CDE # PUBLIC SAFETY COMMUNICATIONS

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1 CDE # PUBLIC SAFETY COMMUNICATIONS B january 2013 B

2 Appropriate Response Protocol for Calls Involving Excited Delirium by Lori VanGilder Like fictional zombies, those suffering from excited delirium may be attracted to bright lights and sounds, and may be profusely sweating and hot to the touch. B january 2013 B photo d13/lightspring urely by now you ve heard the Zombie Apocalypse hype? There appears to be an increasing number of calls coming into communications centers across the world involving people with superhuman strength, seemingly out of control, running around naked, sometimes even biting or eating other people. Some of these calls also include any number of zombie -like symptoms, including extremely aggressive and violent behavior, constant movement, and keening or making unintelligible animal-like noises. Like fictional zombies, the subjects may be attracted to bright lights and sounds, as well as glass and reflective surfaces. They may be profusely sweating and even hot to the touch. So are we really being taken over by zombies? The answer is no. In fact, these calls are not even new to our communications centers. They have been classified as disturbances and/or mentally ill subject calls. What the individuals are most likely suffering from is a state of psychosis known as excited delirium (ExDS). PUBLIC SAFETY COMMUNICATIONS 23

3 Zombie Apocalypse? Developing a Definition If you haven t heard of ExDS, you re not alone. Many agencies are currently working to understand the psychosis and create appropriate response protocols, particularly after the focused media attention on this issue following the May 28, 2012, Miami Zombie Attack. 1 What occurred in Miami, according to various news sources, is that a man was witnessed eating the face of another man. When ordered to stop by a law enforcement officer, he ignored the officer and continued the assault. When the officer shot him, the subject looked up and growled (yes, growled like an animal) at the officer and continued his assault. He was subsequently shot again (several times) and died on scene. So what is ExDS? The Institute for the Prevention of in-custody Deaths, along with the University of Miami, Fla., have created a website to educate others about this psychosis. They define ExDS as occurring with a sudden onset, with symptoms of bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength and hyperthermia. 2 The Seattle Police Department describes ExDS as a state of extreme mental and physiological excitement characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue. 3 ExDS is not just a Florida issue. In May, a Maryland man was arrested after killing and eating part of his roommate. 4 In Pennsylvania, a new mother, still a patient in the maternity ward, went outside the hospital and allegedly ingested the illegal narcotic known by the street name bath salts. When she returned to the maternity ward she became out of control and required multiple hospital staff and security to subdue her. 5 In Georgia, a man was caught running naked at a golf course threatening to eat others while brandishing a golf club. 6 The cases range across the United States and the world. What Are Bath Salts? What Causes ExDS? Although many of the current news reports are focused on bath salts, ExDS can be present in combination with many illegal narcotics, and/or underlying mental health issues. The psychosis normally involves males in their mid- 30s (although we already know from the reports cited above that women are not immune). A variety of research reports are available on the topic, including one conducted in December 2011 by the Less-Lethal Devices Technologies Working Group of the Weapons and Protective Systems Technology Center with cooperation and support from the National Institute of Justice and the Applied Research Laboratory at Pennsylvania State University. This report lists a variety of causation factors that work in combination with illegal narcotics to create a perfect case scenario for the psychosis to take over. 7 The narcotics most commonly seen in ExDS are cocaine, LSD, PCP, methamphetamine, cannabis (which is what was found in the Miami zombie s magnesium sulfate anhydrous/source wikipedia The name bath salts is derived from the drug s appearance, which is white crystals that look like bathing products, such as Epsom salts. The drug was actually first formulated in France in the 1920s, but disappeared until it was rediscovered by an underground chemist. He published the recipe on a website that was shut down in 2004 for sharing too much information about illegal substances. But it was too late; the widespread abuse of bath salts appears to have started in England around 2009 and quickly spread throughout Europe, then found its way to the U.S. 1 Bath salts were originally sold online and in drug paraphernalia stores. The packaging often states not for human consumption in an attempt to avoid the chemical formulation being declared to be illegal narcotics, but chemically the substance has nothing to do with actual bath salts. In September 2011 the U.S. Drug Enforcement Administration used its emergency authority to control three of the synthetic stimulants that are used to make drugs known as bath salts, calling the chemicals an imminent hazard to the public. As a result of this order, these synthetic stimulants are designated as Schedule I substances under the Controlled Substances Act. Bath salts often contain various amphetamine-like chemicals, such as methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone. Mephedrone is of particular concern because it presents the highest risk for overdose. It is a designer drug, meaning it is concocted in a lab. Many recovered bath salts have also been found to have very high levels of caffeine. The drugs may be smoked, mixed with food, snorted or injected. Bath salts are sold under a variety of names, including Blass, Hurricane Charlie, Meow Meow, Stardust and White Knight. (For a more complete list of names, visit drugs_concern/mdpv.pdf.) Reference 1. Bath salts Emerging and dangerous products. (February 2011) In National Institutes of Health, National Institute on Drug Abuse. Retrieved 11/26/12 from drugabuse.gov/about-nida/directors-page/messagesdirector/2011/02/bath-salts-emerging-dangerous-products. 24 PUBLIC SAFETY COMMUNICATIONS B, A january 2013 B, A

