Excited Delirium is defined as, “A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue” (Maio & Maio, 2006).
In 1849 Dr. Luther Bell, a physician for the McLean Asylum for the Insane, in Sommerville, Massachusetts, found what he believed to be a new illness among his patients of the asylum. This new illness became known as “Bell’s Mania.” Dr. Bell also noted many clinical symptoms of Bell’s Mania which included: acute onset of symptoms, mania, violent behavior, need for restraint, refusal of food, inability to sleep, and fatigue deteriorating to exhaustion and circulatory collapse (Maio & Maio, 2006).
These symptoms are believed to be related to the symptoms of Excited Delirium that is known of today. Many of Bell’s patients and other patients at the hospital died from a combination of things such as electrolyte imbalances, dehydration, and other numerous factors.
In the late 19th Century, Dr. Emil Kraeplin, a German psychiatrist, developed some classifications of the mentally ill based on the symptoms presented. The utilization of this classification resulted in being able to identify groups of patients who were at a high risk for sudden death due to Excited Delirium Syndrome (Maio & Maio, 2006). Dr. Bell and Dr. Kraeplin documented some of the earliest cases of Excited Delirium.
By 1933, Dr. Irving M. Derby, a pathologist a Brooklyn State Hospital, began noticing what he called “Manic-Depressive Exhaustion.” He learned this after several deaths occurred with similar symptoms. The entity that he called Manic Depressive Exhaustion was also called by others; Acute Delirium, Acute Dementia Praecox, Catatonic Death or Bell’s Mania. Dr. Derby reported about 148 patients whose very deaths were attributed to Manic Depressive Exhaustion (Maio & Maio, 2006).
In a 1934 Doctor G.M. Davidson reported several deaths were related to Acute Lethal Excitement. This excitement was sudden onset of illness, history of delusions and hallucinations. An acute state lasting 4 to 20 days, with symptoms of: extreme psychomotor excitement and restlessness, rapid physical decline, schizophrenia of the catatonic type, postpartum psychoses of the catatonic type, and manic-depressive psychoses of manic and mixed type (Maio & Maio, 2006). The findings reported by Dr. Davidson prove that they are very consistent of what Dr Bell and Dr. Derby had found in their cases.
1960’s and Today
In the 1960’s, a major shift began to occur. Patients with mental illness began receiving better treatment, which made the deaths relating to the chronic form of Excited Delirium disappear. By the beginning of the 1980’s however, an acute form of Excited Delirium began to take shape. However, this form was mainly diagnosed by the use of illegal stimulants such as cocaine. These deaths were characterized with the following; mostly of male victims, victims that had not been diagnosed with mental illness, sudden death occurring minutes or hours after the development of Excited Delirium, the use of restraints, and involvement of illegal stimulants and medications (Maio & Maio, 2006). Certain symptoms described by Dr. Bell in the chronic form of Excited Delirium are also prevalent in the acute form. The main difference between the chronic form and the acute form is the amount of time that between is the onset of the symptoms and death. For example, in the chronic form this could take a matter of days or weeks. In the acute form this could take a matter of minutes or hours.
In the 1980’s dying from Excited Delirium, more specifically Bell’s Mania, became relatively unknown to medical professionals. The only people who have even heard of this were the people of the psychiatric community. The knowledge of Bell’s Mania began to fade. In fact many of these cases were being misdiagnosed and began showing up as a “heart attack.” Pretty soon things started to change with the use of cocaine and methamphetamines (Maio & Maio, 2006).
During the 1980’s there was major increases in cases reported with behavior related to uncontrolled psychiatric emergency. Most of these cases were in conjunction with cocaine abuse that was starting to hit North America during this time. Cocaine and Excited Delirium Syndrome seemed to be almost intertwined. There has also been cases were Excited Delirium Syndrome occurs with other illegal drugs and with many types of mental illness and their treatment medications. In fact in 1985 the first paper was published for the first time that used the term Excited Delirium.
Causes of Excited Delirium
The “typical person” who shows symptoms of Excited Delirium is a person that has major drug intoxication, and the person might have a history of mental illness struggles with law enforcement. Police may use physical or chemical control measures or even electrical measures to help in controlling the person.The autopsy will fail to recognize a potential cause of death from trauma or natural disease (ACEP Excited Delirium Task Force, 2009).
