Crisis Management: A New Hope?
For my first foray back into the world of blogs in a few months I would like to return to some themes I originally picked up in an earlier blog.
In Making A Drama Out Of A Crisis I discussed my thoughts on how “crises” should be managed and which agencies should be present to help manage them.
This followed a couple of incidents where, once again, people had died after police intervention in what appeared to be situations involving mental health.
These incidents remain under investigation and will not be commented on specifically here.
I watched with interest as various people rose to speak at the vigil for Mark Duggan outside Tottenham Police Station. Several of the speakers were relatives of people who had died in similar circumstances and who still feel that there has been no justice or explanation. Those matters also remain under investigation and will not be commented on specifically here.
In each of these cases there is an apparent degree of commonality and this has been discussed in Dr Jenny Holmes’ blog The Deadly Equation.
In summary it can be written like this:
MENTAL ILL-HEALTH / DISTURBED BEHAVIOUR + POLICE RESTRAINT + POLICE TRANSPORT + POLICE CELL = RISK OF DEATH
So, what are we dealing with here and how best to go about it?
Before I continue I will stress the fact that I am not a medical practitioner and I have no medical qualifications beyond basic first aid training. This blog is about questions – not answers.
In the “Making A Drama” blog I suggested that when called to a situation which appeared to involve a “crisis” that the right people with the right skill sets needed to be present.
I suggested that you needed legal, clinical and mental health experts to descend at the same time and collectively manage the situation with whichever expertise was best fitting.
I argued that the real cause of the crisis might actually need to be determined later on – it was the actual management of the crisis which was crucial and if you get it wrong people die.
Why am I raising this now?
Because we are no nearer a resolution and in the last few days I have discovered that this is a problem which is not confined to the UK and that there are some medical opinions which also think that there has to be a better way of managing these situations.
As I have stated, I am not going to discuss the specifics of any of the ongoing investigations but in each of them the police appear to have been asked to deal with someone who was behaving bizarrely and who then become violent and aggressive and requiring restraint.
In other words – all the hallmarks of Excited Delirium (ExDS).
I mentioned this is a tweet the other day and this introduced me to two new friends.
@Jo_Thomas67 who is a Senior Lecturer in Paramedic Science and Emergency Care.
What I learned from Louis is the ExDS is something which is a problem in the United States where it seems to be the police who have a problem recognising it.
What I learned from Jo is that there is still quite a bit of resistance from clinicians in the UK as to the existence of and how to deal with ExDS.
Jo was kind enough to share some material with me which, because I am sad, I found absolutely fascinating.
Excited Delirium was first medically described in the 1800’s when it was referred to as Bell’s Mania (amongst other things.)
Despite all of the names it has had over time the accounts describe the same sequence of events
“Delirium with agitation (fear, panic, shouting, violence and hyperactivity), sudden cessation of struggle, respiratory arrest and death. In the majority of cases unexpected strength and signs if hyperthermia are described as well.”
ExDS is not currently a recognised medical or psychiatric diagnosis and yet it is being referred to in coroners inquests across the world.
The condition itself may not be officially “recognised” but I can guarantee that the symptoms above will be frighteningly familiar to most front line practitioners.
One of the reports states that ExDS has gained increased public attention due to the “number of post-mortem explanations offered by medical examiners regarding the death of individuals being restrained by the police or being taken into custody.”
“Police brutality” is therefore reported or assumed.
As both @mentalhealthcop and I have observed in previous blogs we have ended up in a situation where, when presented with these symptoms, the police are left with one tactical option:
Restraint – with no obvious exit strategy.
This then leads to the Deadly Equation.
The matter is further compounded by hospitals who have “zero tolerance” policies for violent and aggressive patients (“They aren’t coming here”) and the fact that even if the current guidelines on managing MH detainees are followed patients showing symptoms of ExDS are likely to fall into the category of “wholly unmanageable” and all the guidance suggests that a police cell is where they should be taken.
I have said before that if someone is “wholly unmanageable” then the very last place they should be is in a police cell as it is likely that they will require medical intervention sooner rather than later.
What we actually need is a process which deals with Pre-Police Station or Pre-Hospital situations.
Thanks to Jo I have now read several detailed and comprehensive studies which suggest that, actually, the best way to manage cases like this is with rapid tranquilisation followed by immediate hospital admission and treatment.
I think both of the reports hail from the US where there seems to be less ethical dilemma over police officers applying restraint whilst paramedics administer sedative.
This is a legal and ethical area which would need careful consideration here. At present I would be extremely uncomfortable in expecting my officers to hold someone whilst drugs were administered. In a clinical setting we are all too frequently asked to do this – and I refuse.
However, at the roadside, during the crisis when the patient appears to be showing the signs of ExDS and is struggling violently and with superhuman strength what do I actually want?
I want a solution which doesn’t involve the use of eight police officers frantically trying to hold someone down. No matter how much safer this is (one limb each, one on the head, one observing etc) it LOOKS awful.
We know that pain compliance isn’t going to work and we know that pressure and restraint isn’t working either.
There is currently no way out of this situation. Which, I would suggest, is why officers try to get the situation “under control” and get the person to a police station where they can be further “controlled.”
This isn’t police brutality – it’s panic. It’s taking the only apparently obvious way out of a situation. The “least worst” scenario – when in fact – it is the actual worst scenario.
The case studies I have read over the past few days have been very careful to point out that sedation is not the solution to all violent and aggressive people – for the simple reason that not all violent and aggressive people are suffering with ExDS.
However, in cases where it does appear to be apparent (and I would argue that this is distinctly possible in all of the cases referred to at the start) there is a growing body of medical evidence which points out that:
1. This is a medical emergency
2. That an appropriate dose of the right sedative (which is named in the reports) can lead to rapid chemical restraint and an end to the struggling and fighting.
3. That if this is immediately followed by other medical interventions and then immediate hospitalisation and treatment it seems to work with no evident after effects.
Most importantly – the patient survives.
When I read the case studies I saw that police involvement was necessary because of the types of calls involved. This is always likely to be the case.
What differed was that it was quickly recognised for what it was, the person was tranquilised and then conveyed to hospital.
It was medical – not “criminal”.
The police cells were never considered and the patient was safely – and medically – brought out of the life threatening condition and returned to normality.
After initial sedation this process actually took a period of days as the patient was safely weaned off sedatives and their condition improved.
What this demonstrates is that physical restraint and quick conveyance to a police station is absolutely not what is needed at all. What the person needs is prolonged medical care.
The problem is that of gaining control of the patient in the first place.
At present, in the UK, this person could be refused entry to a hospital for being violent and end up in a police cell for being unmanageable.
The difference is pre-hospital treatment.
The administering of sedative in the appropriate cases by the appropriate people.
THEN the patient can be immediately taken for the medical aftercare they need.
This goes back to the right people being in the right place and working TOGETHER to resolve the crisis.
In the UK it needs further debate and, probably, a change in several laws and procedural guidelines before it can happen.
Having read what I have recently read I am more convinced than ever that it is the way forward. I stress that I am only talking here about cases of apparent ExDS.
If nothing changes then all we will continue to have is prolonged physical restraint followed by much debate about where to take people, who takes them and a list of reasons why certain places cannot accept them.
Look where that has got us in the past.