Medium.com June 16, 2020
A Forensic Analysis
"The centre cannot hold; Mere anarchy is loosed upon the world... The best lack all conviction, while the worst Are full of passionate intensity." - W. B. Yeats, 1919
Truth is the first victim in politics. Factions and passions rule. Random facts are picked as weapons, no one thinks things through.
We need to understand the facts surrounding the death of George Floyd. Many key facts are being ignored:
- Floyd's blood tests showed a lethal concentration of Fentanyl of about THREE times the maximum that has been recorded in a survivor, even when receiving intensive care.
- Fentanyl is a dangerous opioid 50 times more potent than heroin. It has rapidly become the most common cause of death among drug addicts.
- The knee hold used by the police is not a choke hold, it does not impede breathing. It is a body restraint and is not known to have ever caused fatal injury.
- Floyd already began to complain "I can't breathe" a few minutes before the neck restraint was applied, while resisting the officers when they tried to get him into the squad car. Fentanyl affects the breathing, causing death by respiratory arrest.
- It was normal procedure to restrain Floyd 1) because he was resisting arrest, 2) probably in conjunction with excited delirium (EXD), an episode of violent agitation brought on by a drug overdose, typically brief and ending in death from cardiopulmonary arrest.
- The official autopsy gave cardiopulmonary arrest as the cause of death, and stated that injuries he sustained during the arrest were not life-threatening. This contradicts the coroner's own conclusion of homicide.
- Videos of the arrest do not show police beating or striking Floyd, only carefully restraining him
- In one video Floyd is heard shouting and groaning loudly and incoherently while restrained on the ground, which appears to be a sign of the violent, shouting phase of EXD.
Minneapolis police officers have been charged with Floyd's murder. Yet all the evidence points to the fact that Floyd had taken a drug overdose so strong that his imminent death could not have been prevented, whatever the circumstances. In reality, the police were neither an intentional nor accidental cause of his death. These crucial facts have been completely ignored in the uproar.
It is widely believed that George Floyd died from a police officer's knee on his neck, whether due to asphyxiation or neck injury. That may be how it looks, to a naïve viewer. In reality, the county autopsy report says he died of a heart attack, and states that there were "no life-threatening injuries." Then how could they conclude it was homicide?
When scientists review scientific papers, they look primarily at the evidence, and give little weight to the conclusions, which are only the other guy's opinions. To blindly follow "expert opinions" is the Authoritarian View of Knowledge. This is no real knowledge at all, because to assess whether an expert is always right, we would need infinite knowledge, and doubly so when experts disagree. Not thinking for oneself is not really thinking.
So let us stick to the evidence. The county's ambivalent autopsy also included the following hard facts: "Toxicology Findings: Blood samples collected at 9:00 p.m. on May 25th, before Floyd died, tested positive for the following: Fentanyl 11 ng/mL, Norfentanyl 5.6 ng/mL, ... Methamphetamine 19 ng/mL ... 86 ng/mL of morphine," but draws no conclusions therefrom, noting only that "Quantities are given for those who are medically inclined."
Shouldn't we be so inclined? This fentanyl concentration, including its norfentanyl metabolite at its molecular weight, was 20.6 ng/mL That is over three times the lethal overdose, following earlier reports where the highest dose survived was 4.6 ng/mL.
If ever there was a leap before a look, we are in it now. Masses of people have become extremists, screaming to tear down civilization, based on conclusions that are as false as they are hasty.
Regarding suffocation, the county medical examiner's report found "no physical findings that support a diagnosis of traumatic asphyxia or strangulation." However, pressure applied to the side of the neck, as in this case, and not to the throat, has little or no effect on breathing. One can easily verify this oneself.
Excited Delirium Syndrome
An alternative hypothesis involves Excited Delirium Syndrome (EXD), a symptom of drug overdose which sometimes appears in the final minutes preceding death. EXD typically results from fatal drug abuse, in past years from cocaine or crack, more recently from fentanyl, which is 50 times more potent than heroin. Especially dangerous are street drugs like meth laced with fentanyl.
According to an article in the Western Journal of Emergency Medicine (WJEM), 2011: "Excited delirium (EXD) is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs. Subjects typically die from cardiopulmonary arrest... all accounts describe almost the exact same sequence of events: delirium with agitation (fear, panic, shouting, violence and hyperactivity), sudden cessation of struggle, respiratory arrest and death."
