Republished with permission from Police and Security News
In October 2010, Adam Greene was forcefully pulled from his car by peace officers from the Henderson, Nevada, Police Department and the Nevada Highway Patrol (NHP), then battered and kicked for allegedly resisting the officers. A NHP dashcam video captured Mr. Greene’s forceful removal from his vehicle and the applied use. Mr. Greene was thought to be driving under the influence. Shortly after Mr.Greene was placed onto the roadway, officers suspected he was not driving under the influence, but was instead suffering from a diabetic emergency (which caused him to appear intoxicated) and reportedly to be losing consciousness. Many officers and administrators have read or heard about the widely reported $292,000 settlement of Mr. Greene’s civil lawsuit in early 2012.
The goals of this article are to explain diabetes, identify behavioral cues, suggest action steps, and to also communicate how to obtain a complimentary video or DVD and a free poster which can be used as a training aid to help educate about this serious, life threatening medical emergency.
Diabetes Insipidus and Mellitus
There are two broad categories of diabetes: diabetes insipidus and diabetes mellitus. Diabetes insipidus, although rare, causes frequent urination and can dehydrate a person very quickly. Because an individual is urinating frequently, (s)he may experience sleep interruptions, become quickly dehydrated, irritable, listless, vomit, have a fever, or have diarrhea. During an excited delirium instructor training class at a Southern California sheriff’s academy, a female deputy shared how a relative who was diagnosed with diabetes insipidus would go into an altered mental state, develop incredible strength, and destroy things around her. The deputy said that it would often take six or more people to capture, control, and/or restrain her during these medical episodes. Although diabetes insipidus shares many common behavioral cues with diabetes mellitus, it can be caused by damage to the pituitary gland, head injuries, neurosurgery, or genetic disorders. There are also four types of diabetes insipidus: central diabetes insipidus; nephrogenic diabetes insipidus; dipsogenic diabetes insipidus; and, gestational diabetes insipidus.
Central diabetes insipidus can be caused by damage to the pituitary gland, head injuries, neurosurgery, or genetic disorders. The pituitary gland stores a hormone made in the hypothalamus of the brain called AntiDiuretic Hormone (ADH), or vasopressin. ADH is released into the person’s bloodstream via the pituitary gland when needed and basically instructs the kidneys. Diabetes insipidus can develop when there is a disruption in this system. Generally, a synthetic hormone, desmopressin, is given to the patient via injection, nasal spray, or pill which will prevent the individual from urinating frequently.
Nephrogenic diabetes insipidus focuses on the kidneys’ inability to respond to ADH. Although this impairment may not have an identifiable cause, identified causes include, but are not limited to: drugs (e.g., lithium), sickle-cell disease, polycystic kidney disease, kidney failure, and inherited genetic disorders. Desmopressin which may be prescribed for central diabetes insipidus will not work on this form of diabetes insipidus.
When a person’s thirst mechanism is damaged or has a defect, this often results in an abnormal increase in thirst and fluid intake which will often increase urine output. This “fluid overload” can lead to water intoxication which can cause brain damage in the person because of a lowering of sodium in the blood. This form of diabetes is known as dipsogenic diabetes insipidus.
The fourth type of diabetes insipidus is called gestational diabetes insipidus and only occurs during pregnancy. The placenta makes an enzyme which destroys ADH in the mother.
Diabetes Mellitus
Most of us are familiar with diabetes mellitus, commonly referred to as Type I and Type II. Both types of diabetes mellitus are associated with high levels of glucose (sugar) in the blood. Type I diabetes mellitus is often called “insulin dependent” and is often diagnosed in children, but can also be diagnosed in people over the age of 20. In short, the person’s body fails to make insulin, or makes too little insulin which requires that they take daily injections of insulin.
