Excited Delirium

     Historically, a naked, screaming and agitated individual standing in a busy roadway during rush hour traffic required only law enforcement response. Police were expected to remove the subject from the roadway and take him to an appropriate facility. When force was used to subdue the subject, injuries were commonplace, and fire departments and EMS responded at the request of the police and treated the injuries. Medical treatment was focused upon clearing the subject for incarceration into a jail facility. Unfortunately, this scenario often resulted in the untimely and unnecessary death of the subject.

     According to Theresa Di Maio, author of Excited Delirium Syndrome: Cause of Death and Prevention, delirium is a mental state characterized by an acute circumstance of disorientation, disorganized thought process and disturbances in speech.1 When that mental state involves violent behavior, it is called excited delirium. In that state when there is a sudden death and the autopsy fails to reveal a cause, it becomes excited delirium syndrome. Dr. John Peters of the Institute for the Prevention of In-Custody Deaths lists the characteristics of a person in excited or agitated delirium in Table 1.2 This is not a comprehensive list of the characteristics of excited delirium, but a representation of the more easily recognizable ones.

     Educating paramedics, firefighters and police officers is the first step to preventing in-custody deaths. In recent years, police agencies have done an excellent job of educating their officers to recognize the signs of excited delirium. Early attempts at education focused on positional asphyxia as the culprit in in-custody death. Hog-tying became outlawed by many police agencies based upon studies done by a medical examiner from Washington state.3 Even after those studies were refuted and Dr. Donald Reay retracted his conclusions on positional asphyxia, police agencies continue to prevent officers from hog-tying.4 Continued research has shown positional, postural or compressional asphyxia to be a factor of in-custody deaths, but certainly not the only concern needing to be addressed when faced with a potential excited delirium patient.5 Teaching foundations like the Institute for the Prevention of In-Custody Death (www.ipicd.com) serve as a clearinghouse for current research and as an educational resource to any agency looking for a structured teaching program on excited delirium.

     Accurate reporting of in-custody deaths has only recently been implemented with the Death In Custody Reporting Act of 2008. Estimates in previous years vary, depending upon the definition used of what constitutes an in-custody death. So what can agencies do to reduce or prevent these deaths?

Prevention

     The United States Department of Transportation (DOT) Office of EMS produces the curriculum to educate all EMTs, paramedics and firefighters in prehospital emergency care; however, the current curriculum does not mention positional asphyxia or excited delirium. The National Emergency Medical Services Advisory Council recently released updates to the DOT curriculum that include those conditions.6 Unfortunately, this will only be offered to new and future caregivers. Those currently certified can get the information through continuing education classes at their local hospitals. Since the subject matter for these classes varies according to what prehospital medical directors believe is important, it will be up to police personnel to make them aware of just how important this training is.

     Agencies like Miami-Dade Fire Rescue (MDFR) have adopted protocols for aggressively treating patients with excited delirium. Their standing order outlines the signs and symptoms, as well as criteria for using the treatment protocols,7 including rapid capture of the patient by law enforcement and administration of a sedative by EMS to calm the patient and allow for treatment. MDFR gives Versed via the needleless mucosal atomizer device, which allows for drug delivery with minimal risk of accidental needlestick to EMS and positive drug delivery to the patient. Once the patient is calm and accessible, an IV of 60°F normal saline is initiated and infused "wide open." A prophylactic 1 amp sodium bicarbonate is given for acidosis that results from prolonged struggle.

     Prior to implementation of this protocol, no statistics were kept on the number of patients exhibiting signs and symptoms of excited delirium who died in the care of Miami-Dade Fire Rescue. Since the implementation, it has been used on 44 patients,8 none of whom died.

Interagency Cooperation

     One of the factors contributing to the success of the MDFR protocol is cooperation between EMS and police. These agencies developed their reaction strategies together to be mutually beneficial and so each entity understands its role in the scenario.

     Police usually come in contact with excited delirium patients during a call for service involving a subject who is aggressively violent. The first responsibility of the responding officers should always be safety of themselves, fellow officers, onlookers at the scene and the subject who is the focus of the call. Once the subject has been taken into custody and controlled, the officers need to monitor his well-being. Early recognition of the signs of excited delirium and early intervention by both police and EMS is essential in mitigating liability of the agencies.

