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Home > Topics > Clinical
February 25, 2014
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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Police with a psychiatric patient

Police have tasers ready for an agitated man pacing back and forth and sweating — what’s your course of action?

By Patrick Lickiss

Editor's Note: Post your diagnosis in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!

 

While staffing Rescue 6, you are dispatched to a report of police on scene with a psychiatric patient. You are sent non-emergency, but en route are asked by dispatch to upgrade. On the scanner you hear the officers on scene requesting additional resources. 

As you arrive, you count five police cars. The officers are in the street near the corner where one appears to be talking to an approximately 45-year-old male. Several officers have their Tasers out and are instructing the patient to lie down on the ground.

The patient is pacing back and forth, appears agitated and is speaking rapidly. He is visibly sweating and is wearing only underwear despite the temperature being in the low 40s. 

One of the officers approaches your vehicle and tells you that the patient’s wife called when she arrived home to find him pacing around the living room speaking incoherently. The patient has no psychiatric history and is only medicated for hypertension. 

When contacted by the first-responding officers, he ran through the back door of the home. A foot pursuit ensued until the patient was cornered at the current location. 

Based on the limited information available, what is your working diagnosis?

What are some important considerations when responding to these types of situations?

What is your suggested course of action?

Post your comments below, and stay tuned for the conclusion of the case next week.

