Journal Logo

Breaking News

Read breaking news and articles published ahead of print. Tell us what you think and comment on your colleagues’ views about EMN articles.

Wednesday, September 8, 2021

AHEAD OF PRINT: ​Death of Black Man Prompts Reanalysis of ExDS

​Death of Black Man Prompts Reanalysis of ExDS


BY RUTH SORELLE, MPH

The death of Elijah McClain, a 23-year-old Black man reported to police for walking down the street wearing a ski mask in Aurora, CO, highlights the controversy over the term “excited delirium.”

Mr. McClain was not accused of a crime, but police officers subdued him with handcuffs and chokeholds. Emergency medical services personnel then injected him with a large dose of ketamine, and his heart stopped on the way to the hospital. The Adams County Coroner said his cause of death was undetermined, and prosecutors refused to bring charges against the officers because they said Mr. McClain may have died of many causes, among them excited delirium.

Excited delirium is a controversial diagnosis with many reported symptoms, not the least of which is death. The American Medical Association recently adopted a policy opposing excited delirium as a viable diagnosis and warned against using pharmacological interventions “solely for a law enforcement purpose without a legitimate medical reason.” (June 14, 2021; https://bit.ly/3sdcbMJ.) The diagnosis is not included in the DSM-5 or the ICD-10, and the American Psychiatric Association said it “lacks clear diagnostic criteria.” (APA. Feb. 4,2021; https://bit.ly/3yLvZcu.)

After Mr. McClain’s death, Colorado legislators passed a law that sharply curtailed the use of ketamine by EMS personnel. (The Denver Post. July7,2021; https://dpo.st/3jPTQ4E.) The law also put on hold the use of the term as a diagnosis in the prehospital setting because of its imprecise definition, following the position of the AMA. Excited delirium as a diagnosis also garnered recent attention because of cases similar to that of Mr. McClain, where agitated men were judged to have excited delirium, confronted by law enforcement officials, and died after receiving drugs or a shock from a TASER.

Use Questioned
The American College of Emergency Physicians released a white paper 12 years ago accepting the diagnosis and backing ketamine as a treatment (Sept. 10, 2009; https://bit.ly/37HejTu), noting that the task force agreed that excited delirium (ExDS) is “a unique syndrome, which may be identified by the presence of a distinctive group of clinical and behavioral characteristics that can be recognized in the pre-mortem state. ExDS, while potentially fatal, may be amenable to early therapeutic intervention in some cases.”

But last year ACEP mustered a new workgroup to reconsider the condition. The findings have not been released, but information provided by ACEP to EMN said ketamine administered in the right dosage results in fewer complications, notably death. Mark DeBard, MD, who chaired the 2009 task force but is now retired, said it may be time for a fresh look at the issue, although he said he was concerned that not much research had been done in the ensuing decade. “When we wrote our paper, I didn’t think law enforcement had enough knowledge about excited delirium,” Dr. DeBard said. “Years later, I fully expected law enforcement to have that knowledge and to have EMS on the scene for diagnosis and treatment. Instead, it appears law enforcement is diagnosing and prescribing treatments to EMS, when it should be the other way around.”

The American Psychiatric Association said in a December 2020 statement that excited delirium is too nonspecific to describe and convey meaningful information about a person and should not be used until a clear set of diagnostic criteria are validated. The group also advocated for a nationwide investigation of instances where patients were identified as being in that state and recommended establishing evidence-based protocols for using ketamine and similar medications in out-of-hospital medical contexts.

APA board member Kenneth Certa, MD, said he backed the APA and AMA positions on excited delirium and ketamine. “As psychiatrists, dealing with those who are out of control is our bread and butter,” said Dr. Certa, who is also on the AMA’s Section Council on Psychiatry. “The issue is why are they out of control? Is it an underlying psychiatric illness or a derangement of brain from a stroke, drug intoxication, or a seizure? We think that diagnosis and the medications, such as ketamine, tend to be used disproportionately for people of whom EMS or law enforcement are scared because of size and race.”

Dr. Certa said excited delirium isn’t in the DSM-5 for a reason—no accepted studies describe it. “When an inexact diagnosis is treated with drugs that could kill, it makes you question its use,” he said.

