THE HEALTH EFFECTS OF

CONDUCTED
ENERGY
WEAPONS

The Expert Panel on the Medical
and Physiological Impacts of
Conducted Energy Weapons

THE HEALTH EFFECTS OF CONDUCTED ENERGY WEAPONS
The Expert Panel on the Medical and Physiological Impacts of Conducted Energy Weapons

The Health Effects of Conducted Energy Weapons

ii

the Council of Canadian Academies & the Canadian Academy of Health Sciences
180 Elgin Street, Ottawa, ON Canada  K2P 2K3
Notice: The project that is the subject of this report was undertaken with the approval of the Board of Governors of the Council
of Canadian Academies and the Board of the Canadian Academy of Health Sciences under the guidance of a Joint Scientific Advisory
Committee. The members of the expert panel responsible for the report were selected for their special competences and with regard
for appropriate balance. This report was prepared in response to a request from Defence Research and Development Canada. Any
opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors, the Expert Panel on the
Medical and Physiological Impacts of Conducted Energy Weapons, and do not necessarily represent the views of their organizations
of affiliation or employment.

Library and Archives Canada Cataloguing in Publication
The health effects of conducted energy weapons / The Expert Panel on the Medical and Physiological Impacts of Conducted Energy Weapons.
Issued also in French under title: Effets sur la santé de l’utilisation des armes à impulsions.
Includes bibliographical references and index.
Electronic monograph in PDF format.
Issued also in print format.
ISBN 978-1-926558-64-6 (pdf)
1. Stun guns–Health aspects. 2. Nonlethal weapons–Health aspects.
I. Council of Canadian Academies. Expert Panel on the Medical and Physiological Impacts of Conducted Energy Weapons, author
HV7936.E7H43 2013a	

363.2’32	

C2013-905595-9

This report should be cited as: Council of Canadian Academies and Canadian Academy of Health Sciences, 2013. The Health Effects of
Conducted Energy Weapons. Ottawa (ON): The Expert Panel on the Medical and Physiological Impacts of Conducted Energy Weapons.
Council of Canadian Academies and Canadian Academy of Health Sciences.
Disclaimer: The internet data and information referenced in this report were correct, to the best of the Council’s knowledge, at the
time of publication. Due to the dynamic nature of the internet, resources that are free and publicly available may subsequently require
a fee or restrict access, and the location of items may change as menus and webpages are reorganized.
© 2013 Council of Canadian Academies
Printed in Ottawa, Canada

This assessment was made possible with
the support of the Government of Canada.

iii

The Council of Canadian Academies

The Canadian Academy of Health Sciences

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www.cahs-acss.ca

iv

The Health Effects of Conducted Energy Weapons

The Expert Panel on the Medical and Physiological Impacts of Conducted
Energy Weapons
The Honourable Justice Stephen T. Goudge (Chair),
Court of Appeal for Ontario (Toronto, ON)
Mark Bisby, Independent Consultant; Advisor, Canadian
Foundation for Healthcare Improvement and Brain Canada
(Ottawa, ON)
James Brophy, Professor, Departments of Medicine,
Epidemiology, and Biostatistics, McGill University; Staff
Physician, Cardiology Division, McGill University Health
Centre (MUHC) (Montréal, QC)
George Carruthers, FCAHS, Retired; former Professor and
Chair of Medicine, Dalhousie University; former Professor,
Departments of Medicine and Pharmacology and Toxicology,
London Health Sciences Centre and Western University;
former Dean of Medicine, United Arab Emirates University
(Lisburn, United Kingdom)
Igor R. Efimov, Lucy and Stanley Lopata Distinguished
Professor of Biomedical Engineering, Washington University
in St. Louis; Professor of Radiology, Medicine (Cardiology),
and Cell Biology and Physiology, Washington University
School of Medicine in St. Louis (St. Louis, MO)
Derek V. Exner, FRSC, Cardiologist, Heart Rhythm
Specialist, and Professor, University of Calgary; Canada
Research Chair in Cardiovascular Clinical Trials, Medical
Director of Cardiac Pacing and Electrophysiology, Libin
Cardiovascular Institute of Alberta (Calgary, AB)
Robert Gordon, Professor and Director of the School of
Criminology, Simon Fraser University (Vancouver, BC)
Christine Hall, FRCPC, Clinical Assistant Professor,
Department of Emergency Medicine, Faculty of Medicine,
University of British Columbia; Emergency Room Physician,
Vancouver Island Health Authority (Victoria, BC)

Stan Kutcher, FCAHS, Professor, Department of Psychiatry,
Dalhousie University; Staff Psychiatrist and Sun Life Financial
Chair in Adolescent Mental Health, IWK Health Centre;
Director, WHO Collaborating Centre (Halifax, NS)
Bruce McManus, FRSC, FCAHS, Professor, Department of
Pathology and Laboratory Medicine, University of British
Columbia; Co-Director, Institute for Heart + Lung Health;
Director, UBC James Hogg Research Centre; Director,
NCE CECR Centre of Excellence for Prevention of Organ
Failure, St. Paul’s Hospital, University of British Columbia
(Vancouver, BC)
Jason Payne-James, Honorary Senior Lecturer at Cameron
Forensic Medical Sciences, Barts and the London School
of Medicine and Dentistry, University of London; Director,
Forensic Healthcare Services Ltd and Payne-James Ltd;
External Consultant, National Policing Improvement
Agency and to the National Injuries Database (Essex,
United Kingdom)
Susan Sherwin, FRSC, FCAHS, Research Professor Emerita,
Department of Philosophy and Department of Gender
and Women’s Studies, Dalhousie University (Halifax, NS)
Christian Sloane, Associate Clinical Professor, Department
of Emergency Medicine, University of California (San
Diego, CA)
Mario Talajic, Chair, Department of Medicine, Université
de Montréal; Director, Cardiovascular Genetics Centre,
Montreal Heart Institute (Montréal, QC) 

v

Letter from the Chair
Although relatively new to modern policing, conducted
energy weapons (CEWs) have become widespread tools
used by law enforcement and public safety personnel in all
jurisdictions across Canada. Because of this widespread use
and current scrutiny in both scientific and public spheres,
all Canadians have a vested interest in determining what is
known and not known about the physiological and health
effects associated with CEW use.
The Expert Panel on the Medical and Physiological Impacts
of Conducted Energy Weapons is deeply appreciative of
the opportunity to explore this important question and
for the input and assistance it received throughout the
course of its work.
Several individuals and organizations provided very helpful
advice and assistance early in the process. In particular,
Len Goodman, Head (acting), Individual Behaviour and
Performance Section, Defence Research and Development
Canada-Toronto, and Donna Wood, Project Manager,
Conducted Energy Weapons Strategic Initiative (CEWSI),
Defence Research and Development Canada-Centre for
Security Science, provided excellent background on the
work of the CEWSI more broadly and guidance related to
the scoping of the assessment questions. Sergeants Steven

De Ville and Greg Borger of the Ottawa Police Service in
Ontario also generously provided their time and experience
to guide the Panel through a hands-on demonstration of
CEW devices and their uses in policing use-of-force models.
The Panel also wishes to acknowledge the staff of the Quality
Engineering Test Establishment research facilities of National
Defence and the Canadian Forces, who were very helpful
in providing a tour of their research testing facilities in the
initial stages of the assessment and instrumental in providing
testing data related to their work with CEWs for use in the
report. The Panel also appreciates the reconnaissance work
of Public Safety Canada and its important consultation
activities into the use of CEWs in Canada.
Finally, the Panel is most grateful for the outstanding support
it received from the staff members of the Council of Canadian
Academies, whose names are listed below.

The Honourable Justice Stephen T. Goudge
Chair, Expert Panel on the Medical and Physiological Impacts
of Conducted Energy Weapons 

Project Staff of the Council of Canadian Academies
Assessment team:	

Andrew Taylor, Program Director
Jennifer Bassett, Researcher
Kori St. Cyr, Research Associate
Weronika Zych, Program Coordinator

With assistance from:	 Marcius Extavour, Research Consultant
Clare Walker, Editor
Deborah Holmes, Copyeditor, Talk Science to Me
Marcel Gagnon, Certified Translator, English to French
Accurate Communications, Report Design and Production

vi

The Health Effects of Conducted Energy Weapons

Report Review
This report was reviewed in draft form by the individuals
listed below — a group of reviewers selected by the Council
of Canadian Academies and the Canadian Academy
of Health Sciences (CAHS) for their diverse perspectives,
areas of expertise, and broad representation of academic,
industrial, policy, and non-governmental organizations.
The reviewers assessed the objectivity and quality
of the report. Their submissions — which remain
confidential — were considered in full by the Panel, and
many of their suggestions were incorporated into the report.
They were not asked to endorse the conclusions nor did
they see the final draft of the report before its release.
Responsibility for the final content of this report rests entirely
with the Expert Panel on the Medical and Physiological
Impacts of Conducted Energy Weapons, the Council,
and CAHS.
The Council and CAHS wish to thank the following individuals
for their review of this report:
Geoffrey P. Alpert, Professor of Criminology, University
of South Carolina (Columbia, SC)
Matthew J. Bowes, Chief Medical Examiner, Nova Scotia
Medical Examiner Service (Halifax, NS)
Aileen Brunet, Clinical Director, East Coast Forensic
Hospital (Dartmouth, NS)
Paul Dorian, Professor of Medicine, Cardiology, University
of Toronto (Toronto, ON)
John Kleinig, Professor of Philosophy and Criminal
Justice, John Jay College of Criminal Justice, City
University of New York (New York, NY)
Bryan Kolb, FRSC, Professor of Neuroscience, University
of Lethbridge (Lethbridge, AB)
L. Joshua Leon, Dean of Engineering, Dalhousie University
(Halifax, NS)

J. Patrick Reilly, Principal Staff Engineer, Johns Hopkins
University Applied Physics Laboratory; President, Metatec
Associates (Silver Spring, MD)
Robert D. Sheridan, Principal Scientist, Defence
Science and Technology Laboratory (Porton Down,
United Kingdom)
Arthur R. Slutsky, FCAHS, Vice President of Research,
St. Michael’s Hospital; University of Toronto (Toronto, ON)
Eldon R. Smith, O.C., FCAHS, Professor Emeritus,
University of Calgary (Calgary, AB)
Anthony Tang, Electrophysiologist, Medical Director of
the British Columbia Electrophysiology Program, Royal
Jubilee Hospital (Victoria, BC)
The report review procedure was monitored on behalf of
the Boards of the Council and CAHS and the Joint Scientific
Advisory Committee by Dr. Jean Gray, C.M., FCAHS, Professor
of Medicine (Emeritus), Dalhousie University. The role
of the Report Review Monitor is to ensure that the Panel
gives full and fair consideration to the submissions of the
report reviewers. The Boards of the Council and CAHS
authorize public release of an expert panel report only
after the Report Review Monitor confirms that the report
review requirements have been satisfied. The Council and
CAHS thank Dr. Jean Gray for her diligent contribution as
Report Review Monitor.

Elizabeth Dowdeswell, O.C., President and CEO
Council of Canadian Academies

Tom Marrie, FCAHS, President
Canadian Academy of Health Sciences

vii

Executive Summary
Conducted energy weapons (CEWs) are devices that
use electrical energy to induce pain or to immobilize or
incapacitate a person. The broad use-of-force continuum
used by law enforcement and public safety personnel ranges
from the physical presence of an officer through to use
of deadly force. CEWs are one of several options on this
continuum. They are typically used to facilitate arrests of
uncooperative individuals who are resisting. The induced
loss of voluntary muscle control causes subjects to fall
to the ground, where they may be subdued and taken into
custody. Subjects are not meant to experience any lasting
effects after application of the device.
CEWs are used by law enforcement agencies around the
world. They were first adopted by some Canadian law
enforcement agencies in the late 1990s. Currently, there
are approximately 9,174 CEWs in use in Canada and
although the number varies based on jurisdiction, all federal,
provincial, and territorial jurisdictions use the device in some
capacity. Decision-making about the protocols for selecting,
acquiring, and using CEWs is undertaken by local agencies
and varies across geographies. The decision to deploy a CEW
resides not only at the institutional and management levels,
but also in the field and in the moment. In any policing
scenario, the officer on the scene decides whether and
how to use force by following protocol, weighing options
and outcomes, and estimating risk within the limitations
of information available in real time.
CEWs are intended to be safe and potentially injury-reducing
compared to alternative interventions, but they are not
necessarily risk free. Scientific research and public forums
have discussed and debated the potential risk, harm, and
appropriateness of CEWs as a use-of-force option. Based on
media reports and documented inquest processes alone,
to date at least 33 deaths have been proximal to CEW
use in Canada, but were not necessarily results of CEW
deployment. There is no synthesized body of evidence
documenting the number of deaths related to all other
use-of-force encounters to confirm or compare with this
number. Given current scrutiny, a scientific consensus on
what is known and not known about the physiological and
health effects associated with CEW use is essential.

In 2010, the Centre for Security Science at Defence Research
and Development Canada (DRDC) began undertaking the
Conducted Energy Weapons Strategic Initiative (CEWSI),
in partnership with the Director General for Policing Policy
at Public Safety Canada. One of the CEWSI objectives was to
convene a panel of medical experts to conduct an independent
evaluation of existing research aimed at examining the medical
and physiological impacts of CEWs. To fulfill this objective,
DRDC (the Sponsor) asked the Canadian Academy of Health
Sciences (CAHS) to conduct an independent, evidence-based
assessment of the state of knowledge in this area. CAHS
established a partnership with the Council of Canadian
Academies (the Council). Working collaboratively with
CAHS, the Council acted as the secretariat for the sciencebased exploration of the evidence.
The Council and CAHS were asked to answer the
following three main questions:
1.	 What is the current state of scientific knowledge
about the medical and physiological impacts of
conducted energy weapons?
2.	 What gaps exist in the current knowledge about
these impacts?
3.	 What research is required to close these gaps?
To address the charge, the Council and CAHS assembled
a 14-member multidisciplinary panel of experts from
Canada and abroad (the Panel). This report is based on the
consensus reached by Panel members through their review
and deliberation of the evidence: major evidence syntheses,
reviews, and books; peer-reviewed primary research; other
relevant literature on broad topics such as research ethics,
electrophysiology, and electrical engineering; technical
documents outlining testing results established by DRDC;
and a hands-on demonstration of CEW deployment during
a site visit to the Quality Engineering Test Establishment
(QETE) research facilities of the Department of National
Defence Canada and the Canadian Forces.
The Findings

The Panel identified five key findings that serve to answer the
charge put forward by DRDC. The following is a description
of those findings; a more detailed discussion is contained
in the Panel’s full report.

viii

1.	 CEWs are based on the principle that the electrical
discharges delivered by the device are powerful enough
to effectively stimulate motor and sensory nerves,
causing incapacitation and pain, but too brief to
directly stimulate other electrically excitable tissues.
Because the electrical characteristics of CEW devices
are variable and evolving, each CEW device must be
tested on its own merit to assess performance as well
as the ability to induce incapacitation and potential
adverse health effects.
CEWs deliver short, repeated pulses of electricity to the
skin and subcutaneous tissues through two metal probes.
They can be used in two operating modes: probe mode
and drive stun mode. In probe mode, a pair of metal darts
deploys from the CEW, spreads apart, and penetrates and
attaches to the subject’s clothing, skin, and soft tissues. The
darts are connected to thin electrical wires that conduct
the electrical discharge from the device. If the two darts
are spaced widely enough across the body, the resulting
effect is incapacitation. In drive stun mode, the device
is pressed directly against the subject, causing localized
pain. Probe mode is more likely to result in current flow
through the tissues in the chest — including, potentially,
the heart — and carries the most risk of unwanted cardiac
or other health effects.
In addition to causing pain, CEWs influence the peripheral
nervous system in a way that causes temporary, involuntary,
and uncoordinated skeletal muscle contractions. Along with
factors specific to the individual and context, the response
of the human body to a CEW depends on the strength,
duration, and waveform of the electrical discharge, as well
as on the timing of the applied electrical current in relation
to the natural electrical activity occurring in the body. The
ability of CEWs to stimulate some tissues (e.g., nerve cells)
and not others (e.g., heart cells) is dependent on these
characteristics. Nerve cells have waveforms that are much
shorter than those produced by the heart muscle. The
duration of electrical stimulation required to exceed the
threshold in a cardiac muscle cell is about 10 to 100 times
longer than in a motor or sensory nerve cell. Therefore,
the principle guiding the functioning of CEWs is that the
short-duration electrical discharges it delivers are highly
effective in stimulating nerves, causing incapacitation and
pain, but are much less effective in stimulating the heart
muscle and thereby inducing potentially fatal disruptions
to the heart’s rhythm and pumping ability. Specifications
between CEW devices are variable, however, and may

The Health Effects of Conducted Energy Weapons

change with use and under different conditions. CEW
devices and the variations between them are also constantly
evolving, so knowledge based on any particular model
does not necessarily translate to other devices, and the
characteristics of newer devices are unknown. Evaluating
the intended and unintended effects of a CEW requires
testing each device on its own merit and understanding
the context and conditions under which it is used.
2.	 Certain physical injuries such as superficial puncture
wounds are common as a result of CEW discharge, but
rarely pose serious medical risks. Although it is difficult
to state any firm conclusions on the neuroendocrine,
respiratory, and cardiac effects of CEWs due to an
absence of high-quality evidence, available studies
suggest that while fatal complications are biologically
plausible, they would be extremely rare.
The Panel identified a range of CEW-induced physical
injuries. Superficial physical injuries resulting from CEW
probes are common, while more severe injuries resulting
from CEW probes, muscle contractions, and falls associated
with incapacitation occur much less frequently. The Panel
concentrated on acute, short-term physiological and health
effects resulting from the electrical current of CEW devices
and having the most potential for sudden unexpected
death. Because sudden unexpected death is likely the end
result of a variety of intersecting factors that involve the
neuroendocrine, respiratory, and cardiovascular systems,
the Panel focused on physiological changes in these
systems, including activation of the human stress response
and build-up of related levels of stress hormones such as
catecholamines; mechanical impairment of breathing,
changes in blood chemistry, and resulting acidosis; and
changes to heart rhythm and rate and the potential for
arrhythmias. The Panel also examined a range of co-factors
that individually, or in combination, could increase the risk
or severity of these effects and increase the risk of sudden
unexpected death. From the Panel’s review of the available
literature, the majority of which focus on cardiac effects,
several findings emerged:
•	 Although limited studies suggest CEW exposure can
induce the stress response and increase hormone levels,
these increases are of uncertain clinical relevance. It is
also unclear to what extent the discharge of a CEW adds
to the high level of stress already being experienced by
an individual in an arrest scenario.