It appears that an EXD episode began when the officers tried to get Floyd into the squad car. He resisted, citing "claustrophobia" - the onset of the fear and panic phase, and "I can't breathe" - difficulty breathing due to fentanyl locking into the breathing receptors in the brain. (Classic symptoms of EXD are highlighted in bold.) He then exhibited unexpected strength from the adrenaline spike in successfully resisting the efforts of four officers to get him into the car. When Chauvin pulled him out of the car he fell to the ground, likely due to disorientation and reduced coordination. Presumably this was when he injured his mouth and his nose started to bleed, and the police made the first call for paramedics. While restrained on the ground he exhibited agitation (shouting and hyperactivity (trying to move back and forth) for several minutes. This was soon followed "sudden cessation of struggle, respiratory arrest and death." One hears Floyd shouting loudly as in the agitated delirium phase in this video. In a later video, he becomes exhausted, and had stopped breathing as the ambulance arrived.
It appears that disorientation had already set in when the store employees went to Floyd's car and asked him to return the cigarettes he had bought for a fake $20 bill. He refused, and they reported the incident to the police, saying that he appeared to be very intoxicated. He certainly must have been, or he would have left quickly to avoid arrest.
Police Intervention and Intentions
The EXD diagnosis is controversial and in some quarters is viewed as an alibi for police brutality. The WJEM authors note, "Since the victims frequently die while being restrained or in the custody of law enforcement, there has been speculation over the years of police brutality being the underlying cause. However, it is important to note that the vast majority of deaths occur suddenly prior to capture, in the emergency department (ED), or unwitnessed at home."
Regarding restraint, they note, "people experiencing EXD are highly agitated, violent, and show signs of unexpected strength, so it is not surprising that most require physical restraint. The prone maximal restraint position (PMRP, also known as "hobble" or "hogtie"), where the person's ankles and wrists are bound together behind their back, has been used extensively by field personnel. In far fewer cases, persons have been tied to a hospital gurney or manually held prone with knee pressure on the back or neck."
This latter position is what the accused officer Chauvin was applying, although at one point the team did consider using a hobble. It has been proposed that restraint helps to forestall injury and death by conserving the subject's energy. There are also views that restraint increases the likelihood of a fatal outcome.
The charge sheet against Chauvin included this exchange between the two white officers on the squad: ""I am worried about excited delirium or whatever," Lane said. "That's why we have him on his stomach," Chauvin said."
According to this dialogue, Chauvin was apparently was trying to follow the protocol recommended by WJEM. Since Floyd was on his stomach, Chauvin's knee pinned him at the side of his neck, and did not impede breathing. Commentators are referring to Chauvin "kneeling" on Floyd's neck, or resting his weight on it. From videos it is hard to gauge how much weight he applied, but the correct procedure is just enough to restrain movement, not to crush the person.
Chauvin and his team might not have done everything perfectly, but it is easy to underestimate the difficulty of police work, particularly in cases of resisting arrest, whether willfully or due to intoxication.
The American College of Emergency Physicians' White Paper Report on Excited Delirium Syndrome (ACEP, 2009) notes that "a law enforcement officer (LEO) is often present with a person suffering from ExDS because the situation at hand has degenerated to such a degree that someone has deemed it necessary to contact a person of authority to deal with it. LEOs are in the difficult and sometimes impossible position of having to recognize this as a medical emergency, attempting to control an irrational and physically resistive person, ... This already challenging situation has the potential for intense public scrutiny coupled with the expectation of a perfect outcome. Anything less creates a situation of potential public outrage. Unfortunately, this dangerous medical situation makes perfect outcomes difficult." In other words, officers need to be policemen, paramedics and public relations experts all at once.
With a fatal overdose there is no good outcome possible, but there is no way for police to foresee that. Sometimes EXD can last longer, and it is not always fatal. Perhaps the ACEP Task Force on EXD will update their report and provide guidelines to help police identify and deal with EXD while avoiding accusations of police brutality.
