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Excited Delirium Gets More Complicated; What Do To About It

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If it looks like a duck, walks like a duck and quacks like a duck, it’s a duck, right?

Not always. Especially when “it” is “excited delirium,” the complex phenomenon currently regarded in law enforcement circles as the likely cause of many in-custody deaths.

What appears to be the often-irreversibly fatal physical and mental meltdown that characterizes ED may, in fact, be one of at least 5 other critical medical conditions, according to Canadian researcher Chris Lawrence, a technical advisor to the Force Science Research Center at Minnesota State University-Mankato.

Some of these conditions that share symptoms with ED require prompt intervention by medical personnel, not the contain-and-attempt-to-calm approach often recommended for dealing with ED. Delay, in those cases, actually heightens the risk of fatality.

So how can a street cop accurately determine what he’s really dealing with?

“He can’t,” Lawrence declares. “The best he can do when faced with ED-like symptoms is make getting medical assistance to the scene a top priority. And that needs to be the core component of any training or policies designed to address the ED problem.”

Lawrence, a project partner at the Canadian Police Research Center in Ottawa (Ont.), has educated LEOs on ED at a variety of training conferences and departmental programs over the last 4 years. He’s emphasized that the internal stresses on a suspect’s body that are associated with ED are more likely contributors to in-custody death than the favorite whipping boys, restraint positioning or Tasering. And he’s thoroughly delineated the external symptoms commonly exhibited by ED subjects.

These may include, among others, bizarre behavior, confusion and disorientation, unusual agitation or excitement, hallucinations, paranoia, violence, intense struggling against restraint, high body temperature, profuse sweating, undressing and insensitivity to pain.

Lawrence teaches that unless an apparent ED subject is presenting a direct threat to officers, himself or others, he should be regarded more as a medical problem than a police problem. Thus LE first responders need to get the subject into medical hands–and out of police responsibility–as quickly as possible.

Lawrence’s latest research, he says, leaves him more convinced than ever of the value of this approach.

Backed by medical texts and journal articles, Lawrence has recently identified 5 medical emergencies “that can result in behavior very similar to a person experiencing ED.” These can be encountered by any officer during normal patrol activities and should serve as reminders that “not everyone exhibiting ‘ED-like’ behavior” is necessarily on a cocaine binge or mentally ill, factors that are commonly associated with ED.

The ED-mimicking medical emergencies may, in fact, be:

HYPERTHERMIA (abnormally high body temperature)

“Hyperthermia can create problems that can appear similar to intoxication, and in some cases can even appear very similar to ED,” Lawrence reports. Usually, people with high body temperature are sweating. But sometimes side effects from medication for bladder or gastrointestinal problems, asthma, motion sickness and muscular spasms can produce hyperthermia with hot, dry, flushed skin.

“In those cases the subject may be sweating less than normal or not at all,” Lawrence explains. “This may cause disorientation.”

The subject may begin to exhibit problems when his temperature reaches 102 degrees. Brain cells may be destroyed at about 110. The body’s ability to regulate heat is likely to fail, and at 112 degrees death is almost certain. “Early medical assistance is vital when dealing with hyperthermia,” Lawrence emphasizes.

He cites the case of a man who left work on a very hot day because he wasn’t feeling well. En route home on a bus, he “acted like a crazy man” and had to be restrained by other riders. At a hospital, he was received as a psychiatric patient. Only later was he correctly diagnosed as hyperthermic, underscoring the problems even trained medical personnel may have making accurate determinations merely from observation.

Recognized, the problem is treatable by rapid cooling of the body. “Asking medical personnel to take the subject’s temperature could become the most important contribution” an officer can make to “the safety of a subject who has been struggling” against efforts to control him, Lawrence advises.

DIABETES

Low blood sugar in a diabetic “may precipitate sudden mood swings that would appear as sudden anger or crying, sweating, nervousness, rapid heart beat, confusion and seizures,” Lawrence says. “Aggressive behavior may appear similar to ED-type behavior” to a responding officer, “particularly if the officer has never dealt with confirmed ED before. If low blood sugar continues to drop, the subject may go into a coma and die.”

This kind of episode may occur “regardless of whether the subject has a mental illness,” although psychotic illness and its treatment are considered to heighten the risk of diabetes and poor blood-sugar control.

Lawrence points out that the landmark case of Graham v. Connor involved a subject experiencing this type of problem. In that case, the subject “advised officers that he needed sugar to counteract his medical problem. Pay attention to people who make this kind of statement. Fruit juice or candy may indeed improve their situation.”

In the case of a diabetic experiencing high blood sugar levels (hyperglycemia) rather than low, “there will be an increase in acetone levels in the blood,” Lawrence says. “As a result, the subject’s breath may carry the odor of acetone”–think of nail-polish remover–”which you may be able to detect.” Upper levels of hyperglycemia tend to be less associated with aggressive behavior and more with severe debilitation leading to coma.

HEAD INJURY

Sometimes disruptive behavior can result from a head injury that an officer can see little or no evidence of. Traumatic brain damage or “brain insult” can produce psychosis years after the initial injury, Lawrence says. Or pressure on the brain from swelling may produce aggressive behavior. Or a subject may be suffering from viral encephalitis, which can create psychosis, depression, mania, fever and/or disorientation. “Even concussions may result in increasing confusion, restlessness or agitation,” with symptoms of irritability, angry outbursts and violence a la ED.

“The situation could become fatal, depending on what caused the injury,” Lawrence notes. “These injuries must be treated by a physician.”

