Before the protests, before the violin solos and the demands for justice and the chants urging people to say his name, Elijah McClain was not a symbol, but a young man in his prime, a 23-year-old musician and massage therapist, a vegetarian and free spirit, just trying to get home.
That all ended on a warm summer night nearly a year ago. Carrying a bag of iced teas he’d bought at a convenience store, McClain was walking on Billings Street last August 24 when he was accosted by three Aurora police officers, who were responding to a report of a “suspo” — a suspicious person — wearing a ski mask. Officer Nathan Woodyard ordered McClain to stop. McClain kept walking.
“I have a right to go where I’m going,” McClain said.
“I have a right to stop you because you’re being suspicious,” Woodyard said.
Woodyard blocked his path. Officers Jason Rosenblatt and Randy Roedema flanked him. Woodyard told McClain to “stop tensing up.”
“No, let go of me,” McClain said. “No. I am an introvert. Please respect the boundaries that I am speaking. Stop. Stop. Stop. I am going home.”
“Relax, or I am going to have to change this situation,” Woodyard said.
The situation changed rapidly. Most of the horror show of the next eighteen minutes took place out of view of the officers’ body cameras, all of which were apparently dislodged as they pinned McClain against the wall of an apartment building, then took him down to the ground and cuffed him. But glimpses of what took place can be seen in the videos recorded by other officers arriving on the scene, and the audio from the dislodged cameras provides a grim soundtrack of McCain’s pleas, sobs and groans of pain.
Less than a minute into the struggle, Roedema tells the other officers that McClain tried to grab Rosenblatt’s gun. They respond with more force and a call for backup. Twice they apply a carotid control hold to his neck, designed to make a combative suspect lose consciousness. They tell McClain to “stop fighting us” and threaten to tase him; later, another officer threatens to have his dog bite McClain “if you keep messing around.” Six minutes in, with multiple officers pushing him into the ground, McClain apologizes and tries to explain that he’s struggling for air: “I can’t breathe correctly.” A couple of minutes later, McClain vomits.
Members of Aurora Fire Rescue arrive and inject McClain with ketamine, a powerful anesthetic used to sedate agitated patients. Three minutes later, a seemingly unconscious McClain is loaded onto a gurney; less than five minutes after that, he’s found to have no pulse, and medics begin resuscitation efforts in the back of an ambulance.
McClain suffered a second cardiac arrest in the hospital and never regained consciousness. Declared brain dead on August 27, he was removed from life support several days later.
When someone dies in the custody of law enforcement, the event typically triggers a death investigation by the local coroner’s office, including an autopsy to determine the cause and manner of death. Such cases tend to be medically complex and politically sensitive, a minefield of conflicting accounts, evidence that points in different directions and uncertainties that science can’t entirely resolve. But the investigation of McClain’s death by the Adams County Coroner’s Office is particularly problematic. The autopsy report, released nearly three months after McClain’s death, concludes that no conclusion at all can be reached; the report lists both the cause and the manner of death as undetermined.
Stephen Cina, the forensic pathologist who presided over the autopsy, cites a grab bag of potential factors that may have contributed to McClain’s death: his “intense physical exertion” in the encounter with the police; the carotid hold; the ketamine shot; his medical history, including asthma and a small coronary artery; possible drug use, though nothing stronger than marijuana was found in toxicology tests; and a possible bout of “excited delirium,” perhaps caused by “an undiagnosed mental illness.” Since the actual mechanism of death was elusive, Cina wrote, “I cannot determine which manner of death is most likely” — that is, whether McClain’s death should be regarded as a homicide, an accident, or a death by natural causes.
Cina’s report was released last November, late on a Friday afternoon — the preferred time frame for document dumps if you want to minimize media attention. It’s come under greater scrutiny in recent months, after protests following the May 25 in-custody death of George Floyd in Minneapolis cast a national spotlight on similar fatalities and prompted new local, state and federal probes into McClain’s death. The case raises disturbing questions about the supposedly independent, purely scientific process by which coroners determine a cause of death, and the extent to which that process can end up shielding police officers from prosecution; about whether Cina’s speculations on drug use, mental illness and excited delirium provide context or misdirection; and about the role that ketamine might have played in McClain’s death.
