Anjeanette Damon

adamon@rgj.com

When Thomas Purdy arrived at the Washoe County jail in October 2015, he was already hogtied, high on methamphetamine and sure that police were out to kill him.

He had been arrested after acting strangely at the Peppermill Resort Spa Casino, where his frequent-gambler status had earned him a free hotel room. During his arrest, he fought with security guards and Reno police officers.

That's why he ended up in the hogtie restraints, basically a strap that hooked his bound feet to his bound wrists behind his back and kept him from kicking the windows in the police car.

By the time he got to booking, he was sweating profusely, screaming that police wanted to kill him and struggling to breathe.

"Please, just send me to the hospital," Purdy, 38, told a jail intake nurse who asked him some perfunctory questions and attempted to take his blood pressure. "I can't breathe, ma'am."

Deputies had been trying to remove the restraints, but Purdy was struggling against their efforts. They couldn't bend his legs to provide enough slack in the strap to remove it.

Deputies spoke calmly and firmly to Purdy, repeatedly telling him to calm down and relax his legs. Finally, they decided to carry him to a cell.

As they lifted him off the ground in a special sheet with straps designed for carrying an incapacitated inmate, Purdy left a slick of sweat on the jail floor.

"Please don't do this," he screamed as they carried him down the hall in the "burrito." "Don't do this! They're trying to kill me!"

In the cell, four deputies rolled Purdy onto his stomach, lifted his ankles toward his back and held him down as they worked the restraints off. Purdy, who weighed 140 pounds, finally fell silent and stopped struggling.

With the restraints off, the deputies rushed backwards out of the cell, but Purdy remained motionless on his stomach, his hands behind his back and his feet still tucked up toward his buttocks.

"Good job, boys," a deputy says before the camera is turned off.

The sergeant, however, noticed Purdy didn't move after they left the cell, and the team went back in. He was barely breathing. A medical team performed CPR and he was taken to a hospital in an ambulance.

Purdy's family, who had to travel to Reno from the East Coast, agreed to remove him from life support a few days later.

The medical examiner ruled his death a homicide by "complications of excited delirium," a somewhat controversial ruling that describes a condition in which an individual suddenly dies following a period of extreme agitation and exertion brought on by a mental illness or illicit drug use.

In this case, it was ruled a homicide because Purdy likely wouldn't have died if not for the deputies' actions. But the medical examiner explained the term "homicide" does not imply "intent to kill" or negligence.

In fact, an investigation by Sparks police found no crime involved in Purdy's death. The sheriff's office wouldn't comment on whether any of the deputies involved faced disciplinary action after the death.

That explanation isn't enough for Purdy's family. Nor is it enough for the families of Niko Smith and Justin Thompson, who both died like Purdy — after lying on their stomachs struggling with a crowd of deputies at the Washoe County jail.

"They killed my brother," said Jenn Hutchins, Purdy's sister. "They said he was violently aggressive and he was out of control. If you watch the video, that's not the case at all. He was pleading for help."

Their deaths are part of a dramatic increase in the number of in-custody deaths at the Washoe County Detention Facility since Sheriff Chuck Allen took office on Jan. 1, 2015. The number of deaths has jumped from one or two a year over the past decade to seven deaths in 2015 and six deaths in 2016.

An RGJ investigation into the deaths found that when Smith and Purdy arrived at the jail, deputies were ill-equipped to recognize the symptoms of excited delirium due to a dearth of regular training on how to deal with inmates experiencing the syndrome.

And while at least one deputy involved in Smith's death warned the others that Smith could be experiencing excited delirium, the swarm of deputies didn't change its tactics before his heart stopped.

The very diagnosis of excited delirium is a controversial one, especially for family members who view videos of their loved ones struggling at the bottom of a pile of deputies. Lawyers in wrongful death cases argue "excited delirium" is a euphemism for police brutality and several medical associations — including the American Medical Association and the American Psychological Association — don't recognize it as a diagnosable condition.

