The Most Costly Death a City and Police Department Will Ever Face!

In-Custody Deaths - Excited Delirium, It Not Only Kills, 

It Can Be Financial Ruin For a Department and a City.

By Nicholas Ashton, CEO/CIO, CommSmart Global Group

Being caught off guard as a police officer is not the situation we want to walk into.  It is hoped, that the 9/11 dispatcher has gleaned enough information from the caller to prepare us for the type of service call it is that we are attending.  

We then can source analytic based information, through Digital Policing methods where the officer can pull more direct information from the database to more prepare. 

Sometimes though, we have to fly by the seat of our pants and be ready for any eventuality.

Arriving on the scene and observing a crazed individual running among traffic or inside a house being violent and deranged is not a pretty sight.  Then, when they take no heed to your commands whatsoever, what are you going to do to subdue and control? 

Now you must eliminate the risks to all, including the culprit.  Training has taught us to control with the best methods at hand including tasering, fighting and a good old dog pile on the rabbit.  

All applications that are used in the field have their successes, but we have seen the failures and really never knew why.

Excited Delirium or Bell’s Mania is contributing to in-custody deaths worldwide.  Last year alone we saw some 360 deaths that are connected in some way to this dire event. It is not just the death, it is the legal costs that follow. 

One of the things that can cause excited delirium is stimulant abuse, particularly PCP, cocaine, or methamphetamine. 

However, people can have excited delirium with no drug use.

The symptoms of excited delirium include:

· Paranoia

· Disorientation

· Hyper-aggression

· Tachycardia

· Hallucination

· Incoherent speech or shouting

· Superhuman strength when trying to be restrained

· Hyperthermia

Hypothermia would explain why some of these people tear off their clothes and attack others whilst running naked through the streets, disregarding all commands. 

There are many descriptions to be found in medical journals and the Internet.

Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hypothermia and, most notably, sometimes with the death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately, an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium.

Excited Delirium (EXD), first described in the mid-1800’s, has been referred to by many other names – Bell’s mania, lethal catatonia, acute exhaustive mania and agitated delirium. Regardless of the label used, all accounts describe almost the exact same sequence of events: delirium with agitation (fear, panic, shouting, violence and hyperactivity), sudden cessation of struggle, respiratory arrest, and death. In the majority of cases, unexpected strength and signs of hypothermia are described as well. While the incidence of EXD is not known, the purpose of this review is to identify what is known or suspected about the pathophysiology, outcomes and management options associated with EXD to assist medical professionals in the future.

EXD has gained increasing public attention recently due to the number of post-mortem explanations offered by medical examiners regarding the death of individuals being restrained by police or being taken into custody. This diagnosis has caused concern because EXD is not a currently recognized medical or psychiatric diagnosis according to either the Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR) of the American Psychiatric Association or the International Classification of Diseases (ICD-9) of the World Health Organization. 

Likewise, the authors of one review article found enough evidence in the literature to suggest that excited delirium, rhabdomyolysis, and neuroleptic malignant syndrome might represent the clinical spectrum of a single disease. Although more research is needed to elucidate cause and effect, it is important to note that a lack of recognition of the condition in the context of law enforcement activities does not negate the significance of the behavioral and physical signs referred to as EXD. For instance, one important study found that only 18 of 214 individuals identified as having EXD died while being restrained or taken into custody. If anything, the possible association with other life-threatening syndromes only gives impetus to the need for critical emergency medical intervention when encountering a person thought to be in a state of excited delirium.

Although reports of patients with similar symptoms first appeared in the 19th century, the first modern mention of EXD was in 1985. The presentation of excited delirium occurs with a sudden onset, with symptoms of bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength and hypothermia  An extensive review of reported case series reveals that in a majority of cases EXD was precipitated by stimulant drug use and in much fewer cases psychiatric illness (such as mania, depression, or schizophrenia) or systemic illness. Methamphetamine, PCP, and LSD have been reported in a few series, but by far the most prevalent drug of abuse found on toxicology screening was cocaine. 

Since the victims frequently die while being restrained or in the custody of law enforcement, there has been speculation over the years of police brutality being the underlying cause. However, it is important to note that the vast majority of deaths occur suddenly prior to capture, in the emergency department (ED), or unwitnessed at home.

Prior to 1985 most reported cases of sudden death from cocaine intoxication involved “body stuffers” who died secondary to massively high exposure to the drug after packets they were carrying burst. 

A report published by Wetli and Fishbain in 1985 was one of the first case series to examine recreational cocaine users who died following episodes of excited delirium. They noticed that these deaths differed in both presentation and average blood cocaine concentrations from typical cocaine overdose fatalities. In fact, cases of agitated delirium were often associated with lower blood levels of cocaine. Explorations by Pollanen et al and Ruttenber et al showed blood levels of cocaine in EXD cases to be similar to levels found in recreational cocaine users and much lower than levels found in people who died from cocaine-associated intoxication. Moreover, the reports found that the blood levels of benzoylecgonine, the primary metabolite of cocaine, in the cocaine-associated EXD cases were higher than in recreational users, suggesting the cocaine use prior to death was consistent with recent “binge” use. More recently, Stephens et al., in an analysis of the significance of cocaine upon a specific death, confirmed that a pattern of chronic cocaine use characterized by repeated binges is associated with the development of fatal EXD.

In 2013 forward, especially today, we are seeing more and more cases where Zombie drugs are being cited as the cause. This includes “Bath Salts”, readily being sold over the counter and through the Internet by retail sites such as Amazon.com.

No one likes death, especially an in-custody death on your watch and it is becoming more common in the last three years and now is nearly a daily occurrence.

It has reached a point where we cannot ignore the problem any longer.  We must take responsibility for the monetary liabilities being placed on departments and municipalities in the form of civil lawsuits.

The action that is required is one of pure understanding of what we have walked into.  It is recognizing the scene that is unraveling in front of our eyes and how will handle the situation.  It is all tied to a chain of events of which, you were not present at the onset and you will only have to guess the story line.

Training assists on handling all the steps that will protect the individual, the officer, and the city or municipality.  It is the documentation and the reports that will assist your attorneys in the following civil court cases.

You must afford to have all preventive steps to be taken.

Shoring up your Standard Operating Procedures and having team strategy in protecting your citizens, police officers, medics, emergency room doctors, medical examiners, city, county or state lawyers is of the utmost importance.  Civil lawsuits when an in-custody death occurs are expensive to defend and if you lose, even bankrupt a city.

Training your whole operation in how to handle this in-custody death phenomenon which is costing us all dearly, most be a priority.  Budget cuts have reduced your resources, so why risk this situation?

WE are in the NOW and

KEEP YOU; in the KNOW…

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