Executive Summary

•	 Studies of animals subjected to prolonged or repeated
CEW exposure indicate the potential for respiratory
complications (e.g., pronounced acidosis). Although
published experimental data identify respiratory changes
in healthy human subjects typical of vigorous physical
exertion, studies involving more heterogeneous groups
or humans subjected to prolonged or repeated exposure
have not been conducted.
•	 Some animal studies suggest CEWs can induce fatal
cardiac arrhythmias (abnormal heart rhythm) when a
number of discharge characteristics, either alone or in
combination, are in place: probe placement on opposite
sides of the heart (i.e., current is delivered across the
heart), probes embedded deeply near the heart, increased
charge, prolonged discharges, or repeated discharges.
These studies indicate the biological plausibility of adverse
health outcomes following CEW exposure.
•	 A small number of human cases have found a temporal
relationship between CEWs and fatal cardiac arrhythmias,
but available evidence does not allow for confirmation or
exclusion of a causal link. If a causal link does exist, the
likelihood of a fatal cardiac arrhythmia occurring would
be low, but further evidence is required to confirm the
presence and magnitude of any risk.
•	 The roles of co-factors common to real-world CEW
incidents (e.g., intoxication, exertion, restraint) and other
co-factors (e.g., body type, existing health complications)
that may increase susceptibility to adverse effects have
not been adequately tested to properly establish an
understanding of increased vulnerability in humans.
These conclusions are limited by a number of challenges
presented by the available laboratory-based experimental
research studies, including translation of findings from
computer and animal model studies to humans, human
studies with mainly healthy subjects who do not represent
the varying populations involved in CEW events, the absence
of adequate control groups, lack of diverse and robust
experimental designs and monitoring, and small sample
sizes. Large-scale population-based studies that better
capture the complexity of real-world CEW deployment
scenarios, along with a range of potential co-factors,
are lacking.

ix

3.	 Sudden in-custody death resulting from a use-of-force
event typically involves a complicated scenario that
includes multiple factors, all of which can potentially
contribute to a sudden unexpected death. This makes
it difficult to isolate the contribution of any single
factor. Although the electrical characteristics of CEWs
can potentially contribute to sudden in-custody death,
given the limited evidence, CEW exposure cannot be
confirmed or excluded as the primary cause of a fatality
in most real-world settings.
Sudden in-custody death refers to rapid, unexpected death
during detention of individuals by law enforcement or public
safety personnel. These fatalities typically occur during
a complicated scenario, which may include agitation,
physical or chemical restraint, disorientation, stress or
exertion, pre-existing health conditions, and the use of
drugs or alcohol, all of which can potentially contribute to
the death. This makes it difficult to isolate the contribution
of any single factor. Although evidence shows the electrical
characteristics of CEWs can potentially contribute to
sudden in-custody death, no evidence of a clear causal
relationship has been demonstrated by large-scale
prospective studies. In a few coroner reports, however,
CEWs were ruled as the primary cause of death in the
absence of other factors when excessive exposure was
present. Conversely, it has been argued that CEWs could
potentially play protective roles in terminating situations
that might otherwise culminate in sudden in-custody
death. Given the limitations and scarcity of the evidence,
a clear causal relationship between CEW use and sudden
in-custody death cannot be confirmed or excluded at
this time. In addition, there is insufficient evidence to
determine whether the use of CEWs increases or decreases
the probability of sudden in-custody death in the presence
of co-factors such as mental illness or excited delirium
syndrome (a highly controversial classification denoting a
state characterized by signs and symptoms such as agitation,
elevated body temperature, disorientation, and aggression).
If a causal relationship does exist, the likelihood that a
CEW will be the sole cause of a sudden in-custody death
is low. The extent to which the device would play a role
in any death is unclear and dependent on the co-factors
involved. Further research is needed to better define
these relationships.

x

4.	 There are a number of overarching challenges in funding,
conducting, and interpreting CEW research, which create
knowledge gaps related to the health effects of CEWs
across varying populations and across the operational
settings in which CEWs are deployed.
CEWs have been studied in the laboratory, with computer
or animal models and human subjects, and in the field, with
real-world incidents. Animal models allow for more intensive
experimental interventions, which can clarify the various
parameters required to predictably achieve physiological
and health effects following CEW exposure. Despite the
potential advantages of these studies, their applicability and
generalizability to real-world CEW exposures is unclear. The
Panel concluded that prospective large-scale populationbased field studies involving detailed and consistent
collection of information on the characteristics of the
subjects and the events surrounding CEW incidents are
essential for improving the quality of evidence. However,
low injury rates and lack of standardization, among other
challenges, make it difficult to establish meaningful
associations. Because of the challenges present in the
current evidence, the Panel concluded that key issues have
not been fully explored across varying populations or in the
operational settings in which CEWs are actually deployed,
thus pointing to several priorities for future research:
•	 To what extent can the electrical characteristics of CEWs
cause cardiac arrhythmia and sudden in-custody death in
humans when deployed in real-world operational settings?
•	 Are certain groups or individuals with particular
conditions at increased risk for adverse outcomes related
to CEWs, and if so, what are the key co-factors?
•	 What CEW design and deployment features could
minimize the risk of adverse health effects?
The Panel further identified five overarching gaps in
health-related CEW knowledge:
Establishment of causal relationships – Establishing causality
is not a simple task. While some research indicates an
association between CEW exposure and certain health
effects, other research does not, and in many cases there
is simply not enough research to make any definitive
conclusions. The effects of confounding factors may provide
a number of possible explanations for those relationships,
or the lack thereof. Thus, the Panel considered it difficult
to establish the extent to which CEW exposure could act

The Health Effects of Conducted Energy Weapons

as the primary cause of severe adverse health effects in realworld settings, largely due to the challenge of weighting
the contribution of multiple factors.
Establishment of time necessary for probability – There are
no guidelines to specify the length of time needed
between CEW discharge and the development of
a health effect that would allow one to conclude the CEW was
responsible for that effect. It may be beneficial to consider
a continuum where, as the time of a health effect
moves farther away from the time of deployment, the
probability that a CEW was directly responsible for that
event diminishes.
Understanding of varying populations – Laboratorybased experimental CEW research on human subjects
typically involves healthy, physically fit volunteers. There
is therefore a paucity of knowledge of the health effects
associated with CEW use outside controlled settings and
within varying, potentially vulnerable populations. Largescale population-based field studies involving detailed and
consistent collection of information on the characteristics
of the subjects and the events surrounding CEW use hold
promise for addressing ethical constraints and identifying
health effects across a range of populations.
Lack of standardization – The ability to carry out adequate
surveillance and population-based study is hindered by
lack of standardization and inconsistent reporting and
record-keeping practices related to use-of-force events.
There are few central registries with standardized recording
of CEW incidents by both law enforcement and medical
personnel. The lack of standardization hinders the ability
to conduct population-based studies and to form evidencebased conclusions about the relationship between CEW
use and adverse health effects.
Transparency and independence of research – Many
research studies of CEWs appear to be affiliated with, or
receive support from, CEW manufacturers or individuals
with perceived conflicts of interest (e.g., paid medical
experts), and funding sources are not always transparent.
Although these studies may be scientifically robust, there is
a perceived conflict of interest that limits their widespread
acceptance. Independent research by organizations without
financial or other ties to CEW manufacturers or others
with perceived conflicts is desirable.

Executive Summary

5.	 Filling gaps in the state of evidence on the physiological
and health effects of CEWs can best be achieved through
a series of integrated strategies that focus on better
surveillance, monitoring, reporting, and populationbased epidemiological studies.
The Panel was challenged with identifying research activities
and mechanisms that might address the knowledge gaps
related to the physiological and health effects of CEW use.
The Panel determined the need for a series of integrated
strategies underpinned by surveillance, monitoring,
reporting, and population-based epidemiological study.
The following considerations could form the basis of this
integrated response:
Standardizing and centralizing the recording of CEW
incidents – Establishing common definitions of use-of-force
and CEW use, and implementing a standard method of
reporting to enable police and medical personnel to record
a minimum level of information, would make it possible to
compare various parameters at the population level. This
process would be supported by the creation of a central
repository for information about use-of-force in Canada.
Enabling comprehensive medical assessment following
CEW exposure – When subjects are brought to hospitals
following CEW incidents, health care professionals would
benefit from guidance on relevant co-factors and specific
physiological changes and injuries to assess for proper
patient care. With this knowledge, health care professionals
could more routinely perform medical examinations
relevant for evaluating CEW effects. Innovative technologies
could also be integrated into CEW devices to allow for
the instant and automatic recording of health and
circumstantial information.
Improving access to, and sharing and integration of,
knowledge across fields – Researchers could benefit
from improved access to law enforcement and medical
records, based on what is ethically and reasonably possible.
Respecting privacy concerns, a process could be established
to anonymously share and link this information across
disciplines, institutions, and jurisdictions. Improved access
and linking of information could encourage investigation of
a range of relevant phenomena and increase the number of
high-quality publications that examine various associations.

xi

Supporting large-scale, multi-site, population-based studies –
Our body of knowledge would benefit from robust multinational, prospective population-based studies in which a
broad range of health care professionals are trained in the
nature and breadth of CEW injury and conduct consistent,
comprehensive, and detailed medical examinations of
individuals exposed to CEWs. To enable scientific analysis
and reliable comparisons across events, research protocols
would benefit from dynamic evidence-gathering methods
allowing for the capturing of any unforeseen events (and
their characteristics) that may arise during data collection.
Improving understanding of CEW risk relative to other
use-of-force interventions – CEWs exist alongside (and
can be used in conjunction with) many other possible
interventions. To assess the risk of CEWs in relation to other
interventions, future studies should consider comparing
sudden in-custody deaths both related and unrelated
to CEW incidents. Future studies would benefit from
exploring the risks of not using a CEW in a given situation
and accounting for jurisdiction and context, the use-offorce techniques and protocols in place, and the related
adverse health effects that include morbidity, its severity,
and mortality.
Understanding specifications of CEWs manufactured by a
range of companies – By studying and comparing a broad
range of devices, researchers could better understand
how distinct outputs (e.g., waveform specifications and
deployment modes) from CEWs are associated with
physiological effects that vary in type and severity. Properly
defining and articulating testing protocols for CEW devices
would impose standard methods for assessing device
performance over time. Enhancing knowledge in this
area would help establish more robust information around
safety parameters and technical specifications.
Furthering ethical, laboratory-based CEW research – Future
computer modelling and animal studies would benefit from
the application of novel approaches and larger sample sizes
with proper comparison and control groups. Human studies
would benefit from mimicking certain characteristics typical
of subjects in the field (with appropriate ethical and safety
constraints in mind), using more heterogeneous and larger
study samples, and exploring extrapolation techniques.

xii

The Health Effects of Conducted Energy Weapons

Conclusi on

The conclusions reached by the Panel are based on its
interpretation of the best available evidence provided
throughout the report. The Panel recognizes there are
gaps in the literature and undoubtedly this poses challenges
when assessing the physiological and health effects of
these devices. Currently, there are numerous chances to
rethink how we assess and communicate the health effects
of CEWs and of use-of-force interventions more broadly.
Opportunities exist for redesigning and improving research
methodologies, standardizing the collection of information,
and developing partnerships across disciplines, jurisdictions,
and professional practices.
The Panel’s report is intended to provide an in-depth
and authoritative assessment of the state of knowledge
regarding the relationship between CEW use and a range
of health effects. In addition, the Panel acknowledges that
there are a number of factors that go into decision-making
related to CEWs that lie beyond the assessment of health

effects; these factors must also be considered in any largescale assessment of CEW use. This report must therefore
complement other work on testing and approval procedures,
motivations and protocols for appropriate use, safety and
effectiveness standards, appropriateness of the devices
compared to other use-of-force interventions, and other
socio-political considerations that make up the broader
package of information needed to make sound decisions
about public health, policing, and CEW use in Canada.
This assessment presents an opportunity to inform municipal,
provincial, territorial, federal, and international law
enforcement practices, and provides a platform to encourage
improved communication among these jurisdictions.
Ultimately, public perception and emotion, although
important considerations, should not lead the debate —
a range of scientific inquiry, risk assessment, and evidence
must guide policy surrounding the use of CEWs in Canada.

xiii

Table of Contents
1	

Introduction and Charge to the Panel.............................................................................................2

1.1	Background..................................................................................................................................................... 2
1.2	
Charge to the Panel and Scoping Decisions.................................................................................................. 2
1.3	
The Panel’s Approach.................................................................................................................................... 3
1.4	
Organization of the Report............................................................................................................................ 6

2	

Use of Conducted Energy Weapons in Canada...............................................................................9

2.1	
A Brief History of CEW Use in Canada.......................................................................................................... 9
2.2	
Legal and Regulatory Environment............................................................................................................... 9
2.3	
Statistics on CEW Use and Related Injuries and Deaths in Canada........................................................... 12
2.4	Summary....................................................................................................................................................... 14

3	

The Design, Operation, and Intended Effects of Conducted Energy Weapons..........................16

3.1	
Using Electricity on the Human Body......................................................................................................... 16
3.2	
Electrophysiology of Nerves, Muscle, and Heart......................................................................................... 17
3.3	
Design and Operation of CEWs................................................................................................................... 19
3.4	
CEW Waveforms ........................................................................................................................................... 21
3.5	Summary....................................................................................................................................................... 23

4	

Approaches to Conducted Energy Weapon Research...................................................................25

4.1	
Laboratory-Based Experimental Research................................................................................................... 25
4.2	
Population-Based Epidemiological Field Research..................................................................................... 27
4.3	Summary....................................................................................................................................................... 28

5	

Physiological and Health Effects Associated with Conducted Energy Weapons.........................30

5.1	
5.2	
5.3	

Neuroendocrine Effects and Activation of the Human Stress Response.................................................. 30
Disruption of Breathing and Impact on Blood Chemistry.......................................................................... 32
Disruption in Heart Rhythm and Rate......................................................................................................... 35

6	

Role of Conducted Energy Weapons in Sudden In-Custody Death..............................................42

6.1	
Potential Causes and Triggers of Sudden Unexpected Death.................................................................... 42
6.2	
Potential Causes of Sudden In-Custody Death............................................................................................ 44
6.3	
Relationship Between CEWs and Sudden In-Custody Death...................................................................... 47
6.4	
Impact of Co-Factors..................................................................................................................................... 48
6.5	Summary....................................................................................................................................................... 51

7	

Gaps in the Evidence on the Physiological and Health Effects
of Conducted Energy Weapons......................................................................................................53

7.1	
7.2	
7.3	
7.4	
7.5	

Confidence in Establishing Direct Causal Relationships............................................................................ 53
Identifying Length of Time Needed to Establish Probability..................................................................... 55
Understanding Health Effects on Varying Populations.............................................................................. 55
Lack of Standardization of Reporting and Record-Keeping Practices....................................................... 57
Insufficient Funding of Independent CEW Research................................................................................. 58

xiv

The Health Effects of Conducted Energy Weapons

8	

Integrated Strategies to Address Gaps in the State of Evidence
on Conducted Energy Weapons.....................................................................................................61

8.1	
8.2	
8.3	
8.4	
8.5	
8.6	
8.7	

Standardizing and Centralizing the Recording of CEW Incidents............................................................. 61
Enabling Comprehensive Medical Assessment Following CEW Exposure................................................. 61
Improving Access to, and Sharing and Integration of, Knowledge Across Fields ..................................... 62
Supporting Large-Scale, Multi-Site, Population-Based Studies................................................................... 63
Improving Understanding of CEW Risk Relative to Other Use-of-Force Interventions............................ 63
Understanding Specifications of CEWs Manufactured by a Range of Companies.................................... 64
Furthering Ethical Laboratory-Based Experimental CEW Research.......................................................... 64

9	

Summary and Conclusions..............................................................................................................67

9.1	

What Is the Current State of Scientific Knowledge About the Medical
and Physiological Impacts of Conducted Energy Weapons?....................................................................... 67
What Gaps Exist in the Current Knowledge About These Impacts?........................................................... 68
What Research Is Required to Close These Gaps?...................................................................................... 69
Final Reflections .......................................................................................................................................... 70

9.2	
9.3	
9.4	

References..................................................................................................................................................73
APPENDIX A:	Summary of Main Findings from Past Evidence Assessments...........................................86
APPENDIX B:	Physical Injuries Following CEW Exposure.........................................................................88
APPENDIX C:	Summary of Animal Studies Examining Respiratory Dysfunction....................................89
APPENDIX D:	Summary of Animal Studies Examining Variable CEW Characteristics
and Cardiac Dysfunction.....................................................................................................90

List of Figures and Tables

List of Figures and Tables
Figure 2.1	 Milestones in the Use of CEWs in Canada......................................................................................... 10
Figure 2.2	 Estimated Number of CEWs in Use in Canada by RCMP and Provincial
and Municipal Police Agencies........................................................................................................... 11
Figure 2.3	 RCMP-Wide Trends in CEW Use........................................................................................................ 13
Table 3.1	

Comparison of Approximate Characteristics of Varying Electrical Sources..................................... 17

Figure 3.1	 Structure of the Heart and Electrical Activity in Cardiac Muscle and Nerve Cells.......................... 18
Figure 3.2	 A Schematic Side-View of the TASER® X26™.................................................................................... 20
Figure 3.3	 Waveform Comparison of TASER® Models........................................................................................ 22
Figure 5.1	 Depiction of a CEW Probe Deployment to the Chest........................................................................ 37
Figure 6.1	 Potential Factors Associated with Sudden In-Custody Death ........................................................... 43

xv

Introduction and Charge to the Panel

1
Introduction and Charge to the Panel

•	

Background

•	

Charge to the Panel and Scoping Decisions

•	

The Panel’s Approach

•	

Organization of the Report

1

The Health Effects of Conducted Energy Weapons

2

1	Introduction and Charge
to the Panel
1 . 1	B ackground

Conducted energy weapons (CEWs) have been in use by law
enforcement in Canada since the late 1990s and represent
at once a new policing tool, a new bioelectrical device
worthy of medical and scientific study, and a new point of
discussion for the broader media and public discourse on
Canadian public safety and law enforcement. The devices
use electrical energy to induce pain or incapacitate a person.
They are also generically referred to as TASERs — a brand
name specific to devices manufactured and produced by
TASER® International. Other commonly used names for
the devices are listed in Box 1.1.

Box 1.1 	
Common Synonyms for Conducted
Energy Weapons
•	 Conducted Energy Devices
•	 Conductive Electrical Devices
•	 Electronic Control Devices
•	 Electronic Discharge Devices
•	 Electro Stimulation Devices
•	 Electro-muscular Disruption Weapons
•	 Neuromuscular Incapacitating Devices
•	 Electronic Immobilization Guns
•	 Stun Guns

CEWs are one option on the broad use-of-force continuum
employed by law enforcement and public safety personnel.
The continuum spans the physical presence of an officer
through to use of deadly force. CEWs fit into this dynamic
continuum in the category of less-lethal weapons, along with
other tools such as pepper spray, batons, and rubber bullets,
which are intended to control violent situations and contain
subjects, but not to kill. Despite common comparisons
between CEWs and firearms, CEWs are not replacements
for firearms. Instead, the devices are typically used to
facilitate the arrests of uncooperative individuals who are
resisting arrest. The induced loss of voluntary muscle control
is intended to cause individuals to fall to the ground,
where they may be subdued and taken into custody. The
subjects are not meant to experience any lasting effects
after application of the device.

Decision-making about deploying CEWs resides not only
at the institutional and management levels, but also in
the field and in the moment. In any policing scenario,
the officer on the scene decides whether and how to
use force by following protocol, weighing options and
outcomes, and estimating risk within the limitations
of information available in real time. Use-of-force
decisions are not linear and do not follow a steady
upward progression through all force options until
a conflict is over. Rather, the situation unfolds dynamically,
and communication and tactical repositioning occur
throughout each event. CEW use is one small part of this
ongoing decision-making and intervention process.
Although CEWs are intended to be injury-reducing, lesslethal weapons (compared to alternative interventions),
their use is not without risk. Many discussions have focused
on the potential harm associated with the use of these
devices and their appropriateness as a use-of-force option,
yet the potential and actual physiological and health effects
associated with CEW use are not well defined. A scientific
consensus on what is known and not known about the
effects associated with CEW use is essential.
1 .2 	

C harge to the Panel
and Scoping Decisions

In 2010, the Centre for Security Science at Defence Research
and Development Canada (DRDC) began implementing its
Conducted Energy Weapons Strategic Initiative (CEWSI)
in partnership with the Director General for Policing
Policy at Public Safety Canada. The CEWSI has three
main objectives:
•	 recommend a CEW test procedure and develop
comprehensive performance measures for possible
inclusion in pan-Canadian guidelines on the use of CEWs;
•	 convene a panel of medical experts to conduct an
independent evaluation of existing research aimed
at examining the medical and physiological impact of
CEWs; and
•	 develop a less-lethal-weapons approval process that could
be applied to emerging less-lethal technologies.
To fulfill the second objective, DRDC (the Sponsor)
asked the Canadian Academy of Health Sciences (CAHS)
to conduct an independent, evidence-based assessment of
the state of knowledge on the physiological and health effects
of CEWs. To undertake the assessment, CAHS established a
partnership with the Council of Canadian Academies (the
Council). Working collaboratively with CAHS, the Council
acted as the secretariat for the science-based exploration
of the evidence.

