Emergency docs on excited delirium: "Yes, it's for real!"
It's now official: In a move strongly supportive of law enforcement, a special investigative task force of the American College of Emergency Physicians has formally declared that the violent and sometimes lethal phenomenon known as "excited delirium" really does exist.
Some police critics have insisted that ED is nothing more than a convenient concept "manufactured" by law enforcement to cover-up brutality and exonerate authorities when a suspect is roughly arrested or dies in custody.
But after a thorough review of available research, the ACEP group affirms in a recent White Paper that ED is "a unique syndrome" that may not be identified in autopsies but that can be recognized in the field by "a distinctive group of clinical and behavioral characteristics." The task force has presented its report to ACEP's directors but at this writing, it has not yet been publicly released. Force Science News obtained a copy after learning of its existence at the recent IACP conference in Denver.
The report makes clear that the psycho-physiological meltdown known as ED is not always fatal. Indeed, given an appropriate collaboration by responding officers and EMS personnel, the condition might be "amenable to early therapeutic intervention," the document speculates.
But, refreshingly, the task force acknowledges the daunting and controversial challenges involved in an ED encounter from a police perspective. "LEOs are in the difficult and sometimes impossible position of having to recognize this as a medical emergency, attempting to control an irrational and physically resistive person, and minding the safety of all involved" in a situation that has "degenerated to such a degree" that authorities have been called to deal with it, the paper states.
"Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS [excited delirium syndrome] subject, any LEO interaction...risks significant injury or death to either the LEO or the ExDS subject." These cases may draw "intense public scrutiny, coupled with the expectation of a perfect outcome. Anything less creates...potential public outrage. Unfortunately, this dangerous medical situation makes perfect outcomes difficult in many circumstances."
"This paper could be the genesis of a new understanding of the complex issues involved in excited delirium," says Dr. Bill Lewinski, executive director of Force Science. "The report is the clearest and most important effort yet to describe the true nature off this syndrome and the kind of difficulties officers encounter in trying to deal with it on the street.
"Law enforcement authorities can use this document as an important reference source for the media and the general public at the time of an ED crisis and can also make it familiar to medical examiners, coroners, and ER physicians who may not be current with the latest professional literature on the subject.
"Within the last 12 months, I encountered a coroner in a major jurisdiction who flatly denied the existence of excited delirium or anything like it. So there is no doubt that the ACEP's findings are timely and desperately needed."
The task force was formed last year in response to increased reports and media coverage of "sudden deaths in severely agitated subjects" and a lack of "clarity and consistency" within the medical community about the nature and causes of these fatalities.
Eighteen emergency physicians and 1 PhD researcher and neurology professor were named to the group, with a mandate to determine whether ED actually exists as an "entity," and, if so, "whether it could be better defined, identified, and treated." Among the task force members was Dr. Matthew Sztajnkrycer, chairman of emergency medicine research at the Mayo Clinic and a technical advisor to the Force Science Research Center.
The group's White Paper is intended to "raise awareness" of ED among the public and medical personnel and to help law enforcement, corrections officers, EMS personnel, and health care providers "identify best practices to deal with this true medical emergency." It includes a bibliography of 58 articles on the subject from professional publications. [Click here to read a report on the White Paper in Emergency Medical News, based on an interview with the group's chair, Dr. Mark DeBard, professor of emergency medicine at Ohio State University College of Medicine.
According to the group's findings, ED, under various names, has been reported in medical circles for more than 150 years, often with a high mortality rate. In the 1980s, "there was a dramatic increase in the number of reported cases," the White Paper says. Most "were found to be associated with the...abuse of cocaine," as well as other illicit stimulant "drugs of abuse," such as meth and PCP. Among cocaine users, an ED onset "usually appears to occur in the context of a cocaine binge that follows a long history of cocaine abuse," the report says.
A history of psychiatric illness is reported in a "distinctly smaller" portion of ED subjects. In these cases, researchers "frequently cite abrupt cessation of psychotherapeutic medications" as an underlying factor; in short, the subject is off his meds.
In all, the task force estimates that some 250 ED subjects die in the US each year, an estimated eight to 14 percent of those who experience the syndrome. Despite circumstantial relationships with stimulant drug abuse, psychiatric disease, psychiatric drug withdrawal, and underlying metabolic disorders, science has not yet determined how these factors lead to excited delirium or why only some cases end in death.
The "typical course" of an ED episode described in published accounts involves "acute drug intoxication, often a history of mental illness (especially...paranoia), a struggle with law enforcement, physical or noxious chemical control measures or electrical control device (ECD) application, sudden and unexpected death, and an autopsy which fails to reveal a definite cause of death from trauma or natural disease," the task force reports.
The paper points out that while "most organized medical associations...and medical coding reference materials...do not recognize the exact term 'excited delirium,' some professional groups do, such as the National Assn. of Medical Examiners. Moreover, references to the syndrome can be found in the International Classification of Diseases under other names, such as manic excitement, delirium of mixed origin, psychomotor excitement, abnormal excitement, and so on.
The semantics issue "does not indicate that ExDS does not exist," the report emphasizes. It only means that "this exact and specific terminology may not yet be [universally] accepted."
