By late 1988, 11 Black women had been found dead in the same area of Miami with low levels of cocaine in their blood. Forensic pathologist Dr. Charles Wetli of the University of Miami had conducted autopsies that he said, “conclusively showed that they have not been murdered.”^1,2 He attributed their deaths to a female-specific manifestation of the mysterious phenomenon he had identified in men who had also died after consuming less-than-lethal amounts of cocaine. Antoinette Burns was the twelfth victim, a 14-year-old girl without any evidence of cocaine consumption at all. At the urging of her family and later the police, these autopsies were reexamined and eventually reclassified as homicides attributed to a single serial killer, responsible for as many as 32 murders in the area.^3,4

Dr. Wetli was referring to his and a colleague’s publication of a case report, in 1981, and a seven-case series in 1985 describing the novel “excited delirium syndrome” in individuals under the influence of cocaine, “a medical emergency but with a psychiatric presentation.”^5,6 Of the seven, all had been restrained, six by police, and four had been hog-tied or hobbled in a prone position. All seven had died without an “anatomic cause of death,” leaving the reader to infer that the cause had been delirium itself.

It was shortly after these case series that Dr. Wetli, serving as deputy chief medical examiner in Miami, first began attributing the deaths of sex workers to excited delirium in 1986. “For some reason the male of the species becomes psychotic and the female of the species dies in relation to sex” after using cocaine, he said in an interview in the Miami Herald at the time, and speculated that this could be due to genetic traits that were more common in certain populations.⁷

In the decades since, excited delirium has come to be a frequently-cited cause of death for individuals dying in custody or during altercations with law enforcement. This is despite never being identified by a formal diagnostic framework, such as the diagnostic and statistical manual of mental disorders (DSM) or the international classification of diseases (ICD), as a valid diagnostic entity.

In 2009, the Excited Delirium Task Force convened by an ACEP Council resolution authored a white paper that endorsed the existence of excited delirium syndrome and made recommendations for identifying and managing it clinically.^8,9 According to Dr. Fabrice Czarnecki, one of the members of the original task force, the use of a term borrowed from law enforcement was deliberate. “Excited delirium is a term that has been with the cops for 40 or 50 years,” he said. “My goal in joining the working group was, we don’t want people to die in the street. I personally don’t want people to die in police custody. I want to be involved in training cops to recognize the signs of a medical emergency.”

In a comprehensive review of the history of this term, Bhatia, et al. writing for the advocacy organization Physicians for Human Rights note that “there is no clear or consistent definition, established etiology, or known underlying pathophysiology.”² They also summarize literature showing that it was identified as the cause of death in over one out of every six deaths in police custody in Texas, that 62 percent of deaths attributed to excited delirium in Florida involved the use of force by law enforcement, and that from the period 2010-2020, deaths in custody attributed to excited delirium were predominantly made up of people of color.

In October 2023, the ACEP Council and the Board of Directors issued statements withdrawing support for the 2009 white paper and affirming that that the term “excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation.”¹⁰ This shift followed publication of a new 2021 position paper adopted by the Council and authored by a new task force convened to reexamine the issue. This more recent work uses the DSM-derived “hyperactive delirium with severe agitation” to highlight that patients with a variety of underlying causes of delirium may be “at high risk of direct physical trauma, not only unintentional harm from trauma such as falls, but also the metabolic stress that may result from physical restraint that may be required to facilitate the safety of the patient, bystanders, and responding professionals.”¹¹

ACEP followed several other professional organizations in revoking formal support for “excited delirium,” including the National Association of Medical Examiners¹² and the American College of Medical Toxicology.¹³ To examine the death of Elijah McClain, in which excited delirium was ruled as the cause of death and in which two paramedics and a police officer have been convicted of homicide, the Colorado Department of Public Health and the Environment appointed an independent review committee on emergency use of ketamine.¹⁴ In recommending the rejection of excited delirium as a diagnosis, they identified the lack of clear criteria and the biased racial associations with some of the features often attributed to the syndrome, such as “’hyper aggression,’ ‘increased strength,’ and ‘police noncompliance.’”¹⁵

