Excited Delirium

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Excited Delirium

• Understanding and prevention of sudden custody
  death proximal to restraint

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Excited Deliriumdefined

• A state of extreme mental and physiological
  excitement, characterized by extreme agitation,
  hyperthermia, hostility, exceptional strength and
  endurance without apparent fatigue
• (MORRISON SADLER, 2001)

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In simple terms please

• Sympathetic nervous system activation
• Adrenalin pumped into the body
• Primal fight or flight response
• The body can only function this way for a limited
  time
  
• Similar to putting your car in park and pressing
  the peddle to the floor
  
• If it does not slow down eventually you will find
  the weak point in the engine
  

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Sudden in-custody death definition

• An unintentional death that occurs while a
  subject is in custody. Such deaths usually take
  place after the the subject had demonstrated
  bizarre and/or violent behavior, and has been
  restrained
• The death appears similar to sudden death in
  infants. There is no obvious cause of death found
  during initial autopsy.

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Typical incident

• 911 call to Police about a man running in the
  street partially naked and/or acting bizarre
  
• Obvious to officers that subject will resist
• Struggle ensues with multiple officers May
  involve O.C., choke holds, baton, ECD, swarm
  technique
  
• Physical restraints applied Handcuffs/Hobbles
• Struggle continues or escalates after restraint
• Placed in squad for transport to jail

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Typical incident continued

• Apparent resolution period
• Subject becomes calm or slips into
  unconsciousness (officers believe the subject is
  faking or has finally calmed down)
  
• Labored or shallow breathing
• Followed unexpectedly by death
• Resuscitation efforts are futile
• Even when death occurs in the care of paramedics
  or at E.R. resuscitation fails
  

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The local media headlines

• 911 call triggers fatal response as man
  dies after fighting with police officers
  
• Local man dies after police use pepper spray
  and a choke hold
  
• Man dies in police custody after officers
  used a 50,000 volt TASER

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Training goals and objectives

• Education on sudden custody death
• Education on Excited Delirium Syndrome
• Learn to recognize behavioral warning signs of
  Excited Delirium Syndrome
  
• Collaborate with Dispatchers, LE, and EMS for
  handling suspected cases
  
• Reduce the potential for a sudden custody death
  through training
  

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Focus of training

• You are not being trained to provide a clinical
  diagnosis
  
• You are being trained to recognize behavioral
  signs of excited delirium
  
• Understand the risks of confrontation
• If confrontation is necessary, get the subject
  controlled quickly
  
• Treat suspected cases as medical emergency

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History of sudden death proximal to restraint

• 1849 Dr. Luther Bell Physician at McLeon Asylum
  (Mass.) documented 40 cases of a peculiar form
  of delirium. excitement with fear or rage
  accompanied with sympathetic nervous system
  arousal. Patients required restraints. Three
  quarters of the cases ended in unexpected
  fatalities.

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History continued

• South Carolina Mental Hospital. From 1915-1937
  there were 360 deaths listed as, exhaustion due
  to mental excitement
  
• In 1946 Dr. Shulack described this phenomenon as
  sudden exhaustive death in excited manics
  
• In 1952 a study by Bellak described the onset
  symptoms of this syndrome
  
• The problem continues today in mental
  institutions, nursing homes, and hospitals in
  situations where restraint is necessary
  

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Why the sudden interest?

• Media attention to people dying in POLICE custody
  
  
• The media and other groups have attempted to
  establish a link between police tactics and
  unexplained deaths
  
• Police used force, subject died, therefore
  Cause
  
• Post hoc ergo propter hoc logical fallacy, if
  one event happens after another, then the first
  must be the cause of the second
  
• The only things changing are the police
  tools/tactics the underlying factors remain
  
• What are some causes? Rise in street drug use
  and a move away from mental institutionalization
  of patients
  

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History of sudden custody death and police tactics

• Choke holds 1970s through 1980s
• Hogtie and Positional Asphyxia 1980s through
  1990s
  
• Pepper spray 1990s
• TASER 2000 to present

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Deaths in police custody How common are they?

