I was cruising through downtown a while back in the ambulance when I was flagged down by bystanders to some drama on a street corner.* They told my partner and me that there was a fight a block or two ahead and someone was probably hurt. We did what most paramedics would do in that situation - we made a right angle turn and continued about our day. I don’t need to break up a fight. As we drove, though, more and more people saw us and began to flag us down. There comes a point when you can’t avoid a call.
When we arrived on scene, we found two adult males with minor injuries to their faces. One had a nosebleed, I recall. My partner took care of the both of them, so I don’t really know specifics. Instead, I walked up to a shouting man being restrained on the sidewalk. He was a big dude, not fat but big, and seemed rather upset. As near as I could make out, the bystanders thought he was the aggressor in the fight and were holding him down. One bystander was sitting on his stomach (knees on either side of him), while different bystanders were each holding down an arm. So he was lying on the ground, supine, with his arms straight out from his body. When I say upset, I mean that he was loudly, profanely, and constantly explaining how he was going to kick all of our asses. He singled me out specifically, mentioning my shirt. (That always makes me sad. All I did is approach. What did I do to deserve an ass kicking?) Anyway, it didn’t seem like a good idea to let him up. I did tell the bystanders to make sure to not put so much weight onto him that he couldn’t breathe but with the constant volume of air and noise he was putting out, ventilation was obviously not a problem.
I took a minute to make sure the law was headed our way and checked in with my partner. He was handling his patients with no problems, and they didn’t even appear to be heading toward ambulance transport. Getting more of the story, it seems like there was an altercation, the prone angry man punched the two other dudes, and a whole bunch of bystanders took him down and held him there.
By this point, the police were beginning to show up. Three police officers replaced the three bystanders in holding the angry aggressor on the ground. One took his legs and two more took an arm each. To restrain his arms they used nunchuks at his wrists. Keep in mind that the dude is still bellowing threats the whole time. The police rolled him prone in order to handcuff him. I threw out another reminder about facilitating breathing, but the police were doing their thing. They weren’t getting violent and didn’t have much weight on him. In any case, though, the patient seemed to get more and more violent - to the point that a single policeman on an arm couldn’t control that extremity alone. He was putting out enough force to pull a cop with one arm. And doing it on each side. And shouting profane threats of extreme violence the whole time.
So at this point, I knew that things were escalating to the point that the man probably wouldn’t be arrested for assault and transported to jail. His agitation was increasing to the point that chemical restraint would be helpful. That was my plan at that point, at least. The cops had the patient prone by this point and were working on getting both arms behind him at the same time. The patient began to bellow that he couldn’t breathe.
“I CANT BREATHE! I CAN’T FUCKING BREATHE!!” Well, there is my cue. I had been weighing my options: a typical anti-psychotic, a benzodiazepine, or Ketamine. With the breathing screams, I got the Ketamine and a syringe. As I drew up a 500 milligram dose, the patient began to roar. Have you ever heard a patient roar like an animal? The point when they no longer communicate with words, instead they can only make a rage noise? That is excited delirium. The patient was now experiencing a life-threatening emergency.
Similar to a police department’s continuum of force, I think agitated patients present with a continuum of agitation. They don't line up in a 1:1 way, like how you should respond to patient actions, but they are similar in that it is an escalating pattern of actions. The agitation continuum starts with being upset or angry, like this patient probably was just before the fight. Occasionally, though, angry leads to violence. Being in EMS, we forget the fact that violence is rare and unusual. The patient in this case was in this stage when he was punching people. Up to this point it is a police matter. The treatment for jerks is cops. Being angry is not a medical problem. Being violent is not a medical problem.
Moving on, while this patient was on the ground, he was moving into the next stage of the agitation continuum - unreasoning. There is no way that we were going to let him up. But that is what he seemed to expect: “Let me up you assholes! I’m going to kick all your asses!” He’s far enough into the continuum that statements like that one don’t seem unreasonable to him.
If the agitation trail he is running down isn’t stopped, excited delirium is the end point. I have found that complaints of breathing problems is the marker for the transition to excited delirium. When a patient screams that they can’t breathe, especially when they can hit that really terror-filled note with their voice, that is the point that things have gone really, really bad and we’re now in an emergency.
Roaring follows. To me, roaring means that the patient’s body systems are under enough stress that their humanity has stopped functioning. They are making the same noises, with the same thought processes, that a deer makes when a cougar is on its back. It is pure lizard-brain level animal response. Their lower brain knows that they are about to die.
Look at the video here. It is one of the best examples of excited delirium on YouTube. Right off the bat, the shirtless dude is acting squirrelly. But he is making sense. That quickly changes into unreasonableness as he stumbles into traffic. He is controlled enough that in the first minute the responding officer can pretty much cuff him alone with the aid of a carotid restraint. In this case, the "help me" cries (~3:00) are equivalent to the breathing statements discussed in this post in that they are both requests for aid that make no sense. The patient begins roaring by 3:45 when he is being carried. The patient dies (by my eye) at about 5:25; the police begin to realize that fact at about 7:00.
Here is another great example. The roaring is fully engaged by the 9:00 mark.
Ketamine is perfect for this situation, if it is given quickly. It stops the patient’s struggles without affecting their breathing, like a benzo would. They can breathe off all of the acidosis and carbon dioxide they need to. Don’t interfere with their breathing, let them blow off all of those bad things.
I darted this dude right through his pants. I may have even stabbed through his wallet. What can I say, I was in a hurry. The police got him handcuffed, but he was prone with his arms behind him. That is a suboptimal position. He was still roaring and kicking, so it was impossible for me to convince the police to roll him onto his side. I did convince them to not put any weight at all on his torso - there was only one officer holding his legs. I felt like I was watching a horse race between Ketamine and death. One or the other was going to hit this patient first.
Ketamine won. After about a minute (a minute that felt like five), the patient quickly slowed down and then went limp. With some more begging and pleading, I convinced the police to uncuff the patient and roll him onto his back. He had good chest expansion, good ventilations, and was tachypneic as all get out. Perfect. One thing I will tell you: If you have never given Ketamine before, it is kind of scary. All of your training and experience is telling you that this patient needs a tube. Dude has a GCS of 3! Intubate him!
Do. Not. Intubate. Him. He is fine. He may need some suction, but don’t get too aggressive with his airway.
The patient really looks dead. That is how fast and how solidly the medication works. The first time I gave Ketamine, I sat there with a finger on the patient’s carotid pulse. I could feel the pulse and breathing at that finger. It was the only way I could convince myself that the patient wasn’t dead.
Go ahead and start all of your other paramedic stuff - an IV is probably warranted, along with an ECG and oxygen saturation monitoring. You will want to restrain the patient on the bed, both because they may wake up again and because their arms will flop around if you don’t secure them. Go to the hospital with the lights and siren. Excited delirium is a big-deal life threat.
The most important point to take home from this post is that “I CAN’T BREATHE!” is the patient telling you that excited delirium is taking hold. Get the Ketamine.
*So much has been changed about this story that it is now purely fictional. It is actually best described as a conglomeration of a few calls rather than a case study of a specific patient.
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