In refocusing on the clinical relevance of hyperactive delirium as a secondary syndrome with underlying primary causes, the 2021 ACEP position paper also walked away from its use as a postmortem diagnostic entity.¹¹ “The 2021 report strives to highlight that ‘excited delirium with severe agitation’ is not a diagnosis in the living or the deceased,” explained Dr. Jeffrey Goodloe, who serves as an EMS Chief Medical Officer, ACEP Board member, and one of the authors of this recent work. “The terminology change is very purposeful to get everyone focused on the medical needs of these patients and not trapped in debates about older semantics. It’s important that we focus quickly and intently on stabilizing these patients, especially in the out of hospital environment, so that we can safely get them to an emergency department.”

This move is a recognition that “excited delirium,” as a syndrome whose description originated in forensics and law enforcement and never achieved clear diagnostic criteria, may have been a flawed guideline for clinical decision-making. Refocusing on the widely recognized diagnostic entity of hyperactive delirium may be an important way to restate the relevance of these symptoms in guiding law enforcement and clinical interventions on behalf of the patient.

Another author of the 2009 white paper, who spoke with ACEP Now on the condition of anonymity due to ongoing work in the carceral health community, confirmed that communicating with law enforcement about the safety of these patients was a primary motivator of the original work. “The White Paper was never intended to somehow justify in-custody deaths but rather to confirm that there was risk for these individuals and to increase awareness of the vulnerability of this population.”

Despite attempted outreach to each member of the 2009 task force, only Dr. Czarnecki agreed to speak on the record, with several citing the controversy with which their work is now viewed. “Do I think it was successful? No,” Dr. Czarnecki reflected when asked about his goal of improving safety for delirious patients in contact with law enforcement. “The case that always bothers me is that of George Floyd. Look at the loss of life and all the consequences. If the cops had just heard him say he was short of breath, and had responded to that and had just sat him up, called an ambulance and sat him up, you and I would never have heard of the case.”

The expansion of excited delirium from a description of behaviors into a cause of death also raises questions about the role of scientific review. Much of the evidence cited in the white paper and in subsequent literature establishing the diagnosis of excited delirium and exploring its pathology came from only a few individual authors, many of them also authors of the 2009 white paper.^9,16 For example, in a 2011 review article looking at the evidence for excited delirium, 34 percent of the citations were authored by at least one of the excited delirium task force members or Dr. Wetli himself.¹⁷

There continues to be ongoing controversy over whether and to what extent positional asphyxia offers an alternate explanation for many of the deaths attributed to excited delirium. Small physiologic studies, involving healthy volunteers not in a state of physical or emotional agitation, have provided limited evidence both for and against hemodynamic changes that could contribute to death in a prone or restrained position.^18-21

In a recent systematic review, Strömmer, et al.²² systematically identified arguably all 168 cases of either excited delirium or agitated delirium described in the literature. Sixty-two percent of these were fatal, and the authors found that a diagnosis of excited delirium was nearly 10 times as likely to be applied in cases that were fatalities and nearly five times as likely in those that involved aggressive restraint such as hobbling and physical force. Aggressive restraint was itself also strongly associated with fatality (OR 7.4). Given that this review included most, if not all, of the evidence used previously to justify excited delirium as a fatal clinical entity, the authors conclude that “there is no evidence to support [excited delirium] as a cause of death in the absence of restraint.” With restraints employed in 90 percent of deaths where these diagnoses were applied,”when death has occurred in an aggressively restrained individual who fits the profile … restraint-related asphyxia must be considered as a cause of the death.”

The 2023 ACEP statement reiterates that there are valid concerns related to hyperactivity and delirium in the setting of emergency assessment and treatment. It also recognizes that these concerns affect not just emergency physicians but many important partners in these settings, including first responders and law enforcement. The complex history of the terminology used to identify and respond to these agitated patients illustrates the power of ACEP to shape national dialogue. This organizational shift represents an opportunity to reflect on the real-world consequences of that influence, and on the responsibility that comes with it.

Dr. Lee is a second-year resident in emergency medicine at Highland Hospital in her hometown of Oakland, California. Her primary interests are in ultrasound, machine learning, and health justice.

References

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