3

Introduction and Charge to the Panel

The Council and CAHS were asked to focus on the following
three questions:
1.	 What is the current state of scientific knowledge about
the medical and physiological impacts of conducted
energy weapons?
2.	 What gaps exist in the current knowledge about
these impacts?
3.	 What research is required to close these gaps?
To address the charge and develop the final assessment
report, the Council and CAHS assembled a 14-member
multidisciplinary panel of experts from Canada and abroad
(the Panel). The Panel’s composition reflects a range of
expertise, experience, and demonstrated leadership in
academia, industry, and medical science fields. Specifically,
Panel members possess expertise from medical, social
science, and engineering related disciplines including
pathology, electrophysiology, cardiology, epidemiology,
psychiatry, pharmacology, neurology, medical ethics,
experimental design, criminology, emergency medicine,
and biomedical engineering.
To ensure a comprehensive understanding of the charge,
the Panel met with the Sponsor at the start of the assessment
process to discuss the main scope of interest. Based on
the meeting with the Sponsor, the Panel decided the
assessment would aim to:
•	 include evidence-gathering on the potential short-,
medium-, and long-term physiological and health effects
of CEW exposure including, but not limited to, fatalities;
•	 identify differential risks and health effects associated
with CEW use across varying human populations based
on demographic, age, and gender breakdowns, as well
as physical and mental health profiles;
•	 attempt to explore the effects of a range of CEW devices;1
•	 review characteristics of other types of electrical
interventions (e.g., defibrillation devices) for
comparative purposes;
•	 identify gaps in the current literature, including evidence
related to exposing individuals with specific health
conditions and specific sub-populations to CEWs; and
•	 review ethical and valid ways to fill research gaps and build
understanding of differential risks across populations.

1	

In contrast, the assessment would not:
•	 provide definitive positions on the safety of CEWs (or any
particular device) or the appropriateness of their use;
•	 review why and how CEWs were approved for use
in Canada or elsewhere;
•	 focus on use-of-force by law enforcement agencies,
motivations for CEW use, or labelling of CEWs as nonlethal weapons in policing intervention models;
•	 review police and military training, operational policies
and procedures, and protocols;
•	 compare the effectiveness of less-than-lethal weapons
to other use-of-force interventions;
•	 examine the parameters of proper functioning,
technical specifications, or testing thresholds related
to approving devices for use and ensuring safe and
efficient functioning; or
•	 review injuries to law enforcement or to bystanders caused
or prevented by the devices during a use-of-force scenario.
The Panel’s report is intended to provide an in-depth
and authoritative assessment of the state of knowledge
on the relationship between CEWs and a range of health
complications. It complements, and must be considered
along with, other work related to testing and approval
procedures, motivations and protocols for appropriate
use, safety and effectiveness standards, other use-of-force
interventions, and other considerations constituting the
broader package of information needed to make informed
decisions about public health, policing, and CEW use
in Canada. The Panel hopes its assessment will not only
inform decision-makers, health professionals, and law
enforcement about the health effects of CEWs, but also
provide a platform for dialogue among various stakeholders
on a question of public health importance.
1 .3 	

The Panel’s Approach

Over the course of 12 months, the Panel met face-to-face
four times. There were also numerous teleconferences
and other communications involving the Panel as a whole,
with select sub-groups assigned to specific subject areas.
The Panel’s first task was to define key concepts and terms
used in the report (see Box 1.2).

It should be noted the Panel identified very little evidence related to CEW devices other than certain TASER® models.

The Health Effects of Conducted Energy Weapons

4

Box 1.2	
Defining Key Terms and Concepts
Use-of-Force Continuum – Most law enforcement agencies
are guided by an incident management and intervention model
often referred to as the use-of-force continuum. The continuum
involves a continuous assessment process during which the
officer takes into consideration situational factors, subject
behaviours, officer perceptions, and tactical factors to select
the most reasonable option to resolve a situation. Models
vary by jurisdiction, agency, and policing strategies but the
continuum usually involves a series of possible actions to be
taken. Actions can include officer presence, communication
and verbal commands, physical control (ranging from soft
to hard techniques), intermediary weapons (e.g., CEWs), and
lethal force (RCMP, 2009).
Less-Lethal Weapon – The U.S. National Institute of Justice
(NIJ) defines this term as “[a]ny apprehension or restraint
device that, when used as designed and intended, has less
potential for causing death or serious injury than conventional
police lethal weapons” (e.g., a handgun) (NIJ, 2011). Examples
may include impact munitions (e.g., rubber bullets); acoustic
devices; laser devices; chemical devices (e.g., pepper spray);
electrical devices (i.e., CEWs); and distraction devices (e.g.,
flash grenade).
Conducted Energy Weapon (CEW) – A CEW has been defined
as an electrical device designed to immobilize or incapacitate
an individual through induction of pain or disruption of the
nervous system by delivering enough electrical energy to
trigger uncontrollable muscle contractions and to interfere
with voluntary motor responses (Hancock & Grant, 2008; NIJ,
2011). The Panel chose to use the broader term CEW, rather
than refer to a specific make or model because it allows
for an investigation of a range of devices.
Medical and Physiological Impacts – The Panel interpreted
impacts broadly to include any health effect arising from
changes or damage to the normal structure and function
of the respiratory, cardiovascular, nervous, endocrine, or
musculo-skeletal systems in the human body. The Panel included
both physical health and mental illness in the review — that
is, conditions resulting from impaired structure or functioning
of some bodily systems and conditions characterized by
alterations in thinking, mood, or behaviour associated with
distress or impaired functioning (WHO, 2001).

The two key evidence-gathering activities (see Box 1.3)
that informed the Panel’s deliberations were reviews of:
•	 major evidence syntheses, reviews, and books on the
physiological and health effects of CEWs; and
•	 peer-reviewed, primary research exploring the relationship
between CEWs and physiological and health effects.
Other activities included the following:
•	 reviewing technical documents outlining testing results
established by the Sponsor;
•	 attending a hands-on demonstration of CEW deployment
during a site visit to the Quality Engineering Test
Establishment (QETE) research facilities of the
Department of National Defence Canada and the
Canadian Forces, which included QETE research staff/
scientists and members of the Ottawa Police Service; and
•	 reviewing literature relating to broad topics of relevance
to the context of the report, including research ethics,
electrophysiology, and electrical engineering.
To identify the key physiological and health effects
associated with CEW use, the Panel first reviewed several
major evidence reviews and syntheses. These reviews,
undertaken over the last decade in Canada, the United
Kingdom, and the United States, explore CEW safety and
health effects from medical, law enforcement, and legal
perspectives. They include:
•	 statements produced from 2005 to 2012 by the U.K.’s
Defence Scientific Advisory Council Sub-Committee
on the Medical Implications of Less-Lethal Weapons,
based on a review of literature, government testing and
research, and police data (DOMILL, 2005, 2011);
•	 a report to the Canadian House of Commons Standing
Committee on Public Safety and National Security, based
on a review of literature and expert witness testimony
(House of Commons of Canada, 2008);
•	 independent reviews of CEWs commissioned by the Royal
Canadian Mounted Police (RCMP) (Kiedrowski et al.,
2008), the Canadian Police Research Centre (Manojlovic
et al., 2005), and the Canadian Association of Police
Boards (Synyshyn, 2008);
•	 an extensive review of medical/scientific literature,
coroner and police reports, and expert testimony
undertaken by the U.S. National Institute of Justice
(NIJ, 2011); and
•	 a review of CEWs undertaken by the Nova Scotia
Department of Justice (NSDOJ, 2008b).

Introduction and Charge to the Panel

Box 1.3 	
Evidence Syntheses and Primary Research
To identify major evidence syntheses, the Panel reviewed the
research database created as part of the Conducted Energy
Weapons Strategic Initiative (CEWSI) and maintained by the
Sponsor, searched the internet, reviewed popular media articles,
and hand-searched reference lists. The Panel also searched the
following academic databases: Web of Knowledge, PubMed,
Health-Evidence.ca, Cochrane and Campbell Libraries, Centre
for Reviews and Dissemination, and Evidence for Policy and
Practice Information and Co-ordinating Centre (EPPI-Centre).
Search terms included identified synonyms for CEWs (e.g.,
conducted electrical device, stun gun, TASER®) and electromuscular stimulation (e.g., electro-muscular disruption,
neuromuscular incapacitation).
The Panel used additional comprehensive searching
activities to identify and examine primary research studies
published between 1989 and April 2013. The Panel identified
articles from the Electronic Control Device Research Index
(ECDRI) maintained by TASER® International, the CEWSI
research database, and a Panel-led search of the following
databases: PubMed, Web of Knowledge, Embase, Science
Direct, JSTOR, Inspec, and Microsoft Academic. Search terms
included synonyms for health complications (e.g., mortality,
pathophysiology), as well as terms similar to those used in
the search for evidence syntheses. Additional articles were
identified through hand searching of reference lists.
Of the approximately 400 peer-reviewed articles identified
and reviewed, 171 articles were retained based on predetermined criteria related to study design, outcome and
study variables, and study location. Many of the retained
articles then underwent a critical appraisal process, based
on an assessment of quality criteria defined by the Panel and
adapted from standard quality assurance tools (Kmet et al.,
2004; Terracciano et al., 2010). Retained articles also underwent
a data extraction process to identify key information related
to device characteristics, subject characteristics, physiological
and health effects of interest, industry affiliation, and main
conclusions. This process did not result in the elimination of
any of the retained studies; Panel members used it to further
develop the analyses, identify key references to include in
the report discussion, and inform deliberations on research
context, gaps, and potential strategies for future research.

5

From its review of the main findings and conclusions
of these activities (see Appendix A for a summary of the
findings from each review), the Panel determined the key
physiological and health effects most discussed in the
review literature:
•	 potentially fatal cardiac arrest caused by abnormal
heart rhythm;
•	 sudden in-custody death;
•	 physical/musculo-skeletal injuries sustained from direct
effects of probe penetration, burns from electrical
current, or a fall resulting from incapacitation;
•	 excited delirium syndrome (i.e., worsening of a state
of extreme agitation, which can be potentially fatal);
•	 respiratory distress or impairment, and related changes
in blood chemistry; and
•	 other effects of extreme pain and emotional trauma
such as seizures.
To explore the main health effects identified above in more
detail and to narrow the focus of the assessment, the Panel
turned its attention to key primary studies (see Box 1.3).
Several population-based and single case studies suggest that
superficial physical injuries are often associated with CEW
deployment — mainly caused by the weapon’s probes but
also by severe muscle contractions and related falls. While
the occurrence of superficial physical injury is high, these
types of injuries rarely pose significant risk for morbidity and
mortality. There are several case studies that indicate the
potential for more severe injuries including lung perforation,
head injury, bone (and skull) perforation and fractures,
ocular injury, and musculo-skeletal damage. Although
these more serious injuries mainly result from falls, there
is some evidence that certain CEW probes are long enough
to penetrate vital organs when applied at a close distance
(see Appendix B for a summary of key population-based and
case studies). The risk for experiencing a seizure (similar
to a grand mal seizure induced during electroconvulsive
therapy) after receiving a CEW head shot, although
speculated in the literature as being relatively high (Reilly
& Diamant, 2011), has only been documented in a single
case study that involved a CEW shot to the upper back and
head (Bui et al., 2009).
Keeping in mind that all law enforcement interventions
come with a certain risk of physical injury to the suspect
involved (Smith et al., 2010; Paoline III et al., 2012), the
Panel felt that in the case of CEWs, the risk for significant
morbidity and mortality from CEW-induced physical injuries
was minimal. As such, the Panel chose not to focus on
physical injuries caused by the weapon’s probes, or on falls
resulting from severe muscle contractions, in great detail.

The Health Effects of Conducted Energy Weapons

6

Instead (given the dearth of available information on longterm health consequences associated with CEWs), the Panel
concentrated specifically on acute, short-term physiological
and health effects resulting from the electrical characteristics
of CEW devices — effects having the most potential for
sudden unexpected death. Because sudden unexpected
death is likely the end result of a variety of intersecting
factors involving the neuroendocrine, respiratory, and
cardiovascular systems, the Panel focused on physiological
changes in these systems resulting from electrical current
and CEW discharge, including neuroendocrine effects
and elevated stress hormones, disruption in breathing
and related changes to blood chemistry, and changes to
heart rhythm and rate and the potential for arrhythmias.
The Panel also felt that uncertainties surrounding sudden
in-custody death, mental illness, and excited delirium
syndrome should be explored more generally.
Within the evidence there was speculation that several
sub-groups are at higher risk of injury or death, compared
to the general population:
•	 younger and older populations (children, adolescents,
the elderly);
•	 individuals in vulnerable physical states (frail or low body
weight, pregnancy, acute illness, and cardiac weakness
or disease); and
•	 individuals in vulnerable mental states (mental illness,
alcohol or drug intoxication, stress, psychosis).
Exploring the interplay between CEWs and these groups,
along with other common factors involved in use-of-force
events, was integral to the Panel’s review of, and deliberations
on, the evidence. The Panel sought to determine to what
degree these co-factors could increase the likelihood or
severity of each of the physiological and health effects
identified above. Potential co-factors were divided into two
categories: (1) internal co-factors, related to states intrinsic
to the individual such as pre-existing medical conditions or
drug or alcohol impairment, and (2) external co-factors,
related to the situational factors or characteristics extrinsic
to the individual.
Following the completion of evidence-gathering activities
and decisions, the Panel’s penultimate draft report underwent
a rigorous and anonymous peer-review process involving
13 experts with multidisciplinary expertise similar to that
found in the Panel. All reviewer comments were carefully
considered and addressed by the Panel.

1 .4 	

Organization of the R eport

The final report captures the collective wisdom of the
Panel and is based on the consensus reached by all Panel
members. The findings are based on the best available
scientific knowledge and the professional experience
and expertise of the Panel. It is the Panel’s hope that the
report will provide a platform for dialogue and will be
considered alongside other important policy discussions
related to appropriate testing and approval procedures,
protocols for use, and risks of CEWs relative to other
use-of-force interventions.
The report is organized as follows:
Chapter 2 provides a brief history of CEW use by law
enforcement in Canada, along with the legal and regulatory
environment in Canada and other relevant international
jurisdictions. It also presents the available statistics on
CEW use as well as injuries and deaths related to CEW
use in Canada.
Chapter 3 examines the state of the evidence on the
intended effects of CEWs. It begins by comparing the
electrical characteristics of CEW devices to other electrical
interventions, followed by an overview of electrophysiology
to help understand the intended effects of the devices on
the body. It also describes the design and basic operating
principles of CEWs and their electrical outputs.
Chapter 4 discusses in detail the advantages and
disadvantages of various research models used to study
the physiological and health effects of CEWs beyond the
intended effects outlined in Chapter 3. These include
experimental models (such as computer models, animal
studies, and human-based laboratory research) and
population-based epidemiological field studies.
Chapter 5 examines the state of the evidence related to the
three physiological effects most often associated with CEW
exposure and most relevant in the context of understanding
sudden unexpected death and severe health effects:
neuroendocrine effects and the human stress response,
respiratory function and blood chemistry, and changes to
cardiac rhythm and rate. Basic physiology, current knowledge
of CEW impacts, and co-factors with the potential to increase
the likelihood or severity of a health complication following
CEW exposure are explored, for each effect.

Introduction and Charge to the Panel

Chapter 6 looks at the state of the evidence related to the
potential role of CEWs in sudden in-custody death. It also
focuses on two key co-factors: mental illness and excited
delirium syndrome.
Chapter 7 identifies and explores five broad gaps in the
state of knowledge about the relationship between CEW use
and physiological and health effects. It also discusses the
related challenges in funding, conducting, and interpreting
CEW research.
Chapter 8 outlines the Panel’s potential strategies for an
integrated response to address the gaps in CEW evidence.
It presents a number of activities that would help improve
the knowledge base, enable further research, and support
future surveillance and reporting activities.
Chapter 9 summarizes the Panel’s overall findings, grouped
by the three main questions comprising the charge. It also
presents the Panel’s final reflections.

7

The Health Effects of Conducted Energy Weapons

8

2
Use of Conducted Energy Weapons in Canada

•	

A Brief History of CEW Use in Canada

•	

Legal and Regulatory Environment

•	

Statistics on CEW Use and Related Injuries and Deaths in Canada

•	

Summary

9

Use of Conducted Energy Weapons in Canada

2	

Use of Conducted Energy Weapons
in Canada

Key Findings
•	 Decision-making about the protocols for selecting, acquiring,
and using CEWs is undertaken by local law enforcement
and public safety agencies, and varies across Canada
and internationally.
•	 There is no ongoing systematic and consistent documentation
of CEW use in Canada and no standardized way to capture
injuries or deaths related to the devices.
•	 Ad hoc reporting indicates CEW use in Canada is generally
declining, the device is largely used as a deterrent (displayed
rather than fired), and injuries resulting from CEWs are
largely superficial physical injuries; it is challenging, however,
to draw any definitive conclusions related to the physiological
and health effects of CEW use from current monitoring and
reporting practices.
•	 Since 1998, at least 33 deaths in Canada have followed
the deployment of a CEW, but were not necessarily direct
results of CEW deployment.
Conducted energy weapons (CEWs) were introduced as
one of several less-lethal use-of-force options for Canadian
law enforcement in 1998. This chapter briefly outlines the
history and use of CEWs in Canada, along with the legal
and regulatory environment in which they are deployed. It
then goes on to present the available statistics on trends in
CEW use, and what can be said about related injuries and
deaths based on current monitoring and reporting practices.
2 .1 	

A B r i ef H i story of CE W U se
i n C anada

In 1999 and following operational reviews and field trials
carried out by police agencies in the cities of Edmonton
and Victoria, the province of British Columbia became the
first Canadian jurisdiction to approve CEWs for use by law
enforcement (Braidwood Commission, 2009). Following an
assessment of the devices and similar field trials, the RCMP
approved the TASER® M26TM device for use by its officers
across Canada in 2001; select provinces and municipalities
later followed suit (Kiedrowski et al., 2008). Figure 2.1 shows
a timeline of key CEW-related developments over 15 years.

2	

As of May 2013, there were approximately 9,174 CEWs in
use in Canada, including those in service as well as those
used for training or in storage (PSC, 2013).2 This number
includes all RCMP inventory as well as inventories of all
police services under provincial and municipal jurisdictions.
The number of devices currently in use varies greatly based
on jurisdiction, as noted in Figure 2.2. In some jurisdictions
all police agencies are equipped with CEWs (e.g., British
Columbia), while in others only certain agencies use the
devices (e.g., 9 of a total of 31 police agencies use CEWs
in Quebec); however all federal, provincial, and territorial
jurisdictions use CEWs in some capacity across Canada.
2 .2 	

Legal and R egulatory
Env ironment

CEWs are prohibited firearms under the Criminal Code
in Canada and may only be handled by law enforcement
and public safety personnel (Kiedrowski et al., 2008). In
2010 federal, provincial, and territorial ministers of justice
agreed on a set of guidelines for CEW use that involved
certain restrictions on use, and recommendations related to
training policies, device testing procedures, monitoring and
supervision guidance, and maintenance of a usage reporting
system (PSC, 2010). Even with these guidelines in place, the
use of CEWs by law enforcement in Canada is not governed
by a single entity. Decision-making related to their use occurs
at federal, provincial, and municipal levels, depending on
the police force. Although adoption of CEWs by municipal
law enforcement agencies has typically followed federal
or provincial approval of the devices, individual agencies
make local decisions on whether and how to incorporate
CEWs into their practices.
CEWs are also used by law enforcement agencies around the
world. To help law enforcement agencies and communities
select, acquire, and use CEWs, the International Association
of Chiefs of Police has released guidelines for effective
deployment of the devices (IACP, 2007). Based on research
and lessons learned from agencies deploying the devices,
the nine-step strategy involves building a leadership team,
placing CEWs within an intervention model or on a useof-force continuum, assessing the costs and benefits of
use, identifying roles and responsibilities, engaging
communities, developing policies and procedures, creating a
comprehensive training program, using a phased deployment
approach, and continually assessing CEW use (IACP, 2007).
Similar guidelines have been released by the Police Executive
Research Forum and the United States Department of Justice.

