Mental health

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Excited Delirium, the Use of Force and the Death of Natasha McKenna

Update: Taser’s role in the rise of excited delirium diagnoses is an important part of this story. H/T to @SusieMadrak

Last week, police in Fairfax County, Virginia, said a medical examiner determined that a 37 year old mentally ill black woman named Natasha McKenna died of ‘excited delirium’ in February after being tased and restrained by six armored sheriff’s deputies.

I had never heard of excited delirium before, so I dug into it a little bit. The American Psychiatric Association (APA) maintains a resource known as the Diagnostic and Statistical Manual of Mental Disorders, or the DSM. The DSM contains a diagnostic classification list that details all the diagnoses recognized by the APA. It’s a pretty big book that details many, many mental disorders and diagnoses. Delirium is a classified diagnosis, but excited delirium is not.

That’s because there is significant and decades-old debate in the medical and civil liberties communities over whether excited delirium is real or if it’s a scapegoat for police brutality. Back in 2003, the Los Angeles Times reported that in-custody deaths involving excited delirium diagnoses were thought to be on the rise:

Although no one tracks the number of suspected cases — nor are there any public records on the number of people who die in police custody — researchers suspect that the condition accounts for a half-dozen deaths in most major cities each year. By some estimates, excited delirium is now being ruled as the reason behind the majority off all in-custody deaths.

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According to neurologists and medical examiners who have researched the issue, excited delirium is an often-fatal condition that can occur in a small subset of people who use drugs, mostly stimulants like cocaine or methamphetamines, over a long period of time. Typically, as users continue to take the drugs, the number of drug receptors in the brain rises, which helps pump dopamine and other excess hormones out of the brain.

But in people at risk of excited delirium, there is a genetic fault that impairs the brain’s ability to increase those receptors, they say. After drug use, that can lead to a dangerously high level of hormones in a part of the brain known as the amygdala, which later can bring on delirium, paranoia and aggression. More often than not, that attracts the police.

In such instances, even a minimal struggle can lead to too much pressure on the heart or lungs and the person can die. Another problem: Long-term stimulant use can enlarge and weaken the heart, which can be overtaxed during a big adrenaline rush. “It’s a very dangerous toxic mix of events,” says Karch.

The excited delirium diagnosis originated in the early years of the War on Drugs in cases involving cocaine. It therefor comes directly to us from a law enforcement and forensic psychiatry setting. The diagnosis is not recognized by many mainstream associations like the APA. Most cases involve people in distress who are often suffering from mental illness or, as the LA Times noted, substance abuse and addiction — and the use of force against them by law enforcement, many times involving tasers or restraints.

Amanda Truscott, writing in the Canadian Medical Association Journal in 2008, explored the dynamic between excited delirium cases and the use of force. She defined it as “being characterized by agitation, incoherence, bizarre behaviour, high temperature, superhuman strength, a high tolerance for pain — and sometimes, the compulsion to break or bang on glass.”

She tells the story of Robert Dziekanski, who died in-custody after a confrontation with police at the Vancouver International Airport:

Dziekanski touched down in Vancouver on Oct. 14, 2007, following a 13-hour flight from Poland and for 8 hours roamed the immigration lounge, steadfastly insisting that his mother would soon meet him. She, meanwhile, awaited his arrival in the baggage claims area, while airport officials did nothing to ensure the pair could connect. Lost, confused and unable to speak English, Dziekanski used office chairs to build a makeshift barricade between a pair of glass doors as if to ensure that no one could remove him from his meeting place with his mother. Obviously frustrated, he began to throw computer equipment onto the floor and against a glass wall. The police were summoned and in stunning sequence of events captured on video by an eyewitness’s cell phone, Dziekanski was pinned the floor, shot by a taser and eventually died.

The police said medical examiners determined that Dziekanski died of excited delirium.

In cases where an ‘excited’ person is restrained, tased and pinned to the floor and later dies, the excited delirium diagnosis introduces a level of ambiguity that absolves officers of responsibility for that person’s death. While most rational people would read these stories and conclude that, justified or not, it was the struggle and use of force that killed these individuals, excited delirium diagnoses shift the blame to the victim.

After all, isn’t this the primary tactic in law enforcement and criminal justice that got us to this very point of mass incarceration and extreme racism and brutality on behalf of cops and corrections officers? I do not believe the excited delirium diagnosis is all that different from the “super predator” myth of the 1990’s that helped fill American prisons by dehumanizing young black men as animalistic and aggressive. Instead of being treated as patients or just people in need of a crisis intervention, those who are said to have died of excited delirium are similarly labeled as dangerous monsters that needed to be put down.

