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First up, recall as you think about this that "EXD" is not accepted by the WHO, American Psychiatric Association, American Medical Association, EUSEM, is not in the DSM and is not in ICD-10. It is accepted in the US only by the American College of Emergency Physicians (ACEP). Michael Baden calls it "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". Most cases - almost all, and all deaths as far as I can see - are in police custody. The principal advocate for the condition is Axon, formerly known as Taser corporation, makers of the stun guns.
I'd argue that this widespread rejection, absence from ICD-10 and DSM, negligible incidence outside police custody, and advocacy paid for by a company with a vested interest in excusing deaths in police restraint, qualifies it as a fringe diagnosis - and even if you don't accept that, it's clearly a massive WP:REDFLAG.
There are a number of sources that were used in this article, which I have removed, although at face value they pass MEDRS. The reasons are explained in the edit summaries, but I'll go into them here.
There's also strong reporting from Reuters, Brookings and numerous other RS undermining the diagnosis. There have been over 1,000 deaths following Taser use in the US, and Taser is significantly responsible for promoting the diagnosis of excited delirium. Another paid consultant and stockholder, Mark Kroll, has described Tasers as "therapy" for EXD. One reason this is suddenly getting serious attention is because the term was used by police during the murder of George Floyd ("Man Dies After Medical Incident During Police Interaction").
Mash and Wetli cite "Bell's mania" (which redirects here) as an earlier observation of the same symptoms, but Bell's paper is from 1850 and it seems likely that most of those who died in Bell's care were actually suffering from encephalitis - notably, the diagnosis more or less disappeared in the 1950s with the advent of antipsychotics and antibiotics. Wetli claims that it resurged due to cocaine use - rhetoric very much in line with the "war on drugs", and, again, strongly associated with the use of crack (more used by Black people) rather than pure cocaine (more used by white people). Diagnosis is disproportionately seen in Black men, and is closely associated with the racially biased differential treatment of crack vs. white cocaine. While most accidental cocaine toxicity deaths are in white people, those dying of "cocaine-induced EXD" were more likely to be Black, with lower levels of cocaine in their bodies, under restraint by police. "In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained". [1]
Axon's involvement is inescapable. They are quite open about their payments to medical experts to promote narratives of the safety of their products. They placed Robert Stratbucker on a DoJ study on safety of Tasers, until he was rumbled. [2] Their SEC filings [3] acknowledge the impact of litigation on their bottom line, and they call out their investment in paid medical spokespeople and their aggressive strategy of suing MEs who cite Tasers as a cause of death, as turning this round. "Continued aggressive litigation defense to protect our brand equity. We have an assembled team of world class medical experts at our disposal and hired additional internal legal resources during 2005 to provide an efficient means of defending us against numerous product liability claims. We have had a total of 12 cases dismissed or defense judgments in our favour. We view a continued record of successful litigation defense as a key factor for our long term growth." They sued a number of medical examiners and expert witnesses for defamation, product disparagement and tortious interference with trade, when they stated that Tasers had contributed to or caused deaths. And EXD is their go-to in deaths after Taser use.
We have a condition here which is based on an original misdiagnosis of murder, overwhelmingly rejected by the medical profession, where the UK's regulator of forensic pathology has said that is "has been applied in some cases where other important pathological mechanisms, such as positional asphyxia and trauma may have been more appropriate" and should not be used as a cause of death, which is cited as a cause of death in up to 50% of cases where someone dies in police restraint but is almost never seen elsewhere, and whose notable proponents include several people on the payroll of Axon including a couple of cases where there have been massive ethical concerns. That argues very strongly against relying on those advocates as sources. Guy ( help! - typo?) 10:20, 9 May 2021 (UTC)
I think the last major edit has removed some material from the old article, as well as added some new material. That's okay, wikipedia is not a finished product and often moves in big changes - but I want to restore material from the older version of the article.
I think [ [5]] is the version of the article before major editing so I'm going to compare to this version and restore edit as appropriate, and let's see if we can reach aggreement.
I'm not really a fan of just deleting an infobox really, so I've restored that.
While police are routinely taught to look for excited delirium, [1] especially in cases where the victim has been Tasered, [2] excited delirium is not recognized by the vast majority of medical professionals.
looks like WP:Synth to me. I'm restoring the initial sentence about the acceptance of the criteria (which incidentally is far more compelling to me than the new version, which comes across as a bit polemical).
References
If aspersions have been cast about an author and they are referenced and relevant they should be included. But can we try to find newer sources too! For example there is this recent(ish) and open access systematic review: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330
Talpedia ( talk) 19:19, 10 May 2021 (UTC)
Sources
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I sort of feel like the fact that emergency doctors recognise this as a "diagnosis" or maybe a symptom should be in the lead. It does seem to be the case that the diagnosis is used in emergency medicine.
Is this source, [7] tainted, if not perhaps the conclusion from this paper, which would seem to be the best source under WP:MEDRS, would be a good thing to summarize into a sentence or two in the lead. I think the fact that emergency doctors are injecting people with ketamine, antipsychotics and benzodiazapines based on this diagnosis is important enough to be included in the lead.
In conclusion, this unique systematic review of the literature on excited delirium syndrome shows a global predominance of low to very low levels of evidence. Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors. The numerous unresolved questions that remain warrant further investigations. A universal and objective definition must be urgently developed to allow for more structured and standardized research with a better level of evidence, such as with prospective cohorts comprising toxic, metabolomic, and genetic aspects. Randomized and controlled trials on the treatment and care of these patients are essential.
