"A Rational Response
to Taser Strikes"


Don't Be Shocked"


Because restraint asphyxia deaths continue to so frequently occur, I am inundated with wrongful death legal case work, and don't have the time to pen IN-DEPTH reviews of every article I encounter regarding deaths related to restraint asphyxia – or pepper spray, or Taser use.

One of the reasons restraint asphyxia deaths are still occurring, is that SOME Journals and major Associations continue to publish dangerous and entirely inappropriate misinformation about deaths related to restraint asphyxia – or pepper spray, or Taser use. By doing so, these Journals and major Associations act to perpetuate the risk that citizens (adults and children) will suffer DEATH at the hands of the emergency responders or care-providers who are summoned to intervene and/or care for them during their medical or traumatic emergency.
By publishing dangerous and entirely inappropriate misinformation, these Journals and major Associations additionally perpetuate the risk of EMERGENCY RESPONDERS and CARE PROVIDERS CAUSING wrongful death – perpetuating the risk of these individuals suffering the psychological (and financial) trauma of having participated in a "HOMICIDE."

On September 1st, 2005, I needed to immediately post "Ventricular Fibrillation after Stun-Gun Discharge" (N Engl J Med Sep 2005) in my Restraint Asphyxia Library – an article that hints at a LANDMARK Taser Case Study in the offering.
Thus, I could no longer delay posting the two JEMS Taser-related articles that I had collected when they were published (back in MAY of 2005) – I could no longer delay writing some kind of "review" for each of them.
Because of my time-constraints, however, to review these articles I'm simply going to pick ONE BIT from each, then identify and explain why that one bit is dangerous and entirely inappropriate misinformation. After that, readers are responsible for becoming well-educated enough about these subjects that they can recognize – on their own – the OTHER BITS in these articles that represent dangerous and entirely inappropriate misinformation.
My reviews will follow the links to these articles. You can read my reviews before or after reading the articles – however you prefer.

I've posted these two JEMS articles in PDF file format.
If you don't have an Adobe Acrobat PDF file program, you can download a FREE version HERE.

A Rational Response to Taser Strikes

Whitehead, S. A rational response to Taser strikes.
JEMS 2005 May; 30(5):pgs 56-66.

FROM THE EDITOR; Don't Be Shocked

Heightman AJ; From the editor; Don't be shocked.
JEMS 2005 May; 30(5):pgs 12,32.


First, a "POSITIVE" comment about JEMS in general!:
I suspect that many people who peruse my library and read my reviews (especially EMS-providers) develop the opinion that I seem somehow specifically motivated to "ATTACK" The Journal of Emergency Medical Services (JEMS).
That is not, at all, TRUE!
The reason I've written so many negative reviews of JEMS articles is because they've published so many articles about restraint and restraint-related issues. In fact, JEMS has published more restraint-related issues articles than ANY other prehospital emergency medical services journal.
Thus, JEMS is to be highly commended
for addressing restraint-related issues so frequently!

Unfortunately, this means that it is even more FRUSTRATING that every single restraint-related issues article ever published by JEMS has been based upon inadequate research, has always perpetuated the dissemination of misinformation, and has always promoted inappropriate emergency actions.
In fact, it is even MORE detrimental to emergency responders (and their patients) that the ONE emergency medical services journal that manages to frequently address these issues cannot seem to EVER get their information RIGHT!
And, there is absolutely no excuse for JEMS' failure to get this information RIGHT. The editors and authors of JEMS know me. They know that I would be happy to review these articles PRIOR to their publication, so as to ensure that the articles contained accurate and appropriate information and directives. Yet (for reasons known only to JEMS), they persist in failing to invite my participation. Thus, they persist in publishing restraint-related issues articles based upon inadequate research; persist in publishing restraint-related issues articles filled with dangerous misinformation and inappropriate action directives.

Another "POSITIVE" general comment about these two JEMS articles:
Both of them contain several bits of information that ARE entirely accurate and correct!
For instance;

From Steve Whitehead's "A Rational Response to Taser Strikes":
Most of the tased individuals you evaluate will need to be transported to the emergency department (ED). This isn't because of the Taser incident itself, but because of the potentially dangerous factors that led the patient to be tased in the first place and the potentially dangerous factors (e.g., a fall) that occurred immediately after the tasing.

From A.J. Heightman's "FROM THE EDITOR; Don't be shocked":
Certain individuals in states of acute psychological agitation and hyperactivity, and exhibiting a form of behavior disturbance in excess of what the police normally witness (unusually aggressive) don't respond appropriately to reasoning or commands and exhibit unusual strength. They may also be hyperthermic and have fluctuating levels of consciousness. It's these individuals who should trigger a red flag in your mind. These patients may have other conditions that predispose them to excited delirium, such as exhaustion, dehydration and organic brain disease.

