Force Science News #29
October 7, 2005
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10 TRAINING TIPS FOR HANDLING "EXCITED DELIRIUM"
DIRECTOR'S NOTE: One of the missions of the Force Science Research Center is to bring the
latest research (ours and others) to the law enforcement community. Excited Delirium is a very
high profile, significant social problem that although rare in occurrence has been very costly to the
LE in terms of the health and safety of all concerned, reputation of the profession and certainly
financially in terms of lawsuits against officers, departments and community.
It is our hope that this newsletter, which combines the latest research with the resulting
suggested policy and procedures, stimulates thoughtful discussion in the areas of policy, practice
and training.
--Dr. Bill Lewinski, executive director, Force Science Research Center

A representative of a large insurer of law enforcement agencies advises that new criteria are
evolving for dealing with a special type of EDP-the person in the violent throes of Excited
Delirium.
Attorney William Everett, a former police officer, offers 10 recommendations he believes will help
patrol officers better manage high-risk ED confrontations. He presented these last month [9/05] in
Utah at a conference of LE administrators and government risk managers and elaborated on
them recently in an interview with Force Science News.
Litigation stemming from in-custody deaths is not uncommon. "In minimizing risk," Everett says,
"agencies and officers should be aware of the latest developments in medical and scientific
research and use those findings to develop protocols for dealing with ED."
Everett is associate administrator for the League of Minnesota Cities Insurance Trust, which
provides liability coverage for more than 800 communities, and is also a member of the National
Advisory Board of the Force Science Research Center at Minnesota State University-Mankato.
"Studies estimate that ED may be a factor in 50 to 125 in-custody deaths a year in the United
States alone," Everett says. "Part of the problem seems to be that officers tend to see the bizarre
and alarming behavior of a subject experiencing this condition as strictly a control-and-arrest
situation rather than as a serious medical emergency that can be fatal.
"Fifteen to 20 years ago, it became important for officers and trainers to start thinking about
distinguishing the difference between a combative drunk and a person in a diabetic crisis. Even
though they may share some common behaviors, one needs to go to jail and the other needs to
go to a hospital.

"Now, with the research that has been done on ED in the last few years, there's a need to
distinguish between people who are just choosing to act in a violent criminal way and those who
are doing so because of an underlying medical condition that is affecting them mentally and
physically.
"When you put the latter subject in jail without proper medical attention and he dies, you have
both a tragedy and a liability problem."
Excited Delirium has been described as "a state of extreme mental and physiological excitement,"
characterized by exceptional agitation and hyperactivity, overheating, excessive tearing of the
eyes, hostility, superhuman strength, aggression, acute paranoia, and "endurance without
apparent fatigue."
Officers' encounter this condition under "very consistent" circumstances, according to Chris
Lawrence, defensive tactics coordinator at the Ontario Police College in Aylmer (ON) and a
member of FSRC's Technical Advisory Board. Lawrence is recognized as a leading LE authority
on ED. He will soon debut a column on ED and other LE issues for FSRC's strategic partner,
PoliceOne at www.policeone.com.
The subject officers confront, often on a property damage or unusual behavior call, will be "acting
in a bizarre manner, often partially clothed or naked," Lawrence reports. He will likely be
incoherent or speaking in gibberish or what seems to be another language. He'll be yelling or
screaming loudly, seem to be disoriented or hallucinating and may be foaming at the mouth or
drooling. He may be sweating profusely or the opposite, his body temperature soaring and
uncooled by perspiration. Glass often will somehow be involved in the encounter, reason
unknown.
Usually ED symptoms are well underway when officers arrive, but lately Lawrence has found
instances in which a subject is speaking calmly and rationally with officers and then suddenly
explodes into ED. However the onset occurs, the condition, while relatively rare, is always highrisk, he stresses.
As officers try to gain physical control of the subject, his "extraordinary strength" will be "a central
feature of the struggle." Several officers will be needed to overcome his determined resistance
and immunity to pain.
"During the restraint process, the subject will often be grunting and making animal-like noises."
The biggest problem may come after he is controlled-when, after struggling against restraint,
there may come "a period of sudden tranquility." At this point, Lawrence says, "the officers realize
the subject has stopped breathing. Invariably resuscitation efforts fail." At autopsy, "the
pathologist is typically unable to determine the exact cause of death," but the police, of course,
generally end up being blamed.
ED episodes most likely occur between Thursday and Sunday, with Sunday the most common
day, Lawrence has found. The hot months, May through September, are the most common time
of year. Male subjects in their early 30s are most frequently afflicted, with subjects under 20 or
over 50 least likely; female ED subjects are "extremely rare." Of illegal substances potentially
involved, cocaine is most common (more than half the cases). Alcohol is common, too. About
one-third of the time, the subject will have a diagnosed mental illness, schizophrenia most likely.
During his 15 years as a street cop, Everett says he saw "all kinds of people with mental
impairments," but he believes he encountered only one memorable subject exhibiting ED--a
young man pounding furiously on a plate glass window, then jumping on the hood of a car, trying
to gain entry to a bar on a Sunday night when it was closed.