The case also poses potential conflict-of-interest issues for the coroner of Adams and Broomfield counties, Monica Broncucia-Jordan, who’s held the office since 2011. Many elected coroners have a close working relationship with law enforcement; some are former police officers themselves. But the ties in Adams County could be considered closer than most. Broncucia-Jordan — who assisted at McClain’s autopsy and signed off on Cina’s findings — is married to a Denver police officer who was involved in another high-profile deadly encounter with a young person of color five years ago.
“The remarkable thing about the autopsy report is how far it goes to say everything except the obvious,” says Mari Newman, the attorney representing the McClain family. “When you’ve got a perfectly healthy young man who’s walking home and is confronted by law enforcement, subjected to eighteen minutes of profound excessive force, then an injection of ketamine, then dies, it’s obviously a homicide.”
After decades of investigating violent and suspicious deaths, Carol Huser knows the gulf between what people in her profession actually do and what the public expects. A nation raised on CSI and similar television fare has become accustomed to seeing baffling crimes solved in a matter of minutes, thanks to a single scrap of DNA under the dead person’s fingernail. When it came time to write a book about her career, Huser knew what she would call it: Unreasonable Certainty.
“People don’t understand the work we do,” says Huser, who served as the coroner in Durango for ten years after working as a medical examiner in New York and Florida. “They don’t understand the science behind it or how we come up with opinions, and they expect far more certainty than it’s possible to have.”
Now retired, Huser was one of the rare Colorado coroners with the medical qualifications to perform her own autopsies. Roughly half the country operates on a medical examiner system, in which death investigations are overseen by medical professionals — typically, a forensic pathologist like Huser. But many states, including Colorado, rely on elected coroners who may have little or no medical background and must hire pathologists to conduct autopsies. In almost all of Colorado’s counties, any citizen at least eighteen years old can run for coroner, though some training is required after being elected.
The coroner establishes office policy and has considerable say over how deaths get investigated and prioritized. but it’s the forensic pathologist who must render an opinion on cause and manner of death. Yet even the most highly skilled, independent-minded pathologist can’t always provide a clear, unassailable finding of how and why someone died. It’s especially difficult to do so in what Huser calls “restraint-type deaths,” involving a struggle between the decedent and police officers. The struggle might be one cause, but there might also be a history of health problems, a smorgasbord of drugs in the decedent’s system, and other factors.
“It is pretty much never possible to cherry-pick one and say, ‘This is the cause of death,’” Huser says. “It is pretty much impossible to rank them in terms of importance. The science is not adequate, usually, to do that. It’s usually the case that you come up with a basketful of factors. If you’re honest, you just load them all in there and say, ‘Complications of this and this’ — and list a whole bunch of things.”
Some forensic pathologists talk about their profession being divided between “lumpers” and “splitters.” The lumpers tend to present the “basketful of factors” as a cumulative whole, while splitters attempt to zero in on an individual mechanism of death. The autopsy report for George Floyd released by the Hennepin County Medical Examiner’s Office is a classic lumper, noting Floyd’s history of heart disease, the fentanyl and methamphetamine in his system, even the fact that he’d tested positive for COVID-19. But the pathologist had no problem — aided, perhaps, by video of a police officer kneeling on Floyd’s neck for eight minutes — declaring that the death was a homicide, a “cardiopulmonary arrest complicating law enforcement subdual, restraint, and neck compression.”
A second autopsy arranged by Floyd’s family concluded that he died of asphyxiation. Different pathologists often interpret the same evidence differently. But Huser believes that the vast majority of restraint-type deaths should be classified as homicides — a term which, in coroner circles, doesn’t connote intent to kill or criminal culpability by the officers involved, or pass judgment on whether the degree of force used was excessive. It simply means that death occurred as a result of the actions of others.
