Have you ever been given training in Acute Behavioural Disturbance – also known as Excited Delirium? I hope so because attending an incident where someone is affected by this condition can be a life-changing event – for them, because approximately 10% of diagnosed cases result in sudden death, and, for you, through spending the next few years having your actions forensically raked over in response to this tragedy. It’s important, also, that you understand ABD because – I would suggest – those actions of yours need to be different from that which you would normally use for a call suggesting disorder.

That extremely aggressive/violent behaviour.

• Excessive strength / continue to struggle despite restraint.
• Insensitivity to pain
• Acute psychosis with fear of impending doom.
• Constant physical activity without fatigue.
• Abnormally rapid breathing.
• A heart rate over 100 beats per minute.

And finally …

Hyperthermia – overheating … that’s why they’ve taken their clothes off … they’re boiling up whilst simultaneously losing all their inhibitions.

These are all symptoms described by The College of Emergency Medicine.

With ABD, the person’s heart rate is much faster than it should be, in fact so much so that they are at risk of dying if not treated as a medical emergency. And that’s the principal message of this section …

As soon as you suspect that you’re being sent to is an incident of ABD – and that suspicion might arise simply through hearing that someone’s naked and erratic – then declare it over the radio as such and tell the operator that ABD is defined by the College of Emergency Medicine as a medical emergency where the person may need to be giving tranquilisers before they suffer a cardiac arrest, so you need an ambulance to be sent to the scene as well as police with the crew briefed as to what to expect. Finish off your lecture by pointing out that, again according to the College of Emergency Medicine, ABD carries with it a 10% chance of sudden death … that should focus their attention.

There are two reasons for you doing this. Firstly, you’re going to – hopefully – get the medical assistance that you require should your person suffer a cardiac arrest in front of you – it’s never pretty doing CPR on some sweat-ridden naked person – but secondly it justifies the way you deal with them at the scene because these actions will be different to those for someone not affected by ABD.

Let’s face it, under normal circumstances when you go to an incident involving a disorderly person then the situation tends rapidly to deteriorate to ‘hands-on’. With ABD, though, restraint is to be avoided where possible because this, and the bun-fight that follows, maybe the final contributing factor that causes that cardiac arrest and sudden death. Not laying hands-on, of course, might go against all your instincts – it’s natural for us to restrain someone if we fear they are going to hurt themselves or others. It may also go against the helpful advice provided by the public observing this cabaret. I reiterate, though, that with ABD restraint may be the worst thing to do.

So how should we respond instead? Well, anticipate from the outset – while on route – that this person is going to go into cardiac arrest and so you will need a medical ‘Plan B’ for when it all goes wrong. How far is the ambulance away – I know they often refuse to give a journey time but is there any indication? Have you or another patrol got a defib? Are there any specialist units – public order or ARVs perhaps, with TEAMs medics available?

Once you find the person, and you firm up your suspicion that this is an ABD incident, then think in terms of …

Containing as opposed to restraining.

If they’re positioned within a room and not causing any danger then let them stay in that room. If they’re out in public then just picket some officers around them and hope to keep them there. If they move, then try to keep them within a bubble of officers. Offer reassurance in a calming voice – ‘… it’s alright mate – you’re not in any danger …’ because they may be extremely paranoid. I dealt with an ABD incident where the male was convinced that he had escaped from some compound and police had been sent to murder him. Demonstrate non-threatening NVCs, even if your own ‘fight or flight’ reactions are going into overdrive. If you have the public around you – all with their mobile phones out recording – then direct them to move away and create a safe environment; the chances are they won’t of course because they’re being idiotic, but at least you’ve told them and so it’s their responsibility if they get hurt. Your aim throughout this stage is to buy time until medical assistance arrives – you’re trying to orchestrate it so that no hands-on occurs until there’s someone available skilled to deal with the medical side of things if it all goes wrong.

All of this, great though it sounds, maybe terribly impractical because our person is doing something which means they need to be stopped and restrained there and then. And, if that’s the case, then so be it – the important thing is that you have demonstrated a mindset and course of action intended to avoid or at least delay this … it makes for a much better day out at the Coroners’ inquest a few years later.

If you need to restrain then be aware that someone with ABD will classically be, as we said above, insensitive to pain and full of energy. They will also be slippery to hold because they’re sweating so much. Think, more than ever, about the dangers of positional asphyxia – try to avoid holding them face-down in a prone position but instead get them on their back so that it’s easier for them to breathe; don’t forget that if they lay on their stomach with – as classically happens in all the excitement – Bobbies on their back, then they won’t be able to breathe properly and so will be fighting even more.

Remember to use lots of calming tac-coms, the more ‘… it’s alright, you’re going to be fine … try to stay calm … you’re perfectly safe … no one’s going to harm you …’ etc, the better, both for the benefit of your subject but also that crowd videoing you with their phones. If practical, try and get something soft under their head. But always anticipate that they may go into cardiac arrest. Even when they have stopped resisting and have apparently calmed down then prepare for cardiac arrest until assessed by a medical professional.

And, afterwards, don’t take chances; if there’s any suspicion of ABD they need to go to the hospital by ambulance, not a custody suite in a police van. My TEAMs medic instructor used to describe incidents where it was only when the person had seemed to calm down that they went on to suffer cardiac arrest.

A final couple of points. In my experience, some ambulance personnel – and operators – are unfamiliar with ABD. They may feel that what police are asking them to attend is a lesser incident than it is. Your police Control Room operator may also be unfamiliar with the issue and that’s where the ‘lack of communication leading to tragedy’ scenario develops. Don’t be afraid to be forceful over the radio – knowing that it’s all recorded. Explain that 10% chance of sudden death over and over again until you get what you need.

You may also be thinking, Yep, this all sounds logical but I’m the most junior member of the team – who’s going to listen to me when I say we shouldn’t jump all over this person but instead keep away from them and call an ambulance? And that’s a very good point; the dangers of ABD are not well known in police circles and, should you go to an incident involving it today, you may be the most skilled officer present to orchestrate the response simply as a result of reading this blog. So, here’s a solution. Go and speak with your supervisors and tell them how you’ve just learnt about ABD and wish to clarify what the team response would be if such an incident occurred. It may be that they’ve never heard of the condition, so enlighten them. Any good supervisor, on hearing this information, would realise the importance of cascading it down to everyone else on the team, perhaps at the briefing, and so we will get the message out to as many Bobbies as possible, which can only be a good thing – that way they don’t go to the Coroners’ Court.

Stay safe and be lucky!