OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER Chris Vanderveen Director of Special Projects/Investigative Reporter 9Wants to Know, KUSA-TV Denver, CO Good afternoon, Thank you for reaching out. This office strives to follow state and federal law, and nationally recognized stand- ards of practice. Colorado law specifically cites the National Association of Med cal Examiners as the standard. The National Association of Medical Examiners is also recognized across the United States and within the medicolegal community as the leading association in forensic medicine and pathology. The National Associa- tion of Medical Examiners is comprised of forensic pathologists, many of which are board certified in both anatomic and forensic pathology, medicolegal death in- vestigators, and administrators involved in our field. ‘The American Psychiatry Association and the American Medical Association have little to no representation by board-certified forensic pathology experts. The Amer- ican Psychiatry Association is, as expected, comprised of psychiatrists. Likely none of these professionals have medical training or education in forensic pathol- ogy/death investigation and have never performed a forensic autopsy. The Ameri- ‘can Medical Association also has little representation by board certified forensic pathologists. Furthermore, the individuals that wrote the papers you cite likely could not qualify as court experts in death investigation/death certification/forensic pathology within our judicial system. Further, these papers are concerned with the administration of ketamine in the field by EMTs and the assessment, diagnosis, and treatment of excited delirium in the living. It follows logically that if Excited Delirium is a condition that needs to be treated in live people, it may cause death in others, Further, these papers do not offer any conclusion or recommendation in- volving the classification of these deaths. 330 N. 197 AVE, BRIGHTON, CO 80601 P 303.659.1027 F 303.659.4718OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER Dr. James Gill, a scholarly forensic pathologist/medical examiner, who authored one of the more recent articles on excited delirium (The Syndrome of Excited De- lirium, 2014), points out that “excited/agitated delirium” is an acute hyperactive delirium. Hyperactive delirium is recognized in the DSM-V and ICD-10 and has a variety of causes (hyperglycemia, drug and ethanol intoxications, drug and ethanol withdrawal, ketoacidosis, serotonin, and neuroleptic malignant syndromes, etc.). ‘The American College of Emergency Physicians also recognizes hyperactive (ex- cited) delirium as a diagnosis; citing it is a life-threatening constellation of symp- toms manifested as a clinical syndrome. The combination of vital sign abnormali- ties, metabolic derangements, altered mental status/agitation, and potential physi- cal trauma raises serious concerns for impending danger. Clearly, if emergency room physicians feel that this is “a life-threatening constellation of symptoms”, people can dic of this very condition. There are many publications on excited delir- ium, and it is a diagnosis well-established in the forensic literature [Prone Restraint Cardiac Arrest in In-Custody and Arrest-Related Deaths (Weedn, Steinberg, et. al 2022); Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum (Mash 2016); Manner of Death for In- Custody Fatalities (Gill, Girela-Lopez 2015); Cardiac Dysrhythmia During Re- straint (Cina, Davis 2010); Asphyxiation, Suffocation, and Neck Pressure Deaths (Hunsaker, Crooke, et. al 2020); Excited Delirium Syndrome (DiMaio, DiMaio 2005); Sudden Deaths in Custody (Ross, Chan 2005); Forensic Pathology 2» Ed (DiMaio, DiMaio 2001); Handbook of Forensic Pathology 2* Ed (DiMaio, Dana 2006); Spitz. and Fisher’s Medicolegal Investigation of Death 5« Ed (Spitz, Diaz 2020); Forensic Pathology: Principles and Practice (Dolinak, Matshes, et. al 2005); Forensic Pathology for Police, Death Investigators, Attorneys, and Forensic Scien- tists (Prahlow 2010); Basic Competencies in Forensic Pathology: Forensic Pathol- ogy Primer (Prahlow 2006); Handbook of Forensic Pathology (Froede 2003)]. With some variation of semantics, agitated/excited delirium, as a cause of death, is used throughout the United States. Of course, as with any medical opinion, you can often find someone with a difference of opinion. I suppose that is why it is prudent to look at the opinions of the leading forensic experts as a whole. It is my under standing that most forensic pathologists acknowledge this as a legitimate, poten- tially fatal medical condition (which is why the NAME has not taken a position against it). Most of the forensic pathologists in Colorado use this term or similar descriptive terms as a cause of death when it is applicable. Those that shy away 330 N. 197 AVE. BRIGHTON, CO 80601 308.659.1027 F 303.659.4718,OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER seem to do so largely because of the public scrutiny surrounding the term itself and not necessarily because of the legitimacy of the medical diagnosis. Some use dif- ferent language to avoid the controversies surrounding this term (e.g., drug-in- duced psychosis, prolonged agitation during restraint while intoxicated with X, ag- gressive condition associated with X intoxication, hyperactive and violent state during drug intoxication and restraint) but these are all still referencing the same phenomenon, just in a different way. Some avoid the controversy by dropping the term from the cause all together and just call it a drug toxicity death. Since most forensic pathologists agree that there is no therapeutic/ “safe” amount of many il- licit drugs, particularly stimulants, and low blood concentrations are sufficient to cause or