• Approx. 200 deaths proximal to police restraint
  per year in the USA (10-20 in Canada) (Dr. Chris
  Lawrence, 2005)
  
• Estimated as high as 600-800 per year (DiMaio and
  DiMaio, 2006)
  
• 77 die at the scene of their arrest, or while
  being transported to jail cells or hospitals
  (Ross, 1998)
  

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2001 LA study of confinements suspected Excited
delirium

• Stratton, Rogers, Brickett, Gruzinski, 2001
• 216 arrested subjects exhibiting Excited Delirium
  
  
• 18 deaths, all with struggle forced restraint
• 78 stimulant drugs
• 56 chronic disease
• 56 obese
• 13/18 died in ALS ambulance, 5 ECD
• All deaths preceded by less than 5 min quiet
  period
  
• What is it about those 18 vs. the 198 survivors?

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Common theories of sudden custody death

• Cardiomyopathy
• Drug abuse/overdose
• Restraint/Positional Asphyxia
• Excited Delirium

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Cardiomyopathy

• Heart structural abnormality (predisposed to
  sudden cardiac arrest)
  
• Normally not recognized until found in an autopsy
  (inherited trait)
  
• Negative lifestyle choices can put person at risk
  of developing condition Alcohol/Drugs
  
• Sudden cardiac arrest can occur during times of
  extreme exertion Resisting Arrest
  

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Drug abuse/overdose

• Recreational drug use (there is no safe dose of
  cocaine,even a small dose can cause death. 1st
  time vs. 150 time)
  
• Chronic drug abusers at higher risk (cocaine,
  methamphetamines, PCP, Ephedrine and other
  stimulants)
  
• Chronic cocaine abuse can lead to Excited
  Delirium (leads to chemical changes in the
  brain, i.e. dopamine receptors and the
  hypothalamus)
• Death from cocaine overdose and Excited Delirium
  are not the same condition (the toxic overdose
  can lead to the behavioral characteristic of
  excited delirium)

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Drug Use Continued

• Long term use of some prescription drugs can have
  similar affects on the brain
  
• Most common of these are psychotropic drugs
  prescribed for mental illness (lithium for
  example)
  
• Mental illness and excited delirium
• Bi-polar disorder and schizophrenia

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How Excited Delirium can kill

• Body can only do so much before it literally
  gives out
  
• Under normal conditions the brain sends signals
  to the body to stop or calm down as it nears
  exhaustion
  
• Person experiencing Excited Delirium doesnt have
  or is able to ignore this safety mechanism
  
• Can push themselves past exhaustion into
  potentially fatal medical conditions such as
  Metabolic Acidosis and Exertional
  Rhabdomyolysis

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Metabolic Acidosis

• Potentially life-threatening body chemistry
  abnormality caused from a build up of lactic acid
  in the bloodstream
  
• Increased lactic acid build up from continual
  resistance or extreme exertion
  
• Subject not able to rid themselves of enough CO2
  
  
• Hypoxia lack of oxygen
• Extremely low blood PH (acidosis )
• Can lead to cardiac arrhythmia
• Literally exert themselves to death

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Exertional Rhabdomyolysis

• The continued struggle can deplete the bodys
  normal fuel supply. (A byproduct of metabolizing
  normal body fuel is C02. The body rids itself of
  C02 by breathing. The more you burn the faster
  you breathe. When your body can not get rid of
  enough CO2 through respiration it can lead to
  metabolic acidosis.)
• When the normal fuel supply is used up the body
  begins to metabolize muscle tissue for fuel
  
• The byproducts from burning muscle tissue for
  fuel are toxins released in the blood
  
• The kidneys attempt to filter the toxins
• The toxins can clog up the kidneys (kidney
  failure)
  
• When the kidneys clog up other chemicals can be
  released into the blood and can lead to
  arrhythmia
  

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Excited Delirium cases increasing

• Significant rise in street drugs (cocaine,
  methamphetamines)
  
• Significant rise in people with mental disorders
  living outside of mental hospitals (taking or
  improperly taking psychotropic medications)
  
• More incidents of Excited Delirium
• The problem is going to get worse
• Many LE Officers, EMS Medics, Doctors, and
  Medical Examiners lack training in recognition
  and handling of suspected cases
  

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In-custody deaths

• A growing body of evidence supports that many
  in-custody deaths are not the result of a single
  cause, but a cascade effect of multiple factors
  in motion long before law enforcement ever gets
  involved
• LE gets called when the subject suddenly acts
  bizarre and gets out of control
  
• The resulting bizarre behaviors are caused by the
  on-going chemical/medical problems. By the time
  the bizarre behavior occurs they are a long way
  into the medical crisis. The dominos are
  already falling

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In-custody deaths

• The reality is many of the people that die in-
  custody suffer from one or more medical
  conditions that contribute to their mortality
  
• Some have high levels of drugs in their bodies
  that cause adverse physical reactions
  
• Some are in a mental health crisis (bi-polar
  disorder or schizophrenia)
  
• The conditions can be worsened when the subject
  is confronted and restrained by law enforcement
  officers

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What should we do?