The Washoe County Medical Examiner's Office doesn't have reliable statistics on local excited delirium deaths largely because the definition isn't always applied to those who die during a police struggle. According to news accounts, two similar deaths happened in the two decades before Smith and Purdy — one at the jail in 1996 and one in Reno police custody in 2011.

No organization tracks excited delirium deaths nationally, either. Although in-custody deaths in local jails are reported to the U.S. Bureau of Justice Statistics, the agency does not include an excited delirium category in its reports.

Law enforcement organizations that train officers on how to recognize and deal with excited delirium estimate 150 to 200 such deaths happen nationally each year.

Although it's uncommon, in 2014, the FBI advised local law enforcement agencies to "undertake a concerted effort to increase awareness among officers of (excited delirium) to include information to help identify symptoms and to establish protocols to engage the medical community."

That didn't happen at the Washoe County jail until after Purdy died.

Read more of the Death Behind Bar series

Part One: Washoe County Jail inmates are dying from suicide, accidents and homicide

Part Three: High suicide rate follows breakdown in mental health care and prevention efforts at Washoe County Jail

Part Four: Death follows Washoe County Sheriff's decision to award a $5.9 million no-bid contract to NaphCare

Neither Purdy nor Smith received medical intervention before they stopped breathing despite displaying the symptoms of excited delirium.

On Aug. 27, 2015, Smith, 31, stopped breathing as six deputies attempted to wrestle him into submission in a suicide watch cell. He had been left in a holding cell for nearly 12 hours, where he became increasingly erratic.

Six weeks later, Purdy died in a similar fashion.

The jail's response was to circulate a flier on how to recognize the symptoms of excited delirium and to notify arresting agencies that the jail would reject any inmates exhibiting those symptoms.

One year later, 35-year-old Justin Thompson's heart stopped as he fought with deputies trying to take his booking photograph. He had just returned from a trip to Renown Regional Medical Center prompted by his erratic behavior at the jail.

The medical examiner ruled his death a homicide by complications of physical restraint, noting that the death shared several characteristics of an excited delirium death but didn't quite meet all of the criteria.

According to the investigation reports obtained by the Reno Gazette-Journal, all three men exhibited the classic signs of an excited delirium episode before they stopped breathing: They were sweating profusely, acting paranoid and erratically and had enough strength to make it difficult for four to six deputies to restrain them.

Still, the fatal struggles ensued.

At autopsy, the medical examiner determined both Smith and Purdy had methamphetamine in their system — a classic precursor to an excited delirium death.

Thompson, on the other hand, had only traces of marijuana. But Thompson was bipolar and suffering from an "altered mental state" when he died — another classic precursor.

While not all medical associations recognize excited delirium as a medical syndrome, the National Association of Medical Examiners and the American College of Emergency Physicians do. They describe it as a treatable condition and have been working to train law enforcement officers and paramedics on how to deal with it.

Dr. Ellen Clark, who recently retired as Washoe County medical examiner, said some of the controversy comes from the fact that a death from excited delirium doesn't leave physical fingerprints that can be spotted by an autopsy.

"Very often in cases of excited delirium there is no anatomic cause of death identified," Clark said.

During the autopsy, the medical examiner rules out any other cause of death from a natural disease to a fatal trauma. Then, the medical examiner reviews all of the circumstances surrounding the death.

"What we do see is a combination or constellation of findings," Clark said. "Very often there is video documentation of extreme agitation, irrational and bizarre behaviors, followed by physical collapse. Sometimes that's during restraint."

What's clear is that once an individual enters the "fatal spiral" described by Clark, it is very unlikely they will survive. Even if lifesaving measures are taken within moments after an individual stops breathing, as happened with Smith and Purdy, the person almost always dies, Clark said.

As they spiral toward death, their body temperature rises to dangerous levels, damaging the brain. "Metabolic acidosis" has flooded their body with acid, damaging internal organs and interfering with breathing. Ultimately their heart stops.

People in the middle of this fatal spiral are physically unable to calm their body.

"What we believe happens is they have an adrenaline surge that is unrelenting and continuous," Clark said. "They don't recover from that, so they develop cardiac arrest."

