6Advantages of the Taser Less risk of injury to law enforcement officers when subjects actively resistLess risk of injury or death to subjects from law enforcement use of forcePhoto Source: Taser International Instructor Certification Course V12, November 2004
7Thomas A. Swift’s Electric Rifle (TASER) Source:Source:M26 Taser. Manufactured by Taser International
9M26 TaserSource: Taser International Instructor Certification Course V12, November 2004
10Tasers, in and of themselves, are not lethal weapons.
11Tasers Use Electricity 50,000 VoltsStatic Electricitydoor knob35,000 – 100,000 VoltsVan De Graaff Generator:1 – 20 Million VoltsPhoto Source: Taser International Instructor Certification Course V12, November 2004
12Tasers Use Electricity It’s not the voltage it’s the amperage that is dangerousTasers use high voltage, but very low amperageM26: 3.6 milliamps (average current)M26:1.76 joules per pulseX26: 2.1 milliamps (average current)X26: 0.36 joules per pulseX26 Taser delivers 19 pulses per second
13Tasers Use Electricity Cardiac Defibrillators use 150 – 400 joules per pulseThe safety index for the fibrillation threshold ranges from 15 – 42 depending on the weight of the subjectSource: PACE 2005; 28:S284-S287.Pig studyVariable current/constant pulse frquency
14Probe Trajectory Aim like a standard firearm at center of mass Use sights and/or laserRule of Thumb: 1 foot (.3m) spread for every 7 feet (2.1m) of travelReview 8-degree downward spread of bottom probe.When fired, the top probe impacts at point of aim. The laser indicates the point of impact within 3 inches at a distance of 13 feet. The bottom dart travels at an 8-degree angle downward. The spread between probes increases the further you get from your target with the probes separating one foot (.3m) for every 7 feet (2.1m) they travel.The wire is thin insulated wire (copper-clad steel) and can break easily. (Show how thin wire is).(m) m m m m m mTarget Distance (ft) ′ ' ' ' ′ ′ ′Spread (in) ″ " " " " ″ ″(cm) cm cm cm cm cm cm cm
15Taser Effects High voltage affects nerves Leads to intense muscle contractionDoes not affect muscles directly
16Tasers have caused injuries, but most Taser-related injuries are minor.
17Taser Injuries Muscle Contraction Injuries Injuries from Falls Stress fracturesMuscle or tendon strain or tearsBack injuriesJoint injuriesInjuries from FallsMay be serious depending on the height
18Taser Injuries Minor Surface Burns Due to arcingTasers will ignite flammable liquids and gassesPotential for serious burnsPenetrating Eye Injuries
20Taser Dart Injuries The skin at the puncture site is cauterized A swift tug will remove the barb easilyTaser users receive this trainingWipe site with alcohol prepConsider a band-aid
21Source: Taser International X26 User Course V12, November 2004
22News media sources have implied a cause and effect relationship between Tasers and in-custody deaths…
23Concern About Tasers 147 in-custody taser-related deaths since 1999 Source: Robert Anglen, Arizona Republic August 8, 2005The number is growingDraws significant negative media attentionOutcry from human rights activistsAmnesty International
25There is no scientific evidence to date of a cause and effect relationship between Tasers and in-custody deaths.
26Taser Use in Police Training Over 150,000 police volunteersNo deaths
27In-Custody Deaths…Why do some people die following a violent confrontation with police?What role does the taser play, if any?What can police officers do to prevent in-custody deaths?
28Typical Scenario Male subject creating a disturbance Triggers 911 call Obvious to police that subject will resistStruggle ensues with multiple officersMay involve OC, Taser, choke holds, batons, etc.
29Typical Scenario Physical restraints applied Subject subdued in a prone positionOfficers kneeling on subjects backHandcuffs, ankle cuffsHogtying, hobble restraint or TARPProne vs. lateral positioningTransported in a squad car to jail
30Typical Scenario Continued struggle against restraints Sometimes damages squad carApparent resolution periodSubject becomes calm or slips into unconsciousnessLabored or shallow breathingFollowed unexpectedly by…
31Source: Am J Emerg Med; 2001:19(3), 187-191 Typical ScenarioDeathResuscitation efforts are futileLos Angeles County EMS Study18 ED deaths witnessed by paramedics (all were restrained)In 13 – rhythm documentedVT and asystole were most commonNo ventricular fibrillationAll failed resuscitationSource: Am J Emerg Med; 2001:19(3),
32Typical Scenario The press: The Fallacy: “Post hoc ergo proptor hoc” Subject “died after being shocked with taser”Implies cause and effectThe Fallacy: “Post hoc ergo proptor hoc”
33Typical Aftermath Several weeks later – autopsy results… Cause of DeathExcited deliriumIllicit stimulant drug abuseConcurrent medical problemsMinimal injury from police confrontationIt wasn’t the taser after allOfficers exonerated
34Typical Aftermath Meanwhile the officers… Placed on administrative leaveSubjected to investigationFace threat of potential criminal chargesFace threat of potential civil litigationSubjected to public outcryExperience personal and family stressContemplate a career change
35Several forensic pathology studies have cited excited delirium, not Tasers, as the cause of death.
