Transcript Crisis Intervention Team Training

Crisis Intervention Team
Training
Excited Delirium
Excited Delirium
Defined
“ A state of extreme mental and physiological
excitement, characterized by extreme
agitation, hyperthermia, hostility,
exceptional strength and endurance
without apparent fatigue”
(MORRISON & SADLER, 2001)
In Simple Terms
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Sympathetic nervous system activation
Chemicals are pumped into the body
Primal fight or flight response
The body can only function this way for a
limited time
• Analogous to putting your car in park and
pressing the accelerator to the floor
• If it does not slow down eventually you will
find a weak point in the “engine”
Other Terms
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Sickle cell sudden death
Agitated delirium
Cocaine psychosis
Metabolic acidosis
Exertional Rhabdomyolysis
Positional asphyxia
Sudden custody death
Can we agree something exists?
Some Causes
• Mental illness (bipolar and schizophrenia)
• Stimulant drug use and long term abuse
• Sudden cessation of drugs (anti-psychotic and
street drugs)
• Hallucinogenic agents
• New drugs (bath salts and K2)
• Alcohol withdrawal
• Etc.
Cause and Presentation
• The causes of the excited or agitated state
vary but the subjects’ presentations are
usually quite similar
• When you study all the facts after the event
they “read like a script”
• Why do we fail to recognize this condition?
• Lack of training
Training Goals and Objectives
• Education on sudden custody death
• Education on Excited Delirium Syndrome
• Learn to recognize behavioral warning signs
of Excited Delirium Syndrome
• Collaborate with Dispatchers, LE, and EMS
for handling suspected cases
• Reduce the potential for a sudden custody
death through training
Sudden In-Custody Death
• An unintentional death that occurs while a
subject is in custody. Such deaths usually take
place after the subject has demonstrated
bizarre and/or violent behavior, and has been
restrained
• There is often no obvious cause of death
found during autopsy
History of Sudden Death Proximal to
Restraint
• 1849 Dr. Luther Bell Physician at McLean
Asylum (Mass.) documented 40 cases of a
“peculiar form of delirium.” “excitement with
fear or rage accompanied with sympathetic
nervous system arousal.” Patients required
restraints. Three quarters of the cases ended
in unexpected fatalities.
History Continued
• South Carolina Mental Hospital. From 1915-1937
there were 360 deaths listed as, “exhaustion due
to mental excitement”
• In 1946 Dr. Shulack described this phenomenon
as “sudden exhaustive death in excited manics”
• In 1952 a study by Bellak described the onset
symptoms of this syndrome
• The problem continues today in mental
institutions, nursing homes, and hospitals in
situations where restraint is necessary
History Continued
• During the 1950s excited delirium deaths nearly
disappeared
• Why???
• Development of psychotropic medications
• Administered in hospital setting
• Re-immergence in the 1970-1980s
• Why???
• Mental illnesses treated outside hospital setting
• Stimulant drug use and abuse
How Excited Delirium Can Kill?
• Body can only do so much before it literally gives out
• Under normal conditions the brain sends signals to
the body to stop or “calm down” as it nears
exhaustion
• Persons experiencing Excited Delirium appear able
to ignore this safety mechanism
• Can push themselves past exhaustion into potentially
fatal medical conditions
Recognizing Behaviors
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Bizarre, violent, aggressive behavior
Violence toward objects
Attack/break glass
Overheating/excessive sweating or very dry
Public disrobing -partial or full (cooling attempt)
Extreme paranoia
Incoherent shouting (animal noises or loud pressured speech)
Recognize Behaviors cont.
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Irrational physical behavior
Hyperactivity
“Bug Eyes” (They look “nuts”)
Fight or flight response to control
attempts
• Unbelievable strength
• Undistracted by any type of pain
Video Removed
to Save Space
Typical Incident
• 911 call to Police about a man standing in the
street partially naked and/or acting “bizarre”
• Obvious to officers that subject will resist
• Struggle ensues with multiple officers: May involve
O.C., choke holds, baton, ECD, “swarm technique”
• Physical restraints applied: Handcuffs/Hobbles
• Struggle continues or escalates after restraint
• Placed in squad for transport to jail (if you fight with the
cops you go to jail)
Typical Incident cont.
