Midazolam as a Non-Lethal Weapon

Did you know that, in some jurisdictions, police can inject midazolam (better known as Versed) into suspects to subdue them?

"There is no research guideline. There is no validated protocol for this. There's not even a clear set of indications for when this is to be used except when people are agitated. By saying that it's done by the emergency medical personnel, they basically are trying to have it both ways. That is, they’re trying to use a medical protocol that is not validated, not for a police function, arrest and detention," Miles said.

"The decision to administer Versed is based purely on a paramedic decision, not a police decision," Slovis said.

It's up to the officer to call an ambulance and determine if a person is in a condition called excited delirium.

"I don't know if I would use the word diagnosing, but they are assessing the situation and saying, 'This person is not acting rationally. This is something I've been trained to recognize, this seems like excited delirium.' I don't view delirium in the field as a police function. It is a medical emergency. We're giving the drug Versed that's routinely used in thousands of health care settings across the country in the field by trained paramedics. I view what we're doing as the best possible medical practice to a medical emergency," Slovis said.

The biggest side effect is amnesia, which makes it harder for any defendant to defend himself in court.

Posted on July 18, 2008 at 11:28 AM • 69 Comments

Comments

RoyJuly 18, 2008 12:22 PM

It's the perfect date-rape drug, knocking out the victim and preventing memories from forming, producing a truly witless witness incapable of reporting the crime or identifying the officer.

SpiderJuly 18, 2008 12:24 PM

Good to know. I'll keep that in mind for my next trip to Nashville this august.

bobJuly 18, 2008 12:42 PM

@Brandioch Conner: Sounds like his practice is already alive and well in Nashville.

So anytime a cop anticipates doing something he might get sued for, say beating a helpless prisoner; all he needs to do afterward is claim they were agitated? Wow. And of course once he starts beating them, they WILL be agitated so the EMTs will agree that it was appropriate. And the victim wont remember the crime, so the EMT is immune to being held responsible for HIS behavior too. Perfect.

How come the TSA doesnt have this yet? (Or do they?)

sooth sayerJuly 18, 2008 12:42 PM

Let's ship that SF city employee to that jurisdiction for a day and see what we find out.

AnonymousJuly 18, 2008 1:24 PM

If someone is restrained enough to administer an injection, they are restrained enough that you don't need to.

Clive RobinsonJuly 18, 2008 1:34 PM

Just had a look at the contra indications for midazolam some of which are,

shock, hypotension, head injury, and drug or alcohol use.

Now call me thick but what are the chances you are not going to be suffering one or more of these being in the position of a police man calling you irrational and having been forcably restrained so the midazolam can be administered...

Further like a number of hypnotic drugs it has the effect of suppressing breathing. Which is realy a worry when you consider the number of people that have died whilst being restrained by police officers.

Oh and watch what you have for breakfast etc, apparently Grapefruit juice acts as an inhibitor to it being metabolized so possibly leading to an overdose.

Oh and some of the symptoms of overdose are,

Mental confusion, Impaired motor functions (ie impaired reflexes, coordination, balance etc)
Dizziness.

So does this get you another shot under the protocol?

Oh and with just the minor problems of Coma and Death no worries then...

Apparently it is also addictive with psychotropic effects, and is a "listed substance" in quite a few places around the world.

And apparently Simon Le Bon lead singer and songwriter for 90's group Duran Duran had problems with it after receiving it at the dentists and this inspired the album "Medazzaland".

So maybe it gives you the "blues" as well ;)

What is not mentioned is how open your are to "suggestion" whilst under it's influence. One use for midazolam is something called "conscious sedation" which is akin to having been hypnotised to not feel pain, or as a premed (the double whisky effect).

Also it is a hypnotic and what is not comanly known is that a lot of "hypnotics" have a secondary side effect of being mild "truth drugs" that is like alcohol they impare your normal cognative abilities and put you in a suggestable state where you can more easily be influenced...

Hmm sounds like every suspect should have some...

FNORDJuly 18, 2008 2:20 PM

Another interesting fact: they had the subject sign a form immediately upon awakening. He doesn't remember anything about what the form was.

Drugging someone, then having them sign something. No potential for abuse there.

Bob MurphyJuly 18, 2008 2:26 PM

I'm not a fan of this kind of thing since it could easily get out of hand and be misused.

But here's what one of the folks it was used on said about the circumstances in the original article: "Well, that night, I hadn't been properly taking my meds, you know, like I'm supposed to. I got so depressed that when I was up on the bridge running into traffic back and forth, cars dodging me, swerving, I ended up with two sharp objects in my hands."

After a Taser didn't work: "I remember they were holding me down. There was maybe four or five on each side, and I remember they were calling for something, you know. Some guy came up on the left side and hit me with it."

I can easily believe this, since I have a friend who acts very similarly if he misses a few doses of his psychiatrist-prescribed anti-psychotic medications.

So this guy was actively endangering the lives of other people as well as himself, was carrying weapons, and was so insane and hyped that a Taser had no effect and it took 8-10 cops to hold him down. Given the dearth of non-injurious alternatives in such instances, it strikes me that an injection of a dubious tranquilizer was not only justified, but was quite compassionate.

Evan MurphyJuly 18, 2008 2:31 PM

This is pretty terrible, for the reasons above and continuing on Clive's point.

Versed is pretty commonly used for painful emergency room procedures where the patient needs to be calm and relaxed, as well as for minor surgeries. I've had it several times, and compared notes afterwards with the friends who had taken me to the ER. I've also helped other people who've been put under Versed once or twice.

If you've been put under with Versed, or been with someone who's under, you might (or might not!) be aware that it leaves you more-or-less conscious state. Especially on the tail end of the drug's effect, a patient (or detainee) might appear lucid and rational, but be suggestible and form only incomplete memories. Worse, there's no sharp line where the drug is "worn off." You just progressively become more aware of yourself and form better memories. On one occasion, I realized (after the fact) that it took a few hours past being released to be in a normal state.

Hospitals are pretty careful to get patient information and signatures for consent before administering any drugs for this reason (I had a rather testy discussion with a nurse about exactly that, my first time getting it). It's just too easy to get any answer you want or expect, rather than the truth. Obviously, the police who are administering this treatment can't do the same, so any booking and questioning will quite likely be done under the influence of the Versed.

Even if that's done completely in innocence, there's no way to be sure what's true and accurate, much less allow the detainee to actively participate in their detention. The potential for police abuse is enormous, and the path to that abuse is a series of small and reasonable-sounding steps, most of which will never be examined by the people actually subject to the process. Even neutral third parties will not be able to judge if this procedure is being carried out justly---however you might define that.

I can't imagine any medical ethicist would sign off on this---perhaps that's why none have heard of it. I hope the reporter here follows up on the story.

ColeJuly 18, 2008 2:41 PM

I saw this type of thing in an old USSR documentary. This lady was making statements during a "town hall" meeting that the officials didn't agree with. So, the official waves his hand and three police looking guys walks over to her and inject her with some nice sedative. No more complaining from her.

Now, I realize this isn't the USSR, but are we at that point now where untrained individuals making medical decisions under the pre-tense of law enforcement? This is getting painful if this is the case.

Brandioch ConnerJuly 18, 2008 2:42 PM

@Bob Murphy
"Given the dearth of non-injurious alternatives in such instances, it strikes me that an injection of a dubious tranquilizer was not only justified, but was quite compassionate."

No.

#1. Why didn't the cops have alternatives? If 8 cops can hold him down, then it should be easy to get him into some kind of restraint.

#2. The cops did not know his medical condition or allergies.

This drug is used because it induces amnesia.

WallyJuly 18, 2008 2:42 PM

Wow, I bet that puts their D.A.R.E. officer in a bind. "Don't take drugs, kids, unless we force you to." Having been given Versed before, I can attest that this is really a bad idea and lends itself to abuse.

MattJuly 18, 2008 4:07 PM

There has been rumor that the TSA is using this on suspects, or clients, customer, victims, whatever; but nobody can really remember for sure...

Chris DrostJuly 18, 2008 4:46 PM

Protip: if they start saying, "sir, you look like you're excited and delirious, we're going to inject you with Midazolam," don't go into an excitedly delirious rant about Midazolam. It might just make them more confident.

Correct: (looking the paramedic in the eye, calmly:) "I have a right to refuse this injection, and I want to exercise that right."
Wrong: (hysterically railing against policemen holding you down:) "Don't drug me, bro! Don't drug me!"

Since it looks like they still ask paramedics to do the actual injection, you might consider lying to the paramedic, saying, "I'm allergic to benzos and I have respiratory problems. You are going to kill me if you inject me with that." I don't know any paramedic who would be willing to take that risk on a police officer's orders. At the very least, they'd want medical records.

