Report on Conducted Energy Weapons and Excited Delirium Syndrome

Written by:

Sergeant Bruce Stuart, BA
Royal Canadian Mounted Police
Chris Lawrence, MA
Ontario Police College
Force Science Research Center
Minnesota State University-Mankato

Reviewed by:

Christine Hall, MSc MD FRCPC
Canadian Police Research Center
Principle Investigator RESTRAINT Study

October 29, 2007

Executive Summary

The concept of Intermediate Weapons developed in the United States in the 1980s. Canadians adopted this terminology in the 1990s. Intermediate Weapons filled the gap between physical control tactics and lethal force. It was recommended by RCMP Staff Sergeant Peter Sherstan, in his March 2000 report entitled Conducted Energy Weapons (CEW): An Overview of the M26 Advanced TASER®, that this weapon would meet the needs of the RCMP as an effective Intermediate Weapon.

On May 17, 2000, the Conducted Energy Weapon Evaluation Project (CEWEP) was approved by the Assistant Commissioner – Community, Contract and Aboriginal Policing Service (CCAPS). The primary objective of the CEWEP was to assess the effectiveness and suitability of the M26 Advanced TASER® for use by RCMP members. The project consisted of three distinct elements: a technical assessment of the M26 at an independent research laboratory, the testing of the M26 on volunteer subjects, and a six month field trial. The CEWEP recommended the M26 Advanced TASER® be adopted as a less lethal response option by the RCMP. On December 20, 2001, operational policy was published authorizing deployment.

A very important aspect of the CEWEP was the study comparing the M26 with a firearm. Nineteen members underwent 22 exposures where they attempted to fire a blank-loaded pistol, with their finger on the trigger, after the deployment of the CEW. In 11 of the 22 tests, the subject discharged the firearm. Two subjects reported that the discharge was involuntary and as a direct result of the muscular contractions they experienced when exposed to the TASER®’s conducted energy, and not a wilful act on their part.

As a general guideline, the M26 versus Firearm Test indicates that the M26 IS NOT an appropriate intervention option when dealing with individuals armed with a firearm. This was an important factor in considering where use of the CEW would be placed within the Incident Management/Intervention Model.

In May 2003, the manufacturer released the second generation TASER® X26, designed as an improvement on the M26. The evaluation process consisted of two phases of field evaluation to determine reliability of the X26. On October 21, 2005 the TASER® X26 was approved for use and policy amendments were incorporated.

Policy and reporting structures are a method of public accountability and evolve constantly. The most recent CEW policy was published on August 8, 2007. This policy has incorporated new components and bolstered others based on new information derived from the latest research. It was one of the first to involve consultation with the Commission for Public Complaints Against the RCMP (CPC) and they have endorsed it. The continuous evolution of RCMP policy development is based on the most current medical, scientific and legal research available. Ongoing environmental scans and risk assessments assist in identifying policy areas requiring amendments and or enhancements. As well, the RCMP promotes and ensures research efficiencies by collaborating with the Canadian Police Research Center (CPRC), Canadian Association of Chiefs of Police (CACP) and others on various studies.

Reporting methods evolve just as policies do. Initially, CEW reporting was completed through a member’s notes and by informing a supervisor. This evolved to the creation of a specific CEW reporting form and electronic data base where the completed form would be immediately captured.

CCAPS is currently developing policy with respect to Excited Delirium Syndrome (EDS). This policy includes operational guidance and investigational protocols should there be a sudden death. CCAPS is developing Subject Behaviour/Officer Response Reporting policy. This will allow a standardized reporting method which will capture all intervention options used in response to subject behaviours. Because this type of reporting will be stored within the electronic operational records management systems, the RCMP will be able to gather all of the contextual information relevant to the officer’s response to a subject’s behaviour. It is felt that this method of reporting will lead to a greater standardization in use of force articulation

Health issues directly attributed to the CEW consist of minor burns and abrasions which often heal within 2 to 3 days and do not require hospitalization. Other health issues are associated with the probes becoming embedded in sensitive areas such as the subject’s face, throat, or groin. There is also the potential for what have become known as “secondary injuries” relating to CEW use from the subject falling to the ground or falling from heights.

To date there have been approximately 270 deaths worldwide including 17 Canadian deaths proximal to CEW use since 1999. It is difficult to count these events accurately because there is no independent central registry or organization systemically collecting this data. These numbers are largely based on media reports.

Critics have pointed to the CEW as being a lethal intervention option, contrary to the manufacturer’s assertion and police experience. Various methods of restraint have been the subject of blame for sudden, unexpected deaths. In the 1980s the cause of in custody deaths was believed by many to be the use of neck restraints, in the 1990s both Oleoresin Capsicum spray (pepper spray) and prone restraint (hog tie) were blamed. Subsequent medical research into these methods of restraint failed to prove a causal link. The original research surrounding positional asphyxia has subsequently been retracted or scientifically refuted. Currently, CEWs, specifically the TASER®, are now under scrutiny for the association between CEW and in custody death. To date, despite an ongoing and a growing body of independent analysis, no researcher has proven either a causal relationship between CEW and in custody death, or a viable physiologic method for a CEW application facilitating an in custody death. While the various methods of restraint are all different, the characteristics of the person requiring restraint who subsequently suffers in custody death are strikingly similar.

The Canadian Police Research Centre (CPRC) did a literature review in 2005 of current CEW research, entitled Review of Conducted Energy Devices (CED), and concluded the following:

• Definitive research or evidence does not exist that implicates a causal relationship between CEDs and death.
• Existing studies indicate that the risk of cardiac harm to subjects from a CED is very low.
• Excited delirium (ED), although not a universally recognized medical condition is gaining increasing acceptance as a main contributor to deaths proximal to CED use.
• The issue related to multiple CED applications and its impact on respiration, pH levels, and other associated physical effects, offers a plausible theory on the possible connections between deaths, CED use, and people exhibiting the symptoms of ED.

Seven research abstracts were presented as poster sessions at the American College of Emergency Physicians Research Forum, October 8-9, 2007 in Seattle, WA, all addressing the effects of TASER® on human physiology. While the posters were not peer reviewed prior to their presentation, Dr. Jeff Ho, Department of Emergency Medicine Hennepin County Medical Center, Minneapolis, MN, stated at the Excited Delirium Expert Panel, International Association of Chiefs of Police Convention, that his studies are either being written for publication, being peer reviewed or are in press. None pointed to any adverse effects of the CEW on human physiology.

Excited delirium syndrome is an acute condition with multiple potential underlying causes. It can progress rapidly to cardiopulmonary arrest and death in individuals who are struggling violently and are then subdued, either in the pre-hospital or hospital setting. Most reported cases of sudden and unexpected death proximal to restraint seem to involve young men in an “excited” state or one of “agitated delirium” as a result of psychiatric illness or intoxication from illegal drugs, or both.

Dr. Wetli, MD, a retired physician and chief medical examiner who is an internationally recognized expert on EDS, provides a comment on the way forward with respect to understanding better the problem of sudden, unexpected deaths following an altercation with police, indeed, whether or not a CEW was used.

Because of the behavior associated with excited delirium, death often occurs in police custody after a violent confrontation, and the mechanism of death is of intense practical interest. These are legitimate questions that deserve scrutiny to be sure, but the scrutiny must be based on sound, objective investigation with scientific support. Assumptions and “junk science” lead to specious theories and, sometimes, at least, to civil injustice. In the meantime, police managers must cope, police officers must act, and scientists must continue to investigate.

Dr. Christine Hall is a full time emergency department physician at the Vancouver Island Health Authority at the Victoria General Hospital and the Royal Jubilee Hospital who also holds a Master’s Degree in Clinical Epidemiology, and is an internationally recognized expert in EDS. She is already in the early stages of the RESTRAINT Study (Risk of Events in Subjects That Resist: prospective Assessment of Incidence and Nature of ouTcomes), the particular type of research that Dr. Wetli mentions. Assisting Dr. Hall to expand her study with appropriate funding may provide the answers so desperately needed.

Police are encountering cases where people are dying in circumstances where everyone involved would agree that death is not anticipated. The problem has devolved into one of public trust in the police and government authorities. Further, there is no consistent vocabulary applied to these events or understanding of their elements. Canada is uniquely positioned to take a leadership role in advancing a solution to an international problem which seems, in retrospect, to involve some of our most misunderstood citizens. The costs of establishing consistent language, a common appreciation, and best practices when managing these events may seem challenging, but pale in comparison to the cost of an uncoordinated response, the subsequent inquiry, and civil litigation if this is not done. What should never be forgotten is the tragic pain the family endures from the debate and confusion that is allowed to persist.

Presently individual cases of this kind seem to be a rare occurrence within most police environments. On a national scale, however, these deaths may seem to be occurring more frequently which raises public awareness and fuels considerable criticism of the police response and concurrent government oversight. Researchers have little doubt that the denominator for these occurrences can be more clearly understood and the mechanism of death better evaluated. To offset this growing perception, the following three action items are presented:

National funding for research and studies relative to the Conducted Energy Weapon and Excited Delirium Syndrome.

• The Canadian Police Research Centre (CPRC) has indicated that there should be a follow-up literature review of CEW research completed since their last report of 2005. This would provide a Canadian perspective on CEW research.
• The CPRC is currently working on a two year RESTRAINT Study, the first of its kind in the world led by Dr. Christine Hall. This is a prospective study (a study designed to follow participants forward in time rather than retrospectively).

A forum to provide a national perspective on problems related to sudden, and unexpected deaths following restraint.

Sudden, unexpected death following a restraint process is not exclusive to policing. This problem has been identified as occurring in medical settings for over 150 years. It would be prudent to gather a team with a variety of perspectives who could explore potential solutions from various areas. The suggested list could include:

• medical, academic and practical experts experienced in dealing with this problem;
• senior provincial health ministry representatives;
• provincial Chief Coroners;
• the Schizophrenic Society of Canada;
• the Centre for Addiction and Mental Health;
• the Canadian Medical Association;
• the Canadian Psychiatric Association;
• the Canadian Nurses Association;
• the Paramedic Association of Canada;
• the Canadian Police Association;
• the Canadian Association of Chiefs of Police

The funding would cover the venue and gathering of the necessary expertise to facilitate this forum. It could take the form of presentations to address the central issues with discussion and an action plan to follow. It is recommended that the CPRC be approached to facilitate this forum.

Creation of a national Use of Force Centre of Excellence

The creation of a centre comprised of use of force subject matter experts from a cross section of Canadian law enforcement agencies, committed to creating best practices in police use of force would allow for law enforcement agencies to work together creating consistent standards and/or developing best practices that could be used nationally.

Preface

Various methods of restraint have been the subject of blame for sudden, unexpected deaths. In the 1980s the use of neck restraints, in the 1990s both Oleoresin Capsicum Spray (pepper spray) and prone restraint (hog tie) were thought responsible. CEWs and specifically the TASER® are now being implicated in these deaths. While the various modalities of restraint are all different, the characteristics of the people requiring restraint are the same. The deaths have been associated with what has become known as Excited Delirium (ED), or more accurately Excited Delirium Syndrome (EDS). EDS is neither a diagnosis nor a cause of death. There seem to be consistent characteristics but variable underlying medical problems in people experiencing EDS.

Many law enforcement agencies throughout the world, including the RCMP, have come under criticism as a result of sudden unexpected deaths or deaths following police restraint. Current expert consensus indicates that the use of the CEW followed by a quick and effective method of restraint may be the best intervention method in order to gain control and provide medical assistance for individuals displaying EDS. This strategy was affirmed on October 14, 2007 by an expert panel presenting to the International Association Chiefs of Police (IACP), Police Physician Section in New Orleans, LA ( C. W. Lawrence, personal communication, October 20, 2007 ). The recent death of Robert DZIEKANSKI at the Vancouver International Airport has once again raised public concern in the use of CEWs and sudden, unexpected death.

