Constellations

This story was originally featured in Grit City Magazine, Hard Copy 24.

A friend told me this story's most interesting aspect is not the facts and figures I present but rather why I show them. I’m a privileged white woman living in University Place, who may hear of “excited delirium” and think “What an injustice,” but know that this particular injustice will likely never touch my life. Yet, excited delirium has touched my life deeply. I spent the better half of 2024 researching excited delirium. My days were occupied by thoughts of the hundreds of men of color who had died in police custody over the last two decades. That was the important part. It was always in police custody.

People across America have been tased or asphyxiated or hog-tied or had their necks knelt on for nine minutes and they, the victims, were blamed for their deaths because they were said to be suffering (“suffering”) from something called “excited delirium.” The issue is this: excited delirium doesn’t exist, never existed, and is nothing but a scapegoat for racially driven police killings across the country. There are thousands of statistics and years of investigative journalism to back this up. Excited delirium has a questionable past, a present marred by grief and controversy, and a future whose body lies dying on the side of the road.

But why do I care so much?

There was one story that tipped the scales for me. A Seattle Times article, How Manuel Ellis slipped through the cracks of the mental health system, which explored the role of mental illness in the death of Manny Ellis in Tacoma. It was the first article I read that spoke to both mental illness and excited delirium. Often, a mental illness crisis can be mistaken for the symptoms of excited delirium. Suddenly, it felt all too personal. As a person living with a psychotic disorder, this could be me. At 29, I began hearing voices and became paranoid that people close to me could read my mind. I tanked my career, lost my apartment, and would have been homeless if it wasn't for my parents' willingness to take me in. I had developed schizoaffective disorder. In all my rage and personal anguish, I became determined to fix the vast gaps in our mental healthcare system.

Many of these gaps included racial injustice. I learned the unfavorable statistics of fatal police encounters and serious mental health conditions, with the Treatment Advocacy Center citing that people living with serious mental illness (SMI) are 16 times more likely to be involved in a fatal police encounter, and people living with SMI are involved in as little as one-quarter to as many as one-half of all fatal police encounters. The intersections of race and these statistics are unknown due to the lack of official reporting structures. I found insufficient, accurate, or credible data to provide a clear picture of the problem. I don't purport to fully understand race relations, police violence, and all it entails in our city. I didn’t quite know where else to start. So I started with what I knew. I started writing.

I never knew Manny Ellis. We grew up in two different Tacomas. Once, our worlds crossed when I saw him on my 'People You May Know' list on Facebook. We had one or two mutual friends. People I went to high school with who I hadn't really kept in touch with. When I heard of his death and of how he died, I immediately thought of them and the anger and heartbreak and grief they must have felt. I thought of his family and the way they must be grieving. I knew him through a thumbnail profile picture on a social media app as a person who lived in a different world from mine.

Something I learned about Manny while researching this story is that we lived with similar mental illnesses. According to the Pierce County Medical Examiner, Manny's cause of death was homicide. Early the next morning, Pierce County officials attributed his death to excited delirium. It was during the trial of the police accused of murdering him that his mental illness was discussed over and over again. I felt a sort of solidarity in knowing the way a mental illness can be weaponized against a person caught in the criminal justice system or the mental healthcare system. I also learned that Manny fought for himself. He made all his court-ordered appointments. He fought to get on medication for his illness. He fought to keep himself well. He was gracious, committed, and steadfast, as heard in recordings of his court hearings. I feel and I know that fight and I know it takes a hell of a lot of personal strength to keep going. But just because you fight, doesn't mean you win.

I've combed through police records, investigative reports, local and national news articles, think pieces, and podcasts to try to find an answer to why Manuel Ellis died the night of March 3, 2020, on the corner of 96th & Ainsworth in Tacoma. I have come up with as many questions as many of you have. I have come up with as many answers and statistics as any of us can. But Manny isn't a statistic. Manny was a human. I don't intend to tell the story of what happened to Manny the night he died but I do intend to show how Manny's death is part of a much larger, systemic problem in the United States. There is an insidious condition, no longer being diagnosed by doctors, but is still recognized by law enforcement. It can, and has, led to the death of Americans from Tacoma to Minneapolis and all places in between. This sham of a diagnosis has roots dating back to slavery and the Civil Rights Movement. It is known as excited delirium.

The question to be answered in this story is not whether excited delirium is real, but why it was manufactured and how it has continued to contribute to the deaths of black Americans. It has become a key part of the story of police violence against people of color. I want to find out why our society accepts a law enforcement officer diagnosing a proven false condition as a justification for the use of force. I aim to explore how we may change this in Tacoma.

