Renuka Rayasam, Author at KFF Health News

As Foundation for ‘Excited Delirium’ Diagnosis Cracks, Fallout Spreads

Renuka Rayasam and Markian Hawryluk and Samantha Young — Wed, 13 Dec 2023 10:00:00 +0000

When Angelo Quinto’s family learned that officials blamed his 2020 death on “excited delirium,” a term they had never heard before, they couldn’t believe it. To them, it was obvious the science behind the diagnosis wasn’t real.

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Most States Ban Shackling Pregnant Women in Custody, Yet Many Report Being Restrained

Renuka Rayasam — Fri, 17 Nov 2023 10:00:00 +0000

Ashley Denney was about seven months pregnant in 2022 when police handcuffed her during an arrest in Carroll County, Georgia. Officers shackled her even though the state bans the use of restraints on pregnant women in custody beginning at the second trimester.

In early July, she said, it happened again.

“I asked the officer, ‘Please, pull over. I’m not supposed to be handcuffed. I’m pregnant,’” said Denney. At the time, she was near the end of her first trimester, though she believed her pregnancy was more advanced. Arresting officers did not know she was pregnant, said an official with the Carrollton Police Department who reviewed video footage of that arrest.

Medical groups, such as the American College of Obstetricians and Gynecologists, widely condemn shackling pregnant people, which they argue is unethical and unsafe because it increases the risk of falls, hinders medical care, and endangers the fetus.

About 40 states, including Georgia, have passed laws limiting the use of restraints such as handcuffs, leg restraints, and belly chains on pregnant people in law enforcement custody, according to a Johns Hopkins University research group. Laws that seek to improve treatment of pregnant women in jails and prisons have drawn bipartisan support, including the First Step Act, which was passed in 2018 and limits the use of restraints on pregnant people in federal custody. Yet advocates say they continue logging reports of law enforcement agencies and hospital staffers ignoring such prohibitions and allowing pregnant people to be chained, handcuffed, or otherwise restrained.

Confusion over the laws, lack of sanctions for violations, and wide loopholes are contributing to the continued shackling of pregnant women in custody. But it’s nearly impossible to get an accurate picture of the prevalence because of limited data collection and little independent oversight.

“People see laws like these, and they say ‘check.’ They don’t know how they are being implemented and if they are creating the outcomes intended,” said Ashley Lovell, co-director of the Alabama Prison Birth Project, a group that works with pregnant prisoners. Without oversight, these laws “are words on paper,” she said. “They don’t mean anything.”

U.S. jails admit 55,000 pregnant people each year, according to estimates based on 2017 data from research led by Carolyn Sufrin, a gynecology and obstetrics associate professor at Johns Hopkins University who researches pregnancy care in jails and prisons. “The fact that we don’t know what is happening is part of the story itself,” she said.

Yet reports of shackling continue to surface, often making local headlines.

In January, a Georgia woman, 32 weeks pregnant, was shackled for hours while waiting for a medical appointment and during transport, according to Pamela Winn, founder of RestoreHER US.America, a group that works with people entangled in the criminal justice system. The woman did not want to be identified because she is in state custody and fears retaliation. She said her handcuffs were removed only after a request from medical staffers.

Her experience was echoed by women nationwide in law enforcement custody.

Minnesota passed an anti-shackling bill in 2014, but six years later a suburban Minneapolis woman sued Hennepin County after a wrongful arrest during which she was shackled while in active labor — an incident first reported by local media.

And despite Texas’ shackling ban, in August 2022 an officer in Harris County, which includes Houston, chained Amy Growcock’s ankle to a bench in a courthouse holding area for hours.

“It was pretty painful,” said Growcock, who was eight months pregnant and worried about circulation being cut off in her swollen leg.

Prohibitions on shackling have run into the realities of the country’s complicated web of penal institutions. Millions of people are held in a system that includes thousands of county jails, state and federal prisons, and private facilities with varying policies. Facilities often operate with little or no independent oversight, said Corene Kendrick, deputy director of the ACLU National Prison Project.

Some ACLU chapters have been logging complaints about violations of state bans on shackling pregnant people in jails and prisons. It appears, from complaints and oversight reports, that officials are usually left to interpret the law and police their own behavior, said Kendrick.

The Georgia law bans restraining pregnant women in their second and third trimesters and allows restraints in certain circumstances immediately postpartum. The state Department of Corrections maintains an anti-shackling policy for pregnant people in state custody and requires violations to be reported. But agency officials, in response to records requests from KFF Health News, said there were no incident reports regarding shackling in 2022 and through late October.

The Georgia Sheriffs’ Association asks county jails to voluntarily submit data on shackling, but only 74 of the 142 jails sent reports in 2022. Those jails reported holding 1,016 pregnant women but only two inmates who were restrained in the immediate postpartum period.

Association officials contend that shackling is rare. “Our jail people have a lot of common sense and compassion and do not do something to intentionally hurt somebody,” said Bill Hallsworth, director of jail and court services for the association. Many rural jails don’t have medical staffers to immediately verify a pregnancy, he added.

The Carrollton Police Department, whose officers handcuffed Denney, maintain that the law didn’t apply during her arrest, before her booking into a facility, according to public information officer Sgt. Meredith Hoyle Browning.

“It sounds like, to me, that there has been wide interpretation of this bill by the people we are asking to enforce it,” said Georgia state Rep. Sharon Cooper, a Republican who authored the state’s bill. Cooper said she hadn’t been notified of any incidents but added that if pregnant incarcerated women are still being shackled, legislators may need to revise the law.

In addition, some incidents in which jailors shackle pregnant people fall into legal loopholes. In Texas, as in many other states, officers can make exceptions when they feel threatened or perceive a flight risk. Last year 111 pregnant women reported being restrained in jail, according to a Texas Commission on Jail Standards report in April. In more than half the cases, women were shackled during transport even though that’s when they are most likely to fall.

The Texas commission has sent memos to jails that violate the shackling policy, but documents reviewed by KFF Health News show the agency stopped short of issuing sanctions.

Most states don’t allocate funding to educate correctional officers and hospital staff members on the laws. More than 80% of perinatal nurses reported that the pregnant prisoners they care for were sometimes or always shackled, and the vast majority were unaware of laws around the use of restraints, as well as of a nurses association’s position against their use, according to a 2019 study.

Even when medical professionals object to restraints, they generally defer to law enforcement officials.

Southern Regional Medical Center, just south of Atlanta, handles pregnant incarcerated patients from the Georgia Department of Corrections, the Clayton County Jail, and other facilities, said Kimberly Golden-Benner, the hospital’s director of business development, marketing, and communications. She said clinicians request that officers remove restraints when pregnant incarcerated patients arrive at the center for labor and delivery. But it’s still at the officers’ discretion, she said.

The Clayton County Sheriff’s Office didn’t return a request for comment. The state Department of Corrections maintains a policy of limiting the use of restraints on pregnant incarcerated people to only extreme cases, such as when there is an imminent escape risk, said Joan Heath, public affairs director. All staff members at facilities for women are required to complete an annual training course that outlines the policy, she said.

Strengthening the laws will require funding for implementation, such as creating model policies for hospitals and law enforcement staffs; continuous training; tighter reporting requirements; and sanctions for violations, advocates say.

“The laws are a necessary step and draw attention to the issue,” said Sufrin, the Johns Hopkins professor. They are “by no means enough to ensure the practice doesn’t happen.”

Winn wants states to allow pregnant women to bond out of jail immediately and defer sentences until after they give birth. In Colorado a law took effect in August that encourages courts to consider alternative sentences for pregnant defendants. Florida lawmakers considered but did not pass a similar measure this year.

The use of restraints is a window into mistreatment that pregnant women face in jails and prisons.

Denney said that in August she was mistakenly given medication for depression and anxiety instead of nausea; her morning sickness worsened, and she missed a meal.

The medical staff doesn’t have a record of Denney being given the wrong medication, said Brad Robinson, chief deputy of the Carroll County Sheriff’s Office.

“They don’t take you seriously,” Denney said of the pregnancy care she has received while incarcerated. “They should at least make sure the babies are all right.”

Growcock said her initial shackling in Houston was the first sign that officers weren’t equipped to handle pregnant people. She gave birth in a jail cell and nearly lost her son less than two weeks after her arrest. The Texas Commission on Jail Standards acknowledged that Growcock, who photographed her ankle in restraints, had been shackled. But the jail overseer admitted no other wrongdoing in her case, according to a memo the commission sent to the Harris County Jail.

“I felt like if I wasn’t getting treated right already, then the whole experience was going to be bad,” she said. “And it was.”

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Residents of a Rural Arkansas County Grapple With Endemic Gun Violence

Renuka Rayasam — Wed, 25 Oct 2023 09:00:00 +0000

ELAINE, Ark. — On a recent September afternoon, Courtney Porter counted his losses: his mom from old age, his wife from diabetes complications, two of his brothers. While one died of an aneurysm, the shooting death last year of his younger brother, Patro, hit the hardest.

“It tore me up, real bad,” said Porter, 50, from the Stop N Shop, a defunct gas station that is now a convenience shop. “I’ll never get over it.”

Patro, who was 46 when he died, was a barber. He had even cut the hair of the man, then 20, who is accused of shooting him after an argument over a cigarette.