Since there is no noticeable cause of death in an autopsy it is hard to come up with a definitive cause of death. Many people believe this term is an easy way out for law enforcement, when people die as a result of being in-custody (ACEP Excited Delirium Taks Force, 2009).
Stimulant drug abuse can be a cause of Excited Delirium. Stimulant drug use such as: Cocaine, Methamphetamine, Phencyclidine (PCP), and Lysergic Acid Diethylamide (LSD) have been associated with Excited Delirium Syndrome. Acute intoxication has been found to trigger the onset of symptoms for Excited Delirium. These stimulant drugs have also been found to be the cause of Excited Delirium deaths (ACEP Excited Delirium Taks Force, 2009).
Cocaine has been a major problem in dealing with Excited Delirium. Cocaine has been a major cause of Excited Delirium in some people. Excited Delirium usually occurs after people have been on a cocaine binge, and to people who have had long history of cocaine abuse.
Another cause of excited Delirium is mental illness. The two major causes are Mania (Bipolar Disorder), and Psychosis (Schizophrenia) (Barney, 2003). When people enter a psychiatric facility they are sometimes misdiagnosed What the doctors are witnessing is Excited Delirium. Sometimes the underlying illness is untreated at the time the symptoms of Excited Delirium are showing. Health care providers should take heed. Early recognition and training can help prevent many In-custody deaths, in the next chapter this will be explained more in depth.
Awareness and Recognizing Excited Delirium
Excited Delirium is part of some serious psychologic and behavioral symptoms which could include:
“Unbelievable strength, imperviousness to pain, ability to offer effective resistance against multiple officers over an extended period of time, hyperthermia (temperatures in the body can spike between 105-113 degrees Fahrenheit), sweating, shedding of clothes or being naked, bizarre and violent behavior, aggression, hyperactivity, extreme paranoia, incoherent shouting of nonsensical speech, hallucinations, attraction to glass (people will most likely be smashing glass), confusion or disorientation, grunting or animal-sounds while struggling with officers, foaming at the mouth, drooling, and finally dilated pupils” (Kulbarsh, 2011).
Also Excited Delirium is a pumped up version of the flight or fight response in the body. The person will try to run and then try and fight without being effected by pain (Brotheim, 2007). Another physical characteristic of Excited Delirium is animal like behavior including: grunting, biting, scratching, and pushing-very primitive actions (Remsberg C., 2006).
Excited Delirium is a major medical emergency, and is something that should not be taken lightly. It requires medical attention immediately during onset. Excited Delirium makes the sympathetic nervous system go into hyper drive. The sympathetic nervous system is responsible for the release of adrenalin, heart rate, body temperature control, and pain perception. Excited Delirium works with many other dangerous effects on the body including: hyperthermia, changes in blood acidity, electrolyte imbalances, a breakdown of muscle cells, cardiac arrhythmias, and ventricular fibrillation (Kulbarsh, 2011). When death comes to a person who exhibits signs of Excited Delirium the person will exhibit a state of sudden tranquility, either during or after the initial struggle and restraint, followed by cardiac arrest. It is very important that law enforcement officers, medical personnel, and dispatchers recognize the signs of Excited Delirium and sudden death that might follow, that way emergency medical attention can be initiated right away (Kulbarsh, 2011).
Current Standards for Law Enforcement Officers and Agencies
Law enforcement agencies need to establish some protocol ahead of time for dealing with such cases (Kulbarsh, 2011).Dispatchers should also be trained to recognize the signs of Excited Delirium and ask some follow-up questions. If Excited Delirium is the case then the dispatcher should alert officers, and they should alert paramedics to be on standby (Kulbarsh, 2011).
The first officer on the scene, he/she believes it is a case of Excited Delirium then they must call for backup and they should have EMS there as soon as possible. Even before the officers arrive on the scene they should already know, from dispatch, what they are dealing with. It is recommended that several officers come to the scene It is not recommended that one officer come to the scene and try and handle it by themselves (Kulbarsh, 2011).
The first officers on the scene should be ready to manage the subject, making sure that they do not hurt themselves and hurt other individuals. Officers should not approach the subject until proper backup has arrived and paramedics are on standby (Kulbarsh, 2011).
