Excited delirium – detaining the patient and preventing death in custody

This is not medical advice or the result of academic research, only opinion gathered from practical experience.

Before we start, consider this example: Roberto Laudisio Curti was a 21-year-old man from São Paulo, Brazil. He died on 18 March 2012 after being pursued, tackled, tasered, sprayed with OC spray, and physically compressed under the weight of multiple police officers of the New South Wales Police Force in Sydney, Australia.

In this example a man dies suddenly after he is restrained for a short time.

Death in custody is a far greater risk for those suffering excited delirium, psychosis and other mental health or drug related issues. First priority is have the patient conveyed to a medical professional for assessment, regardless of any offences committed.

If the patient is obeying directions, be prepared for their demeanour to suddenly change. Keep weapons out of reach, be aware of exits they might suddenly run toward etc.

Avoid verbal aggression where possible. Shouting may increase their fear and physical aggression. They are unlikely to “snap out of it”, submit and defer to authority.

Do not expect a rational response to directions or commands. They don’t act in their own best interest, let alone anyone else’s.

If they try to escape or become violent, have them physically restrained, sedated and treated by medical professionals as soon as possible. Use the minimum force in the minimum time. Although we want the minimum time, don’t rush and use more force than required, relax and breathe. Take care not to cause injury to the patient, yourself and your colleagues. Once restrained, minimise the time between detainment and medical assessment.

“If he can talk, he can breathe” is a myth. The best way to learn how certain positions and pressure can prevent sufficient breathing and blood flow is to participate some type of grappling class and get crushed yourself. After some time you will intuitively know what is safe and what isn’t. In my opinion, any other method of learning this is inferior.

Immediately search them for weapons once restrained. Self-explanatory but don’t forget it.

Don’t get complacent when they appear to be calming down. They may suddenly explode again and swing between rage, fear, submission, attempts to flee within moments.

They are not superhuman, but they are pushing their body beyond safe limits. They don’t appear to reach a point of exhaustion and reduced effort where most people would slow down. This is not only a concern for the safety of the people who are trying to restrain the patient, but for the patient themselves who risks pushing to the point of permanent damage and death. Their strength will only be a surprise if you have never felt someone resist you with 100% effort.

They may suddenly die. They will push through exhaustion, high body temperature, dehydration, physical trauma. Whatever are the physiological and psychological mechanisms that normally cause people to stop, just don’t seem to be there anymore. They are also likely to suffer poorer general health as a result of substance abuse and/or mental health issues. Some people will die if you ask them to run up a flight of stairs – what do you think will happen if they suffer a mental health or drug induced episode and resist arrest?

They remain conscious when they shouldn’t, absorbing physical trauma or tranquilisers/sedatives/anesthetics which would knock out most people. I’ve observed quadruple the normal dose of sedatives administered by paramedics before any effect is noticed. Don’t think that just because they’ve absorbed what you’ve given them and they continue resisting that they haven’t suffered irreparable or lethal damage.

They will not understand that their actions are futile and that they are losing the fight. A patient suffering excited delirium might not submit or understand that resistance is pointless. Even when handcuffed, strapped to a gurney and completely immobilised, they might continue to resist with 100% effort. They have no plan, they are not thinking beyond even the next second. Their actions are not the result of decisions, their words do not convey thoughts in the most extreme cases.

Avoid “pain compliance”. They either won’t notice, or it will only heighten their excited state – the result is pain defiance. Avoid the use of strikes where possible. You need to go hands-on and gain positional control. If a taser is used, get on them ASAP while they are temporarily incapacitated, because they might just get up and it starts all over again. Further hits from the taser will increase likelihood that they die from the accumulation of stress, exhaustion, injuries and medical conditions already present.

Be cautious when applying handcuffs. Even if every part of their body is held down by several people, after they feel the metal and hear the clicks they might suddenly get a death grip on the other side of the handcuffs before you can secure it around the wrist. People don’t normally resist in this way because it won’t help them escape, it will only delay the inevitable and cause injuries to their hand. But your patient isn’t thinking that far ahead.

Be aware of your own emotional state. When you are restraining them, you might feel that their intentions are malicious. They have no intentions, they have no plan. You might feel justified to use pain compliance, or feel that whatever pressure you are applying to their body is fine because they are still physically resisting with gusto and it looks like they can take it. You think the situation demands more force, but they will continue to babble nonsense and feel physically strong until their last breath, and now you’re sitting on a dead man. Control yourself.

If you know how to grapple and control someone on the ground, you have an advantage. Their movements are strong but erratic and uncoordinated. You CAN control them, especially with the help of a team.

The videos below demonstrate a few other mental health related incidents.

Do not use standing headlocks – unless you’ve trained them A LOT.

The standing headlock is one of the most common positions in street fights. People who are inexperienced in grappling tend to do it instinctively, for better or worse. The results are so-so with some people successfully dragging their opponent to the ground. For others it doesn’t work at all.

It can also be potentially disastrous.

There are limitless examples of “self defence” instructional videos on the internet showing headlock escapes which involve foot stomps, groin strikes, eye gouges, throat grabs and the like, however the most effective and deadly method is the slam or suplex. Any method of throws or slams can kill on a hard surface. Being slammed while holding a headlock is one of the worst ways for it to happen.

