Forensic medicine

Controversial, troubling trend: Death by ‘excited delirium’

 

dovalle@MiamiHerald.com

Naked, hollering and foaming at the mouth, chronic cocaine-abuser Luiz Antunes Goncalves collapsed on a Miami Beach street. Declared dead at a nearby hospital, his body temperature measured at 107 degrees.

Samuel Mason, an abuser of pain killers, began banging his head against walls as he was being booked into a South Miami-Dade prison. It took three officers to restrain him before he stopped breathing and died.

Another drug abuser, Camilo Guzman, 28, shed his clothes and climbed the roof of a North Miami nursing home before attacking officers. One shot him with a Taser stun gun. Guzman soon died.

The Miami-Dade Medical Examiner’s Office classified each man’s recent death as “excited delirium syndrome,” a rare brain malfunction — often fueled by cocaine or mental illness — that researchers say morphs victims into raging, violent, feverish attackers.

First documented in Miami during the cocaine epidemic of the 1980s, the syndrome isn’t well known to the public but has increasingly been recognized by doctors, medical examiners and law enforcement across the country.

But citing it as a cause of death is raising controversy. Most of the deaths involve police action. Some victims have died after being restrained by officers, or in some high-profile cases, shot with Taser stun guns. Groups such as the American Civil Liberties Union and relatives of the dead question the autopsy findings, contending the syndrome is built on shaky medical research as a way to cover for overaggressive police tactics.

“The data supporting it is tenuous. I think excited delirium is often used as a catch-all to explain in-custody deaths,” said Indiana University cardiologist Dr. Douglas Zipes, who testifies on behalf of clients suing Taser International.

Not so, said Dr. Steven Karch, a San Francisco cardiac pathologist who has extensively studied the syndrome. He said most cases of lethal excited delirium do not involve Taser stun guns at all, and usually involve police because of the violent outbursts by sufferers.

“It’s utterly real. It’s a not a made-up disease at all,” Karch said. “It is a first-class medical emergency.”

Indeed, 29 people in Miami-Dade alone have been found to have died because of excited delirium since 2002, according to records from the Medical Examiner’s Office. Of those, only nine had been shot by Taser stun guns. An additional two others, also hit by the Taser stun guns, were found to have died from a similar contributing cause — cocaine intoxication or “psychosis.”

The Medical Examiner’s Office has yet to issue rulings in two other highly publicized deaths involving confrontations with Taser-wielding police.

In a case that drew outrage from supporters, teenage graffiti artist Israel Hernandez died in August after Miami Beach police chased him on foot after he was spotted spray-painting a vacant building, then shot him with a Taser stun gun. The next month, Norman Oosterbroek — naked, striking a neighbor at a Pinecrest mansion and apparently ingesting some sort of drug — was subdued by a police Taser shot, then died.

Both men had body temperatures well over 102 degrees over an hour after they were pronounced dead, according to multiple law enforcement sources. An overheated body is common among people who have been ruled as having died of excited delirium.

“Hyperthermia is often a harbinger of death in these cases,” said Deborah Mash, a University of Miami professor of neurology who studies the syndrome. “You get hot, you reset your core body temperature, you’re going to die. It means you’re going to collapse. That’s why the body temperature is an important bio marker of the condition.”

According to researchers, excited delirium has been identified in psychiatric patients as far back at as the 1840s. But in recent times, the condition did not emerge until the 1980s as cocaine began ravaging the streets of South Florida. Then-associate Dade Medical Examiner Dr. Charles Wetli, along with David Fishbain, published the first research paper about what became known as excited delirium.

Critics have pointed out that the syndrome is not recognized by the American Medical Association, while supporters say it is accepted by the National Association of Medical Examiners and the American College of Emergency Physicians.

One medical task force estimated at least 250 people each year die of the syndrome.

So what is excited delirium? Mash, of the UM’s Brain Endowment Bank, describes the syndrome as a genetic abnormality of the brain that might never reveal itself without the triggering mechanism of stress, mental illness or chronic abuse of hardcore drugs.

The brain sends pulses to the nerves and the heart, often weakened by years of drug abuse, begins beating irregularly, according to Dr. Vincent DiMaio, a nationally known forensic pathologist who was the chief medical examiner in San Antonio, Texas, and wrote a book about the syndrome.

The victim often begins shouting and acting aggressively, becomes panicked and paranoid and can exhibit Herculean strength. The flood of chemicals in the body becomes greater when police are inevitably called to restrain the person, who then collapses and dies.