Trying to control the person who is experiencing Excited Delirium and the situation is very important. Be sure to establish control quickly. The longer the confrontation with a person who is experiencing Excited Delirium, the greater the risk that person will die while in-custody (Kulbarsh, 2011).
Police officers are usually trained to place a suspect in face down position. With someone who is experiencing Excited Delirium this not a really good idea. With a person in the face down position an individual might have hard time breathing. When the suspect that is experiencing Excited Delirium and is in police custody they should placed in a face up position. If the suspect stops resisting his pulse and breathing should be monitored It is imperative that law enforcement officers wait for medical personnel to help in restraining the subject. Medical personnel know how to restrain a person for transport to the emergency room (Kulbarsh, 2011).
Protocols should be put into place for use of force options. If a person is suffering from Excited Delirium, the suspect may have superhuman strength and pain may not even phase the suspect one bit. This makes all pain-based techniques useless. Pepper spray can also be ineffective to person who is impervious to pain. The use of batons and other impact techniques possibly could be effective in stopping movement; it will not be because of pain. TASERs can be effective, because they temporarily override the central nervous system. Use caution with TASERs though there is an increased risk for sudden death for people suffering from Excited Delirium TASERs should be the a last resort. If possible try to control the situation without the use of TASERS (Kulbarsh, 2011).
Transporting a person that is experiencing Excited Delirium in an ambulance is very important. In the ambulance the paramedics can watch the subject’s vitals like: heart rate, blood pressure, respirations, CO2 levels, PH levels, and temperature are a must (Kulbarsh, 2011). If vitals are not checked the person suffering from Excited Delirium could die.
Debriefing after this incident takes place is very important so agencies can learn from the incident, what can be done in the future if they come across this incident again. Agencies could also use debriefings for personnel that has been involved with these types of critical incidents. This is especially important if the person died while in-custody (Kulbarsh, 2011).
It is always important to remember the mnemonic protocol created by Dr. Michael Curtis, P.R.I.O.R.I.T.Y. M.E.D.I.C.A.L. Each letter stands for a symptom of Excited Delirium and what to do when you come upon this situation. Psychological issues, Recent drug/alcohol use, Incoherent thought process, Off (clothes) and sweating, Resistant to presence/dialog, Tough, if not super-human strength, Yelling, Make an informed decision, Enlist backup, Disturbance-resolution model, Intervene (use TASERs with caution), Contain, Attend to medical needs, Least amount of force necessary (Kulbarsh, 2011).
Law enforcement officers are in a unique and very unfamiliar position. They find themselves in an impossible situation where they have to recognize this medical situation. They have to try and control an individual who is irrational and physically resistive, while they are trying to keep everyone safe (ACEP Excited Delirium Taks Force, 2009).
A person who is suffering from Excited Delirium poses a challenging situation, which has the possibility to impose major public scrutiny and the possibility for a horrific outcome. Though there is always that possibility where things could go wrong and there will be some major public outcry (ACEP Excited Delirium Taks Force, 2009).
It is very important that law enforcement officers understand that a person who is suffering from Excited Delirium Syndrome lacks remorse, normal fear and understanding of his or her surroundings, and most importantly rational thoughts of safety. Law enforcement officers must realize that this is and could be a potentially life threatening medical condition (ACEP Excited Delirium Taks Force, 2009).
Up until now, everything the officers have been taught relies on the suspect being able to cooperate and the ability to be rational. The officers also rely on the suspect’s ability to comply with the officer’s commands. Many tools and tactics that are available to law enforcement officers are going to be less effective on a person suffering from Excited Delirium (ACEP Excited Delirium Taks Force, 2009).
One research has indicated that if a person has Excited Delirium and the officers know what is going on, it is not the greatest idea for officers just wait until the situation rectifies itself. This could take hours and the suspect could die as a result of just waiting. Law enforcement officers should realize that Excited Delirium is not a crime, and they should recognize the difference before it is too late (ACEP Excited Delirium Taks Force, 2009).
Emergency Medical Services
Emergency Medical Services (EMS) dispatchers also need to recognize the symptoms of Excited Delirium, they need to listen and find different clues tell other people what they are responding to. With these clues multiple law enforcement officers can respond to the situation including the EMS (ACEP Excited Delirium Taks Force, 2009).
