Crisis Intervention Team Training Excited Delirium

Excited Delirium Defined “ A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue” (MORRISON & SADLER, 2001)

In Simple Terms Sympathetic nervous system activation Chemicals are pumped into the body Primal fight or flight response The body can only function this way for a limited time Analogous to putting your car in park and pressing the accelerator to the floor If it does not slow down eventually you will find a weak point in the “engine”

Other Terms Sickle cell sudden death Agitated delirium Cocaine psychosis Metabolic acidosis Exertional Rhabdomyolysis Positional asphyxia Sudden custody death Can we agree something exists?

Some Causes Mental illness (bipolar and schizophrenia) Stimulant drug use and long term abuse Sudden cessation of drugs (anti-psychotic and street drugs) Hallucinogenic agents New drugs (bath salts and K2) Alcohol withdrawal Etc.

Cause and Presentation The causes of the excited or agitated state vary but the subjects’ presentations are usually quite similar When you study all the facts after the event they “read like a script” Why do we fail to recognize this condition? Lack of training

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

Sudden In-Custody Death An unintentional death that occurs while a subject is in custody. Such deaths usually take place after the subject has demonstrated bizarre and/or violent behavior, and has been restrained There is often no obvious cause of death found during autopsy Stating that there usually are not findings on autopsy that can explain the death is true. Amplify this by adding that even in cases of cocaine excited delirium, there usually isn’t enough cocaine found at autopsy to attribute the death to cocaine toxicity.

History of Sudden Death Proximal to Restraint 1849 Dr. Luther Bell Physician at McLean 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.

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

History Continued During the 1950s excited delirium deaths nearly disappeared Why??? Development of psychotropic medications Administered in hospital setting Re-immergence in the 1970-1980s Mental illnesses treated outside hospital setting Stimulant drug use and abuse

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 Persons experiencing Excited Delirium appear able to ignore this safety mechanism Can push themselves past exhaustion into potentially fatal medical conditions

Recognizing Behaviors Bizarre, violent, aggressive behavior Violence toward objects Attack/break glass Overheating/excessive sweating or very dry Public disrobing -partial or full (cooling attempt) Extreme paranoia Incoherent shouting (animal noises or loud pressured speech)

Recognize Behaviors cont. Irrational physical behavior Hyperactivity “Bug Eyes” (They look “nuts”) Fight or flight response to control attempts Unbelievable strength Undistracted by any type of pain

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Typical Incident 911 call to Police about a man standing 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 (if you fight with the cops you go to jail)

Typical Incident cont. Apparent resolution after restraint 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 Even when death occurs in the care of paramedics or at E.R. resuscitation fails (cardiac rhythm is usually PEA not V-Fib)

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Can it Happen in the Fox Valley? Mid 1980s – (APD #9124 incident) fatality June 1999 - (James W.) survived May 2003 - (72 hr hold/transport) fatality Nov. 2004 - (James W.) fatality Aug. 2006 - Winnebago Co. (car pedestrian) fatality Sept. 2006 - Neenah PD (ECD use) fatality March 2009- Linwood St – protocol/survived June 2009- Jefferson St – protocol/survived August 2009-Division St- protocol/survived August 2011 – Kaukauna PD (fatality) May 2013 – Riverside Cemetery – protocol survived June 2013- Northland/Ballard- protocol survived

Why the Sudden Interest? Media attention to people dying in POLICE custody Prior to the 1970s people were dying in mental institutions (“nobody cared”) The media and other groups have attempted to establish a link between police tactics and unexplained deaths The only things changing are the police tools/tactics; the underlying factors remain

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

Excited Delirium Cases Increasing? Significant rise in street drugs (cocaine, methamphetamines, K2/Bath Salts) Significant rise in people with mental disorders living outside of mental hospitals (not taking or improperly taking psychotropic medications) More incidents of Excited Delirium The problem is going to get worse Ignoring the problem is a big mistake

