The Royal College Of Emergency Medicine and the Faculty of Forensic and Legal Medicine have today published a new best practice guideline on the topic of Acute Behavioural Disturbance.

All 999 response officers, first-responders and street triage police officers need to know about them bearing in mind the number of deaths following police custody or contact that are still linked by Coroners to ‘restraint related’ or ‘cocaine related’ excited delirium, now more often termed acute behavioural disturbance.

The whole classification and conceptualisation of these ideas remains subject to debate within the medical professions, and the document alludes to this by stopping short of regarding these phenomena as a ‘disorder’. My point has always been: regardless of medical taxonomy, Courts and organisations like Inquest tell the police service that people die from whatever it is that’s going on and that alternative approaches are needed to learn lessons from history because we can control or reactions and responses, even if we cannot control the background or underlying issues.

It’s only sixteen pages long and when you strip out references, intros and covers, it’s perfectly consumable and the medical language is not impenetrable to those of us with a first-aid certificate as our highest clinical qualification! It essentially says –

Suspected ED / ABD is a medical emergency until otherwise proved.

Restraint and restrictive interventions need to be seen as a last resort, although they may be unavoidable.

Urgent action to end restraint as soon as possible will be necessary.

Emergency Departments have a role to play – by definition then, so do the ambulance service!

It highlights the police as the inevitable first-responders because clincial presentation is associated with highly unusual, bizarre and often aggressive behaviours.

There is NO minimum safe period of restraint.

Treatment with benzodiazapenes, antipsychotics or ketamine may be required.

It could be safer to consider the application of Taser to allow for medication, rather than manual restraint, becuase the impact upon the person concerned may well be less, given the risks of acidosis in ED / ABD cases.

LEGAL ISSUES

What the document doesn’t massively touch on but which will be relevant for any police or paramedics who become connected to such incidents, is the legal basis for acting – that will also be relevant for EDs. The detention of a person by the police may have already occured before the involvement of healthcare professionals and it could either be for a suspected criminal offence or under the Mental Health Act 1983. Neither of those things matter massively, because neither of them allows for the treatment of the person in the way suggested by this guideline. The Mental Capacity Act will be of relevance to those considering treatment options and where a case of ED / ABD is honestly assessed, there will be few limits to what is urgently justifiable under ss 5/6/4B of the MCA because these situations will be regarded as life-threatening until otherwise assessed and that may well take an ED consultant to do so.

But this revisits that old debate about violence and aggression. Only this week, as part of #MHAW16, I’ve seen police forces proudly telling their public how much they’ve reduced the use of cells for those detained under s136 MHA and that the examples which remain are only those where detainees are ‘unmanageably violent’. Always makes me wonder whose skill base has been able to say, “This is not clinically significant”. The RCEM / FFLM document tells us that fatal outcomes can be expected in 10% of cases, so the odds are difficult ones to ignore if we are talking about potentially fatal outcomes. In reality, it seems we still have officers taking unmanageably violent detainees to cells and detaining them there, without that person having been seen by paramedics, without them having been seen by a DR in ED and with knowledge that the FME may be 90minutes or more away from the police station.

One of the Oxford University Press handbooks for Emergency Medicine says, “Most people who are violent need a policeman [sic] not a doctor.” Exactly the same intellectual proposition can be said in different way, “Some people who are violent need a doctor, not a police officer.” In reality, some situations are going to need both: because I’m fairly confident you don’t really want me taking decisions about your medical welfare when you lack capacity to do so for yourself and when 10% of the time, the outcome could be fatal for you.

Winner of the President’sMedal from the Royal College of Psychiatrists.

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