The RCMP is in constant contact with practical, academic and medical experts both in Canada and abroad who are on the cutting edge of both CEW and in-custody death research, including Excited Delirium Syndrome. Canada is seen as a world leader in the area of first responder, medical protocols, and training relating to excited delirium. One professional in this field is Dr. Christine Hall, a full time emergency department physician at the Vancouver Island Health Authority at the Victoria General Hospital and the Royal Jubilee Hospital who also holds a master’s degree in epidemiology. She has reviewed research and co-authored literature reviews on the safety of CEWs, and is the principal investigator of the ongoing RESTRAINT Study (Risk of Events in Subjects That Resist: prospective Assessment of Incidence and Nature of ouTcomes). Another internationally noted expert in the area of EDS, in-custody deaths and restraint tactics is Chris Lawrence. Mr. Lawrence is currently a project partner at the CPRC, a technical advisor to the Force Science Research Center at Minnesota State University and Team Leader Defensive Tactics Section, Ontario Police College. Mr. Lawrence holds a master of arts degree from Royal Roads University, where his thesis was entitled “Police Response to Excited Delirium.”

Many medical and academic experts, including Dr. Hall and Mr. Lawrence have been attempting to evaluate these deaths in context considering all details rather than focusing on method of restraint.

This document will provide the following information:

• A historical perspective of the CEW within the RCMP;
• RCMP policy development process and related policies;
• Risk issues associated with the CEW;
• CEW and EDS research
• Recommendations on the way forward.

History of CEWs in the RCMP

Conducted Energy Weapons come in different forms and are manufactured by different companies. Some devices are produced for the average citizen (e.g. Nova Consumer Spirit Stun Device; Storm Stun Gun), others are used to prevent prisoner escape (e.g. secpro XR5000 Inmate Stun-Belt), while others are more specific to front line law enforcement (TASER™ and Stinger S-200™). The only CEW deployed by the RCMP is manufactured by TASER International of Scottsdale Arizona.

The original TASER® device, model TF-76, was invented by retired NASA scientist Jack Cover, who rolled his initial business efforts into a company known as TASERtron. Inc. In 1993, brothers Rick and Tom Smith approached Cover who agreed to form a partnership with their ICER Corporation. In December of 1994 the AIR TASER® 34000 was developed for release to the law enforcement market. Ultimately in late 1999 the ADVANCED TASER® M26 emerged from a reorganized company, known as TASER International. The TASER® X26 debuted in 2003 (Taser International, (2007). Appendix 1, An Introduction to TASER® Electronic Control Devices, History, Electricity, Electrical Stimulation, Electrical Measurements, and the Human Body ). At the time of this report, the only CEW deployed by the RCMP is manufactured by TASER International.

The concept of Intermediate Weapons developed in the United States in the 1980s. Canadians adopted this terminology in the 1990s. Intermediate Weapons filled the gap between physical control tactics and lethal force. This class of weapons was to be deployed when physical control tactics were ineffective or unsuitable to the situation and deadly force was not justified. Traditionally Intermediate Weapons consisted solely of police batons. Oleoresin capsicum and CEWs are now generally classed as Intermediate Weapons.

The National Tactical Officers Association (NTOA) has adopted the following philosophy of less lethal force:

a concept of planning and force application, which meets operational objectives, with less potential for causing death or physical injury than conventional police tactics.(National Tactical Officers Association, (2004). Sample Policy for Less-Lethal Extended Range Impact Devices (8B). Doylestown, PA.).

In 1998 Staff Sergeant Peter Button of the Toronto Police Service authored a 55-page document entitled “Less-Lethal Force Technology.” One aspect of the Button report that must be considered is that of the ideal less-lethal weapon. Button has set out six criteria that are central to an effective less lethal device:

1. temporary effect;
2. minimal medical implications;
3. high probability of instantaneous control;
4. effective on the highly motivated;
5. observable effects;
6. ideally only affect the intended.

RCMP Staff Sergeant Peter Sherstan had reviewed events in Alberta which he felt could have been resolved through the use of a CEW without the use of lethal force or less injurious means. As a result, it was recommended by Sherstan in his March 2000 report entitled “Conducted Energy Weapons: An Overview of the M26 Advanced TASER®” that this weapon would meet both the NTOA’s less lethal definition and achieve each of the six criteria outlined by Button.

Sherstan’s position paper on emerging less lethal intervention options was eventually forwarded to the OIC (Officer in Charge) Contract Policing. On May 17, 2000, the Conducted Energy Weapon Evaluation Project (CEWEP) was approved by the Director - Community, Contract and Aboriginal Policing Service Directorate (CCAPS), Assistant Commissioner Dave Cleveland. Financial resources were provided by HQ Contract Policing, the Canadian Police Research Centre (CPRC), and “E” Division and “F” Division. Human Resources, in the form of the project coordinator and certified TASER® Instructors, were provided by “K” and “E” Divisions.

Conducted Energy Weapon Evaluation Project (This report is an internal RCMP/CPRC document. The comments herein are paraphrased from the original.)

The primary objective of the CEWEP was to assess the effectiveness and suitability of the M26 Advanced TASER® for use by RCMP members.

The project consisted of three distinct elements: a technical assessment of the M26 at an independent research laboratory, the testing of the M26 on volunteer subjects, and a six month field testing component. Independent laboratory research was conducted by Bodycote Ortech Laboratory in Mississauga, ON. This facility is a Standards Council of Canada accredited laboratory.

Concurrently, the RCMP contracted with Mike Mandel of Brain Software, a leading human communication specialist to develop a phrase which would generate an effective verbal command, similar to the Police Challenge that would accompany the use of a CEW. The phrase developed is “Stop or you will be hit with 50,000 volts of electricity” and was designed to reorient a subject’s behaviour, causing them to de-escalate, and eliminating the need to fire the weapon.

Quality assurance of Output

The five samples tested met the electrical current specifications of the manufacturer. This is an important finding in that all medical opinions are based on the assumption that the manufacturer’s specifications are consistently reproduced by the M26.

Variances of Barrier

The amount of CEW current which would reach a subject was reduced as clothing barriers were introduced. However, even when significant barriers (five layers of clothing) were introduced between the M26's probes and the high voltage measurement device, a significant amount of current still penetrated this barrier. This was important to determine from a training perspective as it could affect a member’s decision to deploy the weapon based on what a subject was wearing.

Variances of Temperature

The conducted energy output of the select devices was tested over a range of +40º to -30 º C, ensuring operational capability across the range of RCMP geographic realities.

Humna Subject Testing

A total of 110 individual tests were conducted using 104 law enforcement volunteers (five individuals participated in more than one test) at the RCMP Training Academy, Regina, SK. in July, 2000. The device was found to be effective in 89 percent of the tests. Effectiveness was determined by a subject, armed with a simulated edged weapon, being unable to advance toward a target located five metres distant.

M26 vs. Firearm

Nineteen members underwent 22 exposures where they attempted to fire a blank-loaded pistol, with their finger on the trigger, after the deployment of the CEW. In 11 of the 22 tests, the subject discharged the firearm. Two subjects reported that the discharge was involuntary and a direct result of the muscular contractions they experienced when exposed to the CEWs conducted energy and not a wilful act on their part.

As a general guideline, the M26 versus Firearm test indicates that the M26 IS NOT an appropriate intervention option when dealing with individuals holding a firearm.

OC Spray vs. M26

Eighteen members were exposed to both OC spray and the Advanced TASER® M26. They were required to complete a series of police related tasks after being exposed to each weapon system. In summary, all candidates were able to complete tasks after exposure to OC spray while none were able to after exposure to the CEW.

Probe Spread vs. Effectiveness

The relationship between a variance in distance (probe spread) between the upper and lower probes and the effectiveness of the CEW was evaluated. It was determined that the greater the probe spread, the greater the greater the human tissue that will be affected by the conducted energy (e.g. 10 cm spread = mild incapacitation; 37 cm. spread = delayed but total incapacitation).

Simultaneous Discharge (Double Hit)

To demonstrate the effect of a simultaneous discharge of two M26 Advanced TASER®s on a human subject two volunteers who had previously experienced numerous exposures to the M26 were subjected to the conducted energy of two separate M26 Advanced TASER®s discharged at the same time.

Both subjects reported that the effects of the “double hit” were the same as an exposure to a single M26 device. They reported no increase in pain or dysfunction but that the relative intensity was more noticeable since a larger muscle area was engaged by the current. Neither subject reported any negative after-effects from the double hit. The concept of a double hit can be compared to two 100° F cups of water combined into one container; the water does not increase to 200° F. The same is true for electrical output.

Wind Effects

This test was an attempt to determine the effect of a perpendicular wind on the point of impact of the probes fired from an M26 Advanced TASER®. As the perpendicular wind speed increased, the point of impact of the TASER® probes, when compared with the point of aim, was adversely affected.

Flammability

The test was designed to demonstrate the effect of arcing conducted energy from an M26 Advanced TASER® on RCMP issued OC spray, gasoline, and a liquor containing 40 percent alcohol. Deployed probes were then placed in contact with the test liquid/vapours and the TASER® was then activated.

TASER International, (2007). Appendix 1, An Introduction to TASER® Electronic Control Devices, History, Electricity, Electrical Stimulation, Electrical Measurements, and the Human Body.

National Tactical Officers Association, (2004). Sample Policy for Less-Lethal Extended Range Impact Devices (8B). Doylestown, PA.

This report is an internal RCMP/CPRC document. The comments herein are paraphrased from the original.

The RCMP issue OC spray (Defense Technology 10 % Oleoresin Capsicum in MK-3) did not ignite when in contact with the arcing CEW current. NOTE: At the time of this test this OC spray was the only approved product. Since that time SABRE Defense has been deployed. Other reliable sources have tested this product and determined it is not a fire hazard when deployed with either the M26 or X 26 (Toronto Police Service).

However, when working with other law enforcement agencies, which may use different products this may not be the case. Each individual agency must test their own chemical agents and aerosol irritants to determine if their departmentally issued products are flammable.

Probe Removal

Dr. Warren Dufour, Health Services Officer at the RCMP Training Academy, evaluated the safety of the M26 device and the safety of probe removal and found:

The TASER appears to be a safe, efficient method of subduing suspects in certain circumstances. No untoward physical or emotional effects were seen either acutely or in follow-up. Dart removal using a Kelly forceps is quick, relatively painless and does not cause excessive tissue trauma. In addition, after having personally experienced the effects of both capsicum spray and TASER, I can state that while neither experience is pleasant, at least the effects of the TASER dissipated quickly and allowed me a rapid return to normal activities.

Miscellaneous tests

The following aspects of the CEW were also evaluated:

• Moving vs. Stationary: less chance of subject avoiding CEW deployment if the subject is stationary rather than if moving;
• Water: the CEW effect is not increased if the subject is wet or standing in water;
• Methods of Carry: various methods of carrying the CEW, from holsters to pouches, were evaluated.

CEW Field Testing

As part of the CEWEP, six general duty detachments and two Emergency Response Team facilities were selected as test sites where the CEW was to be deployed (29 devices) in a limited manner. Selected members were trained consistent with the manufacturer’s recommendations and the practices and policies of the RCMP, and consistent with the Incident Management/Intervention Model (IM/IM) and the Public and Police Safety Program as created by Learning and Development.

During the course of the field testing, another six detachments independently funded their participation in the project. An additional 116 members were trained as CEW operators and another 15 CEW devices acquired. The equipment, training, and reporting procedures for these detachments were exactly the same as that of the original test group. All data generated from these supplementary detachments was included in the final assessment process.

The field testing began on July 7, 2000 and terminated on April 23, 2001. This test resulted in an effectiveness rating of 86 percent. Ineffective usages in Probe Mode were attributed to:

• clothing barriers
• operator error (operator missed target)
• low batteries
• cartridge misfire or malfunction.

CEW Related Injuries

Acquiring specific medical data on the injuries received due to physician patient confidentiality was difficult. However, based on the limited medical reports acquired through the subject’s written consent, members’ observations, and in the absence of public complaints it appears the most serious confirmed injury in one incident were two sutures required after probe removal. A number of first-and-second degree burns were noted on subjects who volunteered in the study. Typically, these were less than 3 cm. in size and disappeared in one to three days.