• Apparent resolution after restraint
– Subject becomes calm or slips into
unconsciousness (officers believe the subject is
faking or has finally calmed down)
– Labored or shallow breathing
– Followed unexpectedly by death
– Even when death occurs in the care of
paramedics or at E.R. resuscitation fails (cardiac
rhythm is usually PEA not V-Fib)
Video Removed to
Save Space
Can it Happen in the Fox Valley?
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Mid 1980s – (APD #9124 incident) fatality
June 1999 - (James W.) survived
May 2003 - (72 hr hold/transport) fatality
Nov. 2004 - (James W.) fatality
Aug. 2006 - Winnebago Co. (car pedestrian) fatality
Sept. 2006 - Neenah PD (ECD use) fatality
March 2009- Linwood St – protocol/survived
June 2009- Jefferson St – protocol/survived
August 2009-Division St- protocol/survived
August 2011 – Kaukauna PD (fatality)
May 2013 – Riverside Cemetery – protocol survived
June 2013- Northland/Ballard- protocol survived
Why the Sudden Interest?
 Media attention to people dying in POLICE
custody
 Prior to the 1970s people were dying in mental
institutions (“nobody cared”)
 The media and other groups have attempted to
establish a link between police tactics and
unexplained deaths
 The only things changing are the police
tools/tactics; the underlying factors remain
History of Sudden Custody Death and
Police Tactics
• Choke holds: 1970s through 1980s
• “Hogtie” and Positional Asphyxia: 1980s
through 1990s
• Pepper spray: 1990s
• TASER: 2000 to present
Excited Delirium Cases Increasing?
• Significant rise in street drugs (cocaine, methamphetamines,
K2/Bath Salts)
• Significant rise in people with mental disorders
living outside of mental hospitals (not taking or
improperly taking psychotropic medications)
• More incidents of Excited Delirium
• The problem is going to get worse
• Ignoring the problem is a big mistake
In-Custody Deaths
• The reality is many of the people that die incustody suffer from one or more medical
conditions that contribute to their mortality
• Some have high levels of drugs in their bodies
that cause adverse reactions
• Some are in a mental health crisis (bi-polar
disorder or schizophrenia)
• The conditions can be worsened when the subject
is confronted and restrained by law enforcement
officers
In-Custody Deaths
• LE gets called when the subject suddenly acts
bizarre and gets out of control
• The resulting bizarre behaviors are caused by the
on-going mental/chemical/medical problems
• By the time the bizarre behavior occurs they are a
long way into the crisis. The “dominos are already
falling”
• It is too late to start planning your EMS and LE
response protocol
Early Recognition
• Training for Dispatchers is critical
• Key questions asked during the 911 call are
important
• Information gathered during the 911 call can
start the recognition process
• May lead to a simultaneous dispatch of EMS
and LE which could save valuable time
Incoming Call
• “there is a guy acting strange, running in circles”
• Ask questions to draw out description of behaviors
• What specifically is he doing?
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Bizarre, violent, aggressive behavior
Violence toward objects
Attack/break glass (windows and mirrors)
Overheating/excessive sweating or very dry (body shut down perspiration production
because of over demand on system)
Public disrobing -partial or full (cooling attempt)
Extreme paranoia
Incoherent shouting (animal noises)
Unbelievable strength
Undistracted by any type of pain (including broken bones and damaged limbs. Can easily
overpower lone officer)
Irrational physical behavior
• Video Removed to save space
Follow Up Questions
• Does the caller know the subject? If they do,
what do they suspect is causing the behavior?
● Drug ingestion?
1. type
2. how much
3. when
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Drug history?
1. chronic user
2. what type (stimulants, coke, crack, meth.)
