More on Agitated Delirium
Once again, a report in the mainstream media describes "excited delirium" as a "rare and controversial condition." It isn't rare or controversial to the emergency physicians quoted in the article, however:
Contrary to the article, the condition is in fact recognized in the medical literature. A simple medline search reveals several articles and studies describing the condition.
As I mentioned previously,
"Patients with agitated delirium in the setting of a simulant-induced psychosis commonly die while they are being subdued and restrained, whether they have been tazed or not. Yet every time I read about such an occurrence in the media, it is presented as an unusual event. Maybe it was the taser....maybe it was the chokehold.....
Maybe it was the drugs. Ya think?"
The term "excited delirium" began showing up in coroners' reports and in the charts of emergency room doctors in the 1980s, on the coattails of the cocaine epidemic. Dr. Corey Slovis, a professor of emergency medicine and chairman of medicine at Vanderbilt University Medical Center, said patients become "wild and bizarre" and "are often found running down streets, screaming, and sweating until dehydration."
Slovis and others are convinced excited delirium is a "real clinical disorder." But the fact that the disorder seems to manifest most often when people are in police custody, and is often diagnosed only after the victims die, gives civil libertarians cause for concern.
Eric Balaban, a lawyer for the American Civil Liberties Union National Prison Project, says the cause for these arrestees' deaths is police brutality, not excited delirium.
"There remain many questions. Excited delirium still doesn't exist as a recognized diagnosis. It can't be found in any medical textbooks, and the AMA still doesn't recognize it as a diagnosis. Medical examiners only picked up the term to explain and whitewash excessive use of force by the police," he said.
But physicians who have seen people in the throes of excited delirium insist it can't be mistaken for anything else.
Dr. Gary Vilke, an emergency room physician at the University of California at San Diego, said excited delirium causes police intervention, not the other way around. "These are people running around naked, breaking the windows of cars and getting the attention of police. … They are excited and delirious, hence the term. … Cops have to intervene, and a struggle is inevitable."
What's really killing these people isn't police brutality but an overdose of adrenaline, said Dr. Assaad Sayah, chief of emergency medicine at Cambridge Health Alliance. According to Sayah, when people are abused by cops, the trauma is obvious. Excited delirium deaths, he said, are "not related to an actual trauma to the patient."
Contrary to the article, the condition is in fact recognized in the medical literature. A simple medline search reveals several articles and studies describing the condition.
As I mentioned previously,
"Patients with agitated delirium in the setting of a simulant-induced psychosis commonly die while they are being subdued and restrained, whether they have been tazed or not. Yet every time I read about such an occurrence in the media, it is presented as an unusual event. Maybe it was the taser....maybe it was the chokehold.....
Maybe it was the drugs. Ya think?"
posted by scalpel at 10:42 AM
10 Comments:
Had one brought by the police to my last ER, a 40-something woman who had been running down the street stark nekkid, screaming, and completely out of her head. She possessed infected "tracks" up and down both arms and a temp of 105. She had to be strapped face-down by 5 cops--and it wasn't easy for me to get an IV into her while she was upside down. And then she went into rhabdo...
Wow, I had never heard of excited delirium before. Add another one to the list of horrible ways to die... ugh.
Or maybe it was the chokehold.
No, it could never be the drugs. The drugs would never, ever, do anything like that - nope. They're harmless and anyone that says otherwise is a puppet of the government.
/sarcasm.
On a side note, thank you for the comment on my blog concerning my grandmother. It was reassuring. We're still waiting for results although we certainly aren't holding our breath on that they'll find out what's wrong.
Cheers,
SSG
During my forensic pathology rotation (aka play in the ME's office for a month), we did an autopsy of a patient that died in police custody. He was apprehended after a high speed chase and foot pursuit. In the back of the cruiser he was apparently off the wall, banging his head on the frame, screaming, etc. Then he got quiet. They took him to the ED and he was pronounced. In his esophagus and stomach we found several small baggies, one of which had a nice hole in it. He had swallowed his drugs and one of the bags burst giving him a fatal overdose. I've never seen a bunch of happier cops at that moment. I think there were already lawyers threatening suit less than 24hrs after the death.
I keep wondering when the police became objects of fear and corruption rather that people who were respected.
Thanks for the post, Doc. I learned something new tonight.
MJ
Agitated Delirium: is this what we used to call Gone Crazy on PCP?
Plat: sometimes we still call it 'hoped up on the goofballs,' but that might just be the ED where I work.
Blogger ate a comment I had, about "positional asphyxia." A Google or Medline search of articles about that will explain it better than what I had written, anyhow.
Short version: it's the drugs, AND the exertion, AND the takedown, and (especially) the restraint. All together, it's a recipe for being put into a posture where you can't exhale enough CO2 fast enough, at just the time when you really need to. And voila: acidosis.
The use of Taser doesn't correlate at all to deaths... although arguably without the Taser, the subjects would have been brought down by other, more aggressive means. That, or they'd still be out there in their underpants, sprinting down every interstate in the land.
I agree the physical restraint plays a role, but it isn't the "cause" of death. These individuals have to be restrained. The key is to administer chemical restraints (preferably intravenous sedation) as quickly as possible to limit the duration of physical struggling.
Easier said than done, however. We often settle for a B52 (5mg of Haldol and 2mg of Ativan intramuscularly).
I've actually had one of these guys go flatline on the ambulance deck while five of us struggled to maintain control. We thought the guy was playing possum. These patients tend to be very refractory to resuscitation once they code. They will die in the leather restraints too if you let them keep struggling.
I personally love IM versed for these patients. 5 or 10 mg usually does the trick, and the onset of action is comparable to IV ativan without exposing your best nurse to a big needle stick risk.
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