The melee with officers that ensued was "the closest I ever got to an unarmed life-and-death
confrontation," Everett recalls. The difference between that subject and the multitude of other
EDPs he encountered in his career he likens to "the difference between a Tyrannosaurus and a
tabby cat. There's no subtlety about the intensity of energy, the physicality. It doesn't seem like
you're dealing with anything human."
Seemingly invulnerable physically, the subject, in fact, may be experiencing a cluster of lifethreatening physiological stresses, including hyperthermia, a change in blood acidity, electrolyte
imbalances, a breakdown of muscle cells, and a leaching of cellular contents into the blood
stream, all of which put his heart at significant risk.
With more research desperately needed, identifying "definitive, scientifically validated 'best
practices'" for dealing with dangerous and difficult ED subjects may be impossible at present,
Everett concedes. But based on his review of available data, he believes that "the overarching
operational objective" when these individuals are confronted must be to bring them under control
in a manner that does not unnecessarily aggravate their affliction and to get them immediate
medical treatment.
Everett adds that ED is rare and that agencies may have other more prominent life and safety
concerns to deal with. Based on what is known about ED now, he makes these
recommendations:
1. Coordinate in advance with EMS. "ED is a medical emergency that presents itself as a law
enforcement problem." Police and medical communities should strive to develop a coordinated
approach for dealing with these incidents, with everyone involved understanding "what ED is and
what their roles are"
when dealing with an episode.
2. If feasible, train dispatchers to recognize and question for indicators of ED so that responding
officers can be cautioned before reaching the scene. When ED is suspected, EMS personnel and
any available crisis intervention teams should be promptly notified.
3. Where ED seems probable, EMS should be dispatched and stand by at a safe distance until
the individual is restrained. "EMS involvement is warranted as early as possible."
4. "Unless there is an immediate public safety threat, the first responding officers should focus on
containing the subject" in an environment that offers him maximum possible safety and protects
others as well. Unless there are compelling reasons to do otherwise, officers should not approach
the individual until substantial backup and medical personnel are on the scene.
5. As soon as the first responding officers believe they are dealing with ED, "they should ensure
that SEVERAL officers are sent as backup." If physical restraint becomes necessary, they'll be
needed for the protection of everyone involved. "Backing off until help is there makes sense and
rushing to intervene alone, unless there is a compelling public safety threat, is foolhardy."
6. Once sufficient numbers are on hand, including medical personnel, then "police efforts should
be focused on getting the subject under control as quickly and safely as possible." He needs
medical treatment, but there can be no treatment until he has been brought under control.
7. In considering tactics, keep in mind that "ED is often characterized by superhuman strength
and imperviousness to pain. Thus, control through empty-hand, mechanical techniques may be
more difficult to achieve, and pain-based techniques may be relatively ineffective." The subject is
typically "unresponsive to verbal direction."
The effectiveness of pepper spray and impact techniques (baton strikes and beanbag rounds)
"will likely be diminished with individuals who are unresponsive to pain."

