‘Excited delirium’ as a cause of death

On a sweltering afternoon last June, police in Salinas responded to a 911 call about a suspicious man running aimlessly through downtown traffic, acting erratically and complaining of chest pain. The officers tried several times to calm the man, a 41-year-old local resident named Gregory Patton. When that didn’t work, they caught him, forced him to the ground and tried to bind his hands and feet together, a law enforcement restraint technique known as hogtying.

According to the police report, Patton struggled for several minutes -- and continued to complain of chest pain. The police called for paramedics, but before they arrived Patton stopped breathing. He was pronounced dead not long after arriving at a hospital.

Patton’s family and civil rights groups immediately questioned whether excessive police force contributed to Patton’s death. But according to the medical examiner, the cause was a controversial and largely unknown medical condition called excited delirium.

Although it’s considered rare, medical examiners around the country are now using excited delirium to explain a significant number of in-custody deaths. Indeed, although no one tracks the number of suspected cases -- nor are there any public records on the number of people who die in police custody -- researchers suspect that the condition accounts for a half-dozen deaths in most major cities each year. By some estimates, excited delirium is now being ruled as the reason behind the majority off all in-custody deaths.

The Patton case was the second time in nine months that an in-custody death in Salinas -- a city of 150,000 people -- was attributed to the condition.

“This is happening every day,� says Dr. Steven Karch, a cardiac pathologist and assistant medical examiner in San Francisco. “Every time you hear of a man acting crazy and running naked in the middle of the street or someone on drugs comes into the emergency room with six police officers on their arms, it’s excited delirium.�

It’s a trend that worries police watchdogs and civil rights groups such as the National Assn. for the Advancement of Colored People and the American Civil Liberties Union. They fear that the condition is being exploited and used as a medical scapegoat for police abuse. Some point out that most medical associations don’t recognize it. “We’ve never heard of it,� says a spokesman for the American Medical Assn.

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A defense in civil lawsuits

Already, the syndrome is being used as a defense in several civil lawsuits against police filed by families of those who’ve died in custody. That includes two civil cases in the last three years against the Los Angeles County Sheriff’s Department over the deaths of suspects who had been restrained by officers. The outcomes were mixed.

“This is a smokescreen. I’ve never seen any proof that someone can be excited to death, and that’s essentially what they are saying,� says Van Jones, executive director of the San Francisco-based Ella Baker Center for Human Rights.

According to neurologists and medical examiners who have researched the issue, excited delirium is an often-fatal condition that can occur in a small subset of people who use drugs, mostly stimulants like cocaine or methamphetamines, over a long period of time. Typically, as users continue to take the drugs, the number of drug receptors in the brain rises, which helps pump dopamine and other excess hormones out of the brain.

But in people at risk of excited delirium, there is a genetic fault that impairs the brain’s ability to increase those receptors, they say. After drug use, that can lead to a dangerously high level of hormones in a part of the brain known as the amygdala, which later can bring on delirium, paranoia and aggression. More often than not, that attracts the police.

In such instances, even a minimal struggle can lead to too much pressure on the heart or lungs and the person can die. Another problem: Long-term stimulant use can enlarge and weaken the heart, which can be overtaxed during a big adrenaline rush. “It’s a very dangerous toxic mix of events,� says Karch.

The condition is starting also to be diagnosed outside of law enforcement. Two years ago, the death of a 16-year-old mentally disabled girl who died while being restrained at school was attributed to the condition, according to the medical report, as have been a number of cases involving suspected shoplifters and store security guards. It was also blamed for the death of Darrell Porter last summer, the MVP of the 1982 World Series, who died after a car accident and was later found to have cocaine in his system. Still, there are almost no studies on cases outside of law enforcement. So for now, the focus remains on the police.

Researchers and doctors who recognize the condition say it isn’t unusual that most major medical associations such as the AMA don’t; they wouldn’t come across it, they say. The National Assn. of Medical Examiners has recognized it for more than a decade.

In the 1960s, psychiatrists documented cases in patients taking large amounts of antipsychotic medications who suddenly became manic and aggressive and later died, usually after being restrained. (Some suspect antipsychotic medications may have the same effects as stimulants for those susceptible to excited delirium.)

It wasn’t until the 1980s that a link to cocaine was found, and that was by chance. A medical examiner in Miami noticed similarities between several cases of people who died suddenly and had cocaine in their system and what psychiatrists were describing in the patients they said died of excited delirium. The examiner, Dr. Charles Wetli, quickly noticed another link: A large number of the same victims had died while in police custody.