“I don’t really care if someone is supposed to be ‘on the way out’ because of other medical issues,” Huser says. “If somebody kneels on their neck, I’m still going to stay that kneeling on the neck is the cause of death.”
With no damning eight-minute video available to point the way, the McClain death investigation took a decidedly different path. Cina’s report can be read as a master class in equivocation. The cause of death could be this, could be that. Impossible to choose. Who can say?
But not choosing is a kind of choice, too. The body-camera recordings present two competing narratives of what happened on Billings Street that night. A finding that McClain’s death was due to undetermined causes endorses one of those narratives and ignores the other.
The neglected story begins with the 911 call that summoned police to the scene in the first place. The caller reported a black male in a ski mask who was waving his arms and looking “sketchy.” But as far as the caller knew, the man had committed no crime, threatened no one and had no weapon. “He might be a good person or a bad person,” the caller said.
Even before the arrival of the pandemic, there was nothing illegal about wearing a mask or waving your arms while listening to music. Attorney Newman says the Aurora police had no legal basis to stop McClain. But Adams County District Attorney Dave Young concluded that, given the “suspo” report, the officers were justified in detaining McClain and patting him down for weapons — an encounter that quickly escalated when McClain allegedly reached for Rosenblatt’s gun.
“From the officers’ perception, it went from an investigatory stop to a potential life-threatening incident, and it certainly raised the officers’ use of force,” Young wrote, in a letter declining to file charges in the incident.
But what about McClain’s perception? One moment he’s walking down the street, the next cops are putting hands on him. Pretty soon he’s on the ground, in a chokehold that the Aurora Police Department subsequently banned from use, being told to relax. Cuffed and restrained, air squeezed out of him by the pile-on, he has little opportunity to explain himself.
“My name is Elijah McClain,” he says. “I’m just going home…I’m just different…I’m so sorry…I have no gun. I don’t do that stuff. I don’t do any fighting…forgive me…all I was trying to do was become better…Owww, that really hurts…I can’t breathe correctly.”
The officers don’t listen to him. They talk over him, fretting over where they dropped a cell phone and what’s keeping the medics. When they do speak to him, it’s to tell him to stop “fighting,” to stop shifting his body under their weight.
“He wasn’t fighting,” Newman insists. “He was handcuffed and on the ground for fifteen minutes. He was begging for his life. The only moving he’s doing is vomiting, trying to breathe.”
Cina reviewed the body-cam footage, but no mention is made in his report of McClain’s statements about his pain and not being able to breathe — or anything McClain said, for that matter. Cina seems to have assigned far greater significance to comments the officers made about how difficult McClain was to bring down.
“Whatever he’s on, he has incredible strength,” Roedema said.
“Yeah, crazy strength,” Rosenblatt agreed.
“He almost did a push-up with all three of us on his back,” Roedema said.
“The decedent was violently struggling with officers who were attempting to restrain him,” Cina wrote. “Most likely the decedent’s physical exertion contributed to death. It is unclear if the officers’ actions contributed as well.”
The officers’ claims about McClain’s “crazy strength” introduced yet another complication in Cina’s report. It raised the possibility that McClain was experiencing Excited Delirium Syndrome — a controversial diagnosis that some pathologists have embraced, but which others consider a way of deflecting blame in restraint-type deaths, demonizing the dead while absolving the officers involved.
The term “excited delirium” dates back to 1849, when physician Luther Bell attributed deaths among mental patients to a newly identified fatal disease. The disease, which became known as Bell’s mania, involved increasing agitation and confusion over a period of weeks until the patient finally died.
In current usage, though, Excited Delirium Syndrome, or EDS, has nothing to do with Bell’s mania. Rather, it’s an attempt to explain why certain people suddenly die after a struggle with law enforcement, even though there isn’t sufficient evidence of trauma or natural disease to account for the death. In a 2006 book on the subject, Vincent Di Maio, a highly respected medical examiner in Texas, contends that many deaths blamed on police chokeholds or “positional asphyxia” are actually the result of EDS.
