After the Webinar: Excited Delirium and Agitated Chaotic Events. Q&A with the Speakers

Webinar presenters Carrie Hill and Dr. John Peters answered a number of your questions after their presentation, “Excited Delirium and Agitated Chaotic Events.” Here are a few of their responses.


Audience Question: The first question is from Elaine and she’s wondering if any of you have ever seen any current statute regarding in-custody deaths in prisons versus jails.

Dr. John Peters: I haven’t seen any that breaks it down that will be useful because we do not have a national registry that tracks this type of data. Like I said before, any in-custody death, they kind of lump together so we can’t differentiate between heart attacks or somebody getting stabbed or strangled versus somebody who’s in a state of excited delirium. Having said that, the frequency from talking to people and this is anecdotal evidence appears to be more frequent for these types of behaviors in agitated chaotic events in jails rather than in prisons. Carrie?

Carrie Hill: I don’t know specifically if there are any specific tests. I do know that the Bureau of Justice statistics does keep this information. That is something, Aaron,  that we can easily provide to everyone who was on this webinar at a later time. Right off my head, I would only be making a guess.


Audience Question: What are some special considerations for transporting those exhibiting excited delirium to jail or a medical facility? She explains that I work in a rural jurisdiction that is one and a half hours away from the nearest city.

Dr. John Peters: Probably the best thing you can do is have a second officer assist you with the transport if you have that availability, so somebody is monitoring those persons while you are transporting him or her the distance that you’ve talked about. If the person goes unresponsive during that transport and you have somebody monitoring him or her, you can stop and perform CPR or do whatever’s needed at that point.

The other thing we recommend and when I worked on the street at one of my agencies, my closest backup after midnight was about an hour away. I’m familiar with the situation you’re up against. I will encourage you to work something out with your local EMS even though they may be an hour away if they can start having in your direction if they’re having less and you’re having these, you can meet half way and transfer that person because at that point the person is a patient. Even though the person may not survive, at least you can tell a jury and tell everybody else, look, this was our plan. We did have a plan and we enacted that plan, unfortunately, the person didn’t make it but we at least we had something that we were trying to do. I would try to have that plan or certainly a second person, even as a civilian, grab out of the office and say let’s monitor this guy and if he is not responding let me know.


Audience Question: Does the AMA or APA recognize delirium as a medical or mental health condition?

Dr. John Peters: The American Psychiatric Association does recognize delirium as a mental illness diagnosis. The International Classification of Disease Manual also recognizes delirium as a medical diagnosis. You’re trying to have a little crossover in both of these because delirium is a psychiatric event and, in some cases, it would be more from the diagnosis of the psychiatrist or psychologist dealing with the delirium. If it’s acute, they take him to the hospital. The emergency room doctor may have to deal with the delirium from a medical viewpoint. It’s induced. It’s recognized as a mental illness and also a medical condition.


Audience Question: What is the relationship between excited delirium and positional asphyxia?

Dr. John Peters: That’s a great question. Actually, there’s no relationship. There’s not been one study conducted – a scientific study that shows positional asphyxia will kill somebody. In fact, the original study that was done by Dr. Ray, and his associates in Seattle, he retracted his findings when it was found that he used the wrong instrumentation during his research and also the wrong statistical analysis.

Having said that, we still don’t put people face down for an exceptional period of time because of this stigma. Excited Delirium – if the person is truly in an excited delirium state, he or she will not lie still in a face-down position. They’ll be whacking and rolling and it will be upon the officers to try and control that person. If the person suddenly succumbs and goes unresponsive at that point, and they are faced down, the plaintiff is going to argue this was positional asphyxia when in fact your side will have someone come in, usually, medical expert and sometimes a Medical Examiner saying that no, that wasn’t the case. In fact, the case in Omaha the Medical Examiner ruled the cause of death was excited delirium and ruled out other things and that helped out quite a bit.

Having said all of that, I want you to understand there are five types of asphyxia. There’s positional asphyxia. There’s postural asphyxia, that’s where the body gets into a position that impedes breathing. There’s compressional asphyxia and we see that others are alive and well. You can put too much weight on someone and compress their chest so they can’t breathe more than likely we’ll see it when a weekend mechanic put his car up in the blocks, the chains the block slipped and the wheel off his chest. That’s compressional asphyxia. Just yesterday it was reported in national media, a woman got out of her car to gas pump didn’t put it into the park and the car pinned her against the gas pump and she died. Compressional asphyxia is real. Then we have mechanical asphyxia and that historically has been associated with some type of chokehold. Then we have restrained asphyxia that’s morphed to any type of restraint. Generally, what happens and there’s a lot of science on this, you have what’s called the period of peril following a restrained event, where you have the person down and there’s a five-minute window following the end of that confrontation where sometimes people will go unresponsive and die. Well-documented in literature, that period can also extend for up to 20 or 30 minutes. The underlying cause of death may never be identified.


Audience Question: What are your thoughts on the use of the properly applied carotid hold a.k.a. vascular neck restraint which is known as one of the few things that can control an excited delirium subject?

Dr. John Peters: Another good question. Generally speaking, I think most agencies, if you’re dealing with someone who is standing fifteen feet away from you, the recommendation is to capture them with the use of an electronic control device. If you’re up close and personal, many agencies recommend lateral vascular neck restraint or some type of carotid restraint. Again you have to be trained in it, you have to be competent in it. It has to be a first option that’s available to you and understand that there’s a risk involved in using both of those devices. The general consensus is if you’re up close, the best way to capture them and control is the use of carotid if it’s a bit of a distance use a taser.


Audience Question: How does this end the ADA remote to the patrol situations. How should our physical response differ if it is still not what is objectively reasonable?