Talpedia ( talk) 21:22, 10 May 2021 (UTC)
Talpedia ( talk) 08:23, 11 May 2021 (UTC)
The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS.
Let me create a new section for this so that we can discuss how to approach the question of medicines and societies responses to agitation in patients - be it here or in a new article. Since the question here is quite specific and I think the solution we might want could be adding information to another article. Talpedia ( talk) 07:14, 12 May 2021 (UTC) Talpedia ( talk) 07:02, 12 May 2021 (UTC)
The condition was first identified by pathologist Charles Wetli to account for the deaths of nineteen Black prostitutes due to "sexual excitement" while under the influence of cocaine. The women were later found to have been strangled by serial killer Charles Henry Williams.
I don't like this phrasing. I would prefer "the term was first used". This feels a bit WP:NPOVishy because you it assumes that the condition identified then is the same as what is identified now. Going ORy extreme mania in bipolar disorder could look quite like the construct of excited delirium and this has been around forever. I'm fine with this information being included but it seems to imply that the current diagnosis is the same as the historic one.
Talpedia ( talk) 21:52, 10 May 2021 (UTC)
WP:ASPERSIONS / WP:SEALIONing |
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The following discussion has been closed. Please do not modify it. |
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So... it does seem to be the case that excited delirium may show up more in coroners reports and in the testimony of lay witnesses than in medical discussions, *but* there are also situations under which medical doctors will sedate patients against their will due to what they identify as agitation. The suggested treatments in this case seem similar to those for excited delirium. Antipsychotics, benzodiazapines and ketamine. The term "acute behavioural disturbance" links to this article.
Taking quotes from the section "The challenginge patient" of [1]
...
A behavioural emergency can be defined as an unarmed threat by a patient or others character-ized by agitation, aggression, violence and irra-tional or altered behaviour.
...
The aetiology of acute behavioural disturbance in the ED is largely mental illness or substance intoxication and often a combination of the two.17A smaller number have an organic illness, includ-ing dementia, manifesting as a behavioural emer-gency.19 Most patients are male (approximately 65%) and under the age of 40,17,20 and around 20% are brought to the ED in police custody.17,21The majority of unarmed threats occur in the late afternoon, evening and overnight, with a weekly peak on Saturdays.17 Between 58% and 80% of these require some form of chemical or physical restraint as part of management
...
The pharmacological management of the acutely aroused patient is discussed in detail elsewhere (see Chapter 20.6), but the principles should be emphasized. The least traumatic measures are advocated, depending on the desired end point of chemical restraint and the risks to staff and patient in administration.Oral benzodiazepines are preferred where possible and may allow patients a small sense of control if they are able to choose this option ahead of parenteral sedation. Choice between intramuscular or intravenous administration of sedation depends on perceived risks to staff, ease of obtaining intravenous access, need for blood tests or other intravenous therapy and desired rapidity of sedative effect. A standardized intramuscular sedation protocol can be effec-tive and safe.29 Where rapid tranquillization is desired, the intravenous route of administration is required, as the onset of action is within the first 5 minutes rather than the approximate 15 to 20 minutes of intramuscular drugs.30 Commonly used drugs for rapid tranquillization include benzodiazepines (diazepam and midazolam), neuroleptics (droperidol and haloperidol) and antipsychotics (olanzapine). Increasingly, ket-amine is used in patients who are difficult to sedate and in transport situations.31 A combina-tion of intravenous midazolam with droperidol or olanzapine has been shown to be more effective than midazolam alone or than high-dose droperi-dol or olanzapine alone with respect to time to adequate sedation and need for re-sedation.32,33Intravenous midazolam alone may cause more adverse events relating to airway obstruction and over-sedation and is more likely to require re-sedation within an hour. High-dose parenteral midazolam is not supported due to concerns about effect and safety.34 Careful monitoring in a high-acuity area of the ED is required when parenteral chemical restraint is used
Where should this information exist, and I found this source [9] that says:
The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS
I feel like we need to discuss this somewhere and the similarities to excited delirium should be acknowledged. It feels a bit like we are denying the existence of a clinical diagnosis and the involuntary treatment associated with it because a related concept is being used forensically in questionable ways.
Talpedia ( talk) 07:23, 12 May 2021 (UTC)
References
I've started to put together a draft for acute behavioural disturbance: Draft:Acute Behavioral Disturbance to deal with the "official" medical response for aroused behaviour potentially resulting in Chemical restraint or physical restraint. It's not quite there yet, but when it's ready I'm planning to stop disambiguating acute behavioural disturbance and link to this page in the lede. Talpedia ( talk) 01:47, 18 May 2021 (UTC)
Related:
-- Guy Macon ( talk) 16:16, 22 May 2021 (UTC)
The short description was "state of extreme agitation". Although excited delirium is often used interchangeable with Acute behavioural disturbance which is state of agitation, excited delirium is considered to be a well-defined diagnosis in other literuate (particularly when talking about death).
