathing is to place them in the recovery position. The idea is to prevent getting emesis (stomach contents) into the lungs, which is a condition known as aspiration. In medical parlance, the recovery position is called the lateral recumbent position, or sometimes it is referred to as the lateral decubitus position. In nearly every case, first aid providers are advised to place the patient on his or her left side and regularly call it the left lateral recumbent position.
How it Works (Supposedly)
The idea for the recovery position is to allow stomach contents to drain out in case anything is regurgitated. The top of the esophagus (the food pipe) is right next to the top of the trachea (the windpipe). If anything bubbles up from the esophagus, it could easily find its way into the lungs, essentially drowning the patient or creating what is known as aspiration pneumonia (an infection of the lungs from foreign material).
The problem with the recovery position is the same as for many other first aid treatments: it sounds good in theory but nobody knows if it really works. There isn’t much money in first aid unless the treatment requires a drug or a piece of specialty equipment. Positioning someone to prevent them from aspirating is absolutely free. Because there’s nothing to gain, very few people do research on things like the recovery position.
Supporting Evidence (There’s Not Much)
We were able to find exactly one study that looked at the effectiveness of different body positions on aspiration. The study is flawed in that it wasn’t actually comparing body positions as a type of treatment. Instead, this study was comparing the outcomes of patients who had overdosed and vomited before anyone got there. The authors looked at how the patient was found and then compared how well each one made out in the long run.
In that study, the recovery position was better than if the unconscious person was lying flat on his or her back, known as supine. However, the best option for protecting the airway—at least according to this one study—was if the patient was prone, lying on his or her belly. It turns out that if you are lying flat with the drain (your mouth) at the lowest point, then the stuff coming out of your gut won’t find its way into your lungs.
Of course, it’s not quite that simple. They were studying happenstance, not a treatment choice made by rescuers. Most of us would hesitate to flop our patient over completely. For one thing, you have to be able to monitor a patient’s breathing and airway if the patient is that sick. It’s really difficult to do that if you have your patient’s face shoved into the ground. Breathing sand isn’t much better than sucking up lunch, as far as survivability goes.
There’s More to an Overdose than Puking
Another study about positioning an overdose patient makes things a bit more complicated still. Just because a patient has swallowed too many pills doesn’t mean he or she has completely absorbed all the potentially dangerous substance. There almost always are undigested capsules and tablets still in the tummy. Another group of researchers measured the effect of body positioning on how quickly those undigested pill parts made their way into the bloodstream. It’s called absorption, and it turns out that our body position has a lot of influence on how fast we digest.
In this study, left lateral decubitus came out on top. Supine was really the winner, but even these authors conceded that bubbling up stomach contents into your lungs defeated the purpose of slowing down absorption in the first place. Putting the patient on his belly was the worst for slowing down the overdose. In the prone position, patients absorbed the pills much faster.
What if the Patient has Heart Disease?
As if the waters weren’t murky enough, there’s one more potential complication to consider. Patients with a form of heart disease known as congestive heart failure (CHF) do not tolerate the recovery position well at all. These folks have problems keeping the blood pumping through the heart and when they lie on their sides, the heart gets more congested than usual.
A third group of researchers compared 14 healthy volunteers with 14 CHF patients (who were also volunteers). Patients with CHF didn’t change too much when they went from sitting to prone or supine. On their sides, however, they had shortness of breath and lots of discomfort.
What it Means for You
You might be more confused now than when you started this article, but that’s the point. A lot of the treatments taught in first aid are based on theory rather than evidence. If it makes sense, that’s how it’s done. Sometimes, the theories are wrong. Sometimes, the evidence is misread and changes how first aid is performed, only to change back once more evidence is published. CPR is a perfect example of the way first aid practice ebbs and flows with the combination of politics, fashion, and a growing body of evidence.
Unlike CPR, the practice of putting unconscious patients in the recovery position hasn’t changed in decades. That might be because aspiration isn’t really all that common in most patients. In fact, aspiration is mostly a problem with elderly dementia patients who have a hard time swallowing.
The recovery position is taught in a very precise way. Some first aid textbooks—and more advanced texts as well—have the rescuer put the patient on his or her side with one leg bent and the head resting on an arm. The real world isn’t precise. Understanding what you need to accomplish is more important than how you do it. Keep stuff out of your patients’ lungs. If that means you roll them almost all the way on their bellies, so be it. Make sure you are watching their breathing and if they stop, roll them back over and start CPR.