Excited Delirium and In-custody Deaths

1. Excited Delirium and In-custody Deaths Michael Abernethy MD FAAEM Assoc Professor of Emergency Medicine Univ of Wisconsin SMPH

2. Objectives • Excited Delirium • Physical Restraints & Use of TAZERS • Medical Management

3. In-Custody Deaths… • Why do some people die following a violent confrontation with police? • What role does the taser play, if any? • What role does position of the patient play • What can police officers do to prevent in-custody deaths? • What is EMS Role? • What is the ER Role?

4. Case #1 “Willie went ape shit”

5. Typical Scenario • Male subject creating a disturbance • Triggers 911 call • Obvious to police that subject will resist • Struggle ensues with multiple officers • May involve OC, Taser, choke holds, batons, etc.

6. Typical Scenario • Physical restraints applied • Subject subdued in a prone position • Officers kneeling on subjects back • Handcuffs, ankle cuffs • Hogtying, hobble restraint • Prone vs. lateral positioning • Transported in a squad car to jail

7. Typical Scenario • Continued struggle against restraints • Sometimes damages squad car • Apparent resolution period • Subject becomes calm or slips into unconsciousness • Labored or shallow breathing • Followed unexpectedly by…

8. Typical Scenario • Death • Resuscitation efforts are futile • Los Angeles County EMS Study • 18 ED deaths witnessed by paramedics (all were restrained) • In 13 – rhythm documented • VT and asystole were most common • No ventricular fibrillation • All failed resuscitation Source: Am J Emerg Med; 2001:19(3), 187-191

9. Typical Scenario • The press: • Subject “died after being shocked with taser” • Implies cause and effect • The Fallacy: “Post hoc ergo proptor hoc”

10. Typical Aftermath • Several weeks later – autopsy results… • Cause of Death • Excited delirium • Illicit stimulant drug abuse • Concurrent medical problems • Minimal injury from police confrontation • It wasn’t the taser after all • Officers exonerated

11. Restraints and In-Custody Deaths • What roles do physical restraint, restraining technique and restraint position play in excited delirium deaths?

12. Physical Restraints Source: Prehosp Emerg Care, 2003:7(1); 48-55.

13. Physical Restraint Issues • Positional Asphyxia • Deaths have occurred with subjects restrained in a prone position • Theory: restricts breathing • The role of the position is unclear • Little data to support causality • Other factors are the likely culprits

14. Physical Restraint Issues • No clinically significant changes in pulmonary function tests in healthy volunteers • Am J Forensic Med Pathol. 1998 Sep;19(3):201-5.

15. Physical Restraint Issues • Restraint Asphyxia • Increased deaths in restrained patients • Rat Study • 3 fold increase in cocaine-related deaths among “restrained” rats • Life Sci. 1994;55(19):PL379-82. • Numerous studies now show restraint position not causative of death • Routinely now rejected in the courts • It isn’t the restraint that kills them, it is the Excited Delirium.

16. Physical Restraint Issues • Compression asphyxia • What are the adverse effects on breathing and circulation when one or more officers kneel on the subjects back as they handcuff him?

17. Thomas A. Swift’s Electric Rifle (TASER) Source: http://www.pointshooting.com/m26black.jpg Source: http://www.keme.co.uk/~mack/M26.jpg M26 Taser. Manufactured by Taser International

18. Tasers, in and of themselves, are not lethal weapons.

19. Tasers Use Electricity • It’s not the voltage it’s the amperage that is dangerous • Tasers use high voltage, but very low amperage • M26: 3.6 milliamps (average current) • M26:1.76 joules per pulse • X26: 2.1 milliamps (average current) • X26: 0.36 joules per pulse • X26 Taser delivers 19 pulses per second

20. Taser Effects • High voltage affects nerves • Leads to intense muscle contraction • Does not affect muscles directly

21. Taser Safety 215,000 officer have received taser “ride” in training – Myself included Over 500,000 reported taser deployments to date No causal effects for death found

22. Taser Red Flag If anyone exhibits behavior that requires more than 3 taser deployments in order to gain restraint/control – it is a Medical emergency until proven otherwise

23. Academic Emer. Med. 2006June;13(6):589-95 • After 5 second taser ride on numerous subjects: • No EKG changes • No cardiac cell injury • No hyperkalemia • No acidosis

24. There is no scientific evidence to date of a cause and effect relationship between Tasers and in-custody deaths.

25. Several forensic pathology studies have cited excited delirium, not Tasers, as the cause of death.

26. What is Excited Delirium? • An imminently life threatening medical emergency… • Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. • Severe delirium and agitation • Not a crime in progress!

27. The “Freight Train to Death” • How police restrain or position the subject will not stop “the freight train to death” • The sooner the severe agitation is terminated, the better • This requires EMS response and transport to the hospital.