Mental Health Considerations

A total of 26 incidents were recorded where the CEW was used in situations where the person was experiencing a mental health crisis state. Both the British Columbia Schizophrenia Society (BCSS) and the Schizophrenia Society of Alberta (SSA) closely monitored the CEWEP and the actions of other police forces using CEW technology. Both passed resolutions supporting the use of CEW by police in an effort to reduce the incidence of injury and death within their client base.

Medical Opinion

In addition to the comments of Dr. Dufour, medical opinions on the CEW were sought from other physicians including Dr. J.P. Legault, Chief Occupational Health Programs, National Health Services Policy Centre and Dr. Peter Guerra, Institut de Cardiologie de Montreal. All three physicians agreed that the CEW is a safe and effective piece of police technology. Dr. Legault’s conclusion was:

The use of the M26 Advanced TASER under an approved “less lethal” use of force protocol by trained police officers knowledgeable of the possible medical consequences and how to deal with them, should result in significant overall injury-reduction when dealing with the arrest of violent suspects.

Legal Opinion

Nothing in the Criminal Code or existing case law precludes the use of a CEW by police officers (prohibits use by civilians) if used in a reasonable manner.

CEW Use by Other Police Forces

At the time of the CEWEP report, over 800 law enforcement agencies had either adopted or were in the process of evaluating the M26, including major Canadian police services.

Other factors addressed within the CEWEP included the scope of training and distribution of the weapon to members in the field and a training plan.

CEWEP Study Recommendations

It was recommended that:

1. The M26 Advanced TASER® be adopted as a less lethal response option by the RCMP;
2. Those operational units which already have the M26 Advanced TASER® and trained operators be authorized to continue operational deployment until such time as a final decision has been made.
3. A three-year plan be adopted to assure a timely “roll out” of this less lethal technology to front lines of service delivery.
4. An individual be identified and tasked with the responsibility of implementing this process.

The CEWEP was described by the president of TASER International as the most extensive evaluation process of its product undertaken by any law enforcement agency in the world. In addition to replicating tests to confirm or deny the information supplied by the manufacturer, the CEWEP conducted additional testing specific to the environments in which our members work.

On December 20, 2001 operational policy was published authorizing deployment of TASER® M26, Model 3400 for operational use. Policy regarding Model 4400 was published on June 23, 2004.

TASER® X26

In May 2003, the manufacturer released the second generation TASER® X26, designed as an improvement on the M26. CCAPS coordinated an evaluation of the X26. This initial evaluation (field test) involved only six devices and concluded with three devices having failed (Phase I). Consequently, CCAPS initiated a second evaluation process (Phase II) to determine if the findings of Phase I were sound and to establish the reliability of the X26. Twenty-two X26 units were involved in Phase II and only two failed. Phase II confirmed that the X26 was a reliable and effective intervention option. On October 21, 2005 the TASER® X26 Model 26001 CEW was approved for use in accordance with the principles of the IM/IM. It was noted that the RCMP CEW course training standards are interchangeable for both the M26 and X26 users.

The differences between the two devices, from an operational perspective, were so small that almost no policy changes were required. Training was adjusted to incorporate subtle changes between devices. Policy amendments were incorporated August 8, 2007.

The current approved model number is TASER® X26E (Law Enforcement) Model 26012.

The RCMP currently has 1703 TASER® M26s and 1077 TASER® X26s deployed across the country.

The Accountability Process: Policy, and Reporting

“Use of force policies equal accountability and robust reporting protects citizens, officers and departments.”
Scott Greenwood, Attorney at Law and General Counsel for the American Civil Liberties Union

“Any new technology—and in particular, one that has the potential to cause injury and possible death—must be carefully assessed using whatever reliable information is available. That assessment can help law enforcement agencies develop effective policies in their own jurisdictions and at the same time foster accountability by addressing apprehensions of the public”.
US Department of Justice, Office of Community Oriented Policing Services (2006), Conducted Energy Devices:  Development of Standards for Consistency and Guidance The Creation of National CED Policy and Training Guidelines by James M. Cronin and Joshua A. Ederheimer.

Based upon the initial research and testing completed in the CEWEP, the RCMP completed policy development for the CEW. The RCMP develops policy at various levels throughout the organization, from a national, divisional, regional, and unit perspective. This ensures every aspect is covered at the required level of operations. The Operational Policy Section, CCAPS is responsible for the creation of all national operational policy. This is completed using a thorough consultative process, in order to facilitate capturing the wide variety of needs throughout the country.

Policy and reporting structures are a method of public accountability. As with any new technology, new research and data must be captured and reflected in the policies. As such, policies are constantly evolving as are the methods of creating them. The goal is to establish a process which ensures transparency and accountability for our organization to the public.

An operational policy development check sheet has been developed for the drafting, review, and amendment of existing operational policies. This process is seen as a best practice with the end result being sound policies, which provide guidance for operations and public accountability.

The following is the current process used for the development of operational policy:

CHECKLIST FOR NEW POLICY (Updated March 2007)
CCAPS - Operational Policy Section (OPS)

POLICY:
ANALYST ASSIGNED:
DATE:

(Case law, legal amendments, civil suits, new technologies, public complaints and best practices are but some of the driving factors for creation/change to national policy.)

NEEDS ANALYSIS: During needs analysis consider completion of Formal Risk Assessment process (C/Supt. Brian Roberts).

RCMP POLICY NATIONAL: Assess existing OM national policy.

POLICY BULLETIN: Before amending an existing chapter, check for existing bulletins retained within the chapter which may be incorporated, amended or deleted as required. Consider issuing a bulletin if the new policy (or policy amendment ) is urgent.

RCMP POLICY DIVISIONAL: Assess OM divisional policy - (determine if it can be incorporated into national policy)

OTHER POLICE POLICY: Enquire with other police partners concerning their policies. [International (IACP data base)/Provincial/Municipal]

PPS: Confer with Policies and Publications Section (PPS) to determine what other policy centres may be affected.

DRAFT: Prepare draft, adding appropriate references to policy. Mark the draft as a “DRAFT COPY” (watermark) including the date of the draft in the watermark.

LEGAL: Forward policy through appropriate channels to obtain a legal opinion (if applicable.)

SYNERGY CHAMBER: Disseminate/meet with OPS unit members for comments and suggestions.

SRR: Forward the translated draft to the SRR’s (through Mr. Andre Latour, Director, SRR Program).

OCCUPATIONAL/MEMBER SAFETY: Policies with a safety component must be forwarded to the Occupational Health and Safety Directorate.

POLICING AGREEMENTS SECTION: Forward to PAS to determine Contract Partner impact.

OIC OPS POLICY: Forward to the OIC Operational Policy Section (OPS) for verification of content.

OIC NCROPS: Forward for feedback to OIC NCROPS.

TRANSLATION: Forward for translation.

DIVISIONAL CROPS: Disseminate the translated draft to the NCO i/c of each division policy unit for comments and suggestions. Request that they consult with subject matter resources to assist in preparing an appropriate and informed divisional position/response. Track all replies on check list response template.

STAKEHOLDERS/POLICY CENTRE'S: Forward the translated draft to other applicable/appropriate stakeholders/partners affected by the new policy for their information and input.

• Internal Audit, Evaluation & Review (National Review Guide Specialist)
• Clothing Equipment Design Committee (CEDC)
• Depot Division - Training Program Support & Evaluation,
• Depot Division Cadet group
• Ethics Office
• Federal Services [HQ policy centres]
• Health and Safety Committee
• Health Services
• Forensic Science & Identification Services
• Learning and Development
• Assets & Procurement Branch - Uniform and Kit Program
• Protective Services
• Professional Standards External Review Section
• Technical Operations
• Other ______________________

ANALYST: Review all feedback and make necessary changes.

COMMISSION FOR PUBLIC COMPLAINTS AGAINST THE RCMP: Forward for feedback.

OIC OPS. POLICY & OIC NCROPS: Final review for content and feedback.

EDITING: Fill out form 1111 [ICS form] and forward to PPS, requesting anticipated diary date for the draft. In the Subject field write “Please edit the attached amendment and return for publication approval.”

REVIEW: Upon receipt of the edited draft from PPS, thoroughly proofread and compare to the original to ensure the content/context is accurate.

A-5: Prepare an A-5 to the OIC National Criminal Operations Branch from the OIC Ops Policy Section, for signature and approval,

APPROVAL: Make a copy of the approved policy for the file. In addition to the approved policy, ensure that all e-mails, drafts, correspondence, meeting records etc... are PA’d to the file.(IM, IV.3.C.1 and AM, XIII.5.E.7)

PUBLICATION DATE: Send the signed original approved policy to the PPS and request that they advise you of the anticipated publication date.

FINAL NOTIFICATION: Once the policy has been approved, advise stakeholders of the pending change. ie, Depot division, L&D (investigator toolbox), SRR’s, Legal Services, Division Criminal Operations Offices.

OIC MANAGEMENT REVIEW & QUALITY ASSURANCE: Highlight policy clauses which will allow for the development of a National Review Guide (NRG) and consult with the NRG. Forward this material to the NRG specialist formatting/amendments . The NRG specialist will have the NRG translated and added to the NRG national repository. For amended policy determine if updates are required for existing Quality Assurance Guides and forward commendations to OIC MR&QA.

ATIP (Access to Information and Privacy)/VETTED CONTENT: Forward copy of Policy to ATIP for possible vetting and review as per the guide in OM App. 51-2-1 (review for exemption from public access to RCMP manuals). If vetting is required, request Access to Information and Privacy Branch to include new policy reference in AM App. III-11-5. Also, ensure ATIP determines if there are any issues related to information sharing contained within the policy.

FILE COMPLETION: Forward the completed file with all correspondences (Kit approval sheet, etc..) and completed policy checklist to the OIC Operational Policy Section.

This development process has several key features:

• A needs analysis is conducted which involves various forms of risk assessment;
• Research of both RCMP policies and those of other organizations to identify ‘best practices.
• Consultation, including outside expert sources, to provide pertinent information and input.
• Review and revision throughout the process to ensure the highest standards.
• Arm’s length consultation and feedback with the Commission for Public Complaints Against the RCMP (CPC).
• Providing relevant policy material to Management Review & Quality Assurance Section to ensure adherence of policies within operations through audits and review of operations.

The CEW policy was recently revised and published within the Operational Manual on August 8, 2007(see appendix). This policy has incorporated new components and bolstered others based on new information derived from the latest research. New to the policy is a section on Excited Delirium, data collection and a process to have CEWs independently tested should they fail. This policy was one of the first to involve consultation with the CPC and they have endorsed it.

It should be noted that many operational policies involving the deployment of weapons, including the CEW, refer to the IM/IM and its principles. The IM/IM itself, however, is not policy nor should it be considered policy. Operational policies within the RCMP are not like standard operating procedures used by other law enforcement agencies and training is not brought into policy. It is strongly held that training and policy combined will guide members operationally.

Models are for training police officers and to be used to help triers of fact (judges and juries) understand that training and how an event unfolds.(C. W. Lawrence, personal communication, April 10, 2007).

The IM/IM is the framework RCMP members use to assess and manage risk…it promotes continuous risk assessment, aids members in identifying behaviors, and then selecting the best option.(RCMP Staff Sergeant S. Wade, personal communication, May 31, 2007).

Reporting methods evolve just as policies do. Initially CEW reporting was completed through a member’s notes and by informing a supervisor. This evolved to the creation of a specific CEW reporting form retained within the operational file and forwarded to CCAPS. An electronic data base was then created in which the completed form would be immediately captured. This allowed for review at both a divisional and national level if required. Members were required to complete the report within 15 days. Today members are required to complete the report by the end of their shift.

The CEW is designed with an integrated audit feature. Specific data is captured within the weapon and can be downloaded for analysis. Current policy requires divisions to create a method of annually downloading and storing this data. This ensures the information is not lost and provides for immediate review if required.