For this tightknit town of 500, situated on the west bank of the Mississippi River and surrounded by soy and cotton fields, the killing was both shocking and senseless, Porter said.

“Everybody here gets along,” he said. “Everybody had a question, like, ‘Why? Why? Why did he do this?’”

Patro Porter’s death wasn’t an isolated incident. Phillips County, where Elaine is located, is home to about 15,000 people spread across 690 square miles. Data shows they’re at high risk of gun violence. From 2016 to 2020, the county had the country’s highest per capita rate of gun homicides, according to an analysis last year by the Center for American Progress, a policy research institute.

During three days in July, police responded to reports of four homicides in Helena-West Helena, the Phillips County seat. That might be a small number for a major city, but it has an outsize impact in a rural town, said Nick Wilson, senior director for gun violence prevention at the Center for American Progress.

Suicide rates in rural areas have long been higher than in cities. But nationwide, rural gun homicides have risen too, and, in some areas, outpaced their urban counterparts. From 2016 to 2020, 13 of the 20 counties with the highest gun homicide rates were in the rural South, according to the center’s study.

The deaths can devastate small communities. Rural areas often lack the resources and expertise needed to stem gun violence and medical facilities to care for the wounded.

More research is needed to determine what drives rural gun violence in the places it’s most prevalent, but the causes are similar to those in historically “redlined” urban neighborhoods, where Black people have been denied mortgages and other housing opportunities, said Daniel Webster, a distinguished scholar at the Johns Hopkins Center for Gun Violence Solutions. Both types of areas have been starved of resources and opportunities, he said.

“These disadvantages are structural and driven by policy rather than naturally occurring,” he said. “The conditions that lead to structural racism also lead to higher rates of gun violence.” These are places that have lacked investment, where poverty is rampant, unemployment is high, schools are failing, and buildings are crumbling.

Phillips County has a harrowing history of racism. In 1919, Elaine was the site of one of the worst racial massacres in U.S. history. At least 200 Black residents were murdered by white residents and soldiers over a couple of days after a group of Black farmers met one late September evening to demand better payments for their cotton crops.

The descendants still deal with generational trauma, said Brian Mitchell, a historian who researched the massacre and is now director of research and interpretation at the Abraham Lincoln Presidential Library and Museum. Segregation continued, the mechanization of farming sent unemployment soaring, and poverty deepened.

Still, Ora Scaife, 40, remembers a “joyful” childhood in Elaine, where she attended middle and high school football and basketball games and looked forward to seeing store windows decorated for the holidays. “It was popping,” said Scaife, manager at the town’s Dollar General.

Today, Elaine’s shops and restaurants sit empty. Many houses are crumbling. Even the schools shut down because of declining enrollment — children are now bused 30 minutes to Marvell. The Dollar General employs both Patro Porter’s son and the sister of the man accused of shooting him, Scaife said.

After he was shot, Patro Porter was first taken to a medical center 25 miles away, and then flown to a trauma center in Memphis, Tennessee, where he died the next day. The man accused of killing him was captured two months later in Little Rock. He’s now awaiting trial.

Elaine is divided by Main Street, where on a recent afternoon a pickup truck with a Confederate flag license plate sat parked in front of the one-room library. White residents populate the town’s southern portion, and the north, which includes a public housing complex — a cluster of two-story brick buildings where Patro was shot— is a Black community, said Lisa Hicks Gilbert.

“Phillips County is rooted in violence,” said Hicks Gilbert, who became Elaine’s first Black and female mayor in January and is a descendant of an Elaine massacre survivor. “Generational poverty by violence is going to breed violence.”

Under those conditions, even small stressors, like a fight over a cigarette, can lead to a shooting, researchers say. Most homicides in Phillips County, as in urban areas, stem from interpersonal or domestic disputes. A few years ago, a man in Helena shot a man who allegedly stole butter beans from his garden.

“A lot of people think homicides happen very quickly, but they transpire over days and weeks,” said Charles Branas, director of the Columbia Center for Injury Science and Prevention.

In the past, disputes would end up in fistfights, said Kevin Smith, who was Helena-West Helena’s mayor until 2022 and served in the Arkansas state senate. The widespread availability of guns escalates homicides and suicides, according to public health researchers. In the South, gun laws are generally lax. Arkansas already had permissive gun laws and further loosened them in recent years, according to an Axios analysis of state gun laws.

Phillips County, and the entire Mississippi Delta region, has lacked concentrated federal investment and a steady stream of grants that typically flow to bigger cities, Smith said. That affects everything from the lack of mental health care and addiction treatment to the lack of quality public housing and programs needed to stimulate the economy and schools, said Smith, who also serves on the board of the Helena Regional Medical Center. “If you scratch down enough,” Smith said, “it is despair.”

Hicks Gilbert knows the community can’t undo decades of poverty and trauma overnight, but she said residents are used to overcoming big challenges and making do with few resources. “These are the most resilient people, the most resourceful people,” she said.

In April, Hicks Gilbert hired a new police chief — the only full-time law enforcement position in Elaine — from a different part of the state. She is requiring public housing operators to keep properties up to code, bringing in dumpsters to encourage residents to clean up trash, tearing down dilapidated houses, hiring young people to work in city government and at the community center, and starting a tutoring program.

“I am changing the way people see their community and changing the mindset about what is possible,” Hicks Gilbert said.

But persistent poverty and violence take an emotional toll, said Steven Cannon, a pastor who also runs an after-school community center in West Helena.

“What you see can be depressing at times, especially on a young generation,” Cannon said.

Over the past three years, Cannon has handled more than 10 funerals for young people who died of gun violence. Every time, he directs mourners to release balloons into the air to express the loss. The most recent funeral he officiated, for a 15-year-old who was a regular at the community center and was shot last year, was especially hard, Cannon said.

“Because you say, in your mind, ‘When will it stop?’” he said. “‘When will somebody listen?’”

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Doctors Abandon a Diagnosis Used to Justify Police Custody Deaths. It Might Live On, Anyway.

Markian Hawryluk and Renuka Rayasam — Mon, 16 Oct 2023 09:00:00 +0000

Brooks Walsh hadn’t questioned whether “excited delirium syndrome” was a legitimate medical diagnosis before the high-profile police killings of Elijah McClain in Colorado in 2019 and George Floyd in Minnesota in 2020.

The emergency physician in Bridgeport, Connecticut, was familiar with the term from treating patients who were so severely agitated and combative that they needed medication just to be evaluated.

But it gave him pause when excited delirium — and not the restraint tactics used by arresting police officers — was mentioned as a possible factor in the deaths of those two Black men. That’s when Walsh took a closer look at the American College of Emergency Physicians’ 2009 position paper on excited delirium, which he and other physicians had relied on to treat such patients, then decided something needed to be done.

“I was disappointed by a lot of stuff in that paper: the quality of the evidence that they cite and just, frankly, odd language,” Walsh said.

Excited delirium is not listed in the standard reference book of mental health conditions, nor does it have its own diagnostic code under a system used by health professionals to identify diseases and disorders. No blood test or other diagnostic test can confirm the syndrome. Most major medical societies, including the American Medical Association and the American Psychiatric Association, no longer recognize excited delirium as a legitimate medical condition. One of the last medical holdouts, the National Association of Medical Examiners, rejected excited delirium as a cause of death this year.

But the American College of Emergency Physicians, the medical society representing Walsh and more than 36,000 other doctors, still hadn’t disavowed its report that gave excited delirium much of its legitimacy — until this month. On Oct. 12, the group approved a resolution that Walsh co-authored to withdraw the 2009 white paper on excited delirium, removing the only remaining official medical pillar of support for a theory, which despite being based primarily on discredited research and racial biases, has played a key role in absolving police of culpability for in-custody deaths.

“This is the membership of ACEP saying we recognize that this was wrong,” said Sophia Spadafore, an emergency physician at Mount Sinai Hospital in New York City. “And now, as an organization, we need to reckon with our history and try to make up for some of the mistakes that were made and repair some of the damage that we did.”

The vote brought some vindication to Verdell and William Haleck, whose son Sheldon died in 2015 after being pepper-sprayed, shocked with a Taser, and restrained. The Utah family lost its civil case against Honolulu police officers, whose lawyers argued the 38-year-old former Hawaii Air National Guardsman had experienced excited delirium. Watching defense experts paint their son as responsible for his own death was excruciating, his parents said.

“We were right all along,” Verdell Haleck said in response to the ACEP vote. “Now our hopes are that the term can never be used again to cause pain and suffering for another family in their pursuit of justice.”

And momentum is building. Just before the vote, California became the first state to ban excited delirium as a diagnosis and cause of death on death certificates, autopsy reports, and police reports, as well as in civil court proceedings.

Backers of the emergency physicians’ resolution hope such disavowals of the term will lead to better training and greater accountability of paramedics and police when they interact with people in mental health crises.

But it is unlikely the doctors’ vote can affect past wrongful death and criminal cases against police. And it remains unclear whether renouncing the 2009 document will prevent defense lawyers in future cases from using similar victim-blaming concepts — just with alternative terminology.