By Di Maio’s account, an EDS death typically involves a combative suspect, resisting restraint, who has a history of stimulant abuse or mental illness. The suspect might be psychotic or high on cocaine, meth or something else; exhibiting extraordinary strength; disoriented or hallucinating; obese or otherwise in poor health, possibly with an enlarged heart or some other natural defect that makes a heart attack more likely. After a period of overheated and violent activity, the suspect collapses, suffers a cardiac event and dies.
But EDS, like Shaken Baby Syndrome, Sudden Infant Death Syndrome and other loosely defined catch-alls for mysterious deaths, has its share of detractors. Some pathologists believe the term is unnecessary for explaining the physiologic changes that occur as the result of overexertion and merely serves instead to insulate police agencies from litigation. EDS has also been denounced as junk science, most recently in an op-ed in the Washington Post by two neurology residents and a Harvard neurology instructor, who contend that the EDS “diagnosis” encourages more extreme police measures.
“The syndrome is disproportionately diagnosed among young black men,” the authors note. “It winds up being a convenient scapegoat cause of death after a violent confrontation. Or it becomes a justification for police aggression that may be unwarranted.”
Even if the EDS diagnosis might be applicable in some instances, McClain had almost none of the characteristics Di Maio uses to define the syndrome. Although family members have described him as eccentric and an “oddball” — just different, as McClain put it — he had no documented history of mental illness. He wasn’t obese, disoriented, psychotic or hallucinating. He wasn’t high on meth or cocaine.
Curiously, Cina observes at the outset of his report that McClain was hospitalized in 2016 for “LSD intoxication with hyperactive and erratic behavior.” Consequently, he “cannot rule out the presence of a psychoactive drug at very low levels,” levels too low to be detected. Newman regards the mention of a drug episode from three years earlier as an attempt to shore up the case for excited delirium — and just as gratuitous as Cina’s suggestion that McClain might have had an “undiagnosed mental illness.”
“The narrative goes out of its way to try to paint this absolutely innocent young man in a bad light,” Newman says.
Despite skepticism in the medical community of its scientific validity, the concept of excited delirium has been widely adopted by EMTs and other emergency personnel; it even has a treatment protocol. According to one PowerPoint presentation for medics, the ideal method for dealing with an agitated, super-strong, drug-addled, hallucinating EDS patient is to “go big” with an injection of yet another dissociative drug: ketamine.
First synthesized in 1962, ketamine is a structural analog of phencyclidine — also known as PCP or angel dust. It’s been used as a sedative and horse tranquilize; as a recreational, psychoactive drug; and as a battlefield anesthetic during the Vietnam War. In recent years, it’s become the go-to drug for sedating combative suspects, in part because it acts quickly but supposedly with a lesser degree of impact on breathing and heart function than other common anesthetics. In a press release issued shortly after its use on McClain, Aurora Fire Rescue described ketamine as “a standard medication routinely utilized to reduce agitation.”
How routinely? According to a recent KUNC investigation, more than a hundred health agencies in Colorado are authorized to use ketamine to treat excited delirium; EMTs and other emergency responders have administered 902 doses of ketamine across the state since 2018, including 180 in the first half of this year. Subjects like McClain, who were deemed “out of control” by police or other custodians, didn’t have any say about whether they got injected — a situation that invites a thicket of medical ethics and civil-rights debates. (“There definitely needs to be a comprehensive analysis of the weaponization of medication,” Newman says.)
In the McClain case, the restraining officers welcomed the news that the fire crew was on its way and was going to inject the suspect with ketamine. “Perfect, dude, perfect,” Roedema said. From their chatter, it’s clear that they viewed sedation as the best solution to an unfortunate chain of events; since McClain had committed no crime, he’d be taken to a hospital and released once he regained consciousness.
But several things seem to have gone wrong with the plan, starting with the amount of the dosage. A medic estimated McClain’s weight at 100 kilograms (220 pounds) and pumped 500 milligrams of ketamine into his right deltoid, based on a standard dosing formula that calls for five milligrams per kilo. But McClain weighed 140 pounds. The dose was easily 50 percent more than he should have received. As CBS4 first reported a few weeks ago, several anesthesiologists have criticized the dosage as excessive.