Follow Up Continued
• Mental illness or psychiatric history
1. bi-polar disorder
2. schizophrenia
3. does subject take meds for condition
4. medication compliant
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On-set of behaviors
1. sudden (they just went nuts)
If You Suspect Excited Delirium
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Give out the behaviors described by caller
Do not just give out the “CAD label”
Dispatch Patrol Supervisor to the scene
Dispatch EMS (Fire?)
Priority response but no lights/siren in the
area of incident
• Advise EMS to stage in the area
• Keep the caller on the line if possible
What Officers Should Do
• Get EMS on the way prior to confrontation if
possible
• Avoid confrontation if at all possible
• Attempt to contain/isolate the subject without
confrontation
• Attempt verbal de-escalation
• Have as many backup officers as possible
Reality
• Bizarre/violent behaviors most often will require
confrontation and restraint
• Restraint can make the problem worse
• Without restraint this medical emergency can not
be treated
• Physical control: expect fight and/or flight
• Get the fight over quickly (i.e.TASER, swarm)
• Pain compliance will not work
• EMS protocol and transport to the hospital
Video Removed to Save
Space
Video Removed to Save
Space
What Do We Do in the Mean Time?
• Training
• Recognize: an extremely agitated and/or bizarre
subject may be more than a “nut case”
• Anticipate, recognize, and mobilize EMS before
confrontation if possible
• Treat these cases as a medical emergency
– Protocol driven EMS response
Sample EMS Protocol
(Gold Cross Ambulance of Fox Valley)
This protocol will be considered anytime
during the patient contact when the
patient’s behavior indicates the
possibility of excited delirium syndrome.
Initiate this protocol as early as possible.
Protocol Steps
• Ensure scene safety with law enforcement
intervention
• Recognize: The warning signs
• Identify patient’s “at risk” history
• Attempt verbal containment / communication
• If verbal de-escalation is ineffective allow law
enforcement to contain/control the patient
• Secure the patient
• If still combative, administer meds
• Continuous medical assessment
• Transport and radio ahead
Scene Safety
As usual procedures require, if for any reason
you are concerned about your personal safety
contact law enforcement for assistance in
dealing with the patient.
The Warning Signs
• Irrational, bizarre behavior
• Unbelievable strength and endurance
• Aggression toward objects, especially glass or
mirrors
• Impervious to pain
• Resistive to LE tactics
• Removal of clothing
Warning Signs Continued
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Aggression
Hyperactivity
Extreme paranoia
Incoherent Shouting
Grunting or animal like sounds
Perspiration – hyperthermia
At Risk History
• Known drug ingestion or abuse
• Mental illness
• Previous psychiatric history, especially
schizophrenia or bi-polar
• Taking or failure to take psychiatric
medications as prescribed
• Sudden onset of behaviors listed earlier
Intervention Process
• Attempt to de-escalate patient with verbalization. This may
not be possible due to patient's behavior
• If verbalization is ineffective, allow law enforcement to
contain/control subject. Be aware that when confronted a
physical altercation may occur
• Law Enforcement will most likely use an Electronic Control
Device (ECD) or multiple officers
• If during containment process 2 successful ECD applications
fail to subdue the patient and they continue the excited
delirium behaviors, once contained the protocol shall be
started and the subject shall be transported to the hospital
by ambulance
Secure Patient
• Avoid the use of prone or “hog-tied” positions
• Use handcuffs or limb restraints as needed
Medical Intervention
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If subject remains combative….
Administer 5mg Haldol IM, then
Administer 5mg Valium IM
Use 20g needle and inject into lateral thigh,
through clothes if necessary
• Once meds given, transport to hospital is
mandatory
Medical Evaluation
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If possible attempt:
Vital signs, including Sp02
Blood Glucose
EKG Rhythm
Body Temperature (very important)
IV Access should only be attempted if it can be safely
initiated and maintained
• Avoid invasive procedures if patient’s aggression
poses a bio-hazard/sharps risk
Transport
• Transport to medical facility
• Radio ahead so hospital can make
arrangements for security and safety
precautions
• Transport will include a law enforcement
officer riding along in the back of the
ambulance if possible