CCAPS is currently developing policy with respect to Excited Delirium Syndrome (EDS). This policy includes operational guidance and investigational protocols should there be a sudden death. This policy has been developed in consultation with international experts who feel it is a best practice.

CCAPS is developing Subject Behaviour/Officer Response Reporting policy. This will allow a standardized reporting method which will capture all intervention options used in response to subject behaviours. Because this type of reporting will be stored within the electronic operational records management systems, the RCMP will be able to gather all of the contextual information relevant to the officer’s response to a subject’s behaviour. It is felt that this method of reporting will lead to a greater standardization in use of force articulation. This will allow for better accountability and transparency. It is hoped this will also allow for evaluation of the information to recognize trends and facilitate possible training requirements.

Updated March 2007 S Drive: CCAPSDIR/Operational Policy Section/Checklist Policy

C. W. Lawrence, personal communication, April 10, 2007.

RCMP Staff Sergeant S. Wade, personal communication, May 31, 2007.

Health Issues and Related Injuries

Health issues and related injuries directly attributed to CEW use will be addressed. The problem of sudden unexpected death, Excited Delirium Syndrome, and any relationship to CEW use will be discussed later in this report.

The original position of TASER International, through their training information, was that their CEWs were safe to use and posed very little health risk. Based on field experience and training, it has been learned that what the manufacturer described as “signature marks” are in fact minor burns and abrasions. Using dated medical terminology “first and second degree burns” may occur within a 2-3 cm circumference of probe location (CEWEP Report, p.26.) . Abrasions can occur when the CEW is used in the “push stun” mode. Minor injuries can result from contact with the forward edges of the device where the cartridge meets the frame of the CEW. TASER International has been apprised of this issue; however, they advised that this concern impacts a design requirement necessary for efficient functionality. These abrasions often heal within a two or three days and do not require hospitalization.

Other health issues are associated with the probes becoming embedded in the subject’s skin. When the CEW is fired in probe mode, stainless steel probes, tethered to the CEW by thin electrical wires, are propelled toward the subject. The 21 foot authorized operational cartridge probes are described by TASER International as follows:

Mass	1.6 kg
Needle length	0.89 cm
Speed at muzzle	50.6 m/s
Speed at 4 metres	30 m/s
Kinetic energy at muzzle	2.0 kg (m/s) 2
Kinetic energy at 4 metres	0.7 kg (m/s)2 CEW Instructor's Course, Batteries and Air Cartridges, revised 05-06-05

The probes penetrate the subject’s skin to a maximum depth of .89 centimetres and remain secured by barbs. These probes are commonly removed by trained members in the field. The injuries usually associated with probe removal are minor in nature and require no hospitalization.

It is possible for the probes to become embedded in sensitive areas such as the subject’s face, throat, or groin. In an effort to reduce probe penetration of this type, members are trained to deploy a CEW to the subject’s back to the extent possible, given the situation. This tactic can be precluded by the subject’s actions and movement. CEWs are equipped with a laser sight to guide the alignment of the upper probe towards a subject’s centre mass. The lower probe is essentially angled at an 8 degree downward angle, creating a separation rate of 0.30 metre spread for every 2.13 metres traveled. At 2.1-4.6 metres distance, the optimal range, the CEW cartridge is designed to spread the probes approximately 33-66 centimetres (supra n.4) .

Should the probes become embedded in a sensitive area of the subject, members are directed to seek medical treatment. Further, if any unusual reactions occur, or if the member thinks the subject is in distress, or if the subject’s physical condition otherwise warrants, the member should ensure the individual receives prompt medical attention (RCMP Operational Manual, Part 17.7.5. Deployment Aftercare) .

In rare instances, subjects may experience exertion related injuries such as injuries to muscles, tendons, ligaments, the back, joints, and fractures. Similar injuries have been alleged to occur during training (CEW Instructor’s Course, Medical, revised 05-06-05) . To offset the potential for injury, training best practice now recommended that trainers place the member on the ground and provide a warning of the potential for these exertion related injuries. Members are informed of the risks and the training rationale as to the benefits of a limited-duration voluntary exposure. They are then allowed to choose whether or not to participate (CEW Instructor’s Course, Voluntary Exposure, revised 06-08-01) .

There is also potential for what has become known as “secondary injuries” relating to CEW use. These injuries may result from the subject falling to the ground or falling from heights.

Training enables members to evaluate the risk of CEW use in relation to persons identified by police critics as vulnerable populations (e.g. visibly pregnant women, the elderly, and the very young). Members perform a risk assessment through the IM/IM, based on situational factors, to determine whether or not CEW use is prudent.

Members in the field cannot inform subjects of potential risks. While no restraint method is risk free, with or without warning, CEWs have, overall, an established record of significantly reducing injury potential to both citizens and members (TASER International, Crisis Management, Police Information Officer Information and Risk Mgmt.). (Smith, M. R., Kaminski, R. J., Rojek, J., Albert, G. P., Mathis, J. (2007). The impact of conducted energy devices and other types of force and resistance on officer and suspect injuries. Policing: An International Journal of Police Strategies & Management, 30(3), 423-446).

The RCMP findings have been reaffirmed by the research of Dr. Bill Bozeman, an emergency medical specialist at the Wake Forest University School of Medicine, whose findings were presented at ACEP on October 8, 2007. He found that no or minimal injury (injury requiring outpatient care or no care) occurred in 99.7 percent or subjects exposed to the CEW in the field. Thus moderate or severe injury was seen in 0.3 percent. Because his study involved over 900 field applications, the precision of those estimates is excellent with very narrow 95 percent confidence intervals (Bozeman, W. P., Winslow, J. E., Hauda, W. E., Graham, D., Martin, B. P., & Heck, J. J. (2007, October). Injury Profile of TASER ® Electrical Conducted Energy Weapons (CEWs) . Poster session presented at the meeting of the American College of Emergency Physicians Research Forum, Seattle, WA).

CEW and Sudden, Unexpected Deaths

To date there have been approximately 270 deaths worldwide (C. W. Lawrence, personal communication, October 21, 2007) including 17 Canadian deaths associated to CEW use since 1999. It is difficult to count these events accurately because there is no independent central registry or organization systemically collecting this data. These numbers are largely based on media reports.

Critics have pointed to the CEW as being a lethal intervention option, contrary to the manufacturer’s assertion and police experience. Various methods of restraint have been the subject of blame for sudden, unexpected deaths. In the 1980s the cause of in-custody deaths was believed by many to be the use of neck restraints. In the 1990s both Oleoresin Capsicum spray (pepper spray) and prone restraint (hog tie) were blamed. Subsequent medical research into these methods of restraint failed to prove a causal link. The original research surrounding positional asphyxia has subsequently been retracted or scientifically refuted. Currently, CEWs, specifically TASER®s, are now under scrutiny for their association with in-custody death. To date, despite an ongoing and growing body of independent analysis, no researcher has proven either a causal relationship between CEW and in custody death, or a viable physiologic method that would explain a CEW application facilitating an in custody death. While the various methods of restraint are all different, the characteristics of the person requiring restraint, who subsequently suffers in-custody death, are strikingly similar.

Substance abuse involving drugs such as cocaine (Karch, S. B. (2002). Karch's pathology of drug abuse (3rd ed.). Boca Raton, FL: CRC Press.) (Karch, S. B. (Ed.). (1997). Drug abuse handbook . Baca Raton, FL: CRC Press) , methamphetamine (Iyo, M., Sekine, Y., & Mori, N. (2004). Neuromechanism of developing methamphetamine psychosis: A neuroimaging study. Annals of the New York Academy of Sciences, 1025, 288-295) (Sekine, Y., Minabe, Y., Ouchi, Y., Takei, N., Iyo, M., Nakamura, K., et al. (2003). Association of dopamine transporter loss in the orbitofrontal and dorsolateral prefrontal cortices with methamphetamine-related psychiatric symptoms) , and THC (Castle, D. J., & Murray, R. (Eds.). (2004). Marijuana and madness: Psychiatry and neurobiology . Cambridge, UK: University Press) involve an increased level of brain dopamine.  One of the theories on the cause of schizophrenia involves an excess level of brain dopamine.  The threat recognition and response system in the brain is influenced by brain dopamine levels.  This may well point to the presence of excess levels of dopamine in the brain which as been described as, “the wind of the psychotic fire” (Laruelle, M., & Abi-Dargham, A. (1999). Dopamine as the wind of psychotic fire: New evidence from brain imaging studies. Journal of Psychopharmacology, 13(4), 358-371) .  Work by Dr. Deborah Mash, at the University of Miami has shown that people experiencing a state of excited delirium have increased levels of dopamine receptors in their brain (formation of new receptors is an adaptive mechanism that occurs as a result of excess dopamine) (Mash, D. C., Ouyang, Q., Pablo, J., Basile, M., Izenwasser, S., Lieberman, A., et al. (2003). Cocaine abusers have an overexpression of alpha-synuclein in dopamine neurons. Journal of Neuroscience, 23 (7), 2564-2571) (Mash, D. C., Pablo, J., Ouyang, Q., Hearn, W. L., & Izenwasser, S. (2002). Dopamine transport function is elevated in cocaine users. Journal of Neurochemistry, 81 (2), 292-300) (Mash, D. C., & Staley, J. K. (1999). D3 dopamine and kappa opioid receptor alterations in human brain of cocaine-overdose victims. Annals of the New YorkAcademy of Sciences, 877 , 507-522) .

A Canadian expert on police restraint and Excited Delirium, Chris Lawrence, has stated that, “excited delirium may be easiest to understand as a runaway version of the fight-or-flight response that we all possess” (Lawrence, C. W., Mohr, W. K. & Lawrence, S. D. (2002) Sudden In-Custody Death, Beyond Positional Asphyxia. IACP Convention, Minneapolis, MN) . Current leading expert consensus is that death may result from a physiological imbalance created by the subject’s activities, which result in a multi-factoral cascade of events culminating in the subject’s sudden, unexpected death (Ross, D. L., & Chan, T. (Eds.). (2006). Sudden deaths in custody . Totowa, NJ: Humana Press) (Di Maio, V. J. M., & Di Maio, T. G. (2005). Excited delirium syndrome: Cause of death and prevention . Baca Raton, FL: CRC Press) .

Chris Lawrence examined 29 deaths in Ontario, all of which were associated with police response to individuals acting in a state of excited delirium. The results of his analysis are included in his master’s thesis, “Police Response to Excited Delirium" (Lawrence, C. W. (2005). Police response to excited delirium. Unpublished masters thesis, Royal Roads University, Victoria, BC) . Of these deaths, only one involved a CEW. All other deaths were associated with more historical control methods.

Many law enforcement agencies throughout the world, including the RCMP have come under fire as a result of sudden unexpected in-custody deaths or deaths proximal to police restraint. Current expert consensus indicates that the use of the CEW followed up by a quick and effective method of restraint may be the best intervention method in order to gain control and provide medical assistance for EDS (IACP Conference Police/Physician Section Panel, New Orleans, USA, 2007-10-14) (Lawrence, C. W., personal communication, October 21, 2007) . Recent events have once again reignited the ongoing controversy in the use of CEWs and sudden, unexpected death.

Many medical and academic professionals, including Dr. Hall have been attempting to evaluate these deaths in context considering all details rather than focusing on method of restraint.

Dr. Hall is quoted in a news article as follows:

"Now people are focused on the TASER as being the instrument that precipitated death in these individuals." She said the common denominator in these types of in-custody deaths is the delirious state the people are found in, not the type of restraint police use.

"There are still many cases of a profoundly agitated person dying suddenly in custody when a TASER wasn't even part of the equation.

"If we focus on the restraint methodology we're going to miss the real problem."

Hall said when police encounter these delirious people, there's no negotiating with them and the only way to get them to hospital is restrain them.

"How do you investigate something in a person whose initial presentation is extreme violence and combative behaviour and the first sign they're going to die is when they die," she asked. She said psychiatrists have been describing sudden deaths in acutely agitated persons for centuries.

"That's why major tranquilizers were invented," Hall said. Scientists still don't know what causes these people to die, but more study is being done, she said.