Cina’s autopsy report describes the amount of ketamine found in McClain’s system as being at a “therapeutic level” and adds that “the dosage administered or ingested is not as important as the resultant concentration of the drug in the blood.” But what constitutes a therapeutic dose of ketamine turns out to be not that easily distinguishable from a fatal dose. McClain’s level is far less than that of a fatal overdose case that Cina cites, but other case studies indicate that death can result from ketamine blood levels only slightly higher than McClain’s.
The medical literature on ketamine also notes that it can hike blood pressure and increase the risk of stroke or irregular heartbeat; at higher doses, vomiting and difficulty breathing are also risks. McClain was already vomiting before the medics arrived. After the injection took effect, he was moved from the ground and placed supine on a gurney in soft restraints — not on his side, which reduces the risk of inhaling vomit. Cina’s report states that it’s unclear whether McClain aspirated vomit while he was restrained — even though the autopsy found “ingested foreign material” in his right lung.
It doesn’t appear that McClain was monitored constantly after the injection, as guidelines for the anesthetic require. Instead, by the time he was examined in the ambulance, his chest “was not rising on [its] own and he did not have a pulse,” according to one medic’s account. The fact that McClain went into cardiac arrest only minutes after the injection is not, by itself, proof of causality, but several pathologists contacted by Westword say the possibility that ketamine was a major contributor to McClain’s death can’t be easily dismissed.
“We believe in strict linkage,” says Michael Arnall, a veteran forensic pathologist who’s conducted thousands of autopsies across Colorado, including a ten-year stint working for the Adams County coroner. “Here, the temporal relationship is very strong. If you inject someone with a drug, and five minutes later he’s dead, you’ve got some explaining to do.”
Death by over-sedation is a more plausible scenario than others raised in the official report. The McClain family attorney rejects the idea that McClain’s death could be attributed to natural causes, such as an asthma attack or a narrow coronary artery. “Elijah was a runner,” Newman notes. “He had been living with that artery his entire life without any problem whatsoever.”
But take a healthy young man and subject him to nearly twenty minutes of strenuous isometric exercise — a violent push-pull encounter with several large men. The ordeal will send his heart racing and probably lead to dramatic chemical changes in the body. Apply a carotid hold until he loses consciousness, restricting blood flow to the brain. Top it off with an excessive dose of an extremely powerful and cardioactive anesthetic, despite evidence that the subject is nauseous and having difficulty breathing.
Cina’s report treats these factors as if they cancel each other out. Could be this, could be that. Who can say? A former chief medical examiner in Chicago and deputy chief in Florida’s Broward County, Cina isn’t known for vacillation. But another pathologist might take a lumper’s approach, point out that this particular scenario involves a series of actions by other people — starting with the decision by three police officers to detain and subdue a man who’s insisting on his right to go home — and conclude that the manner of death is homicide.
A 2002 guide adopted by the National Association of Medical Examiners states that it’s logical to classify deaths of suspects while being subdued by police as homicides: “In such cases, there may not be intent to kill, but the death results from one or more intentional, volitional, potentially harmful acts directed at the decedent (without consent, of course). Further, there is some value to the homicide classification toward reducing the public perception that a ‘cover up’ is being perpetrated by the death investigation agency.”
Like Huser, Arnall agrees with the position that most restraint-type deaths should be considered homicides. “We don’t believe in coincidences,” he says. “We believe in physiology.”
In 2015, two Denver police officers, responding to a report of a suspicious vehicle, fired into a stolen car advancing on them and killed the driver, seventeen-year-old Jessie Hernandez. Both officers were cleared of any wrongdoing in the incident, but the case generated widespread protests, and the City of Denver eventually agreed to a million-dollar settlement with Hernandez’s family.