Comments
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
William Chapman William Chapman Tuesday, February 25, 2014 8:51:24 PM The symptoms could suggest aspirin poisoning or a narcotic overdose. They could also suggest that he suddenly stopped taking his hypertensions meds and is having some sort of withdrawals.
Denise Bernard Johnson Denise Bernard Johnson Thursday, February 27, 2014 1:37:53 AM The information is really too vague at this point for a diagnosis. I would definitely take "scene safety" to heart, approach the pt. slowly and calmly and explain we're here to help him. If/when he can be convinced to accompany us to the rig, I would give him a blanket and put him on the cot, explaining the belts are for HIS safety, then get a set of vitals including blood sugar. Further interventions would be based on those results. If no medical cause can be determined by our primary/secondary assessment, he would be transported low priority to the closest hospital with mental health/psychiatric services.
Doc Cera Belum Doc Cera Belum Thursday, February 27, 2014 3:47:35 AM Sounds more like excited delirium? Pt needs chemical sedation before he goes into cardiac arrest.
Laura Beach Laura Beach Thursday, February 27, 2014 2:30:24 PM His symptoms suggest an overdose of Beta Blockers, a common group of anti-hypertensives. This is an emergent situation due to the real possibility of respiratory suppression or arrest. First ask the police officers to back away from the man a bit and have them put their Tasers away. Shocking this man could exacerbate any cardiac issues the Beta Blocker overdose may have caused, potentially leading to cardiac arrest. Then try to engage him in conversation. See if you can determine what he is saying and use that to establish a rapport with him. If that is possible then get him to come to the ambulance with you and see if he will sit on the stretcher or at least pace inside the truck. You may have to enter into his world for a bit and work within any delusions he may be having in order to secure his cooperation. As long as his airway is secure, transport him as quickly as possible to the nearest hospital. If you are a BLS unit, request ALS support to meet you en route if you are a significant distance from a hospital. This patient needs IV access and potentially respiratory support. An 12 lead EKG would also be quite useful to determine if there are cardiac issues from the overdose. Physically restrain this patient if necessary, but I do not believe chemical restraint is appropriate outside of a hospital setting because of the dangers of respiratory issues already posed by the potential overdose of Beta Blockers.
Gijsbert Niels Terlaak Poot Gijsbert Niels Terlaak Poot Thursday, February 27, 2014 10:17:53 PM First try to separate or shield the (possible) psychiatric patient from the idiots. Then try to talk him into the ambulance. This may take some time but the environment will help so there is no need for immediate physical force or threats. Transport him to a hospital that can help psychiatric patients so his physical and mental state can be judged. Only then a diagnose can be made, at this moment the patient may have had some kind of overdose or other poisoning.
Matt Sztajnkrycer Matt Sztajnkrycer Saturday, March 01, 2014 5:55:30 AM Although as noted by other individuals, there is a paucity of data, that is often the reality in circumstances such as this. That being said, based upon the description, this is a classic case of excited delirium syndrome: agitation, pacing, incoherent speech, near nudity inappropriate for ambient temperatures, superhuman strength. Most importantly, the key is to recognize that ExDS is a medical emergency and not a psychiatric emergency, and should be treated with a high anticipation for sudden cardiopulmonary collapse (typically respiratory arrest followed by asystole within 5-7 minutes from cessation of struggle). From a law enforcement stand-point, the goal should be rapid control with minimal opportunity to struggle. Unfortunately, this person has already run an unclear distance. From an EMS stand-point, the goal should be rapid control using sedation (avoid neuroleptics), avoidance of prone positioning or anything that impairs respiration, and on-going monitoring of vital signs. Certainly other causes of delirium (head trauma, infection) should be considered. A FSBS to rule out hypoglycemia should be performed as soon as feasible. Most of these patients are hyperthermic (average temp 103 degrees F) but in this case, one has to manage both the hyperthermia with the potential for hypothermia due to ambient conditions. Once control is achieved and the patient is packaged, this patient should be immediately transported to an ED and evaluated, ideally by individuals trained to an ALS standard. Thank you for allowing me to weigh in on this fascinating case.
Michael Schubert Michael Schubert Saturday, March 01, 2014 11:11:13 AM Amphetamine/cocaine overdose. Rapid speech is a dead giveaway, sweating and no clothes are also good indicators. You can never rely on information given by the family if there are possible drugs involved. Too much coordinated movement is shown by the patient to indicate low blood sugar, although chem should be taken. Blood pressure/pulse would help possible dx. Definitely not a narcotic overdose, stimulants are suspect here. Scene safety is paramount, with police on the scene, they are in charge until patient can be treated. Whatever the cause of this, our safety is paramount and whatever the course of action the police choose to control the patient is up to them. Can't advise against using the Tazer because OUR safety comes first. Differential dx might include bath salts, synthetic thc. Once the patient is subdued and vitals taken, start a line, hook up 12 lead & contact the receiving hospital for treatment orders. We aren't doctors, don't use the Versed just because you can. If the patient is restrained & stable, just transport without pushing meds
