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.