4 system) and most recently bath salts. Other contributing factors include underlying mental health issues, such as (but not limited to) manic personality traits or schizophrenia; or preexisting metabolic disorders, such as diabetes, hypoglycemic reactions, and even alcohol withdrawal. Beyond increased use of illegal narcotics, there is an additional theory behind the rise in the numbers of ExDs cases that dates back to In 1849, Dr. Luther Bell, a psychiatrist at the Massachusetts McLean Asylum for the Insane, documented a condition in which approximately 30 violent and aggressive patients suddenly died. It became known at that time as acute exhaustive mania or Bell s mania. The signs and symptoms were similar to those of ExDS psychosis. For a long time, those suffering from mental illnesses were institutionalized and kept out of the mainstream public. Over time, more and more of those institutions have closed, and pharmaceutical therapy is prescribed in a mainstream home environment. When the mentally ill are not taking their prescribed medications, and/or self-medicate with illegal narcotics, it creates an increased number of cases for public safety personnel to handle. 2 ExDS & In-Custody Death But what led Dr. Bell s patients to suddenly die? In addition to aggressive, violent behavior, ExDS may be accompanied by hyperthermia. The combination of factors creates a chemical chain reaction in the body that creates a dangerously high core body temperature. This is why ExDS patients are often hot to the touch, rapidly breathing, profusely sweating and frequently found to be naked and/or inappropriately dressed. Once the person is out of control, they experience a tremendous surge of the fight or flight adrenaline hormone, which contributes to their seemingly superhuman strength. Often, it will take multiple law enforcement officers to restrain the subject from causing themselves or others further harm. This physical exertion continues and has recurrently required officers to handcuff the subject, as well as employ leg irons and/or a hobble. 8 Once the subject is restrained, the period of peril starts. Levels of amino acids, proteins and hormones in the system reach a pinnacle three to five minutes after restraint, while blood potassium levels drop dramatically. These factors create a situation that predisposes the subject to cardiac arrhythmias and has led to incustody cardiac deaths. 7 Due to the in-custody deaths, knowledge of ExDS has been shrouded in concerns of being a police cover up and not a true syndrome. In the course of subduing the subjects, law enforcement officers have used various less lethal B, A january 2013 B, A PUBLIC SAFETY COMMUNICATIONS 25