In this video Chauvin continued to apply the neck restraint although bystanders repeatedly objected, and even after Floyd stopped moving. As Floyd became exhausted, it could have been reasonable to relax the restraint to see if it was really necessary. Chauvin didn't seem to respond to the bystanders to give a medical reason for the restraint. His actions were consistent with a belief that police should restrain the subject until medevacs arrive. Videos show the police focused on restraint, never beating or striking Floyd. The restraint and verbal exchanges with Floyd are also consistent with a belief that he was resisting arrest, by refusing to get in the squad car. When he said "I can't breathe," they responded "You're talking fine." When they said "Get in the car," he didn't agree to.
Subjects suffering from EXD usually resist arrest violently, which requires police to restrain them, but when police see signs of EXD, they also need to call an ambulance. It appears the police may have called for paramedics first when Floyd developed a nosebleed, then for an ambulance, which arrived after Floyd had stopped breathing. .
Videos of EXD incidents generally show subjects violently resisting arrest, and requiring multiple officers to subdue them. There is one video clip about a police departments that was trained to regard EXD as a medical and not a criminal issue, and avoid physical restraint as far as possible; the results are much better.
EXD seems to be the most likely reason why Floyd suddenly refused to get into the squad car, and began to shout and writhe on the ground. With or without EXD or police intervention, he was doomed to die quickly, even if an antidote had been immediately available.
Fentanyl is so deadly because it acts so fast and binds so tightly to dopamine receptors in the brain - even those that control breathing, unlike other narcotics. When Floyd complained "I can't breathe," although he was breathing, and then completely stopped breathing, this was the onset of respiratory arrest, which is how a fentanyl overdose kills.
While police work is needed to trace the source of these dangerous drugs, the problems of drug addiction and crime have deep causes and can only be contained, not solved, by the police. Whatever our society has been doing about these problems is not working.
Right now, our civilization risks being torn apart by the passions of extremism, due to a misunderstanding. Please share this analysis, as an appeal to return to reason.
End of Part I.
Reviewer comment: "My first thought is why it has been left to you to figure this out, when we pay professional journalists to investigate these things, and why aren't the police and politicians telling us about this."
A good question which gives a clue to something I've been wondering about. When other commentators publish within hours, why does it take me a week or two to finish an article like this? Journalists are usually under a deadline to produce stories quickly, whereas it takes a lot of research and reflection to develop an original thesis into a fair and coherent explanation of events.
Everyone tends to have an agenda, and to look for facts to support it. Police brutality or looters running amok may be more newsworthy than a chronic problem like drug abuse. The best agenda now is to take a break to focus on facts, or else an "Excited Delirium" could become a contagion that engulfs our nation.
Part II. The Death of Tony Timpa (Draft)
A highly pertinent question: Has there ever been a confirmed death from a knee hold before? Not finding any data by searching the Net, I posted the question on Quora. One answer soon came.
A young white man died in Dallas a few years ago, after being restrained by the police with the knee on his back. My respondent believed he suffocated, but the actual autopsy said cardiac arrest, cocaine, and stress from restraint by police officers.
Tony Timpa had taken an overdose of cocaine, plus he was off his anti-schizophrenia medicine. Mental illness can also be a trigger for EXD, and according to the autopsy report, he displayed all the classic symptoms. The first phase, fear and panic, was fear of the onset of delirium itself - he himself called 911 for help. By the time the police arrived, security guards had already handcuffed him to restrain him. He was incoherent, out of control, found lying on the ground, the typical EXD position. The police pinned him down with a knee on his back for 13 minutes, saying he was at risk of rolling into the roadway, and suddenly he was dead.
Tony died in 2016. The family got the run-around, and an autopsy was not released until 2019. The body cam footage was released, which showed the police behaving callously towards the subject. The officers were originally charged with homicide, but it was found they were not at fault and charges were dropped and they were reinstated. Timpa's case is very similar to Floyd case in many ways, and there are also many differences - the starkest of course being the intensity of the public reaction.
Here is the text of the Timpa autopsy.
Case: ME Page 7 of8
Timpa, Anthony Alan
Based on the case history and autopsy findings, it is my opinion that Anthony Alan Timpa, a 32-year-old white male, died as a result of sudden cardiac death due to the toxic effects of cocaine and physiologic stress associated with physical restraint.
Cardiac hypertrophy and bipolar disorder contributed to his death.
