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

In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review

Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.

Human Health Risks of Conducted Electrical Weapon Exposure: A Systematic Review

IMPORTANCE

Conducted electrical weapons (CEWs) are used broadly as a less-lethal force option for police officers. However, there is no clear picture of the possible health risks in humans on the basis of rigorously assessed scientific evidence from the international peer-reviewed literature.

OBJECTIVE

To synthesize and systematically evaluate the strength of published evidence for an association between exposure to different models of CEWs and adverse acute as well as chronic conditions.

EVIDENCE REVIEW

Following a preregistered review protocol, the literature search strategy was based on a search of reviews published between January 1, 2000, and April 24, 2020, of PubMed, MEDLINE, EMBASE, Web of Science, PsycINFO, and Cochrane Library, as well as relevant online databases and bibliographic sources, such as reference sections of recent publications. The identified studies were independently assessed in terms of scope, relevance, methodologic bias, and quality. Peer-reviewed publications of human studies were included, using original data and with a focus on the use of taser CEWs in the context of law enforcement. Eligible studies examined clearly defined health outcomes as dependent variables following exposure to a CEW. The review followed the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. A meta-analysis could not be conducted.

FINDINGS

Of the 1081 unique records screened, 33 relevant studies were identified, all of them of experimental design and conducted in the US. Eleven studies had a low risk of bias and 22 had a higher bias risk. Studies focused on outcomes such as physiologic stress responses, heart rate, blood pressure, arrhythmias, or cognitive performance. Independently of bias risk, the studies reported few or no acute health problems, apart from the wounds caused by the darts. Furthermore, no long-term outcomes were studied. Most of the studies were performed on healthy, physically fit individuals (eg, police officers) in a controlled setting, with short exposure duration (5 seconds). Half of the studies, mainly those with a higher risk of bias, were at least partly funded by the manufacturer.

CONCLUSIONS AND RELEVANCE

Based on the findings of the reviewed studies, the risk for adverse health outcomes due to CEW exposure can be currently estimated as low. However, most of the reviewed studies had methodologic limitations. Considering that recruited participants were not representative of the population that usually encounters a CEW deployment, it is not possible to draw conclusions regarding exposure outcomes in potentially vulnerable populations or high-risk groups, such as those under the influence of substances.

Excited delirium syndrome from psychostimulant abuse can mimic a violent scene of death

Background

Previous reported cases on excited delirium syndrome studied on the common clinical manifestations of the syndrome. The usual forensics implication for the syndrome is that death commonly is associated with restraint procedures by law enforcement agencies; however, not many cases reported highlights the difficulties in attributing a violent scene of death to the syndrome.

Case presentation

We present a case of a partially naked body found in an apartment unit under suspicious circumstances with multiple injuries. The scene of death was violent, and the body was found with blood wiped all over the floor and walls. Investigators believed a violent crime had occurred, and a suspect was reprimanded. However, upon autopsy, it was found that all injuries were superficially inflicted and were unlikely to have been part of an act of commission or caused his death. Internal examination found no remarkable pathology. Toxicology revealed a presence of psychostimulants, that is, methamphetamine, MDMA, and ethyl alcohol. Reconstruction of events by the witness, who was initially suspected of the ‘murder’, revealed that the injuries and his death could likely be explained by an episode of excited delirium.

Conclusion

The case highlights the challenges faced when attributing excited delirium syndrome as a cause of death. The syndrome can present with injuries from aggressive or bizarre behaviour, coupled with the destruction of property, which may confuse investigators on the possible manner of death.

Increased Hematocrit Due to Electrical-Waveform Exposures in Splenectomized Sus scrofa

In laboratory studies of the pig Sus scrofa, hematocrit has consistently increased after conducted-electrical-weapon (CEW) exposures, possibly due to contraction of the spleen. Splenectomized animals and intact sham control animals were exposed, each for 30 sec, to a benchtop-produced electrical waveform of net charge levels similar to those of some CEWs. Changes in the blood were compared statistically. Hematocrit increased significantly in both splenectomized and sham animals. There were no significant main-effect differences between values of hematocrit from the two groups. There were, however, significant interactive effects of time and splenectomy for hematocrit, red blood cell count, and hemoglobin. After peak values were reached for these variables, values returned toward baseline levels more slowly in splenectomized animals. This may have been due to the lack of a spleen to sequester red blood cells (thereby resulting in more cells remaining in the general circulation), unlike sham animals with intact spleens.