Better Guidelines
Michael Levy, MD, the president of the National Association of EMS Physicians, said EMS doesn’t generally make diagnoses. “We encounter conditions and syndromes and try to figure out the best way to address that with a focus on patient safety,” he said. “When we encounter someone in the street sweating profusely with a constellation of symptoms, we don’t worry about a diagnosis. The patient has a profound disorder of some type and needs medical care. They may have something life-threatening, they may be wielding a knife and be out of control. We use all kinds of methods to de-escalate the situation. Often when you do that, you can talk the person down. Sometimes, though, they need rapid care.”

Dr. Levy said EMS must start by making sure patients are safe. “Imagine what it would be like to be in the back of an ambulance with a highly agitated patient,” he said. “When these encounters occur, law enforcement often has the person in handcuffs, but that does not treat the metabolic problem.

“Simply using brute force to overcome these patients can lead to cardiovascular collapse. You could ask the patient if you can use soft restraints, but if that doesn’t work, we use the medications at our disposal for safe transports.”
Dr. Levy said these encounters often occur at the intersection of law enforcement and EMS, but giving medications is the job of EMS, and “you don’t give medications to facilitate patients being taken to jail.”

Dr. DeBard agreed that emergency physicians and emergency services personnel have a unique view of excited delirium and the patients who experience it, but he said he understood why Colorado passed a law because the situation seemed out of control. An investigation by the public radio site KUNC and the Colorado Sun, an investigative news site, found that Colorado EMS treated 902 cases of excited delirium in a period when Dr. DeBard said the incidence rate should have been about one case per 250,000 people. (Sept.15, 2020; https://bit.ly/3g3Cmk9.) That means medics administered ketamine for excited delirium 15 times more often than they should have. Instead, they should have encountered 57 cases in that 30-month period for Colorado’s population of about 5.8 million people.

“I think they are going to have to investigate all this and come up with better guidelines on when and how to use it,” Dr. DeBard said. “That will come at a cost. Some of these people will die because EMS is not able to use the best and fastest-acting medication, which is ketamine.”

Large Doses of Ketamine
Randall Clark, MD, the president-elect of the American Society of Anesthesiologists who is based in Denver, said his group was concerned after Mr. McClain’s death because it seemed EMS wanted to have one standard for everyone. His group collaborated with ACEP on a statement saying that ketamine and other drugs like it should not be used for law enforcement purposes. (Aug. 26,2020; https://bit.ly/3m392xJ.)

“When we saw what happened in August of 2019, we became aware of some of the details, including the size of the dose of ketamine being used in EMS situations,” he said. “We believe it can be used in situations where individual EMS teams are encountering a threat to themselves or others, but it really should be an issue of last resort, and other methods should be used first, including de-escalation techniques.

“Our concerns in the EMS encounters were first the size of the dose, and then, at least here in Colorado, its use on individuals who would not, in our opinion, be diagnosed in any state of delirium.”

Use of the drug in the EMS community became popular because personnel believed they were preventing patients from injuring themselves or, as some in the emergency medicine community said, going into a hyperactive physiological state that might produce acidosis and other problems that could kill a patient quickly, Dr. Clark said. “Now we have questions about that physiologic state, and we have not seen clear, convincing evidence that such a condition exists. Yet it’s being used as a justification for very large doses of ketamine.”

It appears clear that “excited delirium is on its way out as a diagnostic term,” said Jeffrey Goodloe, MD, a member of the ACEP board of directors and an emergency physician in Oklahoma, in a statement released by ACEP. “The term ‘excited delirium’ can produce a visceral, negative response in certain communities—particularly among those [who] have complicated relationships with law enforcement or the medical community,” he said. “Physicians who do not practice emergency medicine and oppose the term may not typically see patients with life-threatening behavioral emergencies. One goal in shifting the terminology is to better form consensus around a more medically accurate description for this condition so we can better serve patients and the communities we live in.”

Dr. Levy said he expected the name to change from excited delirium to hyperactive delirium with severe agitation. The symptomology associated with that new term has not been revealed.

Ms. SoRelle has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.