36What is Excited Delirium? A controversial theoryAn imminently life threatening medical emergency…Not a crime in progress!
37What is Excited Delirium? Diagnostic criteriaCharacteristic behavioral componentsMetabolic AcidosisHyperthermiaIdentifiable causeStimulant drugsPsychiatric diseaseIt does not explain all behavior that leads to confrontation with police
38Pathophysiology Central nervous system effects: Changes in dopamine transporter and receptorsAccounts for behavioral changesAccounts for hyperthermia
39Behavioral Components: Delirium “Off the track”ConfusionClouding of consciousnessShifting attentionDisorientationHallucinationsOnset rapid – acuteDuration brief – transient
40Behavioral Components: Psychosis Bizarre behavior and thoughtsHallucinations, paranoia
41Behavioral Components: Excited (Agitated) Extreme agitation, increased activityAggravated by efforts to subdue and restrainNot likely to comply after one or two tasers
42Behavioral Components: Excited (Agitated) Violent or aggressive behaviorTowards inanimate objects, especially smashing glassTowards self, others or policeNoncompliant with requests to desistSuperhuman strengthInsensitive to pain
43Excited Delirium Hyperthermia High body temperature 105 – 113 oF Drug’s effect on temperature control center in brain (hypothalamus)Tell-tale signs:Profuse sweatingUndressing – partial or complete
44Excited Delirium Hyperthermia Aggravated by increased activity the ensuing strugglewarm humid weather (summertime)dehydrationcertain therapeutic medications
45Excited Delirium Metabolic Acidosis Survivors: Potentially life threateningElevated blood potassium levelFactors: dehydration, increased activitySurvivors:Kidney damage due to muscle breakdownMay require dialysis
46Excited Delirium: The Usual Suspects #1 Cause: Stimulant Drug AbuseAcute intoxicationSuperimposed on chronic abuseAcute intoxication triggers the event
47Excited Delirium: The Usual Suspects Underlying psychiatric diseaseFirst described in 1849 before cocaine was first extracted from cocoa leafMania (Bipolar Disorder)Psychosis (Schizophrenia)Noncompliance with medications to control psychosis or bipolar disorderUnusual – #2 CauseRare: New onset schizophrenia
48Stimulant Drugs Cocaine Toxicology studies show… The major offender On the rise due to “crack epidemic”Toxicology studies show…Low to moderate levels of cocaineHigh levels of benzoylecognine (the major breakdown product of cocaine)Suggests recent use superimposed on chronic abuse
49Stimulant Drugs Other known culprits include: MethamphetaminePhencyclidine (PCP)LSDCocaethylene = Cocaine + AlcoholToxic to the heartUnknown role in excited delirium deaths
50Concurrent Health Conditions ObesityHeart DiseaseCoronary artery diseaseCardiomegalyHypertrophic cardiomyopathyMyocarditisFibrotic heart
51Autopsy ProofSpecialized laboratories can identify changes in brain chemistry that are characteristic of excited deliriumBlood and brain tissue levels of benzoylecognine and cocaineTypical ratio 5:1
52Tasers and Excited Delirium Deaths It’s not the TaserMany in-custody deaths long before tasers were ever usedDocumented in 1980s medical literatureDeaths of persons not in custodyFound naked in bathroomsWet towelsEmpty ice cube trays scattered aboutA futile effort to cool themselves
53Tasers and Excited Delirium Deaths It is unknown whether tasers have different adverse effects on people with excited delirium than on healthy volunteersTasersNo proximate temporal relationship between taser use and deathMultiple or continuous taser shocksTaser International’s recent warning against repeated shocks
54Whether repeated or continuous Taser shocks is safe remains unknown Whether repeated or continuous Taser shocks is safe remains unknown. They should probably be avoided, if possible.
55Restraints and In-Custody Deaths What roles do physical restraint, restraining technique and restraint position play in excited delirium deaths?
56Physical RestraintsSource: Prehosp Emerg Care, 2003:7(1);
57Physical Restraint Issues Positional AsphyxiaDeaths have occurred with subjects restrained in a prone positionTheory: restricts breathingThe role of the position is unclearLittle data to support causalityOther factors are the likely culprits
58Physical Restraint Issues No clinically significant changes in pulmonary function tests in healthy volunteersAm J Forensic Med Pathol Sep;19(3):201-5.
59Physical Restraint Issues Restraint AsphyxiaIncreased deaths in restrained patientsRat Study3 fold increase in cocaine-related deaths among “restrained” ratsLife Sci. 1994;55(19):PLWhether these may be contributory remains controversial, but still possibleNot considered causal
60Physical Restraint Issues Compression asphyxiaWhat are the adverse effects on breathing and circulation when one or more officers kneel on the subjects back as they handcuff him?