Excited Delirium

Like most people, I think I first heard the term "excited delirium" after the murder of a man from Minneapolis named George Floyd. Floyd was murdered in May of 2020, just months into the COVID-19 pandemic shutdowns. His death ignited a powder keg of anger and demands at the police officers who killed him and the systems that propped them up. Twenty-six million people in the United States participated in a protest during this time. It was the largest series of demonstrations in the history of the United States, including the Civil Rights Movement.

Floyd's murder became a catalyst for demanding change to police violence against people of color in the 21st century. No longer were Americans willing to accept the status quo, as stories of police killing unarmed black men and women without cause began to pile up nationwide. Already contentious relationships with the police grew hotter. Excited delirium began to make headlines. According to the book, Excited Delirium Syndrome, which is referenced in greater detail later in this piece, excited delirium:

"involves the sudden death of an individual, during or after excited delirium, in which an autopsy fails to reveal evidence of sufficient trauma or natural disease to explain the death. In virtually all such cases, the episode of excited delirium is terminated by a struggle with police or medical personnel, and the use ofphysical restraint.”

One thing is of note here. The death of an individual always occurs with physical restraint.

The supposed condition has a pernicious past—one rooted in slavery, voter suppression, and the silencing of free speech. The first iteration was Dr. Samuel A. Cartwright's drapetomania. Meaning "runaway slave madness" in Greek, it was thought to be brought on by lackadaisical enslavers, with its "cure" being corporal punishment. Near the turn of the 20th century, decades after the enslaved were freed, American psychiatry believed that black men and women were impervious to mental ailments because they were no longer imprisoned by their enslavers and could not think for themselves. All of this frankly, was reductive hypothesizing in lieu of the climbing population of black men and women held in psychiatric institutions around the country.

As American psychiatry aged, so too did its lens on African Americans. Dr. Walter Bromberg and Dr. Franck Simon's 1968 protest psychosis was thought to be a special form of "reactive" psychosis, where black men and women protesting for their human rights became psychotic for doing so. Schizophrenia diagnoses among African Americans soared during this time. Excited delirium is just the tip of the iceberg of a long history of fabricated medical and mental maladies created to subjugate and brutalize black bodies.

Justification of Force

On March 23, 2020, in Rochester, NY, a man named Daniel Prude died under circumstances similar to, and just 20 days after, Manny Ellis. His cause of death was listed as a homicide, with excited delirium as a contributing factor. In Arjun S. Byju's article for Current Affairs on Prude's death and excited delirium, the author sought a definition of the condition. His search landed him dead center at the Seattle Police Department. As the SPD describes, excited delirium is: "A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue." Byju notes that though the condition has been used as a formal cause of death, it is not recognized by any mainstream American or international medical associations, the World Health Organization's International Classification of Diseases, and is not present in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). What is not noted here is that excited delirium is disproportionately "suffered" by people of color. Those "afflicted" with the condition are usually under the influence of illegal drugs or in the midst of a mental health crisis. All are in police custody. This, more than anything, is the defining factor of the condition.

Like Ellis, Prude's case would eventually gain national attention during the George Floyd protests and there would be parallels to Prude and Floyd, who had excited delirium cited as part of their accused's defense. It is also of note that in Antioch, CA, in December of 2020, Angelo Quinto's death in police custody was officially attributed to excited delirium, though his family's independent autopsy findings were consistent with asphyxiation.

These four men were reportedly killed either by or with the contribution of excited delirium. In all four court hearings, excited delirium was argued as a defense but was dismissed each time because the condition was considered invalid by judges and expert witnesses.

So why do we allow a law enforcement officer to diagnose a condition that the medical community has dismissed at large? And even more so, why do we allow one to use that spot diagnosis to justify force?

Like a rabid dog

One of the first primary source documents I read when researching this story was a Tacoma Police Department Intra-Departmental memo from January 2, 2024. The memo, written to the Chief of Police by Assistant Chief Tammy Floyd was titled Complaint Findings and Officer Timothy Rankine. The memo, released after Officer Timothy Rankine, Matthew Collins, and Christopher "Shane" Burbank were acquitted of all charges, detailed the events of the night of Manny Ellis's death and interviewed several of the officers involved, three of whom indicated that they believed Manny was suffering from excited delirium. The memo was the result of an internal investigation and to put forth any findings of misconduct that Officer Rankine may have shown the night Manny Ellis died in police custody. What struck me most was the characterization of the condition by the officers.

Reading the officers describe excited delirium was like reading a person describe the symptoms of a rabid dog.

In a 2021 study performed by 21CP Solutions, excited delirium was still recognized as a condition by local law enforcement. The study, recommending new policies and procedures for TPD, and recommended that if Tacoma continued to recognize excited delirium, then it needed a better protocol to call EMS, Fire, or other rescue professionals. Exactly a year after the death of Manny Ellis, the City of Tacoma could choose to continue to recognize excited delirium as a condition despite years of medical evidence against it.

