Review
Deaths in custody: Are some due to electronic control devices (including TASER® devices) or excited delirium?

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Abstract

Deaths have occurred after law-enforcement incidents involving applications of electronic control devices (ECDs) (including TASER® devices). An “excited delirium” syndrome (reported in the literature prior to the development of ECDs currently in use), however, includes several factors that may be related to such deaths in custody. In this review, potential detrimental effects of ECDs are compared with possible changes due to excited delirium. Although extreme (i.e., long-duration or repeated) exposures to ECDs can result in significant hyperkalaemia, acidaemia, and myoglobinemia in animal models, limited applications (such as those normally used in law-enforcement situations) would appear to have only transient effects. In addition, the hyperthermia observed in patients with excited delirium does not seem to be directly exacerbated by ECD applications. ECD use is unlikely to be a common cause of ventricular fibrillation, but other events that are generally associated with excited delirium (e.g., drug use) may be related to subsequent ventricular fibrillation or asystole. Metabolic or respiratory acidosis may only be serious consequences of long-duration or repeated ECD applications. On the basis of current available information, factors other than ECDs themselves may be more important when death occurs after the use of ECDs.

Introduction

An “electronic control device” (ECD) is an operator-controlled apparatus that transmits short electric pulses either through electrodes (from a “stun gun,” as described by Schmiederer et al.),1 or through wires attached to darts (e.g., from a TASER® [“Thomas A. Swift’s Electric Rifle”] ECD [alternatively referred to as an “electric shocking device” or “conducted energy weapon”]) into a subject, causing involuntary muscle contractions that incapacitate. (TASER® is a registered trademark of TASER International, Inc., Scottsdale, Arizona, USA). Denk et al.2 suggested that TASER ECDs can be more effective than other models of similar devices. (For a recent comprehensive review of ECD effects, see Jenkinson et al.3). Tracings of typical waveforms produced by the TASER model “X26” ECD have been presented previously.4, 5

Although the muscle contraction caused by ECD application is not synonymous with conventional muscular exercise, there may be some similarities. Rhabdomyolysis (breakdown of muscle tissue to the extent that contents are liberated into the circulation) may be caused by either excessive muscular activity6 or electrical injury.7 (Other causes are hyperthermia and direct myotoxins.8 One may expect any possible electrical injury due to ECD exposure, however, to be quite different from conventional electrical injury (due to, e.g., 60 Hz alternating current), since electrical properties (most importantly, current flow) of the two modalities are dissimilar. An important point is the amount of power delivered in a given period of time, or energy in joules (watt–seconds) (see Fechner et al.9 for discussion of these factors).

Medical examiners have listed ECDs as a cause of death (see Remsberg 10 for discussion), despite the lack of a clear-cut unifying pathophysiological hypothesis. At the same time, a syndrome often referred to as “excited delirium” (at least in the United States, if not in other countries)11 is one possible explanation of unanticipated deaths of suspects in police custody.12 Ross13 has reviewed factors that have been associated with past cases of deaths in custody presumed to be related to excited delirium.

In news-media accounts of deaths during incidents involving applications of ECDs, the initial focus is often on the devices themselves as the important factor relating to death, with other issues considered to be secondary. The excited delirium syndrome, however, was reported in the literature prior to the development of ECDs currently in use.

The purposes of this paper are to (1) review potential detrimental effects (as reflected in blood factors and physiological measurements) of exposure to ECDs, (2) assess the relative importance of such factors to survival (in comparison with certain aspects of excited delirium), and (3) summarize current opinions regarding the potential role of ECDs versus that of excited delirium during deaths in custody.

Section snippets

Terminology and definitions of excited delirium

Wetli et al.14 and Karch15 have listed four components to be included in a definition of the excited delirium syndrome: delirium with agitation, respiratory arrest, hyperthermia, and death. One of the first uses of the specific term “excited delirium” was by Wetli and Fishbain16 (although “cocaine-induced delirium” had been described before that time). That particular first use of the term was descriptive of behavior, rather than a diagnosis. The syndrome was earlier described under various

Overview

Some of the factors mentioned in the following sections are interrelated, but are listed separately for discussion purposes. It would be unethical to apply extreme (i.e., long-duration or repeated) exposures of ECDs, which may cause harm or death, to human subjects. Therefore, some of the data discussed in this review are from studies of animals.

The first study of blood factors after any type of ECD exposure was performed by Jauchem et al.)30 The swine as an animal model was selected for

Confounding factors that may be present during ECD application and cases of excited delirium

Active physical restraint and drug use are confounding factors that may occur during incidents involving either applications of ECDs or excited delirium. Law-enforcement personnel may utilize a “prone maximal restraint position”85 to control combative subjects. In a series of 21 cases of death associated with excited delirium,86 all of the subjects had undergone restraint. Chan et al.87 concluded that such a position resulted in a “restrictive pulmonary function pattern,” but with no evidence

Suggestions by other investigators for use of ECDs when excited delirium may be present

The use of ECDs in mental health settings (with individuals experiencing a crisis) is controversial.109 Some investigators have recommended enactment of policies prohibiting the “knowing use” of ECDs on mentally ill individuals (e.g., Stanford Criminal Justice Center).110 Ho et al.,111 however, found that, in nearly half of the cases in one study population, an ECD “was used in place of a firearm even though the law-enforcement use of deadly force would have been authorized and justified in

Concluding remarks

Primary effects of factors coincident with ECD exposure events may, by themselves, be more harmful than effects of limited ECD applications. Many victims of drug-induced excited delirium die without the application of any specific law-enforcement techniques.14 Stone113 noted that, on the basis of medical evidence, ECDs are not “the causes, in and of themselves,” of sudden deaths in custody.

Some investigators have suggested that any description of ECD applications as “the last straw” or “being

Conflict of interest

The author has not had any relationship with any manufacturers of electronic control devices, including employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.

Acknowledgements

This review was supported by the Directed Energy Research Programs Department, National Institute of Justice, Office of Justice Programs, United States Department of Justice.

The views and opinions expressed in this article are the author’s own and do not necessarily state or reflect those of the US Government.

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