DELIRIUM TREMENS (the DTs; alcohol withdrawal)

An alcoholic who suddenly stops drinking, particularly when not eating properly, may experience abrupt, severe and rapidly progressing mental changes. Symptoms commonly occur within the first 72 hours after the last drink, Lawrence says, but may not show up until a week to 10 days later.

Symptoms may include anxiety, rapid emotional changes, sweating, shaking, hallucinations, paranoia (leading to lashing out) and seizures, again mimicking characteristics of ED.

DTs tend to be fatal about 30 per cent of the time, if not treated properly, Lawrence says. These subjects are in an acute medical emergency and need to be “taken directly to a hospital for treatment.”

THYROID STORM

This is a rare, metabolic complication involving an overactive thyroid gland (hyperthyroidism) that is “often precipitated by a physiologically stressful event” and, if “unrecognized and untreated, can be fatal.” It can afflict either gender but, unlike ED which tends predominately to affect males, it “often involves women, aged 20 to 60 years of age.”

Again, the familiar symptoms: psychosis, anxiety, disorientation, heat intolerance, increased sweating, restlessness, wide emotional swings and potential coma.

Diagnosing any of these 5 medical conditions–or even ED itself, for that matter–is “obviously beyond the ability of a police officer,” Lawrence stresses. Any subject exhibiting symptoms that in any way resemble ED “should be assessed by someone with medical training.

“Protracted negotiations, waiting for the subject to calm down, waiting for a crisis team to be called out, putting the subject into a quiet room/cell until he or she calms down, placing them in a restraint chair or on a restraint bed where their ability to harm themselves is believed to be reduced”–all these supposedly helpful responses may actually be harmful, even fatal, to a subject if they delay or are considered substitutes for proper medical attention.

Consequently, Lawrence offers these observations and recommendations for handling ED or anything resembling it:

  1. Dispatchers and officers should be trained to summon medical help IMMEDIATELY upon detecting any symptoms in a subject that resemble ED. “Don’t wait until some police methodology has failed before getting medical responders involved.” Knowledgeable probing of complainants by dispatchers may surface evidence of ED symptoms, allowing EMS to be dispatched simultaneous with officers.
  2. Also get multiple officers on the scene ASAP. Multi-officer control tactics will probably be necessary ultimately to restrain the subject if he is beyond verbal persuasion and is exhibiting the superhuman strength and resistance to pain commonly displayed in apparent ED situations. If a Taser is used to create a window of opportunityt for officers to establish control, it will probably be more effective in the probe mode, which transcends mere pain compliance, than in the stun mode, which is pain-dependant.
  3. If safe to do so, initiate restraint techniques when EMS personnel are present, so that medical attention and transport to a treatment facility can be started promptly thereafter. Depending on response times, that may necessitate some delaying tactics at the scene, which still is probably the most conservative and acceptable approach PROVIDED that safety is not compromised and that medical help is en route.
  4. If possible during this lag, question family members, other witnesses or the subject himself (if coherent) regarding evidence that might relate to one of the 5 non-ED conditions mentioned above. This would include knowledge of recent falls, a history of diabetes or alcohol addiction, medications that may be involved, etc. Convey this information promptly to arriving medics.
  5. In designing training or policies, don’t set expectations for officers’ responses too high. Under pressure to “do something” about this “high-profile problem that isn’t going to go away,” some agencies are trying to construct detailed policies and “better” training programs that, in fact, may not be realistic.
    “Exercise caution,” Lawrence urges. “Ask yourself: how much medical knowledge is it reasonable to expect an officer to retain? How much and what kind of additional training is required? Who should provide it? How will it be evaluated?
    “Realistically, officers should not be expected to ‘diagnose’ beyond determining that a suspect’s behavior or situation is unusual and requires medical attention.”
  6. Do what you can to motivate your medical community-first responders, ER staffs, medical examiners/coroners alike-to learn more about the prevalence and nature of ED and the conditions that can mirror it.
    “It’s amazing how little some medical ‘experts’ know about this condition,” Lawrence says. “I’m shocked at the number of times I encounter ER people who have never heard of ED. Some who’ve heard of it even deny that it can be a cause of death. They consider it ‘made up.’”
    In a worst-case scenario, the result can be an easy rush to judgment from a misdiagnosis or an inadequate autopsy that results in blaming police tactics for an in-custody death that in truth was beyond police control.
    “Talk to your local medical authorities and alert them to this,” Lawrence urges. And do what you can, as well, to educate prosecutors, review boards, the media and others who will inevitably judge your actions in fatal episodes. Getting information into the right hands now, Lawrence says, “will allow people to consider the information with their heads rather than when they are influence by their emotions after a death.”
  7. Perhaps most important, understand–and educate others–that with ED or conditions that provoke similar behavior, you may be in a no-win situation. One medical lecturer has likened ED subjects to being on “a freight train to death.” By the time police are called and respond, these subjects may already be so far advanced in their psychological and physical distress and deterioration that no type or amount of intervention will be able to prevent their ultimate demise. Indeed, Lawrence points out, “people have ED-like episodes while in a hospital, with the best medical professionals and equipment available right at hand, and still do not survive.

“We should always be striving for a better response,” he agrees, “but at the same time we must realize that in situations where ED may be involved a better response will not necessarily guarantee a better outcome for the subject.”

[Note: To see Chris Lawrence’s full report on other medical emergencies that can look like excited delirium, including his documentation, go to the following link on PoliceOne.com:

http://www.policeone.com/writers/columnists/ChrisLawrence/articles/1182796/

[For more information, see Force Science News Transmission #29, 10/7/05, “10 Training Tips for Handling ‘Excited Delirium.” You can also find several other articles by Chris on PoliceOne.com at:

http://www.policeone.com/writers/columnists/ChrisLawrence/

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