Cocaine, Serial Killers, and the Birth of a Pseudoscience

The origins of excited delirium are as wild as one might expect any pseudoscience to be. The term was coined by Charles Wetli in 1986, the then-Deputy Chief Medical Examiner of Miami-Dade County, explain the deaths of 32 black women who worked as sex workers. There was no obvious cause of death for these women, so Wetli hypothesized that the women had died due to a combination of sexual activity and cocaine use. Additionally, he hypothesized that cocaine use would cause black men to become psychotic and violent. When asked why this seemed to affect only black people, Wetli reportedly responded that it could be "genetic" or because of certain "blood types," insinuating that race was the cause of the condition.

In an interesting turn of events, a white serial killer, Charles Henry Williams, was found to be at fault for the deaths of the 32 women. This did not, however, stop Wetli from forcing his excited delirium theory forward. It quickly became a convenient cause for the use of force by police departments nationwide. Even after the arrest of Williams, Wetli still asserted that at least some of the women had died of excited delirium.

Unsurprisingly, the private sector found an opportunity in excited delirium. Particularly the company Axon Enterprise, which manufactures tasers, jumped to promote the diagnosis by publishing medical studies that ultimately pushed their products. The company purchased and gifted complimentary copies of Dr. Vincent and Theresa Di Maio's book, Excited Delirium Syndrome, at conferences. I read parts of the book as research for this piece and I do not recommend it.

In 2008, Axon hosted a conference for the medical and first responder community focused solely on excited delirium. Keynote speakers included none other than Dr. Charles Wetli, Axon’s newest employee. Following the event, the American College of Emergency Physicians published a white paper favoring the excited delirium diagnosis, which was later retracted. As of right now, there are no medical associations that support the existence of excited delirium. Everywhere excited delirium was adopted, it had started to stink.

Yet there were four decades where the diagnosis waged war on people of color in police custody. The number of deaths attributed to the condition is difficult to track. Reuters reported in 2017 a 276-person death toll over 17 years, which averages out to be around 16 people per year. These were all attributed to taser use and the presence of excited delirium. Other studies have shown differing numbers. The important thing to note here is that excited delirium is not a cause of death nor is it a contributing factor because it is not a real medical diagnosis. Referring back to the cases of Ellis, Prude, Floyd, and Quinto, all four men died as a result of lack of oxygen—either hypoxia or asphyxiation.So it begs the question, how did the other 276 die?

Constellations

In June of 2021, the American College of Emergency Physicians (ACEP) saw the writing on the wall. Excited delirium was posing an issue for the agency. However, it was still argued in courtrooms as a defensive tactic and cause of death for police officers accused of murdering men of color through asphyxiation across the country. This was when the ACEP introduced their newest medical diagnosis: hyperactive delirium with severe agitation, or just “hyperactive delirium” for short. State and local jurisdictions across the country stuck to this new diagnosis like glue.

The organization produced a 132-page task force paper on hyperactive delirium, presumably to get ahead of the nationwide implosion of excited delirium. Writing extensively on excited delirium, this new report churned out the same garbage as the initial 2009 report—and spent a lot of its word count doing so. The report claimed that excited delirium is caused by “protein markers” in the blood, and excited delirium is caused by “acute cocaine toxicity.” It claimed that excited delirium has fatal outcomes for men of color because men of color have fatal outcomes when encountering police. “This is a you problem, not a me problem.” It is all the same regurgitated story.

In 2021, after the death of Manny Ellis, after the fallout from George Floyd’s death and the ensuing protests, and the Capitol Hill Occupied Protest/Capitol Hill Autonomous Zone disaster in Seattle, Washington State was looking to start over. Lawmakers passed twelve House Bills aimed at reforming Washington State police departments, and very specifically, police use of force. Excited delirium was out and hyperactive delirium was in. Hyperactive delirium fell under the Revised Code of Washington’s new “Reasonable Care” policies, effectively wiping the hands of officers clean.

The major difference between hyperactive delirium and excited delirium is that there isn’t one. The ACEP admittedly repurposed one diagnosis for another amid a maelstrom of controversy surrounding the excited delirium diagnosis. Both syndromes are described as “constellation[s] of signs and symptoms without a clearly elucidated singular cause or pathophysiologic definition.” Translation: A syndrome with no clear cause or medical definition. The ACEP defines their syndromes by not defining them.

I believe it is a waste of space to compare both definitions when a) it is nothing more than semantics, and b) even the ACEP admits in their 2021 paper that the definitions are virtually the same. The only thing differing in hyperactive delirium is a call to action of sorts. The idea is that once law enforcement encounters someone in the throes of the “syndrome,” officers are ordered to immediately request EMS so people may be examined and administered ketamine therapy, a highly controversial treatment with a mortality rate of a conservative 15 percent. Officers must use de-escalation tactics in the meantime.