Type II diabetes mellitus is more common and usually occurs in adults. However, it is hard to pick up a newspaper, magazine, or watch a television broadcast where writers and newscasters are not discussing the epidemic of Type II diabetes in people living in the United States. Over 20 million Americans are affected by diabetes; approximately 40 million more Americans have early Type II diabetes. In Type II diabetes, the pancreas fails to make enough insulin to maintain normal glucose levels. Associated risk factors include, but are not limited to: obesity (Body Mass Index [BMI] greater than 25); lack of exercise; heart disease; high blood cholesterol levels; age 45 or older; and having a sibling or parent with diabetes.
Manic-Depressives and Diabetes
Manic-depressive people are also more likely to have diabetes because of the newer psychotropic medications they are taking. A 1999 study conducted at Duke University estimated that individuals who have been diagnosed with bipolar disorder may be three times more likely to have diabetes than the general population. Investigators found that ten percent of the hospitalized patients in the study were found to have diabetes.
Symptoms and Warning Signs of Type I and Type II Diabetes
Symptoms of Type I diabetes include, but are not limited to: fatigue; increased thirst; frequent urination; nausea; vomiting; increased appetite; weight loss (even with the increase in appetite).
Symptoms of Type II diabetes include, but are not limited to: increased urination; increased thirst; increased appetite; fatigue; blurred vision.
Hypoglycemia and Hyperglycemia Warning Signs
There are several warning signs law enforcement officers must be able to recognize so they can take appropriate actions steps. Remember, a person who is experiencing a diabetic event may appear to be intoxicated or under the influence of drugs. The person will often be noncooperative. Here are several warnings signs which will require action for individuals who are in a state of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar):
Hypoglycemia – sweating; shakiness; anxiety; confusion; difficulty speaking; uncooperative behavior; paleness; irritability; dizziness; inability to swallow; seizure; and/or loss of consciousness. Hyperglycemia – flushed skin; labored breathing; confusion; cramps; weakness; sweet breath; nausea; and/or loss of consciousness.
Remember that, in addition to these “warning signs,” the individual may also be showing additional symptoms of Type I and Type II diabetes which were previously discussed.
Situational Action Steps • Remember: This is first and foremost a MEDICAL EMERGENCY;
• Ask the person or someone who knows him or her if (s)he is a diabetic;
• Ask the person or someone who knows him or her if (s)he needs medication or sugar;
• Check for a medical identification (e.g., bracelet, necklace, or card), but remember that many people may not wear or have such identification;
• Request Emergency Medical Services (EMS) to either stage nearby if the person is not under control, or to immediately treat the patient if (s)he is under control;
• Try to contain the person;
• Try to have the person sit and relax;
• Speak calmly to the person;
• If necessary, carefully capture the person based upon agency training, directives, and force options;
• Next, control the patient (e.g., possibly using an escort hold);
• Only if necessary, temporarily restrain the patient (extended use of metallic restraints may cause infection in people with diabetes which in rare cases has resulted in amputation of the affected area);
• Immediately provide the hypoglycemic patient (low blood sugar) with sugar (candy bar, sugared soft drink; juice; food) if (s)he requests it or if it becomes known that (s)he needs sugar intervention;
• Immediately have EMS or a qualified medical professional provide the hyperglycemic patient (high blood sugar) with medication to lower his or her blood sugar levels.
• Transport by ambulance (preferable) or patrol car (only if no ambulance is available) to a hospital; and
• Only take a detained (e.g., involuntary hold) or an arrested person to a jail or a prison where (s)he will have immediate access to health care professionals who can help to manage the person’s diabetes. Remember: Experiencing a diabetic event is a medical emergency and not a crime.
Training Materials
The situational action steps may be used when the person you are confronting shows the behavioral cues and/or symptoms of someone experiencing a diabetic event. Knowing these situational action steps often is a result of in-service training programs which are provided by your agency or by outside training firms. Training programs must contain a section about the Americans with Disabilities Act (ADA) because, many times, a severe or “brittle” diabetic will qualify as being disabled under the ADA. Also, make sure this information is contained in lesson plans (e.g., defensive tactics, restraint, transport, etc.).