AndrewJuly 18, 2008 6:01 PM

I am an EMT Basic. This article and most of the comments are totally inaccurate and way off base. This is an emergency medical system issue, not a policing issue.

The authority for a paramedic to inject drugs is medical direction, in other words a physician's approval. Standing orders, i.e. protocols, that permit paramedics to administer this drug to psychotic individuals in the field are incredibly common. Example: http://scctransitions.sccgov.org/SCC/docs/...

"POLICY - Only CCT-Paramedics will be permitted to utilize sedation without base hospital contact. Midazolam will be used for:
"1. ventilator dependent patients requiring sedation or restraint due to agitation, restlessness and/or anxiety that is compromising the patient’s stability.
"2. agitated patients requiring sedation or restraint due to restlessness and/or anxiety that is compromising the patient’s stability"

Police cannot order drugs to be given, even to persons in their custody. These drugs are only given in the medical best interest of the patient as judged by the paramedics. Violation of standing orders is grounds for license revocation.

The very title of the article is misleading. The sedative is not given as a weapon, it is given as a means to get the patient further medical help. Note that no criminal charges were filed in the example given in the article.

As for the person who posted the link to the Wikipedia article on excited delirium, he might want to share his self-admitted BS with all these MD and PhD bearing folks: http://www.ipicd.com/

In custody death is a serious issue. This kind of sensationalism does not help.

"First they came for the carotid restraint . . . then they came for the Taser . . . then they came for the Midazolam . . . and now we just shoot the crazy people like in the old days."

NilsRainJuly 18, 2008 6:05 PM

Maybe you read a different article than I did, but this seemed like a textbook case where someone needs to be sedated. This is an ill person, off their medications who is clearly a danger to themselves and others (running into traffic, charging officers). They need to be brought into a medical facility and given the medical or psychiatric help they need. We can't just back off and let them hurt themselves or others; we have an ethical obligation to get this person help.

It is not possible to safely restrain some people with straps, especially when they are biting and spitting infections material at the people trying to help. I have had people tear the straps right off the cot.

Yet in all that, I've only seen it done twice in seven years. It is our last resort.

From our protocols:
Violent patients judged as unsafe for transport (because of possible injury to patient or EMS personnel) may be sedated by EMT-P (that means paramedic). If sedated, patient must be closely monitored during transport.

Restrain only if necessary for your protection or that of the patient, not for staff convenience. Contact the supervising MD for permission before transporting without consent.

Use the minimum physical restraint required to accomplish necessary patient care and still ensure safe transport.

neillJuly 18, 2008 6:55 PM

maybe we all gotta start carrying poison pills (or antidote) under the tongue (pre-ww2-invention)

wonder when TSA etc will introduce "mouth-screening" (or when people with a lisp will get on their watchlist)

slurpee movementJuly 19, 2008 3:11 AM

"7/11 was an inside job!" - slurpee movement

(rubs big gulp straw and pats spare tire gut)

Clive RobinsonJuly 19, 2008 9:36 AM

A couple of items from the BBC website on the drug.

The first indicates that,

"Midazolam can lead to the patient experiencing daydreams with a sexual content."

The second is about a male nurse who was on trial for (supposedly) using the drug to sexualy abuse woman patients.

Importantly it revolves around the death of another nurse who had an adverse reaction to the drug due to having a minor heart problem and having ingested a relativly small amount of alcohol.

http://news.bbc.co.uk/1/hi/health/medical_notes/...
http://news.bbc.co.uk/1/hi/health/708574.stm

Also this link, gives other links to stories around the world about midazolam

http://www.mongabay.com/health/medications/...

Some of the links to online newspapers are nolonger current but you can hunt around for them in caches etc.

One of the stories in April 08 is about a man who died (in Fridley Minneapolis on 15 Jan ) from Midazolam complications whilst being arested and tazered... Unfortunatly the one article you want to track down is always the hardest 8(

And in this case it's also a good one for those inventing a conspiracy theory as the searches for the information do show up midazolam and also people quoting from the article but guess what nothing in the articals that all appear to have been subsiquently updated...

ColeJuly 19, 2008 6:17 PM

@John Phillips: Yes, thank you for clearing up my memory. The story in the link was what I remembered.

thought policeJuly 19, 2008 9:13 PM

No legislation found.
http://tennessee.google.cdc.nicusa.com/search?...
Government by Google
http://tennessee.google.cdc.nicusa.com/...
© Google Inc. 2008
Walmart is like the new FDA,
It appears we are now being run by corporations because we are. This sounds like some sort of new post legislative plan. Instead of laws, software controls what can and can't be done. If that fails, use chemical weapons to subdue those who won't submit. Goodbye liberty, hello high authority.

thought policeJuly 19, 2008 9:34 PM

Give it time. Wait until the new nano toys start showing up in the system. The goal is to use technology to turn the entire government into some sort of search and destroy organization. Google wants the same benefits the big drug companies have. Convert tax dollars into corporate revenues and wreck the banks in on the bargain. It's a smart strategy because people have to pay taxes. Don't pay, cops show up and shoot to thrill. The first phase is in place and that's to kill all the newspapers while converting state information systems into part of the Google global computer network. You didn't take those little ads seriously did you? The goal is control, not ads. Ads were a first act. What's next? Google is not saying. A guy's dead with three years of mail and everybody is searching the web for BS, buy future to sell futures when there is no future.

LlywelynJuly 19, 2008 11:33 PM

My understanding is it only causes amnesia in anesthetic levels, not at the level used to sedate aggressive patients.

Brandioch ConnerJuly 20, 2008 1:00 PM

@Andrew
"I am an EMT Basic."

Anyone can claim anything on the Internet.

"These drugs are only given in the medical best interest of the patient as judged by the paramedics."

And what determines whether a person is a "patient" or not?

"The sedative is not given as a weapon, it is given as a means to get the patient further medical help."

Again, what defines a "patient"?

"As for the person who posted the link to the Wikipedia article on excited delirium, he might want to share his self-admitted BS with all these MD and PhD bearing folks: http://www.ipicd.com/"

You might want to investigate that link a bit more before you advocate it.

Do not forget that there were doctors who "questioned" a cancer link with smoking.

And there are still doctors who "question" a cancer link with so called "second hand smoke".

Getting a person who is a licensed doctor to support something depends more upon the person and less upon the license.

Which is why the PROFESSIONAL associations do NOT recognize "excited delirium" ... despite what INDIVIDUALS want to believe.

Hence my "Dr. Josef Mengele" comment.

gopiJuly 20, 2008 3:37 PM

@Brandioch Conner:

I used to be an EMT-B in Pennsylvania. What Andrew says is entirely consistent with the official practices that are common in most jurisdictions:

Prescription drugs need to be administered under a physician's supervision. Only the supervising physician of an EMS department can issue protocols, and they are issued in writing. That doesn't mean they are right, but it means that they are public, widely known about, and can be argued against if they are inappropriate.

A police officer can ask an EMT-P to do anything he wants; the EMT is the one who has the legal responsibility for the appropriateness of what they do. If somebody gets a sedative injection, they're going to be riding with EMS to the hospital. If something happens to the patient, the EMT-P is going to have to answer for it.

That's the theory and the law. In practice, I think my biggest concern is what happens when a mildly antagonistic person comes in contact with some of the more arrogant members of the police force. Personally, most of the officers I meet are reasonable people. A few aren't. I can easily see a person who could be reasoned with ending up in an escalating conflict that didn't need to happen.

As to the term, "excited delirium," I'm not qualified to comment. When somebody is flailing about with edged weapons in their hands, determining whether their behaviour has a DSM classification or not isn't really relevant. There is an imminent threat to their safety and that of others around them, and a sedative would seem like the most appropriate response.


Davi OttenheimerJuly 20, 2008 4:22 PM

Reminds me of the RCMP homicide at Vancouver airport:

http://www.cbc.ca/canada/british-columbia/story/...

"Police enter the secure area with no problems and can be seen with Dziekanski standing calmly talking with officers. They appear to direct him to stand against a wall, which he does.

As he is standing there, one of the officers shoots him with a Taser."

Also reminds me of the long-standing controversy over institutionalized assessment of "deranged" behavior, as perhaps illustrated best in One Flew Over the Cuckoo's Nest...

Davi OttenheimerJuly 20, 2008 4:30 PM

"There is an imminent threat to their safety and that of others around them, and a sedative would seem like the most appropriate response."

Set aside the easy cases where someone demonstrates clear and present danger because they hold a gun in their hand and announce they want to kill someone.

The more troubling reality is when humans (especially inexperienced ones) function on a probability scale where they have to make a guess about the danger of another human they do not know anything about.

Dziekanski did not threaten anyone, but the police clearly tried to make a case that he was capable and likely of becoming a threat, and therefore they sent four officers into a room and despite his lack of any threatening gestures or violence they attacked him until he was dead.