This information was provided to the Panel by Public Safety Canada after consultations with the RCMP as well as policing policy officials from all
provinces and territories, and does not include Aboriginal policing services. Information has not been subjected to any additional validation beyond
these consultations, has been collected at varying times through varying methodologies, and is subject to change. Despite these inconsistencies,
these numbers are based on the latest information available and provide the best estimate for the number of CEWs in use across Canada.

1999

• First public commission of inquiry into role
of CEW in a high-profile in-custody death
focuses national attention on CEW use –
Report published 2010 (Braidwood, 2010)

• Widespread distribution
of TASER® M26™ across
Canada (TASER® X26™
followed in 2005)

• BC approves TASER® M26™ device

2008

• Report notes a
drop in threatened
and actual CEW
deployments since 2008
(CPC RCMP, 2012)

2012
COMMISSION
FOR PUBLIC
COMPLAINTS
AGAINST THE
RCMP REPORT

2012

The United States was the first jurisdiction to deploy the modern form of CEWs, and the devices have been in use in that country since the early 1990s. In Canada, field trials began in the late 1990s and,
subsequently, CEW use became widespread across the country in the early 2000s. After a high-profile death and commission of inquiry in the late 2000s, the use of CEWs elicited much more scrutiny and
public debate. This figure depicts key milestones in the use of CEWs since their introduction in Canada.

• New guidelines restrict CEW use, and encourage training,
testing, supervision, and reporting recommendations
(PSC, 2010)

2010

• Report released in 2013 noting
progress in implementing the Braidwood
Commission of Inquiry recommendations
(BC Legislature, 2013)

2012
BC LEGISLATURE APPOINTS
SPECIAL COMMITTEE

2010
FEDERAL, PROVINCIAL, AND TERRITORIAL MINISTERS
OF JUSTICE AGREE TO GUIDELINES ON CEW USE

2008
BRAIDWOOD COMMISSION OF INQUIRY
LAUNCHED BY BC GOVERNMENT

2001
RCMP APPROVES CEW
USE BY OFFICERS

1999
FIRST APPROVAL OF CEWS FOR
USE BY LAW ENFORCEMENT IN
CANADA

2001

Figure 2.1
Milestones in the Use of CEWs in Canada

1998

• 6-month field trial
by Edmonton and
Victoria police

1998
FIRST CEW USE BY
LAW ENFORCEMENT
IN CANADA

10
The Health Effects of Conducted Energy Weapons

11

Use of Conducted Energy Weapons in Canada

Number of CEWs in Use by:
RCMP
Provincial/Municipal Agencies

51
0
45
0

823
424

685
1,856

50
0
100
0
457
11

262
247

32
123
26
6

102
3,418
125
39

207
85

Data source: PSC, 2013

Figure 2.2
Estimated Number of CEWs in Use in Canada by RCMP and Provincial and Municipal Police Agencies
There were approximately 9,174 CEWs in use in Canada as of May 2013. This includes those in service and those used for training or in storage. The numbers
include the RCMP inventory as well as inventories of police services under provincial or municipal jurisdictions. The number of devices currently in use
varies greatly based on jurisdiction as noted in this figure. This information was provided to the Panel by Public Safety Canada (PSC) after consultations
with the RCMP as well as policing policy officials from all provinces and territories, and does not include Aboriginal policing services. Information has
not been subjected to any additional validation beyond these consultations, has been collected at varying times through varying methodologies, and is
subject to change. Despite these inconsistencies, these numbers are based on the latest information available and provide the best estimate for number
of CEWs in use across Canada.

Updated in 2011, these guidelines provide recommendations
about agency policies, reporting and accountability, training
and use of CEWs, medical considerations, and public
information and community relations (PERF, 2011).
The legal landscape for CEW use in the United Kingdom,
United States, and Australia is similar to Canada’s, but
with a few exceptions:
United Kingdom: Initially (in 2003) only police who were
permitted to use firearms were also permitted to use CEWs.
In 2007 this was extended to other specially trained police
officers (DOMILL, 2005). Training and guidance on the use
of less-lethal weapons (including CEWs) by police across

the United Kingdom is provided by the Association of Chief
Police Officers of England, Wales and Northern Ireland
(ACPO) and by its equivalent body in Scotland (ACPOS).
Oversight of the medical effects of CEWs on the public is
provided by an independent body known as the Scientific
Advisory Committee on the Medical Implications of LessLethal Weapons (formerly the Defence Scientific Advisory
Council Sub-Committee on the Medical Implications
of Less-Lethal Weapons). The independent committee
provides advice to ministers and operates at arm’s length
from government. The Home Office of England and Wales
maintains a database of CEW use, which includes the
circumstances of each use, the mode of use, and officerreported injuries (Home Office, 2010).

The Health Effects of Conducted Energy Weapons

12

United States: The modern form of CEWs has been in use
in the United States since the early 1990s. Adoption of
the devices varies greatly across jurisdictions. As of spring
2010, approximately 260,000 CEWs had been distributed to
law enforcement officers in 12,000 agencies in the United
States (NIJ, 2011). A number of CEW devices are also
available for civilian use in certain jurisdictions. Decisions
and guidelines related to the adoption and use of CEWs
by law enforcement are left up to individual agencies, and
there is no centralized body that regulates, authorizes, or
captures information on their use nation-wide.
Australia: CEWs are considered prohibited weapons and
are not available to the public. They were introduced in the
early 2000s for use by tactical and specialist response groups.
Starting in 2007, the devices became more widespread
and are now used by a range of general patrol officers and
specialist and emergency response groups, depending on
jurisdiction (Hancock & Grant, 2008; NSWO, 2008). Each
jurisdiction within the country has its own set of oversight
mechanisms and guidelines governing the use of CEWs
and the recording of that use. All officers must undergo
training and accreditation to carry and use a CEW, and a
recording device is attached to all CEWs used by general
duty officers, to capture details related to deployment
events (NSWO, 2012).
2 . 3	

S tati st i cs on CE W U se and
R elated Inj uri es and Deaths
i n C anada

Similar to all other forms of use-of-force interventions,
the use and number of deployments of CEWs in Canada
are not documented on an ongoing and systematic basis.
Individual agencies do collect use-of-force and CEW
information in their own practices, but this information
is not captured or reported in a uniform, consistent way
across law enforcement, correctional, and other public
safety agencies working under municipal, provincial, and
federal jurisdictions. Although attempts have been made
at the international level to create a less-lethal-weapons
database that provides independent and structured data on
weapon use worldwide (U.K. Steering Group, 2006), at the
time of this report’s publication, the funding and overall
status of the database were unclear. Constraints such as
these have led to ad hoc point-in-time reporting of CEW
use statistics and changes over time, as demonstrated by the
variable reporting from Nova Scotia and British Columbia.

In 2008 and as part of a larger, provincial review of CEWs,
Nova Scotia released CEW use statistics for municipal police
departments, RCMP divisions, and Department of Justice
services (NSDOJ, 2008b). In 2007, 0.05 per cent of the
total calls for service to police involved CEW use. Despite
infrequent overall use, CEW use rose steadily from 2005
to 2007 by about 80 per cent, with deployments mostly
involving presentation of the device (47 per cent), and
with probe (29 per cent) and drive stun (26 per cent)
deployment used less frequently (differences between
probe and drive stun deployment types are described in
greater detail in Chapter 3) (NSDOJ, 2008b).
Also in 2008, British Columbia released CEW use statistics
for the 11 independent municipal police agencies working
in the province (Ryan, 2008). Per-capita deployment rates
between 2001 and 2006 reflect an increase in CEW use
across all agencies. In 2001, CEW incidents ranged from
0 to 43.2 per 100,000 persons across different departments;
however, in 2006, that range increased to a low of 5.2 and
a high of 130.7 incidents per 100,000 persons. Of the total
1,404 incidents reported between 1998 and 2007, a CEW
was displayed in 42.7 per cent of the incidents and deployed
in drive stun and probe mode in 41.2 per cent and 41.8 per
cent of the incidents, respectively (more than one mode
may be used in any one incident) (Ryan, 2008).
At the federal level, the Commission for Public Complaints
Against the Royal Canadian Mounted Police releases statistics
on RCMP use of CEWs on an ongoing basis using the Subject
Behaviour/Officer Response (SB/OR) Reporting System,
a standardized method for recording use of interventions
(CPC RCMP, 2012). Although used only for RCMP forces,
this approach provides a clearer and more consistent picture
of CEW use over time. According to the most recent report,
in 2010 CEWs were used as a deterrent (that is, displayed
but not fired) in about 70 per cent of incidents (CPC
RCMP, 2012). Of the 30 per cent of incidents where CEWs
were actually deployed, 63 per cent of those deployments
were in probe mode and 37 per cent were in drive stun
mode. Overall, RCMP-related CEW deployments have
been consistently dropping since 2004, reflecting a trend
of not only using CEWs less, but also of using them more
as a means for deterrence and de-escalation (rather than
direct incapacitation) (CPC RCMP, 2012). See Figure 2.3 for
RCMP-wide trends in CEW use and deployment over time.

13

Use of Conducted Energy Weapons in Canada

Total Number of CEW Reports

Threatened CEW Use

1,800

100

1,600

90
80

1,400

70

1,200

60

1,000

50
800

40

600

30

400

20

200
0

Per cent of CEW Reports Involving
Threatened Use or Actual Deployment

Number of CEW Reports

CEWs Deployed

10
2002

2003

2004

2005

2006

2007

Year

2008

2009

2010

0

Data source: CPC RCMP, 2012

Figure 2.3
RCMP-Wide Trends in CEW Use
It is difficult to obtain accurate numbers related to the use of CEWs across Canada. At the federal level, the RCMP releases statistics on the use of CEWs
using a standardized method for recording use-of-force interventions. Although used only for RCMP forces, these numbers provide a consistent picture of
CEW use over time. According to the most recent report and noted by the green bars in this figure, overall CEW use has been declining consistently each
year since 2007. In 2010, CEWs were used as a deterrent (that is, displayed but not fired) in about 70 per cent of incidents, furthering an annual trend
of officers increasingly using CEWs as a means of deterrence (as depicted by the blue line). In contrast, the orange line highlights a drop in the actual
deployment of the devices since 2004, further reflecting a trend of not only using CEWs less, but also of using them more as a means for deterrence and
de-escalation rather than direct incapacitation.

No standardized method for recording CEW-related
injuries in Canada, either by police agencies or by medical
practitioners, has been widely adopted across agencies. For
example, minor injuries were not recorded in the 2008
report from Nova Scotia (NSDOJ, 2008b). In contrast, all
CEW-related injuries were noted in the statistics released
for British Columbia, with 24 per cent of the 1,404 incidents
noted as CEW-related injuries, of which 98 per cent were
superficial wounds and 2 per cent were more serious injuries
resulting from falls and dart penetration (Ryan, 2008).
Finally, the 2010 RCMP report on CEW use did not note the
nature of injuries sustained, if any, even though the report
did list when medical attention was required: 10 per cent of
probe deployments and 1 per cent of drive stun deployments
required medical attention in 2010 (CPC RCMP, 2012).
At the time of this report’s publication, a population-based
study exploring police use-of-force (including CEW use) in
seven police agencies in Canada was still in progress; thus,
data on injury rates were not available (Hall, In progress).

Canada also does not have a central repository for reports of
sudden in-custody death, nor is there a database containing
information on CEW-related death. Without a system for
tracking these outcomes, it is very difficult to determine the
number of sudden in-custody deaths in Canada, and the
proportion of deaths that are CEW-related. Based on media
reports and documented inquest processes alone, to date
at least 33 reported deaths have been proximal to CEW use
(Hall, In progress). Across all 33 deaths, reports recording
the incidents were not standardized, resulting in highly
variable information related to the event characteristics of
each death. Although no systematic review of all 33 cases has
been published, a scientific review of 32 of the cases was in
progress at the time of this report’s publication. It is clear
from this initial work that several of the cases were clearly not
related to the CEW, whereas others were more ambiguous
in nature (Hall, In progress). With no synthesized body of
evidence documenting the number of deaths related to useof-force encounters, there is little information to put these
numbers into a larger context (this challenge is discussed
in greater detail in Section 7.4).

14

2 . 4	S u m m ary

Since their introduction in 1998, CEWs have become
widespread across Canadian municipal, provincial,
territorial, and federal jurisdictions. Even with guidance from
various federal, provincial, and territorial governments and
international bodies, decision-making about the protocols
for selecting, acquiring, and using CEWs is undertaken by
local law enforcement and public safety agencies, and varies
across Canada and internationally. There is no ongoing
systematic and consistent documentation of CEW use in
Canada and no standardized way to capture injuries or
deaths related to the devices. Since 1998, at least 33 deaths
have followed the deployment of a CEW in Canada. It is not
clear, however, whether these deaths were results of CEW
deployment. Ultimately, with variable documentation about
the use of CEWs, and with no standardized way to capture
injuries or deaths related to the devices (or to use-of-force
more generally), it is challenging to draw any conclusions
about physiological and health effects of CEWs based on
current monitoring and reporting practices in Canada.

The Health Effects of Conducted Energy Weapons

The Design, Operation, and Intended Effects of Conducted Energy Weapons

3
The Design, Operation, and Intended Effects
of Conducted Energy Weapons
•	

Using Electricity on the Human Body

•	

Electrophysiology of Nerves, Muscle, and Heart

•	

Design and Operation of CEWs

•	

CEW Waveforms

•	

Summary

15

The Health Effects of Conducted Energy Weapons

16

3	

The Design, Operation, and
Intended Effects of Conducted
Energy Weapons

Key Findings
•	 CEWs describe a range of electronic devices designed to
deliver short, repeated pulses of electricity to the skin and
subcutaneous tissues through two metal probes. TASER®
devices are the most studied and documented devices
in the published literature.
•	 CEW deployment can constitute simply displaying the device,
firing a pair of tethered darts into the subject (probe mode),
pressing the device directly against the subject (drive stun
mode), or a combination of these types. Probe mode, used
alone or in combination, has the most potential for causing
adverse effects.
•	 CEWs are manufactured based on the principle that a train of
short-duration electrical impulses with a specially designed
waveform is powerful enough to effectively stimulate motor
and sensory nerves, causing incapacitation and pain, but
is too brief to directly stimulate other electrically excitable
tissues such as the heart muscle.
•	 Because the electrical characteristics and outputs of CEW
devices are variable and evolving, each CEW device must
be tested on its own merit to assess performance as well
as the ability to induce neuromuscular incapacitation and
adverse physiological and health effects.

Conducted energy weapons (CEWs) are intended to be safe
and potentially injury-reducing compared to alternative
interventions, but they are not necessarily risk free. CEWs
work by discharging electrical currents into a subject,
resulting in loss of voluntary muscle control over a large area
of the body. This causes the individual to fall to the ground
and also induces severe but short-lived pain. To help explain
the effects of CEWs, this chapter examines some essential
information about the physiology of nerve and muscle
cells and how these cells, which themselves use electrical
signals, are affected by applied electrical currents. This
chapter also compares CEW characteristics to properties
of other electrical sources and discusses the variability
of these characteristics across devices. It is important to
examine the details of the electrical discharge produced
by CEWs both to understand how they are intended to
function safely, and also to appreciate why there may
be a risk of adverse effects from CEW discharge. This

chapter provides the information necessary for a detailed
discussion of the physiological and health effects of CEW
use in subsequent chapters.
3 .1 	

U sing Electricity
on the H uman B ody

Canadians generally enjoy safe and unremarkable
interactions with electricity every day. Electricity controls
every heartbeat and every movement and sensation in the
human body, but it also has the power to injure and even
kill. Lightning strikes can be fatal; downed or exposed power
lines after a storm can pose a similar risk; and even standard
household electrical outlets can deliver a fatal electrocution
if not used properly or if the wiring is damaged.
Despite their potential for harm, electrical currents
can also be used for therapeutic purposes. Every year
nearly one million people worldwide receive implantable
pacemakers that electrically stimulate the heart. External
cardiac defibrillators are increasingly available in offices
and public places, and internal cardiac defibrillators are
implanted in patients at risk of sudden cardiac death.
These devices use large and carefully shaped pulses of
electricity to restore normal heart rhythm. Electricity is
also used in other common therapeutic contexts, such as
transcutaneous electrical nerve stimulation used in sports
medicine to build strength, reduce pain, and promote
repair; or electro-convulsive therapy used in psychiatric
medicine for the treatment of depression, schizophrenia,
catatonia, and mania (Greenhalgh et al., 2002; Khadilkar
et al., 2006). More recently, non-invasive transcranial brain
stimulation with minute currents has been claimed to have
a variety of benefits for a wide range of neurological and
mental health problems such as major depression (Berlim
et al., 2013).
More than a century of biomedical and biophysical
research has helped develop these safe and effective,
often life-saving electrotherapies. This research established
that the effects of current stimulation on different
tissues depends on the characteristics of the electrical
current, specifically its strength or power, duration, and
waveform, as well as the timing of when the electrical
current is applied in relation to the natural electrical
activity occurring in the body. The strength or power of
an electrical discharge is determined by its current (the
quantity of electricity flowing per unit of time) multiplied
by its voltage (the force or pressure that causes the flow
of electricity). For example, a cardiac defibrillator shock that

17

The Design, Operation, and Intended Effects of Conducted Energy Weapons

delivers 20 amps and 1,000 volts consumes 20,000 watts of
power. Duration refers to how long the current flows. When
the strength and duration are considered together, the
energy delivered per pulse of electricity can be determined
in joules. To continue the example, if a defibrillator has
a pulse duration of 10 milliseconds (0.01 seconds), then
it will deliver 200 joules per pulse. Most electrical discharges,
including those from CEWs, vary rapidly in time and have
the generic shape of an undulating wave when voltage
or current is plotted against time. The variation in voltage
and current of an electrical discharge over its duration is
known as its waveform and will be discussed later in this
chapter. The different characteristics of electrical currents
are important for understanding why certain electrical
sources may be capable of consistently shocking the heart
or inducing other physiological effects while others may
not. Examples of various sources of electrical discharges
are shown in Table 3.1.
The point to remember is that different types of electrical
sources deliver electrical currents with different characteristics.
These characteristics can be optimized to effectively stimulate
a desired tissue or organ, and excessive electrical stimulation
(as through a lightning strike or power-line electrocution)
can cause permanent damage or death.

3 .2 	

Electrophysiology of Ner ves ,
Muscle , and H eart

The nervous system is a network of nerve cells (neurons) that
relay information within the brain and between the brain
and all other parts of the body. Two types of neurons are
relevant for discussion surrounding CEWs: sensory neurons
and motor neurons (Sweeney, 2009a). Sensory neurons carry
information from our sensory organs (including pain signals)
to the brain. Motor neurons carry commands from the brain
and spinal cord to skeletal muscle fibres throughout the body
and control the movement of our skeleton by causing muscles
to contract and relax. The nervous system uses electricity
to communicate, sending small pulses of electricity (about
100 millivolts), known as action potentials, along the nerve
cell processes. Skeletal muscle cells also generate action
potentials when they are stimulated by a motor neuron, and
this causes the muscle cells to contract (Hall, 2011). The
cardiac muscle cells of the heart similarly generate action
potentials, but these are not initiated by motor neurons.
Instead, they are produced by special pacemaker cells in
the sinoatrial node that spontaneously and rhythmically
generate action potentials, which spread across the heart
to cause the coordinated pumping activity of the left and
right ventricle (Katz, 2010), as shown in Figure 3.1. This
rhythmical electrical activity in the heart can be captured
as an electrocardiogram (ECG) through the placement
of electrodes on the skin.