The American Diabetes Association offers a complimentary video or DVD, Treating Diabetes Emergencies: What Police Officers Need to Know and also a free poster, “Diabetes is serious. It can be life threatening.” To order, please call (800)232-6733 or E-mail: ADAOrders@phd.com. A copy of this video has also been posted to YouTube.
Summary
Even with continuous training programs which focus on diabetic events, law enforcement officers may unintentionally “misread” a person. However, it is important to view individuals who are in an altered state of mind as being in a medical emergency. DO NOT assume the person to whom you are speaking is “drunk,” “high on drugs,” or in a state of excited delirium. The individual may be experiencing a diabetic event which is a medical emergency. If possible, ask the person or someone who knows the person if (s)he is a diabetic. Think back to your police academy recruit training when the instructor cautioned everyone about assuming the person you are about to stop for suspected impaired driving might be having a diabetic event. After all, no one wants to live through an Adam Greene traffic stop and lawsuit.
About the Authors:
John G. Peters, Jr., Ph.D., CLS, is President and Chief Learning Officer of the internationally recognized training firm, Institute for the Prevention of In-Custody Deaths, Inc. A former law enforcement administrator and officer, Dr. Peters is often called upon to provide consulting, training, public speaking, and expert witness services. An Americans for Effective Law Enforcement (AELE) Certified Litigation Specialist in police, correctional, and campus law enforcement liability, he is also Adjunct Faculty, University of Phoenix. For training dates, information, and course locations about diabetes and similar events (e.g. excited delirium), please visit IPICD.
A. David Berman, M.S., CLS, is Vice President of the Henderson, Nevada-based Institute for the Prevention of In-Custody Deaths, Inc. and did the literature review for this article. A former law enforcement officer and police academy defensive tactics instructor, David holds a Master of Science degree in criminal justice, and is also a Certified Litigation Specialist in police and campus law enforcement liability.
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In October 2010, Adam Greene was forcefully pulled from his car by peace officers from the Henderson, Nevada, Police Department and the Nevada Highway Patrol (NHP), then battered and kicked for allegedly resisting the officers. A NHP dashcam video captured Mr. Greene’s forceful removal from his vehicle and the applied use. Mr. Greene was thought to be driving under the influence. Shortly after Mr.Greene was placed onto the roadway, officers suspected he was not driving under the influence, but was instead suffering from a diabetic emergency (which caused him to appear intoxicated) and reportedly to be losing consciousness. Many officers and administrators have read or heard about the widely reported $292,000 settlement of Mr. Greene’s civil lawsuit in early 2012.
The goals of this article are to explain diabetes, identify behavioral cues, suggest action steps, and to also communicate how to obtain a complimentary video or DVD and a free poster which can be used as a training aid to help educate about this serious, life threatening medical emergency.
Diabetes Insipidus and Mellitus
There are two broad categories of diabetes: diabetes insipidus and diabetes mellitus. Diabetes insipidus, although rare, causes frequent urination and can dehydrate a person very quickly. Because an individual is urinating frequently, (s)he may experience sleep interruptions, become quickly dehydrated, irritable, listless, vomit, have a fever, or have diarrhea. During an excited delirium instructor training class at a Southern California sheriff’s academy, a female deputy shared how a relative who was diagnosed with diabetes insipidus would go into an altered mental state, develop incredible strength, and destroy things around her. The deputy said that it would often take six or more people to capture, control, and/or restrain her during these medical episodes. Although diabetes insipidus shares many common behavioral cues with diabetes mellitus, it can be caused by damage to the pituitary gland, head injuries, neurosurgery, or genetic disorders. There are also four types of diabetes insipidus: central diabetes insipidus; nephrogenic diabetes insipidus; dipsogenic diabetes insipidus; and, gestational diabetes insipidus.