“Essentially, to put it simply, they’re dying of an overdose of adrenaline,” DiMaio said.

That, investigators say, is what happened to David Jardine, 32, who began attacking customers — smashing one man’s guitar — outside the Cheeseburger Baby in the 1500 block of Washington Avenue in August 2010. A restaurant guard put Jardine, who was sweating profusely and wearing only jogging pants, into a neck hold until officers arrived.

Police grappled for 15 minutes with Jardine, who had battled bipolar disorder, substance abuse and suicidal tendencies. Then, they used a baton and a Taser on “drive stun” mode, which is intended as a less powerful shock.

Jardine stopped breathing and was rushed to Mount Sinai Medical Center. Just before he was pronounced dead, his body temperature was at 101.7.

Not all cases involve drugs.

In December 2002, a longtime mentally ill man, William Diaz, was seen agitated and paranoid behind a shopping center at Southwest 98th Avenue and 40th Street. He collapsed. Paramedics declared him dead at the scene. He was not known to have taken drugs, drunken alcohol or used tobacco.

Still, the cause of death came back as excited delirium associated with chronic paranoid schizophrenia.

Lawyers for the family of 21-year-old George Salgado — the latest Miamian to have been ruled as having died of excited delirium — insist the young man was not on drugs. But Salgado’s friend told police he had taken three tabs of LSD before he went berserk behind his girlfriend’s West Miami-Dade home in April 2012.

Officers shot him several times with a Taser stun gun. At the hospital, he remained “yelling and screaming,” according to a Medical Examiner’s report, before dying. His temperature: 105 degrees.

But a toxicology report found no identifiable drugs in his system. Dr. Emma Lew categorized his death as excited delirium associated with consumption of an “unknown substance,” possibly a “new designer drug” for which no test can yet detect.

Designer drugs, which include those dubbed “bath salts,” became infamous after a police union suggested a South Beach partygoer last year chewed off the face of a homeless man on the MacArthur Causeway.

That man, Rudy Eugene, exhibited the trademarks of excited delirium — he shed his clothes, ripped up a Bible and pounced upon the sleeping victim. His cause of death, however, was not in dispute: a police officer shot and killed Eugene.

In Salgado’s case, lawyers David Gold and Keith Pierro have hired Dr. Zipes to challenge excited delirium in a lawsuit filed against police.

“Its junk science to a lot of board-certified cardiologists,” Gold said. “Some people might buy it, especially with cocaine abuse. But when the toxicology comes back clean? They can’t come up with an excuse on this one. They Tasered him to death, right in the heart.”

“The Taser doesn’t kill these people,” said Miami-Dade Police Benevolent Association President John Rivera. “It’s the drugs they take, it takes their body into a state that’s far greater than what their body can tolerate.”

The weapon is used by more than 17,000 law enforcement agencies. One vocal critic: Amnesty International says 550 people have died after being zapped by a police Taser in the United States since 2001.

As for Taser International, the company in 2009 issued a rare warning about the weapon, cautioning police to avoid striking people in the chest. The warning came amid medical evidence that shots to the chest could induce cardiac arrest in some people but Taser continues to defend its device as a less-than-lethal weapon that saves lives.

The company also has frequently cited excited delirium to explain deaths associated with people shot by Tasers.

Mash, the UM researcher, acknowledged she had been called by Taser International as an expert witness to testify in civil lawsuits many years ago. But she said she was only called because the medical examiners in those cases had consulted her about excited delirium fatalities.

“What I do know is that people died in states of excited delirium before there were Tasers,” Mash said. “As a scientist, I know if Tasers were causing deaths, the use would have resulted in more deaths, not only in people with excited delirium but in other psychiatric patients.”

Mash, who is part of a government study examining the role of stress in excited delirium patients, advocates a national registry aimed at cataloging the cases. Often, those who survive are not diagnosed properly, she said. She has also worked with Dr. Bruce Hyma, Miami-Dade’s Medical Examiner, to help police and paramedics recognize the signs of excited delirium.

Many relatives question whether the science is strong enough to support syndrome findings.

Delia Nuñez said she still doubts that her son, Camilo Guzman, died of excited delirium after his encounter with North Miami police last year at the nursing home, where he ultimately brawled with officers inside a receptionist’s office.

“I don’t think he died of that,” said Nuñez, who is not suing the department. “If they hadn’t tased him, he wouldn’t have died. But how can I dispute it?”

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