EMS find themselves in unfamiliar territory because they have to have a heightened sense of personal safety because of what Excited Delirium involves, and they need to provide timely care to these individuals (ACEP Excited Delirium Taks Force, 2009).
The first thing is that Law Enforcement Officers need to do is control the person with Excited Delirium Syndrome. After control is obtained by the law enforcement officers then EMS can recognize this emergency medical situation and assume the responsibility of assessing and caring for the person (ACEP Excited Delirium Taks Force, 2009).
Medical Examiners are required to decide on a cause of death while individuals that die in police custody. Lack of medical information, and any underlying cardiac and metabolic information, makes it really difficult for the medical examiners to come up with an exact cause of death (ACEP Excited Delirium Taks Force, 2009).
Critical information such as behavior of the suspect, drug history, the history of the suspects psychosis, and the presence of hyperthermia are all factors that can determine to the medical examiner that this is a case of Excited Delirium (ACEP Excited Delirium Taks Force, 2009).
The majority of cases that appear to be Excited Delirium Syndrome occur in people who have a history of cocaine and other stimulant abuse. Sometimes this syndrome will happen even without these drugs in the person’s system. As of right now there is no test out there for medical examiners to test for Excited Delirium Syndrome (ACEP Excited Delirium Taks Force, 2009).
Excited Delirium is extremely rare. It is estimated that between 50 and 125 in-custody deaths in the United States every year are related to Excited Delirium. Most of these cases are of males between the ages of 30 and 40. This syndrome is rarely seen in females. Excited Delirium is increasingly becoming the cause of death in in-custody deaths.
Police intervention is usually blamed when death occurs. It has been proven that Excited Delirium has been the cause of in-custody deaths as early as 1650. This was way before the invention of Tasers, OC, hog-tying or other law enforcement tools and techniques that some critics link to in-custody deaths (Remsberg C., 2006).
It also has been found that Excited Delirium tends to be more of a warm temperature event (meaning that it happens when the temperature is warm and not cold). The situation is also motivated when there is high humidity (Remsberg C., 2006).
Statistics show that Excited Delirium tends happen at the end of the week, on Sunday, than any other day. The heaviest occurrences tend to happen Thursday through Sunday (Remsberg C. , 2006).
Medical personnel at the University of Minnesota Emergency Medical program did a 12-month research experiment were they researched internet search engines for specific words such as: subject gender, age, behavior, arrest, force, weapons use, time of collapse proximal to arrest, force, and presence of illicit substance abuse (Brotheim, 2007). As a result of this study medical personnel at the University of Minnesota Emergency Medical program could identify some the causes that lead to in-custody deaths.
The search results were as follows: 162 in-custody deaths were reported, 96.3 percent were males, the average age was 35.7 years old, 62.9 percent of them were exhibiting bizarre behaviors, and 62.3 percent of them confirmed illicit drug use just prior to their arrest (Brotheim, 2007).
How does this break down as far as people dying in-custody. Well 8.6 percent of the suspects in-custody were hit with impact weapons, 12.3 percent of the people were shot with chemical spray, 30.1 percent were shot with a TASER, 62.3 percent of the people referenced ingested illegal drugs, 68.5 percent went hands-on with police officers, 100 percent while handcuffed. It was noted that many of the people referenced fit more than one of the categories so the results are not going to equal 100 percent (Brotheim, 2007).
This study found that in-custody deaths occur largely to males less than 45 years of age, using illicit substances. In-custody deaths appear to occur within the first 60 minutes when weapons are in play. In-custody deaths never happen instantaneously when a TASER is used (Brotheim, 2007).
Cases of Excited Delirium
Case 1: Jefferson Street, Appleton, WI
The case began on a Monday in June in Appleton, WI. A call to 911 of a complaint of a naked man and ended later in evening at the hospital with the raving a man being calmed down by capable medical personnel. In this situation there was no heavy-handed control tactics, there was no risk to people or property, and there was no lawsuits from angry relatives (Remsberg C., 2009).
Thanks to Lt. Dave Nickels of Appleton Police Department’s patrol division he knew exactly what was going on with the young man at Jefferson Street. He and other officers were up against a terrible situation and managed to take care of this situation with professionalism (Remsberg C., 2009).