AND (this is a truly EXCELLENT bit!):

In addition, when you hear a patient yelling, "I can't breathe," it may be a warning that their increased heart rate and inability of the diaphragm to expand for proper oxygenation may be spiraling them into sudden death.

Thus ends my POSITIVE comments about these two JEMS articles.
Now for my NEGATIVE review of ONE BIT from each:

Remember, I only have time to address ONE negative bit from each.
There are MORE awful bits in each of these articles.
It's YOUR job to find the others!

CHAS' Review of Whitehead, S.' "A Rational Response to Taser Strikes":

From Whitehead's "Sudden Unexpected Death Syndrome:
Understanding the role of excited delirium" SIDEBAR:
Stage 3: Rhabdomyolysis – Insensitive to pain, individuals can push their muscles past their normal limits without feeling pain or exhaustion. Individuals may demonstrate unusual strength. The body now artificially moves past its exhaustion threshold. The muscles begin to cannibalize themselves for energy, and the resulting cellular breakdown releases intracellular toxins, enzymes and myoglobin into the blood stream, a phenomenon known as rhabdomyolysis.14

Because he cites it as "Stage 3" in his "Understanding the role of excited delirium" SIDEBAR – before his "Stage 4: Acidosis and death" discussion – Whitehead makes it sound as though rhabdomyolysis develops before acidosis in these incidents; and is an IMMEDIATELY-OCCURRING side effect of struggle with restrainers.
IT IS NOT! Rhabdomyolysis doesn't develop until HOURS, sometimes even DAYS, after someone has survived an extremely exertive struggle associated with an excited delirium state of altered level of consciousness. Acidosis, on the other hand, IS an IMMEDIATELY-OCCURRING side effect of struggle with restrainers associated with an excited delirium state of altered level of consciousness. (As is DEATH due to the employment of an asphyxial form of restraint.)
Absolutely NOTHING in Whitehead's reference article 14 indicates that rhabdomyolysis is an IMMEDIATELY-OCCURRING side effect of struggle with restrainers.
If you wish to read it and see for yourself, Whitehead's reference article 14 [Lane R, Phillips M: "Rhabdomyolysis." British Medical Journal. 327(7404):115-116, 2003.] was posted in my Restraint Asphyxia Library back in February of 2004:

Thus, by citing rhabdomyolysis as being the effect of a "Stage" that occurs prior to a "Stage" that includes "Acidosis and death," Whitehead's SIDEBAR information is demonstrated to be incredibly inaccurate, misleading, and entirely unhelpful to anyone legitimately interested in "Understanding the role of excited delirium," or understanding what contributes to deaths involving Taser use.
In fact, I wonder if Whitehead placed it where he did in an effort to provide "another factor" upon which to place the "blame" for death, so as to focus the "blame" for death away from the individuals who employed the asphyxial form of restraint that actually caused the death.
If that is motivation for this placement, he is doomed to failure – a fact demonstrated by a quote from the following article;
Coco TJ, Klasner AE: Drug-induced rhabdomyolysis.
Current Opinion in Pediatrics April 2004; 16(2):pgs 206-210.

"With early recognition and a high index of suspicion, [as long as "the airway, ventilation, and perfusion" are ensured] most patients with rhabdomyolysis will have an excellent prognosis."
That article was posted in my Restraint Asphyxia Library in January of 2005: Drug-Induced Rhabdomyolysis

Considering the fact that ALL of Whitehead's "Sudden Unexpected Death Syndrome: Understanding the role of excited delirium" SIDEBAR "Stages" descriptions (and their order) are incredibly inaccurate and rife with misinformation; combined with the "LESSON" Whitehead identifies at its end (quoted below); it seems clear that Whitehead's primary motivation for writing this article is to provide the means with which restrainers can seek to avoid being held responsible for employing asphyxial forms of restraint.

The lesson is clear: Regardless of the method of restraint, patients who undergo a prolonged phase of agitation should be considered in danger of sudden death, even after the combativeness has resolved.

The method of restraint is precisely what causes their death. Altered level of consciousness victims involuntarily-cued to act out in a violent, aggressive, or "combative" manner (excited delirium victims) DO NOT DIE due to "a prolonged phase of agitation" – nor do they die due to prolonged struggle with restrainers – UNLESS they are restrained in a manner that interferes with their ability to BREATHE!
This fact has long been very clearly (and simply) explained in Part Two of my Restraint Asphyxia – Silent Killer article. And, this information has been available since 1998!
Part Two of my article also very clearly (and simply) explains the REAL PHASES ("Stages") demonstrated as CONSISTENTLY preceding EVERY restraint-related "Sudden Unexpected Death" ever reported!
If Whitehead performed ANY kind of Internet research of this subject while writing his article, it is virtually IMPOSSIBLE for him to have MISSED this information.
Consequently, one can only surmise that Whitehead ELECTED to ignore this information when researching and subsequently writing his article.