Table 3.1
Comparison of Approximate Characteristics of Varying Electrical Sources
Electrical Source

Current
(amps; A)

Peak Voltage
(volts; V)

Pulse Duration
(milliseconds; ms)

Energy Delivered
(joules; J)

Lightning Strike

40,000

1 billion

0.12

500 million

Cardiac Defibrillator Shock

10–70

500–2,100

6–17

100–200

North American Household Wall Outlet

15

125

Varies

Varies

CEW (TASER® M26TM)

17

50,000 (5,000–7,000 under load)

0.03

0.5

CEW (TASER® X26TM)

3

50,000 (1,000–1,500 under load)

0.1

0.08

CEW (Stinger® S200TM)

2

800–900 under load

0.3

0.05

Electroconvulsive Therapy (ECT)

0.5–0.9

100–500

0.2–2

10–25 *

Transcutaneous Electrical Nerve
Stimulation (TENS)

0.1
maximum
(adjustable)

50 maximum (adjustable)

0.05–0.25 (adjustable)

Varies

Data sources: (Weaver & Williams, 1986; Achleitner et al., 2001; CHP, 2007; Nanthakumar et al., 2008; NEMA, 2008; McDaniel et al., 2009;
Panescu & Stratbucker, 2009; Peterchev et al., 2010; NIJ, 2011; Reilly & Diamant, 2011; Tens MED, 2011)
All values are approximate per pulse values and vary based on context and impedance load, which is the level of resistance to current flow. During
testing, CEWs are fired into a resistive load that mimics the impedance load of the human body (Adler et al., 2013).
* This number represents joules per entire ECT treatment (e.g., four to eight seconds), not joules per pulse (Weaver & Williams, 1986).

The Health Effects of Conducted Energy Weapons

18

(A) Structure of the Heart

(B) Normal ECG
Sinoatrial
Node

R

T

Right
Atrium

P
Q

Atrioventricular
Node
Left
Ventricle
Right
Ventricle
Ventricular
Muscle

Membrane Potential (millivolts)

Left
Atrium

S

Vulnerable
Period

+50

+50

0

0

-50

-50

-100

0

150

(C) Cardiac Muscle Cell

300

-100

Time (milliseconds)

150

(D) Nerve Cell

(C) Cardiac Muscle Cell and (D) Nerve Cell concepts are adapted and reproduced with permission from CVPhysiology.com

Figure 3.1
Structure of the Heart and Electrical Activity in Cardiac Muscle and Nerve Cells
(A) Diagram of the heart, indicating the location of the atria and ventricles. Action potentials originate in the natural generator (or cardiac pacemaker)
tissue called the sinoatrial node (blue), which is located in the right atrium. This action potential excites atrial muscle, followed by the atrioventricular
node (yellow) from where it excites the ventricular muscle, the contraction of which pumps blood into circulation. (B) Normal ECG, indicating the P wave,
the QRS complex, and the T wave of a normal heartbeat that results from this electrical activity. The P wave is formed by the electrical field generated
by the atria; the QRS complex is formed by excitation of the ventricular muscle; and the T wave represents the end of action potentials in the ventricular
muscle. The QT interval refers to the time between the onset of the Q wave and the completion of the T wave. (C) A cardiac muscle cell action potential
generated by the ventricular muscle. Note that (B) and (C) are aligned to indicate how the ECG tracing is related to the action potential. The vulnerable
period of the action potential and the corresponding period on the ECG are marked with a dashed box. It is during this period that the heart is most
susceptible to injury from the application of an electrical current. (D) A nerve cell action potential. Notice that the action potential for the nerve is much
shorter than that of the cardiac muscle cell. This means that the cardiac cell requires more strength and longer duration from an electrical stimulus in
order to be interrupted.

All action potentials are created by the opening and closing
of channels in the membrane of the nerve and muscle
cells that allow ions such as sodium, potassium, calcium,
and chloride to flow across the cell membrane, and the
exact waveform of the action potential in a particular cell
type will depend on the properties of the ion channels
in its membrane (Katz, 2010). Cardiac muscle action
potentials from different regions of the heart have different
waveforms and durations ranging between 100 and 400
milliseconds (0.10 to 0.40 seconds). Nerve and skeletal
muscle action potential waveforms are much shorter than
those in the heart, and last for as little as one millisecond
(0.001 seconds) (Katz, 2010) (Figure 3.1).
Action potentials can be artificially stimulated in
nerve and muscle cells by the application of electrical
currents — such as those generated by a household wall

outlet, electroconvulsive therapy, or a CEW device. As noted
previously, different cell types have different action potential
waveforms, and thus require the application of different
electrical currents for stimulation. The key determinants
of effective artificial stimulation of an action potential are
strength and duration (Sweeney, 2009a). Depending on
the type of cell being stimulated, the electrical stimulus
has to be applied for a certain duration and reach a certain
strength to generate an action potential. This is known
as reaching a certain threshold. This requirement is due
to the specific properties of the ion channels in the cell
membrane, as well as other electrical properties. For the
purpose of this report, however, it is enough to understand
that an electrical stimulus with strength below the threshold
value will have no effect on the nervous system; however,
once the strength of the stimulus exceeds the threshold
value there will be an effect on the system.

19

The Design, Operation, and Intended Effects of Conducted Energy Weapons

The strength and duration of an applied CEW electrical
discharge must be tuned to the thresholds of the nerve
cells to effectively stimulate them (Sweeney, 2009a; Reilly &
Diamant, 2011). Only an electric shock exceeding the nerve
threshold will impact nerves and cause incapacitation. The
duration of electrical stimulation required to exceed the
threshold in a cardiac muscle cell is about 10 to 100 times
longer than in a motor or sensory nerve cell. Therefore,
the principle guiding the functioning of the CEW is that
the short-duration electrical discharges delivered by
the device are highly effective in stimulating motor and
sensory nerves, causing incapacitation and pain, but are
much less effective in stimulating the heart muscle and
thereby inducing potentially fatal disruptions to the heart’s
rhythm and pumping ability. Excitable tissues other than
the nerve, skeletal muscle, and cardiac cells (e.g., blood
vessels) can also be stimulated or damaged by electrical
intervention; however, a discussion of this phenomenon
is not included in this report due to lack of evidence and
identified connections with CEWs.
Along with strength, duration, and threshold values,
the timing of the CEW exposure is also relevant. The
susceptibility of cardiac muscle to stimulation by an
artificially applied current varies, depending on the point
in the rhythmic cycle of the heart. There is a period of
vulnerability (shown, approximately, as the dashed box
superimposed on the later part of the cardiac muscle
action potential in Figure 3.1) toward the end of an action
potential or heartbeat when a stimulus that would not
reach threshold if applied at the beginning of the action
potential may do so. Again, the reason for this has to do
with the behaviour of the ion channels in the membrane
of the cardiac muscle cells. This phenomenon is important
to understand because certain commonly prescribed drugs
have the effect of prolonging this period of vulnerability
(i.e., they prolong the QT interval of the ECG) (van Noord
et al., 2010). There are therefore multiple factors at play
when considering the possible physiological and health
effects of deploying a CEW. Researchers must take into
account the electrical characteristics delivered by the
device and the tissues influenced by the currents flowing
between the CEW probes and a host of other factors as
well — including potential prescription and other drugs
consumed by the target individual.

3	

Manufacture of the M26TM will soon be discontinued.

3 .3 	

Design and Operation of CEWs

Having discussed these fundamental properties of electricity
and its effects on nerve and muscle cells, this report turns
to examining the workings of CEWs and their effects on the
human body. As mentioned in Chapter 1, this report uses
the term conducted energy weapon to describe the general
category of devices, and TASER to refer specifically to
CEWs manufactured by TASER® International. Other CEW
manufacturers and devices include the MPIDTM from Karbon
Arms®; the Mark 63 TridentTM made by Aegis® Industries; and
other dart-firing baton weapons manufactured by Russian,
Chinese, and Taiwanese companies (Sprague, 2007).
Although traditional stun guns and other modern devices
qualify as CEWs, this discussion of CEW operation focuses
mostly on TASER® devices, for three reasons:
•	 TASER® M26TM and X26TM devices3 are the only CEWs
approved for use by Canadian law enforcement, and
are the dominant CEWs used by law enforcement
agencies worldwide.
•	 The majority of the published research focuses
on TASER® devices.
•	 TASERs® are representative of the class of CEWs that
induce neuromuscular incapacitation by delivering
electrical energy to a subject from a distance using probes
fired from the device. This is in contrast to traditional
stun guns and some other models of CEWs that are
primarily pain-compliance devices.
The general principles of operation and design of TASER®
devices described in this chapter broadly apply to many
other types of CEWs.
CEWs deliver short, repeated pulses of electricity to the
skin and subcutaneous tissues through two metal probes.
Many CEWs are plastic, hand-held devices equipped with a
safety switch and trigger. Additional features may include a
laser aim; an internal memory chip that records the time,
date, and duration of discharge for each deployment; and
a digital readout of battery charge. Trigger action deploys
the electrical discharge. For instance, the discharge from
the TASER® X26TM (see Figure 3.2) involves a series of
brief electrical impulses that last for five seconds, and
the device emits this series of impulses for as long as the
trigger is held down. Each discharge is accompanied by
the release of small confetti-like markers that scatter about

The Health Effects of Conducted Energy Weapons

20

Safety

Trigger
Connection Wire

Unique Marker

Probes

Air Cartridge

Battery

Laser Sight
Adapted and reproduced with permission from TASER® International, Inc.

Figure 3.2
A Schematic Side-View of the TASER® X26™
The TASER® X26™ is the most commonly used CEW in Canada. When the trigger of the device is pulled, a compressed nitrogen cartridge breaks open,
which results in the build-up of pressure. This pressure launches two probes — each with a barbed dart on the end — at 55 metres per second. Thin
wires attached to the darts unspool as the darts fly, maintaining an electrical connection to the device. Each discharge is accompanied by the release of
small confetti-like markers that bear a printed code unique to the CEW (Kroll, 2007). The darts lodge into a subject’s clothing, skin, or soft tissues. If they
land far enough apart, the flow of electrical current between them stimulates many nerves, resulting in widespread loss of voluntary muscle control (or
incapacitation) and generalized intense pain (Hancock & Grant, 2008; NSDOJ, 2008a). This figure highlights some common features of the device.

the discharge site and bear a printed code unique to the
CEW, indicating not only that a device has been fired but
also which device, specifically (Kroll, 2007).
Officers most often use CEWs as deterrents (NSDOJ, 2008b;
CPC RCMP, 2012), by, for example, activating the laser
sight, activating the spark display, drawing and displaying,
or pointing the device at a subject. They may also deploy
the device for defensive purposes (CPC RCMP, 2012).
CEWs can be deployed through one of two basic operating
modes: probe mode and drive stun mode. Field use of the
devices can also involve a combination of these two modes,
termed the three-point deployment option.
Probe mode is most commonly used and most often
associated with the need for medical attention
(CPC RCMP, 2012) due to loss of voluntary muscle
control and increased spread of the current flow
across the body. It is also the most researched type of
deployment in the literature reviewed by the Panel.
In probe mode, a pair of metal darts deploys from the

CEW, spreads apart, and penetrates and attaches to a
subject’s clothing, skin, and soft tissues at a distance of
up to a few metres (although some devices are designed
for longer ranges, such as the TASER® XREPTM). The
darts are connected to thin electrical wires that conduct
the electrical discharge from the device. If the two darts
are spaced widely enough across the body, the flow of
electrical current between them stimulates many nerves,
resulting in widespread loss of voluntary muscle control (or
incapacitation) and generalized intense pain, which typically
cease immediately after the discharge ends (Hancock &
Grant, 2008; NSDOJ, 2008a).The degree of incapacitation
is largely dependent on the spread of the probes, which is
thought to be most effective between 9 to 12 inches (Ho et al.,
2012).4 In probe mode, it is more likely the current will flow
through tissues in the chest, including the heart, which results
in increased risk of unwanted cardiac or other health effects
(Sun & Webster, 2007).

4	 See Reilly and Diamant (2011) for a detailed description of the three likely mechanisms involved in the loss of voluntary muscle control when a
device is fired in probe mode: (1) direct excitation of muscle, (2) stimulation of motor neurons, and (3) activation of reflex activity.

The Design, Operation, and Intended Effects of Conducted Energy Weapons

In drive stun (also known as touch stun) mode, the device
is pressed directly against the subject like a traditional
stun gun. The electrical current is delivered across a
more localized area than in a probe mode deployment
(NSDOJ, 2008a). As a result, the main effect of drive stun
mode is localized pain, and muscle immobilization is
likely to be localized, due primarily to direct stimulation
of skeletal muscle fibres adjacent to the point of contact
with the electrodes.
The combined mode of operation — three-point
deployment option — is a hybrid of probe and drive stun
modes. If one of the two probes fails to make contact
with the subject during a probe mode deployment, or if
the probe spread is too small, the CEW deployment will
not achieve complete incapacitation. In this case, after
the probe deployment and with one or both probes still
embedded in the subject, the CEW hand-held unit can be
brought in contact with the subject. This increases the total
area covered by the combination discharge current and
can increase the likelihood of incapacitation and potential
health complications.
3 .4 	

C E W Wav efor m s

As mentioned previously, the strength and duration of
CEWs are effective in stimulating the nervous system and
inducing incapacitation and pain, but are less effective in
stimulating cardiac muscle. The variation in the strength
of an electrical discharge over its duration is known as its
waveform. The CEW waveform is intended to influence the
peripheral nervous system in a way that causes temporary,
involuntary, and uncoordinated skeletal muscle contraction
(Kunz et al., 2012). This phenomenon is also known as
neuromuscular incapacitation. The next few paragraphs
describe some examples of actual CEW devices and how
characteristics and waveforms differ among them.
The TASER® X26TM delivers 19 pulses per second over a
period of five seconds, with each individual pulse lasting on
the order of 100 microseconds (0.0001 seconds) (Sweeney,
2009a; Reilly & Diamant, 2011). The X26TM is capable of
generating up to 50,000 volts (peak open circuit voltage);
however, the actual voltage delivered to a human subject
when the device is applied to the resistance of skin and
other tissues has been measured to be between 1,000 volts
and 2,000 volts. Peak electric currents have been measured
at between three and four amperes (Sweeney, 2009a;

21

Reilly & Diamant, 2011; Kunz et al., 2012). The precise
value of current and voltage actually delivered to the subject
depends strongly on the nature of the contact between
the probe darts and the subject’s skin and clothing (Reilly
& Diamant, 2011).
In addition to duration, number, and peak voltage and
current of pulses, the detailed shapes of CEW waveforms
are also relevant for understanding physiological and health
effects on the human body. For example, the X26TM waveform
is composed of two phases: an initial 100 kilohertz oscillating
burst lasting 30 microseconds (0.00003 seconds); and
a longer, slowly oscillating tail lasting 70 microseconds
(0.00007 seconds) (Sweeney, 2009a). Laboratory
measurements and computer simulations of electrical
flow in the body suggest that the initial 100 kilohertz
burst is meant to reduce contact resistance with clothing
or skin, while the tail of this waveform drives the ensuing
neuromuscular incapacitation (Sweeney, 2009a).
The older TASER® M26TM device delivers a different
waveform. The M26TM waveform oscillates at a frequency
of 50 kilohertz, while the intensity of the waveform
decreases over a period of 40 to 50 microseconds (0.00004
to 0.00005 seconds). Similar computer simulations suggest
that the strong first 10-microsecond cycle of the M26TM
waveform (before the intensity decays) is responsible for
stimulating the uncontrolled muscle contractions that lead
to incapacitation (Sweeney, 2009b).
Figure 3.3 depicts various CEW waveforms to illustrate
the variability across devices.5 The performance of CEW
devices varies and their electrical outputs can change with
use and under different conditions, for example, under
variable temperatures or humidity (Adler et al., 2013;
NDC, 2013). Because these variations are common and
constantly evolving, each CEW device must be tested on
its own merit to assess performance and ability to induce
neuromuscular incapacitation while avoiding adverse
physiological and health effects. This constant evolution
and variation also mean that knowledge based on any
particular model does not necessarily translate to other
devices and that the characteristics of newer devices are
unknown. Further complicating the issue is that much of
the literature on the electrical characteristics of CEWs is
produced by CEW manufacturers or those affiliated with
the industry and not independent testing facilities.

5	 See McDaniel et al. (2009) and Reilly and Diamant (2011) for depictions of waveforms from additional devices including the Stinger ® S200TM,
Tasertron®, and Sticky Shocker®. For a more detailed discussion of variation in CEW waveforms and effectiveness in causing incapacitation, see
Comeaux et al. (2011) and Reilly et al. (2009).

The Health Effects of Conducted Energy Weapons

22

15.0
Taser® X26™
Taser® M26™
Taser® X2™

Current (amps)

10.0

5.0

0.0

-5.0

-10.0
-20

0

20

60

40

80

100

120

140

Time (microseconds)
Data source: Quality Engineering Test Establishment (QETE), Department of National Defence Canada, 2013

Figure 3.3
Waveform Comparison of TASER® Models
The variation in the strength (vertical axis) of an electrical discharge over its duration (horizontal axis) is known as its waveform. The CEW waveform is
intended to influence the peripheral nervous system in a way that causes temporary, involuntary, and uncoordinated skeletal muscle contraction. The
current waveforms of three CEW devices depicted in this figure were generated in the QETE laboratory by firing into a resistive load of 500-ohms (M26™)
and 600-ohms (X26™ and X2™). Notice that the waveforms for each device differ substantially from one another. Each waveform depicts a single pulse
of the given device, which will be repeated many times during a discharge. For example, the TASER® X26™ delivers approximately 95 pulses over five
seconds, which corresponds to a rate of 19 pulses per second (Adler et al., 2013).

One prominent question in cardiac CEW research is
whether CEW discharges can, in fact, cause abnormal
or dangerous heart rhythms, even though they stimulate
nerves and skeletal muscle more effectively than heart
muscle. That question is addressed more fully in Chapter 5.
Here, the Panel only notes that CEWs are more effectively
at preferentially targeting the skeletal muscle nerves,
by using a lower strength and shorter electrical pulse
duration than what is required to induce a potentially
fatal heart arrhythmia.6 In short, available information
on the strength, duration, and waveform of CEW devices
certainly supports the contention that they effectively target

6	

the skeletal muscle nerves with resultant neuromuscular
incapacitation and disabling pain (Reilly et al., 2009; Reilly
& Diamant, 2011). The possibility that CEWs can have
unintended consequences on heart rhythm and other
physiological systems, however, is still vigorously debated
and may depend on when the CEW is applied during the
timing of the heart’s natural electrical activity. In addition
to artificial electrical stimulation, heart rhythm can be
affected by mechanical force. Box 3.1 describes the effects
of mechanical force on the interruption of heart rhythm.

For more detailed and technical information, see Panescu and Stratbucker (2009); Reilly et al. (2009); Sweeney (2009b); Reilly and Diamant (2011).