"The only predictor of an increase in in-custody death in a community is the prevalence of illicit drug use in that community," said Hall. Sudden in-custody deaths began being explored in a big way in the 1970s when cocaine arrived in North America, she said (Retrieved October 19, 2007 from Terri Theodore, the Canadian Press http://www.570news.com/news/national/article.jsp?content=n1016101A).

CEW Research

Man's death sparks taser backlash

Globe and Mail Update and Canadian Press
October 15, 2007 at 3:41 PM EDT

Mr. Therien, who took part in a RCMP-National Research Council review of tasers, says police now simply accept the manufacturer's recommendations but there are no Canadian standards . (Retrieved October 23, 2007 from http://www.theglobeandmail.com/servlet/story/
RTGAM.20071015.wtaser1015/BNStory/National/
?page=rss&id=RTGAM.20071015.wtaser1015 ) .

The above story relates to an RCMP response to an event in western Canada and captures part of the media focus with respect to the CEW. The above statement is simply not true. While TASER International provides initial instructor training with respect to technical specifications, design features, maintenance, and basic operation of the weapon, it is the RCMP Learning and Development Section, in consultation with in-house subject matter experts, that has created the RCMP training program. While the manufacturer may have provided initial technical information on suggested deployment, the RCMP determined when it would be used and provided operational guidance through scenario-based training in conjunction with policy.

The RCMP not only developed its own training program, but also completed an independent study (CEWEP). The RCMP continuously analyzes research, allowing for training and policy evolution. Critics point out that much of the existing research has been manufacturer funded or controlled. While several papers have been generated by individuals with direct ties to TASER International, an increasing body of independent, peer reviewed research does exist.

Some of the early papers were written prior to the development of the CEWs currently used by the RCMP.

The CPRC did a literature review in 2005, entitled Review of Conducted Energy Devices (Manojlovic, D., Hall, C., Laur, D., Goodkey, S., Lawrence, C., Shaw, R. et al (2005). Review of Conducted Energy Devices . (TR-01-2006, pp. 40-45) Ottawa, ON. Canadian Police Research Centre) and concluded the following:

• Definitive research or evidence does not exist that implicates a causal relationship between CEDs (CED = Conducted Energy Device = CEW) and death.
• Existing studies indicate that the risk of cardiac harm to subjects from a CED is very low.
• Excited delirium (ED), although not a universally recognized medical condition is gaining increasing acceptance as a main contributor to deaths proximal to CED use.
• The issue related to multiple CED applications and its impact on respiration, pH levels, and other associated physical effects, offers a plausible theory on the possible connections between deaths, CED use, and people exhibiting the symptoms of ED.

The contributors to this CPRC report believe that CEDs are effective law enforcement tools that are safe in the vast majority of cases (Manojlovic, D., et al (2005). p. ii) .

At the time the CPRC report was released, much of the research that had identified potential health risks used the porcine (swine) model in settings dissimilar to realistic field settings. For example, a U.S. Air Force study exposed ten pigs to a five second shock followed by a five second hiatus, three times. Results found that blood chemistry was altered causing only “transient effects on blood factors" (Jauchem, J. R., Cook, M. C., & Beason, C. W. (2007). Blood Factors of Sus Scrofa Following a Series of Three TASER® Electronic Control Device Exposures. Journal of Forensic Sciences . [Epub ahead of print]) . Another example, completed after the CPRC report, is a study conducted in Toronto that delivered 150 discharges to six pigs, averaging 110 pounds, with individual animals being shocked approximately 25 times in the same day.  This study demonstrated that circumstances dissimilar to field use can result in dysrhythmia (Nanthkumar, K., Billingsly, I. M., Masse, S., Dorian, P., Cameron, D., Chauhan, V. S. et al (2006). Cardiac Electrophysiological Consequences of Neuromuscular Incapacitating Device Discharges. Journal of the AmericanCollege of Cardiology , 48(4), 798-804) .

In the Journal of the American College of Cardiology, physician researchers discussed the usefulness of extrapolating human effects from research using animal models.

Efforts to study the human effects of TASER shocks by substituting pigs appear to have little rationale or necessity. Important anatomical and electrophysiological differences between humans and pigs make pigs poor surrogates for human responses to cardiac drugs and electrical discharges. Additional confounders include the use of anesthesia, controlled laboratory conditions, repetitive shocks in animals smaller than humans and an inability to interview the subjects about symptoms caused by their TASER exposures.(Pippin, J. J. (2007). Taser Research in Pigs Not Helpful. Journal of the AmericanCollege of Cardiology. 49(6), 731) .

The point is that this type of research has to be performed on animals, because of the legal and ethical inability to perform such tests on humans. Researchers are quite aware of the limitation of experimental models, and extrapolation to humans must be done with great caution. In fact, Dr. Dorian stated, “we agree that it is not possible to directly extrapolate our results to NID (neuromuscular incapacitation device) use in humans" (Dorian, P., & Nanthkumar, K., (2007). Reply. Journal of the AmericanCollege of Cardiology. 49(6), 732-733) .

Seven research abstracts were presented as poster sessions (Not peer reviewed) at the American College of Emergency Physicians’ Research Forum, October 8-9, 2007 in Seattle, WA. The entire abstracts were published as a supplement to Annals of Emergency Medicine ((2007). Annals of Emergency Medicine, 50(3, supplement),S6-S135) , all addressing the effects of the TASER® on human physiology. It should be noted that four of the seven posters are sponsored by TASER® but will undergo scientific peer review prior to publication. Industry sponsored data is not necessarily tainted by conflict of interest. The following issues were addressed:

Poster 16

15-Second Conducted Electrical Weapon Application Does Not Impair Basic Respiratory Parameters, Venous Blood Gases, or Blood Chemistries and Does Not Increase Core Body Temperature

Dawes DM, Ho JD, Johnson MA, Lundin E, Miner JR/Lompoc District Hospital, Lompoc, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ

Study Objectives : The authors previously reported a study in which it was demonstrated that a 15-second exposure from the TASER X26® conducted electrical weapon (CEW) did not significantly impair several respiratory parameters including respiratory rate, tidal volume, PETCO2, and the PETO2. This study expands on that protocol, with the additional determination of venous blood gases, blood chemistries, and core body temperature.

Conclusion : As with the previous study, this study suggests that exposure to a CEW does not significantly impair respiration. As in the previous study, pCO2 decreased and pO2 increased as a result of the exposure. There was no change in blood pH. There was no change in core temperature. While this study is small, it adds to the growing body of literature that is demonstrating that these weapons have a favorable risk-benefit ratio and are appropriate additions to the use of force continua of police agencies.

Poster 173

Physiologic Effects of the TASER on Human Subjects After Exercise

Vilke GM, Sloane C, Suffecool AC, Neuman TS, Castillo EM, Kolkhorst FW, Chan TC/University of California, San Diego Medical Center, San Diego, CA; San Diego State University, San Diego, CA

Study Objectives : The TASER X26 is reported to be used by many police agencies in the United States. This purpose of this study was to examine the effects of a single TASER exposure on blood and cardiovascular (CV) in human subjects after vigorous exercise.

Conclusion : There were no clinically significant or lasting statistically significant changes in selected blood measures or cardiovascular levels in exercised human subjects after rigorous exercise and a five second TASER activation.

Poster 204

Injury Profile of Electrical Conducted Energy Weapons

Bozeman WP, Winslow III JE, Graham D, Martin B, Hauda WE, Heck JJ/Wake Forest University, Winston Salem, NC; Louisiana State University, Shreveport, LA; Inova Fairfax Hospital, Falls Church, VA; University Medical Center, Las Vegas, NV

Study Objectives : Conducted energy weapons (CEWs) are increasingly used by law enforcement agencies and have been associated with reduced overall injury rates among suspects and officers. However, significant controversy remains about the safety of these devices. We sought to perform the first large independent study describing the incidence and severity of injuries associated with CEW use.

Conclusions : After CEW use, 99.5 percent of 597 subjects had no injuries or mild injuries only. The observed significant injury rate was 0.5 percent, and is unlikely to be greater than 1.4 percent. No deaths related to CEWs occurred. These preliminary data represent the largest independent injury epidemiology study of these weapons to date and support the safety of CEW use. Data collection will continue through summer 2007; final data will be presented at the fall ACEP meeting.

Note:  Final Data as presented:

After CEW use, 99.7 percent of 692 subjects had no injuries or mild injuries only. The observed significant (moderate or severe) injury rate was 0.3 percent, and is unlikely to be greater than 1 percent. Skin punctures from CEW probes, contusions and lacerations account for 98.5 percent of mild injuries after CEW use. These data provided the first large, independent, multicenter assessment of the safety of CEW devices under real world conditions. These findings support the safety of CEW use by law enforcement agencies. It is important to recognize that CEWs are not risk free. Significant injuries, while rare, can be caused by these weapons. Steps should be taken to prevent these injuries when possible and to address them when they do occur.

CEWEP Report, p.26.

CEW Instructor’s Course, Batteries and Air Cartridges, revised 05-06-05.

supra n.4

RCMP Operational Manual, Part 17.7.5. Deployment Aftercare.

CEW Instructor’s Course, Medical, revised 05-06-05.

CEW Instructor’s Course, Voluntary Exposure, revised 06-08-01

TASER International, Crisis Management, Police Information Officer Information and Risk Mgmt.

Smith, M. R., Kaminski, R. J., Rojek, J., Albert, G. P., Mathis, J. (2007). The impact of conducted energy devices and other types of force and resistance on officer and suspect injuries. Policing: An International Journal of Police Strategies & Management, 30(3), 423-446.

Bozeman, W. P., Winslow, J. E., Hauda, W. E., Graham, D., Martin, B. P., & Heck, J. J. (2007, October). Injury Profile of TASER ® Electrical Conducted Energy Weapons (CEWs) . Poster session presented at the meeting of the American College of Emergency Physicians Research Forum, Seattle, WA.

C. W. Lawrence, personal communication, October 21, 2007.

Karch, S. B. (2002). Karch's pathology of drug abuse (3rd ed.). Boca Raton, FL: CRC Press.

Karch, S. B. (Ed.). (1997). Drug abuse handbook . Baca Raton, FL: CRC Press.

Iyo, M., Sekine, Y., & Mori, N. (2004). Neuromechanism of developing methamphetamine psychosis: A neuroimaging study. Annals of the New York Academy of Sciences, 1025, 288-295.

Sekine, Y., Minabe, Y., Ouchi, Y., Takei, N., Iyo, M., Nakamura, K., et al. (2003). Association of dopamine transporter loss in the orbitofrontal and dorsolateral prefrontal cortices with methamphetamine-related psychiatric symptoms.

Castle, D. J., & Murray, R. (Eds.). (2004). Marijuana and madness: Psychiatry and neurobiology . Cambridge, UK: University Press.

Laruelle, M., & Abi-Dargham, A. (1999). Dopamine as the wind of psychotic fire: New evidence from brain imaging studies. Journal of Psychopharmacology, 13(4), 358-371.

Mash, D. C., Ouyang, Q., Pablo, J., Basile, M., Izenwasser, S., Lieberman, A., et al. (2003). Cocaine abusers have an overexpression of alpha-synuclein in dopamine neurons. Journal of Neuroscience, 23 (7), 2564-2571.

Mash, D. C., Pablo, J., Ouyang, Q., Hearn, W. L., & Izenwasser, S. (2002). Dopamine transport function is elevated in cocaine users. Journal of Neurochemistry, 81 (2), 292-300.

Mash, D. C., & Staley, J. K. (1999). D3 dopamine and kappa opioid receptor alterations in human brain of cocaine-overdose victims. Annals of the New York Academy of Sciences, 877 , 507-522.

Lawrence, C. W., Mohr, W. K. & Lawrence, S. D. (2002) Sudden In-Custody Death, Beyond Positional Asphyxia. IACP Convention, Minneapolis, MN.

Ross, D. L., & Chan, T. (Eds.). (2006). Sudden deaths in custody . Totowa, NJ: Humana Press.