The mechanism of death in cases such as this is sometimes referred to as "excited delirium." Classically, people affected by EDS are witnessed to exhibit erratic or aggressive behavior, and will often "throw off" attempts at restraint, requiring multiple people to subdue them. The person will appear to calm down and will suddenly become unresponsive. Most cases are associated with drug intoxication and/or illness.
In this case, several factors likely contributed to the death. The surveillance and body cam footage and witness reports fit the classic scenario of excited delirium and cocaine use and illness (bipolar disorder) are common predisposing risk factors for EDS. Cocaine leads to increased heart rate and increased blood pressure, making a cardiac arrhythmia more likely. Due to his prone position and physical restraint by an officer, an element of mechanical or positional asphyxia cannot be ruled out (although he was seen to be yelling and fighting for the majority ofthe restraint). His enlarged heart size also put him at risk for sudden cardiac death.
Although the decedent only had superficial injuries, the manner ofdeath will be ruled a homicide, as the stress of being restrained and extreme physical exertion contributed to his demise.
MANNER OF DEATH: Homicide
[Signatures and seals of medical examiners]
Note that homicide is not the same as murder, it also includes unintentional or accidental actions contributing to death. Even so, in spite of the number of medical examiners signing the report, there are the same logical issues as with Floyd's autopsy - 1) the overdose, and 2), EXD seems to be equally fast and fatal, whether or not in police custody. The stress of restraint is likely incidental or "epiphenomenal". The uncontrolled adrenaline spike will burn the body out either way. WJEM reports on numerous cases of people who died alone at home from EXD; they are typically found in the bathtub where they tried to quench the hyperthermia with ice cubes, but their body burned out all the same.
Timpa autopsy p. 5, blood tests - Cocaine and metabolites
Cocaine, 0.647 mg/L
Ecgonine Methyl Ester, 0.378 mg/L
Benzoylecgonine, 0.843 mg/L
The lethal dose of cocaine is around 0.5 mg/L according to http://www.forensicmed.co.uk/science/toxicology/cocaine/ but only 0.1 mg/L according to https://academic.oup.com/jat/article/38/1/46/831276
If we add the three numbers above for cocaine and metabolytes together it comes to about 18 mg/L. With that overdose, plus the man being without his schizophrenia medication, he had little if any chance of surviving.
It must be observed that the Minneapolis officers acted with far more consideration towards Floyd than the treatment Timpa received in Dallas. The way the officers made fun of Timpa was a scandal. They were evidently surprised when he suddenly died.
In conclusion, excited delirium should be treated as a medical condition, usually quickly fatal. An ambulance should be called immediately, and only the minimum possible restraint applied. The symptoms should become widely known by police and paramedics.
It would be helpful if the AMA would recognize EXD as a real condition, rather than dismissing it as a cover story for police brutality. Ignorance of the symptoms can only lead to unintentional cruelty by police, when they believe they are confronted with a criminal violently resisting arrest, rather than a patient with a life-threatening psychosis.
When we have a real problem in the United States of many shootings by - and of - the police, isn't it odd that such an uproar has arisen, over a case where the police actually had nothing at all to do with the man's demise?
It is also strange that George Floyd's case is considered as a proof of systemic racism, when Tony Timpa got much worse treatment.
 https://www.acsh.org/news/2017/02/02/fentanyl-overdose-dont-count-naloxone-save-you-10822 In other studies of death from heroin and morphine, there were deaths from only 100 ng/ml of morphine and "all cases with a blood concentration of 200 ng/ml and more of free morphine displayed a fatal outcome." https://www.researchgate.net/publication/11040428_Fatal_versus_non-fatal_heroin_overdose_Blood_morphine_concentrations_with_fatal_outcome_in_comparison_to_those_of_intoxicated_drivers Fentanyl is considered 100 times more potent than morphine. By this comparison, Floyd's blood fentanyl concentration could have been 10 times the fatal level. (Heroin quickly metabolizes into morphine.) In addition his morphine concentration of 86 ng/mL would usually be fatal by itself.
 https://www.usatoday.com/story/news/nation/2020/06/01/george-floyd-independent-autopsy-findings-released-monday/5307185002/ A report commissioned by the Floyd family stated that asphyxiation from sustained pressure was consistent with the evidence, but the author Michael Baden didn't have access to all the evidence, and chose not to endorse his opinion with the "expert opinion" label.