     Almost all in-custody deaths result in some type of litigation, usually with a focus on the method of control. Positional and compressional asphyxia are terms frequently heard in civil courtrooms. Methods of restraint become issues of contention in a lawsuit and may be the turning point in the liability of a law enforcement agency. The well-being of a subject in custody is the responsibility of the police.

     Another advantage for cooperative strategy is having an established game plan that lets responding public safety agencies know their role and responsibilities and what other agencies bring to the table. For example: A fire department uses a high-pressure water line to knock down an agitated patient, police use an electric energy device weapon to capture and handcuffs to control, and EMS waits close by with a sedative to calm the subject and then prepare for transport. The amount of time law enforcement needs to remain with the subject can be greatly reduced when EMS is on scene and can take responsibility as soon as it is safely possible.

     EMS and fire agencies typically take a "hands-off" approach when called for a violent patient, since they lack the training and tools to deal with these situations. Only when a patient they are already caring for becomes agitated and violent do they need to take steps to ensure their own safety. Retreating from a patient who needs medical care is sometimes not an option. Control techniques generally involve getting as many people as possible to hold the patient down while medical restraints are applied to control him.

On-Scene Safety

     So what can responders do to improve their safety?

     Using a coordinated and planned approach to the violent patient results in minimum injury to both responders and patient. This type of training is essential for EMS and fire personnel who, while not their primary responsibility, often need to restrain and control a patient so treatment can begin. Many techniques, such as the total appendage restraint procedure (TARP), can be taught to EMS and fire by local law enforcement.9 In TARP, responder #1 talks to the violent subject while other responders station themselves at 45° angles to the subject's position. Two responders to the rear, #4 and #5, are responsible for the subject's legs; the front responders, #2 and #3, are responsible for the subject's arms; and #1 is responsible for the subject's head. Once #1 says "go," all responders move immediately. The subject's legs are held fast, while his arms and upper body are leaned forward. The head is held as his body is lowered to the ground. This technique requires only one hour of instruction and can be used by public safety personnel of all body sizes. The use of verbal or nonverbal clues to put the procedure in action is easily taught between calls at a fire station or in EMS continuing education. EMS agencies and fire departments must have a policy in place to regulate the use of techniques like TARP in order to control their use and protect the public safety workers who use them.

Conclusion

     Having a coordinated strategy when called to deal with a violent patient has advantages for police, EMS and fire. Police can establish a stand-off location that is close to the scene but will provide a safe environment for EMS. Knowing what tools the police will probably use to contain and control the patient allows EMS and fire to bring appropriate equipment to the scene when called. Also, police, EMS and fire attending training together and being involved in planning strategies will build confidence in each other. When EMS or fire requests assistance with an "excited delirium" patient and it proves not to be, police will have a better understanding of why they were requested.

     Excited delirium is a difficult situation made worse when no public service agency claims responsibility for it. The only way EMS, fire and police can prevent excited delirium from becoming an in-custody death is with education, preparation and cooperation.

References

1. Di Maio TG. Excited Delirium Syndrome: Cause of Death and Prevention. CRC Publishing, September 2005.
2. Institute for the Prevention of In-Custody Deaths Incorporated. Roll Call Mini Poster, Dr. John Peters, 2006-2007.
3. Reay DT, Flinger CL, Stillwell AD, Arnold J. Positional asphyxiation during law enforcement transport. American Journal of Forensic Medicine and Pathology 13(2), 1992.
4. Ann Price et al. Plaintiffs v. County of San Diego et al, defendants, 1998.
5. Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional asphyxia. Ann Emerg Med 30(5):578-86, Nov 1997.
6. EMS.gov, National Emergency Services Advisory Council, Draft Standards.
7. Miami-Dade Fire Rescue Medical Operations Manual, Electronic Control Device, Protocol 33, June 2007.
8. Chief John Gardner, Institute for the Prevention of In-Custody Deaths, 2007 Annual Conference, Las Vegas.
9. TARP, RIPP Restraints Training Program, 1996.

     David Kleinman, NREMT-P, is a detective with the Arizona Department of Public Safety. He has worked as a patrol officer, motorcycle officer, staff training officer at the state law enforcement academy, air rescue paramedic and SWAT operator. He teaches BLS, ACLS, PALS, PHTLS and EMT/paramedic training at a local community college.