[

A number of factors can cause a subject to suddenly die in
police custody Recognizing and reacting to them may
help you save lives.

Jeffrey D. Ho. MD. FACEP
It's (/ 20·cfc!gree I/igllt ill (/ lJIaior
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wil/d ("lIifJ {actor is \\'I'II/lelu\\' Zl'ro.
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ach year in the United States, hundTl'<ls of
people die in police custody of no readil)'
apparent reason and without any trauma.
In some cases, officers used one or more
intermediate weapons on the subject prior to arrcst,
in others they used no weapons but one or more
officers went hands-on with the subject, and in
many others, officers barely touched the subject.
Often these GISes [c,ld to blaring headlines that

ag.com August 2005

kicks, scremllS, and .Wits. He struggles agaillst tlle lI(/1ulc/lf7~·. 7111.'1/ slldd('l/Iy, Ite's quiet. Olle officer {ouh
back at tlle prisoller (lIId SO}'S, "Tf/is
guy doeslI't look so S()()(I."
fA'lS is called (lm/mil/fltes later
til(' prisol/er is II/u/('r ti'e ("(m' (III
emagel/c)' rOO/11 team. Bul despite

or

JIIll1lerous aNempts 10 re"il't? lIim,
11(' dies.

rcad something like, "Man Dies After Fight with
Police." Such reports play on reader prejudice Ihat
all cops are brutal, and Ihal the police somehow
direclly caused the death.
But the truth is deemed a little less newsworlhy
and is cert<.linly much less sensational. The reality
is that many people who die in custody suffer from
one or more mcdical conditions that contribute
10 their mortality. Others havc high volumcs of
POLlCE 47

drugs in their hodies lhat cause adverse
physical reactions. Both conditions are
magnified whell the subject is confronted, :-iubdued, and restrained by law en~
forcement officers.
Much of the discussion over vhat is
commonly called in-custody dealh ilttempts to assign a single, uniform
cause. As a society, we want to blame
somebody or something for every unexpected death. This is why, over the
years, reporters and human rights advocates have pointed a finger at police
hand-to-hand combat techniques,
pepper spray, and now Taser weapons
as a primary cause of unexplained prisoner deaths.
Lacking in this analysis is an honest,
objective, factual di:-icussion of the phenomenon based on surveillance and
known llledical data. A growing body
of documented experiences, autopsy results, and data compiled by various
sources supports the theory that many
in-custody deaths are not the result of
a single cause but a cascade of lllultiple
factors that is often set in motion long before law enforcemC'nt ever gets involved.
In-custody death is nothing
ncw. A search of the medical
literature shows that various
reports and studies have
noted the occurrences of incustody death or syndromes
that closely mimic it in institutionalized patients dilting
back to the 1800s.
More recently, physicians
and medical examiners have
ascribed these tragedies to cocaine intoxication, restraint/positional asphyxia, and metabolic acidosis. Here is what
we do know. Medical post-mortem examinations generally support several
distinct factors contributing to many
in-custody deaths. In no specific order,
these include: cardiomyopathy, excited delirium, metabolic acidosis, stimulant abuse/overdose, and positional/restraint asphyXia. Keep in mind thai
any or all of these factors may affect a
single subject before, during, and after
an arrest.
Cardiomyopathy
Cardiomyopathy means that the person has a structural heart abnormality
that predisposes him or her to sudden
48 POLICE

cardiac arrest. This condition is often
not recognized in younger people until
it is found at autopsy. Abnormal heart
structure is ofteil an inherited trait.
However, there arc many lifestyle factors that can put a person at risk for developing the condition. These include
excessive alcohol or drug lise.
Because cardiomyopathy is often a
silent condition that can present problems during times of extreme exertion
such as fleeing law enforcement or re-

sisting arrest, it's a COllllllon factor in
many in-custody death cases. The most
likely symptoms are chest pain, shortness of breath, and/or the sensation of
an abnormal heart beat. However, it's
not uncommon for the person to die
so suddenly that no symptoms are re~
ported. Medical researchers are still not
entirely clear on how or why cardiomyopathy occurs or why it c.llIses
sudden death in some people and not
others.