5 Zombie Apocalypse? use-of-force elements, including pepper spray and tasers. 9 However, these elements, when combined with the subjects elevated heart rate, elevated blood pressure and high core body temperatures, create the possibility of cardiac-related death. Symptoms of ExDS One of the leading issues in establishing a correct response is first recognizing that incidents involving ExDS constitute a true medical emergency, although initial indicators would lead one to believe that they are law enforcement calls. In fact, response to incidents where a person is suffering from an ExDS psychotic event should be a joint response. What are indicators that a call is actually an ExDS case? The following list was compiled as part of the Less- Lethal Devices Technologies Working Group panel: 10 Extremely aggressive and/or violent behaviors; Constant or near constant physical activity; Does not respond to police presence; Attracted to and/or destructive of glass or reflective items; Attracted to bright lights and loud sounds; Naked and/or inappropriately dressed; Hot to the touch; Breathing rapidly; Sweating profusely; Keening (making unintelligible animal-like noises); Insensitive to or extremely tolerant of pain; Excessive strength (out of proportion with build); and/or Does not tire despite heavy exertion. The subject may exhibit any combination of the above indicators. Response Protocols If a call is believed to be a case involving ExDS, the telecommunicator must first ensure that there is a simultaneous law enforcement and EMS response. Additionally, it is important to ensure an adequate number of law enforcement personnel are dispatched to safely handle the situation on scene. In many areas, EMS may stage, or stop a safe distance away, until law enforcement can gain control of the person. Next, law enforcement should work to gain control and/or restrain the subject as soon as possible to reduce the additional health risks created by a prolonged struggle. As soon as it can be safely executed, and within local medical protocols, agencies may consider having EMS personnel sedate the subject, again to reduce the harmful effects of a prolonged struggle. Some agencies protocols allow officers to actively aid EMS in administering sedation. It s also important to reduce external stimulation from the area, including lights and/or siren on field personnel vehicles as well as transport unit lights and siren. Once sedated, the individual should be transported to the nearest medical facility for treatment. 11 One of the forefront agencies in the country regarding policies on ExDS cases is the Seattle Police Department (SPD). The SPD began working years ago with the fire department and EMS personnel at neighboring hospitals to develop a protocol for handling such subjects. A section was added to the SPD Procedures and Tactics manual dealing with excited delirium and alerting personnel, from the calltaker to officers and supervisors in the field, on the appropriate response when confronted with a person exhibiting such symptoms. This protocol is widely regarded as the most innovative of its kind in the U.S. and perhaps the world. The protocol stresses the life safety issues involved and the importance of handling the medical emergency before any relevant criminal consequences of subject behaviors are addressed; it has been credited with saving lives. 12 Prepare Now ExDS is not a recognized psychosis by American Psychiatric Association or the International Classification of Diseases published by the World Health Organization. 13 It is recognized, however, by the National Association of Medical Examiners and the American College of Emergency Physicians. 14 Regardless, ExDS is something that all public safety personnel should be aware of. Consider developing a response policy to guide personnel when such calls come in. Doing so will help protect the law enforcement officers and EMS personnel on scene, and it could also save the life of the subject.,psc, Lori VanGilder has been involved in public safety since 1986 and serves as an adjunct instructor with the APCO Institute. She can be reached at blkhrt911@aol.com. References 1. Eadicicco L. (5/29/12) What caused zombie attack in Miami? In International Business Times. Retrieved 11/26/12 from what-caused-zombie-attack-miamiorgans-burning-alive-suspected-lsd-orbath-salt-use-video What is excited delirium? (n.d.) In Excited Delirium: Education, Research and Information. Retrieved 11/26/12 from indexwhatised2.html. 3. Hughes EL, ed. (December 2011) Excited Delerium Special Panel Review Report 2011 NIJ, Penn State. Delerium-Special-Panel-Review-Report NIJ-Penn-State. 4. Koebler J. (5/31/12) Maryland man arrested after admitting to killing, eating roommate. In U.S. News. Retrieved 11/26/12 from news/articles/2012/05/31/marylandman-arrested-after-admitting-to-killingeating-roommate. 5. Crum A. (7/5/12) Bath salts make new mom violent in hospital. In WebProNews. Retrived 11/26/12 from 6. I m a eat you : Crazy naked man high on bath salts threatens to eat police officers as they try to arrest him on golf course. (7/3/12) In The Daily Mail Online. Retrieved 11/26/12 from 26 PUBLIC SAFETY COMMUNICATIONS B, A january 2013 B, A

