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In the federal trial unfolding in St. Paul for three former Minneapolis officers charged in connection with George Floyd's killing, the defense has repeatedly suggested their clients were following department protocol on how to restrain a suspect showing symptoms of "excited delirium" — a controversial diagnosis for a severe form of agitation.

This month, the Police Department and Mayor Jacob Frey's office claimed that the city halted such training last year, after the nation's largest professional association for physicians declared excited delirium an overly broad term, often misapplied to justify excessive police force or unneeded sedatives.

"The most recent fall 2021 training delivered to all department members by the physician did not include the term excited delirium," said police spokesman Garrett Parten.

But it did.

A video of the new training, obtained through a public records request, shows the Police Department still teaching officers how to respond to excited delirium and using studies with "excited delirium" in the titles.

In the video, Dr. Paul Nystrom, an emergency physician at Hennepin Healthcare, says the the terminology "excited delirium" has become "triggering" for the public. Using a PowerPoint slide with "excited delirium" struck out, he suggests police call it by another name, such as "severe agitation with delirium."

"That being said, the condition exists," says Nystrom. "We all agree the entity exists."

But not everyone does agree. Last year, the American Medical Association (AMA) publicly rejected excited delirium, calling the diagnosis a "manifestation of systemic racism."

Earlier this month, a representative for Frey's office contacted the Star Tribune to say the city had stopped the training after the AMA's new policy, asking for a clarification in a story about excited delirium and the trial of the former officers.

Yet in the training video, Nystrom criticizes doctors who have rejected the science of excited delirium, putting quotation marks around "specialists" and "experts."

"I wouldn't go to an operating room and tell an anesthesiologist how to practice," says Nystrom, who moonlights as a sworn police officer. "Most of us don't appreciate somebody else getting in our lane when they don't do the things that we do."

Excited delirium usually refers to a person possessed by a potentially deadly form of agitation, often abetted by stimulant abuse, with symptoms of aggressive behavior, profuse sweating, public nudity, mouth foaming and superhuman strength. Nystrom says excited delirium can be deadly, despite the media dismissing it as a "coverup for cops to kill people." He then offers the same acronym used in the previous excited delirium training materials — NOTACRIME — to help officers remember how to identify the syndrome. N=Nudity. O=Objective Violence, and so on.

"That still holds," Nystrom says.

Minneapolis police Deputy Chief of Professional Standards Troy Schoenberger stood by the new training. He said the updated version does meet the AMA policy, including enlisting a medical professional to teach the course, which covers de-escalation.

"This training was important in the transition away from the use of the term 'excited delirium,' while still recognizing that there are symptoms that officers may observe, along with his [Nystrom's] recommendations as to how to properly care for patients exhibiting those symptoms," he said.

'Change in name only'

Dr. Michael Freeman, an associate professor of forensic medicine at Maastricht University in the Netherlands, called the new training a "window dressing" that fails to meet the AMA policy, and instead reinforces dangerous police practices based on shoddy research.

"Most cops want a good outcome" when encountering an agitated person, said Freeman, who has published research on these types of encounters. "Educating cops appropriately on how to get a good outcome is critical. Not a wink and a nod that we just won't call it — wink — excited delirium anymore."

Hennepin Healthcare's Dr. Max Fraden also expressed concern over the new training. "This is a change in name only. And the issue with excited delirium is not the name," he said.

Last year, Fraden and other hospital staff drafted a petition asking Hennepin Healthcare leadership to cease training law enforcement on excited delirium. Hospital administrators sent a letter to staff saying they stopped training Minneapolis police in 2018, and any new training would entail "trauma-informed care" and "antiracist framework."

Asked for an interview, hospital spokesman Thomas Hayes sent a statement saying the training is designed to teach police to identify underlying medical conditions that require EMS intervention, and how to support paramedics. "We recognize the need to continue to improve the training and are committed to doing so with urgency and community input," Hayes said.

Nystrom did not respond to a request for an interview. Frey's office provided a statement Saturday night: "The mayor's office will be reviewing with external medical experts what appears to be a failure to follow a directive. In the meantime, Mayor Frey has directed the department to immediately terminate their contract with Dr. Nystrom."

