with Chris Lawrence
What other medical emergencies can look like excited delirium?
By Chris Lawrence
Excited delirium (ED) has become a high profile problem in policing. There is much for us to learn about ED; however, there are some other medical problems that officers may encounter that can result in behavior very similar to a person experiencing ED. Not everyone exhibiting “ED-like” behavior is a substance abuser (although I have included a substance abuse example in this column – the DTs) or a person living with a mental illness. While police officers cannot make a diagnosis, (society only allows physicians to do that) we need to know a little bit about these other problems, particularly because we may encounter them in our patrol activities. Each problem can result in a fatal outcome even if properly handled.
Bottom line here is for anything that resembles ED, subjects should be assessed by someone with medical training beyond that of a police officer. When handling these types of situations, get the subject to medical assistance. In some ED-like situations, drawn out negotiations or waiting for the subject to calm down may not be in the best interest of the subject.
In past columns I used medical texts and research journals for reference documents. In this article I’m using (for the most part) material accessible by the average person so that interested parties can quickly find reliable material without needing access to a university or medical library. Readers should not consider the information as training or medical advice. This effort is intended to inform and hopefully stimulate further local investigation of this information so that with appropriate medical guidance, officer training can be enhanced.
Normal body temperature hovers around 37 degrees Celsius (98.6 degrees Fahrenheit) and fluctuates slightly throughout the day. The mechanisms involved in how the body accomplishes this feat is beyond the scope of this article. In simple terms the human body has a number of feedback mechanisms which allow it to create heat when we are cold and dissipate heat when we are getting too warm (Hoppe & Sinert, 2005).
High body temperatures or hyperthermia can create problems that can appear similar to intoxication, and in some cases can even appear very similar to ED. People with high body temperature usually are sweating. In some cases, due to medication side effects, the subject may have both hyperthermia and hot dry flushed skin. What this means is that the subject may be sweating less than normal or not at all (Challoner, & Newton 2006). This may cause disorientation.
Medications commonly used to treat disorders such as gastrointestinal cramps, urinary bladder spasm, asthma, motion sickness, and muscular spasms can increase the susceptibility to hyperthermia and the same hot, dry skin (The Gale Group, 2005).
Problems for the subject can begin to occur at 39 degrees Celsius (102oF). Heat stroke occurs at 43.7o C (110o F). Brain cells are affected and may be destroyed. Around this temperature the subject’s ability to regulate his or her own heat is likely to fail. Death will occur at 44.4o C (112o F). Early medical assistance is vital when dealing with hyperthermia.
There was a case I mentioned in my last column where the subject left work after a very hot morning because he wasn’t feeling well. While traveling home on the bus he “acted like a crazy man” and had to be restrained by other transit riders. He was taken to hospital where he was sedated and secluded, the physician believing him to be a psychiatric patient. It was later discovered that he had overheated at work and his behavior was the result of hyperthermia (Armstrong, 2003). Even the physician treating the subject didn’t appreciate the real problem at first.
Hyperthermia can be a medical emergency that is treatable by paramedics, nurses and physicians by taking measures to produce rapid cooling of the body. Asking medical personnel to take the subject’s temperature could become the most important contribution you make to the safety of the subject who has been struggling against your efforts to gain control. New equipment allows a “core equivalent” temperature to be taken in seconds, according to research provides a reliable temperature, is non-invasive, and therefore less risky has been the case when older methods of obtaining a core temperature than in the past.
Delirium Tremens is also known as the DTs or alcohol withdrawal. Delirium Tremens can result from an alcoholic person suddenly stopping the use of alcohol, particularly when they are not eating properly. The subject may experience sudden and severe mental changes which may also involve seizures. Symptoms commonly occur within the first 72 hours of the last drink. In some cases the subject may show his or her signs up to 7-10 days after their last drink.
Other signs and symptoms may include:
• Rapid emotional changes;
• Paranoia (may lead to lashing out) and;
These symptoms may be severe and progress rapidly.
