CDE #34046

22 PUBLIC SAFETY COMMUNICATIONS B , A january 2013 B , A www.APCOINTL.Org

Like fictional zombies, those suffering from excited delirium may be attracted to bright lights and sounds, and may be profusely sweating and hot to the touch.

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urely by now you’ve heard the Zombie Apocalypse hype? There appears to be an increasing number of calls coming into communications centers across the world involving people with superhuman strength, seemingly out of control, running around naked, sometimes even biting or “eating” other people. Some of these calls

also include any number of “zombie”-like symptoms, including extremely aggres-sive and violent behavior, constant movement, and keening or making unintelligible animal-like noises. Like fictional zombies, the subjects may be attracted to bright lights and sounds, as well as glass and reflective sur-faces. They may be profusely sweating and even hot to the touch.

So are we really being taken over by zombies? The answer is no. In fact, these calls are not even new to our communications centers. They have been classified as disturbances and/or mentally ill subject calls. What the individuals are most likely suffering from is a state of psychosis known as excited delirium (ExDS).

by Lori vAngiLder

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Zombie ApocAlypse?

Developing a DefinitionIf you haven’t heard of ExDS, you’re not alone. Many agencies are currently working to understand the psychosis and create appropriate response pro-tocols, particularly after the focused media attention on this issue follow-ing the May 28, 2012, “Miami Zom-bie Attack.”1 What occurred in Miami, according to various news sources, is that a man was witnessed eating the face of another man. When ordered to stop by a law enforcement officer, he ignored the officer and continued the assault. When the officer shot him, the subject looked up and growled (yes, growled like an animal) at the officer and continued his assault. He was sub-sequently shot again (several times) and died on scene.

So what is ExDS? The Institute for the Prevention of in-Custody Deaths, along with the University of Miami, Fla., have created a website to educate others about this psychosis. They define ExDS as occurring “with a sudden onset, with symptoms of bizarre and/or aggressive

behavior, shouting, paranoia, panic, vio-lence toward others, unexpected physical strength and hyperthermia.”2

The Seattle Police Department describes ExDS as a “state of extreme mental and physiological excitement characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without appar-ent fatigue.”3

ExDS is not just a Florida issue. In May, a Maryland man was arrested after killing and eating part of his roommate.4 In Pennsylvania, a new mother, still a patient in the maternity ward, went outside the hospital and allegedly ingested the illegal narcotic known by the street name “bath salts.” When she returned to the maternity ward she became out of control and required multiple hospital staff and security to subdue her.5 In Georgia, a man was caught running naked at a golf course threatening to eat oth-ers while brandishing a golf club.6 The cases range across the United States and the world.

What Causes exDs?Although many of the current news reports are focused on bath salts, ExDS can be present in combination with many illegal narcotics, and/or underly-ing mental health issues. The psychosis normally involves males in their mid-30s (although we already know from the reports cited above that women are not immune). A variety of research reports are available on the topic, including one conducted in December 2011 by the Less-Lethal Devices Tech-nologies Working Group of the Weap-ons and Protective Systems Technology Center with cooperation and support from the National Institute of Justice and the Applied Research Laboratory at Pennsylvania State University. This report lists a variety of causation factors that work in combination with illegal narcotics to create a “perfect case sce-nario” for the psychosis to take over.7

The narcotics most commonly seen in ExDS are cocaine, LSD, PCP, meth-amphetamine, cannabis (which is what was found in the Miami “zombie’s”

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The name bath salts is derived from the drug’s appearance, which is white crystals that look like bath-ing products, such as Epsom salts. The drug was actually first formulated in France in the 1920s, but disappeared until it was rediscovered by an underground chemist. He published the recipe on a website that was shut down in 2004 for sharing too much information about illegal

substances. But it was too late; the widespread abuse of bath salts appears to have started in England around 2009 and quickly spread throughout Europe, then found its way to the U.S.1

Bath salts were originally sold online and in drug para-phernalia stores. The packaging often states “not for human consumption” in an attempt to avoid the chemical formulation being declared to be illegal narcotics, but chemically the sub-stance has nothing to do with actual bath salts. In September 2011 the U.S. Drug Enforcement Administration used its emer-

gency authority to control three of the synthetic stimulants that are used to make drugs known as bath salts, calling the chemicals an “imminent hazard” to the public. As a result of this order, these synthetic stimulants are designated as Schedule I substances under the Controlled Substances Act.