Di Maio, V. J. M., & Di Maio, T. G. (2005). Excited delirium syndrome: Cause of death and prevention . Baca Raton, FL: CRC Press.

Lawrence, C. W. (2005). Police response to excited delirium. Unpublished masters thesis, Royal Roads University, Victoria, BC.

Lawrence, C. W., personal communication, October 21, 2007.

Retrieved October 19, 2007 from Terri Theodore, the Canadian Press http://www.570news.com/news/national/article.jsp?content=n1016101A

Retrieved October 23, 2007 from
http://www.theglobeandmail.com/servlet/story/RTGAM.20071015.wtaser
1015/BNStory/National/?page=rss&id=RTGAM.20071015.wtaser1015 .

Manojlovic, D., Hall, C., Laur, D., Goodkey, S., Lawrence, C., Shaw, R. et al (2005). Review of Conducted Energy Devices . (TR-01-2006, pp. 40-45) Ottawa, ON. Canadian Police Research Centre.

CED = Conducted Energy Device = CEW.

Manojlovic, D., et al (2005). p. ii.

Jauchem, J. R., Cook, M. C., & Beason, C. W. (2007). Blood Factors of Sus Scrofa Following a Series of Three TASER® Electronic Control Device Exposures. Journal of Forensic Sciences . [Epub ahead of print].

Nanthkumar, K., Billingsly, I. M., Masse, S., Dorian, P., Cameron, D., Chauhan, V. S. et al (2006). Cardiac Electrophysiological Consequences of Neuromuscular Incapacitating Device Discharges. Journal of the American College of Cardiology , 48(4), 798-804.

Pippin, J. J. (2007). TASER Research in Pigs Not Helpful. Journal of the American College of Cardiology. 49(6), 731.

Dorian, P., & Nanthkumar, K., (2007). Reply. Journal of the American College of Cardiology. 49(6), 732-733.

Not peer reviewed.

(2007). Annals of Emergency Medicine, 50(3, supplement),S6-S135.

Poster 345

Ultrasound Measurement of Cardiac Activity During Conducted Electrical Weapon Application in Exercising Adults

Ho JD, Reardon RF, Dawes DM, Johnson MA, Miner JR/Hennepin County
Medical Center , Minneapolis , MN ; Lompoc District Hospital , Lompoc , CA ; TASER
International, Scottsdale , AZ

Study Objectives : Conducted electrical weapon (CEW) use by law enforcement is increasing. There are concerns about CEW safety and its possible ability to cause cardiac tachyarrhythmia. Previous human CEW research analyzing before and after electrocardiograms in both resting and exhausted populations does not support this. EKG tracings cannot be obtained during CEW exposure due to artifact interference between the CEW and the skin electrodes. This study examines real-time cardiac rate measurement using cardiac ultrasound technology during CEW application on an exercising population.

Conclusion : A 15-second CEW application on exercised volunteers did not demonstrate any evidence of induced tachyarrhythmia. It is unlikely that CEW exposure induces cardiac rate capture or tachyarrhythmia in humans.

Poster 421

The Neuroendocrine Effects of the TASER X26 Conducted Electrical Weapon as Compared to Oleoresin Capsicum

Dawes DM, Ho JD, Miner JR, Johnson M/Lompoc District Hospital, Santa Barbara, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ

Study Objectives : Conducted electrical weapons (CEW) induce neuromuscular incapacitation and pain by the application of an electrical current. The electrical current stimulates both afferent sensory neurons causing pain and efferent motor neurons causing muscle tetany. There has been controversy in the lay press and medical literature with regard to the use of these weapons and sudden, unexpected in-custody death. There has been speculation that exposure to the discharge of a CEW may induce neuroendocrine effects (eg, a stress cardiomyopathy) which might predispose subjects to delayed malignant cardiac arrhythmias and sudden death. The objective of this study is compare the neuroendocrine effects of the TASER X26 CEW to oleoresin capsicum (O.C.), commonly referred to as pepper spray. The latter is a well accepted use of force alternative.

Conclusion : The results suggest a significantly greater level of activation of the SAM cascade with O.C. compared to the CEW. Overlapping confidence intervals preclude a definitive statement about the other measurements, but do not suggest a greater activation of the stress cascade by the CEW than O.C. Given that the CEW is generally considered more efficacious in the control of subjects with impaired nocioception secondary to drug intoxication or an excited delirium, and that it induces a smaller or equal stress response, it maybe the use of force of choice in certain settings.

Poster 423

Breathing Parameters, Venous Blood Gases, and Serum Chemistries With Exposure to a New Wireless Projectile Conducted Electrical Weapon in Human Volunteers

Dawes DM, Ho JD,Johnson MA, Lundin E, Miner J/Lompoc District Hospital, Lompoc, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ

Study Objectives : The TASER X26 conducted electrical weapon (CEW) has a maximum range of 35 feet, limiting its effectiveness in some tactical situations. TASER International has developed a non-tethered CEW that is fired from a 12-gauge shotgun that has a longer range. A previous study showed that the TASER X26 had no significant effect on tidal volume, respiratory rate, PETCO2, and PETO2. The purpose of this study was to study the effects of this new CEW on respiration, venous blood gases, and certain blood chemistries.

Conclusion : This study demonstrates that the new CEW has no important deleterious effects on respiratory parameters, blood chemistries, or venous blood gases. These results are consistent with previous results for the TASER X26 CEW.

Poster 428

Evaluation of the Use of the TASER and Elevated Force to Control Workplace Violence in a Health Care Environment

Norton RL, Granger G/Oregon Health & Science University, Portland , OR

Study Objectives : Violent behavior by patients is one of many occupational hazards faced by health care workers. ED personnel are at high risk for patients carrying weapons, with disruptive behavior or psychotic disorders. When systematic approaches to violent persons do not work, public safety officers (PSO) require additional means of elevated force to control dangerous behavior. The use of the electrical stun gun (TASER) offers an option that is more effective than a baton but less lethal than a firearm. Its use has recently been criticized because of the association with deaths in custody.

Conclusion : A comprehensive approach to workplace violence that allows for the selected use of the TASER and requires mandatory reviews of all uses can be effectively implemented to help to control dangerous situations in heath care environments.

While the posters were not peer reviewed prior to their presentation, Dr. Jeff Ho, a Professor and physician on the faculty of the Department of Emergency Medicine at the University of California, San Diego stated at the Excited Delirium Expert Panel, IACP Convention, that his studies are either being written for publication, being peer reviewed or are in press.

Finally, one peer-reviewed paper to be considered is written by Raymond E. Ideker, MD, PhD; Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, and Derek J. Dosdall, PhD, Department of Biomedical Engineering, University of Alabama at Birmingham, AL. The abstract of this review of the literature reads as follows:

There is only a small amount of experimental data about whether the TASER X26, a nonlethal weapon that delivers a series of brief electrical pulses to cause involuntary muscular contraction to temporarily incapacitate an individual, can initiate ventricular fibrillation to cause sudden cardiac arrest either immediately or sometime after its use. Therefore, this paper uses the fundamental law of electrostimulation and experimental data from the literature to estimate the likelihood of such events. Because of the short duration of the TASER pulses, the large duration of the cardiac cell membrane time constant, the small fraction of current from electrodes on the body surface that passes through the heart, and the resultant high pacing threshold from the body surface, the fundamental law of electrostimulation predicts that the TASER pulses will not stimulate an ectopic beat in the large majority of normal adults. Since the immediate initiation of ventricular fibrillation in a normal heart requires a very premature stimulated ectopic beat and the threshold for such premature beats is higher than less premature beats, it is unlikely that TASER pulses can immediately initiate ventricular fibrillation in such individuals through the direct effect of the electric field generated through the heart by the TASER. In the absence of preexisting heart disease, the delayed development of ventricular fibrillation requires the electrical stimuli to cause electroporation or myocardial necrosis. However, the electrical thresholds for electroporation and necrosis are many times higher than that required to stimulate an ectopic beat. Therefore, it is highly unlikely that the TASER X26 can cause ventricular fibrillation minutes to hours after its use through direct cardiac effects of the electric field generated by the TASER. (emphasis added)(Ideker, R. E., & Dosdall, D. J. (2007). Can the direct cardiac effects of the electric pulses generated by the TASER X26 cause immediate or delayed sudden cardiac arrest in normal adults? American Journal of Forensic Medicine and Pathology, 28(3), 195-201) .

EDS Research

The following six pages of information on excited delirium have been extracted from the National Study On Neck Restraints in Policing (Hall, C. & Butler, C. (2007). National Study on Neck Restraints in Policing . (TR-03-2007, pp. 40-45) Ottawa, ON. Canadian Police Research Centre) .

Excited Delirium

"[Excited Delirium Syndrome] It is a blame-shifting phrase. It is a phrase that shifts the blame from the person exerting the force to the person that dies. Blame the victim."

-attorney Randy Daar, legal council in the case of the in-custody death of Randy Escobedo, Cincinnati.

"Most of the people who die in police custody die not from drugs or some mysterious syndrome but from police abuse." "Police have to learn to de-escalate confrontations with agitated people; they have to practice verbal judo. If 5-foot-2 female social workers and nurses can do it, then I am sure the cops can too."

- Van Jones, executive director, Ella Baker Human Rights Center, San Francisco.

The case of Toney Steele, who died in the custody of San Diego police, was discussed on the television program 60 minutes II, and the concept of excited delirium was explored in the public media. In the Steele case, officers were called to respond to a disturbance on a bus involving Toney Steele. On arrival they described Steele as “…ranting and raving, talking about people that weren’t there”. He was sweating profusely and subsequently became engaged in a fight with 4 officers in the middle of traffic. He was described as having superhuman strength, was eventually subdued in a maximal restraint position and put in the back of a squad car. On arrival at a nearby hospital, he was dead.

In interviews, Steele’s mother rejected the notion of a state of excited delirium as an explanation for her son’s death in the custody of San Diego police officers. While Steele’s mother acknowledged his ongoing difficulties with illicit drugs, she did not believe it was what killed him. “I call this police brutality,” she says. “I just wondered how did they come to that conclusion? I don’t believe that. Hog-tying and suffocation. He suffocated. That’s what I believe.”

Does excited delirium exist as a medical condition?

Critics cite the fact that excited delirium is not listed in the American Medical Association’s list of medical diagnoses, the Canadian Medical Association’s list of diagnoses or the DSM IV/V as evidence that excited delirium “does not exist”.

If excited delirium is a true medical condition, why is it not listed as a diagnosis in these publications? Because it is not a diagnosis. It is a state of being or a condition for which many underlying explanatory diagnoses are possible.

The American Heritage Dictionary of the English Language, an easily accessible nonmedical publication, describes that making a diagnosis is the process of determining the cause of a disease or injury by evaluating the patient’s history, the physical examination and relevant laboratory information. The final diagnosis for any patient’s condition rests with the opinion generated by the physician carrying out the evaluation. Similarly, Webster’s New World Medical Dictionary (2nd edition) determines that the word diagnosis, which originally meant “discrimination, a distinguishing, or a discerning between two possibilities" in ancient Greek, now corresponds much more closely with the concept of a differential diagnosis. A differential diagnosis for a condition is the list of medical diagnoses that could be responsible for the patient’s state for which they seek medical care.

For a true medical diagnosis to be identified, the root cause of a patient’s presentation must be established. In other words, the list of potential differential diagnoses are considered and a final diagnosis chosen because of the features of the patients presentation and course of treatment. For example, many patients are brought to the hospital for evaluation because of shortness of breath. Shortness of breath is not a diagnosis; it is a symptom or state of being. The list of potential diagnoses for someone being short of breath is extremely long and ranges from simple conditions such as viral bronchitis, to commonly fatal conditions such as congestive heart failure or even severe asthma. If a person comes to the hospital very short of breath and then dies of infection in the lung, the diagnosis was not shortness of breath (the person’s state of presentation), the diagnosis was pneumonia.

