Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

A Killer Diagnosis?


Expletive deleted Horror Shows! is firetender’s response to my Thanksgiving Day post Happy Excited Delirium.

Again, firetender is claiming that the officer is making a diagnosis. He is demonstrating this by using non-medical definitions of diagnosis and assessment. Is this any different from the creationists who pretend that a scientific theory is the same as an opinion.

We should not expect a fundamentalist to understand science. Likewise, we should not use a non-medical definition for medical terms.

At 23:48., the room is silent, the cop is on the phone and making the diagnosis.
(Let me say that again: Making a diagnosis!)

That is not a diagnosis. Here is what I wrote –

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case.
This is excellent communication and the right assessment.

This is not a diagnosis.


Image credit.

So, technically, no, that was not an assessment. The Officer specifically used medical terminology to describe a medical condition

What if the police officer says –

I believe we have a diabetic emergency.

I believe we have a GSW (Gun Shot Wound).

I believe we have a cardiac arrest and I am initiating compressions and attaching the AED (Automated External Defibrillator.

Are these diagnoses? They all use medical terminology, but that does not make them diagnoses. Imagine if he had used the word that every EMT learns to use, rather than sweaty – diaphoresis? Would that be a diagnosis?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; restraint and sedation.

If the police mention diabetic emergency on the radio, am I required to initiate treatment under the hypoglycemia portion of an altered mental status protocol?

If the police mention GSW on the radio, am I required to initiate treatment for a GSW under a trauma protocol?

If the police mention cardiac arrest on the radio, am I required to initiate treatment under a cardiac arrest protocol?

What if none of these assessments are accurate?

What if the diabetic patient is not really diabetic, or has a different cause of altered mental status, or does not even have altered mental status?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; dextrose.

What if the GSW patient has not been shot, or the wound is minor, or something else?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; 2 large bore IVs, non-rebreather mask/intubation, rapid transport to a trauma center.

What if the cardiac arrest patient never had a cardiac arrest?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; CPR, intubation, epinephrine, defibrillation, therapeutic hypothermia, et cetera.

In other words, NO. The police do not determine EMS treatment.

Does EMS call the police for treatment orders?

No.

If the mention of excited delirium syndrome by a police officer caused some requirement for sedation, where was the sedation?

It is impossible at present to know how many patients receive a therapeutic intervention that stops the terminal progression of this syndrome.

One reason for that is, as the first article described, the diagnosis is most often applied to a dead person after the fact of forcible restraint by LEOs.

No, but feel free to try to come up with some evidence of this.

I don’t know how more clear this White Paper can get; The diagnosis of Excited Delirium is NOT derived from Evidence-Based Medicine. In that respect, I’d imagine Rogue would have to agree with me; DO NOT ACCEPT ExDS AS A VALID DIAGNOSIS!

The authors of the paper make it clear that they are basing this on the best available evidence. Writing in ALL CAPS does not change that.

There is no current gold standard test for the diagnosis of ExDS.
… combination of delirium, psychomotor agitation, and physiologic excitation differentiates ExDS from other processes that induce delirium only.
…Similarly, subjects who are agitated or violent but who do not also demonstrate features of delirium simply do not meet the definition of ExDS.

What is a syndrome?

Syndrome: A set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease.

What was the title of the white paper?

White Paper Report on Excited Delirium Syndrome.

Do you assume that the definition of syndrome is something that is irrelevant, or do you just not know that it is relevant, or do you just not know what a syndrome is?

Basically, they’re saying that there doesn’t appear to be a “cause and effect” between use of restraint or chemical/electrical controls and death. But, really, how can they say that when the only cases of death through so-called ExDS are precisely on the heels of the application of force?

When people are killed by the application of force, there are usually some signs of the cause of death. Cause and effect. Excited delirium syndrome is different. There is no injury that explains the death. Fighting with police is not necessary, but extreme physical exertion does appear to be necessary.

If you figure out how to sedate people without the exertion, that would be great.

Getting excited delirium syndrome patients to voluntarily stay in a calm comfortable room is great – right up until the patient decides to leave and go play in traffic, and kick little old ladies over and over, and throw children around, and whatever else?

Until there is a safe, dependable, fast acting remote tranquilizer available, force is going to be a part of the solution.