CHAS' Review of Heightman, AJ's "FROM THE EDITOR; Don't Be Shocked":

From A.J. Heightman's "FROM THE EDITOR; Don't Be Shocked":
These authors reference several issues that I want you to be aware of, because you'll begin to see how these factors could relate to the deaths occurring after Taser use. First, you need to be aware that excited delirium is a term used to describe the manifestations of extreme drug abuse. Not a recognized medical or psychiatric condition, it was originally a descriptive phrase coined by medical researchers to describe the extreme end of a continuum of drug abuse effects.2
It's best to keep the term linked to the condition being described, such as "cocaineinduced excited delirium," so it's not mistaken for a recognized medical or psychiatric condition.

"excited delirium is a term used to describe
the manifestations of extreme drug abuse"

[It is] "Not a recognized medical or psychiatric condition..."

"It's best to keep the term linked to the condition being described,
such as 'cocaineinduced excited delirium,'
so it's not mistaken for
a recognized medical or psychiatric condition."

Those are grossly, NEGLIGENTLY, even CRIMINALLY inaccurate and erroneous statements!

I don't know Steve Whitehead (the author of "A Rational Response to Taser Strikes" – the article A.J. is referring to in his EDITORIAL opinion piece). But, I thought I knew A.J. Heightman (JEMS' "Editor-In-Chief").
I thought that A.J. was a CARE-PROVIDER (even though it's been many years since he's actually "worked the streets"). I thought that A.J. was a reasonably-well medically-educated individual.
Apparently, I was wrong!

What the hell HAPPENED to A.J.'s memory that all levels of emergency medical responders are trained to recognize that there are TONZ of medical and traumatic conditions that can cause an ALTERED LEVEL OF CONSCIOUSNESS? And, that ANY of those medical and traumatic altered level of consciousness causes can result in the victim being involuntarily-cued to act out in a violent, agitated, or even "combative" manner?!
How could a presumably well-medically-educated "care provider" make those statements? And, how could A.J. justify making those statements when he ALSO – in the same editorial – states the following:
These patients may have other conditions that predispose them to excited delirium, such as exhaustion, dehydration and organic brain disease.

The number 2 reference that A.J. cites to support his pathetically erroneous statement that excited delirium is "Not a recognized medical or psychiatric condition" according to "medical researchers" is THIS:
2. Benner A, Isaacs SM: "Excited delirium: A two-fold problem." Police Chief Magazine. June 1996.
Oh, surpriZe. That article was NOT written by "medical researchers"! It was written by a San Francisco Police Department Psychologist (Lieutenant Alan W. Benner, Ph.D.), with some kind of assistance from a San Francisco Department of Health employee (S. Marshall Isaacs, M.D.). And, the only "medical" references cited by these individuals to support this grotesque JOKE of an article (and to support the STATEMENTS A.J. references it for) were dated "1987" and "1991." Can we say "WAAAY outdated" information? I think we can.
Furthermore, this sorry article – itself – was written WAAAAAY back in 1996! Interestingly enough, at that time, all the San Francisco city employees were desperately scrambling to defend themselves against accusations such as, "Police Probe of Suspect's Death Called a Cover-up, San Francisco Chronicle, June 6,1995."
If you want to check my facts by reading A.J.'s SORRY, very OLD, # 2 reference article, go to:
Excited Delirium: A Two-Fold Problem
After reading it, use your BACK BUTTON to come RIGHT BACK HERE!

Additionally, MANY other articles have been published SINCE 1996 (articles entirely available to A.J.), that clearly identify excited delirium being the potential result of ANY medical or traumatic altered level of consciousness cause – NOT merely "manifestations of extreme drug abuse!" Among them are these:

Stewart J: "Excited Delirium"
A Dec. 10, 2003 news article that also can be found on CBS NEWS.com:

Stratton SJ, Rogers C, Bricket K, Gruzinski G.
Factors Associated With Sudden Death of Individuals Requiring Restraint for Excited Delirium.

Am J Emerg Med 2001;19:187-191.

O'Halloran RL, Lewman LV.
Asphyxial death during prone restraint revisited: A report of 21 cases.

Am J Forensic Med Pathol (March) 2000, 21(1);39-52.

AND, even in the 12 MONTHS preceding this May of 2005 issue, the journal that A.J. is Editor-In-Chief of (JEMS) published at least FOUR articles that demonstrate the fact that MULTIPLE medical and traumatic emergencies – emergencies apart from "the extreme end of a continuum of drug abuse effects" – can cause an altered level of consciousness that involuntarily cues the victim to act-out in an agitated, violent, or "combative" manner!
I took the liberty of obtaining and posting these JEMS articles, in case anyone wants to check my QUOTES, or read their entirety. [BTW: The underlined text in the quotes is MY treatment.]