23

The Design, Operation, and Intended Effects of Conducted Energy Weapons

Box 3.1 	
Mechanical Force and the Interruption
of Heart Rhythm
Mechanical force may be applied to the chest area during a
CEW deployment and it is well known that a rapidly applied
mechanical force to the area of the chest over the heart
(precordium) can result in the development of a potentially
fatal cardiac arrhythmia (Kohl et al., 2001; Nesbitt et al., 2001).
Arrhythmia typically occurs without any other measurable injury
to the heart and organs in the chest cavity. The phenomenon,
known as commotio cordis, is most often associated with a
very rapid and disorganized heart rhythm called ventricular
fibrillation (Link et al., 1998). The development of ventricular
fibrillation in this setting is influenced by (i) the location of
the impact on the chest, (ii) the stiffness of the impact object
(harder objects are more likely to induce ventricular fibrillation),
(iii) the velocity of the impact object (the minimum velocity
ranges from 48-64 km/h), and (iv) the timing of the impact
relative to the cardiac cycle (the vulnerable period represents
approximately two per cent of the duration of the cycle) (Link
et al., 1998; Link, 2012). Thus, it is a relatively rare event that
requires a confluence of factors for ventricular fibrillation
to be induced by direct physical force on the chest.
The kinetic energy of a standard CEW probe is 1.5 to 2.2 joules
(Dawes & Ho, 2012), and an extended-range CEW (designed
to be fired from a 12-gauge shotgun) fired from a closer
range than recommended has a maximum recorded projectile
energy of 50 joules (Kunz et al., 2011). It has been suggested
that this amount of impact energy is not sufficient to cause
internal organ damage. This assumption is based on the fact
that commotio cordis is typically associated with high impact
energy in sports such as baseball (150 joules) and hockey
(170 joules) (Kunz et al., 2011). Studies have not explicitly
identified, however, the minimum energy level required to
induce the condition, and no clear understanding exists of
whether factors such as pre-existing heart conditions could
lower the threshold required to induce this phenomenon. In
any event, adolescents are more susceptible to the condition
due to their body’s greater flexibility and ability to absorb
more force, which facilitate transmission of energy to the
heart (Deady & Innes, 1999). Adolescents may be at greater
risk of experiencing commotio cordis if exposed to projectiles,
but more research is needed. Overall, based on the available
technical specifications of the devices and the low momentum
of one or both probes striking the chest, it is very unlikely
that a CEW impact would result in ventricular fibrillation due
to commotio cordis.

3 .5 	Summary

CEWs deliver short, repeated pulses of electricity to the
skin and subcutaneous tissues through two metal probes.
They can be used in two operating modes; probe mode
carries the most risk of unwanted cardiac or other health
effects, given the greater likelihood of current running
through the tissues of the chest. In addition to causing
pain, CEWs influence the peripheral nervous system in a
way that causes temporary, involuntary, and uncoordinated
skeletal muscle contractions. The response to a CEW
depends on the strength, duration, and waveform of the
electrical discharge as well as the timing of when the
electrical current is applied in relation to the natural
electrical activity occurring in the body. The principle
guiding the functioning of the CEW is that the shortduration electrical discharges it delivers are highly effective
in stimulating nerves, causing incapacitation and pain,
but these discharges are much less effective in stimulating
the heart muscle and thereby inducing potentially fatal
disruptions to the heart’s rhythm. Specifications between
CEW devices are variable, however, and may change with
use and under different conditions. CEW devices and
the variations between them are also constantly evolving,
so knowledge based on any particular model does not
necessarily translate to other devices, and the characteristics
of newer devices are unknown. Evaluating the intended
and unintended effects of CEWs requires testing each
device on its own merit and understanding the context
and conditions under which it is to be used.

The Health Effects of Conducted Energy Weapons

24

4
Approaches to Conducted Energy Weapon Research

•	

Laboratory-Based Experimental Research

•	

Population-Based Epidemiological Field Research

•	

Summary

25

Approaches to Conducted Energy Weapon Research

4	

Approaches to Conducted Energy
Weapon Research

Key Findings
•	 Computer models are able to simulate different physical
characteristics of subjects and various CEW deployment
scenarios. Animal models allow for more intensive
experimental interventions, which can clarify the intensity
of various parameters that are required to consistently
achieve physiological and health-related effects following
CEW exposure.
•	 Despite the potential advantages, the applicability
of computer and animal models to human physiology
and real-world CEW exposures is unclear.
•	 Human laboratory-based studies allow for greater
applicability, but ethical constraints limit experimental
intervention. Field research can account for real-world
variables that cannot be simulated in the laboratory, but
if there are low injury rates and lack of standardization
it is difficult to establish meaningful associations.
•	 Given the advantages and disadvantages of current research
approaches, to reach any conclusions about the physiological
and health effects of CEWs it is beneficial to consider the
results of a range of varying study designs.

Biomedical and other research is performed to test
a predetermined set of hypotheses about the nature of
the relationship between a set of variables and a particular
outcome. Hypotheses may be tested through experimental
studies attempting to control or manipulate a set of variables
using computer models, animals, or humans, or through
field-based epidemiological studies, which study populations
in real-world circumstances. Each type of research comes
with its own set of challenges that may influence the
findings. Therefore, if a relationship is observed during
these studies, researchers may be able to establish an
association between a particular variable and an outcome;
however, because of the effects of chance, error, bias, or
confounding factors, a number of possible explanations may
exist to establish that relationship. An observed association
does not necessarily mean one variable causes the other,
and the apparent lack of an association does not necessarily
mean a causal relationship is absent. Judgment on whether
an observed association is causal is therefore a difficult task

that involves the review of multiple studies of varying designs
and the consideration of a range of criteria related to the
magnitude, consistency, and plausibility of the relationship
across all related studies (Rothman & Greenland, 2005).
The hypothesis that conducted energy weapons (CEWs)
might cause undesirable physiological or health effects
has been explored using a range of study types:
•	 laboratory-based experimental studies, including:
¡¡ computer modelling;
¡¡ animal model studies; and
¡¡ human studies; and
•	 field-based epidemiological study of real-world incidents
involving CEWs used on varying human populations.
To provide the necessary context for understanding and
assessing the available evidence on the physiological and
health effects of CEW deployment presented in Chapters 5
and 6, and the challenges involved in establishing associations
or cause-and-effect relationships (later discussed in Chapter 7),
this chapter discusses the advantages and disadvantages of
each approach to CEW research.
4 .1 	Laboratory-B ased
Ex per imental R esearch

4.1.1	 Computer Modelling
Computer modelling is a preliminary line of inquiry in the
field of bioelectricity, one which allows investigation without
subjecting humans or animals to electrical stimulation.
Mathematical and computer models have allowed researchers
to predict the probability of responses of excitable cells
and tissues, such as those that comprise the cardiovascular
and nervous systems, to internal and external electrical
stimulation. A typical model consists of two parts: (i) a system
of nonlinear differential equations that describe cellular
excitability; and (ii) a three-dimensional mathematical
description of human or animal anatomy in terms of
electromagnetic properties, such as a finite element model.
Such models are widely used for computer simulations of
cardiac therapeutic stimulation and defibrillation (Efimov
et al., 2009). Experts in the field generally agree that
while anatomy can be faithfully reproduced with simpler
mathematical models, electrical stimulation of the heart
should be simulated using more complex and physiologically
based versions, an example of which is bi-domain models
(Efimov et al., 2009).

26

Key Advantages
Simulating varying scenarios: By adjusting the variables of
a computer model and running additional simulations,
different scenarios can be investigated (e.g., different
probe locations, penetration depths, separation distances)
without having to use human subjects.
Accounting for body size variability: Researchers can account
for select tissue characteristics by using different models.
For example, the NORMAN model depicts the average
European man and the Visible Human model depicts a
larger man (Leitgeb et al., 2012b); and researchers have
used finite element models to mimic a very thin person
(Panescu & Stratbucker, 2009).
Accounting for known co-factors: Certain co-factors, such as
the presence of an implantable pacemaker or a metallic
stent, can be studied using computer modelling (Leitgeb
et al., 2012b). In addition, cellular excitability models can
be adjusted to account for various sympathetic nervous
system or metabolic states or for genetic predisposition
to sudden cardiac death.
Key Disadvantages
Applying relevant models: To date, an advanced bi-domain
model of CEW application has not been developed to
model electrical stimulation of the heart.
Accounting for unknown co-factors: Although computer
models can be modified to account for different physical
characteristics, it is difficult to model some mental
or physiological states (e.g., extreme agitation, drug
intoxication) that are commonly encountered in individuals
exposed to CEWs in the field. The unknown effects of some
unusually encountered or novel drugs on cellular ionic
channels, and therefore on cellular excitability, further
complicate the ability to establish appropriate models.
4.1.2	 Animal Model Studies
Biomedical research uses animal models in researching health
effects and therapies to avoid unnecessary harm to human
subjects until more knowledge can be obtained. Each study
has to be properly and ethically7 conceived, designed, carried
out, and independently replicated, with clear recognition
of the differences inherent in any animal model versus
a human subject. In the context of CEW research, the
Panel found most literature relies on animal models using
pigs, the use of sheep in one study being the exception
(Dawes et al., 2010a). While the genetic endowment of pigs
and humans is remarkably similar, and while pigs share

The Health Effects of Conducted Energy Weapons

many of the mutations associated with disease in humans
(Lunney, 2007), the genetic variations translate into obvious
differences in anatomy, and less obvious differences in
physiology, which makes it challenging to extend some
animal model findings to humans.
Key Advantages
Anatomical relevance and variability: Data dating back to the
1930s show pigs to be sensitive to electrical induction of
ventricular fibrillation, especially in settings of ischemia
(restriction of blood flow to the heart) — a condition that
is particularly relevant for CEW research (Chan & Vilke,
2009). Similar to humans, the weights of pigs are highly
variable; this variation can be used to explore how different
physical parameters may relate to health complications,
such as the connection between weight and ventricular
fibrillation (McDaniel et al., 2005; Chan & Vilke, 2009).
Intensive techniques and co-factors: Fully anesthetized animals
provide enormous potential for various experimental
interventions and monitoring techniques (e.g., multiple
exposures, different probe placements, increases in CEW
charge or duration) that cannot be done with humans
(Chan & Vilke, 2009). It is also possible to replicate certain
field conditions by introducing illicit substances, such as
cocaine, to mimic drug intoxication (Lakkireddy et al.,
2006), or adrenaline to mimic sympathetic (adrenergic)
stress (Nanthakumar et al., 2006).
Key Disadvantages
Comparability of anatomy: Although pigs and humans have
similar cardiac muscle and coronary anatomy (Heusch et al.,
2011), the differences in the anatomy of pigs’ specialized
cardiac electrical conduction system (known as the Purkinje
network) may mean they respond differently to CEW
exposure. There are also differences in skin, connective
tissue, muscle mass, and body geometry between humans
and pigs that may affect comparability of research findings
(Chan & Vilke, 2009).
Comparability of context: Unstressed, resting, anesthetized
healthy animals are often studied. CEWs are used in
the field, however, to help restrain individuals who are
agitated, physically exerted, or possibly intoxicated (Walter
et al., 2008). Swine studies use anesthesia, assisted ventilation
techniques, and/or muscle relaxants that have their own
effects on cardiovascular function, muscle contraction, and
pulmonary ventilation (Walter et al., 2008); the applicability
of this data for understanding humans involves many
unverified and unverifiable assumptions.

7	 Each study must conform to ethical constraints on animal research, such as those outlined in the Canadian Council on Animal Care’s standards
and guidelines, and equivalent regulatory frameworks in other countries.

27

Approaches to Conducted Energy Weapon Research

Multiple exposures: Because sample sizes are generally small
(5 to 20 animals), to establish enough measurements for
comprehensive statistical analyses, each animal is often
exposed multiple times to make the total number of
discharges for the study several-fold higher. If the presence
of a health complication is observed (e.g., arrhythmia),
it can be difficult to ascertain if that complication is a
tissue response to the CEW or a result of changes in the
animal’s physiology due to multiple exposure events over
the course of the study.
4.1.3	 Human Studies
Experimental human studies have often involved a single
CEW exposure of 5 to 15 seconds to healthy, young,
and physically fit volunteers, followed by measurement
of various parameters such as cardiac rhythm or blood
chemistry to check for markers that indicate muscle
damage, stress, impaired respiration, or impaired cardiac
function. Investigators have begun attempting to replicate
field conditions by exposing subjects to CEWs following
physical exertion (Ho et al., 2007c, 2009a, 2009b) or alcohol
consumption (Moscati et al., 2010); deployment into the
chest to deliver a current across the heart has also been
done (Ho et al., 2008). While none of these interventions
can completely simulate field conditions, they lead the
way for more applicable CEW research.
Key Advantages
Sample sizes: In contrast to animal studies, human CEW
studies generally use larger samples of healthy volunteers,
made possible because thousands of officers undergo
training that includes discharge of the CEW in supervised
conditions where data can be collected.
General applicability: Concerns about differences between
animal study subjects and humans, and relevance of
computer models, are no longer issues.
Key Disadvantages
Study recruitment: Human volunteers that are not healthy
police officers may be reluctant to participate in CEW
studies, and research ethics committees may be hesitant
to approve studies (Chan & Vilke, 2009).
Physical characteristics of study subjects: Subjects are usually
law enforcement trainees with above average weights and
heights (Ho et al., 2007a, 2008), which may not reflect the
characteristics of those who are exposed in the field. Subjects

are also usually individuals without health complications
and who are not overly physically or mentally stressed nor
under the influence of illicit substances.
Limitations in experimental design: Probes are often deployed
into the backs of subjects or taped into conductive gel
on the skin, which does not mimic actual deployment
characteristics. Single, short-duration discharges are usually
used; however, in the field, multiple discharges may be
present. Procedures cannot involve invasive monitoring
or an endpoint of an intended adverse event, for ethical
reasons. Control groups (i.e., no exposure) and different
treatment groups (e.g., different exposure times or dart
placements) are often not present, due to limitations in
sample size and difficulties in creating fake deployments.
Blinded studies (where the subject does not know whether
he is receiving the intervention) are unlikely since the pain
of deployment is unmistakable. An additional technical
challenge occurs when attempting to record the heart’s
electrical wave pattern during (as opposed to before or
after) CEW exposure, because discharge of the device
interferes with this recording.
Cost: A comprehensive and detailed randomized controlled
trial is costly because of the equipment, infrastructure,
and human resources required to ethically and accurately
carry out such a study.
4 .2 	

Population-Based Epidemiological
Field R esearch

Large-scale epidemiological research that draws on
information captured from databases and records of realworld CEW deployments can capture a range of conditions
and circumstances. To date, however, published studies that
examine real-world CEW deployments have usually been
retrospective, relying on a range of data such as police
incident reports, medical exams, and autopsy reports to
create more complete pictures of events. Some authors have
also used information from media sources to evaluate cases
where CEWs are proximal to health effects. To date, most
of the CEW field research has focused on collecting data
on the types of injuries that occur, how often these injuries
happen, the characteristics of those who are most often
exposed to CEWs, and the rationale for CEW use. Some
attempt has also been made to reconstruct the details
surrounding CEW usage events, such as the number of
discharges and the anatomical location of the probes.

28

Key Advantages
Collection of real-world data: Collecting and analyzing data
from the types of subjects and events in which CEW
deployments actually occur allows researchers to assess
and evaluate CEW deployment outcomes across a wide
spectrum of variables that would not be captured using
healthy subjects in the laboratory.
Range of populations: Through the collection, analysis, and
reporting of statistical information across populations
exposed to CEWs, a common body of knowledge on CEW
use and its risks will become available. It is impossible to
acquire this through individual case evaluations or single
outcome experimental designs.
Key Disadvantages
Incomplete reporting and diagnosis: Retrospective studies
rely on reports prepared by police and other nonmedical personnel, physicians, or coroners, which can
be incomplete. Data describing the details of a chaotic
use-of-force incident may be subject to recall bias and
recording errors, especially when information is requested
long after the event or if an adverse event has occurred
with disciplinary implications for the officer involved.
In some cases, determination of the presence of mental
illness or its features is made by police officers without the
benefit of accurate medical history, known diagnosis, or
qualified medical opinion (White & Ready, 2009). Even if
medical personnel are involved in preparing or evaluating
case reports, impressions from police officers at the scene
may be needed to make proper judgments and diagnoses
(Bozeman et al., 2012).
Lack of comparability across settings: Various independent police
agencies capture varying information for CEW incidents,
which prevents collation of large amounts of police data and
comparison between sites (unless an agency is specifically
participating in a research study). Even if a well-designed
field study is in place, real-world use-of-force events occur
in chaotic settings where measurements cannot always be
taken at ideal moments.
Need for certain prevalence of injury: Some studies attempt
to link the characteristics of a subject, or the details of a
CEW incident, with physiological and health effects (e.g.,
exploring associations between number of discharges and

The Health Effects of Conducted Energy Weapons

certain injuries) (Bozeman et al., 2009b). It is often difficult,
however, to perform these types of analyses because injuries
more serious than superficial puncture wounds (caused
by probe penetration) are rare, even in studies involving
over a thousand subjects (Bozeman et al., 2009b; Strote
et al., 2010b).
Lack of adequate control groups: To properly examine co-factors
that may lead to physiological or health effects following
exposure to CEWs or other uses of force, investigators must
examine the same factors (e.g., presence of drugs, restraint
tactics) in CEW incidents that do not result in death and
in similar use-of-force incidents that do not involve CEWs.
Although these comparisons may be adequately performed
in some cases (White & Ready, 2009), other studies do
not have controls, focusing solely on analyses of a few
fatal CEW incidents (Strote & Hutson, 2006; Swerdlow
et al., 2009; Vilke et al., 2009a; Zipes, 2012). Selection
bias can be introduced by including only fatalities or
health complications in the evaluation, resulting in overrepresentation of the condition being studied.
4 .3 	Summary

Research on the physiological and health effects of CEW
exposure includes a range of study types, each with its
own advantages and disadvantages. Computer and animal
models allow researchers to simulate or physically test
parameters such as deeply embedded probes and more
intense discharges, which is not possible in human subjects.
By testing scenarios that are more severe than those that
will likely be encountered in real-world situations, these
experiments can help define the upper safety limits for
certain CEW parameters. The uncertainty surrounding
the applicability of these models to human physiology
and to real-world CEW exposures, however, creates several
challenges. Human laboratory experiments address
some of these challenges, but ethical constraints limit
experimental intervention in human subjects. Populationbased epidemiological field research can account for realworld variables that cannot be simulated in the laboratory,
but low injury rates and lack of complete and consistent
data sets make meaningful associations difficult to establish.
Nonetheless, the combination of this range of study types
will continue to further our knowledge surrounding the
overall health effects of CEW exposure.

