Sudden In Custody Death Syndrome (SICDS)

Introduction
What is Sudden In Custody Death Syndrome (SICDS), or Positional Asphyxia, and why is being knowledgeable about it important to my department and its personnel? How much training do my officers need, if any? These may be questions you’ve already addressed, are currently facing, or haven’t yet entertained. This article will endeavor to discuss SICDS training needs and the potential liability that may result with or without this training.

SICDS
This is a phenomenon that results when several signs and symptoms come into play simultaneously. There are four key factors that have been found to be present in previous SICDS cases that identify a person’s risk for SICDS. The first is Cocaine Induced Excited Delirium also know as cocaine psychosis. This physiological occurrence is difficult to predict because it has occurred in first time users as well as more experienced ones. This is a recognized psychiatric emergency and is characterized by disorientation, impaired thinking, visual-hallucinations, purposelessness, and violent and erratic behavior. Because of the paranoia a person affected by this problem exhibits; officers should consider these subjects very dangerous.

The second condition is Neuroleptic Malignant Syndrome. This situation arises within a few days to a few weeks of a person taking Neuroleptic medication. Some medical journals have referred to this condition as “Acute Exhaustive Mania.” In lay terms they’ve called it “being scared to death.” Neuroleptic medications are prescribed for persons with a history of schizophrenia and other such mental conditions and disorders. Activities that trigger the onset of problems are agitation, dehydration and/or a rapid increase in ones dosage. Officers should be on the lookout for muscle rigidity and Hyperthermia as well as any two of the following: difficulty swallowing, tachycardia, hypertension, fluctuation in the person’s blood pressure, tremors, mutism, an inability to control body functions and changes in the level of consciousness.

The third condition also involves cocaine and results from abuse and toxicity of the drug. The use of cocaine predisposes the heart to faulty and improper rhythms, known as dysrrythmias. The above examples are extreme but deal accurately with the deleterious effects of cocaine. Officers must be cognoscente of the subtle effects that take place because of cocaine ingestion such as elevated heart rate, blood pressure and temperature.

Lastly, and more commonly known, is Positional Asphyxia. To understand what takes place and results in positional asphyxia, one must be clear on the how the body functions and reacts. As we breathe an exchange of gases takes place. Carbon dioxide (CO2) must be removed at the cellular level and replaced by oxygen (O2). When the levels of CO2 increase in a person’s body a condition called asphyxia develops. The body requires O2 in order to function and survive. When the cells are deprived of oxygen death will occur unless aggressive and timely intervention takes place.

Training
Departments must include initial and recurring training of its officers in the area of SICDS. Each and every officer must understand that persons on drugs (including alcohol) who are also overweight or have large bellies are at risk for SICDS. If the individual resists arrest and a struggle ensues, the heart and breathing rate of all parties will increase rapidly. For those who’s bodies are in shape (physically in good condition because of an exercise program) this won’t be a problem. On the other hand, the person being arrested is likely not in good physical condition. When they’re heart and breathing rate increase their body isn’t prepared to conduct an efficient and effective gas exchange (CO2 for O2), which results in poor tissue perfusion. When their breathing ability is further restricted by officers placing them on the ground and using their weight to hold them down while they handcuff him, the subject can’t get enough air into his lungs because his chest cannot expand as it should. The technique of “Hogtying” exacerbates the breathing difficulties resulting in subjects expiring because of acute hypoxia and subsequent heart failure.

Officers must be able to recognize the signs and symptoms of persons at risk for SICDS. According to the Mace Security International’s “SICDS Training Manual,” there are 25 signs and symptoms. Each of these has a point value. Officers are trained to recognize these signs and symptoms as well as the scoring method. A score of 0-5 means the subject is at a low risk but should be watched for signs of stress. A score 5-10 means the person is at a moderate risk, should be re-evaluated by another officer familiar with the SICDS scoring system and monitored. A score of 10-16 places the person at high risk for SICDS, should be evaluated by EMS personnel and closely monitored. The last score level is 16 or above. Any score in this range and the person is considered to be at extreme risk for SICDS. The subject must be closely monitored and immediately evaluated by EMS personnel.

Liability
Even if officers are given initial and recurring training in SICDS the potential for liability is still present. In one case involving litigation officers responded to the residence of a white male, approximately 40 years of age, around 6 feet tall, weighing about 240 pounds. The officers were dispatch to a disturbance call made by the male subjects wife. The officers found the male acting in a bizarre manner. He was hallucinating and claimed his children were in trouble. The wife stated she was tired of him acting in this manner. Officers placed the male under arrest, which immediately resulted in a struggle. In total five officers were involved at the residence. By their own account the officers described the male to have abnormal strength, be suffering from paranoia and under the influence of some drug. The male was aggressive towards the officers shouting that ‘the police are trying to shoot me,” and “these aren’t the real police.” At one point in the yard the male began to have difficulty breathing and became cyanotic. EMS was summoned, but later cancelled when the subject began to breath normally again. The subject continued to fight and struggle against the officers, even after arriving at the police department. After getting his personal affects, belt and shoes the subject was placed in a cell. In the cell the male lay on his side and would not sit up when instructed to do so by the senior officer. Upon inspection of the subject it was discovered he wasn’t breathing. CPR was begun and EMS summoned. The male was pronounced dead later at the local hospital.

So you ask, where is the liability here? The officers were acting under color of law in their response to the residence, placing the subject under arrest and in their efforts to subdue and maintain control of him. This is all true, however, they failed to recognize the risk factors present that placed the subject at “extreme risk” for SICDS. The male’s behavior, actions, size and drug use gave him a SICDS score somewhere between 25 and 32. Additionally, what expertise did the officer in charge at the scene have to evaluate the subject’s condition medically and decide it was OK to cancel the EMS response? They can’t plead ignorance because the department began training in SICDS in 1996, several years prior. Is this a “catch 22?”

Summary
What must a department do in order to lessen the potential for being sued in cases involving SICDS? How much training is enough? These are questions that are being asked more frequently. No matter how much training a department provides, if officers don’t utilized what they’ve learned it’s to no avail. It’s safer to have EMS respond if there are concerns about a subjects condition than to second guess who is or isn’t OK. In the long run it’s cheaper to have medical personnel evaluate persons in custody than to assume the person is all right. How do you want your personnel to respond? What if you don’t train your people? You know the potential outcomes (positively and negatively) with training. Failure to train can lead to the establishment of “customs and practices” (written or not), and a finding of “deliberate indifference” in civil proceedings and adjudication by a jury costing the city millions.