Understanding excited delirium and best
practices for law enforcement response
/Abbie Darst, Program Coordinator
n Sept. 5, 2006, Louisville Jefferson County medical examiner’s con-
Metro police responded troversial determination that the TASER did
to a downtown distur- not cause Noles death; instead, he died of
bance call just after 1 a.m. excited delirium scenario.
When officers arrived Across the country, officers and medical
on scene, ex-Marine Larry Noles, 52, was professionals are searching for answers about
standing naked in the middle of the street. this highly-controversial diagnosis. Some po-
Exhibiting extremely aggressive behavior, lice critics have insisted that excited delirium
Noles was damaging cars and not responding is nothing more than a convenient concept
to officer efforts to subdue him. One officer manufactured by law enforcement to cover
on the scene fired two TASER darts carrying up brutality and exonerate authorities when
50,000 volts into Noles’ chest. Noles began a suspect dies in custody. Even Noles’ estate
moving toward the officers and was tased attorney said in an interview that excited de-
two more times before falling to the ground, lirium is known in most circles as death by
unconscious. He was taken to the nearest police.
hospital where he was pronounced dead. However, in October 2009, a special in-
Later, Noles attorney said on the night vestigative task force of the American Col-
of his death Noles was off medication and lege of Emergency Physicians formally de-
suffered from Bipolar disorder. It was the clared that the violent and sometimes lethal >>
Spring 2010| KENTUCKY LAW ENFORCEMENT 19
Inside the Excitement Inside the Excitement
phenomenon known as excited delirium is a Unfortunately, those cases in which an
real condition and should be taken seriously. individual’s confrontation with an officer has
resulted in death have brought about intense
So what exactly is excited media coverage and officer and agency scru-
The term excited delirium first was used in “In forensic pathology … when dealing
1849 by Luther Bell to describe psychiatric with what I would refer to as excited delirium
patients who developed an onset of continu- scenario – to raise that as a possibility, what
ous agitation and mania in the presence of we have to have is a good, thorough investiga-
fever, and suddenly died. According to The- tion by law enforcement and a good avenue
resa Di Maio, author of “Excited Delirium of communication between the forensic pa-
Syndrome: Cause of Death and Prevention,” thologist and the law enforcement investiga-
delirium is a mental state characterized by an tors,” said Dr. Tracey Corey, Kentucky’s chief
acute circumstance of disorientation, disor- medical examiner.
ganized thought process and disturbances in An extremely detailed timeline and wit-
speech. When that mental state involves vio- ness statements are two vital pieces of in-
lent behavior, it is called excited delirium. In formation that medical examiners must have
that state, when there is a sudden death and from law enforcement in a potential ED sce-
the autopsy fails to reveal a cause, it is ruled nario case, Corey explained, because it allows
excited delirium syndrome. the medical examiner to determine exactly
The ACEP group recently affirmed that what happened in the situation.
excited delirium, or ED, is a unique syndrome “If there is an in-car camera, we want to
that can be recognized in the field by a distinc- review that film, because what you will find is
tive group of clinical and behavioral charac- that most of the cases where they are initially
teristics. Individuals exhibiting these common reported by the media as ‘TASER related,’
ED characteristics are hyperaggressive with they’re not really TASER related,” Corey said.
bizarre behavior, impervious to pain, combat- “The person continued to function long after
ive and have abnormally high body tempera- the TASER was deployed. So it really was not
tures, usually around 105 degrees Fahrenheit. involved.
Officers are likely to find them tirelessly re-
sistant, sweating, breathing rapidly, agitated, “But for us to be able to make that deter-
unusually strong and inappropriately clothed mination, we have to work closely with law
or nude. The ACEP report also explained that enforcement and law enforcement has to be
remorse, normal fear, understanding of sur- willing to provide us with a lot of informa-
roundings and rational thoughts for safety are tion,” Corey added.
absent in these individuals. However, law enforcement officers should
Individuals suffering from ED pose a realize that the psycho-physiological melt-
daunting challenge to law enforcement of- down of ED is not always fatal, and that given
ficers. The ACEP report acknowledged that the proper collaboration between responding
“officers are in the difficult and sometimes officers and EMS personnel, the condition
impossible position of having to recognize the might be treated before an untimely, unex-
encounter as a medical emergency while at- pected death occurs.
tempting to control an irrational and physi- Since an estimated 250 ED subjects die
cally resistive person and mind the safety of in the United States each year – an estimated
all involved. 8 to 14 percent of those who experience the
“Given the irrational and potentially vio- syndrome – in order for collaboration be-
lent, dangerous and lethal behavior of an ED tween officers and EMS to take place, officers
subject, any law enforcement officer interac- first must be able to assess the signs and symp-
tion … risks significant injury or death to ei- toms of excited delirium very quickly in an
ther the officer or the ED subject,” the report altercation or confrontation.
continued. Published accounts show that typical ED >>
20 KENTUCKY LAW ENFORCEMENT |Spring 2010 Spring 2010| KENTUCKY LAW ENFORCEMENT 21
Inside the Excitement Inside the Excitement
WHAT’S THE DIFFERENCE?
The term excited delirium is a descriptive phrase for an individual exhibiting the disorder and may
result in death and may not. Excited delirium syndrome is only attached when the individual dies and
there is no pathology or injury to explain the death. However, many medical examiners prefer to use
the terminology excited delirium scenario as opposed to syndrome.
