“I Am Concerned About Excited Delirium….”

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“I am concerned about excited delirium….”

Minneapolis Officer describing George Floyd

The recent release of court documents and body-cam footage surrounding George Floyd’s death predictably thrust Excited Delirium Syndrome (ExD) back into the news.

Following George Floyd’s death, media outlets had already begun to revive the false, anti-police narrative that ExD is nothing more than “pseudo-science,” invented to absolve officers from excessive force. Now, the Brookings Institute, a left-leaning think tank, has attempted to add intellectual firepower to the assault by publishing How “Excited Delirium” is Misused to Justify Police Brutality.

Written by three neurologists, including an Instructor of Neurology at the Harvard Medical School, the article gets straight to the point: ExD “is not recognized by the vast majority of medical professionals,” and is “used by law enforcement to legitimize police brutality.” In a new twist, the authors claim that ExD has “highly racist roots” and has been used in “an inherently racist manner.”

To bolster their position that ExD is an illegitimate medical diagnosis and primarily the product of corrupt and racist police, the authors point to Excited Delirium: A Systematic Review (2017).1 As it turns out, that research article, written by doctors and published in a peer-reviewed medical journal, doesn’t actually support the racist police theory.

It Exists and It Still Kills People

In Systematic Review, the researchers refused to discredit ExD, instead finding: “Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors.” Anticipating allegations of bias, the authors assured readers of their total independence from law enforcement, chemical industries, or weapons manufacturers.

As for evidence of “racist police” using ExD to legitimize police brutality, Systematic Review again provided the Brookings authors no support.

Of the 66 independent studies fully reviewed by the medical researchers, only 9 included the ethnic origins of the ExD patients. Of these 9 studies, only 6 included research from the United States. One U.S. study identified an equal number of black and white patients, two U.S. studies identified a predominance of white patients, and three U.S. studies identified a predominance of black patients.

While the numbers don’t add up to support the racist police narrative, math isn’t the biggest problem facing the Brookings authors. Even among the scant research that identified a predominance of black ExD patients, none were assessing national trends. What’s worse, the Systematic Review didn’t indicate whether police were involved with any of the ExD patients in the referenced studies.

Even assuming the police were present in a percentage of those cases, there is no indication of whether any force was used, or injury sustained. Meaning there is no evidence that officers had a motive to manufacture an ExD diagnosis. Which brings me to my last point, diagnosing ExD is the prerogative of medical professionals, not the police.

The Vast Majority of Medical Professionals

If medical professionals want to debate the usefulness of the ExD diagnosis, I suppose that is a good use of their time. But to claim that ExD “is not recognized by the vast majority of medical professionals” is to ignore the National Association of Medical Examiners (which formally recognized ExD in 2004) and the American College of Emergency Physicians (which formally recognized ExD in 2009).2 Even the American Medical Association recognizes that ExD “is a widely accepted entity in forensic pathology.3

It is frequently argued that ExD is not found in the International Classification of Diseases (ICD-10) and is therefore not relied on by the American Medical Association or the American Psychiatric Association. What is conveniently left out of this argument is that the various conditions that can cause ExD are listed in the ICD-10.

ICD-10 and ExD

Medical professionals do not treat ExD as a unique disease, but rather as a group of symptoms with uncertain and varied causes. These potential causes of ExD can be grouped into five general categories: Metabolic, Neurologic, Psychiatric, Infectious, and Toxicologic. Among these five categories are more than 30 separate conditions believed to cause ExD.4 All 30 of these conditions are listed in the ICD-10.

Because there are a wide variety of conditions that can lead to ExD, emergency medical experts typically focus on the symptoms, which often include delirium, agitation, rapid breathing, accelerated heart rate, overheating, and excessive sweating.

Regardless of the cause, those experiencing ExD may feature bizarre and aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength, high pain tolerance, a period of tranquility, and sudden cardiac arrest.

