By late 1988, 11 Black women had been found dead in the same area of Miami with low levels of cocaine in their blood. Forensic pathologist Dr. Charles Wetli of the University of Miami had conducted autopsies that he said, “conclusively showed that they have not been murdered.”^1,2 He attributed their deaths to a female-specific manifestation of the mysterious phenomenon he had identified in men who had also died after consuming less-than-lethal amounts of cocaine. Antoinette Burns was the twelfth victim, a 14-year-old girl without any evidence of cocaine consumption at all. At the urging of her family and later the police, these autopsies were reexamined and eventually reclassified as homicides attributed to a single serial killer, responsible for as many as 32 murders in the area.^3,4

Dr. Wetli was referring to his and a colleague’s publication of a case report, in 1981, and a seven-case series in 1985 describing the novel “excited delirium syndrome” in individuals under the influence of cocaine, “a medical emergency but with a psychiatric presentation.”^5,6 Of the seven, all had been restrained, six by police, and four had been hog-tied or hobbled in a prone position. All seven had died without an “anatomic cause of death,” leaving the reader to infer that the cause had been delirium itself.

It was shortly after these case series that Dr. Wetli, serving as deputy chief medical examiner in Miami, first began attributing the deaths of sex workers to excited delirium in 1986. “For some reason the male of the species becomes psychotic and the female of the species dies in relation to sex” after using cocaine, he said in an interview in the Miami Herald at the time, and speculated that this could be due to genetic traits that were more common in certain populations.⁷

In the decades since, excited delirium has come to be a frequently-cited cause of death for individuals dying in custody or during altercations with law enforcement. This is despite never being identified by a formal diagnostic framework, such as the diagnostic and statistical manual of mental disorders (DSM) or the international classification of diseases (ICD), as a valid diagnostic entity.

In 2009, the Excited Delirium Task Force convened by an ACEP Council resolution authored a white paper that endorsed the existence of excited delirium syndrome and made recommendations for identifying and managing it clinically.^8,9 According to Dr. Fabrice Czarnecki, one of the members of the original task force, the use of a term borrowed from law enforcement was deliberate. “Excited delirium is a term that has been with the cops for 40 or 50 years,” he said. “My goal in joining the working group was, we don’t want people to die in the street. I personally don’t want people to die in police custody. I want to be involved in training cops to recognize the signs of a medical emergency.”