A frantic call to 911 a mother is in distress because something is happening to her 29-year-old son. The son had a long history of marijuana use. The mom also noticed that he was “acting very strange, he kept on talking and talkingâ€¦like he was on somethingâ€¦saying ‘I’m dying, Mom, I’m dying, Mom’â€¦” She also told 911 “he’s sitting there naked. He certainly doesn’t do that in front of his mother!” (Remsberg C., 2009)
The dispatcher responding to the call alerted two patrol units to respond to the Jefferson Street incident. Nickels, who at the time was patrolling the street in his car, heard the call. The dispatcher was saying there was yelling, strange behavior, repetitious statements, heavy breathing, and unusual nudity. Lt. Dave Nickels decided that he would respond to the call as well (Remsberg C., 2009).
Nickels, is a TASER master instructor, became very interested in a psychological and physiological meltdown known as Excited Delirium. Some of the in-custody deaths in his area were linked to Excited Delirium. He had done some research for more than ten years and developed a training program for his department and other area agencies. He did this in the hope that officers, dispatchers, and medical personnel would become better aware of the symptoms and handling the situation (Remsberg C., 2009).
Two weeks before this incident happen, Nickels put together a small PowerPoint presentation to kind of refresh the officers about how to respond to an Excited Delirium call. He emphasized in the PowerPoint that the subjects are usually “are a long way into the crisis.” They are in a medical nightmare, where they need help. Training from arriving officers will help the officers likely not to view the suspects threatening behavior as a criminal problem (Remsberg C., 2009).
When Lt. Nickels entered the house on Jefferson Street, he witnessed subject with long-hair, well conditioned, gesturing wildly, is entirely naked in the room. He also witnessed that the subject was highly agitated and sweating profusely. The subject is screaming over and over again “Is I’m going to die?!” Meanwhile the mom is trying to hand him some clothing. He continues to yell at the officers.
As Nickels was looking at the situation he remembered some of the principles he stated in his training programs. Being the in charge he managed to be calm and calm voice he called the man by name and showed the man that he had nothing in his hands. He was not confrontational with the man, and he used no threatening language. He did not use any commands, and he did not shout at the man. Nickels says “you do not want to feed these people adrenalin.” Nickels also states “they’re already thinking that you’re going to hurt them. To the extent that’s possible and safe, you want to model calmness for them.” (Remsberg C., 2009)
It was also important that Nickels did not crowd in on the subject. Nickels states “avoid confronting them, if you can.” Nickels managed to get the mother to back away from her son, to give him more space. The man stated that he was going to lie down, Nickels agreed with the man (Remsberg C., 2009).
The main thing is that Nickels had a plan, and when sufficient officers arrived, with medical personnel he was able to set the plan in motion (Remsberg C., 2009).
Nickels had backup, he was positioned inside the front door with a TASER drawn and on, ready to fire if the situation called for it. Nickels also had other backup at the rear of the house. From this point the two officers in the rear of the house could block the rear exit, and bring the suspect to his feet, if need be. An Advanced Life Support (ALS) team was also there ready to administer sedatives if need be.
There was lull in movement of the subject, and Nickels announced “all right, let’s move.” (Remsberg C., 2009) He promptly had the officers control the subject’s limbs. Nickels and another officer grabbed and arm and two other officers lay across his legs. With Nickels permission the paramedics gave a shot of the sedative Haldol and the paramedics then began to strap the subject to a board (Remsberg C., 2009).
“When restraining these subjects is likely to be the critical point,” (Remsberg C., 2009), Nickels states “They fight their hardest then and may think you are trying to kill them. It’s important for EMS to shoot them up quickly – to chemically restrain them – so the sedative can start calming them.” (Remsberg C., 2009)
As they are ready to the subject still continues to yell out gibberish and expels great amounts of air, he growls, screams out “Mom, don’t let them kill me!” (Remsberg C., 2009) At this point he is unable to move. The paramedics then move him out the door and into the ambulance to the emergency room (Remsberg C. , 2009).
At the hospital he was sedated even more. It took about 90 minutes for him to act normal again. When he fully recovered from this he did not even remember anything that had happened to him. He has since resumed his normal everyday activities as a college student, with no side effects (Remsberg C., 2009).
