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Excited delirium: New video, roll call refresher, and a face-off with a happy ending

We all know of excited delirium incidents that go south after police intervene. But we rarely hear of a case that turns out safely for everyone involved because the cops knew how to correctly approach this volatile, often deadly phenomenon.

Well, here’s one. It began one Monday last June in Appleton, Wisc., with a dinner-hour complaint of an inappropriately naked man and ended later that evening with the raving, demented subject being brought calmly back to Earth in the hands of skilled medical personnel. No heavy-handed control tactics, no damage to people or property, no threatened lawsuits from angry relatives.

Lt. David Nickels of Appleton PD’s patrol division recently walked PoliceOne through what happened. Thanks to an on-scene video of the event you can see what he and other responding officers were up against and how they met the challenge with commendable professionalism.

Before the video begins, you can hear the original 911 call from the subject’s mother to the tri-county complaint center that handles dispatch for Appleton and surrounding communities. Soon after arriving home from work, the woman had discovered her 29-year-old son, who had an old history of marijuana use, “acting very strange...talking and talking...like he’s on something...saying, ‘I’m dying, Mom, I’m dying, Mom’...” Plus, “he’s sitting there naked. He certainly doesn’t do that in front of his mother!”

In the background, you can hear a male voice yelling unintelligibly and spewing guttural noises.

A dispatcher tossed the response to two patrol units. But when Nickels, who was working the street in a car of his own, heard her brief summary of the complaint — the yelling, the strange behavior and repetitious statements, the heavy breathing, and especially the unusual nudity — he said he’d respond as well.

Nickels, a TASER master instructor, had been interested in the peculiar psychological and physiological meltdown called excited delirium “even before we knew it by that name,” he says. After some in-custody deaths in his area were associated with the peculiar affliction, he’d researched ED back more than a century and had developed a two-hour training program for his department and other nearby agencies, in hopes of educating dispatchers, cops, and medical responders on its symptoms and handling and “getting us all operating on the same page.”

Indeed, about two weeks before the naked son call, Nickels had put together a brief PowerPoint presentation to refresh the troops at roll call about ED basics. In it, he emphasized that by the time police are called in these cases, the subjects typically “are a long way into the crisis.” They’re locked in a medical nightmare, but without training, arriving officers are likely to view them and their threatening behavior as a criminal problem.

“Handling them as strictly a criminal matter instead of a possible medical emergency,” Nickels says, “only increases the likelihood that the encounter will end badly.” On the 911 tape, you can hear him, as he takes the call, advise the dispatcher to get an ambulance rolling and “give them the behavior signs we have at this point.” He was signaling everyone with a warning flag.

Nickels arrived first at the location, a modest house in a quite, middle-class residential neighborhood. He waited for one other officer to join him, got more en route, turned on the pager-size, departmental video camera attached to the front of his shirt, and headed up the front steps. As he stepped into the living room, he realized that his tentative reading of the call had been correct.

“Holy shit!” he thought.

If you’re a veteran officer watching the video, the scene will no doubt be reminiscent of one you’ve faced at some time in your career. The subject, long-haired, well-conditioned, and gesturing emphatically, stands stark naked in the room. Highly agitated and sweating profusely, he screams over and over at full volume, “Is I’m going to die?!” His mother tries to hand him clothing. He clutches her robe and yells at the officers. His nonsensical outpourings at times sink into raw animal noises. The aura of violence in the cramped quarters hovers near the flashpoint.

Sizing it all up, Nickels carefully adhered to certain key principles he emphasizes in his training programs.

• As the sole officer addressing the subject, he kept his voice calm and cordial, called the man by his first name, and showed him open palms. No confrontational, threatening language. No commands. No attempt to outshout the shouter. “You don’t want to feed these people adrenalin,” Nickels says. “They’re already thinking you’re going to hurt them. To the extent that’s possible and safe, you want to model calmness for them.”

• He did not crowd in on the subject immediately. “Avoid confronting them, if you can,” Nickels says. “Ideally, try to isolate and contain them until the resources you need are there.” Nickels got the mother to back away, giving the subject more space. When the man said something about lying down on the floor, Nickels gently encouraged him to do so — and he did, ending up on his back.

• Nickels formulated a plan, and when sufficient officers had arrived, along with appropriate medical personnel, he activated it.

The camera frame is limited and some of the video has been edited because of time considerations (the encounter extended more than 20 minutes), so not every element can be seen. But this was the strategy deployed:

To Nickels’ right, just inside the front door, his initial backup was positioned with TASER drawn and on, ready for immediate firing if needed. Nickels sent two other backup officers around to the rear door of the house. From there, they could enter through the kitchen to block that possible escape route and to approach the supine subject from his feet. Two other officers, plainclothes operatives from a drug/gang unit who had been in the vicinity, and an Advanced Life Support (ALS) team equipped to administer sedatives were at hand.