Quantifying underreporting of law-enforcement-related deaths in United States vital statistics and news-media-based data sources: A capture-recapture analysis

BACKGROUND

Prior research suggests that United States governmental sources documenting the number of law-enforcement-related deaths (i.e., fatalities due to injuries inflicted by law enforcement officers) undercount these incidents. The National Vital Statistics System (NVSS), administered by the federal government and based on state death certificate data, identifies such deaths by assigning them diagnostic codes corresponding to "legal intervention" in accordance with the International Classification of Diseases-10th Revision (ICD-10). Newer, nongovernmental databases track law-enforcement-related deaths by compiling news media reports and provide an opportunity to assess the magnitude and determinants of suspected NVSS underreporting. Our a priori hypotheses were that underreporting by the NVSS would exceed that by the news media sources, and that underreporting rates would be higher for decedents of color versus white, decedents in lower versus higher income counties, decedents killed by non-firearm (e.g., Taser) versus firearm mechanisms, and deaths recorded by a medical examiner versus coroner.

METHODS AND FINDINGS

We created a new US-wide dataset by matching cases reported in a nongovernmental, news-media-based dataset produced by the newspaper The Guardian, The Counted, to identifiable NVSS mortality records for 2015. We conducted 2 main analyses for this cross-sectional study: (1) an estimate of the total number of deaths and the proportion unreported by each source using capture-recapture analysis and (2) an assessment of correlates of underreporting of law-enforcement-related deaths (demographic characteristics of the decedent, mechanism of death, death investigator type [medical examiner versus coroner], county median income, and county urbanicity) in the NVSS using multilevel logistic regression. We estimated that the total number of law-enforcement-related deaths in 2015 was 1,166 (95% CI: 1,153, 1,184). There were 599 deaths reported in The Counted only, 36 reported in the NVSS only, 487 reported in both lists, and an estimated 44 (95% CI: 31, 62) not reported in either source. The NVSS documented 44.9% (95% CI: 44.2%, 45.4%) of the total number of deaths, and The Counted documented 93.1% (95% CI: 91.7%, 94.2%). In a multivariable mixed-effects logistic model that controlled for all individual- and county-level covariates, decedents injured by non-firearm mechanisms had higher odds of underreporting in the NVSS than those injured by firearms (odds ratio [OR]: 68.2; 95% CI: 15.7, 297.5; p < 0.01), and underreporting was also more likely outside of the highest-income-quintile counties (OR for the lowest versus highest income quintile: 10.1; 95% CI: 2.4, 42.8; p < 0.01). There was no statistically significant difference in the odds of underreporting in the NVSS for deaths certified by coroners compared to medical examiners, and the odds of underreporting did not vary by race/ethnicity. One limitation of our analyses is that we were unable to examine the characteristics of cases that were unreported in The Counted.

CONCLUSIONS

The media-based source, The Counted, reported a considerably higher proportion of law-enforcement-related deaths than the NVSS, which failed to report a majority of these incidents. For the NVSS, rates of underreporting were higher in lower income counties and for decedents killed by non-firearm mechanisms. There was no evidence suggesting that underreporting varied by death investigator type (medical examiner versus coroner) or race/ethnicity.

[The topical problems of the application of the TASER electroshock devices]