laser Weapons and In-Custody Death
Often police who are confronted with subjects who are suffering from
one or more of the <onditions that contribute to in-custody death employ
an intermediate weapon to effect an arrest.
Th;s has led some civil rights organizations and popular media to conclude that there is a direct correlation between intermediate weapons and
in-custody death.
A recent inquiry shows that this is not the case. In more than 50 percent of
in-custody deaths over the last year, intermediate weapons were never used.
Of particular media interest are the conducted electrical weapons manu~
factured by Taser International. The Taser X26 and M26 stun pistols carried
by police have been the subject of much recent public discussion, fueled in
large part by some human rights organizations alleging that Taser application was the cause of death in more than
100 in-custody incidents.
It has never been scientifically proven
that a Taser has directly caused an in-custody death. The type and magnitude of
the electrical charge that the Taser employs makes this association extremely unlikely.
The Taser is a conducted electrical
weapon that incapacitates its target
through involuntary muscle contraction. It
achieves this with a short-duration charge
of 50,000 volts with extremely low amperage. This is the same type of shock delivered by a static discharge from a doorknob in your home.
OK. So if that's the case, why doesn't a static charge from a doorknob send
you crashing to the floor? The difference is that the Taser's charge is applied in
many repetitive cycles per second and that does not allow the external muscles
of the subject to voluntarily move during its application.
Since the Taser is an electrical weapon, if it were to directly cause death
from electrical shock, someone would succumb immediately upon contact
with it, just as if being struck by lightning or touching an overhead power
line. People who die from electrical shock typically succumb due to an immediate abnormal heart rhythm. Since the physical properties of electricity do
not allow it to be stored within the body for later use, you would not expect
to see someone die later from a direct electrical insult as a result of an irregular heart rhythm. This concept is well established in the medical literature.
In all cases that I have reviewed, subjects who have died after Taser exposure have died minutes, hours, and even days after the Taser was applied.
What this suggests is that the electrical stimulus did not cause death due to
heart rhythm abnormality. This finding is supported by a recent study that
demonstrated the Taser to have an excellent cardiac rhythm safety margin.
policemag.com August 2005

Excited Delirium
Another major facfor contributing to
in-custody deaths is excited delirium.
The term refers to a behavioral condition whereby a person exhibits
extreme,
Iy agit,ted and non-coherent behavior,
elevated temperature, aln~ exces\ive en-

Who Dies in Custody
A review of available media
sources reveals the following statistics about people who die in police
custody without trauma.

97%
were between
the ages of 34
and 44

11%

were shot with
chemical spray

8%
were hit with
impact weapons

27%
were Tasered

63%
went hands~on
with officers

53%

,.~
,!U

ingested
illegal drugs

60%
exhibited
bizarre behavior
before arrest
Note: Some subjects fit multiple
categories, so numbers are not
intended to add up to 100%

50 POLICE

dllr,lllce without fatigue. Excited delirilUll is often seen in the context of people under the influence of an illicit
stimulant substance such as cocaine or
in peaRle with a history of mental illness W\lO are not taking tlleir medica~
tion l?,r9perly.
Hcrc's hOWl medical authorities be~ieve that exc4ed delirium\ills. vmlr
body cal; only do so much bCfore it ....'ill
quite literally give out. Under n6rmal
conditions, your brain sends signals to
your body to calm down before somethil1g re111y bad happens. Hut a p~rson
e.xperiencing excited delirium does not
have this safety mechanism.
Because they are not fully aware of
reality, people experiencing ('xcited
delirium have taken their brains out of
the loop. It is believed thilt they (Ire able
to push themselves past the exh,lllstion
point into a potentially fatal medical
C{)l1dition known as metabolic acidosis.
The tHumn body is essentially a selfregulating machine. However, it can
only perform these functions up to ,I
cerWin level. Fortunately, the body
sends cues to the bmin when it's about
to rcdline and the brain sends back iI
signal to the body to slow down.
That's how it works under normal
conditions. But people experiencing excited delirium appear to be able to disregard these normal Clles of exhaustion
and can exceed theirextwuslion threshold by running, fighting with law enforcement. and continuing to resist
even after they are handcuff('d.
The wntinued struggling by these individuals worsens metabolic 'lcidosis. It
is believed that if till..' buildup of lactic
acid in the bloodstrealll is allowed to
become too .~evcre, the he,lrt will ex pcrietKe a dangerous rhytll III 1J<lltern that
is uniformly fatal and the subject will
die from rardiac arrest.
Thc biggest mystery about excited
delirium is why it OCCllTS in some people ,md not others. SolVing that will
help LIS keep more people alive.
Restraint/Positional Asphyxia
Metabolic acidosis is deadly, and it's
believed that certain other factors can
worsen the condition. These factors indude using restrictive restraint devices
such .:IS handcuffing behind the back
and/or the hobble tie, poor positioning
of the person once in custody such ;IS