What must also be discussed is the validity of hyperactive delirium as a diagnosis. If it is admittedly no more than a repackaged concept, does it have any real authority as a medical diagnosis? A few things have changed from excited delirium. For one, only EMS professionals or other medical professionals must make the diagnosis of hyperactive delirium. Second, hyperactive delirium must always be treated as a medical emergency, and police officers should employ reasonable care rather than the use of force. Third, hyperactive delirium is treated with ketamine or other sedation therapy. While these all seem to be a step in the right direction, the report notes that the “syndrome” is still highly volatile. In October of 2023, the ACEP formally retracted its white paper and positions on excited delirium, distancing itself from the term that defined so much of its work in the prior decade.

What I believe to be gravely important is the issue of trust. Why is Washington State electing to trust the guidance of an organization like the American College of Emergency Physicians again? The ACEP spread bad medicine for years and when push came to shove, they repackaged and rebranded and didn’t even do it quietly. Why is Washington State trusting that?

A Scapegoat

If we rely on Reuter's math from their 2017 report, an individual loses their life because of the supposed diagnosis of excited delirium every 22 days. Combine this with the statistic (via the NAACP) that only three law enforcement officers in the United States have been convicted of murder this year, and it paints a stark picture of a law enforcement culture without accountability.

How do we reconcile something that has become so deeply ingrained in our culture without our knowledge or permission? Something that is being used as the scapegoat in the deaths of innocent civilians? Isn't that excited delirium, if not a real medical diagnosis? A scapegoat?

There is light at the end of the tunnel, however.

The family of Angelo Quinto from Antioch led a long but successful charge at banning excited delirium as an official cause of death for coroners and medical examiners across the State of California. In October of 2023, the law went into effect, banning law enforcement officers from using the phrase in their reporting and banning medical examiners, coroners, and others from certifying the condition as a cause of death on a decedent's death certificate. In December of 2023, Colorado followed suit with a similar law applicable to the state. Currently, Hawaii, Minnesota, and New York are entertaining related legislation.

Where Do We Go From Here?

It can all feel so defeating.

The work that has already been done must be acknowledged. After working with the family of Manuel Ellis, the Attorney General’s Office passed a hog-tying ban in Washington State, in February of 2024. The ban prevents police officers from tying a person’s wrists and ankles together, preventing the risk of suffocation. Manny was hog-tied on the night of his death. This inspires me further in my own work on re- examining police use of the prone position and the weight of an officer’s body on another person.

While it remains to be seen whether or not the 2021 State use-of-force standards have helped or hurt Washington State communities, the community must remain vigilant in both understanding and reporting how it interacts with the policing system.

Finally, if this is something the community cares about, know that work is being done. By individuals, by families, and by activist groups.

A Reckoning

Before Daylight Savings Time had occurred and just fourteen days before Tacoma's world shut down due to the COVID-19 pandemic, March 3, 2020, became one of Tacoma's darkest days. One of our own was lost. Our city is still trying to heal from this loss.

Sometimes the conversation around prevention feels empty when there has been such a significant loss. Moving forward feels like moving backward. It feels like erasing what happened.

The officers involved in the death of Manny Ellis were acquitted of all charges. But they were not exonerated. That day, the protest spilled out of the courtroom and out into the streets. Tacoma came together, in a vigil, and peacefully protested, just as we had peacefully protested for Manny and for George and for all the victims of police violence in this country time and time again. We peacefully protested when we could have been raging. Manny's sister, Monét Carter-Mixon, wanted the entire world to know her family's pain and the weight of Manny's death.

There is still so much pain in our city.

The question of “Why?” still looms over Tacoma and Washington State. Why are we still holding on to hyperactive delirium when we could be following suit with other states and outlawing the concept and practice altogether? What value does the State find in continuing to play with fire, knowing full well that it is only a matter of time before another Manny Ellis, another George Floyd, another Daniel Prude, or another Angelo Quinto?

I drive by Manny's mural on 11th & MLK every day on my way home from work. I see his face, as large as a building, smiling. I’ve been pondering what I wish I could say, or do, for Manny. A person whose life never crossed paths with mine and probably never would have. It’s hard for those of us who did not know Manny to extricate him from his death when we speak about or remember him. When I think of him, I think of this line, a small prayer of sorts, from poet Althea Davis: “If I am killed simply for living, may death be kinder than man.” I hope with everything in me for this to be true.

This story is written to honor Manuel Ellis and all the men and women whose deaths and/or circumstances leading up to their deaths were wrongfully attributed to excited delirium.