‘This Drastically Affected Our Lives’

Nearly 14 years ago, Patrick Burns, 50, died after sheriff’s deputies hogtied him and shocked him multiple times with Tasers in Sangamon County, Illinois, according to court documents. A medical examiner concluded the official cause of death was excited delirium.

That diagnosis in Burns’ death stymied the family’s lawsuit against the county officers, which ended in a $40,000 settlement in 2015, said Richard Burns, one of Patrick’s brothers. The label also helped law enforcement create a picture of him as someone who was “out of control,” which ruined his brother’s reputation, Richard said. “That picture is implanted on who my brother was, and that’s not the truth.”

The term “excited delirium” dates back decades but has never been supported by rigorous scientific studies. Still, the term persisted as some of its early researchers earned money for testifying as expert witnesses in cases involving law enforcement and the company now called Axon Enterprises, which makes the Taser stun gun.

The theory suggested that agitated, delirious individuals were dying not because they had been shocked by stun guns, restrained with chokeholds, or held facedown so they couldn’t breathe, but because of this unexplained medical condition that could lead to sudden death.

Funding from Taser International, Axon’s former company name, sponsored some of the research forming the basis of ACEP’s white paper supporting the excited delirium theory, according to a 2017 Reuters investigation. The 19-person task force that drafted the 2009 paper included three people who provided paid testimony or performed consulting work for Taser, that report found. KFF Health News called eight of the task force members but none agreed to interviews. Axon executives did not respond to calls or emails seeking comment on the white paper.

That ACEP paper described patients with excited delirium as having superhuman strength, being impervious to pain, exhibiting aggressive behavior, and making guttural sounds. To Walsh and other doctors behind the push to reject the diagnosis, those descriptions reflected age-old racist tropes of Black men as being stronger than white men or being animalistic. The incorrect notion that Black people feel less pain persists in modern medicine and has led to disparities in pain treatment.

Indeed, excited delirium has been cited more often in cases involving people of color. According to a Virginia Law Review article, at least 56% of police custody deaths from 2010 to 2020 attributed to excited delirium involved Black and Latino victims. Reviews of deaths attributed to excited delirium also found they overwhelmingly occurred when people were being restrained.

Yet the authority of the esteemed doctors group and its position paper helped cement an alternative cause of death that defense attorneys for police argued in court. And now, it’s likely too late for families who lost cases based on an excited delirium defense. Even with ACEP’s disavowal, courts may be reluctant to reopen resolved cases, said Jim Davy, a civil rights lawyer in Philadelphia.

In June, just months after the National Association of Medical Examiners decided excited delirium should no longer be listed as a cause of death, the county coroner changed Patrick Burns’ official manner of death to homicide. The coroner concluded he had suffered brain damage due to a lack of oxygen after being restrained on his stomach, not from excited delirium.

But the Illinois state attorney declined to pursue new charges against the deputies in Burns’ death.

“It’s more than just an unfortunate story,” Richard Burns said. “This drastically affected our lives.”

Racial Reckoning Sparks Shift

At a 2020 American Medical Association policy conference, medical students spurred by the racial reckoning in the wake of the police-involved deaths of Floyd and many others introduced a series of resolutions around combating racism in medicine, including one against excited delirium. But emergency physicians, who also belong to that broader physician group, objected.

“They’re regarded as the content experts on the issue, and so I think it was hard for us to combat some of those counterarguments at that time,” said Rohan Khazanchi, a medical resident and a researcher with the FXB Center for Health and Human Rights at Harvard University.

Emergency physicians see patients with agitation and delirium more often than clinicians in other specialties do and oversee emergency medical technicians and paramedics who encounter such individuals outside of a hospital.

The AMA decided to study the issue. Its subsequent report firmly sided with the medical students and, in 2021, the AMA delegates issued a strong condemnation of excited delirium as a clinical diagnosis.

But ACEP, which represents a predominantly white specialty, dragged its feet in addressing its problematic paper. Instead, the group released a new policy statement in 2021 using the term “hyperactive delirium,” saying the guidance was not meant as an update or refutation of the paper.

Jeffrey Goodloe, an emergency physician in Tulsa, Oklahoma, and one of the authors of the 2021 policy statement, said ACEP didn’t want to issue a statement without providing a clinical document to help guide physicians. And since the task force wanted to focus on clinical considerations, he said, it avoided addressing “excited delirium,” which had been under fire.

“It was being used in nonclinical ways, which no one ever really thought that it would be,” he said. “It was becoming at times a flashpoint between law enforcement and the community at large.”

This spring, the group issued a statement saying it no longer recognized excited delirium as a diagnosis but stopped short of retracting the 2009 white paper. And until this month’s vote, it hadn’t taken any steps to prevent its name and policy statement from being used by defense attorneys defending police in court cases involving in-custody deaths.

Goodloe, who now chairs the ACEP board, said it was hard for ACEP to track individual court cases and what expert witnesses were saying, especially if they were not ACEP members.

“We can’t ensure how nonmedical professionals use a document that is designed to inform and guide medical care,” he said. “I would hope that they would continue to recognize the primary intent of the paper and be very meticulous about avoiding misquoting or mischaracterizing what that paper is for.”

New Terms Arise

The remaining defenders of the term insist that excited delirium is a real condition that puts patients, physicians, and first responders at risk.

One of the 2009 white paper’s co-authors, Deborah Mash, a retired professor of neurology at the University of Miami, declined an interview but wrote in an email that the task force that penned the white paper included some of the most respected thought leaders in emergency medicine at the time, who sought to suggest best practices for treating patients with such symptoms.

Since then, she said, “banning the use of the ‘term’ has caught on with the anti-police movement.”

Mash has testified about excited delirium as an expert witness for the defense in wrongful death claims filed against Axon over the use of its Tasers.

Some lawyers who bring in-custody death cases on behalf of families believe the ACEP reversal will help wipe out a major police defense tactic.

“It has a huge impact on cases going forward, because the white paper was the main vehicle for trying to legitimize excited delirium,” said Julia Sherwin, a civil rights attorney who is representing the family of Mario Gonzalez, who died in police custody in California in 2021.

But eradicating the term “excited delirium” may not stop police from trying to use the theory behind it to justify the deaths of suspects in custody: The Minneapolis Star-Tribune reported last year that a training for the Minneapolis Police Department, which was involved in Floyd’s death, used PowerPoint slides with the words “excited delirium” crossed out and replaced with the term “severe agitation with confusion (delirium).”

Clinical documents from ACEP and other organizations have described the same cluster of symptoms at various times as hyperactive delirium, agitated delirium, or restraint-related cardiac arrest. Defense lawyers might argue the same concept using those terms or rely on other medical conditions to explain a death rather than law enforcement officials’ use of force.

“It’s so easy for them, once the excited delirium argument is dismissed, to use another kind of medical argument that’s quite similar,” said Justin Feldman, a social epidemiologist at Harvard University who studies patterns of in-custody deaths.

In April 2021, Gonzalez died after police officers in Alameda, California, restrained him on his stomach, handcuffed him, and placed their weight on him. The county coroner listed his death as a homicide. But ACEP member Gary Vilke, one of the co-authors of the 2009 white paper, said in a September 2023 deposition he believed that Gonzalez died of cardiac dysrhythmia, an irregular heartbeat.

Vilke testified in the deposition that he could make up to $50,000 as a defense expert in the case, which is set to go to trial later this year, and that he has testified in restraint or law enforcement-related cases 58 times over the past four years. Vilke declined to comment to KFF Health News on the white paper.

California’s new law lists alternative terms — hyperactive delirium, agitated delirium, and exhaustive mania — that will be restricted along with excited delirium starting in January. Nothing in the law prevents defense experts from using other medical explanations, such as cardiac dysrhythmia, for the deaths.

“People in agitated states due to cocaine, methamphetamine or untreated psychiatric illness still require help which is provided by police and first responders,” Mash, who helped create the 2009 paper, wrote in an email. “These individuals are at increased risk of sudden death regardless of what you call it.”

Still, Richard Burns, the Halecks, and others whose loved ones died during police encounters hope the ACEP vote prevents future abuses, pushes more states to follow California’s lead, and boosts police accountability.

“What needs to happen is to focus on the why, the reason, the cause,” said Burns. “The cause is the police brutality, which gets minimized when it’s being able to be hidden behind these terms.”

Chris Vanderveen, KUSA-TV’s director of special projects, contributed to this report.

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Police Blame Some Deaths on ‘Excited Delirium.’ ER Docs Consider Pulling the Plug on the Term.

Markian Hawryluk and Renuka Rayasam — Mon, 02 Oct 2023 09:00:00 +0000

The way Sheldon Haleck’s parents see it, the 38-year-old’s only crime was jaywalking. But that March night in 2015, after Honolulu police found him behaving erratically, they pepper-sprayed him, shocked him with a Taser, and restrained him. Haleck became unresponsive and was taken to a hospital. Before his parents could get from their home in Utah to Hawaii, the former Hawaii Air National Guardsman was taken off life support.

“Nobody’s supposed to die from something like this,” said Haleck’s father, William.

An initial autopsy ruled Haleck’s death a homicide and his family filed a civil lawsuit in federal court against the three officers who tried to remove him from the street. The case should have been “one of the easiest wrongful death cases” to win, said Eric Seitz, an attorney who represented Haleck’s family.