Michael Schubert Michael Schubert Saturday, March 01, 2014 11:15:21 AM Pt could also be postictal, but patient is much too agitated
Eric Verhaak Eric Verhaak Saturday, March 01, 2014 3:06:56 PM First of all; rule out a hypoglycaemia !! don't ever forget glucose..
Kat Niemann Kat Niemann Saturday, March 01, 2014 3:08:45 PM It's Excited Delirium!!!
Cody Uehling Cody Uehling Saturday, March 01, 2014 3:10:37 PM I would probably check his blood sugar first
Jessica Lash Jessica Lash Saturday, March 01, 2014 3:16:12 PM Do not leave your vehicle until police have him detained. Once they have him detained I would gather more info from the patients significant other and conduct a blood glucose test. The fact that he is sweating even though it is cold and he is incoherent and confused but has no history of this type of behavior makes me immediately think it could be sugar related.
Paul West Paul West Saturday, March 01, 2014 3:17:59 PM Get the wife, send a radio car to get her. Put her in the back of the ambulance and see if there is any reaction from patient. If you can't get any compos mentes from him have restrained in soft restraints by cops and transport . FAST possible stroke etc. need vitals sAMPLE with wife's help.
Peter Ruggeri Peter Ruggeri Saturday, March 01, 2014 3:24:52 PM As soon as he is restrained stick him for a glucose. I've seen people do some pretty whacky things and get violent with low glucose
Dennis Dougan Dennis Dougan Saturday, March 01, 2014 3:25:06 PM Excited delirium. Four person coordinated takedown, chemical restraint, transport
Aaron Billiot Aaron Billiot Saturday, March 01, 2014 3:27:16 PM I feel the patient is currently suffering a temporary psychatric episode that induced either by excited delirium or from "popping a Molly." Patient is a definite danger to himself and others at the moment. I would prolly get the opinion of medical control and avoid tazering if possible. Hopefully we could get close enough to give in intranasal sedative and get 4-0point restraints
Andre Ruby Andre Ruby Saturday, March 01, 2014 3:30:32 PM I would say that this is a patient that is suffering from bath salts. It is typical for these patients to remove clothing as it causes hyperthermia. This patients signs makes me believe that he is on a synthetic drug such as bath salts.
Andre Ruby Andre Ruby Saturday, March 01, 2014 3:31:59 PM I would also suggest Versed 5mg IM if possible and just treat the symptoms. Poison control instructs for a CT and ICU Admit to monitor for temp changes.
Tanya Minear Kukuzke Tanya Minear Kukuzke Saturday, March 01, 2014 3:41:15 PM Versed is good for everything :-)
Todd Ritchie Todd Ritchie Saturday, March 01, 2014 3:58:09 PM if possible rule out hypoglycimia,if it is excited delirium protect pt im ketamine maintain abc and cool transport
Ken Wasserstrom Ken Wasserstrom Saturday, March 01, 2014 4:04:42 PM My theory doesn't involve narcotics due to the info provided age and medical history. As a first responder medical provider it is not our job to diagnose but to gather history, information, treat symptoms, and transport. I would suggest the help of officers to get him in the truck reguardless of the situation because of mental status, he has no choice. Once in the truck cover with warm blankets to prevent and or treat possible hypothermia. Try to administer oxygen to treat mental status and possibly calms pt. Check sugar levels, treat appropriately what glucose reading is. Monitor 12 lead reading, iv fluids and transport with officer for saftey reasons. Relay all info to hospial and eta. Contiune vitals in transport watch for cardiac change and monitor for change in mental status
Barbara Hinoj Barbara Hinoj Saturday, March 01, 2014 4:10:57 PM Excited delerium or possibly low blood sugar. Treat it accordingly
Ken Wasserstrom Ken Wasserstrom Saturday, March 01, 2014 4:13:37 PM Where pt has hypertension avoid tazer as much as possible to avoid cardiac changes and or result in possible death.
Anthony Salyers Anthony Salyers Saturday, March 01, 2014 4:22:31 PM This a new onset of psychosis. This person has a coping mechanism not working and manifested in this behavior. Calm non agressive stance to approach him and try to open coherent communications.
Adam Stern Adam Stern Saturday, March 01, 2014 4:31:03 PM The pt. Could suffering from hypoglycemia and be having and state of altered mental status. As per protocol every EDP should be treated at first if they are having a medical emergency till deemed not tobe then behavior disorder protocols should be implemented.
Trevor Stephens Trevor Stephens Saturday, March 01, 2014 4:35:33 PM He is suffering most likely from an acute psychotic episode , also known as excited delirium. Medically, the considerations surround patient safety and rescuer safety. This should be done by police with input from attending EMS. Risk of death is due to severe metabolic acidosis, and hypoxia. Once controlled by less leathal means, sedation is risky but sometimes necessary Pt should secured supine to avoid positional asphyxia. ETC02, cardiac monitor, and Sp02 monitoring are important in addition to treating obvious injury.