I'm changing this to "Condition accompanied by...". Talpedia ( talk) 17:41, 10 July 2021 (UTC)
This article was written with a clear bias against law enforcement and is based almost entirely on opinion and false information and not fact. 2600:387:5:814:0:0:0:14 ( talk) 09:44, 17 December 2021 (UTC)
User:82.112.138.191, would you please discuss your reasons for repeatedly blanking the "Position of the American College of Emergency Physicians" section of this article? Thanks, Generalrelative ( talk) 05:28, 28 December 2021 (UTC)
I encourage Burner50 to discuss this edit and attempt to gain consensus rather than edit warring. The edit in question appears to violate our policy against original synthesis by using an article which does not mention excited delirium to imply something about excited delirium. Indeed, the article in question studies rats, not humans, and makes only tenuous suggestions about avenues for further research in humans, rather than sweeping claims anything approaching what Burner50 has been seeking to add. Generalrelative ( talk) 19:00, 6 January 2023 (UTC)
Excited delirium, a diagnosis not found in the DSM and lacking clear criteria, has been used to explain fatalities of people in police custody, especially deaths of young Black men, and to exculpate police officers from responsibility. The label has also been invoked to justify the forceful restraint and sedation of people who may fail to obey the orders of law enforcement; ketamine, a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress, is often used in these situations. This combination of a dubious diagnosis and a medication with serious side effects has set the stage for tragic outcomes.Generalrelative ( talk) 19:19, 6 January 2023 (UTC)
Coming back here for a final comment because I now see that I'd missed the significance of FFF's comment above. The APA statement is indeed a near-top quality source per
WP:MEDRS and it speaks to this issue directly: Many sedating medications, used in outside of hospital contexts, including ketamine, have significant risks, including respiratory suppression. Supporting respiration may be challenging outside of a hospital setting, where it may require intensive medical oversight or involvement.
Seems to me that the issue is settled.
Generalrelative (
talk) 20:42, 7 January 2023 (UTC)
Late to the party. But just my standard moaning about about the desire for "authoratitive" sources from one field to push out opinions from the other fields, when I would prefer to have disagreements between fields rub uncomfortably against one another for all to see. Position statements by professional organizations are in my opinion pretty dodgy sources because they can be politically motivated, so I would prefer systematic reviews for statements about medical facts, and reserve such position statements to discuss what professional bodies care about. Also... psychiatrists aren't the one's administering the ketamine in this cae I don't think.
I don't think it's good idea to have psychiatry "own" the effects of ketamine. I suspect anaesthesiolgists have a lot to say about the effects of ketamine on respiration and it seems a bit silly to stop their opinions coming into the article, provided we can make it clear that the apply to general administration of ketamine. (See also WP:NOTJUSTANYSYNTH). That said... I would really prefer reviews to a single source. And it'd be better if we could establish more of a link between the two literatures to establish that the material is WP:DUE. My take on excited delirium is that it's a "psychiatric diagnosis" (in the sense that it diagnosis behaviour) constructed outside of psychiatry for use in forensic and emergency medicine, so we shouldn't be surprisied if fields start disagreeing with one another. Talpedia ( talk) 21:59, 7 January 2023 (UTC)
This article seems to spend a lot of time talking about what not to do, but I didn't see any positive recommendations. Imagine the classic EXD story: a man is behaving very strangely, walking unsafely through a public area (e.g., into the path of oncoming vehicles), making incoherent noises, and breaking windows.
This page sort of implies: Don't sedate him, don't restrain him, don't give him ketamine, don't taser him, don't don't don't don't don't.
What I'm missing is: What should be done? Evacuate the area around him and wait until he collapses, at which point someone can sweep up the glass? What's the best path towards having this person alive at the end of this event? WhatamIdoing ( talk) 07:46, 22 June 2023 (UTC)
so maybe that could prevent some deaths. I guess you have to weigh up the risk respiratory risks of police restraint, benzodiazapines, antipsychotics and ketamine. I sometimes wonder if asphyxia due to police restraint is due to unnecessary restraint whe you could use handcuffs. In a hospital physical restraints can be used... which likely reduce the risk of asphyxia... so perhaps you could have physical restraint vans if you handcuffs aren't doing the job. You have to weight this up against the risk of abuse - is it better having 1 in 1000 physical restraints end up in asphyxia or risk having people who don't need physical restraint held in physical restraint for hours in police vans - civil liberties have never come without a corresponding risk to life. If you want to start giving people more powers and capabilities to use physical force and coercion you start having to set up a system of checks and balance, ensuring that is funded and the people advocated for, making sure that the values of the organization are in line with their job (mixing mental health and crime prevention can be a stretch) and ensuring that your legal of advocacy system does not get captured and used as a means of coercion by medicine, the police or society as a whole. Talpedia 11:18, 23 June 2023 (UTC)National Institute for Health and Care Excellence suggest supine rather than prone restraint and that physical restraint should ideally not last longer than 10 minutes.
References
The article claims that there is likely no medical reason to use Ketamine. At the VERY least this should be clarified to pertain only to ExDS, but I'll make the case that this statement should be removed entirely.
Ketamine, while controversial after the death of Elijah McClain, does have significant benefits in the treatment of an ExDS patient, particularly with an onset of acidosis. Without APPROPRIATE treatment, acidosis to the degree seen in ExDS is lethal. Any drug that, when responsibly used, can prevent irreversible cardiac arrest due to acidosis should be considered.
Additionally, to put it bluntly, the sources for this claim are pretty garbage.