Matera PA; MVC & AMS; Never assume the obvious; your patient's life is at stake. JEMS Feb 2004;29(2):pg32.

"A single-vehicle MVC [motor vehicle crash] occurred ... the patient, who has been stuporous, becomes agitated and combative. ... This case illustrates the need to focus on presenting complaints rather than an incomplete diagnosis. In this case, the AMS [altered mental status] caused the MVC, not the other way around. The AMS was caused by hypoglycemia, resulting from improper diet following ingestion of hypoglycemic agents for treatment of NIDDM [diabetes]. It would have been poor medical care and professionally embarrassing for this patient to arrive at a trauma center with untreated hypoglycemia as his only cause of AMS."

Phrampus PE; Concepts in shock; Understand the pathophysiology to better serve your patients. JEMS Mar 2004;29(3):pgs118-132.

"Signs and symptoms of shock can range from mild in minor cases to serious derangements in level of consciousness and vital signs in lifethreatening cases. The severity of the symptoms relates directly to the severity of the shock. ... You will often observe tachypnea [rapid breathing]. This contribution of the respiratory system results in part from the anxiety related to the situation, which can range from mild anxiousness to combative, agitated behavior."

Collins S, Reynolds B; Exertional hyponatremia; The other heat-related emergency. JEMS Jul 2004;29(7):pgs74-88.

"Mental status changes are the key to assessment. ... A recent fatality on an army base occurred when a recruit in boot camp died of cerebral and pulmonary edema after an army medic mistook his hyponatremia for severe heat exhaustion and forced fluids on him. Neurological changes [caused by hyponatremia] include ataxia, slowed speech and impaired cognitive thinking. Inappropriate behaviors, such as combativeness, apathy and withdrawal, may appear. ... Seizures can occur at any time ... Once the patient seizes, his level of consciousness may remain altered."

Stoy W, Gergel R; Jane Doe v. EMS; Viewing EMS under the legal microscope. JEMS Oct 2004;29(10):pgs70-77.

"It's not surprising to see patients with a [respiratory] rate of 32 being combative due to the low oxygen levels. They might also fight you putting on the oxygen mask. In the report the paramedic said that she refused oxygen; she was combative and would not tolerate it. [Her combativeness] would have been for any number of reasons, one of which could have been possibly due to the respiratory distress."


Look at the number 1 reference cited by A.J. Heightman to support his Editorial article's comments – a reference that was NOT cited by Whitehead, within his "A Rational Response to Taser Strikes" article:
Robinson D, Hunt S; Sudden in-custody death syndrome. Topics in Emergency Medicine; Jan/Mar 2005;27:pgs 36-43.

From the Introductory ABSTRACT for this article:

This article discusses the existence of excited delirium in combination with other factors such as alcohol/drug use, physical condition of subject/patient, and the use of physical or mechanical restraints that could lead to a potentially fatal condition known as sudden in-custody death syndrome. The article reviews predisposing factors in combination with potentially hazardous actions by law enforcement and healthcare providers that have led to sudden in-custody death syndrome. It is up to those coming in contact with these subjects/patients who exhibit excited delirium states to be aware of the behaviors and further assess for other precipitating risk factors that may require further medical attention.

From the body of this article:

In the late 1990s, the use of taser stun guns became prevalent in law enforcement. Again touted as a safe way to restrain the combative or violent subject, it was believed that there would be a decrease in subject as well as officer injury. On October 12, 2004, The Arizona Republic published a list of 73 cases of death following taser stun gun use. Dating from September 1999 to October 2004, the commonalities are noted (Fig 3). The use of restraint is mentioned only 29 times, but it would certainly make sense that it was used more number of times than the brief histories report. Obviously in all cases Taser was used.


In "A Rational Response to Taser Strikes," Whitehead presented a terrifically IRRATIONAL discussion of Taser stikes and restraint-asphyxia-related deaths.

In "FROM THE EDITOR; Don't Be Shocked," A.J. Heightman's Editorial statements were SHOCKING!!!

Once again, JEMS has published articles about restraint and restraint-related issues based upon inadequate research, has perpetuated the dissemination of misinformation, and has promoted inappropriate emergency actions.

I cannot HELP but wonder how many OTHER JEMS articles – articles about OTHER SUBJECTS – are inadequately researched, inaccurately written, and promote inappropriate emergency actions?


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Email Charly at: c-d-miller@neb.rr.com
(Those are hyphens/dashes between the "c" and "d" and "miller")