Donna Baer Donna Baer Saturday, March 01, 2014 5:29:20 PM My first thought was excited delirium syndrome, in which case this patient is very much at risk. You do not want officers to use their tasers or get into struggle but you need to get patient quieted and secured as soon as possible to be able to do a physical assessment. First order of assessment should be blood sugar just to rule out hypoglycemia as root cause. Need to get him to hospital as soon as possible due to possibility of collapse if excited dilirium proves to be cause. Must also keep in mind as beginning process that he is danger to you and the officers in current state and act accordingly. Do not transport alone, have at least one officer with you in back of unit to help restrain.
John Gilmore John Gilmore Saturday, March 01, 2014 5:33:58 PM Working diagnosis- gonna go with possible Excited Delerium. Immediate intervention as soon as adequate number of responders present, would be a rapid, controlled take down; followed by 10mg on IN VERSED. Transport without delay to hospital.
Eric Wanta Eric Wanta Saturday, March 01, 2014 5:51:45 PM This sounds like a case of excited delirium. Based on the things that we observed, sweating (hyperthermia), disrobing in 40 degree weather (hyperthermia), agitation/behavioral disturbances/hyperactivity (safe to assume he is having some adrenergic stimulation), it is best to treat it as such while still ruling out other things. We would also look for hyperventilation, the body's way of compensating for the metabolic acidosis that his overly excited state has caused, and dilated pupils (common with cocaine and amphetamine use). Ideally, if we can get a med history, medications, and allergies from his wife quickly we should, but because he is quickly progressing into a deeper acidosis, we need to sedate him and begin treatment before he arrests. We can attempt verbal de-escalation techniques, but the tazer will likely be the safest option for everyone. We should time the tazer deployment and be ready to sedate (with IM Haldol/Droperidol or Ketamine) and restrain at the time of deployment. Our ideal position is probably supine on a LBB. It is then important to ensure his respiration continue at a rapid rate (20+) to continue to compensate for his metabolic acidosis (by causing a respiratory alkalosis). If needed, we should consider RSI/DFAM if he is unable to maintain his airway, and continue hyperventilation for him. We should establish bilateral IVs and administer Lorazapam to continue sedation. We would also want to infuse NS mixed with 1 amp bicarb in one IV, and NS wide open in the other. We would continue saline as needed. This will further stabilize their acidosis, hopefully preventing arrest. It is also important to rule out hypoglycemia and other causes, so we will (obviously) obtain vital signs, including BGL and 12-Lead and then emergently transport. If he is hyperthermic (which he likely will be) we can begin to cool him with ice packs/water fanning to slow his metabolic rate further. If he does arrest, two amps of bicarb would be beneficial.
Jon Dunham Jon Dunham Saturday, March 01, 2014 6:40:59 PM This is an Excited Delirium subject so quick use of the Taser and get the subject restrained is a must. As a Medic rapid use of some sort if traquilizing / sedative drug would be the best course of action. This shot may even take place as soon as it is safe during the restraint process. We need to decrease the amount of agitation as quickly as possible to help with heart rate and other vital sign.
Amy McDaniels Amy McDaniels Saturday, March 01, 2014 7:29:21 PM Rule out hypoglycemia(accucheck), head injury (recent trauma that could trigger AMS) or possible stroke(assess stroke scale), possible drug toxicity depending on medication he's taking. Monitor ALS, cardiac monitor, iv and reassuring the patient that no one is going to harm him. Keep restraints in area accessible if needed.
Michael Brett Waxler Michael Brett Waxler Saturday, March 01, 2014 7:40:04 PM Sounds like "excited delerium." Sedate with ketamine 5mg/kg IM
Ed Woodward Ed Woodward Saturday, March 01, 2014 7:55:40 PM Agreed. Possible ExDS patient. Management would be as you outlined above. I would also keep a close eye on pt's temp and in the event of hyperthermia treat accordingly.
Jamie Lavallee Jamie Lavallee Saturday, March 01, 2014 8:16:31 PM All good suggestions, and lots of info missing Things I am thinking are diabetic emergency, Even extra pyramid symptoms?
Matthew Cristea Matthew Cristea Saturday, March 01, 2014 9:32:24 PM The patient may be having a psychiatric event or it could be an overdose. I would ask the officers if any drugs were found in his home or on his person. As an EMT I would first start with scene saftey and scene size up. I would prepare the restraints in case the officers place the patient on a hold. Once the officers give us the ok start with airway, breathing, and circulation. Because he appears agitated, his respiratory rate may be elevated. I would try to calm him down and bring his respiration down. I would conduct a primary assessment and treat and wounds or injuries. Because of the weather conditions I would put a blanket on him and check for hypothermia and treat accordingly. I would request ALS backup or head to the nearest appropriate receiving facility. Depending on the patients behavior I might request an officer the ride in the back of the ambulance with us. Some important considerations: Scene Safety Environmental Conditions Possibility for Violence