The APA public statement makes the claim that Ketamine can cause respiratory arrest. It's a sedative.....OF COURSE IT CAN CAUSE RESPIRATORY DISTRESS. ExDS patients are a danger to themselves and others and are normally acidotic, sedation is the most appropriate treatment, in our out of hospital. The timing of the article also clearly makes it a response to the death of Elijah McClain.
The other article explicitly uses the death of Elijah McClain as an example as to why Ketamine is bad. Well yeah: if you overdose a kid on a sedative, you'll probably kill him. The Paramedic who OD'd him will probably go to prison for it. Malpractice happens, it's not evidence that a drug or procedure is dangerous, it's evidence that humans are gonna human.
Both sources criticize the use of ExDS as a term, citing loose definitions and diagnosis. That's fair, because Doctors rarely have an opportunity to observe someone with the symptoms. But the presentation in a prehospital scenario is usually pretty clear, and there doesn't necessarily have to be a clear diagnosis to know that a sedative is necessary to both make the scene safe for emergency personnel, and prevent further harm to the patient, either in the form of self(or law enforcement) inflicted trauma or cardiac arrest.
The death of anyone due to malpractice is a tragedy, particularly when there was an unjustified and overbearing police response. But the EM case is really the only one cited as to why "Ketamine Bad" and it's also clearly a malpractice case. If an anesthesiologist ODs someone on propofol, are we going to outlaw that too?
I'm not an MD, or any kind of Dr, but the literature speaks for itself. Mefirefoxes ( talk) 20:34, 23 July 2023 (UTC)
It looks like the ACEP might mostly be switching out names [12]. I'm unclear what the name change means exactly; they likely want to keep some aspects of the diagnosis while getting rid of some of those from excited delirium. As to whether, it just amounts to "name washing" depends on how much of the concept of excited delirium and the literature gets applied to the concept.
This could be a bit of a pain to source correctly, because sources might sayd hyperactive delirium, mean excited delirium, be understood as excited delirium but never actually say so. Talpedia 09:29, 10 October 2023 (UTC)
By their nature, syndromes represent a constellation of signs and symptoms without a clearly elucidated singular cause or pathophysiologic definition. This diagnostic uncertainty, along with the dual use of the nomenclature both to describe the initial patient presentation and to provide a causative etiology on post-mortem examination, has led to controversy over use of the term, “Excited Delirium Syndrome,” within medicine and the lay press. Critics of this terminology have raised concern that it has been employed to explain away preventable in-custody deaths as inevitable outcomes, without proper consideration of other contributing factors and alternative management strategies that might have resulted in survival. Supporters of the use of “Excited Delirium Syndrome” have observed patients with agitated or combative behavior that is associated with a delirious state where the individual is not capable of interacting with other individuals or the environment. They recognize such behavior is frequently associated with physiologic abnormalities and high rates of death, warranting immediate treatment to improve patient outcomes. Moreover, the term is only definitively applied as a postmortem cause of death, rather than prospectively at presentation. Given the increasingly charged nature of the term, ACEP is concerned that its use in this document may distract from the intended delivery of critical information surrounding therapeutic options and best practices focused on the patient’s care and survival. Consequently, explicit discussion of “Excited Delirium Syndrome” will only occur in the context of ACEP Task Force Report on Hyperactive Delirium evidence surroundings its existence as a distinct pathophysiologic phenomenon. Rather, in this paper, we use the term “hyperactive delirium with severe agitation” to describe presentations of interest.
I had a look at a couple sources used to support the use of the word pseudoscientific and neither of them mentioned the word. Are there any sources that talk about whether excited delirium is pseudoscientific? "Convenient umbrella diagnosis existing outside of psychiatry and neurology without a specific mechanism and potentially confused with other preexisting psychotic diagnoses which are already associated with misdiagnosis" is probably what I would go for, but I would not say it is pseudoscientific Talpedia 16:55, 10 October 2023 (UTC)
@ Generalrelative: Hey. So I'm not quite sure on the pseudoscientific thing. The ACEM are basically using excited delirium as a diagnosis, they've just changed it's name to distinguish it from the forensic diagnosis, so I don't think we can say that there is consensus on the diagnosis being pseudoscientific. As there isn't consensus I'm not sure pseudoscientific should go in thelead. I think it's perfectly fine to say that some people described it as pseudoscientific in the article tho, IMO. Talpedia 17:08, 6 November 2023 (UTC)
"excited delirium"
in a JSTOR search; there are many more talking about racism, and half talk about restraint), is a subject that seems to be far down on the list, and I haven't seen anything more than a single sentence. (Example: "He later died, with the medical examiner citing "excited delirium," a racist and pseudoscientific diagnosis used to justify police brutality.")
WhatamIdoing (
talk) 18:46, 6 November 2023 (UTC)
excited delirium pseudoscience
. First one's free: The AMA
doesn't use that language. (The claim in the NYT article links to
this press release, which does not use that language.)