Physiological and Health Effects Associated with Conducted Energy Weapons

5
Physiological and Health Effects Associated
with Conducted Energy Weapons
•	

Neuroendocrine Effects and Activation of the Human Stress Response

•	

Disruption of Breathing and Impact on Blood Chemistry

•	

Disruption in Heart Rhythm and Rate

29

The Health Effects of Conducted Energy Weapons

30

5	

Physiological and Health Effects
Associated with Conducted
Energy Weapons

Key Findings
•	 The absence of evidence on neuroendocrine, respiratory, and
cardiac effects of CEW electrical discharge suggests that
ongoing and more comprehensive investigations are required.
•	 CEWs can induce the release of catecholamines (e.g.,
adrenaline), with undetermined health effects.
•	 Animal studies indicate an association between respiratory
complications and prolonged or repeated CEW discharge;
although published experimental data identify respiratory
changes in healthy human subjects typical of vigorous
physical exertion, studies involving more heterogeneous
groups, and humans subjected to prolonged or repeated
exposure, have not been conducted.
•	 Some animal studies suggest CEWs can induce fatal cardiac
arrhythmias when a number of discharge characteristics,
alone or in combination, are in place: probe placement on
opposite sides of the heart (i.e., current delivered across
heart); probes embedded deeply near the heart; increased
charge; prolonged discharges; or repeated discharges. These
studies indicate biological plausibility of adverse health
outcomes following CEW exposure.
•	 A small number of human cases have found a temporal
relationship between CEWs and fatal cardiac arrhythmias,
but available evidence does not allow for confirmation
or exclusion of a causal link. If a causal link does exist, the
likelihood of a fatal cardiac arrhythmia occurring would be
low, but further evidence is required to confirm the presence
and magnitude of any risk.
•	 The roles of co-factors that may increase susceptibility to
adverse effects, such as drug or alcohol use, body type, and
health status, have not been adequately tested to properly
establish an understanding of vulnerability in humans.
This chapter reviews and assesses the available primary
evidence — the literature and results of population-based
epidemiological studies and experimental research (discussed
in Chapter 4) — on the three adverse physiological and
health effects most often associated with conducted energy
weapon (CEW) exposure and discussed as potential
mechanisms for sudden unexpected death:
•	 neuroendocrine system: activation of the human stress
response and build-up of related levels of stress hormones
such as catecholamines;

•	 respiratory system: mechanical impairment of breathing,
changes in blood chemistry, and resulting acidosis; and
•	 cardiovascular system: changes to heart rhythm and rate
and potential for arrhythmias (abnormal heart rhythm).
The chapter also examines a range of potential co-factors
that, individually or in combination, could increase the risk
or severity of these effects and increase the risk of sudden
unexpected death. In this report, the Panel characterizes cofactors as internal, related to states intrinsic to the individual;
or external, acute situational factors related to the event itself.
Internal co-factors include alcohol or drug intoxication,
pre-existing health complications, implantable medical
devices like pacemakers, and body type. External co-factors
include physical restraint, physical exertion, and a variety of
CEW deployment characteristics such as strength of charge,
length and number of discharges, and probe location and
depth. The majority of the research identified by the Panel
and reviewed in this chapter evaluates potential cardiac
responses to electrical discharges from CEWs in the presence
of various co-factors.
5 .1 	

Neuroendocr ine Effects
and Activation of the H uman
Stress R esponse

5.1.1	 Basic Physiology
The neuroendocrine system is made up of the nervous
and endocrine systems. The brain responds to stress by
activating a structure known as the hypothalamus that, in
turn, activates the pituitary gland at the base of the skull,
which is the master gland of the endocrine system. The
release of the adrenocorticotropic hormone (ACTH) from
the pituitary gland stimulates the release of stress hormones
(also known as catecholamines), such as adrenaline and
noradrenaline. Together, these hormones mediate many
of the physiological reactions of the body to stress and
are largely the focus in research assessing the health
implications of CEW use.
Because CEWs are largely deployed in situations where law
enforcement officers are attempting to subdue or restrain
an individual, a wide range of stimuli may be involved in
activating the stress response, including physical threat,
struggle, injury, or pain (NIJ, 2011). In response to these
stimuli, the body elicits a fight-or-flight reaction that produces
endorphins to help modulate pain, and hormones to increase
heart rate, metabolism, and other functions that help prepare
the body to deal with the stressor. Because the levels of
hormones (e.g., adrenaline) increase in the blood in a
stressed individual, they can serve as biomarkers indicating
the activation of the human stress response (Dawes & Kroll,

Physiological and Health Effects Associated with Conducted Energy Weapons

2009). There is some disagreement, however, regarding
exactly which markers are reliable and accepted for identifying
and measuring catecholamine levels in the blood and for
determining when those levels are dangerous (NIJ, 2011).
The fight-or-flight response to an acute physical or
psychological stress is unlikely to pose a risk to a normal,
healthy individual; after all, this response would not have
evolved if it were frequently likely to cause injury. The
release of these hormones can induce several adaptive
responses including stronger cardiac muscle contractions
and heart rate, increased blood pressure, increased
metabolism, and increased production of heat. If these
hormones are present over a long enough period of time
or interact with other health risks, they may induce several
maladaptive responses including reduction in blood flow
to the heart, irregular heart rhythms, decreased heart
rate, abnormal build-up of fluid in the air sacs of the
lungs, metabolic acidosis, hyperthermia, or sudden death
(Laposata, 2006; Dawes & Kroll, 2009). Elements of the
stress reaction such as rapid heart rate, elevated blood
pressure, and increased tendency of the blood to clot
are also additional risk factors for those already at risk of
cardiac arrhythmias, coronary artery blockage, or strokes.
Psychological factors such as fear, anger, apprehension, and
confusion can by themselves elicit or heighten a person’s
stress level and the stress response (NIJ, 2011). The pain
induced by a CEW could be enough to stimulate the stress
response and likely enhance the effects of these stressors.
Psychological stressors can also be exacerbated in situations
where individuals feel that the circumstances are out of their
control. The severity of the stress response may increase
with the presence of other co-factors such as pre-existing
medical or psychiatric conditions, or stimulants and drugs
(Dawes & Kroll, 2009). An important question is whether
a CEW discharge applied to an individual already under
stress can further heighten the stress response sufficiently to
harm the individual either through increased psychological
stress (e.g., fear of pain or dying) or physical stress (e.g., the
intense pain induced by a CEW).
5.1.2	 Impact of CEWs on the Stress Response
There is speculation that CEW discharge may induce
the stress response, increasing the risk of adverse health
complications and death (Dawes & Kroll, 2009). The
Panel, however, found few studies that specifically
examined the relationship between CEW deployment
and the stress response. In the limited studies available,
researchers used animal and human models to explore
the associations between various forms of restraint,
including CEWs, and biomarkers of the stress response

31

such as the presence of stress-related hormones.
Results indicate that although CEWs can induce the
stress response, the increased hormone levels seen as
a result of CEW exposure are lower than levels activated
by other forms of restraint and stress, and decrease over
time. Key studies include the following:
•	 Werner et al. (2012) explored the effects of stress and
other physiological processes in swine by exposing pigs
to a one-minute CEW discharge, followed by a one-hour
rest and a second discharge of three minutes. Overall,
catecholamines increased during and immediately after
each CEW application, followed by a gradual decline
over time.
•	 Dawes et al., (2009), in a study involving law enforcement
agents, examined the capacity of different types of restraint
mechanisms (and other interventions) to elicit the human
stress response, including pepper spray (oleoresin capsicum
spray), a five-second CEW exposure, cold water tank
immersion, and physical exertion. The authors concluded
that although the CEW did elicit an increase in stress
hormones, physical exertion and pepper spray activated
the stress response more than exposure to a CEW or a
cold water tank.
5.1.3	 Impact of Co-Factors
The situations in which CEWs are deployed are complex
and dynamic and a number of factors may influence the
relationship between CEW exposure and the stress response.
Many of these (such as physical exertion, stimulant use or
withdrawal, and restraint) can activate the stress response,
making it hard to determine the direct effects of CEWs or
any other factor. Further complicating our understanding
is the combined or multiplicative influence of these various
factors. For instance, animal studies (using rats) have
shown that catecholamine levels increase when subjects are
exposed to a combination of stimulants (such as cocaine)
and physical exertion, which is greater than the effects of
either of those stimuli alone (Han et al., 1996).
The Panel identified little research that directly explored
the relationships between CEWs, the stress response, and
co-factors that could increase the likelihood or severity
of the stress response. One experimental study, however,
used a limited number of subjects (n=66), consisting of a
mix of law enforcement officers, public safety personnel,
and academic researchers, to explore the impact of arrestrelated situations on catecholamine levels and other
biomarkers of stress (Ho et al., 2010). Researchers evaluated
the impacts of external stimuli including a simulated
sprint, physical resistance, a 10-second CEW discharge,
a dog chase, and exposure to pepper spray (oleoresin
capsicum spray). Results indicated that although prolonged

The Health Effects of Conducted Energy Weapons

32

or multiple exposures to a CEW increased hormone levels,
the total catecholamine level induced by CEW exposure
was approximately one-half or one-quarter the observed
levels induced by fleeing or physical resistance, respectively
(Ho et al., 2010). Despite these results, it is unlikely that
such tests carried out in controlled situations can mimic
exactly the stresses experienced in real-world situations. In
particular, the key psychological elements of unpredictability
and powerlessness are largely missing, which reduces the
ability to draw any definitive conclusions.
5.1.4	 Summary of the Evidence
Based on the limited research available, CEW exposure
can induce the stress response and increase hormone
levels, and the risk of resulting stress-related adverse health
complications appears similar to vigorous physical exertion.
This conclusion, however, is limited by small sample sizes and
a lack of epidemiological studies and explorations of realworld scenarios that capture the physical and psychological
aspects of stress seen in typical CEW deployments. Finally,
the disagreement over reliable and accepted markers for
identifying and measuring catecholamine levels in the
blood, and for determining when those levels are dangerous,
greatly affects the ability to draw any definitive conclusions
from the research to date (NIJ, 2011).
The most reasonable conclusion to draw is that we do
not know to what extent the discharge of a CEW adds
to the high levels of stress already being experienced by
an individual in an arrest scenario. Addressing this issue
with field research would be challenging because it would
require knowing the levels of stress biomarkers in individuals
both before and after CEW discharge — a practical
impossibility. Additional carefully controlled studies with
healthy volunteers are needed. These studies would be
strengthened by superimposing CEW discharge upon other
stressors such as exertion or psychological stressors, and by
measuring the possible additive effect of CEW discharge
on the stress response caused by other stressors at the time
of discharge. Studies that ethically and safely incorporate
the highly stressful elements of unpredictability would
also be beneficial.
5 . 2	

D i srupt i on of Breath i ng and
I m pact on Blood C he m i stry

5.2.1	 Basic Physiology
The primary function of the respiratory system is continuous
gas exchange, involving inhalation, which supplies the body
with oxygen, and exhalation, which removes carbon dioxide
from the body. To maintain the acid-base balance in the
blood, the body increases or decreases its respiration rate

and tidal volume and resulting gas exchange, based on the
demands of a given situation. For instance, when exercising,
muscles and organs demand more oxygen, and intense muscle
activity can create a build-up of lactic acid in the blood that
can lead to increased blood acidity (acidosis). This acidity
is mitigated through stimulation of respiration, resulting in
more oxygen entering the blood and more carbon dioxide
being removed (Roberts, 2000; Dawes, 2009; NIJ, 2011).
Processes such as hyperventilation, or over-breathing, remove
carbon dioxide at a faster rate than it is being produced by
the tissues, thereby causing the blood to become slightly
alkaline (respiratory alkalosis); conversely, processes such
as hypoventilation, which can be caused by some opiate
drugs, result in decreased removal of carbon dioxide, causing
respiratory acidosis (Dawes, 2009).
The respiratory system is composed of a number of key
muscles that help carry out this function. The diaphragm is
the primary muscle involved in normal breathing, helping
to pull air into the lungs when it contracts and subsequently
eliminating carbon dioxide on exhalation when it relaxes.
The intercostal, scalene, and accessory muscles raise and
stretch the rib cage during inhalation to increase the
volume of the thoracic cavity during increased activity
(Roberts, 2000; Dawes, 2009).
In exploring the relationship between electrical discharge
and respiratory function, CEW studies measure changes in
respiration, impact upon muscles involved in respiration,
impairment of breathing (both inhalation and exhalation),
and changes in blood chemistry and acidity.
5.2.2	 Impact of CEWs on Respiratory Function
Because breathing depends on the contractions of various
respiratory muscles, one could speculate that involuntary
muscle contractions caused by CEWs could impair proper
muscle functioning and the respiration process during
exposure to a CEW discharge (Dawes, 2009; Reilly &
Diamant, 2011). The intense muscle contractions involved in
the incapacitation of an individual during a CEW discharge
could also lead to increased production of lactic acid and
blood acidity (Dawes, 2009). Impairment of the breathing
process could lead to:
•	 diminished ability to remove carbon dioxide from the
blood (hypercarbia), which results in the retention of
carbon dioxide and subsequent production of excess
hydrogen ions leading to respiratory acidosis; or
•	 a lower ability to obtain oxygen (hypoxemia), which
could cause the body to resort to anaerobic metabolism,
resulting in metabolic acidosis or the accumulation of
acid in the blood and tissues.

Physiological and Health Effects Associated with Conducted Energy Weapons

The presence of severe metabolic and respiratory acidosis
has been shown to cause a wide range of dysfunction
in various organs in the body including impairment in
cardiac function, sensitization to disruption in heart
rhythm and rate, decreased respiratory muscle function and
hypoventilation, elevated blood potassium levels, protein
degradation, coma, and death (Adrogue & Madias, 1998).
To explore whether these adverse physiological changes
occur during exposure to a CEW discharge, studies have
examined changes to the following:
•	 tidal volume: the volume of each breath, which is usually
7 to 8 millilitres per kilogram of body weight per
inspiration (ARDS Network, 2000);
•	 respiratory rate: the number of breaths taken within
a minute, which is usually 12 to 18 (Sherwood, 2006);
•	 blood acidity: a measure of the balance between acidity
and alkalinity, with normal pH being very close to 7.4
on a scale of 1 to 14;
•	 lactate levels: the blood lactate concentration, which is
usually 0.5 to 1 mmol/L in unstressed individuals; and
•	 carbon dioxide partial pressure (PCO2): the partial
pressure of carbon dioxide in the blood. Arterial PCO2
is preferred but venous PCO2 is commonly used as
a replacement. Normal values are between 35 and
45 millimetre Hg (Lemoel et al., 2013).
Each of these standard or normal rates varies based on
the characteristics of an individual and formulas used to
calculate them. When combined, however, these measures
allow for proper understanding of changes to respiration,
muscle functioning, and blood chemistry, which may
indicate the presence of acidosis and subsequent risk of
adverse outcomes.
Observations from Animal Studies
Some animal studies have demonstrated a relationship
between respiratory complications (including cessation
of breathing and changes in blood chemistry) and CEW
exposure (for a summary of these studies, see Appendix C).
Studies involving swine indicate the presence of breathing
impairment, decreased pH levels, increased lactate levels,
and higher PCO2 levels:
•	 Breathing impairment: Multiple studies note inhibition
of spontaneous respiratory effort during CEW exposure
(based on visual inspection or tidal volume) and decrease
in respiration rate post-exposure (based on breaths
per minute) (Dennis et al., 2007; Jauchem et al., 2009b;
Jenkins et al., 2013).

33

•	 pH: Clinically meaningful reductions in blood pH were
measured in several studies, with baseline values of ~7.4
and post-exposure values ranging from 6.8 to 7 (Jauchem
et al., 2006; Dennis et al., 2007; Jauchem et al., 2009b;
Jenkins et al., 2013).
•	 Lactate: Several studies reported post-exposure lactate
values 9 to 14 times higher than pre-exposure values,
increasing from ~1-1.5 mmol/L to 14-22 mmol/L (Jauchem
et al., 2006; Dennis et al., 2007; Jauchem et al., 2009b;
Jenkins et al., 2013).
•	 PCO2: Following exposure, PCO2 levels doubled from
~40-60 millimetre Hg to ~100 millimetre Hg (Jauchem
et al., 2006; Dennis et al., 2007; Jauchem et al., 2009b;
Jenkins et al., 2013).
The exposure time in the above experiments ranged from
30 to 80 seconds (or involved repeated five-second exposures).
Thus, it is not possible from the available data to identify
a precise duration that would elicit significant changes
in acid-base blood chemistry (Reilly & Diamant, 2011).
Furthermore, animal studies are commonly complicated by
sedation, and the animals’ breathing can be compromised
by the combination of CEW exposure, sedation, intubation,
and other sometimes unclear factors from the experimental
design, including relatively long duration and repeated
CEW exposures (NIJ, 2011; VanMeenan et al., 2011).
Observations from Human Studies
Despite some epidemiological evidence that the probes
of a CEW can puncture a subject’s lungs (Ryan, 2008;
Hinchey & Subramaniam, 2009), most research in humans
has demonstrated few respiratory-related health effects
resulting from the electrical effects of CEW exposure,
although the duration of the CEW discharge is much less
than that used in animal studies. Although some research
indicates impairment in inhalation during exposure to a
CEW, most studies show that tidal volume, respiratory rates,
and lactate levels typically increase in a manner consistent
with pain or intense physical exertion, and remain within
acceptable ranges. Regardless of the changes observed in
respiratory functioning during CEW exposure, subjects
appear to regain normal breathing ability following that
exposure. Key studies all involved five-second exposures
to the backs of law enforcement personnel using either
probe mode or alligator clips, so they do not provide any
information on the effect of probe placement or duration
of exposure. The following are some key examples:
•	 In a study by Vilke et al. (2007) ventilation, tidal volume,
and respiratory rate increased in all 32 subjects and
values returned to baseline after 10 minutes; there was
no evidence of hypoxemia or hypercarbia.

34

•	 A study of 23 subjects demonstrated both anecdotal and
measured reports suggesting that respiration, particularly
inspiration, was severely impaired; normal breathing
resumed once CEW exposure ceased (VanMeenen
et al., 2013).
•	 In a study involving 66 subjects, lactate levels immediately
increased, then decreased at 16 and 24 hours postdischarge (Ho et al., 2006).
5.2.3	 Impact of Co-Factors
The many factors involved in a CEW deployment scenario
may influence the relationship between CEW exposure
and respiratory function. Some attempts have been made
to evaluate internal co-factors such as alcohol intoxication,
as well as external co-factors such as prolonged exposures
to CEW discharges and physical exertion. Although limited,
these initial studies point to co-factors that could potentially
increase the likelihood or severity of the physiological
effects noted above.
Internal Co-Factors — Alcohol Intoxication
Alcohol intoxication appears to contribute to production
of lactate and acidosis in studies exploring prolonged
exposure. In a study of human subjects intoxicated with
alcohol and exposed to a 15-second CEW discharge,
researchers observed increases in lactate levels (to as
much as 4.19 mmol/L) and a drop in blood pH (to as
low as 7.31 from the 7.4 baseline measure). Researchers
concluded these transient changes were consistent with
what occurs with intoxication or moderate exertion and
not significant enough to result in lasting injury or death
(Moscati et al., 2010).
External Co-Factors — Prolonged Exposure
There is little research on the role of CEW discharge
characteristics, such as dart placement and depth, in
respiratory function (NIJ, 2011). There is speculation,
however, that long-duration or repeated CEW exposure
may be more likely than shorter single exposures to lead to
metabolic or respiratory acidosis, particularly in cases where
suspects exhibit severe non-compliance and aggression. Of
the few studies examining these factors, some have indicated
increased lactate levels similar to those experienced during
vigorous physical exertion when participants are exposed
to a 10-second discharge, while others have demonstrated
no significant changes in tidal volume, respiratory rate,
hypoxemia, or hypercarbia after exposures of up to
15 seconds. For instance, one study of human subjects
observed that exposure to prolonged discharges of
10 seconds can lead to elevated levels of lactate, to as high

The Health Effects of Conducted Energy Weapons

as 5.52 mmol/L (Ho et al., 2010). Another study comparing
respiratory parameters pre-, during, and post-CEW
exposure revealed that adult law enforcement personnel
demonstrated normal tidal volume and no observed
hypoxemia, hypercarbia, or disruption of breathing rate
(Ho et al., 2007a).
External Co-Factors — Physical Exertion
Strenuous physical exertion can produce increased lactate and
metabolic acidosis. Box 5.1 describes the relationship between
CEWs and rhabdomyolysis — a health complication arising
from excessive physical exertion or stress and often associated
with acidosis. It stands to reason that exposure to a CEW
discharge may worsen these physiological changes, increasing
the risk of acidosis and related health complications. Although
few studies have examined this relationship, it appears that
although CEW exposure can increase lactate levels, it does
not increase them any more than vigorous physical exertion,
which, in severe situations, could increase to as much as
approximately 20 mmol/L (Hargreaves et al., 1998). For
example, in a study involving CEW discharge on physically
exhausted subjects, physical exertion alone led to a reduction
in baseline pH from 7.38 to 7.23, and, following a 15-second
CEW exposure, pH was 7.22. Concurrently, lactate levels went
from a baseline of 1.65 mmol/L to 8.39 mmol/L during
the exercise protocol and 9.85 mmol/L after electrical
discharge (returning to baseline after 24 hours) (Ho et al.,
2009a). In a related study involving healthy law enforcement
personnel, a five-second CEW exposure following vigorous
exercise demonstrated no clinically significant changes
in respiratory rate, ability to breathe, or blood chemistry
(Vilke et al., 2009b). Neither study indicated the presence
of severe or lasting acidosis, nor were the additive effects of
CEW exposures clinically significant.
Experimental studies of CEW exposure in the context of
physical exertion are highly relevant to real-world CEW
incidents that often occur with extremely agitated subjects
who are possibly exerting themselves far beyond a resting
state (for example, during pursuit or restraint). Hick et al.
(1999) presented a case series of five individuals with severe
metabolic acidosis (pH ranging from 6.81 to 6.25) who all
struggled violently during restraint by law enforcement.
Four of these cases were fatal. Although CEWs were not
involved in these incidents, the events emphasize the
occurrence of acidosis within use-of-force events more
generally and with extreme exertion alone, which may
complicate the ability to draw any conclusions about the
specific effects of CEWs.