Excited delirium references exist in medical literature as far back as the 1840s, when a psychiatrist noted psychiatric patients suddenly dying after a "profound erratic episode." The term came into more common usage in the 1980s when medical examiners noticed a spate of deaths in Florida connected to cocaine highs.

Dr. Laura Knight, Washoe County's chief medical examiner, said excited delirium deaths can happen even without police involvement, noting a case she had in which an individual high on methamphetamine "went berserk" and died alone in his motel room.

"Excited delirium is not synonymous with police restraint," Knight said. "It's really important to recognize (such deaths) can have nothing to do with police custody and restraint."

Police in other jurisdictions, however, who recognized such symptoms early enough have had success saving individuals by shifting from a law enforcement response to a medical response.

Research shows the struggle against restraints exacerbates the conditions that lead to death and the chance of survival increases if such a fight is avoided.

In addition to exhibiting classic signs of excited delirium, another similarity links the three men who died while being restrained by deputies: They were all on their stomachs when their heart stopped.

"The prone position, on the stomach, is how people die," said Andre Lagomarsino, the Las Vegas lawyer representing Purdy's family. "The jail makes them lie on their stomach and then positions four deputies on them."

Las Vegas lawyer Peter Goldstein, who was hired by Thompson's family, argued an "excited delirium" finding is a scapegoat.

"They died during the restraint process," Goldstein said. "If people are jumping on top of him, then he can't breathe and he can't move. Excited delirium has been challenged repeatedly as a bogus cause of death."

Both Reno police and Washoe County sheriff's deputies are trained not to keep restrained prisoners on their stomachs. Still, combative individuals are routinely placed on their bellies as the quickest way for authorities to gain compliance.

In Purdy's case, Washoe County Sheriff's Capt. Heidi Howe said there was no other way to get him out of his hogtie restraints than to put him on his stomach and force his legs to bend.

Smith, however, is a different case.

Deputies are trained to have inmates who may be uncooperative lie on their stomachs as they clear the cell. Smith cooperated with that request when deputies went in to move him from a holding cell to a suicide watch cell.

He allowed them to handcuff him without a fight. He walked cooperatively down the hall to the new cell.

Once in the suicide watch cell, deputies had to remove Smith's clothing and provide him with a "modesty garment" so he wouldn't "hang himself," Howe said.

"As we were trying to remove the cuffs he wanted to fight," Howe said.

The video of Smith's death does not include audio, so it's difficult to assess the entire situation. But it depicts four deputies pinning Smith to the floor immediately upon entering, despite the fact he was initially cooperative.

About four minutes in, the deputies appear to begin struggling to control Smith's legs as two deputies pin his shoulders to the ground with their knees. They drag him deeper into the cell by his arms, which are twisted into an arm-bar lock position.

Seven minutes in, the deputies decide he needs to be placed into a restraint chair where he can "safely calm down." He never makes it into the chair.

Two minutes later, the deputies appear to notice that Smith is no longer breathing. They jump off him and call for medical help. Although paramedics got his heart started again, he was declared brain dead at Renown Regional Medical Center and his family was asked to take him off of life support.

Thompson also was purposely placed on his stomach by jail deputies.

Thompson, who was bipolar and not taking his medication when he was arrested on suspicion of domestic battery, was combative from the start, according to the police report.

During his arrest, Thompson fought with Reno police officers and spit in the face of a paramedic who ultimately sedated him. Before being taken to the jail, he was checked out at Renown, where he was diagnosed with a closed head wound -- an injury that wasn't further explained in the police report.

Once at the jail, Thompson spent the next 24 hours in a holding cell where he "would rub his fist on the walls and floors, use his own blood to write/draw on the walls and climb on top of the sink/toilet and talk to cracks in the ceiling," the police report said.

Medical staff decided Thompson needed to go back to the hospital. When deputies went to handcuff him, he fought. A deputy struck him twice in the abdomen with a baton during that struggle, according to the police report.

At Renown, Thompson was treated and handed back to deputies within hours. Back at the jail, another struggle ensued. Thompson was punched twice and kicked once in the abdomen by deputies, according to the police report.