If empty-hand techniques are to be tried, "then the officers should be trained in advance to
function as part of a multiple-officer takedown team."
A better choice may be Conducted Energy Devices (Tasers). However, current research cautions
about a possible link "between MULTIPLE such applications and death in persons with symptoms
of ED. To mitigate this risk, a SINGLE Taser application should be made before the subject has
been exhausted."
(The Taser should be used not in the hope of gaining compliance but to create a window of
disablement during which officers can establish physical control of the subject.)
One Taser firing in the probe mode, "followed by a restraint technique that does not impair
respiration, may provide the optimum outcome." NOTE: "The Taser should not be used in the
pain-distraction (push/stun) mode in dealing with ED individuals," since that is primarily a painreliant technique.
Whatever the tactical approach, "without a common plan and without training and practice in
working together in multi-officer techniques, officers may very likely end up working against each
other."
8. Adjust your restraint tactics. "People are designed to fight what is in front of them, and officers
are almost universally trained to place individuals into a prone position because of safety and
control advantages.
This position may make it more difficult for the person to breathe, and this concern is heightened
when dealing with ED." Therefore, once control is achieved, "the subject should be placed on his
side if this can be done without creating an unreasonable risk to officers or others. As soon as he
is controlled, hand him off to the medics."
9. The goal is to get the subject into the hands of Advanced Life Support personnel or into a
hospital as quickly as possible. Ideally, do not transport ED subjects in a police car. "They should
be transported to a hospital in an ambulance," unless waiting for an ambulance would cause
unreasonable delay. Officers should train in advance with EMS on how these individuals should
best be placed on and secured to a stretcher.
10. Medical personnel should have protocols for dealing with ED cases, including the possibility
of considering the prompt use of "chemical restraint" (powerful tranquilizing agents) to bring them
down from their state of extreme agitation and violence. "At the very least, medical personnel are
better equipped to intervene than police officers would be if there is a cardiac event."
Lawrence characterizes Everett's recommendations as "a forward-thinking attempt to advance
our understanding and response" to ED. But he stresses that there are still many mysteries about
this syndrome and that these suggestions should not all be regarded as guaranteed lifesavers.
For example, delaying physical control attempts until more officers and medical personnel are on
hand may, in fact, permit a subject's condition to worsen, although Lawrence agrees that waiting
will likely be more prudent from an officer-safety standpoint.
Similarly, rolling a subject onto his side after he is controlled in the prone position will not
necessarily prevent his dying, "since we don't really know what is killing these people," Lawrence
says. However, he agrees with relieving pressure on the subject's respiratory system in that
manner, provided that his legs are securely restrained to prevent him from kicking officers. Also,
he reminds, the subject needs constant monitoring after being "controlled," given the ability of
many suspects to defeat seemingly secure behind-the-back handcuffing. (Although some medical
critics of police tactics object to using the prone position to gain control because of its potential
restriction on breathing, Lawrence says he has never found a critic who could suggest an
effective alternative. Even the premise that prone positioning is related to ED deaths continues to
be

debated.)
Also, Lawrence points out, in remote locations where distance and lack of ready availability may
delay the arrival of paramedics, it may be safer to quickly transport an ED subject by squad car to
a hospital than to wait at the scene for an ambulance and field medical personnel. "Officers need
to assess the circumstances and do what they think is most appropriate," he advises.
Everett agrees that his recommendations should be considered only "starting points" and that
officers, trainers and agencies are "well advised to continue monitoring ED research for further
developments and insights.
"As more research is done, the best practices will become clearer, and over time these will
become the basis against which the profession is measured.
Agencies that don't keep their training current will inevitably be compared with those that do when
there's a lawsuit."
To assist in understanding and preparing for ED intervention, you may want to view a video
training program developed by the Las Vegas Metro P.D. and posted on the internet at
http://media.cchd.org/ems_excited_delirium.htm.
This presentation includes vivid recreations of ED encounters, plus a post-training test.
Also a comprehensive report on ED, prepared by Sgt. Darren Laur of the Victoria (BC) P.D., is
available through the Canadian Police Research Centre at:
http://www.cprc.org/tr/tr-2005-02_e.pdf

Chris Lawrence has published an article on the proper protocol for investigating sudden incustody deaths, available from the archives of The Police Chief magazine at:
http://policechiefmagazine.org/magazine/index.cfm?fuseaction=display_arch&ar
ticle_id=191&issue_id=12004

FSN readers can contact Lawrence directly at elginsci@execulink.com for a copy of a form he
has designed to guide such investigations. He is currently designing another form which will aid
first responders in capturing "transient evidence" of ED episodes at the scene. This is expected to
be published and posted by the Canadian Police Research Centre by the end of this month
[10/05].
The CPRC also features a significant section on ED in a report of a year-old study of Taser use.
This report can be viewed at www.cprc.org/tr/tr-2006-01.pdf
An information bulletin called "Law Enforcement Responses to Excited Delirium," which contains
Everett's recommendations and background on the ED phenomenon, is scheduled to be
accessible: www.lmnc.org by the end of the week of October 10.