The objective of the present study was the analysis of publications in the foreign medical literature concerning the problems of safety, clinical diagnostics, pathological morphology, and treatment of the patients subjected to the impact by various models of the TASER electroshock devices. The materials for this article were borrowed from the available Internet resources and libraries. The methods of scientific analysis were employed to follow up the dynamics of publication and to determine the number of publications on the issues of interest. The main attention was given to the overview of the subject matter of scientific research and experiments. The review covers 74 foreign articles presenting the discussion of various conditions and circumstances of the action of various types of the TASER electroshock devices (ESD) on the man with special reference to their effectiveness and safety as confirmed by numerous experimental impacts on the volunteers and animals. It is shown that the dynamics of relevant publications in the foreign scientific periodicals gives evidence of the strong interest shown by the specialists in various scientific disciplines to the problem of safety of various models of the TASER electroshock devices. The largest number of the articles (60 or 81.1%) published during the period covered by the present study were submitted by the American authors describing their experiments involving the volunteers, anthropometric dummies, and human corpses (n=38 or 51%). The subject matter of these publications included the forensic medical evaluation of the lethal outcomes of the application of the TASER electroshock devices with the related technical problems and characteristic of various ESD models. Despite the extensive studies on the volunteers and the experimental animals, the authors of the publications failed to present direct and conclusive evidence of the lethal consequences of the application of the TASER electroshock devices (ESD) on the man. Some of them recommend to prohibit (or restrict whenever possible) the targeted application of the electric shock weapons to the thoracic region. Experiments on the animals have demonstrated the possibility of development of cardiovascular and respiratory complications following the application of the TASER X2 electroshock devices operating at a frequency of 40 Hz during 30 minutes. The clinical and laboratory studies with the participation of the volunteers in an alcoholic intoxication condition have confirmed the long-term increase in the blood lactate levels under the influence of the electric shocking weapons. The analogous data suggesting the development of pronounced acidosis under effect of the TASER X2 electroshock devices due to the elevation of the lactate concentration in the venous blood have been obtained in the animal experiments. The studies of humans in a narcotic intoxication condition failed to provide direct evidence of induction of psychic disorders in the form of an acute confusional state (delirium) under the influence of the TASER electroshock devices. The evaluation of changes in the skin cover in the form of the punctured or contused wounds in the victims of the application of the electroshock gun projectiles did not revealed any specific signs of the local electrical action.

A TASER conducted electrical weapon with cardiac biomonitoring capability: Proof of concept and initial human trial

INTRODUCTION

Despite research demonstrating the overall safety of Conducted Electrical Weapons (CEWs), commonly known by the brand name TASER(®), concerns remain regarding cardiac safety. The addition of cardiac biomonitoring capability to a CEW could prove useful and even lifesaving in the rare event of a medical crisis by detecting and analyzing cardiac rhythms during the period immediately after CEW discharge.

OBJECTIVE

To combine an electrocardiogram (ECG) device with a CEW to detect and store ECG signals while still allowing the CEW to perform its primary function of delivering an incapacitating electrical discharge.

METHODS

This work was performed in three phases. In Phase 1 standard law enforcement issue CEW cartridges were modified to demonstrate transmission of ECG signals. In Phase 2, a miniaturized ECG recorder was combined with a standard issue CEW and tested. In Phase 3, a prototype CEW with on-board cardiac biomonitoring was tested on human volunteers to assess its ability to perform its primary function of electrical incapacitation.

RESULTS

Bench testing demonstrated that slightly modified CEW cartridge wires transmitted simulated ECG signals produced by an ECG rhythm generator and from a human volunteer. Ultimately, a modified CEW incorporating ECG monitoring successfully delivered incapacitating current to human volunteers and successfully recorded ECG signals from subcutaneous CEW probes after firing.

CONCLUSION

An ECG recording device was successfully incorporated into a standard issue CEW without impeding the functioning of the device. This serves as proof-of-concept that safety measures such as cardiac biomonitoring can be incorporated into CEWs and possibly other law enforcement devices.

Exposures to conducted electrical weapons (including TASER® devices): how many and for how long are acceptable?

TASER(®) conducted electrical weapons (CEWs) are an important law-enforcement tool. The purposes of this study are a) to review recent literature regarding potential pathophysiological responses to applications of CEWs, and other related issues and b) to evaluate whether enough data exist to determine the acceptability of longer-duration (or repeated) exposures. This is a narrative review, using a multidisciplinary approach of analyzing reports from physiological, legal-medical, and police-strategy literature sources. In general, short-duration exposures to CEWs result in limited effects. Longer-duration or repeated exposures may be utilized with caution, although there are currently not enough data to determine the acceptability of all types of exposures. Data examined in the literature have inherent limitations. Appropriateness of specific types of CEW usage may be determined by individual police agencies, applying risk/benefit analyses unique to each organization. While more research is recommended, initial concepts of potential future long-duration or repeated CEW applications are presented.