laying thc prisoner face down, and having multiple officers on top of the person during tile restraint process.
All of these things have the potential
to restrict a person's ability to take normal breaths. Since breathing is the pri.
mary method o[ ridding the body of
waste factors quickly, it stands to reason
that restricting this process can injure or
~i\l someone, nut~hemedica'community is torn on the issuE.' of positioning
and restraints ~s contributing factors in
the sudden death of people in custody
because there have been studies demonstrating vari,lble effects of these f,lctors
on the process of metabolic acidosis.
Drug Abuse/Overdose
Another f,ICtor that is commonly reported in cases of in-custody death is
the acut(' ingestion of an illicit substance, usually in doses well over the
norlll for recreational users.
What is often discovered at autopsy
is that the subject ingested a massive
amount of drugs in an attempt to destroy or hide evidence. Subjects have
choked on packages of drugs that they
swallowed to avoid arrest and effectively suffocated themselves to death. Others who have successfully swallowed the
drugs or hid them in their rectums have
been unfortunate enough to have the
wrappers or bags break, and they have
absorbed massive doses of the drug.
If the subslilnce is a stimulant and the
dose is sufficiently large, the body experiences the eqUivalent of a l1lflssive
adrenalinc dump. This leads to the risk
of the Ill::art taking 011 an abnorlll,ll
rhythm which is almost uniformly
fatal, and the subject will die of cardiac
arrest.
In-custody deaths have ,tlsa resulted
from recreational stimulant use. It appears thilt long-term .1busers of illicit
stimulants (such as cocaine and
methampllCl<lmine) develop substantial
(·hangcs ill their brain. These changes
appear to correlate with .~ubstantiill risk
for dcwloping the condition.
Cascade Effect
PE.'ople who die unexpectedly in police custody often have more than one
of these conditions. In fact, it appears
that excited delirium is the result of a
lllllitifactori,llcilscade of events.
Thes(' factors 1TI,ly include but arc 110t
poticemag.com August 2005

limited to: se of illicit substances sllch
as cocail{e or methamphetamine, mis·
I ' substances such as alcohol
use of legal
and melha health medications. noncOlllplianc with prescribed medications suah a. failing to take some mental health medications, and physical
exertion SllC as resisting arrest.

Who Dies in Custody?
People w10 die shortly after arrest
withou trauma appear t~ have some
things in cormon. I hav~ conducted
an inquiry into this phenorcnon and
have rcJiewJt eight mOllt~s of in-clIst1dy de~th d}ta. The findin 'S of this in-

quID"" ,
•

·IT~:overw~.~llIling

\'-=i

maj rity 0}7%)

of peo.~e who\?ie suddenly ill police
custody are m<\l.¢s between 34 and 44
years old. The average age of these men
is 16.
Drug users who fight with police
before. during, and even after arrest.
may be showing signs of excited
delirium and could be prone to
sudden and unexplained death.