28. What is Excited Delirium? • Diagnostic criteria • Characteristic behavioral components • Metabolic Acidosis • Hyperthermia • Identifiable cause • Stimulant drugs • Psychiatric disease • Alcohol or medical problems rarely can cause • It does not explain all behavior that leads to confrontation with police

29. Pathophysiology • Central nervous system effects: • Changes in dopamine transporter and receptors • High release of other neurotransmitters • Accounts for behavioral changes • Accounts for hyperthermia

30. Behavioral Components: Delirium • Delirium: • “Off the track” • Confusion • Clouding of consciousness • Shifting attention • Disorientation • Hallucinations • Onset rapid – acute • Duration brief – transient

31. Behavioral Components:Excited (Agitated) • Extreme agitation, increased activity • Aggravated by efforts to subdue and restrain • Not likely to comply after one or two tasers • Pressured speech, grunting • Inappropriate words and flight of ideas.

32. Behavioral Components:Excited (Agitated) • Violent or aggressive behavior • Towards inanimate objects, especially smashing glass • Towards self, others or police • Noncompliant with requests to desist • Superhuman strength • Insensitive to pain

33. Excited Delirium • Hyperthermia • High body temperature • 105 – 113 oF • Drug’s effect on temperature control center in brain (hypothalamus) • Tell-tale signs: • Profuse sweating • Undressing – partial or complete

34. Excited Delirium • Hyperthermia • Aggravated by • increased activity • the ensuing struggle • warm humid weather (summertime) • dehydration • certain therapeutic medications

35. Excited Delirium • Metabolic Acidosis • Potentially life threatening • Elevated blood potassium level • Factors: dehydration, increased activity • Survivors: • Kidney damage due to muscle breakdown • May require dialysis

36. Excited Delirium: The Usual Suspects • #1 Cause: Stimulant Drug Abuse • Acute intoxication • Superimposed on chronic abuse • Acute intoxication triggers the event

37. Excited Delirium: The Usual Suspects • Underlying psychiatric disease • First described in 1849 before cocaine was first extracted from cocoa leaf • Mania (Bipolar Disorder) • Psychosis (Schizophrenia) • Noncompliance with medications to control psychosis or bipolar disorder • Unusual – #2 Cause • Rare: New onset schizophrenia

38. Stimulant Drugs • Cocaine • The major offender • On the rise due to “crack epidemic” • Toxicology studies show… • Low to moderate levels of cocaine • High levels of benzoylecognine (the major breakdown product of cocaine) • Suggests recent use superimposed on chronic abuse

39. Stimulant Drugs • Other known culprits include: • Methamphetamine • Phencyclidine (PCP) • LSD • Cocaethylene = Cocaine + Alcohol • Toxic to the heart • Unknown role in excited delirium deaths

40. Concurrent Health Conditions • Obesity • Heart Disease • Coronary artery disease • Cardiomegaly • Hypertrophic cardiomyopathy • Myocarditis • Fibrotic heart

41. Autopsy Proof • Specialized laboratories can identify changes in brain chemistry that are characteristic of excited delirium • Blood and brain tissue levels of benzoylecognine and cocaine • Typical ratio 5:1

42. Tasers and Excited Delirium Deaths • It’s not the Taser • Many in-custody deaths long before tasers were ever used • Documented in 1980s medical literature • Deaths of persons not in custody • Found naked in bathrooms • Wet towels • Empty ice cube trays scattered about • A futile effort to cool themselves

43. Excited delirium is an imminently life-threatening medical emergency.

44. The behavioral features of excited delirium include criminal acts, but…

45. Excited delirium is not a crime in progress, and responders must recognize the difference, before it’s too late.

46. Recognizing Excited Delirium • Agitation or Excitement = Increased activity and intensity • Aggressive, threatening or combative – gets worse when challenged or injured • Amazing feats of strength • Pressured loud incoherent speech • Sweating (or loss of sweating late) • Dilated pupils/less reactive to light • Rapid breathing

47. Recognizing Excited Delirium • Delirium = Confusion • Disoriented • Person, place, time, purpose • Rapid onset over a short period of recent time • “He just started acting strange” • Easily distracted/lack of focus • Decreased awareness and perception • Rapid changes in emotions (laughter, anger, sadness)

48. Recognizing Excited Delirium • Psychotic = bizarre behavior • Thought content inappropriate for circumstances • Hallucinations (visual or auditory) • Delusions (grandeur, paranoia or reference) • Flight of ideas/tangential thinking • Makes you feel uncomfortable

49. Bad Behavior: Other Reasons • Alcohol intoxication or withdrawal • Other drug use problems • Example: Cocaine psychosis • Pure psychiatric disease • Head injury • Dementia (Alzheimer’s Disease) • Hypoglycemia • Hyperthyroidism

50. Patients with excited delirium need rapid aggressive medical intervention.