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On a hot July day, fire and police are called to the home of a 55 year old man suffering from heat stroke. Police arrive first and find the man sitting on a bench in his front yard. When the officers approach the man and ask him to give them his cane, he becomes agitated and non-compliant. One officer suddenly grabs the cane away from the man, who screams and suddenly stands up. The man is tased, taken to the ground, beaten and handcuffed. He is transported to the hospital where ER physicians confirm a diagnosis of heat stroke. The man has no criminal history. He sustains numerous moderate injuries which keep him from returning to work for several weeks. The officers and agency are sued and settle out of court.

Deputies are dispatched to a residence after their Emergency 9-1-1 center receive a number of 9-1-1 hang up calls where the caller sounds agitated. They contact the parents and brother of a subject in his 30s who is agitated, chaotic and possibly under the influence of drugs. After being assured by the family that they will handle the chaotic son, they begin to leave. At this point, they observe the son to pull his mother back into the house. The deputies re-enter the home and confront the son who is clearly acting bizarrely. When the paranoid son hides behind his mother and hugs her from behind, the deputies decide to tase the man. A violent struggle ensues to capture and restrain him which results in the use of pepper spray and repeated hard baton strikes. The man becomes unresponsive and dies at the scene. The deputies and agency are sued. A civil trial jury finds that the deputies were poorly trained and used excessive force. The jury's damages verdict is in the millions and is the largest in the county's history.

On a warm early September morning, police receive numerous calls of a naked man running into the street, yelling that he is God and pounding on passing vehicles. The first officer to arrive on-scene observes the naked man walk out from behind a building and stand quietly on the curb. Without waiting for back-up to arrive, the officer approaches and engages the man while yelling at him to put his hands up. The naked man immediately becomes agitated. He yells at the lone officer and then rapidly approaches him while swinging a closed fist. The officer responds by tasing the man, who falls to the ground disoriented. The man sits up and is ordered to lie on his stomach while still being tased. Despite the presence of two more officers who could have physically controlled the subject; he is tased four more times before officers handcuff him. The naked man experiences respiratory distress, agonal breathing; and then suffers a cardiac arrest and dies in-custody. An autopsy finds no drugs in his system. The cause of death is classified as "natural." The cause of death is listed as "agitated-excited delirium in concert with psychosis." The use of an electronic control weapon that delivered 21 seconds of electrical load in the upper chest within a 23 second time span is not even listed as a contributing cause of death. The officers and agency are sued for wrongful death and excessive force.

Paramedics and police are called to the home of a 53 year old UPS driver who has suffered a seizure after returning home from work. Paramedics find the man disoriented and standing on his bed. Officers arrive simultaneously and yell at the man to get off the bed and to lie on his stomach. The man moves to a window and is tackled by paramedics; and then repeatedly tased by the officers. The man suffers moderate injuries from the police encounter and is transported to the hospital. ER physicians diagnose that the man suffered from a seizure. His toxicology is negative for drugs and he has no criminal history. He does not return to work following this incident. He has sued the municipality.

Hyperthermia; agitated-chaotic events; excited delirium syndrome; seizures; drug influence; mental health disorders and psychosis - all of these are classified as psycho-medical emergencies or "PMEs." Psycho-medical emergencies are serious, life threatening events that can rapidly degrade to sudden in-custody death (ICD) incidents if not handled properly. PME incidents are on the increase; as are the statistics for ICDs. As the high-profile ICD cases in West Palm Beach, FL, Kern Co. CA and Baltimore to name just a few demonstrate. PMEs are some of the most dangerous and challenging critical incident circumstances that officers face. They are also an increasing area of criminal prosecution and civil litigation for officers, agencies and municipalities.

How serious are psycho-medical emergencies and what are the "best practices" in responding to them? First, any response to a PME should be integrated and involve all of the first responder role players: dispatchers, police, and Medical Services Directors, EMS and ER physicians. This type of multidisciplinary response cannot happen without first developing and implanting a solid training platform that teaches dispatchers and responders how to recognize the "cues" of a classic psycho-medical emergency; and then the best protocol of response and police/medical intervention and mitigation.

The "best practices" PME response protocol involves identification; pre-contact threat and PME assessment; isolation/containment; communication; capture, control and restraint; sedation, medical intervention; and transport to hospital for treatment. All role players should have defined areas of responsibility and should understand that the ultimate objective of their symbiotic relationship is the safety of the public, themselves and the involved subject.

Officers and dispatchers are not physicians; nor are they necessarily medically trained. While they do not diagnose; they should be properly trained to assess and evaluate subjects to determine whether they might be experiencing a psycho-medical emergency. Training should involve core learning in the recognition of four basic "cues" or signs of psycho-medical distress. The cues are categorized as verbal, physical, behavioral and/or psychological. First responders need to quickly determine whether the subject's cues indicate that they are gravely disabled; in need of immediate medical intervention; and/or are a danger to themselves and/or others sufficient to justify an involuntary commitment to a hospital or psychiatric facility for evaluation.

