Elijah McClain's death at the hands of suburban Denver police and paramedics was much in the news during the Black Lives Matter protests of 2020. The three police officers and two paramedics involved in the young Black man's death each faced criminal charges resulting from the event, in which the 23 year-old massage therapist was walking home from a nearby convenience store after buying iced tea. He had no idea that someone had reported a suspicious person.
In the frigid winter weather, the young man had a ski mask on, listening to music on his headphones, and did not hear or respond to the officers who stopped him on the street for questioning. The officers apparently assumed he was ignoring them and being non-compliant. When physically stopped by one of the officers, Elijah declared, “I have a right to go where I am going,” at which point they the officers him to the ground and used a choke hold, which reduced blood flow to his brain. Paramedics soon arrived on the scene and, concluding that McClain was experiencing “excited delirium,” injected him with a large dose of ketamine, a powerful sedative used primarily as an anesthetic.
Despite never being suspected or accused of committing any crimes, police took the 145-pound McClain to the ground here just minutes after they first contacted him. He was unarmed, but was thrown to the ground several times, and given at least two carotid holds. Then paramedics delivered a dose of ketamine, a powerful sedative, and loaded him into an ambulance, handcuffed, where he lost his pulse and never recovered.
Two of the police officers involved were acquitted, but Officer Randy Roedema, who put the young man in carotid holds twice for extended periods, was sentenced to 14 months in jail, and four years of probation. Aurora Fire department medic Jeremy Cooper, who administered the fatal dose of ketamine, was sentenced to 14 months in jail and work release. Cooper's boss, Peter Chinicac, was sentenced to five years in prison for unlawful administration of drugs.
Excited delirium is not recognized as an actual diagnosis by the American Psychiatric Association (APA), and lacks any clear criteria, yet it has been used to explain fatalities of people in police custody for decades, especially deaths of young Black men, and to acquit police officers from any responsibility for these tragic outcomes. The label has also been invoked to justify the forceful restraint and sedation of people who may fail to obey the orders of law enforcement, and is often accompanied with a dose of ketamine, a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress, as in the Elijah McClain case. This combination of a dubious diagnosis and a medication with serious side effects has set the stage for tragic outcomes.
As mentioned, excited delirium is not a formal diagnosis, has no clear definition, and can encompass agitated states resulting from a variety of possible causes. The term has become a lightning rod that evokes strong reactions on all sides of the issue. Advocates for more police restraint in critical mental and behavioral health incidents, and many in the medical profession have raised legitimate concerns that the term “excited delirium” was being used too broadly and to justify too many fatal incidents involving police restraint, and which disproportionately involve people of color.
Excited delirium was first popularized in 1985, when it was used to describe the cases of seven people who died while intoxicated with cocaine—five of whom were in police custody when they passed. Characteristics of excited delirium were said to include “fear, panic, shouting, physical violence, hyperactivity, and thrashing,” along with unexpected strength and hyperthermia. Although never recognized as a formal diagnosis by either the American Psychiatric Association (APA) in the official Diagnostic and Statistical Manual of Mental Disorders (DSM), or by the World Health Organization in their International Classification of Diseases, over the years, excited delirium became popular among medical examiners as an explanation for deaths that occurred in police custody.
Yet, even though lacking clear scientific criteria or recognized by professionals in the field – excited delirium has been used to explain numerous fatalities of people in police custody, especially, as mentioned, deaths of young Black men, and to excuse police officers from responsibility for these lethal outcomes. The label has also been invoked to justify the forceful restraint and sedation of people who may fail to obey the orders of law enforcement personnel. Ketamine, a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress, has often been used in these situations.
Along with the APA, the American Medical Association’s updated policies agree that current evidence does not support “excited delirium” as an official diagnosis, as do wide variety of additional relevant professional organizations including the American Academy of Emergency Medicine, National Association of Medical Examiners, American College of Medical Toxicology, and American College of Emergency Physicians, among numerous others.
The problematic role of ketamine in this discussion cannot be ignored, as it has become the sedative of choice for people who are believed to have excited delirium. Studies suggest that ketamine works more rapidly than other sedative medications, which has contributed to its popularity. It has also been known to disproportionately lead to respiratory distress, especially when coupled with the carotid hold, as in the case of Elijah McClain.
In Colorado, a new statute bars the use of ketamine for excited delirium, and prohibits the police from attempting to influence a decision to use ketamine. Paramedics are also required to seek a verbal order from their supervising physician before administering the drug. Other states have also begun to examine their procedures which will likely lead to similar prohibitions on ketamine.
As a recent report from the Council on Science and Public Health of the American Medical Association (AMA) made clear, the diagnosis of excited delirium has persisted despite a lack of scientific evidence, a universally recognized definition, a clear understanding of pathophysiologic mechanisms, or a specific diagnostic test, yet law enforcement and emergency medical services personnel are frequently taught that excited delirium is a potentially deadly medical condition. Of all US medical associations, only the American College of Emergency Physicians (ACEP), whose members often supervise paramedics in the field, has embraced the diagnosis. However, an ACEP white paper endorsing excited delirium conceded that, “It has generally been used to describe a small group of patients with a set of symptoms that has eluded a unifying, prospective clinical definition”.
The American Medical Association more clearly stated in 2021 that “current evidence does not support ‘excited delirium’ or ‘excited delirium syndrome’ as a medical diagnosis, and AMA opposes the use of the terms until a clear set of diagnostic criteria are validated.” AMA also expressed concern that “law enforcement officer use of force accompanying ‘excited delirium’ . . . leads to disproportionately high mortality among communities of color, particularly among Black men.”
It is not only medical and mental health organizations, but also numerous authoritative law enforcement and criminal justice policy developers that have determined the phrase “excited delirium” should be done away with.
Lexipol, who offers policy manuals, trainings, and consulting services to law enforcement agencies and other public safety departments, has removed the term since 2022, and recommends that all public safety agencies carefully review with local counsel whether to use the term in reports, policies and procedures. There’s more information about Lexipol’s decision in the article, “Excited Delirium: Understanding the Evolution Away from a Controversial Term.”
The International Association of Chiefs of Police (IACP)National Law Enforcement Policy Center has offered extensive and enlightened guidance in their 2018 paper Responding to Persons Experiencing a Mental Health Crisis: “It is the policy of this agency that officers be provided with training to determine whether a person’s behavior is indicative of a mental health crisis and with guidance, techniques, response options, and resources so that the situation may be resolved in as constructive, safe, and humane a manner as possible.”
The Police Executive Research Forum (PERF) has also been examining this issue, encouraging law enforcement leadership to provide officers with better guidance on how best to respond in these circumstances, and to develop protocols for police based on sound medical advice that can best protect the person in crisis and others from harm.
Police will continue to encounter these people, whether we call their crises ‘excited delirium,’ ‘hyperactive delirium,’ or simply describe their behavior. If we want to improve the response and the outcomes, we need to reevaluate policies, training, and coordination between the various responders, including police, dispatchers, EMS, and medical staff at hospitals.”
References:
Modern Health Care, June 15, 2021
Police 1, Nov. 2023
Police Executive Research Forum, March 2024
American Psychiatric Assn Psychiatry online.org, May 2022
NPR April, 2024
American Medical Association, Council on Science and Public Health, June 2021
American Journal of Emergency Medicine, Nov. 2019
leg.colorado.gov/sites/default/files/2021a_1251uly 2021
STAT, April 2021
