Excited Delirium Understanding and prevention of sudden custody death proximal to restraint

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 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”

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.

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

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

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”

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

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

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.

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

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

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

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)

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?

Common theories of sudden custody death: Cardiomyopathy Drug abuse/overdose Restraint/Positional Asphyxia Excited Delirium

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 Genetics and poor lifestyle choices. Pre-existing condition

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) Swanson Case Engelbrecht case Potassium chloride vs sodium chloride

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

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 doesn’t 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” Arterial blood gas sampling is essential for the diagnosis. A pH under 7.1 is an emergency, due to the risk of cardiac arrhythmias, and may warrant treatment with intravenous bicarbonate.

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

Exertional Rhabdomyolysis The continued struggle can deplete the body’s 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

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

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

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

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

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

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)

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”)

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

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

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

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.)

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 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

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