"Sudden Deaths in Custody," a book that deals with ED, is scheduled to be published next
January ['06] by Humana Press. Authors are Darrell Ross of East Carolina University and Ted
Chan of the University of California-San Diego.
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NAKED SUSPECT INFO PAYS DOUBLE FOR THREATENED OFFICER

When Sgt. Drury Bishop read our report last April about the exceptional danger posed to officers
by naked suspects, he decided to share it with his patrol platoon on the Anne Arundel County
(MD) P.D.
Scarcely a month later, his newest officer, a 22-year-old rookie fresh from field training, came
face to face with a violent nude offender and drew on the information to defend himself with 4
rounds from his Sig-Sauer 229 .40-cal. when the suspect lunged for his throat.
Now the report has been used again--this time in testimony before a grand jury investigating the
shooting. "I'm sure it helped," Bishop told Force Science News. Last month [9/16/05], the panel
cleared the officer of any wrongdoing.
The shooting evolved from a dispatch one evening last May to a townhouse in a low-income
neighborhood in Glen Burnie, MD. A 20-year-old subject who was living there with a relative was
said to be in "a delusional state," using drugs, "claiming people were after him" and otherwise
behaving strangely.
During one phone call from the residence to police, gunshots could be heard in the background,
Bishop recalls.
Later the subject's family would claim he was on the verge of "turning his life around," but on that
Tuesday he was still headed in the wrong direction. When Bishop and other responders arrived
they found that "6 or 8 9mm rounds had been fired through a bathroom door." Some of these had
penetrated the common wall to the adjoining townhouse where, fortunately, no one was home.
"The subject had jumped out of a second-floor bedroom window, landing in the backyard," Bishop
explains. In scrambling over a 6-foot wooden privacy fence, he snagged his shirt, which he
wiggled free of and left hanging there as he fled across several other properties.
"In a neighboring street, he jumped into a van occupied by 2 males and screamed for them to
take him away," says Bishop. To reinforce his demands or to carjack the vehicle, he reached
toward his waistband, apparently intending to brandish his gun. He discovered he no longer had
it. During their investigation at the townhouse, officers recovered the weapon near where he had
hit the ground after his leap from the window.
The suspect then bailed from the van and ran into nearby woods, disappearing from sight.
Rookie Officer Tommy Pleasant was among patrol personnel canvassing the area by car when
he spotted the suspect hiding behind an electrical box near a roadway. "By this time the guy was
stark naked," apparently having stripped off the rest of his clothing in the woods, Bishop says.
Pleasant exited his unit and at gunpoint commanded the suspect to get down on the ground.
Instead, Bishop says, the man, sweaty and muscular, "charged at him. Pleasant retreated
backward, trying to give himself more time and distance, but the subject kept coming, and lunged
for the officer's throat."
Pleasant fired 4 fast rounds, all hits. One struck the subject in the face, the others in the shoulder
and lower torso. "The autopsy revealed that all the shots were at a downward angle, indicating
the subject was leaning forward-lunging," Bishop says. "He had enough 'road rash' to indicate he
was moving quite rapidly when he hit the pavement."
This contradicted the statement of one eyewitness who claimed the naked man was "trotting
toward the officer, with arms outstretched as if pleading for help." Other witnesses supported
Pleasant's version of things.

At the station after the shooting, Bishop pulled a copy of the article on naked suspects from his
files and asked Pleasant if he remembered it.
Indeed he did, Pleasant replied, as well as the training session that Bishop had fashioned around
it for the platoon. "He said the information flashed through his mind as soon as he saw the
subject was naked," Bishop recalls. "He told himself, 'This guy is trouble.'"
Among other things, the article quoted Dr. Bill Lewinski, executive director of the Force Science
Research Center at Minnesota State University-Mankato, as saying, "The vast majority of police
contacts with mentally ill subjects are nonviolent. But naked people are among those categories
that are particularly difficult...[T]he chances are overwhelming that they're in the midst of a fullblown psychotic episode...and potentially very dangerous."
See Force Science News #16 ("Naked Suspects: No Laughing Matter") at:
http://www.forcesciencenews.com/home/detail.html?serial=16
Per protocol, Pleasant's shooting was reviewed by a county grand jury.
During the proceeding, the state's attorney asked Bishop to read the full FSN article to the jurors,
who listened attentively. When they voted a no bill afterward, that ended all criminal investigation
of the encounter.
A lawyer for the dead man's family responded bitterly. "It seems like the only time when they go
into a grand jury and come out without an indictment is when they go in with a police officer's
case," he told a reporter.
But Pleasant's attorney observed, "Until you've been in the position he's been in, it is easy to
second-guess."
"Naked people continue to be a threat to officers," Lewinski says. He is currently involved as an
expert in 2 fatal naked-subject shootings, one in Michigan, where the officer has been charged
criminally, and the other in Oregon, where a grand jury is investigating circumstances that have
sparked significant local controversy.
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