While critics like to refer to the lack of diagnosis status for excited delirium as a basis for their claim that the concept of excited delirium is a “cover up” term or “trumped up diagnosis”, there can be no dispute that the concept of a delirious state is recognized by virtually every medical and paramedical professional. Delirium and its investigation is essential knowledge for all medical practitioners and delirious states are associated with a wide variety of medical conditions that result in the common findings of delirium: an altered level of consciousness with loss of both cognition (thinking and reasoning) and perception (input from the senses). In medical practice, delirium is recognized not as a specific diagnosis of its own but rather a clinical state for which the list of potential differential diagnoses is broad. Many a medical book chapter is dedicated to the investigation and diagnosis of delirious states and every medical dictionary defines it. Determining the specific cause or a delirious state often requires extensive medical investigation; the cause is often not readily apparent at first contact with the individual.

Some delirious states, such as those associated with fevers or the use of sedatives and pain killers are characterized by the loss of cognition and perception but have little or no increase in physical and/or mental activity. Evidence of excitement in human physiology can be observed in the vital signs with elevated temperature, heart rate and/or respiratory rate but may not be evident to the casual observer. Lay persons asked to describe delirium often imagine a person lying semi conscious, moaning in a bed of tangled sheets. This kind of delirium could be described as obtunded or quiet delirium and any parent who has had a child ill with high fever is familiar with its features.

However, illicit drug use, acute psychosis or mania, or a combination of psychiatric illness and illicit drug use can generate other kinds of delirious states. These delirious states are also defined by a loss of normal thinking and interpretation of sensory input but they are associated with a profound increase in physical and mental activity leading to the subject being described as extremely agitated or in a state of extreme excitation. Physiologic excitement in terms of elevated temperature, heart rate, blood pressure and/or respiratory rate may also be detected once physical examination is possible; however the agitated state of the individual makes these assessments impossible at the outset.

It is the combination of extreme physical exertion and a delirious mental state that leads medical practitioners to describe a subject’s condition on the whole as consistent with “Excited Delirium” as opposed to a quietly delirious state. An excitedly delirious state has many potential causes (differential diagnoses). This large number of potential causes generates some variation in the symptoms seen leading to difficulty in determining a consistent definition or set of features with which to describe excited delirium as a syndrome. For example, persons in a state of excited delirium from mental health problems such as acute psychosis may share some but not necessarily all of the features seen with some drug overdoses that result in an excitedly delirious state.

Members of the general public are familiar with the concept of excited delirium as most know of the “DT’s” as a consequence of alcohol addiction and withdrawal. True delirium tremens is an excellent example of an excited delirium state as persons suffering from delirium tremens are agitated, hallucinating, have high fever, high blood pressure and elevated heart rates. If left untreated, persons suffering from delirium tremens have a mortality rate approaching 35 percent. Even with medical treatment including sedation and blood pressure, mortality from delirium tremens is as high as 5 percent.

Excited Delirium has been recently described as “a state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, epiphoria, hostility, exceptional strength and endurance without apparent fatigue”. Some physicians may prefer a more general description such as “an altered level of consciousness combined with extreme physical exertion”, which allows for some variation in the symptom cluster but does not address the physiologic derangement which is simultaneously thought to be occurring.

The concept of excited delirium is not new. In 1849, Bell first described a “peculiar form” of delirium that was fatal in at least three quarters of those suffering it. With the advent of adequate psychiatric medications, Bell’s mania in its pure form (from mental illness alone) was described less and less in the medical literature until recreational sympathomimetic drugs and hallucinogenic drugs emerged on the forefront in the 1970s.

Ideker, R. E., & Dosdall, D. J. (2007). Can the direct cardiac effects of the electric pulses generated by the TASER X26 cause immediate or delayed sudden cardiac arrest in normal adults? American Journal of Forensic Medicine and Pathology, 28(3), 195-201.

Hall, C. & Butler, C. (2007). National Study on Neck Restraints in Policing . (TR-03-2007, pp. 40-45) Ottawa, ON. Canadian Police Research Centre.

Cocaine induced excited delirium is now a commonly seen variant of excited delirium which has received more academic scrutiny and first came to the attention of physicians in the early 1980s as the cocaine epidemic gained momentum in the United States. The exact pathogenesis of excited delirium and cocaine induced excited delirium is unknown at this time but much work is being done by neurophysiologic researchers to determine its exact pathophysiology. Whether this phenomenon can be extrapolated to include methamphetamine induced excited delirium is unknown, although the extrapolation makes intuitive sense and has biologic plausibility.

Death of the agitated individual suffering cocaine induced excited delirium has not infrequently occurred while the subject is in police custody after being restrained to protect public interests. While it is tempting to suggest that persons suffering from excited delirium simply be allowed to “wind down”, there are public interest and subject specific reasons not to allow the subject to continue to run rampant. Usually, police engagement is requested as a result of property damage concerns, dangerous or threatening behaviors and commonly, real concerns about the imminent danger to the subjects themselves. Risk to the individual is not necessarily mitigated by containing the individual in a large space until such time as exhaustion sets in. Not only are property owners not content to watch police allow a subject to continue to destroy property, there is some medical evidence that suggests that progression to a state of exhaustion is, in itself, dangerous. Prior to effective treatment for the acute phase of mania or psychosis, death as a consequence of exhaustion in psychiatric patients was reported. In 1952, it was described that “sustained motor and mental excitement with continued activity for a period of time” was a risk factor for sudden death due to excited delirium, prompting the subsequent development of the use of sedation protocols to control individuals and to mitigate potential risk.

Excited delirium (ED) is an acute condition with multiple potential underlying etiologies that can progress rapidly to cardiopulmonary arrest and death in individuals who are struggling violently and are then subdued either in the prehospital or hospital setting.

The typical scenario for a subject with excited delirium is a rapid onset of acute paranoia, followed by aggression toward inanimate objects, often glass such as windows, mirrors or automobile windshields and windows. This activity is frequently accompanied by a variety of bizarre activities including (but not limited to) disrobing, running, yelling, hiding, exhibitions of superhuman strength, extreme aggression to individuals, resistance to pain and physical restraint. The subject is usually male, often has a known psychiatric disorder, may show evidence of intoxication with cocaine or other illicit substances, fails to respond appropriately to external cues such as police presence, and usually demonstrates incoherent speech or incoherent screaming. Subjects very frequently exhibit profound struggling against officers and/or restraints for upwards of 15 minutes after restraints are applied despite the futility of such struggle, can be extremely hot to the touch (clinical hyperthermia) and may or may not have excessive sweating (diaphoresis). Individuals suffering from excited delirium are thought to be at risk of sudden death very soon after being physically and/or chemically restrained. Death of these individuals has occurred in the prehospital setting, in the care of EMS providers and in hospitals. Death in this syndrome occurs within seconds to minutes of a period of quietness that is misinterpreted as “giving up” or tranquility or the cessation of struggling. In pre-hospital reports of cases of death due to excited delirium, persons of police interest who have required restraint have progressed from extreme violence and agitation to death in a matter of minutes, with or without presence of emergency medical personnel.

Most reported cases of sudden and unexpected death proximal to restraint seem to involve young men in an “excited” state or one of “agitated delirium” as a result of psychiatric illness or intoxication from illegal drugs or both. These individuals are combative, violent, and often struggle, sometimes sustaining traumatic injuries as a result of confrontation with law enforcement before being subdued. However, no author has prospectively documented the frequency with which any of these features exist, or their association with sudden death in the prehospital setting. Lack of such information prevents adequate planning of investigational or interventional strategies.

Much attention has been paid to the method of police restraint when an individual suddenly dies proximal to police restraint. Theory generation and debate is widespread surrounding the rationale for these deaths as it relates to the use of force. Police agencies have been criticized and individual police officers have been charged criminally with unnecessary or unskillful use of force, and many revisions to police policy have been undertaken in an attempt to mitigate risk to subjects being arrested while still protecting the public interest by subduing unruly individuals. Multiple methods of restraint have been implicated in unexpected death. As police services change use of force tactics and methods, litigation follows that tries to criminally implicate each method. Yet, the incidence of sudden in custody death remains unchanged even as methods of restraint are abandoned in favor of allegedly “safer” methodology. As previously stated in this report, the only current known predictor of a change in the incidence of death in custody is a change in the pattern of recreational drug use in the community in question.

While discussions around restraint methodology used use by police abound in the current press, within each Canadian case of death following police restraint are also found the following situational and individual characteristics: male subjects, police activated for concerns of public or subject safety, subjects fleeing police or resisting interaction with police, erratic behavior, violent behavior, suspected or known drug intoxication, cessation of breathing immediately following a struggle, and the inability for the medical examiner to determine the specific cause of death. Unfortunately, the startling similarity of the context of these sudden deaths is largely ignored while the specific method of restraint is heavily criticized.

Thus, while much attention has been focused on the method of restraint, it is possible that features of the individual involved and the nature of the situation itself may also be predictive of outcome. It is possible that either the use of restraint methodology serves only as a marker for the severity of the situation, or that the restraint methodology may be implicated in specific subject presentation. Specific interest in methods of police restraint is currently focused on conducted energy device utilization, whereas interest in and criticism of vascular neck restraint, use of multiple officer restraint, pepper spray, position of maximal restraint use and lethal force such as firearms has been historically common. For example, in the 1990s the American Civil Liberties Union and other human rights activists advocated that pepper spray was the real killer in sudden death in custody. Currently their chief interest in restraint has shifted and lies with the criticism of conducted energy weapons, which were developed in part to replace other methods of restraint such as Vascular Neck Restraint (VNR).

No scientifically robust data exists to determine whether there are situational or individual features that predict a mortality outcome, or whether the existence of a certain set of features, such as excited delirium, might determine which method should or should not be used to subdue an individual. Whether it is the act of restraint itself and not specific measures of restraint that is problematic for individuals in an excitedly delirious state is unknown. Critics of police interventions and policy are quick to criticize each method of restraint of combative and violent individuals as it emerges. Some would argue that restraint should never be employed.

However, it is imperative for people to understand that a subject in a state of excited delirium is suffering from severe abnormalities in cognitive thinking and sensory perception. Traditional negotiation techniques are fruitless as the subject cannot interpret his own sensory input correctly or make appropriate judgments from it. The notion that such an individual can be ‘talked down” reflects a disrespect for and inadequate understanding of delirious states.

Very often, lay persons and watchdog agencies admonish that the appropriate management of these individuals is to “transport them to hospital for medical evaluation.” The simple question is “how?” Paramedics cannot transport violent, combative individuals in ambulances safely. Hospital staff will not enter into the care of agitated and violent individuals unless they can be first physically contained/restrained. Physicians, paramedics and even social workers do not engage in therapeutic talk relationships with incoherent, violent individuals. As a testimony to the difficulties of dealing with violent individuals and the effects of illicit drug use, police agencies are finding themselves more frequently summoned to hospitals for assistance in the physical containment of a violent individual in hospital emergency departments as hospital security staff become overwhelmed.

Even in hospital, physical restraint is a precursor to any attempt at chemical restraint or even the most basic medical evaluation since there is no safe method for delivering adequate sedatives from a distance. Paramedics and nurses do not attempt to give intramuscular injections or initiate intravenous line access in acutely violent individuals who are physically unrestrained. There is no treatment of these individuals without initial physical restraint (end of excerpt) (End of excerpt, National Study on Neck Restraints in Policing . (TR-03-2007, pp. 40-45) .

There are now two recent, medically referenced textbooks that address the subject of sudden in-custody deaths (Ross, D. L., & Chan, T. (Eds.). (2006). Sudden Deaths in Custody . Totawa, NJ: Humana Press) and excited delirium syndrome (Di Maio, V. J. M., & Di Maio, T. G. (2005). Excited Delirium Syndrome: Cause of Death and Prevention . Boca Raton, FL: CRC Press) . The first book is a collection of papers authored by researchers familiar with the issues associated with the malady that has become known as Excited Delirium Syndrome. The second book addresses the issue head on. Each book deals with the issue of CEWs and sudden death, concluding that they are unlikely the cause of death.