Dr. John Peters: I’ll give you a couple of examples and hopefully this might apply. Any use of force is subjective. The officer decides to use it, the officer decides what type of force to use. That’s subjective. The analysis of the force is objective or should be objective.

Having said that, if you have come across a person in a wheelchair, for example, one of the notations under the Americans with Disabilities Act is what type of question can you ask that person. For example, a man is in a wheelchair and you got a dispatch to go see a man on a wheelchair who just exposed himself to a group of first-graders at an elementary school, you can approach that person. You can’t ask him what their disability is, you can’t say “hey what’s wrong with you, why are you in a wheelchair?” That’s not going to work but you can certainly say “Sir, can you move your hands? Can you move your arms?” because you’re in your investigation phase taking about and if he says “yeah, I can’t move them at all,” then it might not be the person so you have to pursue that just a little bit more as well?  You may have an individual that is deaf and you are giving him commands to do something and he’s not doing it. You may have an individual inside or outside the facility where you go handcuff them and they only have one arm. Have you been trained on how to handcuff people with one arm? Have you been trained to handcuff people who are tight in the shoulders, who tell you “look, I’ve had a shoulder replacement? I can’t lift my arm above my shoulders. It won’t go any higher.” What’s the reasonable accommodation at that point? The reasonable accommodation at that point could be the multiple handcuffs and maybe the handcuff’s in the front. Before somebody suddenly jumps at me and says, we don’t handcuff people in the front well, think about it. You may have to. You’re not going to handcuff an 8-month pregnant woman probably behind the back because she is not probably able to do it. You may not take a person who’s 85 and handcuff them behind the back. You may do it in the front. There are lots of options available to you the question is have you been trained to make that reasonable accommodation? A person who can’t speak, for example, get a piece of paper. Write the questions, Have him or her write the answers back. You may have to get an American Sign Language interpreter to come to the scene. If you do that, the municipality pays for it. It’s not the disabled person who pays for that.

At the same time, we have to be cognizant of the fact that just because someone’s disabled don’t mean they cannot hurt us. Two Riverside police officers in Southern California were shot and killed by a guy who was in a wheelchair. We have at another end of the spectrum in Florida where a corrections officer wanted to search the guy in a wheelchair and dumped him out of the wheelchair onto the porch to see what he was searching. So when you go up to someone who is disabled, you may ask “do you have medical devices?” What if they are wearing a colostomy bag? What if he is wearing an anal bag? What if they have oxygen flowing into their nose? These are all going to be variables you have to assess very quickly because you are not going to use a taser for somebody who has oxygen flowing. You are not going to throw somebody necessarily out of the chair who is attached to it, who may have bedsores or some other ailment. When you work at dealing with people who have disabilities, part of it is your approach, part of it is what you’re reasonable. Part of it is making reasonable accommodations to them. At the end of the day, we don’t want to cause some more embarrassment or treat them any differently than somebody who may not have that disability. Carrie, you might want to help with that.

Carrie Hill: Well I don’t disagree with anything you said, John. I agree.


Audience Question: Carrie, John, what are your thoughts on writing force options within a narrative of the report thus only having a singular report?

Dr. John Peters: Well I would describe the force options used. I would identify the force options that you were in uniform and the person recognized you as being in uniform and your position. I would describe the verbal commands because that’s another force option. I will also line out a little bit what force you did use whether it was at the end or what have you. You have to understand the use of force options continuum, for those of who still use that antiquated device called a continuum. Those are not for standards. Continuums only identify force options. You would want to full front that if you still have it, you can plug that in and say these are the options that I use. If you take the witness stand and you are questioned on that or you are questioned in the deposition, you can say, look, I have other force options available that I thought were not appropriate to use I would certainly include force options in your report so people know what you used and also where those force options are effective. You say I used verbal commands. So what? What happened? I told him to sit down and he laughed at me and he spits at me at that point and he started to walk away. Okay, that certainly shows us the first option didn’t work. Not only I would also include the force option and I would also include what the outcome was from that option

Carrie Hill: One of the things that’s really important with the use of force especially within the jail, if we look at Kingsley vs Hendrickson and we look at the nine-part test?  or some may say it’s the eight-part test? depending on how you nail them together but by all means one of the elements that efforts made to temper which we are going to identify any of the force options that were tried, what the results were from that. Again, we are focusing on the individuals’ behavior because that is really going to take us down to the path. We gave them this command or this is what we chose and this is what the inmate did. This is how the inmate responded. This is what happened. All of that becomes part of the written narrative using the elements of Kingsley vs Hendrickson. just like John, I would like to reiterate that the use force continuum, bladders, wheels, we really want those taken out of policy. They are fantastic in the training arena. As far as your policy goes and as far as the report writing goes, the reason that you’re choosing the force that you are using is really going to be based on the threat presented and the need for the use of force literally going through the options as laid out by the United States Supreme Court, focusing on what the legal requirements are. That’s what the FBI does. Let’s make sure that we are doing that especially jail setting, articulating what those are. I liked what you talked about especially efforts made to temper. What did you try? What was effective? Why was it effective? What was it not effective? When did things escalate? Then describe it. It’s required a narrative and just taking the time to describe the facts as John was discussing, Aaron?

Dr. John Peters: I would just say a line very quickly, Carrie. In the case lead, I was the expert before I went to the Supreme Court, again when I came back from the Supreme Court, one of the problems was the officer said we had to use a taser in order to get Kingsley unhandcuffed because we were afraid he would fall off the bunk and get injured. Then they all walked out. In cross-examination, the plaintiff said you guys were all out. Isn’t the injury concern still there? They acknowledged that it was. Fortunately, it was a favorable verdict for the officers of the –. You have to kind of think through what your rationale is.


Click Here to Watch a Recording of “Excited Delirium and Agitated Chaotic Events.

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