Editor’s Note: This is a guest post written by Jerry Staton. Jerry is the owner of ARTT: Affordable Realistic Tactical Training.
Though some may still try to deny it exists, excited delirium is real and needs to be addressed in your agencies’ training program. Canton v. Harris held that municipalities have a duty to train officers in core tasks. The Supreme Court wisely decided not to identify which core tasks require training, or how much training was “enough”. Since officers regularly encounter individuals that present an increased risk for a sudden unexpected death event, it stands to reason they should be trained on how to handle such problems. That is not to say in-custody deaths occur on a frequent basis, but the potential is always present and the aftermath can be devastating. How often do your officers interact with individuals with mental illness, that have been abusing illicit drugs, that fail to take prescription drugs or overdose on those medications, or individuals with pre-existing physical conditions putting them at risk for a sudden in-custody death event? Everyday! These are just some of the individuals at risk for an in-custody death.
Excited delirium is one of the conditions predisposing an individual to an unexplained sudden death. Even though excited delirium (or the more accepted term agitated delirium) has been around for over 150 years, law enforcement is just now getting the word out on how to handle a person suspected of experiencing excited delirium. As is frequently the case with “new” problems, there is not a consensus on the best approach to handle this situation. Some feel the solution is to contain the individual and wait for them to become less aggressive. Others suggest calm language and non-violent actions to keep the situation from becoming more violent. If possible we are told not to make contact with the person as this may cause them to become more violent.
This “wait and see approach” may be a good idea for someone with a mental illness or just off their medication, but not the best practice for the person in the throws of excited delirium. As scientists and medical personnel learn more about this condition early intervention by law enforcement becomes increasingly more defensible. The Institute for Prevention of In-Custody Deaths, Inc, a prominent consulting company and training provider for in-custody deaths, has been doing research into these events for years. IPICD, Inc. established guidelines pioneered by the medical community but synthesized to fit law enforcement’s needs. The approach they teach is simple, effective, and minimizes the exposure to injury for all parties.
Before initiating an action plan we must first recognize an individual as being at risk for an in-custody death. Some of the warning signs include but are not limited to being naked in public, exhibiting violence towards objects (especially glass or shiny objects), possessing superhuman strength and endurance, exhibiting bizarre behavior, sweating profusely, a sudden onset of symptoms, and incoherent speech. If trained to ask the right questions, these early warning signs can often be identified by call takers or dispatchers. With this type of recognition the appropriate number of units can be dispatched immediately instead of having to wait for the first units to arrive and determine the scope of the problem.
Upon arrival and assessing the scene, the first responder should wait for sufficient back-up before approaching the individual. This includes medical or EMS personnel as well as multiple officers (when available). In rural areas first contact may require a combination of police, fire and EMS. After formulating a plan the first step is to capture the individual quickly. This may be accomplished with traditional force techniques (overwhelming manpower) but when available, electronic control devices (ECDs) are proving to be faster, more reliable, and causing fewer injuries. OC sprays seems to have little effect on excited delirium individuals and make handling them more difficult due to contamination issues affecting everyone present. Specialty impact munitions are also prone to fail. Circumstances will dictate the need for lethal cover, but should it not be ignored just because of the absence of weapons. Remember, this individual is highly unlikely to respond to traditional pain compliance techniques and may have unlimited energy. Officers dealing with these individuals however, tire quickly and may reach exhaustion long before the struggle is over.
Once the person has been captured he now needs to be controlled. There has been a lot of criticism over the traditional face down position, but science is supportive of this position as being neutral. As no one has found a more effective way to control a highly resistive suspect, face down is the only logical alternative. In light of the perception that face down is dangerous, this position should be maintained just long enough to take the next step which is to restrain the person.
Once handcuffed and if necessary for officer and suspect safety, maximal restraint procedures applied, all weight should be removed from the person. This is referred to as using transient compression. Again, more for perception than any real danger to the person, after restraint, position the person sitting up or on their side when possible. Keep in mind it is possible to cause a death with long term compression of two minutes or longer, but the exact amount of weight required to “crush” someone will vary.
The next step may need to be left out and will be decided according to your medical protocol. If allowed, chemically sedate the patient (once restrained he becomes a patient first and a prisoner second). Naturally, EMS personnel would be in charge of administering any sedative. Please note there has been no definitive medical research or established protocols showing to a reasonable degree of medical certainty that chemical sedation is generally advisable. There has been some limited success using sedation in excited delirium events. However there are not enough events on record to establish a proven dosage or preferred method of administering the sedative. It is commonly accepted that continued exertion is the primary cause of death in many of these events. Therefore, reducing the patient’s exertion appears to cause more positive than negative results.
The last step in the action plan is to ensure the patient is immediately transported to a medical facility. Air transport is preferred if the medical facility is not within easy driving distance. Advanced life support ambulance is the next preferred mode of transportation. Placing them in a patrol unit should only be done as a last resort. Do not take them to your jail. Even if the person has “calmed down” and no longer resisting, they are experiencing a medical emergency and are in need of immediate medical treatment. The calm may be due to respiratory distress which is often followed by respiratory arrest, which if not corrected will be followed by cardiac arrest and death.
In summary the action plan suggested by IPICD involves early detection, a planned response including, capture the individual, control the individual, restrain the individual, chemically sedate if possible, and transport the individual to the nearest medical facility, preferably in an ambulance and not your unit.
There will continue to be individuals or organizations refusing to accept the reality of excited delirium, remember, they are not the ones having to deal with this issue. They are the ones that will be critical of your actions when the outcome is negative. Do not look for the same individuals or organizations to praise you when the outcome is positive. Get training in how to handle this event. Do what we always do – the best you can under the circumstances, and be prepared to explain what you did and why you did it in a detailed use of force/offense report. Expect to be second guessed, but know in the realm of police work, there is no perfect solution to a complicated problem like excited delirium.
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