Brandioch ConnerJuly 20, 2008 4:36 PM

@gopi
"If something happens to the patient, the EMT-P is going to have to answer for it."

Yes, by filing the "cause of death" as "excited delirium". As seems to be happening in more and more cases.

Now you may be okay with playing executioner but that does not mean that society has to accept it.

There still has not been any explanation as to what makes some your "patient".

"As to the term, "excited delirium," I'm not qualified to comment."

Yet you would support a lethal injection of Midazolam based upon something that you are "not qualified to comment" upon.

And that makes sense to you?

randomJuly 20, 2008 5:30 PM

Brandioch: I'm not a doctor, but in my opinion restraining someone who's in a state of severe anxiety is cruel if you can give them a benzodiazepine instead. IMHO it's not so important that they don't know the persons exact diagnosis; benzos have a general calming, worry-dissolving effect.

As far as I'm aware, benzos have quite good safety profile (possibly safer than risking some sort of muscle damage from the person trying to break free from restraints).

I agree that the amnesia and the possibility that the person has already taken other depressants (-> overdose) are issues. But all in all this seems quite humane to me compared to other methods.

bobJuly 21, 2008 7:03 AM

@random: If 4-8 cops come up to you and start violating your civil rights and you object, that is the "excited delirium" we are talking about here. Not someone who actually has a medical condition. If you had a choice between being restrained so that you could later sue for your rights or trusting the people who are abusing you to begin with to look out for your rights while you are sedated, which would you choose?

In the Soviet Union if you were in favor of changing the system, even through legal means, you were declared "mentally ill" and put in a sanitorium; because obviously anyone who could want to modify the "worker's paradise" had to be deranged.

They tried that dodge with the "MiG Pilot" (Viktor Belenko), fortunately he was (according to the book) such a universally high-performing individual mentally, professionally and physically that he was able to call their bluff. But it was SOP and used routinely.

Brandioch ConnerJuly 21, 2008 9:06 AM

I have to agree with bob on that.

Such simple questions that no one can answer.

#1. What determines when your become a "patient" who can be injected with whatever the "medical personnel" WANT to inject you with?

#2. How can someone be diagnosed with "Excited Delirium" during a routine exam by his/her regular doctor?

gopiJuly 21, 2008 3:14 PM

@Brandioch Conner
"Yet you would support a lethal injection of Midazolam based upon something that you are "not qualified to comment" upon.
And that makes sense to you?"

I don't support a lethal injection of anything. You mean *potentially* lethal. All medical treatments have potential side effects; lack of treatment also carries risks. Using inaccurate and loaded language does not add to the debate.

Also, you seem to misunderstand what a psychiatric diagnosis actually is. I said I wasn't qualified to comment on whether there was a sufficiently distinct and common set of conditions that could be identified clearly enough to be named.

For that matter, I'm pretty sure that in most states EMT-Ps are not qualified to decide which specific psychiatric condition a patient has. EMS is for dealing with emergency stabilization. Formally naming the condition is irrelevant.

You ask how somebody becomes a patient. The first thing to be clear on is that there is a significant legal difference between a layperson and a medically certified person regarding duty of care.

When my PA EMT-B certificate was valid, I had a duty of care. (Note: You are *not* required to compromise your own safety; you are expected to place your safety as a priority since adding another patient to an accident doesn't help anybody) I won't get in to edge cases, but, for example, if I was walking down the street and somebody came up and said, "Help! I'm having breathing problems!" I can't ignore them. I have a legal obligation to assist.

I must continue treating the person, patient, human being, whatever you want to call them, until either (a) I pass responsibility on to an equal or higher qualified person or (b) they refuse further treatment. As an EMT-B (basic), I was not trained sufficiently to determine that a patient was not in further need of treatment. If I told you, "You're fine, go home" I would be in serious trouble.

If somebody called us out, and we asked a patient how they were doing, at that point we were under a legal obligation to provide care to them. They can, of course refuse. However, if it is obvious that they are experiencing an altered mental state, things get somewhat more complicated.

The same way that an obviously drunk and incoherent person can't consent to giving you all their money, they also can't refuse medical treatment. That doesn't mean you have carte blanche to give them a facelift, maybe remove that ugly tatoo, etc. etc. It means that basic life-saving treatment must be provided.

"Such simple questions that no one can answer.
#1. What determines when your become a "patient" who can be injected with whatever the "medical personnel" WANT to inject you with?"

Read the laws of your state to determine when and how the duty of care begins. I gave you an outline of what is common but not universal.

I love your scare quotes around "medical personnel." I don't know why you hold medical personnel in such contempt, but as I had previously explained, an EMT-P can not decide to inject you with "anything they want." The EMS department in question will have a formal, written protocol that determines what is acceptable, and when. There are specific legal rules regarding writing the protocols; they're not something that can just be changed because somebody wants to be mean to you.

If you are genuinely interested in understanding how mental state is evaluated in EMS situations, the Glasgow Coma Scale is commonly used. If I were contacting a commanding physician about a patient who was refusing, their GCS is one of the things I'd be asked to provide.

Brandioch ConnerJuly 21, 2008 6:29 PM

@gopi
"I don't support a lethal injection of anything. You mean *potentially* lethal."

Please pay attention.

The "diagnosis" of "excited delirium" is turning up on the DEATH CERTIFICATES.

Lethal
Death
You can make the connection.

And you still manage to not answer the simple questions I have posted.

Why is it that someone who claims to have been an EMT cannot answer such simple questions?

gopiJuly 21, 2008 10:29 PM

@Brandioch Conner:

"And you still manage to not answer the simple questions I have posted."

I did answer the one within my scope of knowledge.

You asked two questions:
"#1. What determines when your become a "patient""

I wrote three paragraphs explaining duty of care. That is the most relevant legal area if you want to ask whether somebody is being treated or not.

I'll try to give you a shorter answer to see if it helps:

Technically speaking, legally, if I ask somebody a question about a medical problem, I am considered to be treating them. I have a legal obligation to continue treating them.

I do not recall for certain, but I believe that walking past a person who I noticed to be in obvious medical distress would also obligate me to provide assistance.

Your second question was about physician diagnosis, which is way outside of an EMT's scope. The fact that you would expect an EMT-B to have an answer to that question indicates that you are not very aware of what these different terms mean.

"Please pay attention."

I have been doing my best. However, I do find it more challenging to pay attention when people adopt the condescending tone you used in your most recent post.

I'll try to avoid doing the same thing you did but...
"potentially". As in, not every time. Sometimes. At least in my usage of the English language, "lethal injection" means an injection that is supposed to be guaranteed lethal. "Potentially lethal" is the right way to describe something that poses a risk of death.


AndrewJuly 22, 2008 2:23 AM

@Brandioch Conner

Your personal attacks are way out of line. My employer has my registry information. The agency I volunteer with has a copy of my certs. As you point out, anyone can say anything. This apparently includes you. Please tone it down a notch. You are making yourself look very bad and hurting your cause thereby.

If you must make matters personal, Mr. Conner, please start by stating your credentials and/or your personal experiences. If you have neither, your arrest record will serve in its place.

>> And what determines whether a person is a "patient" or not?

That's a really cogent question. Most EMS agencies respond to a call for service, whether generated by a 911 call center based on a telephone call, less often by radio request from police, and once in a great while from self-dispatch (i.e. discovering a traffic accident or eating lunch when someone chokes).

So the medics are almost always there because someone called. Passers by, relatives, the manager or security or police, etc. Generally people who want to make sure that the ill or injured person gets help.

Most patients want help and will say so when asked. A stroke patient may be reduced to squeezing the medic's hand in reply, but would you prefer that we dump them in the street because they cannot verbalize a loud "Please help me, my body doesn't work and I can't move or talk!"

Patient refusal of medical care is taken very seriously. A conscious adult without clear (and thereby noteworthy, as in hold up in court documentation) signs of altered mental status has the absolute right to refuse care. The medics whip out an AMA ("against medical advice") form, ask the person to sign, and document either their signature or their refusal to sign. Then the medics clear the call and leave. This may save several thousand in ambulance bills, or cost a life. But it was not the choice of the medics, but rather the patient.

A cardinal rule of the EMS system is that except in emergencies, no one works alone. This saves lots of problems and guarantees witnesses in touchy situations, which are common enough that all EMS personnel are trained for them.

It is standard policy when a person refuses care and the medics think they need care to call for a higher level of care (i.e. paramedics) and/or the police. This is also true when a parent withholds important care from a child, as in an apparent abuse situation.

A prisoner already in police custody when medics arrive is in an awkward position. The prisoner's ability to refuse care is much more limited. Generally, basic life saving care must be provided and if life is in danger, transport to an appropriate hospital facility is required.

