First Responder Medical Awareness for Psychological Emergencies

The efforts put forth by many municipalities to address psychological emergencies have increased over the last several years while the amount of federal funding has decreased over that same time period. Across the nation, many states are making budget cuts for mental health spending. However, the loss of funding does not equate to a lower call volume of psychological emergencies.

When we speak of psychological emergencies, responders typically think of a one-dimensional response and are sometimes dismissive or complacent in regard to this call type. The fact is, the call for service may be perceived as psychological in nature but may actually be caused by an underlying medical condition, thus causing us to fail in properly caring for our citizens.

Our citizens are the focus of our response; our customers in effect become patients and vice versa. Some of these responses consist of emergencies on multiple levels. If we fail to recognize our patients' immediate needs for service at any level, then we have failed our customers and their families.

When we respond to a call for a psychological emergency, we must assume an all-risk approach including a possible medical condition, as this leads us to provide a safer approach for our customers. We may see that patients are possibly suffering from an underlying, unknown, or undiagnosed medical condition. We must practice due diligence in our awareness that an underlying medical condition may exist, and consider how it may relate to the patient's presentation. This is readily accomplished by questioning the patient about their medical history. If they are unable or unwilling to provide a medical history, the patient’s family may be a good source for a pertinent past medical history. Even with a known medical history, however, we have not exhausted all the possibilities for an underlying medical condition. Remember, a new or undiagnosed medical condition may not be readily apparent.

Why should we assume the all-risk approach when addressing behavioral emergencies? The most pressing and significant reason is that all the needs of the customer should be met. The possibility that a medical condition may exist and may be mimicking extreme agitation or altered mentation may elude some responders. Diabetes or heatstroke can easily be mistaken for excited delirium or an acutely intoxicated individual. Other underlying medical conditions such as infections, metabolic abnormalities and electrolyte imbalances can cause changes to a person’s mental status. These are just a few examples of medical problems that can put a citizen in a combative or confused, but medically fragile, state.

When responding to a call for a combative or extremely agitated citizen, there are several factors to consider. One is that the process of physically restraining and subduing the patient places them at higher risk for respiratory failure or ventilatory compromise. This problem may also be compounded by an underlying heart disease. Decreased respirations or labored respirations are precursors to sudden death of a patient.¹

Often a drug-induced psychosis results in a struggle with law enforcement personnel. The patient will continue to struggle even after being physically restrained, and deaths can result from the continued struggle during and after the restraining process. Several studies indicate the cessation of the struggle by the patient is the point at which the patient crosses the line from being restrained due to extreme agitation to sudden death.^2,3 Shortly after the cessation of struggle, the patient continues to the next stage of respiratory arrest, and ultimately, cardiac arrest.⁴

Again, the presence of a heart problem or some other underlying medical condition will certainly increase the probability of the citizen’s death. Law enforcement personnel are often blamed for the death, because the family and general public on scene observe the incident.³ They perceive the death as being caused by the arresting officers. Typically, other than the excited delirium being exhibited, there is no underlying organic cause of death as it relates to the restraining and subduing of the patient.

Excited delirium is not a widely accepted term in the medical field, though a white paper written by the American College of Emergency Physicians defines excited delirium as a real, complex and poorly understood syndrome. In regard to excited delirium as a cause of death, this study demonstrated that excited delirium follows a typical sequence of events. These events usually begin with some form of drug intoxication followed by a struggle with law enforcement and ultimately, death. The cause of death usually has no clear anatomical cause.²

The main goal of the police officer is to provide safety for all involved. Next should be the recognition of excited delirium, based on the presentation of the patient’s actions, as well as other signs and symptoms. After recognizing a patient as potentially suffering from excited delirium, law enforcement personnel should initiate an EMS response. Upon their declaration of scene safety, law enforcements' actions should be immediately augmented with chemical sedation by the first arriving EMS personnel.

Continuous monitoring in an ambulance by the attending EMS personnel will be needed for the remainder of the encounter, during transport and ultimately delivery to the hospital.³ Observation can only be discontinued upon the final patient transfer to the attending emergency department physician. Continued observation is required since the medications may have an effect on the patient’s central nervous system and could affect their respiratory drive. To achieve the desired effect as it relates to chemical sedation, different combinations of medications may be required. In some instances patients may even require cold fluids via IV access to address elevated body temperatures.²

There are no long term studies supporting the use of chemical sedation as an effective intervention for patients showing signs and symptoms of extreme agitation or excited delirium. However, we do know through anecdotal evidence that these interventions play an important role in preventing complications.  Often the success of preventing these complications depends on the nature of the complicating factors such as drug or alcohol use.

In the event of an extremely agitated patient, EMS and law enforcement must approach the call as a team, each playing a very important role. EMS must stage at a safe distance until the scene and the patient have been secured by law enforcement. If needed, law enforcement’s response can be augmented with the use of chemical sedation by EMS personnel. Although some EMS systems have embraced and ultimately changed their protocols for the use of chemical sedation to assist law enforcement with the agitated citizen, it is not common practice on a national level. Many assume that it’s a normal operating function for EMS systems to work in collaboration with law enforcement when addressing the extremely agitated citizen; however these interactions do differ across municipalities.

Excited delirium or extreme agitation should not result in death. A positive outcome for the patient can be achieved through early recognition by law enforcement and early initiation of the EMS system. This collaboration of efforts must become the rule and not the exception. EMS and law enforcement must recognize the opportunity that working in collaboration will result in a more positive outcome for the patient and the overall community.

References

1. Stratton SJ, Rogers C, et al. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med, 2001 May; 19(3):187-91.

2. American College of Emergency Physicians. White Paper Report on Excited Delirium Syndrome, 2009: 22.

3. Karch SB, Stephens BG. Drug abusers who die during cardiac arrest or in custody. J R Soc Med, 1999; (19)92: 110–113.

4. O’Halloran RL, Lewman RV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol, 1993; 14(4): 289–285.

Christopher Velasquez is a paramedic/firefighter for the San Antonio (TX) Fire Department.

David A. Wampler, PhD, LP, is an assistant professor of Emergency Health Sciences, University of Texas Health Science Center at San Antonio, TX. He is also a member of EMS World’s editorial advisory board.