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Handling Excited Delirium and Dangerous Patients

Chief Gary Ludwig hit the nail on the head in his recent column, EMS Calls Can Be Dangerous Too. I have been involved in some of my police department’s Crisis Intervention Training in the past. Prior to writing this column, I did a little research. PERF, the Police Executive Research Forum, had a 30-page document on Crisis Intervention Training. I did a search for “Fire, EMS and Emergency Medical” and got zero hits on the article. It was completely a law enforcement approach with no mention of immediate medical attention.

Crisis intervention must be a combined effort between the police department and the fire and or EMS department. Staging is an absolute must and it requires rapid communication between the municipality’s police and fire departments. For the purpose of this article, fire department can be substituted with EMS department. 

Careful monitoring of a call sheet’s comments is a must. If there is any sign of Excited Delirium, like the patient being naked or shedding clothes (a sign of hyperthermia) or bizarre behavior, and the police are not enroute, stop the rig and get them assigned.

Pick a staging area a few blocks away. My preferred method of handling these types of calls is to have everyone run Code 3 (lights and siren) to the staging area and wait for everyone to arrive. The ranking police officer should be the incident commander until the patient is in custody and restrained. Typically, I would call for four to six officers on the call depending on if there were weapons or not. At the staging area, everyone should glove up and then be handed assignments. Sweaty, naked people are very hard to grab a hold of.

If there is a weapon involved, I will assign an officer or possibly two to cover with a firearm (hard cover), a TASER officer, two to four hands-on officers and a negotiator. My hard cover, negotiator and Taser officer are all in a position to sling or holster their weapon to assist if hands-on becomes the method of restraint. The take down should be done as rapidly as possible. Studies have shown the two best weapons that cause the least injuries to responders and patients are the LVNR (Lateral Vascular Neck Restraint) and the Taser. The ambulance would follow us and stage within sight of the incident until we have the patient in custody. The second that the patient is in custody, the paramedics are needed to rush in and immediately begin treatment. The paramedics should not be part of the take down team unless it is an absolute emergency, like rural areas where it would be near impossible to assemble a team of six officers. In that situation, bunker jackets should be worn to protect against bite wounds.   

Note how I use the term patient and not arrestee. Excited Delirium has now been documented by emergency physicians as a true medical emergency. Since it has been declared a real disorder and research is being done to reverse the condition. The biggest cause of Excited Delirium is the street drug PCP; also known as “wet” and “angel dust.”  PCP is Phencyclidine, which can come in a powder form, tablet or, most likely, a liquid in a very small brown bottle about the size of a thimble. Cigarettes are dipped in the liquid and smoked. Do not handle a suspected PCP bottle without gloves on as it can be absorbed through your skin. Acute cocaine overdose can also cause Excited Delirium. Bath salts are a new drug that has hit the streets that cause similar behavior. A very small percentage of Excited Delirium patients are not on anything, they are just that mentally ill. 

Different states have different laws and names for an involuntary commitment to a psychiatric emergency room by law enforcement. Anyone who has been on an ambulance crew has had a patient expire on them. Here is where it gets tricky. If someone in the custody of law enforcement dies, it is (in most states) treated as a death in custody, the same as if an officer shoots and kills someone. The case can make its way to the grand jury and sometimes the firefighters or medics are also included with the officers in the grand jury referral. All firefighters and EMS workers should have some legal protection, either through a union or on their own. A blanket $2 million umbrella insurance policy can be purchased for as little as $20 a month. Protect your family and make sure you have legal representation through some means.

I’ve given the optimal way to handle a critical incident response through the eyes of law enforcement. We know that rarely do things work out the way they should, such as ambulance stages, but the engine company goes straight to the call. Maybe it is two officers rolling up alone on someone with Excited Delirium.

We all know Murphy’s Law, so if you and your partner and possibly even an engine company arrive on an Excited Delirium patient, don’t be a victim, be a good witness. If the patient runs off, let the officers know which way the patient went when they arrive. Most Excited Delirium patients don’t feel pain, so it doesn’t matter if you are an MMA fighter...that 105-pound, 5-foot nothing will wear you out. If you are backed into a corner, speak softly and look for an escape route. As a last resort, do what you have to do to defend yourself if you are cornered with no other options. You may run on these calls and follow my advice and it will seem like a big production over what turns out to be nothing. All I can say is how many structure fire calls turn out to be working fires?

Be safe, your family needs you to come home every day in as good or better condition than you left the house.

MICHAEL J. MAGIERA is a police lieutenant and a volunteer firefighter in Texas.