6 article /man-high-bath-saltsstrips-naked-attacks-police-officersgolf-course-saying-wants-eat-faces. html#ixzz21ybtrcfd. 7. Hughes EL, ed. (December 2011) Special panel review of excited delirium. Less Than Lethal Devices Technologies Working Group of the Weapons and Protective Systems Technology Center. In JustNet.org. Retrieved 11/26/12 from Panel-Report-FINAL.pdf. 8. For law enforcement. (n.d.) In Excited Delirium: Education, Research and Information. Retrieved 11/26/12 from indexforlawenforcement.html. 9. Kulbarsh P. (3/19/07) In-custody deaths: excited delirium. In Officer. com. Retrieved 11/26/12 from in-custody-deaths-excited-delirium. 10. Excited delirium cards for patrol. In Critical Research and Training: CRT Less Lethal, Inc. Retrieved 11/26/12 from excited-delirium-cards-for-patrol. 11. Wesley K. (2/1/11) Excited delirium strikes without warning. In JEMS. com. Retrieved 11/26/12 from excited-delirium-strikes-witho. 12. Seattle Police Department. (n.d.) Use of force by Seattle Police Department officers in In seattle.gov. Retrieved 11/26/12 from seattle.gov/police/publications/policy/ UseofForceReport2010.pdf. 13. Correa F. (5/17/12) Excited delirium syndrome lacks research, coding. In ACEP News. Retrieved 11/26/12 from php?id=514&tx_ttnews[tt_news]=1345& chash=d cb06fa0c94609c1eb6 e67e. 14. Lawrence C. (1/20/26) Excited delirium and its medical status. In PoliceOne.com. Retrieved 11/26/12 from articles/ excited-delirium-andits-medical-status. d CLASS SCHEDULE APCO Institute 351 N. Williamson Blvd. Daytona Beach, FL / / Fax: 386/ institute@apco911.org Active Shooter Incidents for Public Safety Communications $ Fort Smith, Ark. Jan Online Starts Jan Online Starts Feb. 27 CALEA Public Safety Communications Accreditation Manager Online Starts April 3 Communications Center Supervisor, 4th Ed. $ Online Starts Jan Henderson, N.C. Jan Online Starts Feb Sarasota, Fla. Feb Online Starts Feb. 20 Communications Training Officer 5th Ed. $ Online Starts Jan Wayne, N.J. Feb Batavia, N.Y. Feb Online Starts Feb. 27 Communications Training Officer 5th Ed., Instructor $ Online Starts Jan Online Starts Feb. 6 Crisis Negotiations for Telecommunicators $ Fort Smith, Ark. Jan Holbrook, Mass. Jan Online Starts Feb East Hampton, N.Y. Feb. 26 Customer Service in Today s Public Safety Communications Center $ Holbrook, Mass. Jan Bridgeton, N.J. Feb. 20 Disaster Operations & the Communication Center $ Online Starts Jan Sturbridge, Mass. March 7 Emergency Medical Dispatcher 5.2 $ Online Starts Jan Online Starts Feb. 27 Emergency Medical Dispatch Instructor $ Online Starts Feb. 13 EMD Manager $ Online Starts Jan Online Starts Feb. 6 Fire Service Communications 1st Ed. $ Online Starts Jan Online Starts Feb. 13 Fire Service Communications 1st Ed., Instructor $ Online Starts Jan Online Starts Feb. 6 Leadership Certificate Program Registered Public Safety Leader $995* Public Safety Telecommunicator 1, 6th Ed. $ Ithaca, N.Y. Jan Online Starts Jan Online Starts Jan. 23 Public Safety Telecommunicator 1, 6th Ed., Canada $ Online Starts March 27 Public Safety Telecommunicator 1, 6th Ed. Instructor $ Online Starts Jan Online Starts Feb. 6 Public Safety Communications Staffing & Employee Retention $ Online Starts Jan Online Starts Feb. 13 Stress in Emergency Communications $ Online Starts Jan Holbrook, Mass. Jan. 25 *By invitation only. d APCO Institute Presents Web Seminars For a complete list of seminars on topics vital to your agency, visit com/institute/webinars.htm. Current APCO members receive a $20 discount. Dates, locations and prices are subject to change. Students who enroll in Institute Online classes will be assessed a $50 Distance Learning fee. Tuition is in U.S. funds. B, A january 2013 B, A PUBLIC SAFETY COMMUNICATIONS 27

7 Save More Lives d CDE Exam #34046: Zombie Apocalypse? 1. Excited delirium is considered: a. A medical emergency b. A law enforcement situation c. A psychotic episode d. Both a and b 2. An individual suffering from ExDS enters the period of peril : a. 3 5 minutes after restraint b minutes after restraint c minutes after restraint d. 1 hour after restraint 3. For calltaking, which of the following behaviors are indicative of excited delirium? a. violent behavior b. aggressive behavior c. naked d. all the above 4. Excited delirium cases may be called in as: a. zombie attacks b. violent disturbances c. mentally ill persons d. all the above 6. Subjects suffering from excited delirium may be experiencing: a. hyperthermia b. hypothermia 7. Excited delirium is not recognized by the: a. American Psychiatric Association b. National Association of Medical Examiners c. American College of Emergency Physicians 8. Subjects who are only under the influence of cannabis cannot suffer from excited delirium. a. true b. false 9. All persons who suffer ExDS are schizophrenic? a. true b. false 10. Excited delirium is most commonly seen in: a. Males b. Males in mid-30s c. Females d. Females in mid-30s 5. Excited delirium is a new disease caused by the illegal narcotic known as bath salts. a. true b. false Using the CDE Articles for Credit APCO Institute Continuing Dispatch Education 1. Study the CDE article in this issue. 2. Answer the test questions using this form. Photocopies are acceptable, but don t enlarge them. 3. Fill out the appropriate information section(s), and submit the form to: APCO Institute 351 N. Williamson Blvd. Daytona Beach, FL Questions? Call us at 888/APCO Ordering Information: If you are APCO certified and will be using the CDE tests for recer tification, complete this section and return the form when you send in your request for recertifi cation. Do not send in the tests every month. There is no cost for APCO-certified personnel to use the CDE article program. APCO Instructor Certificate # Expiration Date: APCO EMD Basic Certificate # Expiration Date: If you are not APCO certified and would like to use the CDE tests for other certifications, fill out this section and send in the completed form with payment of $15 for each test. You will receive an APCO certificate in the mail to verify test completion. (APCO instructors and EMD students please use section above also.) Name: Title: Address: Organization: Phone: Fax: I am certified by: q MPC q PowerPhone q Other If other, specify: q My check is enclosed, payable to APCO Institute for $15. q Use the attached purchase order for payment. 28 PUBLIC SAFETY COMMUNICATIONS B, A january 2013 B, A