Behind the headlines about excited delirium; what cops & EMS need to know
Editor’s note: Please share this article with all local emergency medical services personnel
Three truths are becoming clear about excited delirium, the perplexing and violent human meltdown that is increasingly confronting LE and EMS personnel as a menacing problem.
These critical facts were the core of a frank debriefing by ED authority Dr. Michael Curtis, attended by PoliceOne and an audience of firefighters, LE officers, EMTs and hospital ER personnel at Waukesha County Technical College near Milwaukee. Curtis, an EMS medical director and an advisor to the Wisconsin Law Enforcement Standards Board, will be featured in a roll call training package on ED that the state’s Department of Justice is preparing.
"We have been lulled into a sense of security about medication taking care of psychiatric problems," Curtis stated. "But now we’re seeing an increasing number of people who stop taking their meds, along with a rise in methamphetamine and cocaine use." That baleful blend, in his opinion, means "we’re going to see more and more and more ED confrontations. Major cities may see more than rural areas, but it can strike anywhere."
Much about ED remains a mystery, although the syndrome has been recognized since 1849 or earlier. Modern experience shows that the typical encounter with first responders begins with an "agitated, excited" adult male creating a disturbance, triggering a call to 911.
As Curtis describes it, the subject will exhibit confused, disoriented ("Where am I?") and bizarre behavior that has begun abruptly ("He just snapped, out of the blue!" witnesses may exclaim.). This may include visual or auditory hallucinations, distortions (he may interpret benign noises as gunshots, for example), signs of "unusual fear," and violence directed at objects, especially shiny items and glass.
Hyperthermia (overheating) may be spiking his body temperature from 105 to 113 degrees, so he’s often sweating profusely, although perspiration may cease "in the later phases of the emergency." Frequently ED subjects will be tearing at their clothing or already be partially or totally naked. When police arrive, they probably find the subject "yelling and screaming," with emotions very unstable ("all over the place") and attention span "very short."
Typically a struggle ensues when officers try to restrain him. Because he has "superhuman strength and insensitivity to pain," multiple officers probably get involved ("It may take six to displace him."). He continues to fight even after restrained. Typically, he’s "transported in a police vehicle to jail."
He dies in custody. And the police, police tactics and police equipment are blamed.
[For more details on ED, Curtis recommended that responders consult the PoliceOne Web site, where a number of authoritative reports on the subject are archived. Another resource is the Institute for the Prevention of In-Custody Deaths, headed by Dr. John Peters Jr. (www.ipicd.com).]
Curtis then explained what often doesn’t make the headlines:
Intervention and survivability
Researchers in Los Angeles County studied 18 cases in which ED subjects were placed not in a police vehicle but in an ambulance after being restrained, with paramedics monitoring them. Despite cardiac treatment, all died, and all attempts at resuscitation failed.
Once their body crash begins and "they go over the edge, there is [generally] no bringing them back," Curtis said. Paramedics may try "every trick they have up their sleeve" to no avail. "ED creates some kind of profound derangement of underlying physiology," and in the vast majority of known cases subjects "can’t be resuscitated by any means." Whatever the intervention, "they usually die anyway."
Those who do happen to survive "often have severe medical problems for weeks afterward, including muscle breakdown and kidney failure that may require dialysis," Curtis reported.
The blame game
An autopsy typically shows that the subject suffered "minimal injury from the police confrontation," and that he had "illicit stimulant drugs" in his system. Because of the ineffectiveness of OC, baton strikes and other pain-compliance measures, a Taser may have been used to control his combativeness.
"The news media have implied a cause-and-effect relationship between Tasers and in-custody deaths," including those involving ED. But, Curtis asserted, "if you search the medical literature, there is no scientific evidence to date" that such a relationship exists.
Nor, he said, is there valid evidence that the way these subjects were restrained caused death via so-called positional asphyxia or hog-tying.
"If you [conduct a Web search for] ‘Taser and death,’ you’ll find news articles from all over the U.S., and the headline is always the same: ‘Dies After Being Stunned by Taser,’" Curtis said. "Cause-and-effect is assumed, but that is a fallacy of logic. Even though ‘B’ came before ‘C’ doesn’t mean that ‘B’ caused ‘C,’ especially if an alternative explanation, ‘A,’ better explains the result" ("A," in this case, being the nature of ED itself).
"Several forensic pathology studies" have confirmed that ED "is an imminently life-threatening medical emergency" that can produce fatal consequences, Curtis said. In short, the ED subject is already a medical mess before responders arrive.
"Because of pathology going on in his brain, his body can’t cool itself and his temperature just keeps shooting up" toward lethal levels. This is aggravated by his extreme physical activity (agitation and violence) and by dehydration.