Delirium Tremens can be a fatal condition (30%) if not treated properly. The DT’s constitute a medical emergency. People experiencing the DT’s are to be taken directly to a hospital for treatment (Owens, 2005; Grossman, 2005).
Psychotic illness and its treatment are associated with an increased risk of diabetes and worsening blood sugar control (Lambert & Chapman, 2004, p.544). Regardless of whether or not the subject has a mental illness, low blood sugar may precipitate sudden mood swings that could appear as sudden anger or crying, sweating, nervousness, rapid heart beat, confusion, and seizures. Aggressive behavior may appear similar to ED-type behavior (Padder, Udyawar, Azhar, & Jaghab, 2005), particularly if the officer has never dealt with a subject experiencing ED before. If low blood sugar continues to drop the subject may go into a coma and die (Cronin, 2005).
Not every person who has low blood sugar levels will exhibit ED-type behavior. In fact, the landmark case of Graham v. Connor involved a person experiencing a similar problem. In that case the plaintiff Graham advised the involved officers that he needed sugar to counteract his medical problem. Pay attention to people who make this kind of statement. Fruit juice or candy may indeed improve their situation.
In hyperglycemia (high blood sugar levels) there will be an increase in acetone levels in the blood, as a result the subject’s breath may carry the odor of acetone, which you may be able to detect on the subject’s breath. If blood sugar levels are too high the subject will likely not exhibit aggressive behavior, but rather become very ill and may go into a coma.
Whether the blood-sugar level is too high or too low the subject needs to go to the hospital.
Psychosis can result several years after traumatic brain injury (Fujii, 2002). In such cases a police officer may be unaware of the subject’s history. Head injury, or more correctly stated, brain insult can result from multiple causes. These subjects may be suffering as a result of a swelling of the brain. Pressure on the brain can create aggressive behavior (National Institute of Neurological Disorders and Stroke, 2006). Even concussions may result in increasing confusion, restlessness or agitation (Hammeke, 2004; Marianjoy Rehabilitation Hospital, 2005). The most common symptoms will be irritability, anger outbursts, and violence.
The subject may be experiencing a viral encephalitis which can include psychosis, depression, mania, fever, and/or disorientation. The subject’s behavior may look similar to ED. The situation could become fatal to the subject depending on what caused the injury, or brain insult. These types of injuries must be treated by physician.
The thyroid gland is located in the front of the neck below the voice box. This gland produces hormones that regulate the rate of metabolism (American Academy of Otolaryngology-Head and Neck Surgery, 2006). Thyroid storm is a rare complication of hyperthyroidism (over-active gland). Thyroid storm is often precipitated by a physiologically stressful event. Thyroid storm, if unrecognized and untreated, is often fatal.
The symptoms of thyroid storm include:
• Heat intolerance;
• Increased sweating;
• Wide emotional swings; and
Thyroid storm can affect either gender, however often involves women, aged 20 to 60 years of age.
Poorly controlled hyperthyroidism (which the subject may be unaware of) can progress to a thyroid storm by:
• Pulmonary (chest) infection;
• Diabetic acidosis;
• Emotional stress (Manifold, 2005).
While thyroid storm is a relatively rare event, its presentation can appear similar to that of ED and may result in a call for police assistance in controlling the subject. Determining whether or not a subject is experiencing a thyroid storm is obviously beyond the ability of a police officer, and provides another reason why persons acting in a manner similar to ED should be taken directly to medical attention.
Police officers are not trained nor allowed to make a medical assessment beyond determining that a subject’s behavior or situation is unusual and requires medical attention. When addressing the inevitable response to a problem that isn’t going to go away, that is changes in policy, and/or more/better training, decision makers should exercise caution and assess their response from a systems based approach. While improving police crisis response training is a prudent decision everyone must realize that some subjects may be experiencing medical conditions that could be worsened by delaying access to medical assistance beyond that of a police officer. Protracted negotiations, waiting for the subject to calm down, waiting for a crisis team to be called out, putting the subject into a quiet room/cell until he or she calms down, placing them in a restraint chair or on a restraint bed where their ability to harm themselves is believed to be reduced; each potential response has substantial merit given the right situation. Each strategy can also be harmful to the subject if their medical needs have been assessed incorrectly.