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 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

In-Custody Deaths LE gets called when the subject suddenly acts bizarre and gets out of control The resulting bizarre behaviors are caused by the on-going mental/chemical/medical problems By the time the bizarre behavior occurs they are a long way into the crisis. The “dominos are already falling” It is too late to start planning your EMS and LE response protocol

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

Incoming Call “there is a guy acting strange, running in circles” 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.) Remember that ED in the setting of drug use follows one of three patterns…1) A recent binge superimposed on a long history of abuse (e.g., cocaine excited delirium); 2) Recent abrupt cessation certain anti-psychotic or anti-depressant medications; or 3) use of abuse of a drug that can produce delirium (e.g., mushroom poisoning).

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)

If You Suspect Excited Delirium Give out the behaviors described by caller Do not just give out the “CAD label” Dispatch Patrol Supervisor to the scene Dispatch EMS (Fire?) Priority response but no lights/siren in the area of incident Advise EMS to stage in the area Keep the caller on the line if possible

What Officers Should Do Get EMS on the way prior to confrontation if possible 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

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 Physical control: expect fight and/or flight Get the fight over quickly (i.e.TASER, swarm) Pain compliance will not work EMS protocol and transport to the hospital

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What Do We Do in the Mean Time? Training Recognize: an extremely agitated and/or bizarre subject may be more than a “nut case” Anticipate, recognize, and mobilize EMS before confrontation if possible Treat these cases as a medical emergency Protocol driven EMS response

Sample EMS Protocol (Gold Cross Ambulance of Fox Valley) This protocol will be considered anytime during the patient contact when the patient’s behavior indicates the possibility of excited delirium syndrome. Initiate this protocol as early as possible.

Protocol Steps Ensure scene safety with law enforcement intervention Recognize: The warning signs Identify patient’s “at risk” history Attempt verbal containment / communication If verbal de-escalation is ineffective allow law enforcement to contain/control the patient Secure the patient If still combative, administer meds Continuous medical assessment Transport and radio ahead

Scene Safety As usual procedures require, if for any reason you are concerned about your personal safety contact law enforcement for assistance in dealing with the patient.

The Warning Signs Irrational, bizarre behavior Unbelievable strength and endurance Aggression toward objects, especially glass or mirrors Impervious to pain Resistive to LE tactics Removal of clothing

Warning Signs Continued Aggression Hyperactivity Extreme paranoia Incoherent Shouting Grunting or animal like sounds Perspiration – hyperthermia

At Risk History Known drug ingestion or abuse Mental illness Previous psychiatric history, especially schizophrenia or bi-polar Taking or failure to take psychiatric medications as prescribed Sudden onset of behaviors listed earlier

Intervention Process Attempt to de-escalate patient with verbalization. This may not be possible due to patient's behavior If verbalization is ineffective, allow law enforcement to contain/control subject. Be aware that when confronted a physical altercation may occur Law Enforcement will most likely use an Electronic Control Device (ECD) or multiple officers If during containment process 2 successful ECD applications fail to subdue the patient and they continue the excited delirium behaviors, once contained the protocol shall be started and the subject shall be transported to the hospital by ambulance

Secure Patient Avoid the use of prone or “hog-tied” positions Use handcuffs or limb restraints as needed

Medical Intervention If subject remains combative…. Administer 5mg Haldol IM, then Administer 5mg Valium IM Use 20g needle and inject into lateral thigh, through clothes if necessary Once meds given, transport to hospital is mandatory

Medical Evaluation If possible attempt: Vital signs, including Sp02 Blood Glucose EKG Rhythm Body Temperature (very important) IV Access should only be attempted if it can be safely initiated and maintained Avoid invasive procedures if patient’s aggression poses a bio-hazard/sharps risk

Transport Transport to medical facility Radio ahead so hospital can make arrangements for security and safety precautions Transport will include a law enforcement officer riding along in the back of the ambulance if possible