Otherwise, a prisoner who refused care might die in custody. That would be bad. Flinging blood and body fluids on police is also frowned upon (and a serious crime), so someone bleeding might end up with bandages they don't necessarily want for that reason.

Almost all medics do not work for the police (exception: some are EMT-Basics, a handful work for combined police /fire agencies, plus some state police have flight paramedics or nurses.) Medics do not gather evidence for police nor do they believe that their job is to judge their patients. If physically prevented by police from doing their jobs, they report this immediately to medical direction and document in great detail.

Not incidentally, jail facilities will refuse to take prisoners if the facility is not equipped to handle the prisoner's apparent medical needs, including psychiatric if applicable.

All EMS system actions are documented and carefully tracked. This quality of care assessment is continuous and supervised by physicians and government officials. Misconduct can and does result in remediation and license actions.

>> If 4-8 cops come up to you and start violating your civil rights and you object, that is the "excited delirium" we are talking about here.

No, no, and HELL NO. Medics do not normally get involved in police activity. Doctrine is to stage nearby pending police arrival and only enter when the scene is secure. Exception: Tactical EMS which is performed by peace officers (full or part time) who happen to have medical skills, sometimes carry guns and usually accompany SWAT teams.

A handcuffed person on drugs sitting up in the back of a squad car and screaming at the cops while bleeding from a cut is so routine as to be yawnworthy. As long as they're screaming, they've got an airway. As long as they're moderately competent in their swearing, they've probably got a normal mental status. It is a thankless job to check. "Hi, sir, what's your name and do you know where you are?" is as often greeted by "Go F@#% Yourself" as it is "What does it look like, I'm in the back of a pigmobile and my name is Suspect #1." Either one is probably a normal mental status, all things considered -- but the medics still go down the checklists, and sometimes find that the drunk is actually a diabetic, or the guy smashing cars with a rake is actually the victim of a prior mugging that resulted in head injury.

ED is when you get a call about a guy who is extremely violent, has torn off all his clothes, has smashed out windows he could reach, is screaming in the street, has little or no reaction when spoken to, and it's a multiple casualty incident because there are two or three injured cops as well. He's literally hot to the touch, feels no effect from all police weapons (including being shot!) but Taser and that only briefly, and is on a rapid road to death, whether immediate from hyperthermia or positional asphyxiation, or later in the hospital from metabolic damage and multi system failure.

There can be no mistaking an ED case for an angry suspect, or an ordinary citizen who is asserting their rights, or even an ordinary person under the influence of drugs. It's not LSD or cocaine or meth either. It's a life threatening medical emergency that presents as extremely violent behavior with the signs above.

Now if this person with ED was your father, what would you have the police do? Shoot him? Or call for the medics (who are independent witnesses to police behavior!) to stabilize him after control is finally gained. Or (perish the thought) ask that the medics inject him with a 'lethal dose' of something other than high velocity lead?

>> @gopi
"If something happens to the patient, the EMT-P is going to have to answer for it." >> Yes, by filing the "cause of death" as "excited delirium". As seems to be happening in more and more cases.

I thought the ignorance about the EMS system was appalling. Apparently knowledge of homicide investigation and the operation of the coroner's office is also lacking here.

Paramedics have nothing to do with death investigations other than being a witness and filing accurate reports.

To assert that a paramedic would be willing to lose their license by lying is absurd. Trust me, medics do not feel that much loyalty to cops, or even to other medics.

>> Now you may be okay with playing executioner but that does not mean that society has to accept it.

Snarf. Are you a troll?

Paramedics bust their butts day in and day out to save the lives of people that many of us would step over in the gutter. The forgotten, the unloved, the vicious. EMTs in their own humble way try to make life easier on paramedics, but still do the majority of lifesaving in rural communities.

>> Yet you would support a lethal injection of Midazolam

You fail the laugh test. I've had it for a medical procedure and I am very much alive (pinches to check). Any medical procedure has risks, including emphatically any medication, but calling Versed 'lethal' is grossly ignorant.

I'll take a shot at the 'simple questions.'

>> #1. What determines when your become a "patient" who can be injected with whatever the "medical personnel" WANT to inject you with?

You, assuming that you are competent to refuse care.

If you are not competent to refuse care, any doctor or a licensed member of the community EMS system, operating under protocol and thereby under a doctor's supervision, can assert that you are a patient. They must then carefully document and account for their actions and bet their license on every action taken that the action was in YOUR interest. The civil law provides for this (Section 5150 of the Health and Safety Code in California). There are criminal and civil sanctions possible if this is abused and every medical professional knows it well.

>> #2. How can someone be diagnosed with "Excited Delirium" during a routine exam by his/her regular doctor?

Not at all. I am indulging in the most idle speculation here, but I cannot imagine a person experiencing ED would be getting a routine exam, any more than would the victim of a car wreck or gunshot wound or heart attack or stroke. It is by nature an acute and life threatening medical emergency.

A doctor would promptly call 911 and probably flee their own office if an ED victim were to suddenly materialize inside. Their only tool would, ironically enough given where we started, be powerful muscle relaxants or tranquilizers given IM, followed by rapid recognition of heat stroke once they took effect. If the doctor didn't have ready access to appropriate medications, we'd be back to police restraint and paramedic treatment, with many of the same risk factors as in the street.

As for ED, National Association of Medical Examiners does recognize it; AMA and AHA does not. It is not in the DSM-IV. I've taken training on ED and seen videos of ED episodes.

I'm not disputing that police are a major contributing factor with respect to in-custody death. I am disputing the idea that police somehow want to go out of their way to kill suspects, or are engaged in a massive conspiracy of silence to literally get away with murder in most public and brutal fashion.

Positional asphyxia can and does kill persons in custody. Training police to recognize and prevent it is vital. Any medic immediately recognizes it as an airway threat -- a skill not beyond that of the intermediate first-aider, which all police are supposed to be.

Besides, as any resident of Chicago can tell you, drop guns are the accepted method for police murder.

Brandioch ConnerJuly 22, 2008 9:53 AM

@gopi
"I wrote three paragraphs explaining duty of care. That is the most relevant legal area if you want to ask whether somebody is being treated or not."

And you still did not answer the question. Spewing your stream of consciousness is not answering a question.

"Technically speaking, legally, if I ask somebody a question about a medical problem, I am considered to be treating them. I have a legal obligation to continue treating them."

So, by your "logic", you can walk up to ANYONE on the street and ask them if they have high blood pressure and then you may inject them with whatever you want.

No. That is incorrect. Just because you ask someone a question does NOT mean that they have no rights regarding any "medical" "treatment" you may feel you want to "provide".

Why do you believe otherwise?

Brandioch ConnerJuly 22, 2008 11:00 AM

@Andrew
"If you must make matters personal, Mr. Conner, please start by stating your credentials and/or your personal experiences. If you have neither, your arrest record will serve in its place."

So why do you think I have an arrest record?

Is it just because I question the inability of someone with your claimed credentials to answer very basic questions?

"That's a really cogent question."

Yes it is. That is why I asked it. And instead of answering it, you spew more stream of consciousness hoping to obscure the fact that you cannot answer it.

The answer is simple:
Someone becomes a patient when they (or a responsible family member) agree to let the medical person treat them or take custody of them. Or when they are physically unable to refuse treatment AND are suffering life-threatening (their life) physical injuries.

The points are:

#1. People are dying in police custody.

#2. The reports are listing "excited delirium" as the cause of death.

#3. The AMA does not recognize "excited delirium" as a medical condition.

#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

Continue to try to obfuscate those points with your verbal spew of tangents. I'll keep correcting you and bringing the conversation back on track.

gopiJuly 22, 2008 12:57 PM

@Brandioch Conner:

"Continue to try to obfuscate..."

The fact that you can't understand something doesn't make it obfuscated. It simply means you're having some reading comprehension problems.

"And you still did not answer the question."

How would you know? You've obviously skipped major parts of what I said.

'No. That is incorrect. Just because you ask someone a question does NOT mean that they have no rights regarding any "medical" "treatment" you may feel you want to "provide".'

Of course not. I was answering the question, when am I treating somebody? They of course have the right to refuse treatment *unless* I can document that their altered mental status, or serious physical injuries meant they were unable to consent.

If they are unable to consent, then implied consent comes in to play. That still requires that the care be medically appropriate.

"The answer is simple:
Someone becomes a patient..."

Sorry, that's not very accurate in Pennsylvania law. Since you seem to insist that anything more than two sentences is an obfuscating stream of consciousness, I'll punt on trying to correct you and refer you to RTFL.

Brandioch, if you are truly interested in learning, I suggest you search out some local resources and talk to people. Look to see if a local college has an EMS program. Somebody used to teaching there will probably do a better job educating somebody such as yourself with zero knowledge of what an EMS department does.