But the officers’ attorneys seized on a largely discredited, four-decade-old diagnostic theory called “excited delirium,” which has been increasingly used over the past 15 years as a legal defense to explain how a person experiencing severe agitation can die suddenly through no fault of the police. “The entire use of that particular theory, I think, is what convinced the jury,” Seitz said.

Haleck’s case is just one legal battle in which the theory of excited delirium exonerated law enforcement despite mounting opposition to the term among most prominent medical groups. The theory has been cited as a defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California. It figures in a criminal trial against two police officers involved in the 2019 death of Elijah McClain in Aurora, Colorado, now underway. It has allowed defense attorneys to argue that individuals in police custody died not of restraint, not of a Taser shock, but of a medical condition that can lead to sudden death.

But now, the American College of Emergency Physicians will vote at an October meeting on whether to formally disavow its 2009 position paper supporting excited delirium as a diagnosis that helped undergird those court cases. The draft resolution also calls on ACEP to discourage physicians who serve as expert witnesses from promoting the theory in criminal and civil trials.

“It’s junk science,” said Martin Chenevert, an emergency medicine physician at UCLA Santa Monica Medical Center, who often testifies as an expert witness. The theory has been used to provide a cover for police misconduct, he said. “It had an agenda.”

Passing the resolution wouldn’t bring Haleck back, but his parents hope it would prevent other families from experiencing their agony. “May that excited delirium die here,” said his mother, Verdell.

Democratic California Gov. Gavin Newsom is considering signing into law a bill passed Sept. 12 that would do much of the same in his state.

“If we don’t fully denounce this now, it will be there for the grasping, again,” said Jennifer Brody, a physician with the Boston Health Care for the Homeless Program, who co-authored a 2021 editorial calling on organized medicine to denounce excited delirium. “Historically, we know what happens: The pendulum swings the other way.”

Most major medical societies, including the American Medical Association and the American Psychiatric Association, don’t recognize excited delirium as a medical condition. This year, the National Association of Medical Examiners rejected excited delirium as a cause of death. No blood test or other diagnostic test can confirm the syndrome. It’s not listed in the Diagnostic and Statistical Manual of Mental Disorders, a reference book of mental health conditions, nor does it have its own diagnostic code, a system used by health professionals to identify diseases and disorders.

But the argument’s pervasiveness in excessive-use-of-force cases has persisted in large part because of the American College of Emergency Physicians’ 2009 white paper proposing that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

The ACEP white paper has been cited in cases across the U.S., and lawyers who file police misconduct cases said that courts and judges accept the science without sufficient scrutiny.

ACEP’s position “has done a lot of harm” by justifying first responder tactics that contribute to a person’s death, said Joanna Naples-Mitchell, an attorney who worked on a Physicians for Human Rights review of excited delirium. The term has also been used in cases in Australia, the United Kingdom, Canada, and other countries, according to the group.

“This is a really important opportunity for ACEP to make things right,” she said of the upcoming vote.

ACEP officials declined KFF Health News requests for an interview.

Starting in the mid-1990s, the leading proponents of excited delirium produced research with funding from Taser International, a maker of stun guns used by police, which later changed its name to Axon. The research purported to show that the technique of prone restraint, in which suspects are lying face down on the ground with the police officer’s weight on top of them, and Taser shocks couldn’t kill someone. That research formed the basis of the white paper, providing an alternative cause of death that defense attorneys could argue in court. Many emergency physicians say the ACEP document never lived up to the group’s standard for clinical guidelines.

Axon officials did not respond to a call or email seeking comment on the white paper or the upcoming ACEP vote. In 2017, Taser officials used the American College of Emergency Physicians’ position on excited delirium as evidence that it is a “universally recognized condition,” according to Reuters.

A recent review published in the journal Forensic Science, Medicine, and Pathology concluded no scientific evidence exists for the diagnosis, and that the authors of the 2009 white paper engaged in circular reasoning and faulty logic.

“Excited delirium is a proxy for prone-related restraint when there is a death,” said Michael Freeman, an associate professor of forensic medicine at Maastricht University in the Netherlands, who co-authored the review. “You don’t find that people get ‘excited delirium’ if they haven’t also been restrained.”

Between 2009 and 2019, Florida medical examiners attributed 85 deaths to excited delirium, and at least 62% involved the use of force by law enforcement, according to a January 2020 report in Florida Today. Black and Hispanic people accounted for 56% of 166 deaths in police custody attributed to excited delirium from 2010 to 2020, according to a December 2021 Virginia Law Review article.

This year, ACEP issued a formal statement saying the group no longer recognizes the term “excited delirium” and new guidance to doctors on how to treat individuals presenting with delirium and agitation in what it now calls “hyperactive delirium syndrome.” But the group stopped short of retracting the 2009 white paper. For the past 14 years, ACEP took no steps to withdraw the document or to discourage defense attorneys from using it in court.

Even now, lawyers say, they must continually debunk the theory.

“Excited delirium has continued to come up in every single restraint asphyxia case that my partner and I have handled,” said Julia Sherwin, a California civil rights attorney. “Instead of acknowledging that the person died from the police tactics, they want to point to this alternate theory of deaths.”

Now, plaintiffs’ attorneys say, if ACEP passes the resolution it would be the most meaningful step yet toward keeping the theory out of the courtroom. The resolution calls on ACEP to “clarify its position in writing that the 2009 white paper is inaccurate and outdated,” and to withdraw approval for it.

Despite the theory’s lack of scientific underpinning, backers of the ACEP resolution expect heated debate before the vote scheduled for the weekend of Oct. 7-8. Emergency physicians often encounter patients with agitation and delirium, they say, and are sympathetic to other first responders who share the challenge of managing such patients. While they have tools like sedation to help them in the emergency room, law enforcement officials must often subdue potentially dangerous individuals without such help.

Most people won’t die as a result of police tactics such as prone restraint or Taser use, but a small fraction do.

“It’s a crappy, crappy situation, when you have someone who’s out of control, who can’t make decisions for himself, and is potentially a threat somewhere,” said Jared Strote, an emergency medicine professor at the University of Washington. “It’s not like they have a sticker on their head that says, ‘Hey, I’m at high risk. If you hold me down, then I could go into sudden cardiac arrest.’”

Nonetheless, sentiment is growing among emergency physicians that the 2009 ACEP white paper has resulted in real harm and injustices, and it’s time to set it aside.

“We’ll be able to close the chapter on it and move forward to recognize explicitly that this was in error,” said Brooks Walsh, an emergency physician from Bridgeport, Connecticut, and a key player in bringing the resolution up for a vote. “We definitely have an ethical responsibility to address mistakes or evolutions in medical thinking.”

Chris Vanderveen, KUSA-TV’s director of special projects, contributed to this report.

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Parents See Own Health Spiral as Their Kids’ Mental Illnesses Worsen

Renuka Rayasam — Mon, 14 Aug 2023 09:00:00 +0000

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing “988,” or the Crisis Text Line by texting “HOME” to 741741.

After her teenage daughter attempted suicide and began to cycle through emergency rooms and mental health programs during the past three years, Sarah Delarosa noticed her own health also declined.

She suffered from mini strokes and stomach bleeding, the mother of four in Corpus Christi, Texas, said. To make things worse, her daughter’s failing behavioral and mental health caused Delarosa to miss hours from her job as a home health aide, losing out on income needed to support her family.

“Access to help, when it’s needed, it’s not available,” said Delarosa, about the hopelessness she felt as she sought support for Amanda, 16, who has been diagnosed with bipolar disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder. Amanda has at times lashed out in anger or shattered light bulbs and used the broken glass to cut herself.

Delarosa often feels overwhelmed, and she has noticed her youngest son acting out. “Now we have a whole family that needs help,” she said.

A national shortage of mental health care providers, and the search for affordable care, has exacerbated strain on parents, often the primary caregivers who maintain the health and well-being of their children. Their day-to-day struggle has led to its own health crisis, say psychologists, researchers, and advocates for families.

As parents navigate the mental health care system’s shortcomings, stress can start to take a physical and mental health toll that disrupts their ability to continue providing care, said Christine Crawford, the associate medical director at the National Alliance on Mental Illness, an advocacy group that helps families find care. Parents pour their energy into helping their kids, often at the expense of their own health, Crawford said.

“When you are worrying about whether or not your child is going to survive the day, you are constantly living on edge,” she said. “Your fight-or-flight is constantly activated.”

And the number of parents in crisis is greater than it seems.

Recent reports from the Centers for Disease Control and Prevention, the surgeon general’s office, and medical providers all show an alarming number of kids in the U.S. are experiencing severe mental health challenges. About 40% of U.S. parents with children younger than 18 say they are extremely or very worried their children might struggle with anxiety or depression at some point, according to a January study from the Pew Research Center.

Evidence-based therapies to address a child’s mental health should include the parents, say researchers and pediatric mental health specialists. But the focus on the adult caregivers and their anxiety and stress too often falls short. For example, parent-child interaction therapy coaches parents to manage their young child’s behavior to prevent more severe problems in the child later on. While this may help the child, it doesn’t directly support the parent’s health.