What's more consistent are the "common characteristics" observed among subjects in the throes of the syndrome. "These subjects are hyperaggressive with bizarre behavior, and are impervious to pain, combative, hyperthermic [abnormally high body temperature], and tachycardic [rapid heart rate]," the report says.
Officers are likely to find them tirelessly resistant, sweating, breathing rapidly, agitated, unusually strong, and inappropriately clothed (especially nude). "[R]emorse, normal fear and understanding of surroundings, and rational thoughts for safety are absent in such subjects," the report explains.
Like much else about ED, why some subjects exhibiting these symptoms die and others do not is "not fully understood," the task force notes. Some researchers suspect that "chronic stimulant-induced abnormalities of dopamine transporter pathways" in the brain, as well as "elevation of heat shock proteins," may be involved. Others are exploring possible "genetic susceptibility." At the moment, the true significance of any potential causative influence "remains unknown."
It is clear, though, that the "majority of lethal ExDS patients die shortly after a violent struggle" that becomes "more severe than anyone anticipates," the report says. "Many have already sustained traumatic injuries before the arrival of law enforcement and still exhibit intense struggling, even when a struggle is futile and self mutilation is a result." The subject may experience a "sudden collapse after restraint" and lapse into a "period of tranquility" or "giving up" shortly before dying. Even "aggressive resuscitation" efforts may then prove unsuccessful.
Expecting an ED encounter to be resolved without a potentially fatal struggle may be asking the near impossible of responding officers. As the task force acknowledges: "[A]lmost everything taught to LEOs about control of subjects relies on a suspect to either be rational, appropriate, or to comply with painful stimuli. Tools and tactics...(such as pepper spray, impact batons, joint lock maneuvers, punches and kicks, and ECDs, especially when used for pain compliance) that are traditionally effective in controlling resisting subjects, are likely to be less effective on ExDS subjects.
"When methods such as pain compliance maneuvers or tools of force fail, the LEO is left with few options. It is not feasible for them to wait for the ExDS subject to calm down, as this may take hours in a potentially medically unstable situation fraught with scene safety concerns."
Two resolution possibilities that most officers would consider would be a physical "swarming" of the subject if sufficient manpower is available or the firing of a Taser. Unfortunately, the task force does not offer recommendations or even a listing of pros and cons regarding these specific options. Nor does it address the controversy regarding Tasering and in-custody deaths.
A member of the task force told Force Science News that there was "much debate" about these issues, but that the final consensus seemed to be that "we should not dictate to cops what to do. We are physicians, not use-of-force experts." Sztajnkrycer explains: "The purpose of the report was to emphasize rapid medical recognition" of the syndrome.
The report says simply that "Some of the goals of LEOs in these situations should be to 1) recognize possible ExDS, contain the subject, and call for EMS; 2) take the subject into custody quickly, safely, and efficiently if necessary; and 3) then immediately turn the care of the subject over to EMS personnel when they arrive for treatment and transport to definitive medical care."
Because "control measures are a prerequisite for medical assessment and intervention," the report goes on, "this should be accomplished as rapidly and safely as possible...[i]n subjects who do not respond to verbal calming and de-escalation techniques.... Recent research indicates that physical struggle is a much greater [potential danger] than other causes of exertion or noxious stimuli.... [S]pecific physical control methods employed should optimally minimize the time spent struggling, while safely achieving physical control. The use of multiple personnel with training in safe physical control measures is encouraged."
And: "There are well-documented cases of ExDS deaths with minimal restraint such as handcuffs without ECD use. This underscores that this is a potentially fatal syndrome in and of itself, sometimes reversible when expert medical treatment is immediately available."
Once the subject is handed off to EMS, "Officers should attempt to ensure that the tactile temperature of these subjects is documented and request EMS to measure it," the report advises. "In fatal cases, a significantly elevated temperature may suggest that a life-threatening disease or condition was present" and that any death that might result "was independent of the police intervention."
Once in EMS care, the subject is probably best sedated immediately and cooled as quickly as possible "to reduce the risk of death," the task force suggests. "As with any critically ill patient, treatment should proceed concurrently with evaluation for precipitating causes or additional pathology" while the crew is en route to a medical facility. "The risk of death is likely increased with physiologic stress [so] attempts to minimize such stress are needed in the management of these patients," the report says.
At this time, the White Paper concludes, there is "insufficient data...to determine whether fatal ExDS is preventable, or whether there is a point of no return after which the patient will die regardless of advanced life support interventions."
The task force recommends several goals for the future to expand the understanding of ED. These include: studies to "identify susceptibility genes," more research into "the role of law enforcement control techniques and devices in the death of subjects," the establishment of a national "report registry" to compile documentation about fatal and nonfatal known and suspected ED cases, and research that would lead to "field protocols and techniques that allow police, EMS, and hospital personnel to interact with these agitated, aggressive patients in a manner safe both for the patients and the providers....
"While many of the current deaths from ExDS are likely not preventable, there may be an unidentified subset in whom death could be averted with early directed therapeutic intervention."
Only more research and greater understanding of the intricacies of this vexing condition will tell.
NOTE: What Dr. Lewinski describes as "the best swarming technique that can be used in an ED situation" is the Star Tactic, developed by FSRC board member and internationally known DT trainer Gary Klugiewicz.