S4 POLICE

Circle No. 157 on Reader Service Card

policemag.com August 2005

• There does nol appear 10 be a geographic prevalence to these in<:ideilis.
• With regard to officer usc of force
issues, there appear to be two filctors
that have a high association with incustody death incidents: handcuffs and
empty-hand control tl'c1lni<lu/..'S.
Do not misread
, this data. This does
not me'1I1 that placing someone in
handcuffs or using empty-hand l'ontrol
tL>(:hniques are th causes of in,custody
deaths. It just shuws that people who
are confronted by ~lict· who ~re likely
to suffer an in-custody death ~n behave in\,.a manner that requires fficers
to go ha ds-on with them and
train
them.
Contra to popular belief and tlk
contention of Amnesty Internatibnal
and the Al1lebcan Civil Liberties Union,
my data sho~s that in-custody death is
lIot nCl'essarlly asJociated with the use
~
of intermediate l"'eaponry such as
chemie<ll sprays, Impact weapons, or
conductive siun \ capons such as the
TaSt..'r.
Of Ihe subjects hat I reviewed, I I
percent were spray with aerosolizl'<l

I

policemag.com August 2005

chemical spray, eight pen:ellt were
struck with an impact we'lImn, and 27
percent were subjected to a Taser application. To keep this in perspective,
it is also important to note that il full
63 percent of these subjects received
no application of an intermediate
weapon. Therefore, public calls for intermediate weapon moratoriums appear to be unjustified and are based
solely on anecdotal evideno: or speculative conjecture.
Police weapon usc does not appear to
be a pr('dictive factor for in-custody
death, but personal bcha~or does. The
same inquiry shows thatts3 percent of
people who die suddenly in police custody have ing~ed i1JiCi\ subStances
proximal to thei collapse. Additionally, in 60 percent 0 IJ -in-custody deaths
that I reviewed th subje('ts exhibited
odd or bizarre bel}i!Vior just prior to
their collapst'.
Exhibition of these behaviors appears
to correlate with an increased risk for
in-custody death. So it would behoove
any responding officers to keep this in
mind and consider sC'eking immediate

,

medical attention for any subject taken
into custody who fits this profile.

What Can You Do?
As law enforcement officers, it is imperative that yOll have a good understanding of the facts surrounding incustody death. If you know what to
look for, you Illay be able to take i.cHon
that will save the subject's life.
Police administrators should dictate
that when a subjed is encountered who
is exhibiting some of the danger signs.
the officers involved should lise every
means available to immediately bring
the person under control. Allowing the
subject to continue to exert himself
through agitated and resistive behavior
only heightens the risk for sudden car·
dial' death from metabolic acidosis.
If a subject continues to resist, despite
being in restraints, it is imperative that
you recognize this as a potential medical emergency. The subject needs
prompt evaluation by emergency medical personnel.
Additionally, until the debate on position and restraint is definitively set·

Circle No. 195 on Reader Service Card
POLICE 55

Sometimes cops have
no other choice but to
place an arrested
subject on his or her
stomach, but care
should be taken to
prevent positional
asphyxia.

tied, it is recon ne ded
that officers avoid placing
the subject in any type of
position or restraint that
could impair the ability of

the person to breathe
normally. This includes
avoiding devices such as
anti-spit face masks and
the usc of multiple offiecrs to pin the person on
the ground.
It would also behoove
individual agencies to ensure that their emergency

and medical communities arc educated
in the potential G1USl'S of in-custody
death. There have been numerous cases
of subjects experiencing excited delirium that is mistaken fOr psychiatric illness. The subject is then taken to a psychiatric faCility where he or she
subsequciltly d·es. Persons exhibiting
cxcited delirium Should IX' rushed to an
e!llcrgencx dc~artme.nt, noLa-..lnental
health c{'me.
By learniJl q to recognize the warning
signs and subject profiles of persons at
risk for sudden in-custody death, you
will be armed with important informa+
tion. You will also realize that such
deaths are the result of multiple factors
and conditions, and they may be preventablc to some degree. Armed with
this information, you can save lives. $Dr.feffrey Ho is 11 board-cuririI'd ell/erselic)' metfic;lIc plwsiciall (lml (l liei'meeligible peace officer. He lias been iI/vvlved willi caring (or St'l'C!ml actl/al mul
lIe(/r-lJIis.~ ill-clis/ody (/mtJt

:wIJjects. Dr.
Ho (-OI/StIItS witll/aw tm(orcellll'IJI asell-

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Circle No.210 on Reader Service Card
56 POLICE

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