“I have so many parents sit across from me on the couch and cry,” said Danielle Martinez, a behavioral health specialist at Driscoll Children’s Hospital in Corpus Christi. The hospital is creating peer support groups, to launch by the fall, for family members whose children are under the facility’s care.

“They felt so alone, felt like bad parents, felt like giving up,” Martinez said, “and then felt guilty for wanting to give up.”

When the parent’s mental and physical health deteriorates, it complicates their ability to prevent the child’s condition from getting worse, said Mary Ann McCabe, a member of the board of directors at the American Psychological Association, an associate clinical professor of pediatrics at the George Washington University School of Medicine, and a psychologist in independent clinical practice. Parents are a kid’s most important resource and need to be a concern, she said.

Delarosa said many residential treatment centers cited a shortage of providers in refusing to admit her daughter. Amanda, who is covered through Medicaid, would be on weeks-long waiting lists while she “spiraled out of control,” running away from home and disappearing for days, said her mom.

In April, Amanda was admitted to an inpatient residential treatment facility nearly 200 miles away, in San Marcos, Texas. With Amanda away, Delarosa said, she had a “chance to breathe,” but the reprieve would be temporary. She wants to see a therapist but hasn’t had time amid the demands of caring for Amanda and her youngest child, a son. Before Amanda left for treatment, her 7-year-old brother started cussing, throwing and breaking objects in the home, and saying things like he wished he weren’t alive, though his behaviors settled down while his sister was away.

Other parents also said they are feeling the strain on their mental and physical health.

“The children are in crisis. But the families are also in crisis,” said Robin Gurwitch, a professor in psychiatry and behavioral sciences at Duke University. “They are struggling to figure out how best to help their children in a system that doesn’t come with a manual.”

Brandon Masters, a middle school principal in San Antonio, developed a rash on the back of his arms and neck last year that he says his doctor told him was connected to stress.

Even though he is insured through his job, Masters estimates he paid about $22,000 last year on care for his teenage son Braylon, who spent 60 days in residential treatment centers in Texas and California following a diagnosis of bipolar disorder. Braylon spent an additional month in juvenile detention later in 2022 after he bit his dad and brandished a knife. So far this year, Braylon, now 17, has attempted suicide twice, but Masters has been unable to find a residential treatment center he can afford and that will admit Braylon.

“There is this huge wave of anxiety that comes over me that makes it difficult to be around him,” Masters said.

Anne Grady’s 20-year-old son has autism, severe mood disorder, developmental delays, and other conditions. For nearly 17 years he has been on a Texas waiting list to receive full-time care.

Grady, who lives in a suburb of Austin, Texas, developed a tumor in her salivary glands and temporary facial paralysis, which added to the stress she faced navigating care for her son.

“It’s mentally exhausting for families,” Grady said. The lack of care is “punishing the kids and punishing for families,” she said.

Medicaid is the state-federal program that pays medical and other health-related bills for low-income and disabled people. Yet while many state Medicaid programs pay for family therapy and parenting programs, they don’t address the parent as an individual patient affected by their child’s health under a child’s plan, said Elisabeth Burak, a senior fellow at Georgetown University’s Center for Children and Families. Parents who live in one of the 10 states that haven’t expanded Medicaid, including Texas, face an additional challenge getting care for their own mental health.

Still, states are starting to recognize that caregivers need more support. Many states allow Medicaid to cover services from certified family peer specialists or navigators, who have experience raising a child with mental illness and additional training to guide other families. In July, California awarded money to support parents as part of a child mental health initiative.

“The most important thing that we should give families is a sense of hope that things will get better,” said Gurwitch. Instead, the lack of quality mental health care services for youth exacerbates their risk for illnesses. Without appropriate help, these conditions follow a child — and their parents — for years, she said.

With Amanda returning home from the residential treatment program this month, Delarosa worries she won’t be equipped to manage her daughter’s bouts of depression.

“It’s the same thing over and over, nonstop,” Delarosa said. “I have driven myself crazy.”

When Grady’s son turned 18, she acquired continued guardianship so she could continue arranging his care outside their home. “I love him more than anything in the world, but I can’t protect him,” she said.

Masters, whose skin conditions have worsened, is just trying to get Braylon through his final year of high school, which starts this month. He’s also renewing his search for a residential treatment center, because Braylon’s negative behaviors have escalated.

“When they are born, you have all these dreams for your kids,” said Masters. Instead, health professionals who have cared for Braylon told Masters, he needs to be prepared to look after his son even after he finishes high school. “No parent wants to hear that,” he said.

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The Painful Legacy of ‘Law and Order’ Treatment of Addiction in Jail

Renuka Rayasam — Wed, 19 Jul 2023 10:00:00 +0000

JASPER, Ala. — Megan Dunn, who has struggled with addiction since her teens, points to the moment her life went “deeply downhill.”

After dropping out of high school, she gave birth at age 19 to a son she named Preston. Six weeks later, Dunn said, he died of sudden infant death syndrome.

“From then on, I went into this, like, PTSD, depression,” said Dunn, now 28.

Shortly after the baby’s death, Dunn said, she started using pain pills again. Eventually, she said, she was arrested on charges related to her illicit drug use, such as trespassing. She said she has had more than 30 stays in Walker County’s jail, a brick building in downtown Jasper. And each time, Dunn said, she was forced into drug withdrawal in her cell without medical care.

“I was literally praying to God to end me,” Dunn said about the pain and despair she felt.

People with drug addictions fill U.S. jails and are often left to endure withdrawal in concrete cells rather than in medical facilities. That’s especially true in Alabama, which has some of the toughest drug laws in the country. More than 5,000 people were arrested in Alabama on drug charges in 2021, and more than 90% of those were for possessing drugs rather than selling them, according to state data.

Dunn survived her stay in a holding cell in Walker County’s jail that’s known, she said, as the “drunk tank,” a concrete room that lacks water, a bed, or a toilet. Others have not.

In January, Anthony Mitchell, 33, allegedly froze to death after spending 14 days in the tank, according to a federal lawsuit his family filed in February against Sheriff Nick Smith, his deputies, and other jail employees.

Mitchell had “spiraled into worsening drug addiction,” the lawsuit said, and his cousin called 911 to send an ambulance to his home because Mitchell “appeared to be having a mental breakdown.” Instead, sheriff’s deputies arrived and then a SWAT team, the lawsuit said. On Facebook, the sheriff’s office posted that “Mitchell brandished a handgun” and, from the scene, a deputy published a photo of his arrest, the suit said.

In jail, Mitchell was “denied access to medical treatment,” the suit said, citing video footage from the jail, and he died in custody. His death has sparked a debate in Walker County about the treatment by law enforcement of people with addiction and mental illness.

Crime and Punishment: ‘People Are Scared to Say “I Need Help”’

Walker County, nestled in northwestern Alabama’s Appalachian foothills and dotted with coal mines, has one of the nation’s highest nonfatal overdose rates. The county was among the communities that pharmaceutical companies flooded with millions of pain pills in the 2000s. Addiction rates soared. Over time, people moved on to illicit drugs.

Walker County Sheriff Nick Smith, first elected in 2018, campaigned to keep his job in last year’s election, in which he was unopposed, by saying he’d “confronted the drug epidemic head on” by “taking criminals off the streets and putting them in jail where they belong.”

He also touted his drug arrests in a paid political announcement published in 2021 in the Daily Mountain Eagle, a newspaper in Jasper. He has deployed resources to boost the number of narcotics officers from two to five, and his staff has made about 2,500 drug arrests to date, Smith told KFF Health News.

Smith also said that his office helps people with addiction. It gives people a list of treatment resources when they’re released, he said, and has doubled medical supervision in the jail from eight to 16 hours a day.

Drug possession and distribution, Smith said, are crimes he’s tasked with enforcing. “We are going to do our job,” he said. With so many people addicted to illegal drugs in Walker County, the power of the sheriff’s office and threat of arrest loom large.

“People are scared to say ‘I need help,’” said Kayse Brown, who added that she faced down her own addiction and then became a certified peer support specialist to help others.

According to the lawsuit, a sheriff’s deputy allegedly told Mitchell’s cousin words to the effect of: “We’re going to detox him and then we’ll see how much of his brain is left.” No one checked his vitals or gave him the medication he needed, the lawsuit said. Within days, Mitchell was without a mat or blanket and “had to lie naked on the bare concrete floor,” the suit said.

When Mitchell arrived at Walker Baptist Medical Center two weeks after his arrest, his internal body temperature was 72 degrees Fahrenheit, the lawsuit said. That’s more than 20 degrees below what is considered “dangerously low,” according to the Mayo Clinic.

In response to the lawsuit, Smith and other defendants said that Mitchell was a “drug addict” who was “arrested in a psychotic and delusional state.” Court records show they don’t dispute what doctors reported about Mitchell’s condition in the medical records. But they deny most of the lawsuit’s other claims, including any liability for Mitchell’s death. They asked that the lawsuit be halted while the FBI and the state of Alabama consider filing criminal charges in the case, according to court records. A judge denied the request in June.

After Mitchell’s death, community activists called for Smith’s resignation, circulating a petition that has more than 4,000 signatures. Ryan Cagle, a pastor who started the petition, said the sheriff’s office doesn’t see addiction as a chronic condition. Instead, Cagle said, its officials shame people who use drugs by posting their mug shots and arrest details on Facebook.