Ultimately, they wrestled him into submission, placed a spit hood over his head and strapped him face-down on a gurney to get him to his cell. Thompson stopped breathing on the cell floor while lying handcuffed on his stomach as three deputies kneeled on his legs and hips, the police report said.

Sparks police found the force used against Thompson during the struggles was justified.

Some research shows lying on your stomach is the most dangerous position for someone undergoing excited delirium. As acid builds in the body, it interferes with an individual's ability to breathe. Add pressure on the diaphragm from the floor and deputies kneeling on your shoulders and hips, and your heart can stop quickly.

"With a prone restraint, the diaphragm is inhibited and is unable to expand and allow for oxygenation," wrote Debra Robinson, a registered nurse who authored an article for the Advanced Emergency Nursing Journal in 2005. "Panic and increased oxygen demand occurs and, after a relatively short amount of time, there is cardiac and respiratory collapse."

In one study conducted in 2001, 100 percent of the people who died were on their stomachs and hogtied. Both police and paramedics are trained not to transport a prisoner or patients on their stomachs.

Other medical experts, including Knight, dispute so-called positional asphyxia.

Some police training experts also discount the dangers of initially placing a prisoner on his stomach to gain control.

David Berman, a staff instructor for the Institute for the Prevention of In-Custody Deaths, which is run by former law enforcement officers and recently conducted training in Washoe County, continues to train officers to lay a prisoner on his stomach as the most effective way of gaining control of the person.

They teach an officer to then roll the person onto their side or sit them up once handcuffed, but not because of "the alleged risks" of suffocation, Berman said. Rather, it is easier to monitor whether the person is still breathing and conscious if they are sitting.

"For somebody to put their knee on somebody and use compressional restraint in order to hold somebody on the ground is a temporary situation," Berman said.

Howe noted that officers are trained to gain control of an individual exhibiting excited delirium signs as quickly as possible. That usually takes more than one individual, she said.

In the past decade, more law enforcement and paramedic agencies have begun to focus on developing protocols for dealing with excited delirium episodes as medical emergencies, and not as criminal incidents. The training focuses on recognizing the signs, controlling the individuals and providing immediate emergency medical intervention.

Such training can be successful.

Sgt. Dan Flynn, who works for the Port of Seattle Police Department, can tell one of those success stories.

Flynn attended training as a member of the department's Special Weapons and Tactics team several years ago. He still carries a laminated card that lists the signs of excited delirium.

One afternoon in 2014, he was called to a disturbance at an airport gate. The dispatcher who was watching the passenger on a surveillance camera warned Flynn the man's behavior was unlike anything she had seen before.

"I arrived with two other officers and we just watched this guy for a second," Flynn said. "He took a stance almost like a gorilla would, kind of bent at the waist and his arms straight down. He was grunting and groaning and not making any sense. He was almost acting like an animal."

At one point, the man ran away from officers toward a pair of secured doors. He grabbed the handles, hoisted his feet onto the doors and madly began trying to open them.

"When I saw him trying to rip open those doors, my mind started going down the excited delirium route," Flynn said.

Fortunately, the man began to respond to police commands to kneel and put his hands over his head. They were able to secure him in handcuffs. But when they went to move him, he began to fight, showing extreme strength.

A third telling sign struck Flynn's attention: "Oh brother, this guy was hot and sweaty. It felt like an oven, that kind of radiant heat. I knew the person needed to go to sleep. That is the only way you are going to save these people.

"I said, 'We need the medics here now. He needs to go to sleep or he is going to die.'"

Paramedics arrived, sedated the man and took him to the hospital, where he was stabilized. The man, a veteran who had been in Seattle for post-traumatic stress disorder treatment, recovered and returned to the airport to fly home without incident, Flynn said.

Flynn and his team were recognized at an award ceremony last year for saving the man's life.

He said if they had handcuffed the man and put him in a police car, instead of calling for medical help, he likely would have died.

Flynn's advice to other officers: "If you see a person displaying behaviors that are extremely out of the ordinary, maybe they're ripping their clothes off, they're sweating profusely, start going down the excited delirium route and getting the medical people out."