Oh, and;
"Why do you believe otherwise?"

Perhaps because I have had hundreds of hours of training in this field, in addition to formal certification? (since expired; I moved out of state. EMT credentials are generally state by state.)

Also, if you're just doing this to be a troll, my purpose in posting here is to make sure that whatever peanut gallery is left doesn't get misinformed by your mistakes.

AndrewJuly 22, 2008 1:12 PM

I am just a working grunt pointing out what seems to me to be gross errors in a subject I happen to know a few things about. I'm not trained as a scientist or as a medical professional above the very basic "Load and Go" expected of any EMT, or to use the phrase we dislike, 'ambulance driver.' Anything I happen to get right, great. Anything I get wrong, sorry. I'm engaged in a search for truth and if I learn something I didn't know, so much the better.

If anyone reading this wants to become an educated layperson, great. The Intarwebs are at your disposal. If you want to go further and take a First Responder (53 hour) or EMT-Basic (120 hour) training class, so much the better. This training will equip you to help save lives without requiring that you make a full time career of it.

If you don't have that kind of time, contact your local EMS and ask to do a ride-along with the medics. If you are really concerned about ED and/or police misconduct, you might do better to request a ride-along with the police, but be aware that you might learn something about policing along the way.

I answered Conner's question, paraphrased as "What makes a [nonconsenting] adult into a patient in the EMS system in the United States?" in great detail.

His purported answer to the "how to become a patient" question is wrong on so many counts I hardly know where to start. Let me quote him:

>> Someone becomes a patient when they (or a responsible family member) agree to let the medical person treat them ...

A "responsible family member" cannot make such decisions over the wishes of a competent adult in the field. A durable power of attorney for health care is the only 'field' document that a medic can accept. "When in doubt, transport" is the rule.

>> or take custody of them.

Let me spell this out clearly. Involuntary civil custody requires physician and police involvement.

>> Or when they are physically unable to refuse treatment

Withholding verbal consent is sufficient. There is no requirement that a patient be able to fight off a medic.

Also, a patient with a DNR order and/or medallion has refused care in advance, sometimes even life-saving care, because of their personal beliefs.

The doctrine of implied consent (taught in first aid!) is that an unconscious person is presumed to need emergency medical help. A bystander is not required to help; people with a legal duty (i.e. you were in a car wreck with them) can incur civil liability by not calling for help; licensed professionals and emergency responders MUST help.

>> AND are suffering life-threatening (their life) physical injuries.

Your caveat ("their life") makes no sense in this context. If someone is threatening someone else's life, the police are well within their rules to shoot the aggressor, if lesser means fail. (Depending on local law, there may be no requirement to even attempt lesser means . . .)

You also exclude illness as a life-threatening condition, which in altered mental status cases is a more common cause than injury.

AEIOUTIPS (Alcohol, Epilepsy, Insulin, Overdose, Underdose, Trauma, Ingestion/Infection, Psychological, Stroke)

I suppose this is just me spewing out more tangents. Any medics got my back here?

In reply to Conner's points:

>> #1. People are dying in police custody.

True. It's a problem. Versed isn't killing them, and neither are the paramedics. The police and a number of in-custody death experts argue that the police aren't killing them either. Thus the ED hypothesis. While this claim should be viewed with several grains of salt, especially because of its sources, correlation is not causation.

I believe the burden should be on the police to prove that they are not killing these people. So do many police and almost all medical examiners. Thus the term 'ED' as a phenomena, field protocols (which include calling the medics immediately!) and postmortem evidence collection including brain temperatures.

>> #2. The reports are listing "excited delirium" as the cause of death.

True. This determination is being made primarily by medical examiners, whose job it is to make such determinations. Cocaine or other hard drug overdose doesn't seem to fit, neither does heat stroke, and autopsy results are incompatible with them being beaten to death or for that matter shocked to death. Positional asphyxia is almost certainly a contributing factor in some cases, but not the primary cause of death. I'm neither qualified to nor interested in disputing M.E.s, who are career experts in causes of death.

>> #3. The AMA does not recognize "excited delirium" as a medical condition.

So what? The AMA is just another industry association. Appeals to authority are boring at best. Show me an AMA statement condemning ED as junk science, or doctors or medical examiners stating authoritatively that it does not exist, and I'll be far more interested.

>> #4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

Medical personnel are being called to respond to the life-threatening emergency which we call "excited delirium" (for lack of a better term, you can call it crazy naked man running in the street if you want). The tools in their box are very limited because medics don't carry Tasers (nor should they). They have lots of warm bodies (firefighters are good for something :) ), soft restraints and Versed. That's about it.

Are you trying to say that medics are not qualified to recognize ED? Or that police are not qualified to recognize ED? When trained police are routinely called as expert witnesses to alcohol and drug intoxication in almost every court in the country?

Once the medics show up, they administer the care that the patient requires in the medic's best professional judgment, under the authority of their license and their medical direction. No one (in my county and I strongly suspect in any urban county in this state) is giving these drugs in the field who is not a paramedic, that's over 800 hours of training followed by extensive internship; after being a working EMT-Basic for at least one year.

A medic ordered to inject drugs into a patient by a police officer would refuse. Many would document the request to prove that it was not honored, to cover themselves. Some would complain informally; others would make the complaint formal and at length.

>> #5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

Medical history, true. I challenge you to take a history on someone who is not verbally responsive and suffering from any severe drug reaction. If you happen to glimpse a Medic Alert bracelet, etc. great. If witnesses or relatives are present and will answer questions, even better. If prescription bottles are available, that's helpful too.

Current condition, false. Medics are trained to evaluate a person's condition using whatever tools are at hand. Re-read my description of a classic ED case above. You don't need to slap on a BP cuff and insert a thermometer to realize that this person is in a bad, bad way and needs immediate help.

This last part is specifically for Conner.

I ask again: What are your credentials, other than as a computer wonk? (As everyone on this site should know well, expertise in one subject does not make a person an expert in other subjects.)

Again, please state your credentials, or personal experiences, or even prejudices so that we can give your opinions the proper weight they deserve. I will settle for "Google-fu" but would prefer evidence of you having read material you disagree with.

Conner, you're right, I jumped to the conclusion that you've had negative contact with police. If you behaved in the street as you behave here, you'd almost certainly have an arrest record.

Please read my answers carefully. If you need words or concepts explained, I will do my best. There is a lot in this world that you do not know, just as there is a lot in this world that I do not know. Please don't dismiss my posts as 'stream of consciousness' just because it is foreign to your past experience.

If you continue to believe that I am making up nonsense to confuse you, the Constitution gives you the right to believe this. I don't have to humor you. I don't accept correction from you either. I have a chain of command and supervisors for that.

What is your theory with respect to ED? What do you think is causing this type of well-documented death? I'm all ears.

Conner, I want to know what your agenda is, because right now I frankly don't see anything other than police-bashing extended by proxy to medic-bashing, in all apparent ignorance of any difference.

That bothers me and I need your help to understand your point of view. Thanks.

AndrewJuly 22, 2008 1:33 PM

Conner, that's two medics (EMT-Basics, which is the same as saying 'pond scum' in the medical community) now that you've accused of spewing streams of consciousness.

Hey, gopi, is this pt delusional? Can we inject him yet? (The last two sentences were a JOKE, as in funny, as in not at all serious.)

@gopi who said "Technically speaking, legally, if I ask somebody a question about a medical problem, I am considered to be treating them. I have a legal obligation to continue treating them."

This is true. In the face of a patient who refuses care but appears to have a serious condition, I can't force them to accept care. That would be battery. However, I can't go about my business and forget about it, because that would be abandonment. Either causes my license to fly away on little wings into the sunset and never, never come back. The First Time.

Of course, if I call 911 for a non-serious condition, that's another form of misconduct. The problem is, I may not know for sure . . . but based on my training and experience, I have a Real Bad Feeling. Such as a person with sudden onset chest pain that lasts more than five minutes, is accompanied by profuse sweating and is not relieved by rest. Any of the three is a concern; the combination is alarming.

So the accepted response is to punt and call for help. Only higher medical authority can get me off the hook, and that is the EMS system responders with uniforms, run forms, insurance carriers who are sticklers for liability, and last but certainly not least, a pile of 'refusal' forms.

So I wait nearby until they show up, hoping with fingers crossed that the patient does not crash out before they show up. Give my verbal passdown to the medics (who promptly ignore it and do their own patient assessment, as is proper and expected), show my EMT license to make sure my name is on the forms for tracking and when released, leave.

It is far more frightening to NOT make the call, by the way, when you know you don't have a patient but well meaning bystanders want to call 911. That error, however unlikely, is completely unforgivable. "When in doubt, call" is drilled into us and for good reason.