“The people who are elected, the people who have the power, they do not see people suffering under substance abuse as human or worthy of dignity,” said Cagle, who runs a food pantry. Cagle’s brother is married to Brown. His father dealt with addiction, and earlier this year he lost a 20-year-old cousin to an overdose.

Smith wouldn’t comment on the Mitchell case because of the pending lawsuit and said that Dunn’s experiences happened before he took office. But, he said, “the burden of mental health is put on every sheriff in Alabama.” The shortage of mental health treatment and lack of early intervention means people who need help land in jail instead. In one case, he said, a person with mental health disorders faced an 18-month waiting list for space to open at the secure medical facility in Tuscaloosa.

Systemic Change Is Not Easy

Walker County’s challenges are indicative of those faced across the country. People with addictions often end up incarcerated, and Stephen Taylor, a Birmingham-based doctor and president-elect of the American Society of Addiction Medicine, points to a failure of the public health system to create a sustainable and robust addiction care infrastructure.

“We know what to do to treat addiction,” Taylor said in written testimony to a Senate subcommittee in May. But systemic change and disruption of the status quo is “exceptionally difficult,” he acknowledged.

Sources inside the system say that more than half of the people placed on the Alabama Department of Mental Health’s waiting list for residential substance abuse treatment either die, drop off the list, or end up incarcerated, according to a 2020 report from the Alabama Appleseed Center for Law & Justice, an advocacy group that says the state’s “prison system is broken.”

In Walker County, at least 2,800 people with a substance use disorder are not receiving treatment and existing treatment is limited, according to a September 2019 assessment conducted through a federally funded planning grant that helps rural communities respond to opioid overdoses.

Though treatment options are growing in the area, there are not enough to meet demand, some local recovery experts said. For example, the number of peer support specialists — those in recovery who are state-certified to help people before, during, and after treatment — increased to nine in 2022 from one in 2018, according to the Healing Network of Walker County, a group that organizes mental health and substance use-related resources in the county. A handful of providers offer medication-assisted treatment, including buprenorphine, which provides relief from severe symptoms of opioid withdrawal and, over time, reduces opioid cravings. A program now exists to help pregnant and parenting women experiencing addiction.

The need for more treatment services is especially acute in Alabama, one of 10 states that have not expanded Medicaid, which has provided insurance coverage to people with substance use disorders in other states.

“We operate the whole addiction system in a crisis mode, as opposed to looking at it over the long term,” said Regina LaBelle, director of the Addiction and Public Policy Initiative at Georgetown University. Law enforcement officials with no health care training exercise almost total authority over the lives of inmates with addiction, and they are more likely to view substance abuse as a crime to be punished than a health crisis to be treated, say academic researchers, reform advocates, and formerly incarcerated people.

“Right now, our system is still so focused on punishing people,” said Leah Nelson, research director at Alabama Appleseed.

Dunn said she felt continually harassed by law enforcement officials because she was known to be a drug user. Because she once missed the jail’s 4:30 a.m. breakfast call, she said, she was put in the same “drunk tank” where Mitchell spent his final days.

Smith said that he’s exploring the idea of treating people with addiction in Walker County’s jail with medications, but that the final decision rests with the county commission. Even though some people in county leadership disagree with the idea of treating people at the jail, “we’re at the point where all options are on the table,” he said.

“That is huge for Walker County,” said Nicole Walden, an associate commissioner at the Alabama Department of Mental Health. She has had initial conversations with the Walker County Sheriff’s Office about the idea. “The stigma around substance use, in the South, it is a lot worse. Alabama is very much a law-and-order state.”

Fewer than a fifth of U.S. jails, and just 13% in the South, start people on medications to treat opioid use withdrawal, according to a U.S. Department of Justice report published in April. Only one Alabama jail currently offers medication-assisted treatment, Walden said.

Dunn checked into residential treatment outside the county about six times. Each time she relapsed. Eventually, after missing court dates and once trying to escape from jail, Dunn ended up in prison for nearly two years, where, she said, “drugs were everywhere.”

The Long Road to Recovery

Nationally, police arrested more than a million people for drug possession in 2020. U.S. courts and police departments tasked with treating addiction have mixed results.

“Jails are not the most ideal place to treat them, but it’s the reality of where they end up,” said Andrew Klein, senior scientist for criminal justice at Advocates for Human Potential, a social services advocacy organization.

The Walker County Sheriff’s Office runs a program to help people find treatment. But it’s limited to those without an outstanding arrest warrant and with no more than two drug convictions, so few residents who are in need qualify. In its first two years, 20 people completed some sort of addiction treatment, according to the September 2019 assessment.

Nikki Warren benefited from the county drug court program, which requires participants to take drug tests and pay thousands of dollars in fees. Warren joined the program at the recommendation of a judge. She was arrested in 2018 after she blacked out when she mistakenly took fentanyl instead of heroin.

“I needed that wake-up call,” said Warren, who is now an outreach supervisor at Recovery Organization of Support Specialists. After completing the program, her charges were dismissed, she said.

Dunn said the drug court program was “too hard.” But she was released from prison 3½ years ago determined to change her life. She recalled thinking to herself, “Dang, girl, all them years that I wasted.”

She spends time reading the Bible and singing, she said, but has struggled to find stable footing. She has lost several friends to overdoses, she said. Dunn said she would like to see a counselor but is uninsured. She relapsed for about a week this year, she said. She wants to work, perhaps at the front desk of a factory, but she goes to job interviews with a felony record and no high school diploma.

“Here I am — I quit school, my baby is dead,” Dunn said. She feels she is still being punished by the system. “I’m not perfect,” she said. But “they don’t give us a chance.”

Kara Nelson of KFF Health News contributed to this report.

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As More Hospitals Create Police Forces, Critics Warn of Pitfalls

Renuka Rayasam — Mon, 15 May 2023 09:00:00 +0000

ATLANTA — When Destiny heard screams, she raced to a hospital room where she saw a patient assaulting a care technician. As a charge nurse at Northeast Georgia Health System, she was trained to de-escalate violent situations.

But that day in spring 2021, as Destiny intervened, for several minutes the patient punched, kicked, and bit her. And by the time a team of security guards and other nurses could free her, the patient had ripped out chunks of Destiny’s hair.

“We are not protected on our floors,” she said as she recapped the story during testimony later that year to the Georgia Senate Study Committee on Violence Against Healthcare Workers. Destiny used only her first name at the hearing, for fear of retaliation for speaking out against the patient who assaulted her.

In May, Republican Gov. Brian Kemp signed a law that boosts criminal penalties for assaults against hospital workers and allows health care facilities in the state to create independent police forces. The law is a response to that testimony as well as hospital lobbying and data documenting a rise in violence against health care workers. In enacting the law, Georgia joined other states attempting to reverse a rise in violence over the last several years through stiffer criminal penalties and enhanced law enforcement.

Nearly 40 states have laws that establish or increase penalties for assaults on health care workers, according to the American Nurses Association. And lawmakers in 29 states have approved or are working on similar laws, as well as ones that allow the creation of hospital police forces. Members of those forces can carry firearms and make arrests. In addition, they have higher training requirements than noncertified officers such as security guards, according to the International Association for Healthcare Security and Safety.

Groups representing nurses and hospitals argue that such laws address the daily reality of aggressive or agitated patients who sometimes become violent. Still, such interventions are relatively new. Critics worry that establishing hospital police forces will escalate violence in health care settings and could have downstream effects.

“I worry about all the reasons patients have to not trust me and trust the health care system,” said Elinore Kaufman, a trauma surgeon at the University of Pennsylvania.

Health care workers are five times as likely to experience violence as employees in other industries, according to federal data. The day after Kemp signed the Safer Hospitals Act into law, a person opened fire in a midtown Atlanta medical office, killing one woman and injuring four others, including workers at the medical practice.

Verbal and physical threats, which increased during the pandemic, are exacerbating a dire nursing shortage, said Matt Caseman, CEO of the Georgia Nurses Association. Destiny testified that one of her co-workers left nursing after the 2021 assault, in which the patient smashed the care technician’s face into a wall and the floor. Destiny also suffered from post-concussion headaches for months, she said.

The Centers for Medicare & Medicaid Services noted the alarming rise of violence in health care settings last November. The federal agency recommended hospitals implement a patient risk assessment strategy, increase staffing levels, and improve training and education for staffers. There was no mention of boosting law enforcement presence.

Health centers say they are better able to retain workers and improve patient care when they can reduce the number of violent incidents, said Mike Hodges, secretary of the Georgia chapter of the International Association for Healthcare Security and Safety. State laws governing how hospitals can respond to violence vary.

In Georgia, the new law boosts criminal penalties for aggravated assaults against all health care workers on a hospital campus, not just those in emergency rooms, which were already regulated. And hospitals can now establish law enforcement offices like those on university campuses. The officers must be certified by the Georgia Peace Officer Standards and Training Council and maintain law enforcement records that can be made public.

Having a dedicated police force helps hospitals better train officers to work in a health care setting, said Republican State Rep. Matt Reeves, who co-sponsored the Georgia bill. Officers can get to know staff members and regular patients, as well as the layout and protocols of hospital campuses. “If you have a specialized police department, they are more in tune with the needs of the facility,” he said.