Police use of TASER devices in mental health emergencies: a review

The proliferation of TASER devices among police forces internationally has been accompanied by concerns about injuries and health effects, and about the use of TASER devices on vulnerable populations such as people with mental illness. TASER devices have generated a flood of research studies, although there remain unanswered questions about some of the key issues. This paper outlines the introduction of TASER devices to policing and their subsequent widespread adoption. The paper considers the role of police in mental health emergencies with a particular focus on use of TASER devices. Some factors contribute to the special vulnerability of people with mental illness to the effects of TASER devices. The paper also reviews research into use of TASER devices and raises issues about conflict of interest in research into TASER devices. We conclude that TASER devices look set to play a significant role in policing in the future. We make suggestions for a future research programme, and suggest guidelines for publication of papers in which there may be a conflict of interest.

Forensic standardizations in torture and death in custody investigations

Torture and death in custody have incurred rapid development as juridical subject in recent years in Europe, with the implementation of the European Convention of Human Rights. Evaluation of sufferance severity, which is the consequence of pathology with chronic evolution, the predictability of decompensation of a subclinical pathology, and translating these medical information on a scale measuring the severity of detention consequences, are all challenges for the modern detention healthcare system, in which most allegations of torture are due to lack of appropriate medical treatment administered to inmates. Where ethics are concerned, the main data difficulties are addressed in ethical conflicts between officials and experts of the parties and also between experts and judiciary officials who handle cases of torture or death in detention; this is why standardization is very important in such cases both in clinical expertise and in autopsies or exhumations.

DISCUSSIONS

We must improve the forensic expertise methodology, the process of collecting data with statistical purposes, and sound evaluation criteria, all in a strong connection with the need for a balanced legal framework applied in the case of civil compensations granted after death in custody, and the biunique relation between medico-legal expertise and case investigation has to be standardized.

40-Hz square-wave stimulation requires less energy to produce muscle contraction: compared with the TASER® X26 conducted energy weapon

Conducted energy weapons (CEWs) (including the Advanced TASER(®) X26 model produced by TASER International, Inc.) incapacitate individuals by causing muscle contractions. In this study using anesthetized swine, the potential incapacitating effect of primarily monophasic, 19-Hz voltage imposed by the commercial CEW was compared with the effect of voltages imposed by a laboratory device that created 40-Hz square waves. Forces of muscle contraction were measured with the use of strain gauges. Stimulation with 40-Hz square waves required less pulse energy than stimulation with the commercial CEW to produce similar muscle contraction. The square-pulse stimulation, at the higher repetition rate, caused a more complete tetanus at a lower energy. Use of such a simple shape of waveform may be used to make future nonlethal weapon devices more efficient.

Blood lactate concentration after exposure to conducted energy weapons (including TASER® devices): is it clinically relevant?

In previous studies, blood lactate concentration (BLac) consistently increased in anesthetized animals and in human subjects after exposures to TASER(®) conducted energy weapons (CEWs). Some have suggested the increased BLac would have detrimental consequences. In the current review, the following are evaluated: (a) the nature of muscle contractions due to CEWs, (b) general aspects of increased BLac, (c) previous studies of conventional neuromuscular electrical stimulation and CEW exposures, and (d) BLac in disease states. On the basis of these analyses, one can conclude that BLac, per se (independent of acidemia), would not be clinically relevant immediately after short-duration CEW applications, due to the short time course of any increase.

Effects of a TASER® conducted energy weapon on the circulating red-blood-cell population and other factors in Sus scrofa

In previous studies hematocrit has been consistently increased in an anesthetized animal model after exposures to TASER(®) conducted energy weapons (CEWs). In the present study we analyzed changes in blood cell counts and red blood cell membrane proteins following two 30-s applications of a TASER C2 device (which is designed for civilian use). Hematocrit increased significantly from 33.2 ± 2.4 (mean ± SD) to 42.8 ± 4.6 % immediately after CEW exposure of eleven pigs (Sus scrofa). Red blood cell count increased significantly from 6.10 ± 0.55 × 10(12)/L to 7.45 ± 0.94 × 10(12)/L, and mean corpuscular volume increased significantly from 54.5 ± 2.4 fl to 57.8 ± 2.6 fl. Mean corpuscular hemoglobin concentration decreased significantly from 20.5 ± 0.7 to 18.5 ± 0.6 mM. Thirty protein spots (from two-dimensional sodium dodecyl sulfate polyacrylamide gel electrophoresis, selected for detailed comparison) exhibited greater densities 30-min post-exposure compared with pre-exposure values. A greater number of echinocytes were observed following CEW exposure. On the basis of these results it appears that, during the strong muscle contractions produced by TASER CEWs, a specific population of red blood cells (RBCs) may be released from the spleen or other reservoirs within the body. The total time of CEW exposure in the present study was relatively long compared with exposures in common law-enforcement scenarios. Despite statistically significant changes in red blood cell counts (and other measures directly related to RBCs), the alterations were short-lived. The transient nature of the changes would be likely to counteract any potentially detrimental effects.