• Get EMS on the way prior to confrontation if
  possible (emergency response)
  
• Avoid confrontation if at all possible
• Attempt to contain/isolate the subject without
  confrontation
  
• Attempt verbal de-escalation
• Have as many backup officers as possible

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Reality

• Bizarre/violent behaviors most often will require
  confrontation and restraint
  
• Restraint can make the problem worse
• Without restraint this medical emergency can not
  be treated
  
• Get the fight over quickly (i.e.TASER, swarm)
• Pain compliance techniques will not work (do not
  use the TASER with cartridge removed, stun mode,
  OC, or other pain compliance techniques)
  
• EMS protocols and transport to the hospital

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Recognizing behaviors

• Bizarre, violent, aggressive behavior
• Violence toward objects
• Attack/break glass (windows and mirrors)
• Overheating/excessive sweating or very dry (Body
  shut down perspiration production because of over
  demand on system)
  
• Public disrobing -partial or full (cooling
  attempt)
  
• Extreme paranoia
• Incoherent shouting (animal noises or loud
  pressured speech)
  

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Recognize behaviors cont.

• Unbelievable strength
• Undistracted by any type of pain (Including
  broken bones and damaged limbs. Can easily
  overpower lone officer)
  
• Irrational physical behavior
• Fight or flight behavior (Subject perceives
  attempts to restrain as threat to his existence.
  It is a primal sympathetic nervous system
  response)
• Hyperactivity
• Bug Eyes (They look nuts)

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Early recognition

• Training for Dispatchers is critical
• Key questions asked during the 911 call are
  important
  
• Information gathered during the 911 call can
  start the recognition process
  
• May lead to a simultaneous dispatch of EMS and LE
  which could save valuable time

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How do we do this?

• Excited Delirium training for Dispatchers
• Develop questions based on behavioral signs of
  excited delirium
  
• Establish an Emergency Medical Dispatch protocol
  for this medical condition
  

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Incoming call

• there is a guy exposing himself on Wis. Ave.
• Ask questions to draw out description of
  behaviors
  
• What specifically is he doing?
• Bizarre, violent, aggressive behavior
• Violence toward objects
• Attack/break glass (windows and mirrors)
• Overheating/excessive sweating or very dry (Body
  shut down perspiration production because of over
  demand on system)
  
• Public disrobing -partial or full (cooling
  attempt)
  
• Extreme paranoia
• Incoherent shouting (animal noises)
• Unbelievable strength
• Undistracted by any type of pain (Including
  broken bones and damaged limbs. Can easily
  overpower lone officer)
  
• Irrational physical behavior

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Follow up questions

• Does the caller know the subject? If they do,
  what do they suspect is causing the behavior?
  
• ? Drug ingestion?
• 1. type
• 2. how much
• 3. when
• ? Drug history?
• 1. chronic user
• 2. what type (stimulants, coke, crack,
  meth.)

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Follow up continued

• Mental illness or psychiatric history
• 1. bi-polar disorder
• 2. schizophrenia
• 3. does subject take meds for
  condition
  
• 4. medication compliant
• ? On-set of behaviors
• 1. sudden (they just went nuts)

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If you suspect Excited Delirium

• Update responding officers
• Dispatch Patrol Supervisor to the scene
• Dispatch EMS (Fire?)
• Advise EMS to stage in the area
• Keep the caller on the line if possible

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What do we do in the mean time?

• Training
• Recognize an extremely agitated and/or bizarre
  subject may be experiencing a medical emergency
  
• Recognize an excited delirium state is a SYMPTOM
  of advanced physiologic problem that may
  contribute to sudden custody death
  
• Treat these cases as a medical emergency
• Anticipate, recognize, and mobilize EMS before
  confrontation if possible
  
• Protocol driven EMS response