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

- Rogue Medic

Is This Another Excited Delirium Death

There is another death of a man under circumstances that suggest excited delirium.

A video camera worn by one of the officers captured the Sept. 9, 2010, confrontation, which occurred after the YMCA asked police to eject Smith, a mentally ill 28-year old who was acting bizarrely. The video shows the officers used a Taser several times before they could subdue Smith. But after nearly four minutes holding Smith down, the officers realized he was not breathing. He died a week later.[1]

So many points in just this one paragraph.

1. mentally ill . . . acting bizarrely.

This should be presumed to be excited delirium until there is reason to believe otherwise.

Why?

Because we want to avoid a deadly outcome. Appropriate sedation is probably the best way to do that.

2. officers used a Taser several times before they could subdue Smith.

This support excited delirium, although it is not at all clear what this means. The video shows the Taser being used and David Cornelius Smith hitting the ground, apparently no longer combative, but what happened that this was not enough to control him? The video is cut so many times that we cannot tell what happened at what point. The video seems to be missing a lot of what happened.

But after nearly four minutes holding Smith down, the officers realized he was not breathing. He died a week later.

No. He probably died at that time. He was apparently resuscitated and died again, without being able to be resuscitated, a week later.

Should we distinguish between clinically dead and legally dead?

Yes, but both are dead. Pulseless, apneic, unresponsive with a leathal rhythm is dead. This is clinically dead while the person is still being treated as a patient. This becomes legally dead once the patient is pronounced dead and all resuscitative efforts are stopped, or when resuscitative efforts are not even initiated.


Image credit.

But a lawsuit filed by Smith’s uncle claims Gorman and Callahan suffocated Smith by putting excessive weight on his upper back, and cites the autopsy report that classifies the death as a homicide. By focusing on the officers’ use of prone restraint, the suit calls into question a police practice that has raised concerns across the country.[1]

Is it a good idea to have weight on top of the back of someone in restraints?

No.

Did that cause the death of Mr. Smith?

That is a much more complicated question that probably cannot be proved.

Medical experts who have studied the issue disagree about the danger of prone restraint. Still, officers are often warned in training programs about the potential harm to those being restrained, especially if the pressure on the back is prolonged. Minneapolis Police Department policy specifies that “when ANY restraint technique is used on a subject, the subject shall not be left in a prone position and shall be placed on their side as soon as they are secured.”[1]

The officers do not appear to have followed department policy, but that is not clear from the video, since I cannot really tell what is going on.

The Hennepin County Medical Examiner attributed Smith’s death to “mechanical asphyxia,” noting significant conditions that included the prone restraint position, cold medicines in his system, mental illness and physical exertion during the struggle.[1]

According to this, positional asphyxia is much more than just the prone restraint position, but includes the typical ingredients of excited delirium – medicines, mental illness, physical exertion, and a struggle.

Would Mr. Smith have lived if he had not been restrained face down with pressure on his back?

We do not know.

This is why I am advocating for aggressive sedation of these patients.

Sedation is expected to treat these conditions, rather than exacerbate them by not sedating the patient.

Medicines – Almost always, stimulants are involved. Sedation is the same treatment that would be provided in the ED (Emergency Department) for overstimulation due to stimulants. If the drugs are not stimulants, then this does not appear to contribute to excited delirium.

Mental illness – Sedation is the ED treatment for agitated, out of control patients with mental illness.

Physical exertion/struggle – The patient is not just a little stimulated, but stimulated to the point of cardiac arrest. Sedation interrupts that feedback loop of ever increasing stress on the body.

We would not let a CHF (Congestive Heart Failure) patient continue to increase the stress on his heart by depriving him of treatment, so why do we ever deprive excited delirium patients of treatment?

 

Excited delirium is an extreme metabolic emergency that can kill.

 

Medical and police experts who reviewed the videos and autopsy report at the request of the Star Tribune differed on their interpetations.[1]

That is another of the clues of excited delirium. We do not completely understand excited delirium, but that does not mean that we should avoid aggressive treatment of the things we expect to lead to death in some of these patients.

ACEP (American College of Emergency Physicians) is clear that excited delirium is a real condition. No physicians have more experience with excited delirium than emergency physicians, so until there is some valid evidence to the contrary, excited delirium is real and should be treated aggressively according to recommendations by ACEP.[2]

Footnotes:

[1] Minn. Man’s Death Puts Police Tactic Under Scrutiny
Randy Furst Source
Star Tribune (MINNEAPOLIS, MN)
Created: February 7, 2012
Article

[2] 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 link to PDF 7/23/2018.

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Comments

  1. But you don’t get it, medical directors have openly said that something more than one example I heard of 10 mg of Valium IV is more than enough for any patient, because it worked in one case they saw and mixing benzodiazepines or god forbid something like morphine or the ever scary fentanyl with valium, versed or ativan would be akin to crossing the beams and should be avoided at all costs. If those are the ones making the rules, what hope do we have for protecting ourselves when they’re still in this state and police go “here you go, have fun” and take off?

  2. I do a lot of math, how many fatal cases of excited delirium occur outside custody? How many times do the police have tape issues when there is not a death? This sounds a lot like the guy with 17 bullet holes being the worst case of suicide the cops ever saw. I don’t care if you shoot me in the back of the head, but this story seems to be reaching along ways to make up a syndrome for letting cops go.

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