Eric Wanta Eric Wanta Saturday, March 01, 2014 9:56:41 PM I'm just curious, but other than the low chance of causing Malignant Neuroleptic Syndrome, do you know of any other reasons for avoiding Neuroleptics?
Todd Noftsger Tyashu Dean Todd Noftsger Tyashu Dean Saturday, March 01, 2014 10:34:20 PM My boyfriend is a Police Officer and I am a Firefighter & EMR. Fire Department policy is to stage nearby until the scene is safe. I do think that having that many Police Officer's with Tasers pulled is only agitating the man even more. I would ask the patients wife more detailed questions about her husbands medical history. The man seems to have taken something that has made him delusional or his blood level could be low. If getting the patient into the ambulance is unsuccessful then the Police Officer would need to detain him and escort him to a hospital to be checked out. I am not a EMT or Paramedic...yet, will be starting classes in a few months. I just wanted to give my opinion of what I thought. I hope no one minds.
Barnet Wexler Barnet Wexler Sunday, March 02, 2014 7:53:06 AM I would consider a drug overdose first, then possibly a mental health crisis. I would attempt to communicate with the patient myself, if possible. I would attempt to assess viral signs. If not possible, the patient needs to be placed on the stretcher, possibly in physical restraints then evaluated. With the public health laws being different as to jurisdictions, here the only people who can remove a persons freedom of choice are police officers. So the final option is not mine.
Melinda Teaster Williams Melinda Teaster Williams Sunday, March 02, 2014 8:20:58 AM Has anyone tried talking to the Patient? (I do not mean yelling, ordering or down talking) The guy is in obvious distress weather it be a blood sugar issue or overdose of unknow medication. This man does not need to be man handled or tased, if you or you poartner can calm him down to at least get a set of basic vitals could reveal alot. ask the least over excited officer to help you and ride along with you. I would start with a blood sugar check. in the mean time send someone to talk to the wife get a better history.
Matt Sztajnkrycer Matt Sztajnkrycer Sunday, March 02, 2014 8:46:12 AM Neuroleptics are associated with an increase in mortality in toxin-induced delirium. They alter thermoregulation, are pro-arrhythmic, and in this case, ExDS is speculated to result from alterations in brain dopamine response. In fact, some of the original ExDS papers from the late 1980s described the syndrome as a cocaine-induced NMS.
Laura Lynn Deptola Laura Lynn Deptola Sunday, March 02, 2014 3:05:53 PM The patient is AMS with no psych history. I would be thinking hypoglycemia
Mariellen McGovern Mariellen McGovern Sunday, March 02, 2014 5:06:45 PM Excited delirium would be my impression. Call for medic...need ativan or something similiar to sedate. Have pd restrain pt with care taken to maintain airway. Rapid transport needed due to fatality possibly if not taken to definitive care and medicated. Als needs to be established asap
Mike Pace Mike Pace Sunday, March 02, 2014 5:49:36 PM who cares
Nisa Iraheta Nisa Iraheta Sunday, March 02, 2014 8:45:58 PM Probably he hasn't had his B/P medicine in a while which is costing him to have AMS.
Louise McEvoy Louise McEvoy Sunday, March 02, 2014 8:53:59 PM Although he is young, the hypertension hx requires to consider acute stroke. While it can mess up being able to think clearly, speak coherently, can also mess with thermoregulation. I would consider having a familiar person to him be involved with helping try and calm him and persuade him to go to the hospital. Using the tazer should be avoided. Obviously safety of the crew and the patient are high priority so the less agitation the better. Transport with no lights and sirens off, have family with him, along with a policeman in the back if the bus in case he becomes agitated again. Semi-fowlers position with lights dim, get accurate vitals and transport to a stroke center with proper hospital notification
Leon Cribb Leon Cribb Monday, March 03, 2014 12:39:08 AM The patient is agitated and pacing he does not display violent behaviour he does not have a history of drug abuse or other external influences. He may have a cerebral event explaining his behaviour or he could even be septic causing changes in his normal actions. The number of Police may be adding to his actions. Would first try one on one chat to establish a connection with pt to determin his mental perception which could my line of treatment if I could coax him into my vehicle. I would try to avoid a physical take down which could lead to further injury to anyone and even his death. From the information supplied you have time to sort out his condition. Slow and steady always wins the race. Speak to the wife she may have more information then she has a Ready told the Police. It could be as simple as a UTI.
Jorge Solsol Figueroa Jorge Solsol Figueroa Monday, March 03, 2014 5:41:57 PM excelent
Bill Harrison Bill Harrison Saturday, April 19, 2014 10:15:23 AM I'm hypoglycemic and have to always have food around. I'll get the shakes and messed up feeling. I can understand what you're saying. It is a very miss understood affection.

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