>> So, by your "logic", you can walk up to ANYONE on the street and ask them if they have high blood pressure and then you may inject them with whatever you want.

Not a chance, any more than a doctor could. If an EMT-P (paramedic) injects someone, they do so with the authority of their medical direction physician according to protocol. If they err or engage in misconduct, their license is the one flying away on little wings.

>> Why do you believe otherwise?

You don't know the subject. You need to learn something. When out of the population of people who read this blog, two medics jump in who have never met, worked in different states and systems, and have nearly identical views in opposition to yours . . . which is more likely, that we are conspiring to collude against you, or that we are both sample products of the larger EMS system which you clearly do not understand?

Brandioch ConnerJuly 22, 2008 2:06 PM

@Andrew
"I am just a working grunt pointing out what seems to me to be gross errors in a subject I happen to know a few things about."

Again, you can claim anything you want to on the Internet.

I will point out that I can provide very concise points for my position.

You have a stream of consciousness spew that seems to wander around the subject material without ever actually addressing it.

Particularly where you attempt to dismiss the AMA as "just another industry association".

Yes, someone claiming to be an EMT dismissing the AMA. Welcome to the Internet.

Street CopJuly 22, 2008 2:46 PM

@ Brandioch Conner and many others: I searched and didn't find any comments here from actual street cops.

We once were called to a home with a history of domestic violence cases. She always dropped the charges against her boyfriend in court (common, unfortunately.) This time, however, he killed her.

As we were taking him into custody, her teenage son (no relation to the boyfriend/killer) arrived, learned what happened, and went as ballistic as you'd expect, trying to get at the prisoner for revenge. None of us blamed him, but the law doesn't allow us to let him do that.

There was a total of about 1400 lbs (about 635kg) of cops on him (six). We could keep him down, but the kind of "restraints" that would have been needed under your plan would have been a complete hog-tie -- very unpopular, and we would have had to hurt him, which we did *not* want to do. (He wasn't the criminal here. And picture yourself confronting the guy who killed your mother. We understood.) If you've never confronted a person in full rage, you have no idea of the kind of strength the "fight or flight" adrenaline can give them.

The paramedics arrived, assessed, communicated with the hospital, and were given authority to inject Thorazine, the drug of choice at the time. He was subdued, peacefully, and taken to the hospital for observation and until they deemed he was safe to release.

This was definitely kinder and gentler than the kind of force that would have been required to have done as you suggested.

Many people make knee-jerk opinions about things they have not personally encountered and cannot correctly imagine.

Brandioch ConnerJuly 22, 2008 3:32 PM

@Street Cop
"Many people make knee-jerk opinions about things they have not personally encountered and cannot correctly imagine."

Yes, many people do. And what is your point? Why are your talking about "many people"?

Are you referring to yourself? Okay.

I will go over some points for you.

#1. People are dying in police custody.

#2. The reports are listing "excited delirium" as the cause of death.

#3. The AMA does not recognize "excited delirium" as a medical condition.

#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

gopiJuly 22, 2008 3:50 PM

@Brandioch Conner:

"I will go over some points for you."

And by "go over", you mean "restate verbatim without correcting the mistakes."

'#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".'

The EMS personnel in question are independent of the police and will not do something just because the police say somebody was combative.

'#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.'

No knowledge of current condition? You've already had it explained to you. Yes, in fact, they *will* know about the person's current condition. If they administer drugs, or any sort of treatment determining anything about the person's current condition, they'll find their license pulled and they'll be looking for a new line of work.


gopiJuly 22, 2008 4:09 PM

@Brandioch Conner:

"I will point out that I can provide very concise points for my position."

The conciseness of an explanation is only something to be proud of if it can be combined with correctness.

The reason you're seeing such long responses is because of the sheer density of wrongness in your concise "positions."

The reason our explanations are long is because the situation is complex.

When you have a valid EMT certificate, you have a duty of care.

A quick googling pulls up this reference:
http://www.lbfdtraining.com/Pages/emt/sectionf/...
I have only skimmed it, but it seems like it would be a good introduction.

Part of the reason you're getting such complex answers is because there are so many edge cases to think about.

If I'm talking to a stranger and they suddenly start clutching their heart, I can't ignore it and walk away - a non-certified person can walk away.

What if I ask somebody, "what's up?" and they say, "Man, I've been sweating all day and I'm sore." Those could be signs of a heart attack. Do I have a duty of care or not?

Another part of your problem is that you are asking these questions in a fundamentally backwards way. You're asking, when is somebody "my patient." I don't own them. I provide care and treatment to them. I am obligated to provide, and continue to provide, care.

At first, I thought you had an interest in learning. Now it seems like you're just re-stating politician-grade talking points.

Brandioch ConnerJuly 22, 2008 8:56 PM

@gopi
"The EMS personnel in question are independent of the police and will not do something just because the police say somebody was combative."

The facts seem to contradict you. But then, that's what those pesky facts keep doing, isn't it?

#1. People are dying in police custody.

#2. The reports are listing "excited delirium" as the cause of death.

#3. The AMA does not recognize "excited delirium" as a medical condition.

#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

gopiJuly 22, 2008 9:53 PM

@Brandioch Conner:

I was hoping you would at least be willing to carry on a meaningful debate, instead of merely re-stating your previous opinions and refusing to actually rebut my arguments.

"The facts seem to contradict you."

Which of your 5 supposed facts contradicts me? Are you confusing me with somebody else? Because I haven't even disagreed with the first three.

"#1. People are dying in police custody."

I agree with that.

"#2. The reports are listing "excited delirium" as the cause of death."

Poorly phrased. Do you mean some reports, or all reports? If you mean some reports, then that's an obvious and verifiable fact. If you mean to claim that every police death lists that as a cause, that's ridiculous. If you are going to assert that everybody who is injected with Midazolam during an altercation with police has "excited delirium" listed as the cause of death, that is also patently false.

"#3. The AMA does not recognize "excited delirium" as a medical condition."

Poorly phrased. The AMA has no policy on the matter. Still, essentially correct.

"#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium"."

Poorly phrased. Seems to indicate that the police are directing EMS to perform specific medical treatment. If that is the actual claim, then that behaviour is clearly illegal and sanctionable. If you are going to assert that this is the case, you should:
a. Clarify if you think this is EMS personnel *everywhere*, or you think this is a problem limited to certain areas.
b. Provide some rationale as to why you are qualified to say this. News articles, personal experience, epistemology, something.

"#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition."

Again, very poorly phrased. Are you saying that there is *never* any knowledge of the patient's medical history? That's patently false; there are often relatives around to give information.

No knowledge of the patient's current condition? What? Are they using blow guns? Are they running up behind the person and injecting them?

Any trained EMT is going to have *some* knowledge of a patient's current condition merely by observing them - probably a lot more knowledge than you would expect.

If you are instead arguing that they are administering these drugs without *sufficient* knowledge, you've at least made an argument that isn't patently false.

Earlier, you sounded proud at the simplicity of your points. Unfortunately, you have sacrificed accuracy for simplicity.

If you are willing to debate, I will answer your rebuttal. If you choose to repeat what you just did, which is to merely re-state your prior position and add a content-free insult to it, I am going to stop wasting my time.

I find it interesting to debate with people who are honest, clear, open minded and willing to either rebut my positions or modify their own if there are problems. What's going on right here, though, is like reading a book by an extremist political commentator. The opinions stay the same, and any counter-arguments are simply ignored.

gopiJuly 22, 2008 10:06 PM

Oh, and something else that I was thinking that is related:

As far as I have been able to find out, the death rate from Midazolam is not very high. Now, obviously, even if it's zero, if the drug is administered to aid police abuse, it's absolutely wrong. However, my point is that a person wishing to maliciously administer Midazolam is at worst causing a risk to the patient; they aren't going to be expecting death.

If a police officer is abusing a victim, and wants to be nasty to them, is sending them to the hospital unconscious the best way for them to do that? They'll wake up, probably reasonably well rested, to a nurse who'll be asking them what they want and how they're feeling.

I would've thought that if a policeman wants to do something to you, and they have an EMS department who's willing to ignore the law and do what the police ask, a traditional baton beatdown would seem more likely. Beat the victim till he's unconscious, then let the EMTs carry him away, and explain how he was viciously attacking the police.

What's my point? If you assume people have the mindset that it seems Brandioch believes they have, the scenario he describes is still not the likely outcome.

Street CopJuly 23, 2008 1:25 AM

@Brandioch and company:

“Never try to teach a pig to sing; it wastes your time and it annoys the pig.” --
Robert Heinlein.

