Did George Floyd Die of a Drug Overdose?
Fatal Fentanyl: A Forensic Analysis
“The centre cannot hold; Mere anarchy is loosed upon the world.”
— 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 concentration of Fentanyl of about three times the fatal dose.
- 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 because he was resisting arrest, 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 did indeed give cardiopulmonary arrest as the cause of death, and stated that injuries he sustained during the arrest were not life-threatening.
- Videos of the arrest do not show police beating or striking Floyd, only calmly 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. His ability to resist four officers trying to get him into the squad car is typical of EXD cases. A short spurt of superhuman strength is a classic EXD symptom.
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 hardly have been prevented. In all likelihood, 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 less weight to the conclusions, which are only the other fellow’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, 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.” 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.
One difficulty is that there are public statements to the effect that the coroner ruled it a homicide, and the title of the autopsy report includes the term “neck compression.” But the words “homicide,” “restraint,” “stress” or “compression” do not appear in the 20-page body of the report. References to the neck are few — a couple minor abrasions, a contusion on the shoulder, and “The cervical spinal column is palpably stable and free of hemorrhage.” It is as if the title was chosen in regard to what was expected or proposed, but which was never found, and the title was never updated. There seems to be no support at all in the report body for the report title, which reads, “Cardiopulmonary arrest complicating law enforcement subdual, restraint, and neck compression.”
The term “cause of death” does not appear. The words “death” and “fatal” only appear in this comment in the lab report: “Signs associated with fentanyl toxicity include severe respiratory depression, seizures, hypotension, coma and death. In fatalities from fentanyl, blood concentrations are variable and have been reported as low as 3 ng/mL.” Floyd’s fentanyl level was seven times higher.
If first impressions via the media fooled the coroner’s office, until they examined the body, we too can be fooled at first, but change our opinion according to the evidence.
Excited Delirium Syndrome
An additional 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, heroin or cocaine 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. We may never know whether Floyd’s agitation was caused purely from the EXD adrenaline spike, or if it was aggravated by police attempts to subdue him — but a subject defying the efforts of multiple officers to subdue him is a very common theme.
When Chauvin pulled him out of the car he fell to the ground, perhaps 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, Floyd exhibited agitation (shouting and hyperactivity, trying to move back and forth) for several minutes. There is one brief video at this point. One hears Floyd shouting very loudly, as in the agitated delirium phase — it sounds like, “My face is stoned… ah hah, ah haaa, ah please people, please, please let me stand, please, ah hah, ah haaa!”. In a few minutes this was followed by “sudden cessation of struggle, respiratory arrest and death,” shown in a later video, where he becomes exhausted, and had stopped breathing when 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 either returned the cigarettes or left quickly to avoid arrest. Loss of judgment is a symptom of the syndrome; this includes futile efforts to resist 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. Physical restraint of the subject has always been the classical procedure, to prevent the subject harming themselves or others. It has been proposed that restraint helps to forestall injury and death by conserving the subject’s energy, but most experts believe that by leading to an intense struggle, it increases the likelihood of a fatal outcome.
Since knowingly using counterfeit currency is a fairly serious offense, the Minneapolis officers were required to arrest Floyd and try to bring him in. When he violently resisted, the optimal choice could have been to let him sit against a wall and guard him while calling an ambulance. To be able to quickly switch from law enforcement mode to emergency care mode requires training in recognizing the symptoms.
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. If they had been clairvoyant clinicians, they would have called an ambulance the moment they saw him. Better training is needed. Was the police department then responsible? Might the department have given the needed training if the AMA had acknowledged the existence of the syndrome? This brings up a paradox: could police critics who deny the syndrome then bear part of the responsibility for the deaths they decry? The syndrome is being recognized by law enforcement after the fact. It needs to be recognized as it is happening.
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 one 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 news clip about a police department 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 going to die quickly from fentanyl, short of immediate intensive care. A common treatment for EXD is sedation with drugs like ketamine. The usual antidote for fentanyl is naloxone. Higher levels of fentanyl may require intravenous naloxone for 24 hours or more.