There were other similarities. In most cases, the cause of death was a heart attack or, less frequently, respiratory failure. A more thorough look at police reports showed that several had become agitated or delirious before getting involved in a struggle with police.

Many of the similarities, from the heart attacks to the erratic behavior, coincided with what psychiatrists had noticed in the patients they believed died of excited delirium.

Wetli concluded that what he was seeing was the same thing and began using the condition as a cause of death for in-custody cases in Miami. By the early 1990s, others such as Karch in San Francisco did the same. Now it’s used by medical examiners in most major cities around the country.

Experts suspect the number of cases may be rising, not just the number of diagnoses. One reason: Use of cocaine has climbed as much as 20% in the U.S. since 1990, according to the most recent Department of Health and Human Services’ National Household Survey on Drug Abuse.

Even a small number of cases may have a large significance. In-custody deaths draw enormous media attention and can severely raise tensions between police and the public, who often assume the police are at least partially responsible if only because of their proximity. And if police knew what to look for, it’s possible they could save some victims by getting medical attention more quickly. The Berkeley Police Department now trains its officers to look for excited delirium symptoms and requires them to get immediate medical attention.

Most medical examiners who diagnose the syndrome say it’s hard to know for sure if it has occurred just by doing an autopsy. Much as they do with sudden infant death syndrome, they rely on symptoms and police reports and work backward to the cause. But they do point to a clear and successive set of symptoms in all of the cases.

First, body temperature skyrockets as high as 107 degrees. Not long after, the victim shows signs of delirium and mania, and many talk too fast and uncontrollably for anyone to understand. If they become agitated or involved in a struggle, they may demonstrate unusual strength and often show signs of labored breathing. Many soon suddenly collapse and can die within an hour of first showing signs of dementia. Some victims have just one-fifth the amount of drugs in their system than what’s normally believed to cause an overdose.

Critics are quick to counter that the drugs could easily cause some of these characteristics, such as the agitation and bizarre behavior and speech. And they ask: Wouldn’t the fact that many of these deaths happen during or soon after restraint clearly imply police abuse?

Jones, of the Ella Barker Institute, and others such as the ACLU remain adamant that most in-custody deaths are the result of excessive force and improper restraint techniques, such as hogtying and the use of pepper spray. For years, there has been concern that suspects who are hogtied while face down could die of something called “positional asphyxia.� For that reason, many departments, though not all, have banned the practice.

In its place, more are using pepper spray, but that’s becoming equally controversial. The chemical spray has only been legal for police use in states for about a decade, and some worry its effects are just starting to be known. According to the ACLU, several dozen people in the U.S. have died of allergic reactions to pepper spray since the early 1990s.

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Men more at risk

A 2001 study published in the Journal of Emergency Medicine found there might be some statistically significant patterns to those most at risk for excited delirium. Researchers in Los Angeles studied 18 cases of documented excited delirium that occurred from 1992 to 1998 in the U.S. They found that almost all were men, many were overweight and the average age was 32. (Much like those most likely to be involved in altercations, critics add.) Researchers also noted that the cases were almost evenly divided among whites, Latinos and African Americans.

Most of the studies are admittedly small, and it’s hard to tell how accurately they reflect the larger population. Groups such as the NAACP contend that excited delirium is more often used to explain in-custody deaths in minorities than in whites, a claim that is hard to dispute considering the lack of national data. “This condition reminds me of the argument they gave us 10 years ago about the chokehold. They said black men’s necks were more susceptible to dying in a chokehold, which of course was a lie. This is no different,� says Frank Berry, Western regional director for the NAACP.

Meanwhile, a University of Miami neurologist, Deborah Mash, says she has devised a neurochemical test that can definitively show whether excited delirium occurred. While it’s not required in forensic examinations, medical examiners can send a sample of brain tissue to the university’s brain bank, where lab workers look for signs such as intense overstimulation in the brain’s dopamine receptors. One caveat is that because cocaine and other stimulants often metabolize quickly in the system (faster if the body temperature is high), medical examiners must take the sample in the first 12 hours after death for it to be useful. “We’ve done dozens of these tests so far,� says Mash.

In Salinas, the Pattons and the family of the second person ruled an excited delirium victim have filed a civil complaint and a lawsuit against the Police Department and the officers involved. While the litigation is pending, police won’t comment on the cases. But the department did recently announce a change in some of their restraint procedures. The major change: They’ve banned hogtying.