WhatamIdoing (
talk) 01:55, 7 November 2023 (UTC)
have misread the paper or something
This sentence:
While diagnosis is habitually of men under police restraint, medical preconditions and symptoms attributed to the syndrome are far more varied. [2]
is in the ==Deaths== section, but I can't figure out what it has to do with the deaths. I also couldn't figure out where else to put it. The structure of this article is unusual, and I'm not sure that it's serving us well. WhatamIdoing ( talk) 22:43, 4 November 2023 (UTC)
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First up, recall as you think about this that "EXD" is not accepted by the WHO, American Psychiatric Association, American Medical Association, EUSEM, is not in the DSM and is not in ICD-10. It is accepted in the US only by the American College of Emergency Physicians (ACEP). Michael Baden calls it "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". Most cases - almost all, and all deaths as far as I can see - are in police custody. The principal advocate for the condition is Axon, formerly known as Taser corporation, makers of the stun guns.
I'd argue that this widespread rejection, absence from ICD-10 and DSM, negligible incidence outside police custody, and advocacy paid for by a company with a vested interest in excusing deaths in police restraint, qualifies it as a fringe diagnosis - and even if you don't accept that, it's clearly a massive WP:REDFLAG.
There are a number of sources that were used in this article, which I have removed, although at face value they pass MEDRS. The reasons are explained in the edit summaries, but I'll go into them here.
There's also strong reporting from Reuters, Brookings and numerous other RS undermining the diagnosis. There have been over 1,000 deaths following Taser use in the US, and Taser is significantly responsible for promoting the diagnosis of excited delirium. Another paid consultant and stockholder, Mark Kroll, has described Tasers as "therapy" for EXD. One reason this is suddenly getting serious attention is because the term was used by police during the murder of George Floyd ("Man Dies After Medical Incident During Police Interaction").
Mash and Wetli cite "Bell's mania" (which redirects here) as an earlier observation of the same symptoms, but Bell's paper is from 1850 and it seems likely that most of those who died in Bell's care were actually suffering from encephalitis - notably, the diagnosis more or less disappeared in the 1950s with the advent of antipsychotics and antibiotics. Wetli claims that it resurged due to cocaine use - rhetoric very much in line with the "war on drugs", and, again, strongly associated with the use of crack (more used by Black people) rather than pure cocaine (more used by white people). Diagnosis is disproportionately seen in Black men, and is closely associated with the racially biased differential treatment of crack vs. white cocaine. While most accidental cocaine toxicity deaths are in white people, those dying of "cocaine-induced EXD" were more likely to be Black, with lower levels of cocaine in their bodies, under restraint by police. "In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained". [1]
Axon's involvement is inescapable. They are quite open about their payments to medical experts to promote narratives of the safety of their products. They placed Robert Stratbucker on a DoJ study on safety of Tasers, until he was rumbled. [2] Their SEC filings [3] acknowledge the impact of litigation on their bottom line, and they call out their investment in paid medical spokespeople and their aggressive strategy of suing MEs who cite Tasers as a cause of death, as turning this round. "Continued aggressive litigation defense to protect our brand equity. We have an assembled team of world class medical experts at our disposal and hired additional internal legal resources during 2005 to provide an efficient means of defending us against numerous product liability claims. We have had a total of 12 cases dismissed or defense judgments in our favour. We view a continued record of successful litigation defense as a key factor for our long term growth." They sued a number of medical examiners and expert witnesses for defamation, product disparagement and tortious interference with trade, when they stated that Tasers had contributed to or caused deaths. And EXD is their go-to in deaths after Taser use.
We have a condition here which is based on an original misdiagnosis of murder, overwhelmingly rejected by the medical profession, where the UK's regulator of forensic pathology has said that is "has been applied in some cases where other important pathological mechanisms, such as positional asphyxia and trauma may have been more appropriate" and should not be used as a cause of death, which is cited as a cause of death in up to 50% of cases where someone dies in police restraint but is almost never seen elsewhere, and whose notable proponents include several people on the payroll of Axon including a couple of cases where there have been massive ethical concerns. That argues very strongly against relying on those advocates as sources. Guy ( help! - typo?) 10:20, 9 May 2021 (UTC)
I think the last major edit has removed some material from the old article, as well as added some new material. That's okay, wikipedia is not a finished product and often moves in big changes - but I want to restore material from the older version of the article.
I think [ [5]] is the version of the article before major editing so I'm going to compare to this version and restore edit as appropriate, and let's see if we can reach aggreement.
I'm not really a fan of just deleting an infobox really, so I've restored that.
While police are routinely taught to look for excited delirium, [1] especially in cases where the victim has been Tasered, [2] excited delirium is not recognized by the vast majority of medical professionals.
looks like WP:Synth to me. I'm restoring the initial sentence about the acceptance of the criteria (which incidentally is far more compelling to me than the new version, which comes across as a bit polemical).
References
If aspersions have been cast about an author and they are referenced and relevant they should be included. But can we try to find newer sources too! For example there is this recent(ish) and open access systematic review: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330
Talpedia ( talk) 19:19, 10 May 2021 (UTC)
Sources
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I sort of feel like the fact that emergency doctors recognise this as a "diagnosis" or maybe a symptom should be in the lead. It does seem to be the case that the diagnosis is used in emergency medicine.
Is this source, [7] tainted, if not perhaps the conclusion from this paper, which would seem to be the best source under WP:MEDRS, would be a good thing to summarize into a sentence or two in the lead. I think the fact that emergency doctors are injecting people with ketamine, antipsychotics and benzodiazapines based on this diagnosis is important enough to be included in the lead.