 The knee on the neck is a body hold, not a chokehold or carotid restraint, which involves putting pressure precisely on both carotid arteries, located on either side of the throat. A carotid restraint is usually applied by an elbow, and causes the subject to pass out in as little as 15 seconds. Blocking the arteries does not stop the breathing or heartbeat (pulmonary or cardiac arrest), which Floyd suffered after being restrained for many minutes. Once pressure on the arteries is released, the subject normally regains consciousness quickly.
 From the incident report of the fire truck that was called to the scene, it appears that both police and bystanders called 911 for emergency medical services (EMS). The first call was Code 2, apparently for Floyd's nosebleed, which summoned a fire truck, followed by a more urgent code 3, which was said to bring an ambulance within six minutes. It appears the police called the ambulance when Floyd's breathing and heartbeat stopped. https://www.startribune.com/first-responders-worked-nearly-an-hour-to-save-floyd-before-he-was-pronounced-dead/570806682/ "Floyd goes limp and appears to lose consciousness. Hennepin EMS then arrive six minutes after the distress call." The article refers to the incident report by the fire truck, http://www.minneapolismn.gov/www/groups/public/@mpd/documents/webcontent/wcmsp-224680.pdf which has a note implying the first call to EMS was from police and another call came from bystanders: "No clear info on pt [patient] or location was given by either initial pd [police department] officers or bystanders." We need an incident report from the ambulance.
 TV news clips showing police restraining subjects who are exhibiting EXD symptoms and violently resisting arrest https://www.youtube.com/watch?v=6qCqjuqEWEc A TV news report and cellphone video on a more humane method of managing an EXD case, thanks to police training, putting safety of the subject and of bystanders first, rather than restraints. However, no details are given about the outcome or the drug dose. https://www.youtube.com/watch?v=6qCqjuqEWEc
 https://columnhealth.com/blog_posts/why-is-fentanyl-so-dangerous/ . Deaths from fentanyl have skyrocketed in the last seven years.
 Wikipedia has a detailed narrative of the incident here https://en.wikipedia.org/wiki/Killing_of_George_Floyd . Certain notes there support the thesis of fentanyl intoxication, and resisting arrest as part of an EXD syndrome. Floyd struggled with Lane before leaving his own vehicle, and again when Kueng, then all four officers, tried to get him into the squad car. Floyd already complained he couldn't breathe before they tried to get him into the police car, without any neck restraint, indicating the onset of respiratory arrest from the fentanyl overdose. https://abcnews.go.com/US/george-floyd-protest-updates-arrests-america-approaching-10000/story?id=71038665 "They all tried to force Floyd into the backseat, during which time Floyd said he could not breathe, according to the complaint."
He also fell down twice, which could be seen either as a sign of intoxication or resisting arrest. The officers knew it was a drug overdose, as Thao told bystanders, "This is why you don't do drugs, kids." By the way, this Wikipedia article should be named "Death of George Floyd," as an accused is innocent until proven guilty.
Draft Notes and odds and ends
There are many similarities, many points to compare and contrast between the GF and TT cases. In neither case was restraint the only or main cause of death. So I don't see we have a confirmed case of death from a knee restraint yet.
In both cases the examiner assumed that stress from restraint contributed to the fatal heart attack, along with drug intoxication. However, both cases displayed the symptoms of Excited Delirium Syndrome / EXD which is usually caused by drug overdose, can also be due to mental illness, and generally ends quickly in fatal cardiopulmonary arrest, regardless of restraint or not. The Dallas coroner found that EXD was the main cause of death.
In both cases the drug concentration in the blood was way above the lethal level.
Killing of Tony Timpa Wikipedia entry
On August 10, 2016, Dallas Police killed Tony Timpa, a 32-year-old resident who had not taken his medication. Timpa was already handcuffed while a group of officers pressed his body into the ground while he squirmed. It took over three years for footage of the incident to be released. The footage contradicted claims by Dallas Police that Timpa was aggressive. The officers involved were Sgt. Kevin Mansell and Officers Danny Vasquez and Dustin Dillard. Criminal charges against three officers were dropped in March 2019 and officers returned to active duty.
Wikipedia doesn't even mention cocaine in the Timpa case, although that was the main cause of death.
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