The varied causes of ExD, the overlap of its symptoms with other conditions, and its rare occurrence are just some of the reasons first responders are not expected to diagnose ExD. Even so, the absence of a specific diagnosis does not negate the seriousness of the behavioral and physical symptoms.

ExD by Any Other Name

Excited delirium symptoms warn of a potentially fatal medical condition. Officers properly trained to recognize ExD are more likely to practice arrest and restraint techniques that mitigate the risk to the patient. They are more likely to have planned, trained, and initiated a cooperative emergency response with dispatchers, emergency medical services, and hospital emergency staff.

If communities choose to send a team of highly trained and equipped medical professionals to supervise the management of ExD in the field, I suspect the police would welcome the assistance. However, critics who attack ExD in an attempt to undermine police credibility and advance a “racist-police” narrative, are risking the exact training officers need to recognize and respond to these life-threatening emergencies.

  1. Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330 []
  2. DeBard ML, Adler J, Bozeman W, Chan T, et al: ACEP Excited Delirium Task Force White Paper Report on Excited Delirium Syndrome, September 10, 2009, last accessed on June 24, 2020, at https://www.prisonlegalnews.org/media/publications/acep_report_on_excited_delirium_syndrome_sept_2009.pdf []
  3. See REPORT 6 OF THE COUNCIL ON SCIENCE AND PUBLIC HEALTH (A-09), Use of Tasers® by Law Enforcement Agencies (Reference Committee D), at https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/Council%20Reports/council-on-science-public-health/a09-csaph-tasers.pdf []
  4. Kasha Bornstein, Tim Montrief, MD, Mehruba Anwar Parris, MD. Excited Delirium: Acute Management in the ED Setting. Emer. Mgmt. Resident. April 8, 2019, last accessed at https://www.emra.org/emresident/article/excited-delirium/ []
14 Responses
  1. R.B.S.

    ED is REAL. I’ve seen it. Other officers have seen it. Medical professionals have treated and seen it. About time someone put out something about how the lamestream media continues to push their anti-cop socialist BS.

  2. Dave

    I wonder if those same authors deny the existence of sudden infant death syndrome (SIDS)? By definition, SIDS is not the result of a particular medical malady, but is used to explain an otherwise unexplainable death of an infant. In comparison, excited delirium seems pretty well defined.

  3. Gerhard

    Yes, very well said – but it doesn’t explain away anything – imho. If you cuff George Floyd, bring him up and then he dies from ExD, Heart Attack or the impact of Starship Enterprise, then it is like so. If you still kneel on his neck – and I don’t think, the take is a fake – then a big room for explanation will exist forever.
    I recall a similar scenery when in Vienna, Austria – a male suspect, also black, also died on whatever you name it – was cuffed, lying face down on the tarmac between curb and wheel of a car and in the relevant video you see a MD(!) standing(!) on the suspects chest and having a relaxed smoke(!) while taking a phone call.
    What I miss in the Officer Training Program is a branch, that helps the Officer to recognize, when he has won (= and that he can stop action). In this sensitive,, high adrenaline, high Angst and extreme stress situation it is hard to stop the high revving machine: it’s clear – this happens with Officers AND suspects and explains some of the incidents. But it does not mean, you must not do anything against it – and on the one, legal, side, you could do it.

    1. Joel

      This article is not trying to excuse any behavior of those officers. It is countering the false premise that ExD is not real and therefore racist.

  4. Stan Neufeld

    I agree and very well said.
    On a related topic, why can’t these incidences and all/99.999% of police contacts with the public are the results of the public’s actions, which led to law enforcement being called to respond? The media will rarely communicate this, if at all. An interesting narrative to suggest to the public/media would be, what if we were to have a “lawful or a compliant society.” Then none of these incidences would ever transpire!

