Advice for those who are tasked with gaining control of patients suffering excited delirium for the purpose of bringing them to a medical professional for assessment.

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.

Death in custody is a far greater risk for those suffering excited delirium.

If the patient is obeying directions, be prepared for the situation to change suddenly. 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. This is a balancing act of using the minimum force in the minimum time. Take care not to cause injury to the patient and yourself/colleagues, don’t rush and use more force than required, relax and breathe. At the same time don’t drag it out, and 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 and dangerous.

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.

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.

Cop stabbed in back, partner slow to respond

OC spray and Taser were used to take the man into custody following this. The police officer suffered a 6cm wound and survived.

An ambush gives the attacker initiative. They have had time to mentally and tactically prepare for the situation. The defender may not be psychologically prepared or have any kind of plan, and is at minimum a few seconds behind the attacker to even understand what is happening.

The cop who stood there for a few seconds either did not understand what was happening or was in a kind of denial for some time. This is not a conscious decision made while observing the situation. It is likely a result of inadequate training.

Police officer shot twice on door entry and is trapped, colleagues free him

A police officer kicks down a door, enters and is immediately shot twice. His body cam falls to the ground and he is trapped inside, moving to the garage where he is later freed by his colleagues.

  • Forced entry without gun drawn
  • Immediate entry failed, preferably the room could be partially cleared by carefully pie-ing the door from outside
  • A single officer entered even though multiple officers were available

Moments after the first police officer was shot, a second officer standing outside behind a tree is hit in the hand.

  • Police standing in daylight outside are at a disadvantage to the suspect who shoots from the dark inside the house

HENRY COUNTY, Ga. – Henry County police have released chilling body camera footage of the moments officers entered a home on a “trouble unknown” call Thursday and the suspect began to fire at them. Officers Keegan Merritt and Taylor Webb were both shot and are now recovering at Grady Memorial Hospital. Police said Merritt and Webb went to the home after family members reported seeing a woman unresponsive in the garage. The shootings kicked-off a 17-hour-long standoff with the suspect. Police later found the gunman, a pregnant woman and her teenage son dead inside the home. Sandra White, 39, and her son Arkeyvion, 16, were identified as the victims. Police said the gunman, Anthony Bailey, died of a self-inflicted gunshot wound. Merritt was shot in the hand and Webb was shot in the torso and hip, police said.

OC spray, Taser, Baton ineffective against drug affected man

Reluctant to go hands-on, police use their baton, then Taser which fails multiple times. One police officer attempts to knock over the man by rushing at him from behind but ultimately loses control as he stands up. The Taser is used again, then OC spray before the Taser is used once more before the man is taken into custody.

All of the tools police used in this instance depend on pain compliance, apart from the Taser which incapacitates for mere seconds IF the two prongs make contact correctly and in the correct positions on the body. Physical control with grappling techniques may have resulted in a faster and safer arrest, however these officers either lack those skills or were not willing to go hands-on.