During a momentary lull in the subject’s diatribe, Nickels said quietly, “All right, let’s move” and the officers promptly initiated a well-practiced “swarm” to control the subject’s limbs. Nickels and a gang officer each grabbed an arm and the two uniformed officers lay across his legs. At Nickels’ prompting, the paramedics administered a shot of the sedative Haldol and promptly began strapping the subject to a board.

“When you restrain these subjects is likely to be the critical point,” Nickels says. “They fight their hardest then and may think you are going to kill them. It’s important for EMS to shoot them up quickly — to chemically restrain them — so the sedative can start calming them.”

In the video, you see the subject’s agitation flood back and escalate in reaction to being strapped down. He rails gibberish about grabbing his balls, he expels great bursts of air, he growls from deep in his throat, he screams out “Mom, don’t let them kill me!” — but at that point, he is unable physically to give vent to any violent urges, because he’s controlled. In a matter of seconds, he’s out the door, en route to the emergency room.

“At the hospital, he was further sedated,” Nickels says. “In about 90 minutes, he was beginning to act normal again. When he fully recovered he had no memory whatsoever of the episode.” Since then, he has resumed his usual daily activities as a college student, apparently with no lingering aftereffects.

The etiology of excited delirium is not yet completely understood, but “most often there’s an association with a history of mental illness (especially bipolar and schizophrenic conditions) and/or drug abuse,” Nickels explains. “In this case, the subject said he had ingested some hallucinogenic mushrooms he ordered over the Internet.”

His ordeal was not as intense or as violent as some, but he exhibited a number of the common symptoms: fear, high body temperature, repetitious and incoherent speech, paranoia, profuse sweating, nudity, irrational shouting, bizarre statements and behavior. If you haven’t seen ED in action before, watching Nickels’ video may help you recognize it when you do.

For the safety of subjects and officers alike, there are important lessons that Nickels believes this incident reinforces:

1. All officers, dispatchers, and responding medical personnel need to be educated to recognize the behavioral warning signs of ED. “Education on what it is and how it presents is the first big key to handling it successfully,” Nickels says. “Periodic reinforcement is important, because ED is one of those ‘low-frequency/high-risk’ events.”

2. Based on knowledgeable questioning of complainants, dispatchers can get medical personnel and police rolling to the scene simultaneously. Having an ALS unit on hand to promptly administer tranquilizing drugs will minimize the time the subject fights against restraint. Intense struggling has proven to be a telltale forerunner of death in numerous ED cases. “High exertion under high body temperature is one of the worst things for the cardiovascular system,” Nickels says.

3. Until adequate police and medical resources are on hand, try to avoid initiating physical contact. “ED subjects often display superhuman strength and are usually able to overpower one or two officers,” Nickels says. “Once you initiate contact, do it decisively and quickly.”

4. Officers need to train as a team in applying control techniques so that each knows his/her job and where it fits into the big picture. Hands-on rehearsals are critical. “Remember that pain compliance won’t work on these subjects,” Nickels says. “An electronic control device that causes incapacitation may be your best option below deadly force if they’re violently aggressive. But a TASER should never be used just as punishment for screaming and yelling.”

5. The proper destination for an ED subject is the hospital, not the jail. “We sent two officers along in the ambulance,” Nickels says, “and they stayed with the subject until he was completely sedated in the emergency room.” If criminal activity has been involved, the subject can always be released to police custody after he/she has been treated and the medical crisis has passed.

6. Do a proper debriefing after the incident. “Before the encounter in June, we had an earlier confrontation with a mental patient that didn’t go as smoothly,” Nickels recalls. “It was after we debriefed that and identified several shortcomings that we decided to do the ED refresher training at roll call. The refresher helped everybody realize right away what we were dealing with in the latest incident.”

Even with the best approach, there are no guarantees where ED is concerned, Nickels concedes. “Regardless of how proficient the police and medics are, these people often are so deeply in crisis that they end up dying anyway.

“But we need to have training and protocols in place to offer the best chance of a positive outcome. It’s not a matter of ‘if’ an ED event is going to happen in your jurisdiction, it’s ‘when.’ Protocols exist for both law enforcement and medical personnel. There’s no excuse for not instituting them.”


Note: Nickels is scheduled to give a full critique of the Appleton incident at the 4th annual Sudden Death and Excited Delirium Conference, sponsored by the Institute for the Prevention of In-Custody Deaths, November 11-13 in Las Vegas. For more information, visit: www.ipicd.com.


Our thanks to Gary Klugiewicz, PoliceOne trainer and Verbal Judo instructor, along with Capt. Peter Jaskulski of the Milwaukee County (Wis.) SO, for their valuable assistance with this report.

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