BOSTON — The IACP executive board approved the “Management of Behavioral Health Emergencies” resolution, submitted by the Police Physicians Section, at the 2024 IACP conference and exhibition. Behavioral emergencies represent a broad spectrum of disorders including severe agitation.
The resolution resulted from several years of effort by the IACP Police Physicians Section to clarify and advocate for collaboration between law enforcement and EMS. That work was spurred by the death of Elijiah McClain and the investigation and conviction of a police officer and two paramedics, as well as other high-profile incidents, which also has led to legislation that seeks to criminalize ketamine administration and communication between police officers and EMS personnel.
At the 2024 IACP conference, Scott Coyne, MD, Suffolk County (New York) Police Department, discussed the process to develop the “Management of Behavioral Health Emergencies” resolution and the importance of treating patients experiencing a behavioral health emergency as a medical emergency.
“This is now the position of the IACP,” Coyne said.
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Coyne also mentioned the recently released “Consensus Statement of the National Association of EMS Physicians, International Association of Fire Chiefs and the International Association of Chiefs of Police: Best Practices for Collaboration Between Law Enforcement and Emergency Medical Services During Acute Behavioral Emergencies.”
Metabolic acidosis contribution to in-custody death
David McArdle, a reserve officer with the Denver (Colorado) Police Department, continued the IACP presentation on behavioral emergencies by reviewing several in-custody deaths attended by paramedics. McArdle emphasized the importance of paramedics doing a hands-on physical exam as hyperthermia was present in these incidents, but it wasn’t observed by paramedics who failed to touch the patient’s skin during their assessment and before administering medication.
“It doesn’t matter why the fight started — criminal act or psychiatric emergency,” McArdle said. “Struggling, along with underlying drug intoxication, ramps up the metabolic impact on the body. The need to blow off (exhale) carbon dioxide is under-appreciated by public safety personnel.”
McArdle shared these highlights from case reviews and relevant research:
- Prone restraint deaths result from metabolic acidosis, no hypoxic asphyxia
- Metabolic demand is increased by stimulant drugs, physical exertion and stress
- Metabolic acidosis requires hyperventilation to “blow off” carbon dioxide
- Prolonged restraint in the prone position may prevent adequate elimination of carbon dioxide
- An initial ECG rhythm of pulseless electrical activity (PEA) or asystole after cardiac arrest is generally inconsistent with primary cardiac etiology
He concluded his discussion of cases by sharing a video demonstration of tarp-assisted cooling — immersing a patient in a tarp filled with ice water — to assist in rapid cooling of a patient experiencing hyperthermia.
“It is incumbent on you as police chiefs to collaborate with other responders to train together as a team of police, fire and EMS. Anyone who is fighting with police is at risk of sudden death of custody,” McCardle said. “It is key that we stress to EMS personnel to put hands on these folks.”