Bath salts often contain various amphetamine-like chemicals, such as methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone. Mephedrone is of particu-lar concern because it presents the highest risk for over-dose. It is a designer drug, meaning it is concocted in a lab. Many recovered bath salts have also been found to have very high levels of caffeine. The drugs may be smoked, mixed with food, snorted or injected. Bath salts are sold under a variety of names, including Blass, Hurricane Char-lie, Meow Meow, Stardust and White Knight. (For a more complete list of names, visit www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf.)

RefeRenCe1. ‘Bath salts’—Emerging and dangerous products. (February

2011) In National Institutes of Health, National Institute on Drug Abuse. Retrieved 11/26/12 from http://www.drugabuse.gov/about-nida/directors-page/messages-director/2011/02/bath-salts-emerging-dangerous-products.

What Are Bath Salts?

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system) and most recently bath salts. Other contributing factors include underlying mental health issues, such as (but not limited to) manic person-ality traits or schizophrenia; or pre-existing metabolic disorders, such as diabetes, hypoglycemic reactions, and even alcohol withdrawal.

Beyond increased use of illegal nar-cotics, there is an additional theory behind the rise in the numbers of ExDs cases that dates back to 1849. In

1849, Dr. Luther Bell, a psychiatrist at the Massachusetts McLean Asylum for the Insane, documented a condi-tion in which approximately 30 violent and aggressive patients suddenly died. It became known at that time as acute exhaustive mania or “Bell’s mania.” The signs and symptoms were similar to those of ExDS psychosis. For a long time, those suffering from mental ill-nesses were institutionalized and kept out of the mainstream public. Over

time, more and more of those institu-tions have closed, and pharmaceutical therapy is prescribed in a mainstream home environment. When the men-tally ill are not taking their prescribed medications, and/or self-medicate with illegal narcotics, it creates an increased number of cases for public safety per-sonnel to handle.2

exDs & in-CustoDy DeathBut what led Dr. Bell’s patients to sud-

denly die? In addition to aggres-sive, violent behavior, ExDS may be accompanied by hyperther-mia. The combination of factors creates a chemical chain reaction in the body that creates a danger-ously high core body tempera-ture. This is why ExDS patients are often hot to the touch, rap-idly breathing, profusely sweating and frequently found to be naked and/or inappropriately dressed.

Once the person is out of con-trol, they experience a tremen-dous surge of the “fight or flight” adrenaline hormone, which con-tributes to their seemingly super-human strength. Often, it will take multiple law enforcement officers to restrain the subject from causing themselves or oth-ers further harm. This physical exertion continues and has recur-rently required officers to hand-cuff the subject, as well as employ leg irons and/or a hobble.8

Once the subject is restrained, the “period of peril” starts. Levels of amino acids, proteins and hor-mones in the system reach a pin-nacle three to five minutes after restraint, while blood potassium levels drop dramatically. These factors create a situation that pre-disposes the subject to cardiac arrhythmias and has led to in-custody cardiac deaths.7 Due to the in-custody deaths, knowledge of ExDS has been shrouded in concerns of being a “police cover up” and not a true syndrome. In the course of subduing the subjects, law enforcement offi-cers have used various less lethal

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Zombie ApocAlypse?

use-of-force elements, including pep-per spray and tasers.9 However, these elements, when combined with the subjects’ elevated heart rate, elevated blood pressure and high core body temperatures, create the possibility of cardiac-related death.

symptoms of exDsOne of the leading issues in establish-ing a correct response is first recog-nizing that incidents involving ExDS constitute a true medical emergency, although initial indicators would lead one to believe that they are law enforce-ment calls. In fact, response to inci-dents where a person is suffering from an ExDS psychotic event should be a joint response.