Sedative or dissociative agents such as benzodiazepines, major tranquilizers, and ketamine are suggested but there is no evidence yet to prove that these will result in a lower morbidity or mortality.

There does not appear to be any research to demonstrate clearly that sedation saves lives, but we do know that continuing extreme exertion by these patients frequently results in death. What is frequently? That is difficult to answer. They do estimate that the dramatic decrease in estimates of the death rate is due to psychiatric medication.

What would be the treatment for a patient in an ICU with similar extremes of metabolism?

Sedation?

White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated to add link to the White Paper being discussed on 7/23/2018. This should have been included originally.

Comments

  1. Two words

    Droperidol dartguns….

  2. Look at SIDS, Sudden Infant Death SYNDROME. (I like Capitals, Rogue, it’s an Old School thing!). In retrospect, it wasn’t a Syndrome at all, was it?

    It’s positional.

    My position is that the White Paper made it clear no one really knows the proper diagnosis, etiology or proper treatment of (so-called) ExDS. How could they if Step #1 is to forcibly restrain when eliciting resistance appears to be the straw that breaks the camel’s back and leads to death?

    It’s a deadly circle that needs to be addressed.

    Even the medical community-at-large has not accepted it as a valid diagnosis. The White Paper is not going to change that. In my view, in point-after-point it made clear how much we do not know!

    I don’t see any of your evidence-based medicine in it, sorry. Certainly not enough to warrant a label. Do we even use SIDS as a descriptor anymore? If we don’t, it’s because the evidence has shown otherwise.

    ExDS is too new, and it’s also driven by seeking to place a label on why some people suddenly die while being restrained by LEO’s, much in the same way as SIDS was being used as a catch-all to exonerate the parents from culpability in the death of their infants.

    Don’t get me wrong; in either case it isn’t about willful acts being taken to cause death, but death is what happens. Proper positioning of the infant will be likely to PREVENT infant death in much the same way as elimination of forcible restraint in drug-induced states of extreme agitation could PREVENT death of the affected person.

    So with SIDS, now there is a major education program going on to make sure people are aware of the potential consequences of improperly positioning your infant. Much the same needs to go on with LEOs and EMS personnel. That is UNTIL we learn more about it. Right now, we DO know there is a direct correlation between death and forcible restraint.

    The alarm sounded for me when I observed a significant difference in the presentations of the subjects in Video #1 and Video #2. I made that very clear. No, I don’t believe forcible restraint was appropriate in either case for anything other than convenience and the inability of the system to take the time it takes to isolate the individuals from harming themselves or others.

    Sometimes, of course, you really don’t have that option. In Video #2, based on the number of cops available to pounce on the guy, I’d say there were enough bodies to secure a perimeter around him as well.

    (To be quite frank, after watching Video #2 I wasn’t quite sure if I had just seen my first Snuff Film; I was completely appalled!)

    Oddly enough, however, my treatment plan in either case would be to isolate and observe, and then — when it would be determined to be necessary to protect the life of the patient and/or bystanders, do as our colleague usalsfyre suggests;

    Get out the Dart Gun!

    …and i say this without one smidgen of mockery. usalsfyre is brilliantly on the right track, even on your terms, Rogue. If sedation is the goal, it can be delivered to the patient without forcible restraint, as safely and easily as Taser to the shooter, and considering the numbers of our medics that are into guns, a lot more fun!

    • One more point:

      For so-called ExDS patients the intervention begins with forcible restraint. Typically, the medic, once arriving on the scene, has to work with what is given him/her. The Cops, whether they make a diagnosis or not, are still essentially dealing with a Perpetrator. As such THEY, in practice, define the primary intervention and it’s really not based on a medical evaluation. (One point for Rogue!)

      The medics, however, are called on to treat a Patient. So the point is, the first and most crucially deadly step has already been decided upon; forcible restraint, whether it’s appropriate or not. That falls into the realm of maintaining peace rather than treating a patient’s medical condition.

      And now this question arises; Where in the literature does it say that Medics have made ExDS patients dead by forcible restraint without the presence of LEOs?

      As far as I can see, it’s a Syndrome whose primary ingredient is Cops.

  3. Rogue,

    I’m interested in your response to Russ’s question:

    “If the guy in Video #2 was NOT given anything to resist, might he be alive today?”

    Although obvious difficult to answer as we’re not prophets, that seems to be the crux of the matter.

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