In light of all of this, it’s fair to say Natasha McKenna’s purported cause of death could probably use an outside 2nd opinion.

h/t my old friend Kirk Murphy for bringing this to my attention

1 Comment Posted on Rikers Island

Against Reform: Beyond Rikers Island

There are a couple of things I want to say about the 10 reform bills proposed in the NYC Council this week targeting the Department of Corrections.

First, as I mentioned in my rundown, even if these bills pass, they will be meaningless without rigorous enforcement and oversight by the council. Much of the problem here is not that the city lacks regulations over its jails — it’s that the Department of Corrections seems to follow its own rules and break theirs with impunity. For evidence of this, read pretty much any post I’ve written about Rikers Island.

My next point is more of a confession and a question than anything else. I understand why the council is leading its charge with bills aimed at transparency and reporting. They need this data in order to make well-informed decisions about how to change laws governing incarceration in New York City.

But in the end, I can’t help but think back to the final chapter of Nell Bernstein’s incredible book on ending juvenile incarceration, Burning Down The House.

In the chapter titled, “Against Reform: Beyond the Juvenile Prison,” Bernstein writes:

A great strength of our democracy, our reformist nature is also a critical weakness, blinding us to those occasions when a long-standing institution has a fundamental, conceptual flaw– the kind that demands not a wrench but a wrecking ball. If a reform proves inadequate, we simply try again. Another task force is assembled to supplant a now-defunct commission; new committees are assigned to exhume the wreckage of the old. Sometimes, these efforts pay off, and progress — our national religion — is attained. But there are also occasions when our reformist zeal leaves us patching the roof of a building that lacks a foundation.

Are the Mayor and the City Council approaching their criminal justice crisis with the “wrecking ball” it deserves, or the “wrench?” By maintaining juvenile incarceration, establishing the ESHU and keeping Corizon (among other things), is New York “patching the roof of a building that lacks a foundation?”

14 Comments Posted on Inmate Healthcare

Medical Examiner Says Mentally Ill Inmate Natasha McKenna Died of Excited Delirium

UPDATE: More on ‘excited delirium’ and its diagnosis in in-custody deaths involving the use of force.

According to the Fairfax County Police, a medical examiner has ruled that 37-year old inmate Natasha McKenna died of ‘excited delirium’ while in custody last February.

Natasha suffered from schizophrenia and bi-polar disorder, and was arrested on January 26th after she called 911 to report she had been assaulted. After taking her to the hospital, police realized they had a warrant for her arrest stemming from an alleged assault on a police officer a few weeks earlier.

After a few days behind bars, Natasha’s condition deteriorated rapidly to the point that jail officials felt it necessary to remove the distressed 5’3″, 130 pound woman from her cell using six armor-clad sheriff’s deputies, a spit hood, restraints and tasers.

It’s unclear whether Natasha was receiving any kind of mental health treatment prior to her detention, and there hasn’t been any indication yet of the quality of care she received behind bars.

If the Fairfax County Police were negligent in providing adequate mental healthcare to Natasha, and thereafter chose to use brute force, weapons and restraints to confront her, it’s not hard to see how she might die from a state of excited delirium.

6 Comments Posted on All Posts, Inmate Healthcare, Privatization, Rikers Island

Corizon Health Staff on Rikers Island File Federal Labor Complaint Over Dangerous Work Environment

According to the NY Daily News, a group of medical staffers from New York City jail medical contractor Corizon Health Services filed a federal labor complaint with the Occupational Safety and Health Administration (OSHA) on April 11th for Corizon’s failure to protect them from inmate assaults.

From the Daily News:

The staffers charge that the nation’s largest jail health care provider repeatedly failed to protect them from dangerous inmates who were never properly restrained or labeled as serious threats, given their prior case histories.

The OSHA complaint cited an assault on a petite nurse who was brutally punched in the head by a 6-foot-tall, 160-pound inmate during a mental health assessment in a prison clinic on April 6.

“He hit me several times on the side of my head, arms and shoulder,” said the unidentified nurse, who suffered multiple bruises on her arm and shoulder.

In September of last year, Corizon was fined $71,000 by OSHA for failing to protect employees from violence, including “one willful violation for failing to develop and implement an effective workplace violence prevention program for its employees.”

Since then, city officials have scrambled to reform practices and policies concerning the conduct of medical staff and correction officers. But the changes appear to be slow-going: a recent report on the new Enhanced Supervision Housing Unit found that many medical staff were sometimes too afraid to work with inmates when they were locked out of their cells. They also encountered difficulty finding appropriate space in the ESHU to conduct their sessions. Along with chronic understaffing, poor recruitment and limited training, factors like these can quickly conspire to obstruct the delivery of medical attention and care to inmates.

It is in this setting that the city asks medical staff to make critical and often life-or-death determinations, such as those pertaining to the placement of inmates in solitary confinement — despite the fact that such demands are, as one recent report found, in fundamental opposition to medical ethics.