Kentucky’s Chief Medical Examiner Tracey Corey described a syndrome as a consolation of physical
ﬁndings and symptoms, and in the case of excited delirium, it is more of a presentation because scene
information and a historical timeline have to be taken into account in addition to the physical ﬁndings.
>> subjects experiencing an episode exhibit signs about excited delirium in June 2009.
of acute drug intoxication and often have a his- Officers should attempt to document the
tory of mental illness such as paranoia. These body temperature of the individual at the
subjects struggle with law enforcement; do scene, because in fatal cases, a significantly
not respond to physical control measures, use
elevated temperature is present. Once in
of pepper spray or electronic control devices;
EMS care, the individual should be cooled as
and suffer a sudden death. In most cases, au-
quickly as possible through either intravenous
topsy fails to reveal a definite cause of death
fluids or spritzing with cool water and blown
from trauma or natural disease.
with a fan, to reduce the risk of death. Other
Cases show a majority of lethal ED sub- suggestions include medication to produce a
jects die shortly after a violent struggle. Many rapid calming effect, oxygen saturation and
already have sustained traumatic injuries be- monitoring and cardiac monitoring.
fore the arrival of law enforcement and still
struggle intensely with officers, the ACEP “At this time there is insufficient data to
report stated. determine whether fatal ED syndrome is pre-
ventable, or whether there is a point of no re-
“Expecting an ED encounter to be resolved turn after which a patient will die regardless /Excerpts taken from July 20, 2009 Force Science News
without a potentially fatal struggle may be of advanced life support intervention,” the
asking the near impossible of responding of- he concept of excited delirium states randomly assigned 60 law enforcement words, only the administration of OC was
ACEP report concluded. frequently appears in literature and civilian volunteers to one of five groups in slightly less stress inducing to the subject than
ficers,” the ACEP task force report said. “Al-
most everything taught to law enforcement In recent years, hundreds of cases of un- about TASERs. Patients with ex- which they: a TASER zap. In addition, tasering generated
officers about control of subjects relies on a expected, in-custody deaths have been docu- cited delirium usually are vio- sprinted 164 yards, simulating flight nearly 3.5 times less adrenaline than the simu-
suspect to either be rational, appropriate or mented and researched, leaving involved law lent and aggressive.They may be from law enforcement officers lated fighting.
to comply with painful stimuli. …Tools and enforcement officers and their agencies mired difficult to subdue and need to be detained for hit and kicked a heavy bag for 45 sec- “The comparison of use-of-force encoun-
tactics (such as pepper spray, impact batons, in media and legal scrutiny. Though research their own safety and the safety of others. It is onds, simulating physical combat with ters demonstrated that the electrical control
joint lock maneuvers, punches and kicks and into excited delirium syndrome, its causes understandable that law enforcement officers officers device was one of the least activating” of stress
[TASERS]) that are traditionally effective in and possible prevention is still very much would rather subdue these individuals with a chemicals, Ho wrote in his study report.
TASER device than in a physical confronta- took a 10-second hit with at TASER X26 “These results … suggest that fighting with
controlling resisting subjects are likely to be ongoing, officers now can be proactive in un-
less effective on ED subjects.” derstanding signs and symptoms of ED and tion. The controversy comes when the use of a endured a K-9 training exercise attack law enforcement officers may be the most
knowing what steps to take to ensure the best TASER is thought to cause the death instead of for 30 seconds detrimental [to subjects] from a physiologic
In situations where officers realize they are
possible outcome. excited delirium syndrome, or that the stress- standpoint.” J
dealing with an ED individual, they should were sprayed in the face with OC spray
related chemicals released as a result of the use
immediately call for EMS and try to contain “All of these cases are going to have to go
of a TASER aggravated the symptoms of ED.
the individual. Officers should try to take the to post mortem examination,” Corey said. The test subjects were predominantly male
individual into custody quickly, safely and ef- “So we’re going to work with the coroner and A study headed by Dr. Jeffrey Ho, a depu- with a median age of 35. There was no sig-
ficiently, if necessary, and then immediately the investigating law enforcement agency, but ty sheriff and emergency medicine specialist nificant difference between the five groups in
turn the care of the individual over to EMS they have to bring a lot … of detailed infor- with the Hennepin County, Minn. Medical terms of stress-chemical levels prior to their
personnel when they arrive. mation to us so that we can put that in the Center turns that premise upside down. At an assigned tasks.
Though there is no specific protocol for context of the overall investigation, includ- international conference in Australia in June The researchers discovered that the high-
Kentucky officers in ED encounters, Dr. Wil- ing what we find on toxicology, what we see 2009, Ho reported that TASER application is est level of stress chemicals was generated by
liam Smock, a professor of emergency medi- grossly, that is with our naked eye at autopsy, one of the weakest stimulants of stress chemi- the heavy bag exercise, which simulated the
cine at the University of Louisville’s Depart- [and] what our microscopic findings are. We cals among sources that are commonly present struggle with officers. After that, in decreasing
ment of Emergency Medicine, made several are going to take a lot of things into account. during a police confrontation. order, came the sprint group, the K-9 group,
protocol suggestions during a presentation These are complicated, complex cases.” J Ho and a team of researchers from four the TASER group and the OC group. In other
22 KENTUCKY LAW ENFORCEMENT |Spring 2010