21-12 - Integrated Medical Interventions

The purpose of this newsletter is to inform Department personnel they may request paramedics to employ an Integrated Medical Intervention (IMI) for patients exhibiting erratic, combative, self­ destructive, and sometimes bizarre behavior.

BACKGROUND

In the course of our work, Department personnel may encounter people who are exhibiting erratic, combative, self-destructive, and sometimes bizarre behavior that may be the result of many factors including but not limited to: mental health issues, substance abuse, brain injury, physiological imbalance, or uncontrolled emotional states.

These events can lead to serious physical injuries for the affected person and sometimes death. When Department members are required to interact with individuals exhibiting the above-mentioned behaviors or actions, force is often unavoidable. This can result in injuries to Department personnel, injury to the individual, civil claims, and a negative public image for the Department.

Paramedics in Los Angeles County have the ability to administer therapeutic medical interventions (Midazolam/Versed) to calm subjects who exhibit the described behaviors and meet certain criteria. These interventions allow for safer interactions with the subject. These therapeutic medical interventions are most often administered to the subject by injection through the use of a hypodermic syringe into a large muscle group.

Generally, subjects who are candidates for IMI must be exhibiting two or more of the following symptoms: profuse sweating, combativeness/aggressiveness, increased body temperature, confusion, or rapid heart rate.

Paramedics have the ultimate authority over the use of IMI. Department personnel do not have the authority to override a paramedic regarding the use or non-use of IMI.

Paramedics are responsible for determining the need for and administering of an IMI injection. Patient care and monitoring following IMI administration is also the responsibility of Paramedics in coordination with their base hospital. Department personnel may need to maintain control of the subject for a short time after an IMI injection to allow it to take effect.

NOTE: County of Los Angeles Department of Health Services treatment Protocol No. 1208 outlines a paramedic's procedure for evaluating and treating individuals who are exhibiting erratic, combative, self-destructive, and sometimes bizarre behavior that may be the result of many factors including but not limited to: mental health issues, substance abuse, brain injury, physiological imbalance, or uncontrolled emotional states.

If required, Department personnel will be responsible for controlling/restraining the subject who is to receive IMI and protecting themselves as well as others at the scene.

The use of a hypodermic needle on an agitated person who is in very close proximity to others is inherently dangerous. Department personnel should follow the Department's use of force guidelines to safely use the minimum amount of force reasonably necessary to control a person prior to injection.

Department members should attempt to restrain and control a person in such a way as to allow paramedics clear access to one of the major muscle groups (shoulder, buttocks, or upper leg) to safely inject the patient. In addition, the patient's airway and ability to breathe shall not be hindered.

IMI may not work on all people. Department personnel should be prepared to maintain control of a subject until the IMI injection takes effect. A subject who is experiencing the effects of IMI may become calm, passive, and provide little or no resistance. They may be unconscious or appear sleepy. If this occurs, Department members should coordinate with paramedics to safely transition the person to a gurney, determine the safest body position for that person, and the appropriate restraints to secure the person.

Unless otherwise instructed by a higher medical authority on scene, an unconscious person should be placed on their side (left is preferable) and their airway and vital signs (pulse and breathing) shall be monitored. Appropriate lifesaving steps shall be taken if required.

All Department force reporting policies and procedures apply (rescue force, medical assistance force, team take down, etc.). Paramedics are considered Medical Staff for the purpose of adhering to Department policy concerning the use of rescue or medical assistance force.

Department personnel shall note the use and results of IMI in their documentation of the incident. When documenting these incidents, personnel are advised to document the subject's observable symptoms, actions, and your observations. Personnel should avoid trying to identify any specific condition. Failed attempts, paramedic denials, and lack of availability of requested IMI should also be noted. Additionally, to assist the Department in tracking the use of an IMI, Department Personnel should use stat code 789 to clear an incident where an IMI was utilized.

NOTE: On October 8, 2023, the Governor signed Assembly Bill 360, which will add sections 24400 and 24402 to the Health and Safety Code. Section 24402 states: "Peace Officers shall not use the term excited delirium to describe an individual in an incident report completed by a peace officer." Section 24400 of the Health and Safety Code states "Excited delirium also includes excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania." Due to this new law personnel shall not use any of these terms in Department reports.

If you have any questions, please call or email Field Operations Support Services at[REDACTED TEXT]

REFERENCES

MPP 3-01/110.23 - Handcuffing Prisoners

MPP 3-10/004.00 - Use of Force Terms Defined