On the other hand, those who have extensive training in the position are able to use it safely and effectively. They understand how to apply a throw, how to set up the position, how to transition to something else and when to disengage. Watch the below demonstration for an example of a safe (for both parties) and effective throw:

If you don’t understand the position inside and out, simply do not use it. You might feel like you’re doing something useful, but the risks do far outweigh anything you might pull off with nothing more than luck.

To Maim: Do eye gouges, bites and groin strikes work in a real fight?

“Street effective” techniques like eye gouges, biting, groin strikes and the like are considered by many self defense experts as some of the most effective techniques in a street fight, almost like a kind of off-switch for bad guys. The following video appears to confirm this:

And a groin kick seems to be effective at ending this fight:

These techniques can be effective. However, they are not the self defence panacea many believe them to be.

Jewellery Store Stabbing

The victim is stabbed repeatedly. He used everything he had to defend himself: punches, kicks and throws, and attempted two eye gouges and two groin strikes.

None were effective -the assailant moved his head away when eye gouges attempted and blocked kicks to groin.

It should also be noted that although the victim was stabbed many times, he was still capable of fighting and managed to escape – neither person was incapacitated, and both were capable of continuing the fight.

Groin kick attempt 1. The offender lifts his knee and blocks the kick.
Eye gouge attempt 1. Unclear if defender was able to cause any harm. No apparent effect.
Groin kick attempt 2, seems to connect in some way but no effect
Eye gouge attempt 2. From this shot it looks like a finger may be completely embedded in the eye, though it is impossible to know for certain. No effect.

Any technique can fail or be blocked and countered. Eye gouges and groin strikes are not special in this respect. There is no magic technique.

Yuki Nakai blinded in MMA fight

In 1995, Yuki Nakai entered an MMA knockout tournament. Competitors would have multiple fights and be eliminated with their first loss.

Note the sporting context – his life was not at risk, he could have chosen to stop any time he wished.

His first opponent was Gerard Gordeau. Gerard illegally eye gouged Yuki, which left him permanently blind in his right eye.

Nakai speaks with his corner backstage following his first match.

Yuki continued to fight and won by heel hook in the fourth round. He told no one that he had been blinded. The photo above shows Yuki talking to his corner backstage after the first fight.

His next opponent that night was Craig Pittman, an american wrestler with a 100 pound weight advantage. Yuki won via armbar.

In the third and final bout, Yuki fought BJJ legend Rickson Gracie and lost at 6:22 in the first round via rear naked choke.

Yuki was not taken out of the fight when he was eye gouged. He was still capable of fighting and his will remained unbroken.

He stopped fighting when he was incapacitated with a strangle. He was now physically unable to continue, despite any level of motivation to win.

The distinction between maiming and incapacitation is an important one which we’ll look at later.

Groin strikes traded

The first two strikes in this one are groin kicks thrown by both parties. They both seem to lose confidence in the groin kick and immediately go to punches.

Man uses knee strike to groin of police officer

The man who kneed the police officer in the groin had no plan beyond the groin shot. This is the critical mistake mentioned at the beginning of the video – he probably expected that the cop would go down from the strike. The reality was that he had initiated a physical fight in that moment which he was totally unprepared for.

While the groin strike may have caused pain, the punch he took in return left him incapacitated.

Werdum vs Travis Browne

The following image shows an accidental eye poke during an MMA match. It’s quite obvious that the finger has entered the eye all the way to the first knuckle. However Werdum, the fighter who suffered the eye poke, continued the match as if nothing happened and won by decision. He did say afterwards that his eye was a little sore.


Two main things to note here:

  1. Biting is possible at any time a grip is established and from any range and position, and it can happen very quickly;
  2. Despite having about one third of his lower lip bitten off, the victim of the bite was willing to continue fighting. It was the biter who stepped back, put his palms up then walked away. Biting does not incapacitate and will at best discourage.

A man is able to continue fighting despite having his ear bitten off, and in fact is dominating the fight when the video ends.

Above, a bite from an inferior position only causes the other man to escalate the level of violence. Biting did not end the fight or cause the person in control of the fight to release him.

Joint breaks and maiming generally

  • Maiming is permanent damage caused by techniques such as eye gouge, biting, joint break. This might reduce an individual’s capability to some extent or incapacitate them, or it may effectively do little more than cause pain.
  • Incapacitation or physical restraint may be required to stop an individual who has a high pain threshold and high motivation.

What is commonly known as a “submission” in combat sports is a break in reality. When no one submits and the technique is taken to completion, the end result should be a torn joint or broken bone.

Below are two sport examples where a fighter has refused to tap out and was willing to continue the fight, and two examples in street fights where limbs AND the will to fight were broken.


Strangulation is an effective way to incapacitate, although what to do when they wake up must be considered. By then you should have a dominant position at least.


  • Nothing is 100% reliable 100% of the time.
  • Depending on a small set of methods (e.g. bite, eye gouge, groin strike alone) is foolish and not a replacement for hard training. Use a mix of skills, training and systems to prepare for reality.
  • Maiming does not necessarily end the fight;
  • Because many people are able to fight on despite severe injury and  pain.
  • In this case, the goal must be incapacitation and/or physical restraint, even if maiming is used to facilitate it.