Juan Lozano’s death in South Texas during the summer of 2006 was a mystery.
Dimmit County Sheriff’s deputies came upon the 26-year-old Crystal City man around midnight after a call about a man behaving bizarrely: screaming, running in the street and hiding in the bushes. A struggle broke out — officers say they pushed him to the ground after he tried to flee — and Lozano was handcuffed. Soon he started making choking noises. By the time he arrived at the hospital, he was dead.
A justice of the peace noted no signs of physical trauma. An autopsy revealed no obvious clues.
But Bexar County Medical Examiner Vincent Di Maio had an explanation: a controversial cause of death, which rarely occurs without a police struggle, called excited delirium. Critics say it’s a term that obscures police actions that may have contributed to a subject’s death; law enforcement and emergency responders say it is a very real syndrome that demands decisive action and quick medical treatment.
In Lozano’s autopsy report, Di Maio explained the finding involves a sudden fatality “in which an autopsy fails to reveal evidence of sufficient trauma or natural disease to explain the death.” As a result of Lozano’s struggle with police and the cocaine in his system, Lozano was in effect killed by “high levels of ‘adrenaline,’” he wrote.
An American-Statesman investigation into each non-shooting death of a person in police custody since 2005 reveals that Lozano’s cause of death is common in Texas: More than one in six of the 289 such deaths have been attributed to excited delirium.
In many of the 50 cases, subjects died after violent, extended struggles with police. Fourteen were shocked by Tasers before they died.
Minority men are disproportionately represented among those who die by excited delirium in police custody. Nearly 85 percent involved black or Hispanic men. Only eight were white — less than half the percentage of whites killed overall during in-custody struggles, according to the Statesman’s analysis.
Experts said one reason behind the skewed numbers is that minorities disproportionately fatally overdose on cocaine, the drug most closely associated with excited delirium. Yet statistics from the Texas Department of State Health Services show that the proportion of blacks and Hispanics who died of excited delirium is still considerably higher than those who died from simple cocaine overdoses.
‘It basically gives police a pass’
Emergency physicians, medical examiners and police groups say that while excited delirium leaves no obvious evidence in the human body, it is a bona fide syndrome that requires specific treatment and training. But neither the American Medical Association nor the American Psychological Association recognize it and it’s not an official cause of death in federal or state death databases.
A Canadian judge, ruling in an excited delirium case involving a Taser shock in 2009, blasted the diagnosis, saying it “conveniently avoids having to examine the underlying medical condition or conditions that actually caused death, let alone examining whether use of the conducted energy weapon and/or subsequent measures to physically restrain the subject contributed to those causes of death.”
“When an autopsy says ‘excited delirium’ those are two words civil rights lawyers don’t like to hear, because it basically gives police a pass for their behavior,” added Dallas attorney Scott Palmer. “Are they really saying he was moving, he was conscious, he was breathing — and he was just going to drop dead? The added element is unnecessary police conduct.”
Though its validity is debated, a constellation of commonly present symptoms has emerged in law enforcement and emergency room circles. They include subjects who are highly agitated, combative and often impervious to pepper spray and electric stun guns. Those with excited delirium often sweat profusely and disrobe because of dangerously high body temperatures. And while the condition is associated with cocaine and, less often, methamphetamine, it has also been noted in those with histories of manic mental illness.
The Statesman’s analysis showed that excited delirium designations occurred at different rates across the state, perhaps reflecting its complexity, as well as subjectivity among medical examiners involved in determining it as a cause of death. The highest number of excited delirium deaths — 12 — occurred in San Antonio, where Di Maio, author of a 2005 book on the subject, headed the Bexar County Medical Examiner’s office from 1981 through 2006. Dallas had nine cases; Corpus Christi has seen four.
The state’s largest metro area, Houston, had just one excited delirium case over between 2005 and 2016, and none since 2006. (Luis Arturo Sanchez, Harris County’s chief medical examiner since 2003, declined to comment.) Austin and surrounding counties have not had a single excited delirium in-custody death in 11 years.
Yet other in-custody deaths in Texas exhibited similar characteristics but were not labeled excited delirium.
In 2015, Robert Brandon Edwards died after being restrained by police at a south Austin H-E-B, where witnesses saw him struggling to walk and screaming erratically for help. The Travis County Medical Examiner ruled Edwards died of the “combined effects of methamphetamine, PCP and the stress associated with restraint procedures.”
Generally, “We don’t report it as a cause of death, but as a symptom,” a spokeswoman for the Travis County Medical Examiner explained.
“I think that the concept is well-accepted in the ME community, but there are lots of different ways of certifying death,” Dr. Brian Peterson, president of the National Association of Medical Examiners and chief medical examiner for Milwaukee County, wrote in an email. “I have certified such cases in the past by listing the various stressors (eg, struggle with police, TASER application, restraint position, whatever, all due to, say, drug intoxication) without actually using the term ‘excited delirium.’ I do it that way so as not to be accused of covering something up (like a police use of force).”
Syndrome often linked to cocaine
Excited delirium-like symptoms first appeared as a cause of death in the medical literature of the 1800’s, when a Massachusetts psychiatrist described an “exhaustive mania and delirium” among insane asylum residents with a 75 percent mortality rate. “Bell’s Mania” involved hyperactivity, hallucinations, delusions and high body temperature.