In conclusion, this unique systematic review of the literature on excited delirium syndrome shows a global predominance of low to very low levels of evidence. Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors. The numerous unresolved questions that remain warrant further investigations. A universal and objective definition must be urgently developed to allow for more structured and standardized research with a better level of evidence, such as with prospective cohorts comprising toxic, metabolomic, and genetic aspects. Randomized and controlled trials on the treatment and care of these patients are essential.
Talpedia ( talk) 21:22, 10 May 2021 (UTC)
Talpedia ( talk) 08:23, 11 May 2021 (UTC)
The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS.
Let me create a new section for this so that we can discuss how to approach the question of medicines and societies responses to agitation in patients - be it here or in a new article. Since the question here is quite specific and I think the solution we might want could be adding information to another article. Talpedia ( talk) 07:14, 12 May 2021 (UTC) Talpedia ( talk) 07:02, 12 May 2021 (UTC)
The condition was first identified by pathologist Charles Wetli to account for the deaths of nineteen Black prostitutes due to "sexual excitement" while under the influence of cocaine. The women were later found to have been strangled by serial killer Charles Henry Williams.
I don't like this phrasing. I would prefer "the term was first used". This feels a bit WP:NPOVishy because you it assumes that the condition identified then is the same as what is identified now. Going ORy extreme mania in bipolar disorder could look quite like the construct of excited delirium and this has been around forever. I'm fine with this information being included but it seems to imply that the current diagnosis is the same as the historic one.
Talpedia ( talk) 21:52, 10 May 2021 (UTC)
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So... it does seem to be the case that excited delirium may show up more in coroners reports and in the testimony of lay witnesses than in medical discussions, *but* there are also situations under which medical doctors will sedate patients against their will due to what they identify as agitation. The suggested treatments in this case seem similar to those for excited delirium. Antipsychotics, benzodiazapines and ketamine. The term "acute behavioural disturbance" links to this article.
Taking quotes from the section "The challenginge patient" of [1]
...
A behavioural emergency can be defined as an unarmed threat by a patient or others character-ized by agitation, aggression, violence and irra-tional or altered behaviour.
...
The aetiology of acute behavioural disturbance in the ED is largely mental illness or substance intoxication and often a combination of the two.17A smaller number have an organic illness, includ-ing dementia, manifesting as a behavioural emer-gency.19 Most patients are male (approximately 65%) and under the age of 40,17,20 and around 20% are brought to the ED in police custody.17,21The majority of unarmed threats occur in the late afternoon, evening and overnight, with a weekly peak on Saturdays.17 Between 58% and 80% of these require some form of chemical or physical restraint as part of management
...
The pharmacological management of the acutely aroused patient is discussed in detail elsewhere (see Chapter 20.6), but the principles should be emphasized. The least traumatic measures are advocated, depending on the desired end point of chemical restraint and the risks to staff and patient in administration.Oral benzodiazepines are preferred where possible and may allow patients a small sense of control if they are able to choose this option ahead of parenteral sedation. Choice between intramuscular or intravenous administration of sedation depends on perceived risks to staff, ease of obtaining intravenous access, need for blood tests or other intravenous therapy and desired rapidity of sedative effect. A standardized intramuscular sedation protocol can be effec-tive and safe.29 Where rapid tranquillization is desired, the intravenous route of administration is required, as the onset of action is within the first 5 minutes rather than the approximate 15 to 20 minutes of intramuscular drugs.30 Commonly used drugs for rapid tranquillization include benzodiazepines (diazepam and midazolam), neuroleptics (droperidol and haloperidol) and antipsychotics (olanzapine). Increasingly, ket-amine is used in patients who are difficult to sedate and in transport situations.31 A combina-tion of intravenous midazolam with droperidol or olanzapine has been shown to be more effective than midazolam alone or than high-dose droperi-dol or olanzapine alone with respect to time to adequate sedation and need for re-sedation.32,33Intravenous midazolam alone may cause more adverse events relating to airway obstruction and over-sedation and is more likely to require re-sedation within an hour. High-dose parenteral midazolam is not supported due to concerns about effect and safety.34 Careful monitoring in a high-acuity area of the ED is required when parenteral chemical restraint is used
Where should this information exist, and I found this source [9] that says:
The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS
I feel like we need to discuss this somewhere and the similarities to excited delirium should be acknowledged. It feels a bit like we are denying the existence of a clinical diagnosis and the involuntary treatment associated with it because a related concept is being used forensically in questionable ways.
Talpedia ( talk) 07:23, 12 May 2021 (UTC)
References
I've started to put together a draft for acute behavioural disturbance: Draft:Acute Behavioral Disturbance to deal with the "official" medical response for aroused behaviour potentially resulting in Chemical restraint or physical restraint. It's not quite there yet, but when it's ready I'm planning to stop disambiguating acute behavioural disturbance and link to this page in the lede. Talpedia ( talk) 01:47, 18 May 2021 (UTC)
Related:
-- Guy Macon ( talk) 16:16, 22 May 2021 (UTC)
The short description was "state of extreme agitation". Although excited delirium is often used interchangeable with Acute behavioural disturbance which is state of agitation, excited delirium is considered to be a well-defined diagnosis in other literuate (particularly when talking about death).