Central diabetes insipidus can be caused by damage to the pituitary gland, head injuries, neurosurgery, or genetic disorders. The pituitary gland stores a hormone made in the hypothalamus of the brain called AntiDiuretic Hormone (ADH), or vasopressin. ADH is released into the person’s bloodstream via the pituitary gland when needed and basically instructs the kidneys. Diabetes insipidus can develop when there is a disruption in this system. Generally, a synthetic hormone, desmopressin, is given to the patient via injection, nasal spray, or pill which will prevent the individual from urinating frequently.
Nephrogenic diabetes insipidus focuses on the kidneys’ inability to respond to ADH. Although this impairment may not have an identifiable cause, identified causes include, but are not limited to: drugs (e.g., lithium), sickle-cell disease, polycystic kidney disease, kidney failure, and inherited genetic disorders. Desmopressin which may be prescribed for central diabetes insipidus will not work on this form of diabetes insipidus.
When a person’s thirst mechanism is damaged or has a defect, this often results in an abnormal increase in thirst and fluid intake which will often increase urine output. This “fluid overload” can lead to water intoxication which can cause brain damage in the person because of a lowering of sodium in the blood. This form of diabetes is known as dipsogenic diabetes insipidus.
The fourth type of diabetes insipidus is called gestational diabetes insipidus and only occurs during pregnancy. The placenta makes an enzyme which destroys ADH in the mother.
Diabetes Mellitus
Most of us are familiar with diabetes mellitus, commonly referred to as Type I and Type II. Both types of diabetes mellitus are associated with high levels of glucose (sugar) in the blood. Type I diabetes mellitus is often called “insulin dependent” and is often diagnosed in children, but can also be diagnosed in people over the age of 20. In short, the person’s body fails to make insulin, or makes too little insulin which requires that they take daily injections of insulin.
Type II diabetes mellitus is more common and usually occurs in adults. However, it is hard to pick up a newspaper, magazine, or watch a television broadcast where writers and newscasters are not discussing the epidemic of Type II diabetes in people living in the United States. Over 20 million Americans are affected by diabetes; approximately 40 million more Americans have early Type II diabetes. In Type II diabetes, the pancreas fails to make enough insulin to maintain normal glucose levels. Associated risk factors include, but are not limited to: obesity (Body Mass Index [BMI] greater than 25); lack of exercise; heart disease; high blood cholesterol levels; age 45 or older; and having a sibling or parent with diabetes.
Manic-Depressives and Diabetes
Manic-depressive people are also more likely to have diabetes because of the newer psychotropic medications they are taking. A 1999 study conducted at Duke University estimated that individuals who have been diagnosed with bipolar disorder may be three times more likely to have diabetes than the general population. Investigators found that ten percent of the hospitalized patients in the study were found to have diabetes.
Symptoms and Warning Signs of Type I and Type II Diabetes
Symptoms of Type I diabetes include, but are not limited to: fatigue; increased thirst; frequent urination; nausea; vomiting; increased appetite; weight loss (even with the increase in appetite).
Symptoms of Type II diabetes include, but are not limited to: increased urination; increased thirst; increased appetite; fatigue; blurred vision.
Hypoglycemia and Hyperglycemia Warning Signs
There are several warning signs law enforcement officers must be able to recognize so they can take appropriate actions steps. Remember, a person who is experiencing a diabetic event may appear to be intoxicated or under the influence of drugs. The person will often be noncooperative. Here are several warnings signs which will require action for individuals who are in a state of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar):
Hypoglycemia – sweating; shakiness; anxiety; confusion; difficulty speaking; uncooperative behavior; paleness; irritability; dizziness; inability to swallow; seizure; and/or loss of consciousness. Hyperglycemia – flushed skin; labored breathing; confusion; cramps; weakness; sweet breath; nausea; and/or loss of consciousness.
Remember that, in addition to these “warning signs,” the individual may also be showing additional symptoms of Type I and Type II diabetes which were previously discussed.
