Electronic Control Likely Best Option For Excited Delirium, Docs Say

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Important practical takeaways for officers on how best to deal with subjects in the throes of excited delirium are included in a recently published book on forensic medicine—and well worth roll call review, considering that these volatile encounters are expected to increase in the days ahead.

The recommendations stress the critical importance of getting highly agitated and violently disruptive individuals under control and safely restrained as fast as possible in hopes of preventing their dangerous condition from culminating in a fatal outcome.

In expert opinion, verbal de-escalation efforts are likely to prove futile…physical struggles will probably worsen the risk…a TASER electronic control device may be the odds-on favorite tool of choice for hurrying the afflicted party toward life-saving medical care.

The advice comes from two physicians with close ties to law enforcement, Dr. Gary Vilke and Dr. Jason Payne-James. Vilke is a professor of clinical emergency medicine at the University of California-San Diego and is also responsible for inmate health care at multiple sheriff’s jails. Payne-James is a specialist in forensic and legal medicine in the United Kingdom who frequently collaborates with police agencies there on medical research and related matters.

They are authors of a chapter on Excited Delirium Syndrome (ExDS) in the new anthology, Current Practices in Forensic Medicine, vol. 2, available through Amazon.

Given its association with stimulant abuse and mental illness, both pervasive in today’s society, the prevalence of ExDS, already a matter of increasing concern, “is likely to grow,” the doctors warn. Increased awareness and education about it and early recognition of its symptoms are urgently important in improving the rate of survival among those who experience it.

After a thorough discourse on the history and nature of this affliction, Vilke and Payne-James offer street-tailored tips for cops who encounter it.

RECOGNITION

Although the police are commonly “the first to be called in response to the often bizarre and aggressive public presentations” of ExDS, officers are “neither expected nor in a position to make” an official medical diagnosis of the condition, the doctors write.

Officers do, however, need to recognize the common symptoms of this “acute behavioral disturbance” and understand that they are dealing with a critical medical crisis with a significant risk of lethal results. Getting the afflicted into the hands of competent medical professionals as quickly as possible is key.

Tell-tale indicators include: “delirium, extreme agitation, constant or near-constant physical activity, not responding to police presence or verbal commands, superhuman strength, immunity to significant pain, rapid breathing, not tiring despite heavy physical exertion, being naked or inappropriately clothed for the environment, “keening” (unintelligible animal-like noises), profuse sweating, hot to the touch, attraction to or destruction of glass and reflective surfaces, and continued struggle even against overwhelming force or restraint.”

There may be “some quiescent periods followed by sudden outbursts of extreme agitation and power,” the doctors note.

The “main challenge” in dealing with all this, they say, “lies in the safe initial management” of ExDS subjects.

APPROACH

These people “should be approached in the same way that all agitated patients are approached—cautiously,” with officers keeping “their own safety in mind,” Vilke and Payne-James advise.

Unfortunately, the customary formula for soothing agitated individuals—speaking directly in a calm, firm voice, along with reducing stimuli in the surrounding environment—is rarely effective with ExDS.

“[T]hese patients respond poorly to direction from police,” the authors explain. “There may be multiple voices from many individuals attempting to engage the patient, including bystanders and family members.” In a “chaotic and dynamic locale,” the environment may include stimuli from flashing lights and sirens, police dogs, additional responding officers, and other ambient noises. “This can increase the chaos in the mind of the ExDS subject and can impede gaining rapid and efficient control of the patient so that therapy can be initiated.”

Typically, force becomes the inevitable required intervention.

CONTROL/RESTRAINT

Tactics to gain dominance “should focus on rapid control and minimization of the patient’s exertional activity, while maintaining the safety of officers and the subject,” the doctors write.

Pain compliance usually doesn’t work because of the subject’s extraordinarily high pain tolerance level.

Wrestling or fighting with him will stimulate “heavy physical exertion” on his part, “which has been shown to have a deleterious effect” on his body chemistry and “contribute to a greater risk for cardiac arrest.” Indeed, of ExDS subjects who ultimately die, “the majority do so shortly after a violent struggle, often within minutes of the cessation of the struggle,” the doctors write.

Bottom line: “The use of a TASER…to gain control and restrain someone exhibiting signs of ExDS is felt by many experts to be preferable….” Compared to “significant prolonged exertion,” a “short burst from an ECD [electronic control device] and subsequent rapid restraint” lessens the risk of cardiac arrest and seems safer for everyone involved, including the agitated individual, Vilke and Payne-James advise.

EMS ROLE

Once the subject is controlled and restrained, EMS personnel can safely begin sedation, airway protection, cooling, and other preliminary medical treatment en route to the more sophisticated services of an emergency facility.

“[A]ggressive medication therapy is the mainstay of treatment and needs to be given as early as possible,” the doctors emphasize. A sizeable section of their chapter is devoted to what are currently considered “appropriate medication therapies” for ExDS.

For reasons that currently remain a mystery, a significant percentage of ExDS cases “will progress to sudden cardiac arrest and eventual death,” regardless of what intervention is attempted. “The combination of physiological and anatomical factors responsible for [this outcome] is not fully understood and which individuals [are fated to this result] is also not clear,” the authors note.

What is clear, however, is that “ExDS is not universally fatal,” as was once believed. Results are still undeniably something of a dice toss, based on current gaps in the medical understanding of these events. But “[m]ost experts agree that early coordinated interventions by police, EMS, and Emergency Department personnel are important in helping [these patients] and can impact survival.”

Our thanks to Dr. Mark Kroll, adjunct professor of biomedical engineering at the University of Minnesota, for bringing this timely resource to our attention. Kroll adds: “ExDS is typically a ‘lose-lose’ situation for law-enforcement. If officers do nothing, the subject usually continues with behavior dangerous to himself or others. In many cases, the subject will die regardless and then the agency is sued with an argument that ExDS is a “medical emergency” so it should not have been handled with conventional control techniques.

“Of course, the agitated or excited delirium patient is having a medical emergency! However, the emergency medical personnel will not touch the patient until the law-enforcement personnel have him under control.

“In response to this common academic observation, some law-enforcement experts have wryly suggested that physician volunteers should be tasked with dealing with the excited delirium cases to ensure that they are handled properly; i.e. 911 operators would call these physician volunteers, instead of law enforcement, since they are dealing with a medical emergency.”

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