I'm changing this to "Condition accompanied by...". Talpedia ( talk) 17:41, 10 July 2021 (UTC)
This article was written with a clear bias against law enforcement and is based almost entirely on opinion and false information and not fact. 2600:387:5:814:0:0:0:14 ( talk) 09:44, 17 December 2021 (UTC)
User:82.112.138.191, would you please discuss your reasons for repeatedly blanking the "Position of the American College of Emergency Physicians" section of this article? Thanks, Generalrelative ( talk) 05:28, 28 December 2021 (UTC)
I encourage Burner50 to discuss this edit and attempt to gain consensus rather than edit warring. The edit in question appears to violate our policy against original synthesis by using an article which does not mention excited delirium to imply something about excited delirium. Indeed, the article in question studies rats, not humans, and makes only tenuous suggestions about avenues for further research in humans, rather than sweeping claims anything approaching what Burner50 has been seeking to add. Generalrelative ( talk) 19:00, 6 January 2023 (UTC)
Excited delirium, a diagnosis not found in the DSM and lacking clear criteria, has been used to explain fatalities of people in police custody, especially deaths of young Black men, and to exculpate police officers from responsibility. The label has also been invoked to justify the forceful restraint and sedation of people who may fail to obey the orders of law enforcement; ketamine, a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress, is often used in these situations. This combination of a dubious diagnosis and a medication with serious side effects has set the stage for tragic outcomes.Generalrelative ( talk) 19:19, 6 January 2023 (UTC)
Coming back here for a final comment because I now see that I'd missed the significance of FFF's comment above. The APA statement is indeed a near-top quality source per
WP:MEDRS and it speaks to this issue directly: Many sedating medications, used in outside of hospital contexts, including ketamine, have significant risks, including respiratory suppression. Supporting respiration may be challenging outside of a hospital setting, where it may require intensive medical oversight or involvement.
Seems to me that the issue is settled.
Generalrelative (
talk) 20:42, 7 January 2023 (UTC)
Late to the party. But just my standard moaning about about the desire for "authoratitive" sources from one field to push out opinions from the other fields, when I would prefer to have disagreements between fields rub uncomfortably against one another for all to see. Position statements by professional organizations are in my opinion pretty dodgy sources because they can be politically motivated, so I would prefer systematic reviews for statements about medical facts, and reserve such position statements to discuss what professional bodies care about. Also... psychiatrists aren't the one's administering the ketamine in this cae I don't think.
I don't think it's good idea to have psychiatry "own" the effects of ketamine. I suspect anaesthesiolgists have a lot to say about the effects of ketamine on respiration and it seems a bit silly to stop their opinions coming into the article, provided we can make it clear that the apply to general administration of ketamine. (See also WP:NOTJUSTANYSYNTH). That said... I would really prefer reviews to a single source. And it'd be better if we could establish more of a link between the two literatures to establish that the material is WP:DUE. My take on excited delirium is that it's a "psychiatric diagnosis" (in the sense that it diagnosis behaviour) constructed outside of psychiatry for use in forensic and emergency medicine, so we shouldn't be surprisied if fields start disagreeing with one another. Talpedia ( talk) 21:59, 7 January 2023 (UTC)
This article seems to spend a lot of time talking about what not to do, but I didn't see any positive recommendations. Imagine the classic EXD story: a man is behaving very strangely, walking unsafely through a public area (e.g., into the path of oncoming vehicles), making incoherent noises, and breaking windows.
This page sort of implies: Don't sedate him, don't restrain him, don't give him ketamine, don't taser him, don't don't don't don't don't.
What I'm missing is: What should be done? Evacuate the area around him and wait until he collapses, at which point someone can sweep up the glass? What's the best path towards having this person alive at the end of this event? WhatamIdoing ( talk) 07:46, 22 June 2023 (UTC)
so maybe that could prevent some deaths. I guess you have to weigh up the risk respiratory risks of police restraint, benzodiazapines, antipsychotics and ketamine. I sometimes wonder if asphyxia due to police restraint is due to unnecessary restraint whe you could use handcuffs. In a hospital physical restraints can be used... which likely reduce the risk of asphyxia... so perhaps you could have physical restraint vans if you handcuffs aren't doing the job. You have to weight this up against the risk of abuse - is it better having 1 in 1000 physical restraints end up in asphyxia or risk having people who don't need physical restraint held in physical restraint for hours in police vans - civil liberties have never come without a corresponding risk to life. If you want to start giving people more powers and capabilities to use physical force and coercion you start having to set up a system of checks and balance, ensuring that is funded and the people advocated for, making sure that the values of the organization are in line with their job (mixing mental health and crime prevention can be a stretch) and ensuring that your legal of advocacy system does not get captured and used as a means of coercion by medicine, the police or society as a whole. Talpedia 11:18, 23 June 2023 (UTC)National Institute for Health and Care Excellence suggest supine rather than prone restraint and that physical restraint should ideally not last longer than 10 minutes.
References
The article claims that there is likely no medical reason to use Ketamine. At the VERY least this should be clarified to pertain only to ExDS, but I'll make the case that this statement should be removed entirely.
Ketamine, while controversial after the death of Elijah McClain, does have significant benefits in the treatment of an ExDS patient, particularly with an onset of acidosis. Without APPROPRIATE treatment, acidosis to the degree seen in ExDS is lethal. Any drug that, when responsibly used, can prevent irreversible cardiac arrest due to acidosis should be considered.
Additionally, to put it bluntly, the sources for this claim are pretty garbage.