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.
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
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 due to cocaine, overdose EXD, and stress from restraint by police officers.
Tony Timpa had not only 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 Timpa 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, 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 of 8
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 of death 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.)
Anthony 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 ranges from around 0.1 mg/L to 0.6 mg/L, according to different sources 
If we add the three numbers above for cocaine and metabolytes together it comes to about 18 mg/L. This is anywhere from 3 to 18 times the lethal dose. With such an overdose, plus being without his schizophrenia medication, Timpa had little if any chance of surviving.
Here’s the Wikipedia entry on Timpa, part of a series on the Dallas police.
“Killing of Tony Timpa 
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… Criminal charges against three officers were dropped in March 2019 and officers returned to active duty.”
Wikipedia doesn’t even mention cocaine, although that was the main cause of death. Likewise, the Wikipedia article https://en.wikipedia.org/wiki/Killing_of_George_Floyd makes no mention of a drug overdose or excited delirium. By entitling the articles “Killing” rather than “Death,” Wikipedians appoint themselves as a court of law.
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.  Then they were surprised when he suddenly died.
It is strange that George Floyd’s case is taken as proof of systemic racism, when Tony Timpa got much worse treatment — even though Timpa hadn’t committed any crime, had no police record, and even called 911 himself.
Isn’t it odd, when we have a problem in the United States of many shootings by — and of — the police, that such an uproar has arisen, over a case where the police actually had little or nothing to do with the man’s demise?
The stress of restraint is most likely incidental. As reported by the WJEM, “Victims who do not immediately come to police attention are often found dead in the bathroom surrounded by wet towels and/or clothing and empty ice trays, apparently succumbing during failed attempts to rapidly cool down.” Hyperthermia or high body temperature is a classic symptom of EXD. Enormous energy is released by an uncontrolled adrenaline spike. The heat also feeds delirium, which is a familiar symptom of high fever.
Normally, it’s assumed that stress factors contribute to a heart attack, as medical examiners wrote in both the Floyd and Timpa cases. Yet the WJEM notes that “one important study found that only 18 of 214 individuals identified as having EXD died while being restrained or taken into custody.” All victims died of cardiopulmonary arrest. Drug overdose and EXD are sufficient causes for this outcome.
Both Floyd and Timpa had taken overdoses at triple the lethal level. Enough drugs to kill them three times over. Yet you can only die once… so how could the stress of restraint contribute more to their deaths? You can’t contribute to a glass that’s already full three times over. That is a little like saying that someone died because their parachute didn’t open, and the weight of their backpack also contributed to the fall. But they die from the fall once they hit the ground, whether it’s at 120 mph or 122 mph.
It’s true, that in this analogy, the extra weight makes the jumper hit the ground a little sooner. Forcibly restraining the victim can cause them to struggle and consume energy more quickly, accelerating the burnout. Giving the subject a little space and empathy could help calm them. In this case, restraint might reduce energy loss. If that delays cardiac arrest until an ambulance arrives, the patient might be saved. Victims are less likely to struggle when strapped to a gurney than when held down by police. 
We can compare Excited Delirium to an explosion or a wildfire, that rapidly consumes all the energy in the body. The police try to contain the explosion by restraining it, but can one blame the firefighter for the fire? The explosion continues until all the fuel is gone. Then life’s flame flickers out, and the drug-intoxicated body can not be resuscitated. Presumably, the blood must be circulating in order for the antidote to neutralize the fentanyl.
In conclusion, excited delirium should be treated as a medical condition, at high risk of ending quickly in sudden death. An ambulance should be called immediately. Only the minimum necessary restraint should be applied. Police and paramedics should be trained in the symptoms and handling protocols.
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 lead to unintentional cruelty by police, when they assume they are confronted by a typical case of a criminal violently resisting arrest, rather than a patient with a life-threatening intoxication.
See the link below for all the references as well as multiple hyperlinks.