Researchers believe advances in psychiatric drugs during the 20th century helped eradicate mentions of the phenomenon. But with the arrival of cocaine in the 1970s and 1980s, officials started reporting delirium-like deaths similar to those seen a century earlier.
Di Maio said medical examiners began noticing a growing number of deaths involving a police arrest, a struggle and sudden death. “Essentially you had a dead person who was normal except for some scrapes and bangs,” he said. “People were asking — ‘They act crazy and they have super-human strength — what’s going on?’ They run around naked and punch out windows or run through traffic.”
In 2016, University of Miami researcher Deborah Mash concluded the syndrome’s biological roots lie in faulty wiring in the brain and that stimulant drug users, especially binge users, and those undergoing acute manic episodes are both at risk of producing excessive dopamine, which can ultimately lead to “cardio respiratory collapse.”
Indeed, the newspaper’s analysis showed 75 percent of Texas excited delirium deaths involved some form of cocaine. Another five involved PCP or methamphetamine. Five of the deaths involved no illegal drug use, though records showed each subject was involved in a mental health crisis.
In January 2014, Michael Peden had been held in the Van Zandt County jail for six weeks after his arrest for failing to pay child support and evading arrest. The 37-year-old suffered from severe bi-polar disorder, court documents show.
On January 19, Peden started banging on his cell door, screaming nonsense words. A scuffle with jail officers ensued; Peden was shocked with a Taser several times and held down on his stomach for five minutes, according to court documents: “When the officer rolled Peden back over, he was dead.”
“The witness reports fit the classic scenario of excited delirium,” the Dallas County medical examiner concluded in its autopsy.
Because of their unpredictability, aggression, strength and imperviousness to pain, those experiencing excited delirium often end up engaged in intense physical struggles. Police and autopsy reports indicate some excited delirium deaths were complicated by actions of police or emergency responders.
In 2009, Jamaal Valentine died after a confrontation with La Marque police. He had already been handcuffed when one of the officers hit him with a flashlight hard enough to open a gash on the back of his head.
In a lawsuit that resulted in an undisclosed settlement with family members, attorneys said Valentine had complained of chest pains and gone outside, where he told a passing motorist he was having a heart attack. The man called 911, but police disregarded Valentine’s need for medical attention and instead sought to subdue and detain him, according to the lawsuit.
Police said they were dispatched to attend to a man “rolling on the ground” who seemed “messed up on crack cocaine,” according to the passerby. A lengthy struggle ensued in which officers tased Valentine multiple times without effect. An officer said he tried to swat Valentine’s hands from his waist, mistakenly striking him in the back of the head with a flashlight.
The lawsuit also alleges officers left Valentine bleeding and struggling for breath for “as long as 30 minutes” before an ambulance arrived.
A Galveston County medical examiner determined Valentine was killed by cocaine and PCP drug toxicity “with associated excited delirium” and bleeding around the brain. Blunt head trauma during police restraint was listed as a significant condition and the death was ruled a homicide.
As with every case of excited delirium reviewed by the paper, police received no discipline for their conduct in taking Valentine into custody. A Galveston County Grand jury recommended no legal action against the officers involved after hearing six days of testimony in 2009.
Quick recognition is key for police
Police and experts say excited delirium cases are among the most difficult for police to handle. A 2009 American College of Emergency Physicians’ report said law enforcement agencies “are in the difficult and sometimes impossible position of having to recognize this as a medical emergency, attempting to control an irrational and physically resistive person, and minding the safety of all involved.”
Training on excited delirium is part of the basic mental health curriculum for Texas peace officers and some departments, like the Austin Police Department, have adopted strict policies on the subject.
Officers should only engage subjects who display excited delirium behaviors “when adequate back-up assistance is present,” the Austin Police Department manual states. “For the safety of both officers and subjects, recognition is imperative.”
All officers undergo excited delirium training, and if subjects aren’t an immediate threat, police are taught to give them space until other officers arrive and emergency medical responders are notified. Ideally, a five-person team would surround the person and quickly take him or her into custody.
Last year, Austin officer Geoffrey Freeman was fired in part for failing to follow that policy. Freeman shot and killed high school student David Joseph as he ran nude towards the officer.
Jerry Staton, a former Austin police officer who trains departments in handling excited delirium situations, said one key to ensuring survival is “overwhelming force” in restraining a subject. “Get the struggle over as soon as possible,” he said. “The reason most people don’t survive is because the struggles take so long.”
The in-custody death files maintained by the Texas Attorney General detail several cases where struggles, some involving numerous officers, continued for many minutes.
Excited delirium cases are similarly among the hardest cases for emergency room staffers to control. In response, researchers have begun studying the effect of ketamine, also known as the party drug Special K, on people in the grips of excited delirium.
The standard treatment is a drug cocktail made up of Benadryl, an anti-anxiety drug and the anti-psychotic drug Haldol. The cocktail has been linked to seizures and breathing difficulties, however, and in several Texas cases, people died minutes after receiving such a sedative.
A 2014 Florida study found that ketamine, which can block pain and distress signals, effectively sedated nearly all study patients, with just three experiencing minor negative side effects. Researchers concluded the drug is a “good choice to gain rapid medical control of patients with potential excited delirium and those exhibiting violent and agitated behavior.”