Disruption of the subject’s metabolic functions, particularly a dangerous lowering of his blood’s acidity (pH) level, tends also be a significant characteristic of violent activity and dehydration — and of ED, Curtis explained. "The body works best within a narrow range of pH;" outside that range, there may be dire consequences.
Less clear but also a common associated factor in ED deaths is the subject’s "noncompliance with medications to control psychosis or bipolar disorder," Curtis said. Perhaps the effects of sudden withdrawal without being under medical supervision has placed these people "more at risk."
The dominant cause underlying this physiological chaos, Curtis said, is most often "stimulant drug abuse. A characteristic pattern is binging for two to four days before the ED episode. Acute intoxication with one of the stimulants — cocaine, meth, PCP — triggers the event" and sets the subject up for a calamitous outcome.
Mix into all this possible contributory health threats such as obesity, diabetes and heart disease, and you have a subject who’s "on a freight train to death," Curtis said, quoting a phrase coined by Sgt. Dennis Angle of Waukesha, Wis., Police Department.
In some cases, Curtis acknowledged, coroners or medical examiners have blamed Tasering for ED deaths, "but when subjected to scrutiny these determinations have not held up." The ED syndrome itself "is the underlying reason for these people dying, not intervention. So far, no one has been able to show a pathophysiological pathway from Taser to death."
When a dispatcher or officer perceives symptoms that may suggest ED, EMS should be sent to the scene immediately. They and law enforcement should coordinate efforts to give the subject the best chance for surviving. That means transporting him ASAP to a medical facility, not initially to jail. "The criminal prosecution can wait," as Curtis put it, "but the medical emergency will not wait."
Describing the EMS-LE relationship, Curtis noted that "the first goal of therapy is to control violent behavior." In other words, the medics can’t help until the cops get the subject restrained.
"Attempts at verbal de-escalation probably will not work," Curtis said. Containment with lots of backup, use of a Taser (ideally before a violent struggle ensues, if possible) and/or multi-officer physical control will most likely be necessary.
Soft restraints from EMS, controlling the hands, limbs and chest, should be maintained in the ambulance during transport, with an officer riding along for security in case a determined subject breaks loose. A spit net should be placed over the subject’s head, as well.
In jurisdictions where it’s permitted, Curtis recommended that EMS personnel administer "a tranquilizer by thigh or butt injection that is rapidly effective with the first dose and that carries no adverse side effects." Otherwise, the subject will continue to struggle, worsening his prospects.
In his opinion, "the ultimate drug of choice" in this regard is ketamine, used in tranquilizer dart guns. It can be effective in less than 5 minutes. But note: "Ketamine has never been studied for use under these circumstances," raising possible liability concerns. Other possibilities are benzadiazepines, neuroleptics and atypical antipsychotics, but drugs in these groups require longer (up to 10 to 15 minutes) to begin to take effect.
A rectal temperature reading should also be taken right away to document the subject’s status at the start of intervention. (Later, if he dies, his brain should be harvested within 12 hours of death so an expert analysis can be conducted by a specialized laboratory that "can identify changes in brain chemistry that are characteristic of ED.")
"The second goal of therapy is to stabilize the underlying psychological and physiological problems," Curtis said. EMS, if permitted, can attempt this during transportation by cooling the subject by misting and fanning his body or by applying ice packs in the groin and armpits and working to correct his dehydration and metabolic acidosis with IV fluids. Some experts suspect that ED subjects may be experiencing dangerously high potassium levels, which can also be addressed.
"Head for the nearest hospital, if your ‘preferred’ one is a lot farther away," Curtis advised. The ER should be alerted to "stand by for a violent patient." Ideally ER personnel need to be educated about ED well in advance of an episode. "Sometimes cops bring these people to the ER, they’re combative, the ER personnel say, ‘Get ’em out of here, take ’em to jail,’" Curtis laments, and the opportunity for potentially helpful medical attention goes down the tubes.
Curtis urged law enforcement to "stimulate dialog" with EMS services and hospitals in their jurisdiction and "work together to develop a collaborative protocol" to deal with agitated, combative patients of the ED type. Unfortunately, such protocols "are not widely available at this point."
In locations where he has helped to work out LE-EMS protocols and to educate local medical examiners about ED, he has then gone "to the press and explained what has been done and why," providing a thorough walk-through of what’s known about the problem. "If you do this," he said, "the press may be easier on you if you have a person die in custody."
[Note: Dr. Curtis can be reached at email@example.com or by phoning (715) 393-2529. Our thanks to the Criminal Justice/Law Enforcement division of Waukesha County Technical College for providing access to his presentation.]
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