That’s the case at Atrium Health Navicent, which operates hospitals across central Georgia, said Delvecchio Finley, its president. The health system was one of a handful to staff certified law enforcement before the new law.

Atrium Health recruits officers who reflect the diversity of the community, conducts training to counteract implicit biases, and holds debriefings after any incidents, Finley said. Officers are trained to react when someone becomes violent at one of the facilities.

“The biggest thing for us to convey to officers is that they are in the setting where we provide a safe environment where we care for anyone,” he said.

Unlike other businesses, hospitals can’t merely throw out patients who misbehave, said Terri Sullivan, an emergency nurse in Atlanta. A patient once punched her in the chest, fracturing two ribs, before running out of the room and trying to punch his physician. Sullivan said that, in her experience, the presence of hospital security can prevent patients from acting out.

Still, little data exists on whether such forces are effective at preventing hospital violence. Ji Seon Song, a University of California-Irvine law professor who studies policing in health care settings, worries about the “unintended consequences” of legislation that boosts the presence of law enforcement in places people receive medical care.

“You can see where there might be a lot of problems,” she said, “especially if the patient is African American, undocumented, Latino — something that makes them prone to being criminalized.”

A ProPublica investigation found Cleveland Clinic’s private police force disproportionately charges and cites Black people. And in March, a video emerged showing police and hospital staff members in Virginia holding down a patient who was experiencing a mental health crisis, leading to his death. In 23% of emergency department shootings from 2000 to 2011, the perpetrator took a gun from a security officer, according to a Johns Hopkins University study. The CMS memo noted several hospital incidents involving police, in which the agency cited the facility for failing to provide a safe environment.

The Georgia law doesn’t require hospital police officers to arrest patients with outstanding warrants for offenses that occurred off a hospital campus, such as violating probation. But it doesn’t limit those powers either, said Mazie Lynn Guertin, executive director of the Georgia Association of Criminal Defense Lawyers.

“Unless discretion is limited, it will be exercised at some point, by someone,” she said.

Law enforcement should always be the last resort, argued Kaufman, the trauma surgeon. While the threat of violence is concerning, hospitals can spend more on health care staffing, boost overall training, and teach de-escalation skills.

“Our primary lens shouldn’t be that our patients are a danger to us,” she said. “It’s a harmful lens and a racist one. We should develop safe and healthy workplaces through other ways.”

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Expectant Mom Needed $15,000 Overnight to Save Her Twins

Renuka Rayasam — Thu, 27 Apr 2023 09:00:00 +0000

It was Labor Day weekend 2021 when Sara Walsh, who was 24 weeks pregnant with twins, began to experience severe lower-back pain.

On Wednesday, a few days later, a maternal-fetal specialist near her home in Winter Haven, Florida, diagnosed Walsh with twin-to-twin transfusion syndrome, a rare complication that occurs when fetuses share blood unevenly through the same placenta. The doctor told her that the fetuses were experiencing cardiac issues and that she should prepare for treatment the following day, Walsh said.

Her OB-GYN told her that, without immediate surgery, her twins had a high chance of perinatal death, and she could also die.

Both doctors referred Walsh to a fetal surgeon about four hours away, describing him as an expert on the condition.

As Walsh prepared to leave, she received a call from the surgeon’s practice, the Fetal Institute. Walsh said a billing representative told her that before surgeon Ruben Quintero would see her, she needed to pay in full for the consultation, surgery, and postoperative care — a total estimate of $15,000.

Although Walsh had insurance, the biller said the surgeon was not in any private insurance networks nor did he offer payment plans.

“I burst into tears,” Walsh said. “’I don’t want to lose these babies.’”

Her mother agreed to give her money, and Walsh also called her insurer, who advised her to apply for a waiver that could allow them to reclassify the care as in network.

Late Wednesday, Walsh and her husband checked into a hotel near the practice’s office in Coral Gables. The next morning, she handed her credit card and then her mother’s credit card to the clerk at the Fetal Institute. Quintero said her case had advanced to stage 3, meaning there were problems that could cause heart failure in one or both fetuses.

He performed surgery later that day at a hospital about 90 minutes away. On Friday morning, she traveled back to his office for a follow-up. In the following weeks, she had two more consultations.

About five weeks after the surgery, Walsh gave birth to twin girls. They were premature but otherwise healthy.

Then she waited for her insurance reimbursement to come.

The Patient: Sara Walsh, 39, is covered by Blue Cross and Blue Shield of Texas through her employer, a national newspaper publisher.

Medical Service: Fetoscopic laser surgery for treatment of twin-to-twin transfusion syndrome, as well as pre- and postoperative evaluations and X-rays.

Service Provider: The Fetal Institute in Coral Gables, Florida, a practice that specializes in treating rare pregnancy complications.

Total Bill: $18,610 over multiple visits for surgery; pre- and post-surgical consultations; and two follow-up consultations for potential complications that didn’t ultimately require more treatment. Walsh ended up putting $14,472.35 on her and her mother’s credit cards. Her health plan eventually paid the Fetal Institute $5,419.44. Walsh was later partially reimbursed but ultimately paid more than $13,000 out-of-pocket.

What Gives: Walsh’s case falls into a gray area of medical billing between emergency and elective care. Despite being insured, Walsh paid most of the full charges upfront and out-of-pocket for care that three doctors said she urgently needed to save her twins. And she knew the surgeon was an out-of-network provider.

Within 20 hours, Walsh gathered the thousands of dollars she was told she needed to pay before the surgeon would meet with her and prepared to undergo surgery in an unfamiliar hospital. “That 20 hours was just insanity,” she said.

When Walsh called BCBS before her procedure, a representative told her that Quintero was in its network at a few facilities but not at his private practice, where he would evaluate her. Laura Kersey, a billing representative with the Fetal Institute, confirmed to KFF Health News that the practice accepts Medicaid — which covers nearly half of all births in Florida — but does not contract with private insurance.

“Our highly specialized practice sees patients from across the globe,” Quintero said in a statement to KFF Health News. “It would be impractical to join all health plans. If any patient is unable to pay in full for a procedure, we offer them CareCredit or an alternative payment plan, on a case by case basis.”

Neither option was available to Walsh. Approval for CareCredit, a medical credit card, would not have come in time for her next-morning procedure. Walsh said the Fetal Institute denied her request to pay half the bill upfront and the rest over time.

Kersey said requiring upfront payment is the Fetal Institute’s “normal practice.” She said they are transparent about their billing practices and disclose them to potential patients ahead of time. If someone cannot pay, she said, the Fetal Institute sends the person back to the referring physician to find another option.

Walsh said the BCBS representative advised her to complete a waiver intended for patients who receive urgently needed care from an out-of-network provider when it is not feasible to see an in-network provider. Walsh did not have the days or even weeks needed to undergo the insurer’s formal preauthorization process, which could have told her in advance whether BCBS would cover the claim.

Walsh and her mother had paid the Fetal Institute nearly $13,000 related to her surgery, hopeful that BCBS would reimburse them.

In the weeks before Walsh gave birth, the specialist in Winter Haven sent her back to Quintero twice. Both times Quintero evaluated Walsh and sent her home without further treatment. She paid nearly $1,475 more for those visits.

Walsh said she had trouble getting all the documentation BCBS said she needed. In early November, she received the letter of medical necessity explaining the diagnosis.

The letter, signed by Quintero, said that twin-to-twin transfusion syndrome, when left untreated, results in pregnancy loss in 95% of patients.

But Walsh’s situation didn’t count as the type of emergency that could have qualified her for federal billing protections, said Erin Fuse Brown, a law professor and the director of the Center for Law, Health & Society at Georgia State University.

Walsh sought care that was “knowingly out of network, even though there was a figurative gun to her head,” Fuse Brown said, referring to the potential loss of her twins or even her own life.

The federal No Surprises Act, which took effect last year, months after Walsh’s surgery, protects patients who receive emergency services inadvertently from out-of-network providers and only in certain settings — particularly emergency departments and urgent care centers. It also covers nonemergency services received from out-of-network providers, but only at in-network facilities.

Federal laws requiring public access to emergency services apply only to hospitals, not individual providers in their offices, Fuse Brown said. Physicians generally can refuse new patients and charge what they want, if they are transparent about costs, she added.

“It’s not a surprise medical bill if it’s not a surprise,” Fuse Brown said.

Only about 30 to 40 hospitals nationwide can perform fetoscopic laser surgery to treat twin-to-twin transfusion syndrome, Yale Medicine estimates.

Walsh said the specialist who referred her for a next-day surgical appointment gave her just two options for providers in the region, only one of whom practiced in her state. That was Quintero, who is renowned for his work on the condition. He is credited with pioneering the procedure Walsh needed and, with his colleagues, also developed a way to assess the condition’s severity, known as the Quintero staging system.

But it turns out there was another option in Florida. Neither the specialist nor BCBS told Walsh about the possibility of getting care at the University of South Florida, she said. At the time, USF was the only other facility in her state that could have performed the procedure, according to Alejandro Rodriguez, a maternal-fetal medicine physician and an assistant professor at the USF Health Morsani College of Medicine in Tampa. Rodriguez said that USF accepts private insurance, Medicaid, and Medicare and doesn’t require patients to pay upfront for care.