Is it reasonable to expect police officers to add an increased level of medical knowledge to their responsibilities? How much additional training is required? Who should provide the training? How often will that training be evaluated? These are just a few of the questions that come to mind. These questions should be considered with the knowledge that even when people experiencing ED-like behavior arrive at hospital some do not survive and die after several days of sophisticated medical assessment and treatment. In fact, people have an ED-like episode while in hospital and do not survive.
ED-like behavior is not always the result of drug abuse (cocaine, methamphetamine, PCP) or mental illness. These other medical problems may appear very similar to ED-type behavior and can be fatal if untreated. Slowing or changing police response to a person thought to be experiencing ED may not always the best course of action. As is the case with many things in life, nothing is guaranteed to work every time.
NOTE: I wish to thank Dr. Ivanhoe Becker MB.ChB., CCFP, for his generosity and assistance in reviewing this paper.
The views expressed are those of the author and do not necessarily represent the opinions or policies of the Ontario Police College or the Ministry of Community Safety and Correctional Services.
American Academy of Otolaryngology-Head and Neck Surgery. (2006). Thyroid Gland. Retrieved May 9, 2006 from http://www.entnet.org/healthinfo/thyroid/thryoid_gland.cfm.
Armstrong, L. E. (Ed.). (2003). Exertional heat illnesses. Champaign, IL: Human Kinetics.
Challoner, K. & Newton, E. (2006). Toxicity, neuroleptic agents. Retrieved May 8, 2006 from http://www.emedicine.com/emerg/topic338.htm
Cronin, C. (2005). Symptoms of low blood sugar. Retrieved May 8, 2006 from http://health.msn.com/encyclopedia/healthtopics/articlepage.aspx?cp-documentid=100055896.
Fujii, D. (2002). Neuropsychiatry of Psychosis Secondary to Traumatic Brain Injury Psychiatric Times 19 (8). Retrieved May 8, 2006 from http://www.psychiatrictimes.com/p020833.html.
Gossman, W. (2005). Retrieved May 4, 2006 from http://www.emedicine.com/emerg/topic123.htm.
Graham v. Connor, 490 U.S. 386 (1989) Retrieved September 20, 2006 from http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=US&vol=490&invol=386.
Hemmeke, T. A. (2004). Sports concussions a growing concern. Retrieved May 9, 2006 from http://healthlink.mcw.edu/article/1007069756.html.
Hoppe, J. & Sinert, R. (2005). Heat exhaustion and heatstroke. Retrieved May 7, 2006 from http://www.emedicine.com/EMERG/topic236.htm.
Manifold, C. A. (2005). Hyperthyroidism, Thyroid Storm, and Graves Disease. Retrieved May 4, 2006 from http://www.emedicine.com/EMERG/topic269.htm.
Marianjoy Rehabilitation Hospital. (2005). Glossary of Terms - Concussion. Retrieved May 9, 2006 from http://www.marianjoy.org/stellent/groups/public/documents/www/mj_116506.hcsp.
National Institute of Neurological Disorders and Stroke (2006). Encephalopathy Information Page. Retrieved May 8, 2006 from http://www.ninds.nih.gov/disorders/encephalopathy/encephalopathy.htm.
Owens, T. A. (2005). Retrieved May 4, 2006 from http://www.nlm.nih.gov/medlineplus/ency/article/000766.htm.
Padder, T., Udyawar, A., Azhar, N. & Jaghab, K. (2005). Acute Hypoglycemia Presenting as Acute Psychosis. Retrieved May 8, 2006 from http://www.priory.com/psych/hypg.htm.
The Gale Group, Inc. (2005) Gale Encyclopedia of Neurological Disorders. Retrieved May 7, 2006 from http://www.answers.com/topic/anticholinergic.
Lambert, T. J. R., & Chapman, L. H. (2004). Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement. Medical Journal of Australia 181(10), 544-548. Retrieved May 4, 2006 from http://www.mja.com.au/public/issues/181_10_151104/lam10435_fm.html.