What are indicators that a call is actually an ExDS case? The following list was compiled as part of the Less-Lethal Devices Technologies Working Group panel:10

• Extremely aggressive and/or vio-lent behaviors;

• Constant or near constant physi-cal activity;

• Does not respond to police presence;

• Attracted to and/or destructive of glass or reflective items;

• Attracted to bright lights and loud sounds;

• Naked and/or inappropriately dressed;

• Hot to the touch;• Breathing rapidly;• Sweating profusely;• Keening (making unintelligible

animal-like noises);• Insensitive to or extremely toler-

ant of pain;• Excessive strength (out of pro-

portion with build); and/or• Does not tire despite heavy

exertion.The subject may exhibit any combi-

nation of the above indicators.

Response pRotoColsIf a call is believed to be a case involv-ing ExDS, the telecommunicator must first ensure that there is a simultaneous law enforcement and EMS response. Additionally, it is important to ensure

an adequate number of law enforce-ment personnel are dispatched to safely handle the situation on scene. In many areas, EMS may stage, or stop a safe distance away, until law enforcement can gain control of the person.

Next, law enforcement should work to gain control and/or restrain the sub-ject as soon as possible to reduce the additional health risks created by a pro-longed struggle. As soon as it can be safely executed, and within local medi-cal protocols, agencies may consider having EMS personnel sedate the sub-ject, again to reduce the harmful effects of a prolonged struggle. Some agencies’ protocols allow officers to actively aid EMS in administering sedation.

It’s also important to reduce exter-nal stimulation from the area, including lights and/or siren on field personnel vehicles as well as transport unit lights and siren. Once sedated, the individual should be transported to the nearest medical facility for treatment.11

One of the forefront agencies in the country regarding policies on ExDS cases is the Seattle Police Department (SPD). The SPD began working years ago with the fire department and EMS personnel at neighboring hospitals to develop a protocol for handling such subjects. A section was added to the SPD Procedures and Tactics manual dealing with excited delirium and alert-ing personnel, from the 9-1-1 call-taker to officers and supervisors in the field, on the appropriate response when confronted with a person exhib-iting such symptoms. This protocol is widely regarded as the most innova-tive of its kind in the U.S. and per-haps the world. The protocol stresses the life safety issues involved and the importance of handling the medical emergency before any relevant crimi-nal consequences of subject behaviors are addressed; it has been credited with saving lives.12

pRepaRe noWExDS is not a recognized psychosis by American Psychiatric Association or the International Classification of Diseases published by the World Health Orga-nization.13 It is recognized, however,

by the National Association of Medical Examiners and the American College of Emergency Physicians.14

Regardless, ExDS is something that all public safety personnel should be aware of. Consider developing a response policy to guide personnel when such calls come in. Doing so will help protect the law enforcement offi-cers and EMS personnel on scene, and it could also save the life of the subject.

,PSC,

Lori vAngiLder has been involved in pub-lic safety since 1986 and serves as an adjunct instructor with the APCO Institute. She can be reached at blkhrt911@aol.com.

RefeRenCes1. Eadicicco L. (5/29/12) What caused

zombie attack in Miami? In International Business Times. Retrieved 11/26/12 from http://www.ibtimes.com/what-caused-zombie-attack-miami-organs-burning-alive-suspected-lsd-or-bath-salt-use-video-700359.

2. What is excited delirium? (n.d.) In Excited Delirium: Education, Research and Information. Retrieved 11/26/12 from http://www.exciteddelirium.org/indexwhatisED2.html.

3. Hughes EL, ed. (December 2011) Excited Delerium—Special Panel Review Report 2011—NIJ, Penn State. http://www.scribd.com/doc/81030066/Excited-Delerium-Special-Panel-Review-Report-2011-NIJ-Penn-State.

4. Koebler J. (5/31/12) Maryland man arrested after admitting to killing, eating roommate. In U.S. News. Retrieved 11/26/12 from http://www.usnews.com/news/articles/2012/05/31/maryland-man-arrested-after-admitting-to-killing-eating-roommate.