The good news was that this experience was not as intense or as violet some Excited Delirium cases are. The subject did exhibit a number of common symptoms associated with Excited Delirium: fear, high body temperature, repetitious and incoherent speech, paranoia, profuse sweating, nudity, irrational shouting, bizarre statements and behavior. Watching the video of the incident is a good reminder of how dangerous Excited Delirium can be. It also shows people how to recognize Excited Delirium when they see it.
Important lessons that were learned from this incident reinforce many things like: all officers, dispatchers, and responding medical personnel should be educated the signs of Excited Delirium. Nickels states “Education on what it is and how it presents is the first big key to handling it successfully.” He goes on by saying “Periodic reinforcement is important, because ED is one of those ‘low-frequency/high-risk’ events.” (Remsberg C., 2009)
Based on what the dispatchers are receiving, they can get medical personnel and police to the scene quickly. An ALS unit on hand can promptly give tranquilizing drugs to minimize the time the subjects fight against restraint. The more the intense struggling takes the better chance that the subject will die from Excited Delirium. “High exertion under high body temperature is one of the worst things for the cardiovascular system,” states Nickels (Remsberg C., 2009).
Until more backup and medical personnel are hand, it is very important that officers avoid physical contact. “ED subjects often display superhuman strength and are usually able to overpower one or two officer,” Nickels said (Remsberg C., 2009). He also says “Once you initiate contact, do it decisively and quickly.” (Remsberg C., 2009)
It is very important that officers train as a team to apply control techniques. Hands-on practice is very important. Nickels said “Remember that pain compliance won’t work on these subjects. An electronic control device that causes incapacitation may be your best option below deadly force if they’re violently aggressive. But the TASER should never be used just as punishment for screaming and yelling.” (Remsberg C., 2009)
The proper place for a person suffering from Excited Delirium is the hospital, more specifically the emergency room, not jail. Nickels said “We sent two officers along in the ambulance and they stayed with the subject until he was completely sedated in the emergency room.” (Remsberg C., 2009) If the subject has been involved in criminal activity, it is very important that he/she has been treated for the medical crisis, after that they can be released into police custody (Remsberg C., 2009).
Debriefing is a must when this incident happens Nickels remembers “Before the encounter in June, we had a confrontation with a mental patient that didn’t go as smoothly. It was after we debriefed that and identified several shortcomings that we decided to do the ED refresher training at roll call. The refresher helped everybody realize right away what we were dealing with in the latest incident.” (Remsberg C., 2009)
Even with practice from the officers, dispatchers, and medical personnel people still die from ED, Nickels admits “Regardless of how proficient the police and medics are, these people often are so deeply in crisis that they end up dying anyway.” (Remsberg C., 2009)
Nickels also admits “But we need to have training and protocols in place to offer the best chance of a positive outcome. It’s not a matter of ‘if’ an ED event is going to happen in your jurisdiction, it’s ‘when.’ Protocols exist for both law enforcement and medical personnel. There’s no excuse for not instituting them.” (Remsberg C., 2009)
Case 2 Scottsdale, AZ
Experiencing Excited Delirium is different than just reading about it, especially when your life is on the line. Things are also different when the officer shoots the suspect with .40-cal. round and has blown up the suspect’s aorta and another bullet has hit the suspect’s spine. Even with all of these wounds the suspect continues to struggle with the officer and threatens to kill the officer. The officer is trying control this crazed situation while in the middle of a high-speed highway (Lewinski, 2006).
This exact situation occurred to Officer James Peters a 6-year veteran of the Scottsdale, AZ Police Department. Peters was eventually exonerated of the shooting death of person suffering from Excited Delirium (Lewinski, 2006).
The call started early on a Monday morning in October, Peters and a K-9 Officer Dave Alvarado got a call about an attempted break-in of a car, in a parking lot of an automobile paint and body repair shop (Lewinski, 2006).
A security officer had reported that he discovered a window of a car had been smashed. He had also seen a person nearby; the security officer claimed that the person appeared to be on something. When the security officer challenged the young man, he took off his shirt, said he had a gun, and lifted a 40-lb. landscaping rock and threw it at the guard. None of these little details were included in the dispatch that Peters and Alvarado had heard, the dispatcher made sure to say that the suspect did claim to have a gun and that he had thrown a rock