Historically, a naked, screaming and agitated individual standing in a busy roadway during rush hour traffic required only law enforcement response. Police were expected to remove the subject from the roadway and take him to an appropriate facility. When force was used to subdue the subject, injuries were commonplace, and fire departments and EMS responded at the request of the police and treated the injuries. Medical treatment was focused upon clearing the subject for incarceration into a jail facility. Unfortunately, this scenario often resulted in the untimely and unnecessary death of the subject.
According to Theresa Di Maio, author of Excited Delirium Syndrome: Cause of Death and Prevention, delirium is a mental state characterized by an acute circumstance of disorientation, disorganized thought process and disturbances in speech.1 When that mental state involves violent behavior, it is called excited delirium. In that state when there is a sudden death and the autopsy fails to reveal a cause, it becomes excited delirium syndrome. Dr. John Peters of the Institute for the Prevention of In-Custody Deaths lists the characteristics of a person in excited or agitated delirium in Table 1.2 This is not a comprehensive list of the characteristics of excited delirium, but a representation of the more easily recognizable ones.
Educating paramedics, firefighters and police officers is the first step to preventing in-custody deaths. In recent years, police agencies have done an excellent job of educating their officers to recognize the signs of excited delirium. Early attempts at education focused on positional asphyxia as the culprit in in-custody death. Hog-tying became outlawed by many police agencies based upon studies done by a medical examiner from Washington state.3 Even after those studies were refuted and Dr. Donald Reay retracted his conclusions on positional asphyxia, police agencies continue to prevent officers from hog-tying.4 Continued research has shown positional, postural or compressional asphyxia to be a factor of in-custody deaths, but certainly not the only concern needing to be addressed when faced with a potential excited delirium patient.5 Teaching foundations like the Institute for the Prevention of In-Custody Death (www.ipicd.com) serve as a clearinghouse for current research and as an educational resource to any agency looking for a structured teaching program on excited delirium.
Accurate reporting of in-custody deaths has only recently been implemented with the Death In Custody Reporting Act of 2008. Estimates in previous years vary, depending upon the definition used of what constitutes an in-custody death. So what can agencies do to reduce or prevent these deaths?
The United States Department of Transportation (DOT) Office of EMS produces the curriculum to educate all EMTs, paramedics and firefighters in prehospital emergency care; however, the current curriculum does not mention positional asphyxia or excited delirium. The National Emergency Medical Services Advisory Council recently released updates to the DOT curriculum that include those conditions.6 Unfortunately, this will only be offered to new and future caregivers. Those currently certified can get the information through continuing education classes at their local hospitals. Since the subject matter for these classes varies according to what prehospital medical directors believe is important, it will be up to police personnel to make them aware of just how important this training is.
Agencies like Miami-Dade Fire Rescue (MDFR) have adopted protocols for aggressively treating patients with excited delirium. Their standing order outlines the signs and symptoms, as well as criteria for using the treatment protocols,7 including rapid capture of the patient by law enforcement and administration of a sedative by EMS to calm the patient and allow for treatment. MDFR gives Versed via the needleless mucosal atomizer device, which allows for drug delivery with minimal risk of accidental needlestick to EMS and positive drug delivery to the patient. Once the patient is calm and accessible, an IV of 60°F normal saline is initiated and infused "wide open." A prophylactic 1 amp sodium bicarbonate is given for acidosis that results from prolonged struggle.