5. Crum A. (7/5/12) Bath salts make new mom violent in hospital. In WebProNews. Retrived 11/26/12 from http://www.webpronews.com/bath-salts-make-new-mom-violent-in-hospital-2012-07.

6. ‘I’m a eat you’: Crazy naked man high on bath salts threatens to eat police officers as they try to arrest him on golf course. (7/3/12) In The Daily Mail Online. Retrieved 11/26/12 from http://www.dailymail.co.uk/news/

26 PUBLIC SAFETY COMMUNICATIONS B , A january 2013 B , A www.APCOINTL.Org

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article-2168050/Man-high-bath-salts-strips-naked-attacks-police-officers-golf-course-saying-wants-eat-faces.html#ixzz21YbtRcFd.

7. Hughes EL, ed. (December 2011) Special panel review of excited delirium. Less Than Lethal Devices Technologies Working Group of the Weapons and Protective Systems Technology Center. In JustNet.org. Retrieved 11/26/12 from https://www.justnet.org/pdf/ExDS-Panel-Report-FINAL.pdf.

8. For law enforcement. (n.d.) In Excited Delirium: Education, Research and Information. Retrieved 11/26/12 from http://www.exciteddelirium.org/indexForLawEnforcement.html.

9. Kulbarsh P. (3/19/07) In-custody deaths: excited delirium. In Officer.com. Retrieved 11/26/12 from http://www.officer.com/article/10250061/in-custody-deaths-excited-delirium.

10. Excited delirium cards for patrol. In Critical Research and Training: CRT Less Lethal, Inc. Retrieved 11/26/12 from http://www.crtlesslethal.com/training/excited-delirium-cards-for-patrol.

11. Wesley K. (2/1/11) Excited delirium strikes without warning. In JEMS.com. Retrieved 11/26/12 from http://www.jems.com/article/patient-care/excited-delirium-strikes-witho.

12. Seattle Police Department. (n.d.) Use of force by Seattle Police Department

officers in 2010. In seattle.gov. Retrieved 11/26/12 from http://www.seattle.gov/police/publications/policy/UseofForceReport2010.pdf.

13. Correa F. (5/17/12) Excited delirium syndrome lacks research, coding. In ACEP News. Retrieved 11/26/12 from http://www.acepnews.com/index.php?id=514&tx_ttnews[tt_news]=1345&cHash=d257135701cb06fa0c94609c1eb6e67e.

14. Lawrence C. (1/20/26) Excited delirium and its medical status. In PoliceOne.com. Retrieved 11/26/12 from http://www.policeone.com/edp/articles/121675-Excited-Delirium-and-its-medical-status.

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sAve more livesd CDE ExAm #34046: ZOmBIE APOCALyPSE?

1. Excited delirium is considered: a. A medical emergency b. A law enforcement situation c. A psychotic episode d. Both a and b

2. An individual suffering from ExDS enters the “period of peril”:

a. 3–5 minutes after restraint b. 15–30 minutes after restraint c. 30–45 minutes after restraint d. 1 hour after restraint

3. For calltaking, which of the following behaviors are indicative of excited delirium?

a. violent behavior b. aggressive behavior c. naked d. all the above

4. Excited delirium cases may be called in as: a. zombie attacks b. violent disturbances c. mentally ill persons d. all the above

5. Excited delirium is a new disease caused by the illegal narcotic known as “bath salts.”

a. true b. false

6. Subjects suffering from excited delirium may be experiencing:

a. hyperthermia b. hypothermia

7. Excited delirium is not recognized by the: a. American Psychiatric Association b. National Association of Medical Examiners c. American College of Emergency

Physicians

8. Subjects who are only under the influence of cannabis cannot suffer from excited delirium.

a. true b. false

9. All persons who suffer ExDS are schizophrenic? a. true b. false

10. Excited delirium is most commonly seen in: a. Males 18–25 b. Males in mid-30s c. Females 18–25 d. Females in mid-30s

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