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News from ILEETA 2011: A multidisciplinary approach to excited delirium subjects

There should be policies, procedures, and practices that have been trained by all the participants — beginning with LEOs and EMS, but also including 911 call takers and dispatchers — for incidents involving excited delirium subjects

Would you send the fire department to handle a bank robbery? Would you send EMS to handle a domestic dispute? Probably not, right? But we know all too well that many, many police officers respond — on a consistent basis — to known medical emergencies masquerading as law enforcement events. We’re talking, of course, about incidents involving Excited Delirium (ExD) subjects. This was the topic of discussion this morning in a session led by Lt. Michael Paulus, Field Training Program Commander for the Champaign (Ill.) Police Department during a session at ILEETA 2011 in Wheeling.

“What do you have on your belt that can handle a person with hyperthermia?” Paulus asked.

“Ice water, but that’d be back in the squad car,” replied one attendee.

The room rumbled in laughter. Paulus, chuckling, pressed on, “You’re not going to send the fire department to handle a bank robbery and you’re not going to send EMS to handle a domestic dispute, but we send the police to deal with these medical emergencies.”

A Severe Medical Emergency
Paulus, who has taught extensively throughout the country on excited delirium awareness, response, and protocol development, showed a slide listing some of the medical issues you might be dealing with during an encounter with a subject in an excited delirium state:

• Hyperthermia
• Hypoventilation
• Acidosis
• Catecholamine storm
• Cardiovascular collapse
• Rhabdomyolysis

It should be noted here that excited delirium can be — and tragically has been — fatal. It is a medical emergency that may be caused by cocaine or methamphetamine abuse, withdrawal from these (or other) controlled substances, and/or mental illness. Intense physical exertion — such as when a subject violently resists arrest for prolonged periods — may increase the risk of death.

In one of the documents Paulus furnished during the session, excited delirium was described as “a behavioral condition whereby a person exhibits extremely agitated and non-coherent behavior, elevated temperature, and excessive endurance without apparent fatigue. Excited delirium is often seen in the context of people under the influence of an illicit stimulant substance or in people with a history of mental illness who are not taking their medications properly.”

A Monkey Humping a Football
Like I said, it’s a medical emergency masquerading as a law enforcement event. But to be fair, when you look at the behaviors exhibited, you can easily see how an excited delirium call might be identified by the 911 call taker and/or the dispatcher as a police-response incident. For example, “due to an elevated body temperature, many of these individuals remove one or more items of clothing, and they often appear impervious to pain,” said one of Paulus’ handouts made available on the conference thumb drive from ILEETA 2011.

Paulus suggested you’re talking many times about people engaging in:

• Violent or bizarre behavior
• Reduced sense of pain
• Superhuman strength
• Seemingly unlimited endurance

Furthermore, a person in an excited delirium state may exhibit one or more of the following:

• Agitation
• Excitability
• Paranoia
• Aggressiveness
• Unusual strength
• Fear
• Rage
• Violence toward others
• Depression
• Confusion
• Shouting
• Violence toward objects
• Sudden calmness
• Hyperactive
• Apathy
• Sweating
• Hyperthermia
• Attraction to glass

“No one expects police officers to ‘diagnose’ excited delirium,” Paulus said. “But most officers have seen that monkey humping a football. We all know what that looks like.”

Paulus explained that in essence, identifying someone as an excited delirium subject is a ‘field impression’ that activates a set of policies, procedures, and protocols to guide the response — a response must be multidisciplinary.

A Multidisciplinary Approach
Clearly there’s a need for law enforcers to come in and control this subject, and there’s clearly the need for EMS to come in and address this subject’s medical emergency. Since both law enforcement and EMS need to be sent to this event, we must develop a multidisciplinary approach to this multi-factorial problem. There should be policies, procedures, and practices that have been taught and trained by all the participants — beginning with LEOs and EMS, but also including 911 call takers and dispatchers.

“We’ve been looking at this thing kind of cock-eyed. We keep thinking this is a law enforcement issue. It’s not. When you frame this as an EMS or Emergency Room problem, and approach the EMS director or the ER Administrator with the message, ‘How can I best help you with this problem?’ you are much more likely to create the best possibility that the subject in question will survive the incident.”

There’s absolutely no way on Earth I can summarize in a few hundred words all of what was discussed in today’s two-hour session — indeed, it’s a bit of a feat that Paulus was able to cram into those two hours what probably requires a week of two-hour sessions. What I can do is pass along the overarching theme of the session, and encourage you to reach out to Paulus (through me) or investigate further some of his excellent research on this stuff. That theme — in case you haven’t yet picked up on it — is that subjects exhibiting symptoms of excited delirium will need the attention of both police and EMS, and that response should be well-thought out and practiced in advance.

I’ll close this bit of ILEETA coverage with something Paulus had on one of his PowerPoint slides: “Excited delirium is an imminently life-threatening medical emergency, not a crime in progress... The criminal prosecution can wait, the medical emergency will not!”

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