One of the officers involved in that shooting, Gabriel Jordan, is the husband of Adams County coroner Monica Broncucia-Jordan. It’s a small world, the world of pathologists and coroners and the cops and lawyers they work with. Years ago, Broncucia-Jordan and current Boulder coroner Emma Hall both worked for Broncucia-Jordan’s predecessor in Adams County, James Hibbard, a former deputy sheriff. They were among the plaintiffs in a sexual-harassment lawsuit against Hibbard that was settled for $1.6 million. The law firm that represented them in that civil action, Killmer, Lane & Newman, is the same firm that is now representing the family of Elijah McClain.
For critics of the official investigation of McClain’s death, the coroner’s personal relationship with a police officer who was involved in another high-profile fatality raises the specter of bias — or, at the very least, the appearance of a conflict of interest. In rare instances, coroners or the pathologists who work for them have recused themselves from death investigations when they have some professional or personal connection to parties involved. Whether the Adams County coroner considered recusal in the McClain investigation is unknown; Broncucia-Jordan declined requests to interview her and Cina.
“I look forward to having the opportunity to discuss this case in the future,” Broncucia-Jordan said in an email to Westword. “However, it would be inappropriate to do so at present due to the ongoing investigations.”
One alternative to recusal is to invite an outside pathologist to render a second opinion on cause and manner of death — a useful strategy when there might be questions about the lead agency’s impartiality. That seldom happens, but last year Broncucia-Jordan took that step in the death of Kate Petrocco, the daughter of a former district court judge, who’d been involved in an acrimonious divorce with a prominent Adams County business executive and a romantic relationship with District Attorney Dave Young. Cina’s autopsy report concluded that Petrocco had committed suicide, and an additional review by James Caruso, Denver’s chief medical examiner, concurred with that finding.
But no second expert opinion was sought in McClain’s death. Instead, Cina’s autopsy was conducted with two members of the Aurora Police Department and two reps from the district attorney’s office in attendance. Law enforcement agencies investigating a death frequently sit in on autopsies, but Newman questions the presence of Aurora officers in this instance. “The autopsy is tainted by the fact that representatives of the very department that killed him were there, influencing the findings,” she says.
Cina’s conclusion that the cause of death couldn’t be determined squelched any prospect of charges being filed.
District Attorney Young has stated that he was inclined to believe that the ketamine shot was responsible for McClain’s death — until he read the autopsy report. But now Colorado Attorney General Phil Weiser is reviewing Young’s investigation, with an eye toward possible criminal charges that might be filed in McClain’s death. The FBI and Justice Department are probing possible civil-rights violations. Aurora’s city council is in the process of assembling a panel of outside experts to examine the police department’s policies and practices for stops and arrests and the use of ketamine by Aurora Fire; the Colorado Department of Public Health and Environment is also looking more closely at how and why ketamine was administered that night.
So far, none of these inquiries are directed at a re-evaluation of the autopsy report’s findings. Yet without a more definite ruling on cause and manner of death, it’s difficult to see how any of the fresh investigations now under way could lead to any prosecution.
Reaching a different ending involves revisiting what happened that night, in all its confusion and strife. If there is a single turning point in the painful last minutes of Elijah McClain, it comes scarcely thirty seconds into the confrontation, when the officers are dragging him to the wall. McClain flares up, refuses to acquiesce to the manhandling.
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“I intend to take my power back,” he says.
He struggles, but it’s no use. There are more of them than there are of him, all acting together. It’s right after McClain’s remark about taking his power back that Roedema tells Rosenblatt, “He just grabbed your gun, dude!” — and the “subdual force” escalates dramatically. (From subsequent comments on the audio by Rosenblatt, it appears that he didn’t see or detect any grab for his holstered gun.)
McClain never got to take his power back. The protests in his name seek to do that for him. They are a direct challenge to the official story of how he died, a story that offers no path to accountability, no sense of right or wrong. Might be a good person or a bad person, might be a natural death or an accident or homicide. Who can tell?
Not all stories end so badly. Shortly before he was taken up to heaven in a flaming chariot, the prophet Elijah sought shelter in a cave from the people trying to kill him. A powerful wind came, then an earthquake, then fire, and God wasn’t in any of them. But after the fire came a still, small voice, telling the prophet how to take his power back.