‘Excited Delirium’: The Medical Debate Lurking Behind Chauvin Trial

Debate over excited delirium syndrome has raged in medical circles since George Floyd’s death last year. Major medical organizations don’t recognize it, but the emergency physicians and pathologists who see the most cases say it’s real.

In this image from body cam video, Minneapolis police officers attempt to remove George Floyd from a vehicle on May 25, 2020. (Court TV via AP, Pool)

MINNEAPOLIS (CN) — “I just worry about the excited delirium or whatever,” Minneapolis police officer Thomas Lane told his co-worker Derek Chauvin on May 25, 2020. Both officers were kneeling atop George Floyd at the time, and Lane was asking if the Black man should be rolled on his side. 

In Chauvin’s ongoing murder trial for Floyd’s death, that phrase has come up as one of many causes of death suggested by defense attorney Eric Nelson. Three different witnesses testified on excited delirium in Chauvin’s murder trial — a police officer, the emergency doctor who attempted to resuscitate Floyd in the hospital and the in-house surgeon for the Louisville Metro Police Department. Both of the doctors ruled out the possibility that Floyd suffered from the condition. The officer didn’t opine, but said she would defer to an emergency doctor’s judgment. 

The condition isn’t part of Nelson’s chief theory of Floyd’s death. In opening statements, he put forward the idea that Floyd died of a cardiac arrhythmia, brought on by a combination of drug intoxication, high blood pressure, coronary disease and an adrenaline-secreting tumor. In his efforts to sow doubt in the prosecution’s arguments, however, Nelson jumped on the first mention of excited delirium. He called MPD Medical Support Coordinator Nicole Mackenzie back to testify for the defense after she mentioned the department’s excited delirium training in cross examination. 

These lines of questioning have drawn attention to an ongoing debate over the condition in the medical community. Excited delirium syndrome, commonly abbreviated as ExDS, is recognized by the American College of Emergency Physicians and the National Association of Medical Examiners, but not by the American Medical Association, American Psychiatric Association or the World Health Organization.

Critics argue that it’s a diagnosis of convenience, used to get police officers off the hook for dangerous conduct or to justify sedating subjects with ketamine or other drugs. In 2019, police and paramedics in Aurora, Colorado, dosed 23-year-old Elijah McClain with ketamine on suspicion that he was suffering from the syndrome. He died a few days later. McClain and Floyd’s deaths are the highest-profile among a series of incidents attributed to the syndrome. 

Drs. Joshua Budhu, Méabh O’Hare and Altaaf Saadi denounced the frequent diagnoses of police brutality victims with ExDS in August in an opinion piece for the Brookings Institution. “The diagnosis is a misappropriation of medical terminology, used by law enforcement to legitimize police brutality and to retroactively explain certain deaths occurring in police custody,” they wrote. 

Budhu was still blunter in an interview.

“Excited delirium doesn’t exist. It’s a fictional construct that was devised in the 1980s,” he said. He also noted that the diagnosis was applied to about 10% of America’s deaths in police custody, and argued that the symptoms and warning signs attributed to the condition play on racist stereotypes. 

The phrase “excited delirium” was indeed coined in 1985 by pathologist Charles Wetli and psychiatrist David Fishbain in a paper titled “Cocaine-induced Psychosis and Sudden Death in Recreational Cocaine Users.” They studied the cases of seven patients with high cocaine toxicity, five of whom died in police custody, and used the phrase to describe their condition.

In 2009, a task force for the American College of Emergency Physicians published a white paper on the subject. Led by Dr. Mark DeBard, then a professor of emergency medicine at Ohio State University’s College of Medicine, the task force formalized the name excited delirium syndrome, ExDS for short, and began to formalize a list of warning signs for the syndrome. It included a heightened pain tolerance; rapid breathing; sweating; agitation; hyperthermia, or excessive heat; noncompliance with police; unusual strength, referred to by Mackenzie and Dr. Bill Smock, the Louisville police surgeon, as “superhuman strength;” a lack of tiring; inappropriate clothing for the circumstances; and, in a small fraction of cases, an attraction to glass or mirrors. They cited stimulant use as a major contributing factor, and noted that most subjects were men with an average age of 36. 

They also traced the phenomenon back to an earlier observation by Luther Bell, a co-founder of the APA who served as superintendent of the McLean Asylum in Massachusetts in the mid-19th century. Bell identified cases, the commission wrote, that similarly featured delirium and had a 75% mortality rate. 

DeBard stood by the task force’s findings in an email, but said he wasn’t thrilled with its use by police. 

“Excited delirium syndrome was recognized in 2009 by the American College of Emergency Physicians and the National Association of Medical Examiners, the only two medical specialties that actually see such patients,” he said. “Law enforcement has had 12 years to teach its officers about this medical condition and how to respond to it via proper protocols.” 

“Unfortunately, it has occasionally been used by law enforcement to justify deaths in persons undergoing restraint by officers,” DeBard continued. “This is not, and has not been for some years, an excuse for these deaths; indeed, it is an indictment of law enforcement procedures that continue to allow these needless deaths to occur.”

Continued study of the syndrome, however, has yielded ambiguous results. In 2017, a collection of emergency physicians at the Lausanne University Hospital in Switzerland performed a literature review of work on the topic, and found that while “our results suggest that ExDS is a real clinical entity that still kills people and that has probably specific mechanisms and risk factors,” the “overall quality of studies was poor” and lacked a universally recognized definition. 

“Our study was relatively disappointing on this point, as it shows the lack of information available on the subject,” professor Pierre-Nicolas Carron wrote in a French-language email on the paper he co-authored. “If one starts from the hypothesis that this type of extremely agitated presentation exists, as the practices of the American urgent-care doctors of the ACEP seem to confirm, the mechanisms, causes, frequency and measures of prevention and treatment are still poorly understood.”

Budhu argued that the condition has been flawed from the start. Wetli, he said, went on to attribute the deaths of 32 Floridians to excited delirium in the 1980s and early 1990s who were later found to have been murdered by a serial killer, and Bell’s earlier observations took place over weeks, not hours. The symptoms, too, he said, are related to ongoing racism in the medical profession.

“It’s an unfortunate part of medicine —there’s a racial stereotype that Blacks experience less pain than whites,” Budhu said. “Physicians, as well as other types of medical professionals, undervalue their pain, and undertreat it as well.”

He added that “superhuman” strength, as Mackenzie and Smock put it, was also rooted in longtime racist stereotypes. 

“The whole concept of a syndrome that affects young Black men, that happens when they interact with police, that makes them dangerous and impervious to pain, and that inevitably results in their death — really, it’s farcical,” Budhu said.

A neurologist by specialty, Budhu called for a more aggressive effort by the medical profession to discredit the syndrome. 

“We need to do a better job of condemning this,” he said. “From our standpoint, it’s not controversial, it just doesn’t exist. And I think we need medical and professional societies to come out and say that.”

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