contribute to death, these deaths may be diagnosed as drug-induced ex- cited delirium or simply acute drug toxicity. Abolishing the term does not change the outcome; rather it deprives the community of the public health benefit that al- lows these deaths to be tracked, identified, and studied to improve patient care in the living and to better understand the phenomenon. The National Association of Medical Examiners (NAME) has NOT abandoned this as a medical diagnosis. In fact, a recent paper on in-custody deaths [National Association of Medical Exam- iners Position Paper: Recommendations of the Definition, Investigation, Postmor- tem Examination, and Reporting of Deaths in Custody (Mitchell Jr., Diaz, et. al 2017)], adopted by NAME as a position paper, acknowledges this diagnosis and does not dispute it. In your email you identified a male forensic pathologist in the state of Colorado that “will not use the term ‘excited delirium’”. There are esti- mated to be less than 20 forensic pathologists in Colorado. To my understanding, most, if not all, of the forensic pathologists in Colorado accept this as a legitimate cause of death and use or have used this term OR similar descriptive language (im- plying agitation, psychosis, delirium, aggression) to identify this clinical syndrome as the cause of death, this includes but is not limited to Dr. Amall, Dr. Burson, Dr. Caruso, Dr. Cina, Dr. Wilkerson, Dr. White, and Dr. Carver). Saying “will not” does not mean “have not” and different semantics do not change the essence of the term Excited Delirium. Controversy also arises on deaths in custody involving restraint in a prone position. The forensic pathology literature is conflicted on the issue of restraint in a prone position as a cause of or contributory factor in deaths in custody. When death oc- curs and prone restraint is involved, a variety of factors must be considered (e.g., person’s medical/mental history, acute medical status, intoxication status, their 330 N.19™ AVE. BRIGHTON, CO 80601 P 303.659.1027 F 303.659.4718OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER weight, and habitus, how long they were placed prone, if pressure was being ap- plied to the body and where, ete.). Obviously, prone restraint with the application of pressure to the neck by a knee is much different than prone restraint without ap- plication to the neck or back. No two cases are the same. It is irrational to ump all these deaths together simply because they involved prone restraint, or conversely because they involved the use of illegal intoxicants. In-custody/law enforcement involved deaths are dynamic and each must be looked at individually and within the context of the evidence as a whole. In some cases, such as the George Floyd fa- tality, restraint played a major role in death. In others, underlying medical issues or drug toxicity predominantly result in death. It is also true that medical and/or toxi- cological findings in concert with prolonged prone restraint can result in death. It is important to understand that the coroner/medical examiner office is a public health office. Deaths are classified in accordance with the accepted standards and the office is not charged with establishing culpability. As evidenced by many cases, the cause and manner of death opinion does not preclude criminal and civil prosecution, nor does it facilitate it. For example, there are many deaths that coro- ners/medical examiners have called homicide that have not been prosecuted due to evidence supporting the justification of the killing. Additionally, by convention, motor vehicle deaths and deaths in which a medical professional made an error re- sulting in a patient’s death, are classified as accident. However, many of these cases are prosecuted criminally as vehicular homicide or civilly as wrongful death/malpractice, respectively. This office is mandated to determine the cause and manner of death and relies on the accepted national standards of practice to do so. My approach to these cases, and the approach of my staff, will evolve and change as the accepted forensic standards of practice change through research/conclusions/positions of the recog- nized leading experts in this field. If the NAME takes a position that opposes the use of excited delirium in classifying death, then under my leadership, this office will follow accordingly. Tam sensitive to the concerns involving law enforcement deaths and ensuring that they are appropriately investigated and classified. At the heart of many of these cases is an individual intoxicated with an illegal substance and often having a men- tal health crisis, a bereaved family experiencing loss, and a community questioning how the actions of law enforcement impacted the outcome. There are limitations 330 N. 19" AVE, BRIGHTON, CO 80601 P 303.659.1027 F 303.659.4718OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER within forensic medicine/science and the forensic autopsy/death investigation is not always able to answer the many questions that surround these deaths. It is im- portant to recognize that the determination of the cause and manner of death by a forensic pathologist is only one component of these cases. It is unreasonable and wrong to expect coroners/medical examiners to classify deaths differently to help facilitate criminal or civil prosecution of law enforcement; exonerate law enforce- ment; or rectify systemic issues in law enforcement. That is not the role of the cor- oner/medical examiner. The cause and manner of death as determined by the coro- net/medical examiner is important, but the burden falls on the legal system to de- termine whether criminal and/or civil prosecution is advisable. Monica Broncucia-Jordan, 330 N. 197 AVE, BRIGHTON, CO 80601 P 303.659.1027 F 303.659.4718