I'll waste just enough more time to point out that you've completely missed (or ignored) every point in my anecdote, so here they are again, in your preferred numbered-list style:

1) We, the police, did not administer any drugs, nor did we "order" the paramedics to do so. We have no authority to tell paramedics how to do their jobs.

2) The paramedics were sent upon receiving the call of the domestic violence. Unfortunately, the victim was DOA (dead on arrival), but they were present to assess the victim's son.

3) By its nature, first-response care cannot possibly know a patient/victim's entire medical history (perhaps only a diabetic bracelet or pacemaker warning, if that); they must assess what is before them.

4) The paramedics did not decide to administer a sedative. They radioed the hospital ER, where a physician, presumably certified in emergency medicine, took the information available at the time (which is also all that ER physicians can do in person, if you are brought in unconscious, no ID, too drunk to talk, gunshot wounds, etc., etc.), and prescribed the sedative.

I doubt that the doctor would have made any diagnosis like "excitative delirium", and also doubt that he was a psychiatrist. "Uncontrollable rage", or, in more medical terms, "Assaultive violence", would have met the legal standard, which is "Clear and present danger to himself or others".

5) The victim's son understandably wanted to kill his mother's murderer. Had we, the police, allowed this, we would have been sanctioned severely (probably criminally), and rightfully so. Therefore, we had a duty to restrain him.

6) To restrain the son completely in his uncontrolled, and uncontrollable, rage without the chemical sedation prescribed by the ER physician, we could have:

a) Beat the crap out of him. Another Rodney King story on the evening news.

b) Put him in a choke hold. Highly effective, but it has in fact caused some accidental deaths, and has been barred by some departments.

c) Used very forceful armlocks and leglocks until all four limbs could be cuffed or cable-tied, which, given his resistance, could well have resulted in an accidental broken arm, wrist, etc. I know of one instance where a 120-lb (55kg) female officer was attempting to remove a large, disorderly drunk from a bar. He refused to leave his bar stool. She applied the standard wristlock, the drunk fell off his bar stool, and broke his wrist.

(Note to Anonymous: Do you see how "being restrained enough to administer an injection" was not "restrained enough"?)

Nothing you wrote refuted anything I said, that in this one case, at least, chemical sedation was clearly the least harmful to the individual involved, not to mention the officers, who presumably are public punching-bags, or the paramedics. Obviously, I can't speak for all cases of sedative use. But equally obviously, neither you nor anyone else can make a blanket condemnation without a case-by-case evaluation of the facts.

If you were interested in knowledge, you might also be interested to know that when persons are admitted to some psychiatric wards (even voluntary self-admission), they are asked (if they are lucid enough to decide) that if they should require restraint, whether they prefer physical or chemical sedation.

Unless you can logically refute any of this, or add anything other than repeating the same five sentences, I'll assume you are merely trolling. Enough bandwidth wasted on the non-singing (person).

Brandioch ConnerJuly 23, 2008 2:25 PM

@Street Cop
"I'll waste just enough more time to point out that you've completely missed (or ignored) every point in my anecdote, so here they are again, in your preferred numbered-list style:"

You need to work on your written communication skills because you have, once again, managed to completely miss the point.

Read
The
Article

No one cares about your anecdote. You are an anonymous poster on the Internet claiming that you have seen X but not able to identify the people in X.

The funniest part is that you believe it.

Want me to state the facts again? Verifiable facts? Hey, I can do that. You cannot, but I can.

#1. People are dying in police custody.

#2. The reports are listing "excited delirium" as the cause of death.

#3. The AMA does not recognize "excited delirium" as a medical condition.

#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

But feel free to post about how your sister's boyfriend's cousin's friend's wife's best friend heard about how someone did something different.

Now, any normal GOOD cop would understand the worthlessness of "hearsay" in a discussion. But you do not, do you? LOL

Brandioch ConnerJuly 23, 2008 2:31 PM

@gopi
"I was hoping you would at least be willing to carry on a meaningful debate, instead of merely re-stating your previous opinions and refusing to actually rebut my arguments."

They are not "opinions" because they are verifiable facts.

Once again, you are wrong.

And I will remind you that you have been unable to identify what makes someone your "patient" as opposed to a free-willed member of society.

After 2 failures on your part, I posted the criteria.

At which point you simply denied that I was correct, without posting what the correct criteria would be.

These are the facts. Even if you do not like them.

#1. People are dying in police custody.

#2. The reports are listing "excited delirium" as the cause of death.

#3. The AMA does not recognize "excited delirium" as a medical condition.

#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from "excited delirium".

#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition.

gopiJuly 23, 2008 3:20 PM

@Brandioch:

"They are not "opinions" because they are verifiable facts."

Please provide verification, then.

I will remind you that I explained numerous ways in which your facts were vague and unclear; you have chosen to ignore my request for clarification.

"And I will remind you that you have been unable to identify what makes someone your "patient" as opposed to a free-willed member of society."

No, you have been unable to comprehend the answer. There's a difference.

Your question is, as I said before, poorly phrased.

If I am treating somebody, they are a free-willed member of society.

Only in rare and exceptional circumstances can treatment be performed without consent - and only very limited treatment. The patient must be clearly experiencing an altered mental state that prevents them from understanding what is going on.

Let me give you a hypothetical: A man is walking down the middle of the road, bleeding from his head. Any time somebody comes near, he announces that he is the Queen of Sheba, and that nobody may touch him.

In this situation, do you think that the reasonable course of action is to accept his statements as a refusal to accept medical treatment, and leave him alone to wander the streets until he bleeds to death?

In my experience, the EMTs I worked with really did not want to treat people who didn't want treatment. Their view was, essentially, if you're too stupid to get medical treatment, you're free to suffer.

The viewpoint you seem to have, that most EMS personnel have a desire to treat everybody whether they want it or not, goes against my personal experience, and it goes against what the law says as well.

So, again, I ask you: Please provide verification for your facts.

Brandioch ConnerJuly 23, 2008 10:17 PM

@gopi
"Please provide verification, then."

So now you are claiming that those are not facts?

Either you accept them as facts (which they are).

Or you are so uninformed on this matter that you are unaware of the basic facts. All the while claiming to have been an EMT.

Please, continue with your uninformed opinions while claiming to have been an EMT.

gopiJuly 23, 2008 10:35 PM

@Brandioch Conner:

"So now you are claiming that those are not facts?"

No, I am asking you to provide verification.

You made a claim, let's see your evidence.

I like to see independent, reliable sources for information...even when I *do* agree with claims. I find it actually helps me learn, and it helps me educate other people as well.

You said your facts were verifiable. Please show me your verification.

Brandioch ConnerJuly 24, 2008 6:53 AM

@gopi
"No, I am asking you to provide verification."

If I said that 1+1=2 and you said "prove it" then the only thing you are demonstrating is your lack of knowledge on the subject.

Congratulations. You have demonstrated your lack of knowledge on the subject.

"I like to see independent, reliable sources for information...even when I *do* agree with claims."

Which means that you are uninformed on this matter. Otherwise you would have already seen the "independent, reliable sources" when you became informed.

You are now reduced to crying for "verification" of facts that you should already know.

And you claim to have been an EMT. And yet you are ignorant of basic facts.

Andrew July 24, 2008 11:28 AM

@Street Cop

Thanks for the real life example which proves our point.

When Conner says, "No one cares about your anecdote," he is wrong. I do. One person is enough. Thank you for what you do out there.

@Everyone Else

Conner (henceforth quoted as "BC") is a troll. From 10 May 2008, a comment by him in Linux Today reveals that he's in the habit of this type of psuedo-discourse.

http://www.linuxtoday.com/news_story.php3?...

His quotes from the article he is attacking with some items edited for length in [brackets] are headed with JP, the initials of the original author. The original article is here: http://blogs.zdnet.com/BTL/?p=8769.

Brandioch Conner - Subject: More from ZDNet. ( May 10, 2008, 00:59:30 )

JP> ...Can the Linux community get over its �not invented here� ideology [...]

BC> That's it. No substantiation. No facts. Just claims.

BC> And a headline that's designed to bring in the page hits.

JP> ...The message that was intended was that Ubuntu, for all its [advantages], is still years away from becoming an enterprise and mid-range scalable OS on commodity hardware.

BC> Does he give specifics on what "an enterprise and mid-range scalable OS" would encompass?

BC> No. He's not about facts. He's about page hits.

JP> ...I�m just someone who appreciates what OpenSolaris is trying to accomplish.

BC> Right.

BC> Most people already know that you don't have to denigrate everything else just because your favoured platform isn't very popular.

BC> Unless you write for ZDNet, of course. It's all about the page hits.

JP> ...In addition to this blog on ZDNet, I�m Sr. Technology Editor for Linux Magazine.

BC> Anyone need any other reason to skip Linux Magazine?