Fraden said the video shows Hennepin Healthcare leadership is "not living up to their word."

"This seems very blatantly opposed to what Hennepin says their policy is," said Fraden. "There's clearly no oversight."

A 'catch-all' phrase

One point that skeptics and proponents of excited delirium agree upon: Paramedics and police do encounter agitated, erratic people who are difficult to calm and may pose a danger to themselves or others.

Nick Nudell, a Colorado paramedic of 23 years, said he's been attacked by people like this , and has relied on police to help when verbal de-escalation fails.

"Sometimes you're in the middle of a parking lot and it's 10 degrees outside and the person is naked and flailing around," said Nudell, president of the American Paramedic Association.

First responders should be trained on how to treat severely agitated people, said Dr. Jennifer Brody, an internal medicine and addiction specialist who teaches at Harvard Medical School. But Brody said excited delirium is an umbrella term, often invoked inconsistently in a manner not supported by clear science.

"Excited delirium has been this catch-all phrase for this vague, unstable collection of signs and symptoms with a variety of kinds of outcomes, including sometimes very aggressive forms of restraint," she said.

Brody called the new training video "a superficial adjustment in language" that attempts to debunk, rather than adopt, the AMA recommendations.

"We're not concerned because the term is triggering," said Brody. "We're concerned because it's being used in profoundly inequitable ways to harm people."

In the training, Nystrom cites research that found excited delirium leads to death in 8-10% of cases. "So even if you don't like the idea … for the safety of our patients, err on the side of: This is a thing," he says.

Brody said there's no clear data that excited delirium ever leads to death.

On the contrary, she cited a 2020 study that found excited delirium-related deaths were actually linked to aggressive restraints of patients. "There is no evidence to support [excited delirium] as a cause of death in the absence of restraint," concluded the study in Forensic Science, Medicine and Pathology .

"What one would have hoped is that when these trainings were devised that there would be some nuance," Brody said.

Freeman, who coauthored that study, said some patients do need to be restrained during 911 calls, but police should be taught that "the severity, duration and nature of restraint" will dictate if the person survives the encounter. "Not the fact that they're delirious. Not the fact they're agitated. Not the fact they've got drugs on board."

Freeman said police should regard restraints as "one step away from pulling out your firearm."

Nystrom also teaches the benefits of ketamine vs. other sedatives. However, per Minneapolis policy, paramedics — not police — are tasked with making decisions on which sedatives are appropriate.

Dr. Altaf Saadi, a neurologist at Massachusetts General Hospital, said the new training rightfully instructs officers to use de-escalation tactics before restraint, but the changes in language are "not adequate" in complying with the AMA policy.

"He [Nystrom] continued to rely on literature focused on 'excited delirium,' accepting it as a legitimate medical entity," said Saadi, who also teaches at Harvard Medical School. "He reviewed data laden with conflicts of interest without mentioning those conflicts of interest, including articles written by physicians paid by law enforcement organizations."

Training key to defense

In the last moments of Floyd's life, one of the men restraining him brought up excited delirium.

"Should we roll him on the side?" former officer Thomas Lane asked. "I just worry about the excited delirium or whatever."

"Well, that's why we have the ambulance coming," replied his former training officer, Derek Chauvin.

This moment has become key to the defense of Lane, J. Alexander Kueng and Tou Thao. Over the past three weeks of testimony, their attorneys have pored over training and cross-examined police witnesses on the teaching of excited delirium — so much that one attorney joked last week they'd "kind of beat this to a pulp."

The defense attorneys have pointed out Floyd was sweating, acting erratically and a white substance formed around his mouth — all taught by Minneapolis police as symptoms of excited delirium.

"This is training that's meant to teach officers to recognize the potential signs of excited delirium, and to recognize this is a medical emergency," testified Nicole Mackenzie, medical support coordinator for Minneapolis police.

Inspector Katie Blackwell testified that officers are taught to use force to restrain a combative suspect showing signs of excited delirium while waiting for paramedics, and the syndrome may be diagnosed by a single symptom.

The training slideshow featured an image of several officers detaining a suspect by placing a knee to the back of his neck, similar to how Chauvin pinned Floyd. He has since been convicted in Floyd's murder and pleaded guilty to federal civil rights charges.