The city is said to be considering ending its contract with Corizon, which wouldn’t fix everything but would be a great place to start making some real changes. I’m still wondering: How many more of these incidents will the NYCDOC tolerate before they cancel this contract?

5 Comments Posted on All Posts, Inmate Healthcare, Rikers Island

New solitary confinement unit plagued by old problems on Rikers Island

At the beginning of March, New York City’s Board of Correction released a preliminary report on Rikers Island’s controversial new isolation facility, the Enhanced Supervision Housing Unit (ESHU). The $14.8 million ESHU was proposed to house 250 of Rikers’ so-called “most dangerous” inmates– a small minority of the prison population that officials claim is responsible for the majority of inmate violence.

Amid federal, state and municipal investigations and a seemingly endless stream of lawsuits alleging horrendous civil rights violations, city officials vowed to change the abusive and dysfunctional culture of the Department of Correction.

The opening of the ESHU at the beginning of this year is one of the first and only of the proposed reforms to have been implemented so far.

Meet the ESHU

Basic demographic information on the 18 ESH inmates

Basic demographic information on the 18 ESH inmates

Like the rest of Rikers Island, the overwhelming majority of people confined to the ESHU are young black males: the report says that 72% are African American and the average inmate is in his mid-20’s.

Despite promises to divert mentally ill prisoners from the ESHU, 13 of the 18 inmates (72%) living there have been given an “m status.”

28% of ESH inmates came directly from punitive segregation and 6% came from long-term isolation units known as Restrictive Housing Units (RHU).

ESH inmates averaged 129 days in punitive segregation in the past year. The Board notes that “with the recent punitive segregation restrictions of no more than 30 consecutive days or 60 days within any six month period, inmates who have maxed out their time in punitive segregation (which includes RHU) may be transferred to ESH.” They promise to closely watch the flow of inmates from punitive segregation to the ESHU.

Continue reading →

2 Comments Posted on All Posts, Inmate Healthcare, Juvenile Detention, Rikers Island

NYC DOC withholding records on violence against developmentally disabled juvenile inmate: lawsuit

A lawsuit filed on March 12th in the eastern district of New York claims that the New York City Department of Corrections (DOC) withheld important records from a federally-mandated disability advocate after they learned guards had brutally attacked a developmentally disabled juvenile inmate at the Robert N. Davoren Complex on Rikers Island.

Disability Rights New York is suing the Department of Corrections for records on a young inmate known only as “AB,” who told the group during a monitoring visit that he was “physically assaulted by corrections staff on or about December 9, 2014.”

As the lawsuit explains:

A.B. reported to DRNY that, on or about December 9, 2014, a corrections officer told A.B. that he was speaking disrespectfully.

A.B. reported to DRNY that he was led to a room, and he was punched and kicked by one or more corrections officers.

A.B. reported to DRNY that he was seen by medical staff at RNDC and was transferred to Elmhurst Hospital for evaluation and treatment of injuries to his face and elbow, and was hospitalized overnight.

DRNY requested AB’s medical records, security camera footage and incident reports from the Depts. of Health and Mental Hygeine (DOHMH) and DOC, the complaint states. DOHMH promptly provided the documents, but the DOC allegedly refused, claiming they could not be released while an internal investigation was still ongoing. Continue reading →

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Florida plans to rebid and revamp troubled prison medical contracts

Florida’s newly-minted corrections chief Julie Jones has announced that her department will rebid $1.4 billion worth of private contracts to provide healthcare to approximately 100,000 inmates across the state.

The majority of those contracts are held by the nation’s largest and most controversial prison medical provider, Corizon Health Services. Another private provider, Wexford Health Sources, will have its contracts put up for bidding as well. Under those agreements, Florida was to pay Corizon $229 million per year until June, 2018 and Wexford $48 million per year until December, 2017.

Corizon and Wexford were fined $22,500 by the state at the end of January for providing ‘deficient care’ to its prisoners. Shortly thereafter, Jones threatened to cut ties with both contractors unless they negotiated a new deal “with an eye to enhancing prescription drug delivery, mental health services and nursing care [including] requiring more registered nurses to be on hand rather than less-skilled staffers.” Apparently those demands could not be met.

The Florida Department of Correction notes that rebidding the contracts will cause healthcare spending in prisons to increase. Considering these companies have been known to engage in cruel profit-maximizing strategies (such as hiring and underpaying too-few and often underqualified staff or changing / denying inmates’ prescriptions) this was somewhat inevitable without further-compromising inmate healthcare.

Some of these problems were baked right into the contracts themselves; for instance, Corizon agreed to the ridiculous term that its services would cost the state “7% less [to provide care] than what it cost in 2010,” despite a growing prison population and rapidly increasing healthcare costs. As a result, incarcerated people in Florida and their families and loved ones have greatly suffered: Continue reading →