The APA public statement makes the claim that Ketamine can cause respiratory arrest. It's a sedative.....OF COURSE IT CAN CAUSE RESPIRATORY DISTRESS. ExDS patients are a danger to themselves and others and are normally acidotic, sedation is the most appropriate treatment, in our out of hospital. The timing of the article also clearly makes it a response to the death of Elijah McClain.
The other article explicitly uses the death of Elijah McClain as an example as to why Ketamine is bad. Well yeah: if you overdose a kid on a sedative, you'll probably kill him. The Paramedic who OD'd him will probably go to prison for it. Malpractice happens, it's not evidence that a drug or procedure is dangerous, it's evidence that humans are gonna human.
Both sources criticize the use of ExDS as a term, citing loose definitions and diagnosis. That's fair, because Doctors rarely have an opportunity to observe someone with the symptoms. But the presentation in a prehospital scenario is usually pretty clear, and there doesn't necessarily have to be a clear diagnosis to know that a sedative is necessary to both make the scene safe for emergency personnel, and prevent further harm to the patient, either in the form of self(or law enforcement) inflicted trauma or cardiac arrest.
The death of anyone due to malpractice is a tragedy, particularly when there was an unjustified and overbearing police response. But the EM case is really the only one cited as to why "Ketamine Bad" and it's also clearly a malpractice case. If an anesthesiologist ODs someone on propofol, are we going to outlaw that too?
I'm not an MD, or any kind of Dr, but the literature speaks for itself. Mefirefoxes ( talk) 20:34, 23 July 2023 (UTC)
It looks like the ACEP might mostly be switching out names [12]. I'm unclear what the name change means exactly; they likely want to keep some aspects of the diagnosis while getting rid of some of those from excited delirium. As to whether, it just amounts to "name washing" depends on how much of the concept of excited delirium and the literature gets applied to the concept.
This could be a bit of a pain to source correctly, because sources might sayd hyperactive delirium, mean excited delirium, be understood as excited delirium but never actually say so. Talpedia 09:29, 10 October 2023 (UTC)
By their nature, syndromes represent a constellation of signs and symptoms without a clearly elucidated singular cause or pathophysiologic definition. This diagnostic uncertainty, along with the dual use of the nomenclature both to describe the initial patient presentation and to provide a causative etiology on post-mortem examination, has led to controversy over use of the term, “Excited Delirium Syndrome,” within medicine and the lay press. Critics of this terminology have raised concern that it has been employed to explain away preventable in-custody deaths as inevitable outcomes, without proper consideration of other contributing factors and alternative management strategies that might have resulted in survival. Supporters of the use of “Excited Delirium Syndrome” have observed patients with agitated or combative behavior that is associated with a delirious state where the individual is not capable of interacting with other individuals or the environment. They recognize such behavior is frequently associated with physiologic abnormalities and high rates of death, warranting immediate treatment to improve patient outcomes. Moreover, the term is only definitively applied as a postmortem cause of death, rather than prospectively at presentation. Given the increasingly charged nature of the term, ACEP is concerned that its use in this document may distract from the intended delivery of critical information surrounding therapeutic options and best practices focused on the patient’s care and survival. Consequently, explicit discussion of “Excited Delirium Syndrome” will only occur in the context of ACEP Task Force Report on Hyperactive Delirium evidence surroundings its existence as a distinct pathophysiologic phenomenon. Rather, in this paper, we use the term “hyperactive delirium with severe agitation” to describe presentations of interest.
I had a look at a couple sources used to support the use of the word pseudoscientific and neither of them mentioned the word. Are there any sources that talk about whether excited delirium is pseudoscientific? "Convenient umbrella diagnosis existing outside of psychiatry and neurology without a specific mechanism and potentially confused with other preexisting psychotic diagnoses which are already associated with misdiagnosis" is probably what I would go for, but I would not say it is pseudoscientific Talpedia 16:55, 10 October 2023 (UTC)
@ Generalrelative: Hey. So I'm not quite sure on the pseudoscientific thing. The ACEM are basically using excited delirium as a diagnosis, they've just changed it's name to distinguish it from the forensic diagnosis, so I don't think we can say that there is consensus on the diagnosis being pseudoscientific. As there isn't consensus I'm not sure pseudoscientific should go in thelead. I think it's perfectly fine to say that some people described it as pseudoscientific in the article tho, IMO. Talpedia 17:08, 6 November 2023 (UTC)
"excited delirium"
in a JSTOR search; there are many more talking about racism, and half talk about restraint), is a subject that seems to be far down on the list, and I haven't seen anything more than a single sentence. (Example: "He later died, with the medical examiner citing "excited delirium," a racist and pseudoscientific diagnosis used to justify police brutality.")
WhatamIdoing (
talk) 18:46, 6 November 2023 (UTC)
excited delirium pseudoscience
. First one's free: The AMA
doesn't use that language. (The claim in the NYT article links to
this press release, which does not use that language.)
WhatamIdoing (
talk) 01:55, 7 November 2023 (UTC)
have misread the paper or something
This sentence:
While diagnosis is habitually of men under police restraint, medical preconditions and symptoms attributed to the syndrome are far more varied. [2]
is in the ==Deaths== section, but I can't figure out what it has to do with the deaths. I also couldn't figure out where else to put it. The structure of this article is unusual, and I'm not sure that it's serving us well. WhatamIdoing ( talk) 22:43, 4 November 2023 (UTC)