Injuries associated with law enforcement use of force

Prehospital personnel and physicians working in acute care settings need to be cognizant of the issues related to law enforcement use of force in order to properly evaluate and manage these patients. Types of force used by law enforcement range along a spectrum from physical presence to lethal use of firearms. Although the vast majority of use of force incidents does not lead to significant injury, certain weapons and situations may require more extensive evaluation and higher levels of concern.

Acute pathophysiological influences of conducted electrical weapons in humans: A review of current literature

Conducted electrical weapons (CEWs) deliver short high-voltage, low current energy pulses to temporarily paralyze a person by causing muscular contraction. The narrative of this article is a methodical analysis on acute pathophysiological changes within the central nervous system, cardiovascular, neuroendocrine, sympatho-adrenergic and muskuloskeletal system which can occur after application of conducted electrical weapons on human subjects. The results are based on wide-ranging literature analysis and source studies. The majority of the recent scientific publications on humans classify the health risks of an appropriate use of the CEWs device as minor. However, there still is an uncertainty about possible side-effects of these devices. Therefore medical supervision with human application is advised.

Increased hematocrit after applications of conducted energy weapons (including TASER(®) devices) to Sus scrofa

Conducted energy weapons (CEWs) are used by law enforcement personnel to incapacitate individuals quickly and effectively, without intending to cause lethality. CEWs have been deployed for relatively long or repeated exposures in some cases. In laboratory animal models, central venous hematocrit has increased significantly after CEW exposure. Even limited applications (e.g., three 5-sec applications) resulted in statistically significant increases in hematocrit. Preexposure hematocrit was significantly higher in nonsurvivors versus survivors after more extreme CEW applications. The purpose of this technical note is to address specific questions that may be generated when examining these results. Comparisons among results of CEW applications, other electrical muscle stimulation, and exercise/voluntary muscle contraction are included. The anesthetized swine appears to be an acceptable animal model for studying changes in hematocrit and associated red blood cell changes. Potential detrimental effects of increased hematocrit, and considerations during law enforcement use, are discussed.

Muscle contraction during electro-muscular incapacitation: A comparison between square-wave pulses and the TASER(®) X26 Electronic control device

Electronic control devices (including the Advanced TASER(®) X26 model produced by TASER International) incapacitate individuals by causing muscle contractions. To provide information relevant to development of future potential devices, effects of monophasic square waves with different parameters were compared with those of the X26 electronic control device, using two animal models (frogs and swine). Pulse power, electrical pulse charge, pulse duration, and pulse repetition frequency affected muscle contraction. There was no difference in the charge required, between the square waveform and the X26 waveform, to cause approximately the same muscle-contraction response (in terms of the strength-duration curve). Thus, on the basis of these initial studies, the detailed shape of a waveform may not be important in terms of generating electro-muscular incapacitation. More detailed studies, however, may be required to thoroughly test all potential waveforms to be considered for future use in ECDs.

Numerically simulated cardiac exposure to electric current densities induced by TASER X-26 pulses in adult men

There is still an ongoing debate whether or not electronic stun devices (ESDs) induce cardiac fibrillation. To assess the ventricular fibrillation risk of law enforcing electronic control devices, quantitative estimates of cardiac electric current densities induced by delivered electric pulses are essential. Numerical simulations were performed with the finite integration technique and the anatomical model of a standardized European man (NORMAN) segmented into 2 mm voxels and 35 different tissues. The load-dependent delivery of TASER X-26 pulses has been taken into account. Cardiac exposure to electric current densities of vertically and horizontally aligned dart electrodes was quantified and different hit scenarios compared. Since fibrillation thresholds critically depend on exposed volume, the provided quantitative data are essential for risk assessment. The maximum cardiac rms current densities amounted to 7730 A m(-2). Such high current densities and exposed cardiac volumes do not exclude ventricular fibrillation.