“There was no mention of shopping around,” Walsh said. And with her doctors telling her the lives of her children — and potentially her own — were urgently at stake, she said it seemed her only option was to pay up.

“No parent should face the choice of ‘How much money can I raise in the next 12 hours and is it enough to save the lives of my children?’” Walsh said.

The Resolution: Walsh has spent more than a year trying to get reimbursed by her health plan, repeatedly explaining her complicated case as representatives tried to sort out the proper billing codes for the rare, newer treatment. “No one understood how a doctor charged me more than $10,000 upfront to treat me,” she said.

Walsh also reached out to a medical advocate, who she said concluded that Quintero had billed correctly.

Walsh’s insurance covered Wellington Regional Medical Center, the in-network hospital where Quintero performed the procedure.

The Fetal Institute also filed claims for Walsh’s care with BCBS, telling her they were filing on her behalf. BCBS processed the claims — including for Quintero’s surgical services at the in-network hospital — as out-of-network care and reimbursed Walsh for just a fraction of the more than $18,000 charged.

Her “explanation of benefits” documents stated that Walsh was on the hook for the balance between what Quintero’s practice charged and the $5,419.44 that BCBS paid.

Walsh said BCBS covered her pregnancy-related visits to other, in-network providers, adding that her plan fully covers all diagnostic and laboratory maternity care.

In early 2022, the Fetal Institute forwarded Walsh a check for about $1,282. According to the practice’s records shared with KFF Health News, the check corrected an overpayment on the full charges, totaling $18,610 — which Walsh’s payments and BCBS’ reimbursements had together fulfilled.

Walsh said she had not received any other reimbursement.

BCBS declined to comment on Walsh’s case, citing privacy concerns even though Walsh waived federal health privacy protections, which would allow the insurer to speak to a reporter about the case.

After a KFF Health News reporter contacted the insurer, Walsh said, a BCBS representative called to inform her that her claims had been “escalated,” but eventually determined that the reimbursement was “appropriate” because the provider was out of its network.

The insurer said that the full amount of her balance doesn’t apply toward out-of-pocket maximums in her plan.

The Takeaway: Federal billing protections are not designed to protect patients who choose out-of-network care, even when they find themselves in an urgent situation with few options and little time for comparison shopping.

And often only a handful of specialized providers can treat rare conditions. While that dearth of options raises ethical questions about whether it is OK for a doctor to demand payment upfront for lifesaving surgery, it is legal to do so, experts say. Many Americans would be challenged to raise $15,000 overnight.

“The patient did everything she could,” said Fuse Brown.

Worse, still, she said: When a patient pays upfront, there’s little incentive for providers and insurers to negotiate a fair payment or even cooperate to help patients get reimbursement.

The case shows how consumer protections are still lacking in many situations. “This could still happen tomorrow,” Fuse Brown said.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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States Try to Obscure Execution Details as Drugmakers Hinder Lethal Injection

Renuka Rayasam — Thu, 30 Mar 2023 09:00:00 +0000

In 2011, Jeffrey Motts was executed in South Carolina. More than a decade later, the state hasn’t carried out another execution because officials have struggled to obtain the drugs needed for lethal injection.

Now, to resume executions, lawmakers are debating a bill that would further shroud the state’s lethal injection protocols from public scrutiny by shielding the identities of the drug suppliers.

More than a dozen states have passed such “shield” laws that conceal key details about the lethal injection process, including the identities of the execution team or drug suppliers, according to the Death Penalty Information Center, a nonprofit research organization. All 17 states that carried out executions between January 2011 and August 2018 withheld some information about the process. Georgia even calls information about its executions a “state secret.”

Backers of such laws say they are needed to protect suppliers and medical professionals involved in executions. But Austin Sarat, a political science and law professor at Amherst College, who teaches courses on the death penalty, said such policies conceal the problems connected to lethal injection.

“The legitimacy of capital punishment has been tied up with the promise that it’s safe and humane,” he said. Secrecy hinders “the public’s ability to judge what is being done in its name.”

Still, it’s far from clear whether — or how — South Carolina and other states will be able to obtain the needed drugs, even with a cloak of secrecy. For more than a decade, many U.S., European, and Asian pharmaceutical companies have opposed the use of their medications in executions, arguing the drugs they manufacture should be used to heal, not kill, people. Some pharmaceutical companies have even sued states to prevent their drugs from being used on death row.

“With increasing frequency, drug companies don’t want to be associated with this process,” said Eric Berger, a constitutional law professor at the Nebraska College of Law who researches the death penalty.

That opposition has brought executions in many states to a grinding halt. Only six of the 27 states that allow the death penalty carried out executions in 2022, totaling just 18 executions nationwide, down from 98 in 1999.

But it’s still often the method of choice for state prisons. Since 1982, when Texas became the first state to use lethal injection, more than 88% of U.S. executions have been carried out by lethal injection, according to the Death Penalty Information Center.

The U.S. Supreme Court has upheld the lethal injection procedures that have come before it as constitutional, said Berger. Some states authorize other protocols including electrocution, lethal gas, hanging, and firing squads. But lower courts have said some of those execution methods violate state law or the Eighth Amendment’s ban on cruel and unusual punishment. In South Carolina, for example, a state court halted executions by electric chair or firing squad after state lawmakers approved those methods in 2021.

The proposed South Carolina shield law would help the state restart executions after a more than decade-long pause, Republican state Sen. Greg Hembree, who sponsored the bill, said during a committee hearing.

“You’ve got a law and can’t carry it out because of some corporate policy,” he said.

Even if approved, the measure does not guarantee the state will be able to obtain the drugs. Idaho instituted a similar shield law last year, but the state has had so much trouble finding supplies that Republican Gov. Brad Little signed a law on March 24 that allows execution by firing squad — a method last used in the U.S. by Utah in 2010.

In Ohio, pharmaceutical companies threatened to stop selling drugs to the state if they found any of their medications had been diverted for lethal injections. In 2020, the state’s Republican governor, Mike DeWine, placed a moratorium on executions because state officials had been unable to find execution drugs, despite Ohio’s secrecy law.

To circumvent drugmaker opposition, some states have resorted to elaborate practices to obtain the drugs. In 2011, federal agents seized doses of a lethal injection sedative used in South Carolina and other states for being illegally imported, while Idaho officials boarded private planes that year and the next with thousands of dollars in cash to buy drugs from compounding pharmacies in Utah and Washington.

In 2018, an Oklahoma official admitted to calling pharmacies “on the Indian subcontinent” and turning to what he described as “seedy” people to find such drugs. In 2021, Oklahoma resumed executions by lethal injection after a six-year hiatus but did not disclose where it obtained the drugs.

And Texas has executed five people so far this year after an unsuccessful legal challenge from three of the men on death row who argued that the state extended the use-by dates of the lethal injection drugs.

The U.S. is one of at least 18 countries where one or more executions took place in 2021, according to Amnesty International, a human rights advocacy group headquartered in London that opposes the death penalty. Most U.S. executions take place in the South and Black men are disproportionately executed, according to the Death Penalty Information Center.

Lethal injection protocols usually include a sedative, followed by a drug that paralyzes the body and one that stops the heart. But some states use only one drug, dosed to be lethal. The drugs that states use for executions have been approved for uses such as anesthesia, but their off-label use for lethal injection has not been tested.

The drug doses are determined without considering a person’s medical condition or history. Often things go wrong. Last year, seven out of 20 execution attempts in the U.S. were “visibly problematic,” according to the Death Penalty Information Center, including cases in which executioners couldn’t find a person’s vein or failed to follow protocol.

Typically courts and legislatures, not medical professionals, determine lethal injection protocols. In Montana, lawmakers are trying to broaden the types of substances that can be used in lethal injection after a state court said the previous protocol violated state law. One lawmaker suggested using fentanyl, something the Trump administration also reportedly considered doing.

“Lethal injection is not a medical act, but it’s designed to impersonate one,” said Dr. Joel Zivot, an anesthesiology professor at Emory University who reviews autopsies of people who die by lethal injection and is a critic of the practice.

Zivot’s research sparked an NPR review of more than 200 lethal injection cases. In 84% of them, the deceased showed signs of pulmonary edema, which causes a feeling of drowning and suffocating. “That is very painful,” said Zivot.

Last year, two men in Oklahoma asked to be executed by a firing squad rather than lethal injection because they argued the former would be quicker.

Of all the ways to execute people, lethal injection has been the method most riddled with problems, said Sarat, the Amherst professor.

Missouri passed its shield law, concealing who participates in executions and where the state obtains drugs, in 2007, after a doctor testified that he had made mistakes while administering lethal injection drugs.

Alabama recently announced it would resume executions after three botched lethal injections last year. One person’s arm was cut open to find a vein to deliver lethal injection drugs. Two other executions were halted when officials couldn’t find the men’s veins at all. Yet an internal state review revealed little about what went wrong, including whether a medical professional was involved.

“It’s not surprising that every time the secrecy veil has been pierced something illegal or immoral or unethical has been discovered,” said Robert Dunham, who stepped down in January as the executive director of the Death Penalty Information Center.

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Renuka Rayasam, Author at KFF Health News

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