With respect to the issue of the term “excited delirium”: the Disease State Manual list delirium, beginning on page 136. Delirium can run a continuum from an obtunded (mentally dulled) version to one that is highly agitated. The term was coined in 1985 by Dr. Charles Wetli and Dr. Donald Fishbain, and used as a descriptive phrase (Wetli, C. V., & Fishbain, D. A. (1985). Cocaine-induced psychosis and sudden death in recreational cocaine users. Journal of Forensic Sciences, 30(3), 873 – 880) . While the American Civil Liberties Union is of the opinion that “excited delirium” is being exploited by police and being used to cover-up excessive use of force (Wetli, C. V. (2006). Excited delirium. In D. L. Ross & T. C. Chan (Eds.), Sudden deaths in custody (pp. 99-112). Totowa, NJ: Humana Press) the National Association of Medical Examiners has recognized the term for over 10 years (Stephens, B. G., Jentzen, J. M., Karch, S. B., Wetli, C. V., & Mash, D. C. (2004). National Association of Medical Examiners position paper on the certification of cocaine-related deaths. American Journal of Forensic Medicine and Pathology, 25(1), 11-13) . Currently, police officers use the term to efficiently communicate information to describe the common features associated with this medical emergency.

Dr. Wetli MD, a retired physician and chief medical examiner who is an internationally recognized expert on EDS provides a comment on the way forward with respect to better understanding the problem of sudden, unexpected deaths following an altercation with police, indeed, whether or not a CEW was used.

Because of the behavior associated with excited delirium, death often occurs in police custody after a violent confrontation, and the mechanism of death is of intense practical interest. These are legitimate questions that deserve scrutiny to be sure, but the scrutiny must be based on sound, objective investigation with scientific support. Assumptions and “junk science” lead to specious theories and, sometimes, at least, to civil injustice. In the meantime, police managers must cope, police officers must act, and scientists must continue to investigate. p.111 (Wetli, C. V. (2006). Excited delirium. In D. L. Ross & T. C. Chan (Eds.), Sudden deaths in custody (pp. 99-112). Totowa, NJ: Humana Press) .

Dr. Christine Hall, is already in the early stages of the RESTRAINT Study (Risk of Events in Subjects That Resist: prospective Assessment of Incidence and Nature of ouTcomes), the particular type of research that Dr. Wetli mentions. Assisting Dr. Hall to expand her study with appropriate funding may produce the answers so desperately needed.

Action Items

Police are encountering cases where people are dying in circumstances where everyone involved would agree that death is not anticipated. The problem has devolved into one of public trust in the police and government authorities. Further, there is no consistent vocabulary applied to these events or understanding of their elements. Canada is uniquely positioned to take a leadership role in advancing a solution to an international problem which seems, in retrospect, to involve some of our most misunderstood citizens. The costs of establishing consistent language, a common appreciation, and best practices when managing these events may seem challenging, but pale in comparison to the cost of an uncoordinated response, the subsequent inquiry, and civil litigation if this is not done. What should never be forgotten is the tragic pain the family endures from the debate and confusion that is allowed to persist.

Presently individual cases of this kind seem to be a rare occurrence within most police environments. On a national scale, however, these deaths may seem to be occurring more frequently which raises public awareness and fuels considerable criticism of the police response and concurrent government oversight. Researchers have little doubt that the denominator for these occurrences can be more clearly understood and the mechanism of death better evaluated. To offset this growing perception, the following three action items are presented:

National funding for research and studies relative to the Conducted Energy Weapon and Excited Delirium Syndrome.

The Canadian Police research Centre (CPRC) is an internationally recognized organization in law enforcement research. The CPRC has indicated that there should be a follow up literature-review of CEW research completed since their last report of 2005. This would provide a Canadian perspective on CEW research, in addition to avoiding the stigma of industry-sponsored research. It would serve as a basis not only for the RCMP but all Canadian and international law enforcement for decisions in creating and amending policies and training relative to the CEW.

The CPRC is currently working on a two-year RESTRAINT Study, the first of its kind in the world led by Dr. Christine Hall. This is a prospective study (a study designed to follow participants forward in time rather than retrospectively (Retrieved October 22, 2007 from http://www.amfar.org/cgi-bin/iowa/bridge.html?page=P) ). It will document and evaluate the characteristics surrounding police restraint of persons who resist the police and undergo restraint and determine the outcome (mortality) proximal to police restraint for those persons. Evaluation of that data will determine the incidence of subject death, and the relationship between varying methods of restraint and the risk of death in the restrained subject. This study will capture much-needed data directly from police situations in subjects with and without EDS.

End of excerpt, National Study on Neck Restraints in Policing . (TR-03-2007, pp. 40-45)

Ross, D. L., & Chan, T. (Eds.). (2006). Sudden Deaths in Custody . Totawa, NJ: Humana Press.

Di Maio, V. J. M., & Di Maio, T. G. (2005). Excited Delirium Syndrome: Cause of Death and Prevention . Boca Raton, FL: CRC Press.

Wetli, C. V., & Fishbain, D. A. (1985). Cocaine-induced psychosis and sudden death in recreational cocaine users. Journal of Forensic Sciences, 30(3), 873 – 880.

Wetli, C. V. (2006). Excited delirium. In D. L. Ross & T. C. Chan (Eds.), Sudden deaths in custody (pp. 99-112). Totowa, NJ: Humana Press.

Stephens, B. G., Jentzen, J. M., Karch, S. B., Wetli, C. V., & Mash, D. C. (2004). National Association of Medical Examiners position paper on the certification of cocaine-related deaths. American Journal of Forensic Medicine and Pathology, 25(1), 11-13.

Wetli, C. V. (2006). Excited delirium. In D. L. Ross & T. C. Chan (Eds.), Sudden deaths in custody (pp. 99-112). Totowa, NJ: Humana Press.

Retrieved October 22, 2007 from http://www.amfar.org/cgi-bin/iowa/bridge.html?page=P

A forum to provide a national perspective on problems related to sudden, and unexpected deaths following restraint.

Sudden, unexpected death following a restraint process is not exclusive to policing. This problem has occurred in medical settings for over a 150 years. People have died under similar circumstances in group homes, jails, and psychiatric and acute care medical facilities (Weiss, E. M. (1998, 11-17 October). Deadly restraint: A nationwide pattern of death . Hartford Courant) . This appears to be a systems-based problem requiring a systems-based solution. It would be prudent to gather a variety of perspectives and explore potential solutions from various areas. The suggested list includes individuals who have expertise in and/or are responsible to management and outcome for acutely agitated individuals including those with underlying psychiatric illness or who present in emergency settings or prehospital environments. Perspectives would be invited from:

• medical, academic and practical experts experienced in dealing with this problem;
• senior provincial health ministry representatives;
• provincial Chief Coroners;
• the Schizophrenic Society of Canada;
• the Centre for Addiction and Mental Health;
• the Canadian Medical Association;
• the Canadian Psychiatric Association;
• the Canadian Nurses Association;
• the Paramedic Association of Canada;
• the Canadian Police Association;
• the Canadian Association of Chiefs of Police

The funding would cover the venue and gathering of the necessary expertise to facilitate this forum. It could take the form of presentations to address the central issues with discussion and an action plan to follow. It is recommended that the CPRC be approached to facilitate this forum.

Creation of a national Use of Force Centre of Excellence.

Such a center would comprise use of force subject matter experts from a cross section of Canadian law enforcement agencies, committed to establishing best practices in police use of force. This would allow for law enforcement agencies to work together creating standards and/or develop best practices that could be used nationally. The CPRC has already established strong credibility in use of force issues through efforts such as the National Use of Force Framework, the Review of Conducted Energy Devices, and the National Study on Neck Restraints in Policing in Canada. The CPRC has established memorandums of understanding with international police research centres. They are well placed within the police and research cultures to continue this direction by providing such a venue for such a centre.

Conclusion

Unanticipated in-custody deaths will likely never be completely eradicated. A proactive, comprehensive and dynamic approach in the evaluation of this phenomenon is required to understand which features are predictive and which are not. Adopting a reactionary stance, such as suspending all CEW use, will not only remove a modern, humane force option proven to reduce citizen and law enforcement injuries, but will also reinforce over-responsiveness to anecdote and abandonment of scientific principles in the evaluation of in-custody deaths. This would expose unnecessarily the public and law enforcement personnel to increased risk during police interaction and/or violent confrontations.

While comments from the media, police oversight agencies and the public are welcome and important, criticism must be balanced by leadership and commitment to public safety. Maintaining trust in law enforcement agencies must be based on rational thought, careful attention to science and consideration of all aspects of police interactions and their outcomes

>Bios

Sergeant Bruce Stuart
Royal Canadian Mounted Police

Sgt. Stuart holds a Bachelor of Arts degree from Acadia University and is a 18-year member of the RCMP. He is currently the Senior Incident Management/Intervention Model Analyst to the Operational Policy Unit of the National Criminal Operations Branch and is responsible for all use of force matters. This includes developing all policies and conducting needs analyses and implementation of new equipment and training. He is a member of the National Incident Management Intervention Working Group. Sgt. Stuart is an Instructor Trainer in the Conducted Energy Weapon, Basic Firearms Instructor and Public and Police Safety Instructor programs. He has been involved in the development and revision of lesson plans used for training, and provided a Legal Articulation lecture for the Investigators Courses within British Columbia for the RCMP.

Chris Lawrence
Ontario Police College

Mr. Lawrence is the Team Leader of the Defensive Tactics Training Section at the Ontario Police College in Aylmer, Ontario. He began his police career in 1979 and has experience working in Patrol, Underwater Search and Recovery, Marine Operations, Tactical & Rescue Unit, Criminal Investigation Bureau and Training. Mr. Lawrence has a graduate degree in leadership and training from Royal Roads University; is a Technical Advisor to the Force Science Research Institute, Minnesota State University-Mankato; a Research Partner with the Canadian Police Research Centre; and a columnist with PoliceOne.com. He has testified regarding use of force training and subject control in Canada and the United States, and has presented on the topic of police use of force and sudden, unexpected deaths throughout North America, in Australia and Europe to groups as diverse as police trainers, police executives, lawyers, and physicians.

Dr. Christine Hall

Dr. Christine Hall received her MD from the University of Calgary in 1996 and completed her five year residency in Emergency Medicine in the Royal College of Physicians and Surgeons (FRCP) Program in Emergency Medicine at the University of Calgary Faculty of Medicine from 1996 to 2001. During her residency, Dr. Hall completed a master’s degree in Clinical Epidemiology and completed her thesis in 2003 as a staff physician.

Upon completion of her residency, Dr. Hall became a full time Emergency Department physician at the Calgary Health Region. She was the Division Chief of Research, the coordinator of Resident Research, a member of the Adult Research Committee for the Calgary Health Region, a member of the departmental executive for the Department of Emergency Medicine, Calgary Health Region and also served as the Program Director for the FRCP Program in Emergency Medicine during her tenure at the Calgary Health Region. Dr. Hall was a clinical lecturer at the University of Calgary Faculty of Medicine. Dr. Hall also served as a flight physician with the Shock Trauma Air Rescue Society of Alberta for six years. She is now an emergency department physician at the Vancouver Island Health Authority.

Dr. Hall has been participating in the investigation of sudden in-custody death for several years and is the Principal Investigator for the RESTRAINT Study, a multicentre, international epidemiologic study of features surrounding the use of restraint in police interactions; an effort funded by both the Canadian Police Research Centre and the National Institute of Justice (USA). Dr. Hall collaborates in this research effort with notable experts in the field such as Drs. Ted Chan, Gary Vilke, Bill Bozeman and Deborah Mash. Dr. Hall has contributed to the understanding of excited delirium syndrome and in custody death evaluations through her presentations at seminars and conferences, participation as an expert witness at relevant inquests and investigations and in her ongoing research efforts. She has participated in several reviews of restraint methodologies including the CPRC technical report surrounding the use of conducted energy weapons.

Appendix - RCMP Operational Manual, Part 17 - Conducted Energy Weapon

Weiss, E. M. (1998, 11-17 October). Deadly restraint: A nationwide pattern of death . Hartford Courant.