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					   THE



INSIDE
      EXCITEMENT
   Understanding excited delirium and best
   practices for law enforcement response



   O
   /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-
                                             delirium?                                           tiny.
                                             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




                                                                                                                                    IS IT
              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




                                                                                                                               THE TASER?
              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-




                                                                                                                         T
                  “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

				
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