  5. Brian

    On a related subject, “ED doctors opining beyond their knowledge base are not isolated incidents.” This is from Artwohl’s book, Deadly Force Encounters (p. 124), where she reports a medical journal finding as:
    97.8% of ER doctors said they had treated patients whom they suspect were victims of excessive force.
    65% said they recognized two or more case of excessive force a year.
    7% said they believe excessive force often occurs or very often.
    “The data these doctors used to make this determination? Believe it not, the suspects themselves!”
    Artwohl goes on to reference Lewinski (Remsberg, 2009a) of the FSI who points out the absurdity of the doctor’s claims.

  6. D.S

    It’s very real, and a real problem for law enforcement. Medics, who are needed urgently in these scenarios, will not approach one of these subjects until deemed “safe.” Some area best practices approach is to subdue the subject as rapidly as possibly to limit the exertion and stresses that come from protracted confrontations. That approach often suggests using the carotid restraint to accomplish the task. Interesting that in light of the push to ban the carotid, many states may be taking away the very tool that gives an ExD subject the best chance to get medical attention and live.

  7. M.J.

    I’m a military veteran (Marines, 6 years) and a veteran law enforcement officer (federal), in some of the worst neighborhoods in Philly, DC, and Baltimore. I’m also a Firearms, Use of Force, and Defensive Tactics instructor. I’ve been in dozens of physical altercations with violent subjects who refused to comply initially, until they were forcibly subdued and restrained.

    However, if you have ever been in law enforcement or corrections, then you know that LEO’s and CO’s use all kind of bullshit reasons to justify their use of excessive force. I’ve done it myself, especially when a subject has pissed me off (i.e. a few extra kicks to the subject’s ribs just for having the balls to throw that first punch to begin with).

    In the heat of the fight, we sometimes lose our self-control. There were a few times when I had to say to myself, “okay Mike, he’s had enough”, when the subject had clearly stopped fighting me, yet I was still hitting them. Unlike the rest of you, I’m being completely honest and transparent about my actions.

    Here’s the problem with the attempt to justify excessive force with this EXD bullshit: In my military training, law enforcement training, Use of Force and Defensive Tactics Instructor certification classes, I have never once been taught to kneel on a subject’s neck (handcuffed or not), for ANY REASON. It is completely inappropriate and dangerous to do so!!! because of the disastrous consequences that could result (i.e. death or severe spinal injury). And in terms of neck restraints (i.e. chokeholds), they’re great until they’re applied incorrectly and crush a person’s windpipe like in the case of Eric Garner, in New York.

    As a former LEO, I know that you do whatever you have to do to win the fight and go home safely at the end of your shift, but when the subject is restrained and no longer resisting, then the FORCE MUST STOP!!! PERIOD!!! If the subject is no longer a threat (i.e. he or she is successfully restrained, facedown on the ground, in handcuffs, and not actively resisting) then why are you still using any level of force at all? THAT’S THE VERY DEFINITION OF EXCESSIVE FORCE!!!


    Anyone who condones this type of EXD nonsense as justification for the violent and illegal violation of simple human decency is either ignorant of Use of Force policies in general, or a complete idiot, or both.

    1. Von Kliem

      I haven’t heard anyone point to ExD to explain the kneeling on the neck or back. I have heard a lot of people point to ExD as a reason to avoid those control options. I suspect ExD will be discussed more in relation to cause of death.

    2. Sam

      You’re completely misinterpreting the article. We can all agree what happened to George Floyd was not in any way justified. But ExD is real and exists. Saying that is real in exists doesn’t justify using excessive force, Force Science Institute definitely doesn’t justify or teach using excessive force in an ExD event and doesn’t teach tactics. Therefore they would never say put your knee on someone’s neck for ANY reasons at all.
      There recommendation in dealing with a subject with ExD is treat it as a medical emergency and not a criminal event. Have paramedics on standby. The use of the VNR is recommended if the agency allows its use and is properly trained. Another way is tasing the subject and cuffing them under power. Once cuffed, medical would begin treating the subject to get their heart rate down to a normal level. So what’s the harm in any of that?

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