Dispatchers - should be trained to recognize the cues of agitated, chaotic, abnormal, bizarre and/or under the influence behavior from 9-1-1 callers, reporting persons and witnesses. These cues should be accurately documented in the Computer Aided Dispatch (CAD) log and thoroughly described to responding officers, supervisors and EMS personnel who should be dispatched at the same time as officers. Dispatchers should be trained to provide as much information as possible so that responding officers and EMS personnel can develop tactical plans and make decisions regarding staging plans while enroute to the call.

Officers - should be trained to handle every potential PME call as a high-risk critical incident. In absence of a supervisor; officers should immediately engage the trained PME protocol. A critical component of the arrival protocol once the suspected PME subject is located, is to conduct a pre-contact threat and PME assessment.

In the case of subjects presenting with agitated-chaotic behavior, it is extremely important that officers not compress distance in approaching the subject unless exigent circumstances exist. Case histories have clearly shown that distance compression with delirious and/or paranoid subjects significantly increases agitation; which in turn can exacerbate their psycho-medical condition. Getting too close too quickly also compromises the reactionary gap of officer action-reaction lag time in controlling and/or defending against violent subjects. This scenario rarely ends well for officers and subjects.

Whenever safe and practical to do so, officers should make sure that all components and resources are marshaled and immediately available to engage and complete the capture/control, sedate and medical intervention of the PME subject. EMS should be staged at a safe location proximate to the scene to allow for a rapid response for the immediate sedation and medical intervention of the subject.

EMS should be equipped administer sedatives such as versed nasally; or ketamine intramuscularly as needed. It is critical that officers understand that most agitated-chaotic subjects are hyperthermic (overheated) and may be presenting with agitated-excited delirium syndrome (ExDS); which is often fatal during or immediately following police uses of force. Therefore, it is important that these subjects be medically sedated as soon as possible to reduce cardiovascular stressors that lead to respiratory and cardiac failures that are major causes of sudden in-custody death.

Force Options - The best engagement with an agitated- chaotic PME subject is one that avoids unnecessary uses of force. Always have a studied response, rather than an emotional reaction, to perceived or actual resistance. If the subject is not presenting with extreme agitation, delirium, or hallucinating; attempt to calmly and patiently converse with them to assuage them and calm them down. Try not to yell orders, directions, or commands. Maintain distance and continue to assess the subject's ability to comprehend and comply. If force is anticipated and must be used; make sure that your arrest/restraint team is ready. Have a plan and move quickly with commitment. Remember that if you use an electronic control weapon (ECW); minimize load cycles and cuff the subject under load. Remember that while ECWs and or body compression alone rarely cause death; they most certainly exacerbate the factors that caused the subject's psycho-medical emergency; and can significantly increase respiratory and cardiovascular stressors. Supervisors - should be trained to immediately respond to the scene to manage personnel; provide direction and logistical support; and to assist in managing any potential crime scene that might result from any major use of force. Remember that evidence collection at the scene is critical.

Supervisors should always be present at the hospital to provide ER staff with an immediate medical history of the PME subject's cues at the scene and all force that was used. If the supervisor does not know this information, radio for one of the involved officers to response to provide this important information.

Evidence collection - at the hospital is every bit as critical as at the scene because ER staff are concerned with saving lives; not collecting evidence. Photograph and video the subject; especially if they are still alive. Capture any verbal, physical, behavioral and/or psychological cues via video. It is critical to have the ER staff capture and document internal body core temperatures to confirm hyperthermia.

Medical Directors - need to work with law enforcement to establish medical response and intervention protocols for handling PMEs; as well as forensic investigation protocols for the proper identification, documentation and collection of medical evidence to diagnose subjects who die in-custody and forensically determine the accurate cause of death, manner of death, contributing causes of death, and any mechanisms of injury associated with an in-custody death.

Summary - Psycho-medical emergencies have become one of the most serious, challenging and risky scenarios that law enforcement and medical professionals face today. They often result in serious injury and in-custody death to the PME subject and will most likely be heavily scrutinized by the media and litigated as either a civil rights or criminal case. It is imperative that all responders to a PME incident know their roles and follow the PME response and evidence collection protocols when dealing with subjects in distress.

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Dr. Ron Martinelli, is a nationally renowned forensic criminologist and a federal/state courts qualified law enforcement and premises liability expert who is also a Certified Medical Investigator (physician's level) accredited by the MO State Medical Association. Dr. Martinelli directs the nation's only Forensic Death Investigations & Independent Review Team and specializes in officer-involved death cases, civilian self-defense shooting cases and premises liability/security cases.

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