Situational Action Steps • Remember: This is first and foremost a MEDICAL EMERGENCY;
• Ask the person or someone who knows him or her if (s)he is a diabetic;
• Ask the person or someone who knows him or her if (s)he needs medication or sugar;
• Check for a medical identification (e.g., bracelet, necklace, or card), but remember that many people may not wear or have such identification;
• Request Emergency Medical Services (EMS) to either stage nearby if the person is not under control, or to immediately treat the patient if (s)he is under control;
• Try to contain the person;
• Try to have the person sit and relax;
• Speak calmly to the person;
• If necessary, carefully capture the person based upon agency training, directives, and force options;
• Next, control the patient (e.g., possibly using an escort hold);
• Only if necessary, temporarily restrain the patient (extended use of metallic restraints may cause infection in people with diabetes which in rare cases has resulted in amputation of the affected area);
• Immediately provide the hypoglycemic patient (low blood sugar) with sugar (candy bar, sugared soft drink; juice; food) if (s)he requests it or if it becomes known that (s)he needs sugar intervention;
• Immediately have EMS or a qualified medical professional provide the hyperglycemic patient (high blood sugar) with medication to lower his or her blood sugar levels.
• Transport by ambulance (preferable) or patrol car (only if no ambulance is available) to a hospital; and
• Only take a detained (e.g., involuntary hold) or an arrested person to a jail or a prison where (s)he will have immediate access to health care professionals who can help to manage the person’s diabetes. Remember: Experiencing a diabetic event is a medical emergency and not a crime.
Training Materials
The situational action steps may be used when the person you are confronting shows the behavioral cues and/or symptoms of someone experiencing a diabetic event. Knowing these situational action steps often is a result of in-service training programs which are provided by your agency or by outside training firms. Training programs must contain a section about the Americans with Disabilities Act (ADA) because, many times, a severe or “brittle” diabetic will qualify as being disabled under the ADA. Also, make sure this information is contained in lesson plans (e.g., defensive tactics, restraint, transport, etc.).
The American Diabetes Association offers a complimentary video or DVD, Treating Diabetes Emergencies: What Police Officers Need to Know and also a free poster, “Diabetes is serious. It can be life threatening.” To order, please call (800)232-6733 or E-mail: ADAOrders@phd.com. A copy of this video has also been posted to YouTube.
Summary
Even with continuous training programs which focus on diabetic events, law enforcement officers may unintentionally “misread” a person. However, it is important to view individuals who are in an altered state of mind as being in a medical emergency. DO NOT assume the person to whom you are speaking is “drunk,” “high on drugs,” or in a state of excited delirium. The individual may be experiencing a diabetic event which is a medical emergency. If possible, ask the person or someone who knows the person if (s)he is a diabetic. Think back to your police academy recruit training when the instructor cautioned everyone about assuming the person you are about to stop for suspected impaired driving might be having a diabetic event. After all, no one wants to live through an Adam Greene traffic stop and lawsuit.
About the Authors:
John G. Peters, Jr., Ph.D., CLS, is President and Chief Learning Officer of the internationally recognized training firm, Institute for the Prevention of In-Custody Deaths, Inc. A former law enforcement administrator and officer, Dr. Peters is often called upon to provide consulting, training, public speaking, and expert witness services. An Americans for Effective Law Enforcement (AELE) Certified Litigation Specialist in police, correctional, and campus law enforcement liability, he is also Adjunct Faculty, University of Phoenix. For training dates, information, and course locations about diabetes and similar events (e.g. excited delirium), please visit IPICD.
A. David Berman, M.S., CLS, is Vice President of the Henderson, Nevada-based Institute for the Prevention of In-Custody Deaths, Inc. and did the literature review for this article. A former law enforcement officer and police academy defensive tactics instructor, David holds a Master of Science degree in criminal justice, and is also a Certified Litigation Specialist in police and campus law enforcement liability.