Comment by Andrew: it is silly to the point of ridiculousness that the senior technology editor for Linux Magazine would think that "Linux sucks."

JP> ...A supercomputing cluster for compute intensive tasks where loads are distributed among many networked systems doth not monolithic scalability make.

BC> Now it's about "monolithic scalability".

JP> ...I am referring to large, highly parallelized big iron systems, what would be referred to as a �big mini� or a midrange multiprocessor system such as a IBM pSeries 595 (which runs AIX or Linux, but scales Linux using LPARs and virtualization, not monolithically) or a Sun E25K or an HP Integrity.

BC> Translation: things that look a lot like a mainframe.

Comment by Andrew: no, that's not what JP is saying. He's distinguishing a particular type of mainframe from others, because he is an expert in his field and sees differences that Conner is blind to. Familiar pattern, anyone?

BC> Linux sucks because it isn't a mainframe OS.

JP> ...To use a supercomputing cluster or grid such as a Beowulf or something like a CGI render farm for something like Renderman or a bioinformatics application such as genome sequencing requires writing to a specific distributed muliprocessor cluster API such as MPI/MPICH2 and does not address general computing, cloud computing or virtualization needs.

BC> Wait! Now it's about "general computing". Not about mainframes.

BC> Say whatever you like about Jason Perlow, but you have to give him credit for not knowing what he's talking about.

Comment by Andrew: again, here we go with the personal attack because Conner does not understand the point. Ironically, as with many personal attacks, this one is double edged.

JP> ...Let�s also not forget that as supercomputing clusters are connected usually by Ethernet and/or Myrinet, and that I/O bandwidth and moving things in and out of memory is always going to be a limiting factor.

BC> Remember! He's not talking about those Beowulf cluster things.

BC> Besides, they aren't that cool anyway.

BC> Stream of consciousness anyone?

Comment by Andrew: and this is the identical attack he has levied against me and others on this forum. A pattern emerges.

JP> ...With virtual infrastructure, you can cluster a group of virtualization hosts, such as thru VMWare ESX or Xen, and manage it like one seamless box, but you are still limited by [details].

BC> And now he's onto VMWare.

BC> Not mainframes.

BC> Not Beowulf clusters.

BC> VMWare. (and don't forget that Linux sucks)

BC> And so on and so forth. No pattern (except that Linux sucks and I can name a lot of computer systems). No rhyme. No reasoning.

BC> Linux sucks because ... and it doesn't run on mainframes which aren't VMWare virtual boxes because Beowulf clusters have Ethernet limits.

BC> Linux sucks.

Comment by Andrew: and at last it is revealed . . . so does Brandioch Conner, who is neither interested in reading comprehension nor in respecting the views of others who may happen to disagree with his personal and unsupported prejudices.

@BC

Assertion is not proof.

Just because something is printed in a newspaper article, especially one written as poorly as the subject of this blog, does not make it true.

Engaging in intellectual muggings on subjects you do not understand may make you feel self-important, but it wins you neither respect for your views nor respect for you as an individual.

BC says:

>> Want me to state the facts again? Verifiable facts? Hey, I can do that. You cannot, but I can.

No, thank you. Go away now.

AndrewJuly 24, 2008 11:36 AM

An aside on EMT status as a security authentication issue.

I could if I chose provide proof, verifiable over the Internet, that I am in the National Registry. I could post a scan of my EMT license issued by my county, or one of two identification cards issued by other agencies.

However this would not only compromise my anonymity but open me up to identity theft. Anyone could go around claiming to be me.

The claim that I am an EMT is therefore supported by what I wrote: material which BC dismisses as 'stream of consciousness' but is in fact readily recognized by other EMTs and those who work in prehospital emergency medical care.

It's very hard to 'sling the lingo' without at least passing familiarity with the subject. I could not convincingly emulate a network engineer, for example, by blathering about TCP/IP, stacks, Ethernet, port numbers etc. I might fool a layperson but most of the readers of this group would see right through it and I would lose all credibility.

This is a business where our words are our reputation. In a strange sort of way, the ability to discourse meaningfully on an arcane subject is itself a form of biometric security.

gopiJuly 24, 2008 2:50 PM

@Brandioch Conner:

"If I said that 1+1=2 and you said "prove it" then the only thing you are demonstrating is your lack of knowledge on the subject."

http://www.cut-the-knot.com/selfreference/...

There we go. Proof that 1+1=2. Took me less than 5 minutes to find a good reference to it.

If you need more background material, the entire book is here:

http://quod.lib.umich.edu/cgi/t/text/text-idx?...

It's quite common for people with only a slight understanding of a field to consider things self-evidently true. People in the field who know what they are talking about are aware how often self-evidently true things have turned out to be false upon proper investigation.

If your facts are all so obviously true, surely you can take a minute away from insulting and prove me wrong instead of merely asserting its self-evidence?

ModeratorJuly 24, 2008 9:32 PM

Andrew, please don't use this as a place to settle scores from other forums.

Everyone: there's been some good stuff posted in this thread, but the conversation is just going in a circle now, generating more and more heat in the process. I don't think repeating the same points again is going to change anyone's mind.

jOctober 22, 2008 9:44 PM

Versed is a very bad drug which shouldn't be used at all, on anybody, for any reason. If the cops only wanted sedation they would be hammering people with a plain old sedative, not this brain melting drug Versed. Many people BECOME aggressive and out of control when given this drug. I would think that shooting somebody who is ALREADY out of control up with this poison would be the very last thing that they would do... Except for that nice amnesia factor where they can beat the dog snot out of the subject and then CLAIM that the person had this so-called "excited delirium" horse crap.

BillMay 17, 2009 8:34 AM

So this drug can be used on a woman,who can then be felt up,stripped or even raped and it could be dismissed as a sexual hallucination daydream side effect.Not that that happens mind you,but how convenient.

Rogue MedicSeptember 29, 2010 10:20 PM

I apologize for posting to such an old thread, but this is an important topic.

To answer Brandon's 5 points.

"#1. People are dying in police custody."

The people being given midazolam are not the ones dying. The midazolam provides protection against many of the things that are killing the patient.

Hyperthermia. Body temperature is elevated to the point that it can cause permanent damage or death. Sedation stops the person from continuing to fight against restraints, which is one reason the body temperature increases.

Tachycardia. Elevated heart rate that also can lead to permanent damage or death.

Tachypnea. Elevated respirations.

Acidosis. Poor control of acid/base balance. Many of these patients will have been so physically active that they cannot remove the excess acid that builds up in the body.


"#2. The reports are listing "excited delirium" as the cause of death."

The reports are not listing midazolam as cause of death. Those dying are the people not treated with midazolam.


"#3. The AMA does not recognize "excited delirium" as a medical condition."

The AMA does recognize all of the conditions I mentioned.

The disagreement is not whether people are dying of medical conditions, but what exactly is going on. In custody deaths are a problem. Midazolam is just one way of attempting to prevent those deaths.


"#4. Medical personnel are being called in to administer drugs to control people deemed to be suffering from 'excited delirium'."

EMS is routinely dispatched to treat emergency medical conditions. The specific diagnostic term is not important. Emergency treatment is often aimed at symptoms, rather than diagnoses. This is true in the ambulance and in the emergency department.

The diagnosis is not made before treatment is begun, so arguing over a diagnostic term is not important. Treatment is to sedate the patient to protect the patient, so that the patient can be safely transported to the hospital.

Medications, whether midazolam, lorazepam, diazepam, haloperidol, droperidol, ketamine, diphenhydramine, or others, are used to sedate patients to prevent them from hurting themselves and/or other people.

These patients are transported to the hospital.

If the police transport the person to the hospital without any treatment by EMS, then the patient will receive the same treatment in the hospital. That is assuming that the patient's medical condition does not kill the patient before treatment can be begun.

This is not any kind of punishment. Often these patients are behaving as they are because of drugs (cocaine and amphetamine are common). Other times, this can be because of delirium tremens. Other possibilities are scidosis due to a diabetic condition, a psychiatric illness, a head injury (midazolam is not contraindicated for head injuries), heat stroke, fever, medication reactions, and more. The specific diagnosis is less important than calming the patient down and interrupting the damage being caused. Sedation is an excellent way to do this.

None of this is new, or secret.


"#5. Those drugs are being administered to the victim without any knowledge of the victim's medical history or current condition."

These drugs are commonly administered to patients who do not have the mental capacity to answer questions about their medical problems.

These drugs are used because they are the safest way to protect the patient from his/her self-destructive behavior.

These patients are rarely in custody when treated by EMS. If the person's mental condition prevents them from making informed decisions for themselves, that is one of the best defenses against any criminal charge.

Midazolam is a safe and effective drug that is used to protect patients. Because these people are patients, they are transported to the emergency department for continuing treatment.
.

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