DALLAS — Police found 23-year-old Jose Romero in his underwear, screaming gibberish and waving a large kitchen knife from his neighbor's porch.
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Romero kept approaching with the knife, so officers shocked him repeatedly with a stun gun. Then he stopped breathing. His family blames police brutality for the death, but the Dallas County medical examiner attributed it to a disputed condition known as "excited delirium."
Excited delirium is defined as a condition in which the heart races wildly — often because of drug use or mental illness — and finally gives out.
Medical examiners nationwide are increasingly citing the condition when suspects die in police custody. But some doctors say the rare syndrome is being overdiagnosed, and some civil rights groups question whether it exists at all.
"For psychiatrists, this is a rare condition that occurs once in a blue moon," said Warren Spitz, a former chief medical examiner in Michigan. "Now suddenly you are seeing it all the time among medical examiners. And always, police and police restraint are involved."
Excited delirium came to doctors' attention in the 1980s as cocaine use soared, said Vincent DiMaio, chief medical examiner in Bexar County, Texas, and a proponent of the diagnosis. No reliable national figures exist on how many suspects die from excited delirium because county medical examiners make the ruling, and some use different terminology.
In Dallas, at least three in-custody deaths in the past five months have been linked to excited delirium. This prompted the police department to start offering mental health assessment training they say will stem the sudden deaths.
Other police departments, including San Diego, have done the same to try to prevent community protests and costly lawsuits. In Phoenix, a jury awarded $9 million in April to the parents of a suspect whose death was attributed to excited delirium.
The condition, described as an overdose of adrenaline, largely affects men with histories of drug use or mental illness, DiMaio said. He said most cases are triggered by drugs such as cocaine and methamphetamine.
The drugs elevate blood pressure and heart rate, and the increase is pronounced if a person is experiencing paranoia, hallucinations and violent impulses, DiMaio said.
Police often respond to calls of sufferers stripping off clothes to cope with a soaring body temperature, breaking glass and threatening others. The officers and the suspect struggle, and the excitement stresses the suspect's heart until it fails, DiMaio said.
"You are gunning your motor more and more and more, and it is like you blow out your motor," said DiMaio, who estimates that the condition kills as many as 800 people nationwide each year. "You are just overexciting your heart from the drugs and from the struggle."
Medical examiners and emergency room doctors know the syndrome well, but psychiatrists seldom see it because sufferers almost always die before they can get mental help, DiMaio said.
The chief psychiatric reference book, The Diagnostic and Statistical Manual of Mental Disorders, does not specifically recognize "excited delirium" as a diagnosis. The International Association of Chiefs of Police says not enough is known about it.
"It is not a recognized medical or psychiatric condition," said spokeswoman Wendy Balazik. "That is why we don't use it and have not taken a position on it."
Dr. Matthew D. Sztajnkrycer, an emergency room doctor for 10 years and associate professor at the Mayo Clinic in Minnesota, said he has seen cases of excited delirium but has many questions about it.
"It is not like a heart attack where you can just get a blood test and know you have the right diagnosis," he said. "Part of the problem is that post-mortem there is a paucity of physical evidence."
He said more research is needed to understand excited delirium and how commonly it occurs. Then doctors can better diagnose it and police can learn how to handle it, he said.
Controversy over role of police
Spitz and other critics say the condition is questionable because it almost never occurs without police restraint techniques.
"By explaining deaths with excited delirium, it takes the focus away from where it should be," said Dawn Edwards, director of PoliceWatch at the Ella Baker Center for Human Rights in Oakland, Calif. "What it comes down to is the policemen, at the time of the death, were using excessive force."
But even critics like Edwards praise the Dallas plan, which they say could also curb brutality.
It calls for an ambulance any time a suspect is behaving erratically, and mental-illness training for police, 911 operators and dispatchers.
Instructor and Senior Cpl. Herb Cotner said officers will learn to defuse encounters with mentally ill suspects by slowing things down, using suspects' first names and trying to avoid the use of force.
Cotner recalled a suspect years ago who appeared in the throes of excited delirium. The man scaled a six-foot wrought-iron fence, tore his leg open, raced on for several blocks and almost bit off a fireman's finger, Cotner said. He fought police who were trying to restrain him and provide medical care. Then his heart stopped, and he died in the street.
"Call it anything you want, it doesn't matter," Cotner said. "I know these people exist. I have handled these people."
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