61Excited delirium is an imminently life-threatening medical emergency.
62The “Freight Train to Death” How police restrain or position the subject will not stop “the freight train to death”
63The behavioral features of excited delirium include criminal acts, but…
64Excited delirium is not a crime in progress, and responders must recognize the difference, before it’s too late.
65Recognizing Excited Delirium How they actHow they lookWhat they say and how they say itWhat they are doingHow they make you feelHow they respond to youHow they respond to forceHow they respond to the taser
66Recognizing Excited Delirium Agitation or Excitement = Increased activity and intensityAggressive, threatening or combative – gets worse when challenged or injuredAmazing feats of strengthPressured loud incoherent speechSweating (or loss of sweating late)Dilated pupils/less reactive to lightRapid breathing
67Recognizing Excited Delirium Delirium = ConfusionDisorientedPerson, place, time, purposeRapid onset over a short period of recent time“He just started acting strange”Easily distracted/lack of focusDecreased awareness and perceptionRapid changes in emotions (laughter, anger, sadness)
68Recognizing Excited Delirium Psychotic = bizarre behaviorThought content inappropriate for circumstancesHallucinations (visual or auditory)Delusions (grandeur, paranoia or reference)Flight of ideas/tangential thinkingMakes you feel uncomfortable
69Mnemonic: NOT A CRIME Naked – and sweating from hyperthermia Objects – violence against, especially glassTough – unstoppable, insensitive to painAcute onset – “He just snapped!”Confused – person, place, purpose, perceptionResistant – will not follow commands to desistIncoherent speech – shouting, bizarre contentMental Health or Makes you uncomfortableEarly EMS Back-up
70Bad Behavior: Other Reasons Alcohol intoxication or withdrawalOther drug use problemsExample: Cocaine psychosisPure psychiatric diseaseHead injuryDementia (Alzheimer’s Disease)HypoglycemiaHyperthyroidism
71Patients with excited delirium need rapid aggressive medical intervention.
72Alternative Strategy Attempt verbal de-escalation Summon back-up quicklySummon EMS as early as possibleUse taser before a struggle ensuesJump the subject and administer tranquillizerBack off and contain the subject without restraintOnce calm transport (no restraints?)Minimize struggle and restraintsUnrealistically simplified?? – Maybe!
73The first goal of therapy is to gain control of the violent behavior.
74The “Ideal” Drug Rapid effective tranquilization No repeat dosingNo significant adverse effectsrespiratory depressioncardiovascular depressionneurological adverse effectsEasy to administer (IM)Allows easy assessment of neurological status on ED arrival
75In Search of The “Ideal” Drug BenzodiazepinesNeurolepticsAtypical antipsychoticsKetamine
76Benzodiazepines Effective But usually require repeat doses Adverse reactions:HypotensionRespiratory DepressionOver sedation
77Neuroleptics and Atypical Antipsychotics Rapid onset (10 – 15 minutes or less)Can be very effective in a single doseProlong the QT Interval (Droperidol)Target dopamine D2 receptorsMay exacerbate hyperthermia
78Ketamine Very rapid onset of action (<5 minutes) Highly effective in a single doseFavorable safety profile in healthy patientsPotential adverse effects:Adrenergic over stimulation in excited delirium“Emergence reactions” in adults
79The second goal of therapy is to stabilize the underlying pathophysiologic processes.
80Other ALS Interventions Dehydration/Metabolic Acidosis:IV NS X 2 W/OHyperthermia:Cool environment, disrobe, tepid mist and fanning, cooling blanketsHyperkalemia?:Fluids, Calcium Chloride, Sodium Bicarbonate, AlbuterolRapid transport
81Fall Back Position Proceed to customary practices at any point when This strategy appears to failSafety appears to be endangeredIt is necessary to escalate the level of force based on the threat levelDon’t transport in a squad carUse the least amount of force needed
82CaveatsNever place an agitated and combative patient in an ambulance without physical restraintsNever transport a restrained patient without an officer present who can unlock the restraintsShould the transporting officer disable his/her weapons?
83Potential Pitfalls Can’t wait for back-up or EMS ALS not available Struggle and restraints cannot be avoided
84SummaryExcited Delirium is an imminently life threatening medical emergency, not a crime in progressIn-custody deaths likely related to excited deliriumTasers – if used early – may help (remains unproven)ALS medics can give potent tranquilizersRapid aggressive medical stabilization needed
85Summary Beware of potential side effects of therapeutic drugs Treat for hyperthermia, dehydration, metabolic acidosis and potential hyperkalemia
86The End Michael D. Curtis, MD EMS Medical Director Questions?Thank You!Michael D. Curtis, MDEMS Medical DirectorSaint Michael’s HospitalSaint Clare’s Hospital