Berman said he trains officers not to attempt to diagnose an individual with excited delirium, but to recognize the signs and act accordingly.

"The goal is once they are captured, controlled and restrained is to turn them over for medical treatment," Berman said. "Ideally, in a perfect situation we would have paramedics standing by with the attitude that as soon as we get this person controlled, he's your patient and if you need us we are right here."

Medical treatment can include sedation with the use of certain drugs, cooling the body and administering sodium bicarbonate to lower acid levels, he said.

Washoe County Sheriff's Capt. Peter Petzing noted that jail personnel are shifting to a medical-first intervention. That can be made difficult, however, when an inmate is acting violently and needs to be restrained.

"Now we are really looking to get them cleared, to get them healthy before we take true law enforcement action," Petzing said. "But that's not to say that from a safety standpoint we are going to forgo our safety."

Crisis intervention training — which focuses on de-escalating a situation rather than immediately resorting to force — is also key. More than 60 percent of the jail's personnel has undergone such training.

Since Purdy died, Howe, who is in charge of detention services at the jail, has begun changing the way the jail deals with individuals exhibiting excited delirium symptoms, instituted annual training, conducted a "train the trainers" course for jail personnel on excited delirium and developed a stronger partnership with REMSA.

Arrestees will be diverted to a hospital if they exhibit signs at booking. If an inmate who is already booked has a problem, jail staff will call REMSA to stand by ready to sedate.

"We're doing as much as we can as far as the training piece," Howe said. "Now if we could get the community to stop abusing drugs, that would be fantastic."

Howe said the jail does not rely on its on-site medical personnel to sedate inmates in the throes of excited delirium.

"We do some sedation with people who have mental illness, but it has to be ordered by a doctor," she said. "We have an on-call doctor and a full-time doctor, but he is not here all the time."

Sedation also carries its own risks, depending on the drug being administered.

Howe said the jail, given its limited resources, also must be careful when it diverts an inmate to a hospital for medical help. Inmates often exhibit erratic behavior during booking due to drugs, mental illness or a variety of factors that don't necessarily lead to sudden death, she said.

"We have people who have been in fights with police on the street or other individuals, they've been out in the sun, drinking all day, using drugs," Howe said. "We have people come in sweaty all the time."

"We gotta be very careful because I don't have enough staff; we can't afford to have 15 people sitting at the hospital," she said. "I'd have nobody to work."

Berman said he sympathizes with the limited resources argument but points out such deaths often end up in expensive litigation.

"It will cost you on one side or the other," Berman said. "You either pay up front and protect your staff and your arrestees and your inmates, or you pay on the back side through lawsuits."

Smith's and Purdy's family members want things to change at the jail.

Smith's older brother, Romeo Smith, is sickened by his brother's death. He acknowledged that Niko Smith "wasn't no saint," having been in and out of jail. But he loved life, loved his family and easily made friends.

Romeo Smith has been searching for answers for more than a year. When he arrived with his distraught mother at the hospital, the doctors couldn't tell them much.

"The doctor said he, when he came in here (earlier in the day), he was walking and talking and was just fine," Romeo Smith said. "He said, 'We don't know what transpired at the jail, but when he returned, he returned brain dead.'"

Romeo Smith watched the videos of his brother's struggle with deputies.

"I just didn't see no altercation," he said. "You guys just swamped my brother. You guys killed my brother."

Hutchins, Purdy's sister, had a similar reaction after watching the video of her brother's final moments.

"I hope the people are disciplined and willing to change," she said. "Something needs to happen."

Romeo Smith is troubled by his last interaction with his little brother. He was angry that Niko Smith wound up back in jail and lectured him about getting his life on track.

"I was on that boy until the end," Romeo Smith said of his efforts to keep him out of jail and off drugs. "Maybe I shouldn't have been so tough on him."

He hopes his brother's death will provoke change. He's filed a wrongful death lawsuit against the sheriff's office that is pending in federal court.

"I hope they can learn from this, that people can learn from it so other families won't have to go through this," he said. "All lives matter."