Medical Malpractice Insights: Excited Delirium

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

This month’s case is another reminder to think of spinal epidural abscess in back pain patients. This diagnosis continues to be missed far too often. Doing the right thing, while not always keeping one from getting sued, will (almost always) keep a jury on your side. We are not responsible for foreseeing the future. We are responsible for keeping an open mind, developing a broad differential, testing appropriately and documenting our findings.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Excited delirium: A medical problem, not a police problem

Patient removed from ICU at physician’s request, dies in jail. 

Facts: A 26-year-old male alcoholic and meth addict well-known to the police and hospital staff is brought to the ED with extreme agitation, violent outbursts and seizures. After a brief stay in the ED, he is admitted to the ICU where he is given low doses of lorazepam (3 mg total IV) and haloperidol (10 mg IM). His violent and erratic behavior remains uncontrolled for the next 2 1/2 hours, at which time the physician asks that the police be called to remove him from the hospital. He is placed in a wheelchair with difficulty, taken out of the hospital and left in a nearby park without any discharge meds or instructions. The physician documents his condition on discharge as “stable,” despite a CO2 level of 16 and a sodium 126. Five hours later he is found in the park naked, arrested for lewd conduct and booked into jail. He is placed in a “restraint chair” for several hours, then moved to a cell. The next morning he asks to go to the hospital. The request is denied. He has a seizure and dies in his cell 24 hours later. His estate files a lawsuit.

Plaintiff: You told the police I was “stable” for discharge when I was anything BUT stable. In fact, had the police found me somewhere other than in the hospital in my condition, they would have considered me unstable and brought me TO the hospital. I had already had 2 seizures in the previous 12 hours. You gave me ridiculously low doses of lorazepam and haloperidol during my stay. In fact, you gave me the haloperidol only 20 minutes before the police took me out. It didn’t have time to work. Even if you had given me the right dosages, you could have done more to bring my behavior under control. You could have called an anesthesiologist and/or used propofol, ketamine, or even chemical paralysis and intubation. My labs were out of whack, and you didn’t check my VS on discharge. In fact, I wasn’t discharged. I was kicked out, even though I was getting worse, not better. You never checked my old record. It contains a virtual “recipe” of the drug regimen that other doctors had used for my prior similar episodes. It worked so well that they could discharge me from the ED without admission. I would not have died if you’d given me appropriate doses of medications for my condition, controlled my seizures and let me calm down.

Defense: I wrote orders for “2 mg IV lorazepam q3h prn anxiety and agitation.” I included a plan to “transfer [you] to an inpatient detox facility as soon as [you became] stable enough to be discharged.” I determined that you were medically cleared to be in police custody.

Result: After an expert reviewed the record and submitted a declaration supporting the patient’s claims, a pre-trial settlement was reached for an undisclosed amount.

Takeaways:

1. Controlling medically unstable behavior is the responsibility of the physician, not the police.
2. A variety of options may be utilized for chemical restraint, including haloperidol or droperidol and/or benzodiazepines.
3. Ketamine 4-5 mg/kg IM or 1-2 mg/kg IV can provide rapid control. If this is utilized, the patient requires close monitoring.
4. Medical ethics and the standard of care do not allow a patient to be “discharged” because his behavior is inconvenient or otherwise unacceptable.
5. Having the police remove a patient with excited delirium from the ICU is not a discharge plan.

References:

1. Assessment and emergency management of the acutely agitated or violent adult. Moore G, Pfaff JA. UpToDate Online, updated Sep 21, 2021. https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult?source=search_result&search=acute agitation&selectedTitle=1~150
2. emDocs Cases: ED Approach to Agitation. Brit Long. emDocs.net, Feb 5, 2018. http://www.emdocs.net/emdocs-cases-ed-approach-agitation/
3. A 5-step approach to the agitated patient Anton Helman. ACEP Now. November 16, 2018. https://www.acepnow.com/article/a-5-step-approach-to-the-agitated-patient/
4. Excited Delirium: The ED Minefield. Gabrielle Bunney. emDocs.net, Jun 21, 2021. http://www.emdocs.net/excited-delirium-the-ed-minefield/