35

Physiological and Health Effects Associated with Conducted Energy Weapons

Box 5.1 	
Rhabdomyolysis and Changes
in Blood Chemistry
Rhabdomyolysis is a clinical condition that develops when
skeletal muscle is broken down and its contents are released
into the bloodstream. It is caused by overuse of muscle fibres
or muscle injury associated with events such as excessive
physical exertion, or electrical injury involving a strong current
conducted through the body (Moscati & Cloud, 2009). Diagnosis
of the condition is characterized through measurements of
serum markers of muscle injury such as creatine phosphokinase
(CPK) and myoglobin, both released from ruptured muscle
fibres. Complications arising from rhabdomyolysis include
metabolic acidosis, excessive potassium ion concentration,
and increased blood clotting, all of which can lead to cardiac
arrhythmias (Moscati & Cloud, 2009). The most often noted
complication associated with the condition is acute renal
(kidney) failure. A diagnosis of rhabdomyolysis following a
CEW exposure could be indicative of skeletal muscle injury
and increased risk for cardiac or renal complications (Moscati
& Cloud, 2009; Reilly & Diamant, 2011).
Research studies (Bozeman et al., 2009b) and case reports
(Schwarz et al., 2009; Sanford et al., 2011) suggest mild
rhabdomyolysis is observed in very few cases of CEW exposure,
and when it is identified there are a number of co-factors
present (e.g., stimulant use and physical exertion) that have
been implicated in the development of the condition in the
absence of CEW application. Although associations between
CEW application and the development of rhabdomyolysis are
limited, the health effects of prolonged or multiple discharges
remain untested in humans (Reilly & Diamant, 2011).

5.2.4	 Summary of the Evidence
Studies of animals subjected to prolonged or repeated CEW
exposure indicate the potential for respiratory complications
(e.g., pronounced acidosis). Published experimental studies
identify few complications in healthy human subjects, but to
date, this has not been fully investigated in other populations.
One possible reason for this conflict could be that animal
studies are commonly complicated by sedation, which
depresses respiration; and the animals’ breathing can be
compromised by the combination of CEW exposure, sedation,
intubation, and other, sometimes unclear, factors from the
experimental design (NIJ, 2011; VanMeenan et al., 2011).

When considering the effects of co-factors that may worsen
health complications, such as alcohol intoxication, prolonged
exposure, or physical exertion, research suggests CEW
discharge does not impact breathing and blood chemistry
beyond the typical changes seen during vigorous physical
exertion. The effects on subjects with lung disease, however,
are unknown. There are limited data on the impact of probe
positioning on respiration (NIJ, 2011) since studies examining
the impact of discharge characteristics have focused mostly
on cardiac responses (discussed in Section 5.3).
5 .3 	

Disruption in H eart R hythm
and R ate

5.3.1	 Basic Physiology
The heart is a specialized muscle that pumps blood
throughout the body through a series of coordinated
contractions, under the influence of electrical activity.
The heart consists of four chambers: the two atria,
which pump blood returning from the veins at low
pressure into the ventricles; and the two ventricles.
The right ventricle pumps deoxygenated blood to the
lungs, and the left ventricle pumps oxygenated blood
to all the body’s organs at relatively high pressure.
As previously noted, the beating of the heart results from
an electrical impulse generated from the sinoatrial node,
at a rate of 60 to 100 beats per minute (Katz, 2010).
5.3.2	 Impact of CEWs on Cardiac Function
External electrical stimulation has the potential to disrupt
the heart’s internal electrical system, which may translate
into adverse physiological effects and health complications.
Cardiac disturbances considered in research exploring the
impacts of CEW exposure include ventricular fibrillation,
ventricular tachycardia, cardiac capture, and pulseless
electrical activity. Although each of these has the potential to
cause fatal cardiac arrest if the disturbance is not terminated
in time (NIJ, 2011), the two most studied are:
•	 Ventricular fibrillation: Irregular, rapid, and
uncoordinated contraction of the ventricular muscle
due to rapid repetitive excitation of the muscle fibres with
inadequate ventricular contraction. These disorganized
contractions of the ventricles lead to ineffective ejection
of blood from the heart, which may cause cardiac arrest.
(O’Toole, 2003; Rubart & Zipes, 2005).
•	 Cardiac capture: The induction of at least one extra
heartbeat by electrical stimulation. This results in a change
to the heart’s rhythm and requires far less charge than does
the induction of ventricular fibrillation (Kroll et al., 2009).

The Health Effects of Conducted Energy Weapons

36

Experiments performed in computer, animal, and human
study models seek to determine whether electric stimulation
from CEWs can directly disrupt cardiac rhythm and rate,
causing cardiac disturbances. Generally speaking, animal
model studies suggest that ventricular fibrillation is a
possible, although highly unlikely, event that is dependent
on the location and depth of the CEW probes and the
length of the CEW discharge. Even if the location and depth
are set for maximal probability of ventricular fibrillation
induction, it is still unlikely to occur in real-world CEW
applications given the charge strength of a standard CEW
(see Section 5.3.3 for a thorough review of these factors).
No cardiac arrhythmias have been observed in experimental
human studies using commercially available CEWs; however,
an episode of cardiac capture was observed in a study by Ho
et al. (2011c) during experimental testing of an unreleased
CEW. The device was discharged for 10 seconds, with one
probe in the centre of the subject’s chest and one near the
right hip. The CEW was then redesigned and testing of the
new version proceeded without incident (Ho et al., 2011c).
This episode supports the idea that certain waveforms may
capture the heart.
In the field, there has not been a conclusive case of fatal
ventricular fibrillation caused solely by the electrical effects
of a CEW (NIJ, 2011). A small number of human cases have
found a temporal relationship between CEWs and fatal
cardiac arrhythmias (Swerdlow et al., 2009; Zipes, 2012)
but they do not allow for confirmation or exclusion of
a clear causal link. The study by Zipes (2012) is particularly
questionable since the author had a potential conflict
of interest and used eight isolated and controversial cases
as part of the analysis (Myerburg & Junttila, 2012). In
addition, both studies examined individual cases of CEWproximal deaths without any corresponding data from
control cases where death was not the outcome (Swerdlow
et al., 2009; Zipes, 2012). Use-of-force events are complex
and chaotic, involving the interaction of many different
factors; therefore, it is difficult to consider the electrical
effects of CEWs on the heart in isolation. In many cases, it
is likely that several factors lead to the onset of arrhythmias.
However, without properly controlled, large-scale studies,
it is not possible to determine which factors are associated
with lethal cardiac effects and how CEWs interact with
these predisposing factors.
Nonetheless, as inconclusive as these studies may be, they
still provide some of the only available evidence from field
scenarios that explore cardiac disruption. Since subjects

8	

are not monitored during use-of-force encounters, it would
be extremely difficult to document arrhythmias during or
immediately following CEW exposure. Furthermore, even
in the laboratory it can be difficult to record the heart’s
electrical wave pattern during exposure, since the CEW
discharge interferes with this recording. Thus, technical,
situational, and other barriers (discussed in Chapter 7) have
limited the collection of population-based data to confirm
the speculation raised in these isolated case reports, but
the biological plausibility of arrhythmia is evident.
5.3.3	 Impact of Co-Factors
External co-factors most researched in the literature on
cardiac effects include the characteristics of the actual
CEW deployment (e.g., probe location and depth, strength
and length of charge, and deployment mode). While the
Panel acknowledges that properties of the CEW waveform
other than strength of charge (such as current and pulse
duration) are also important for determining whether the
heart is affected, delivered charge is the electrical parameter
that is commonly varied in experimental studies. Most
researched internal co-factors include presence of drugs
or alcohol, pre-existing cardiac conditions, implantable
medical devices, and body type. Many of these co-factors can
increase the risk for health complications in general, even
in the absence of a CEW. Although not investigated fully,
some co-factors point to potential increases in susceptibility
to disruption of cardiac function following CEW exposure.
External Co-Factors — Discharge Characteristics
Numerous aspects of the discharge itself undoubtedly
impact the likelihood that cardiac effects will ensue. It is
difficult to discuss these characteristics in isolation, since
studies often examine multiple characteristics without
controlling for the effects of each one. The Panel’s review
of the literature revealed four important features of a
discharge: probe location, probe depth, strength of charge,
and length and number of discharges.
An important issue in the discussion about probe location
is the position of the darts in relation to the heart. Darts
placed in various positions on either side of the heart will
cause the CEW current to flow across the heart. This results
in exposure of cardiac tissue to different current densities,8
which depends on the precise dart configuration (Leitgeb
et al., 2010). Darts in these positions may be referred to as
transcardiac vectors. Figure 5.1 depicts the placement of
probes across the heart.

Current density refers to the current per unit of area (i.e., the amount of current flowing through a given area). For example, it may be reported
as amps per metres squared (A/m2) or milliamps per millimetres squared (mA/mm2) (Holden et al., 2007; Leitgeb et al., 2010).

37

Physiological and Health Effects Associated with Conducted Energy Weapons

RIGHT LUNG

LEFT LUNG

CEW Probe

Left Atrium

Right Atrium

Right Ventricle

Left Ventricle

CEW Probe

Figure 5.1
Depiction of a CEW Probe Deployment to the Chest
It is generally thought that a CEW deployment to the chest holds potentially more risk for adverse health effects due to the increased likelihood of the
current from the device crossing the heart. This figure depicts the heart situated in the chest cavity. The CEW probes are positioned in such a manner
that the current from the device will directly cross the subject’s heart, thereby potentially increasing the risk of cardiac arrhythmias. For obvious ethical
reasons this type of deployment has not been extensively researched in humans, but it is important for understanding the physiological and health effects
of CEW use in relation to the heart.

For obvious ethical reasons, the effects of CEW discharge
characteristics on disruption of cardiac functioning have been
studied much more extensively in animals than in humans.
The main findings of these animal studies are as follows
(for more information on these studies, see Appendix D):
•	 Cardiac capture is more common when the CEW probes
are located such that a current pathway directly crosses
the heart; however, ventricular fibrillation is a rare
event (Nanthakumar et al., 2006; Lakkireddy et al., 2008;
Valentino et al., 2008a).
•	 As the distance from the tip of the probe to the heart gets
smaller, the likelihood of ventricular fibrillation increases
because the amount of current flowing through the heart
increases. If a dart were to penetrate fully (at the most
sensitive location) in a human with a small skin-to-heart
distance, it would be within the range at which pigs
experienced ventricular fibrillation. Approximately five
per cent of humans have a small enough skin-to-heart
distance for this to be possible (Wu et al., 2008).

•	 The strength of a standard CEW discharge is unlikely
to induce ventricular fibrillation. Generally, a charge of
between 5 and 15 times greater than standard is required
(McDaniel et al., 2005; Lakkireddy et al., 2008; Kroll
et al., 2009).
•	 Prolonged or multiple discharges may increase the risk
of ventricular fibrillation. Approximately 80 to 90
seconds of exposure, either delivered continuously
or with one short pause, has been shown to induce
ventricular fibrillation (Dennis et al., 2007; Walter et al.,
2008; Kroll et al., 2010); however, studies that directly
compare different charge lengths are lacking. There
is also evidence that ventricular fibrillation does not
occur during prolonged or multiple discharges, even
when the current is delivered across the heart. For
example, one study using a 60-second exposure failed to
observe any episodes of ventricular fibrillation (Jauchem
et al., 2009a). An additional study used a protocol that
involved five five-second exposures in a row, repeating
this pattern four times with rest in between, for a total
of 20 exposures in 31 minutes. Similarly, no episodes

The Health Effects of Conducted Energy Weapons

38

of ventricular fibrillation occurred (Esquivel et al., 2007).
In an extreme example, Jenkins et al. (2013) subjected
animals to up to 30 minutes of continuous CEW exposure;
although several animals died, the deaths were attributed
to mechanical cardiac muscle failure and not electrically
induced ventricular fibrillation.
More limited than animal studies, human studies primarily
involve discharges that do not deliver a current across the
heart. The CEW current is typically applied by firing the
probes into the backs of subjects (Ho et al., 2006; Dawes
et al., 2009); taping the CEW probes to the skin within
conductive gel (Ho et al., 2009b; Dawes et al., 2010d); or
attaching the CEW wires with alligator clips (Vilke et al.,
2008; Bozeman et al., 2009a). Many of these methods fail
to mimic the actual application of CEW devices in the field.
A few studies have tested discharges across the heart in
humans; two involved pre-placed probes (Ho et al., 2007c,
2008), and two involved discharges into the chest (Dawes
et al., 2010c; Ho et al., 2011c). As discussed in Section 5.3.2,
Ho et al. (2011c) observed a single episode of cardiac
capture during testing of a commercially unavailable CEW,
but no other cases of cardiac disruption have been noted
in any other study. No additional experimental studies with
healthy human volunteers have identified cardiac injury
(using direct cardiac monitoring or biomarkers) following
CEW exposures of less than 45 seconds (Ho et al., 2007a,
2009a, 2009b, 2011a; Dawes et al., 2010b; Moscati et al.,
2010; NIJ, 2011).
Exposures that deliver a current pathway across the heart
occur at a rate of approximately 15 per cent in the field
(Bozeman et al., 2012), but data relating probe location to
cardiac effects are not available. A retrospective study relying
on media reports of CEW events showed that fatal incidents
were more likely to involve multiple deployments than were
non-fatal incidents (White & Ready, 2009); however, these
results have been called into question due to the reliability
of the information sources used. Available evidence from a
few case reports of real-world incidents support a temporal
(but not necessarily causal) relationship between CEWs
and fatal cardiac arrhythmias (Swerdlow et al., 2009; Zipes,
2012). The study by Zipes (2012) examined eight cases of
sudden cardiac arrest where subjects experienced immediate
loss of consciousness following CEW exposure with at least
one probe near the heart. Autopsy reports indicated that
four subjects had structural heart disease. Initial cardiac
rhythms, recorded anywhere from 4.5 to 13 minutes after
CEW application, were ventricular fibrillation in 6 of
8 subjects. Zipes suggested that electrical stimulation
from the CEW in the presence of heart disease could have

disrupted cardiac rhythm. Details of the study by Swerdlow
et al. (2009) are discussed in Section 6.3. Although these
case reports are compelling, they can only point to potential
hypotheses and not any firm conclusions.
To estimate the probability of inducing ventricular
fibrillation without performing human experiments,
computer models and calculations based on electrostimulation laws have been used. The resulting
conclusions are:
•	 Probe depth and location: In agreement with animal
studies, computer models have indicated the probability
of ventricular fibrillation increases as the dart-to-heart
distance decreases (Sun et al., 2010; Leitgeb et al., 2011).
Based on current densities at various distances from the
tip of the CEW probe and typical skin-to-heart distances
in humans, ventricular fibrillation remains a possible,
though unlikely, event (Panescu et al., 2008). Although
computer models predict the overall risk is extremely low,
if the CEW probes land in a critical position (referred
to as a worst-case dart hit), the ventricular fibrillation
probability may increase to a level high enough to explain
occasional ventricular fibrillation (Leitgeb et al., 2011).
•	 Strength of charge: Using electro-stimulation standards
and existing experimental data, researchers determined
that a one-ampere current of a standard CEW pulse
is less than half the minimum strength required for
cardiac capture. The authors calculated that 0.4
per cent of individuals could experience cardiac
capture (but not necessarily ventricular fibrillation)
if the CEW probes were placed at the most sensitive
position (across the chest) (Ideker & Dosdall, 2007).
Using a computer-based model of a human, Holden
et al. (2007) calculated the peak current density at
the ventricles following discharge across the heart.
A current density greater than 60 times the value
predicted by the model was required to induce cardiac
capture in isolated guinea pig hearts, and ventricular
fibrillation required an even higher density (Holden
et al., 2007).
External Co-Factors — Deployment Mode
Studies have been conducted to determine the increased
cardiac risk for probe and drive stun modes (see Section 3.3
for a description of deployment modes). The risk of
ventricular fibrillation is extremely low when a CEW is
applied to a subject in drive stun mode (NIJ, 2011). First,
because the probes on standard CEWs are recessed (i.e.,
below the surface of the cartridge), they are not expected
to make perfect electrical contact with the subject’s body
when the cartridge is pressed against the subject (Panescu

Physiological and Health Effects Associated with Conducted Energy Weapons

et al., 2009). Second, computer modelling studies have
shown that when CEW darts are close together, much
of the current travels from one to the other near the
surface. Alternatively, when the darts are far apart (as in
probe deployment), the current travels deeper into the
tissue, potentially causing a higher current density at the
location of the heart (Sun & Webster, 2007). In animal
studies, discharges in drive stun mode of up to 80 seconds
on the hind limb (Valentino et al., 2007a, 2008b) or over
the heart (Valentino et al., 2007b) failed to induce any
cardiac rhythm changes.
When drive stun and probe modes are used together in
a three-point deployment option, the probes are applied
to the subject following firing of the darts. The current
passes from a single probe to either or both of two drive
stun probes that are pressed against the skin. Concerns
have been raised about use of this mode, with two drive
stun probes on a subject’s back and a probe lodged into the
subject’s chest (Panescu et al., 2009). A computer model
comparing current densities in the tissues following threepoint deployment and probe mode suggests that three-point
mode would be as safe as, or safer than, probe mode. The
model predicted that the majority of the current would
be shunted between the two drive stun probes instead of
penetrating deep into tissues (Panescu et al., 2009).
Internal Co-Factors — Drugs and Alcohol
Drug use is common in individuals exposed to CEWs
(NIJ, 2011). A handful of animal and human studies
have investigated the possible role of drugs or alcohol in
contributing to cardiac effects following CEW exposure.
One study examined the effect of cocaine on ventricular
fibrillation induction by CEWs in a pig model (Lakkireddy
et al., 2006). The authors concluded the drug actually
decreased the likelihood of CEW-induced ventricular
fibrillation, which is confusing because cocaine is known
for its pro-arrhythmic properties. The study, however,
was limited by lack of controls and the need for complex
manipulation of the animals (NIJ, 2011). In another
animal study using methamphetamine, CEW exposure
exacerbated atrial and ventricular irritability induced
by methamphetamine intoxication in sheep, but only
in smaller animals and not in larger, adult-sized ones.
Ventricular fibrillation did not occur in any of the animals
(Dawes et al., 2010a).
For ethical reasons, this is a difficult area to research in
humans. One study examined the effects of a 15-second
CEW exposure in alcohol-intoxicated individuals and found
no clinically significant effects on markers of cardiac injury;

39

however, direct cardiac monitoring was not performed
in this study (Moscati et al., 2010). Based on the Panel’s
analysis of these and related studies, it is not possible to
form any definitive conclusions about potential interactions
between drugs, alcohol, and CEW exposure in eliciting
cardiac effects.
Internal Co-Factors — Pre-existing
Cardiac Conditions
There is no evidence to show that electrical stimulation by
CEWs contributes to the development of cardiac conditions
such as coronary artery disease (narrowing of the vessels that
supply the heart with blood and oxygen) or cardiomyopathy
(weakening of the heart muscle) (Dosdall & Ideker, 2009).
Correlative studies have, however, shown a high incidence of
cardiac disease in subjects who died following CEW exposure
(Strote & Hutson, 2006; Swerdlow et al., 2009). Although the
deaths were all temporally proximate to a CEW incident,
the CEW was not ruled as a potential cause of death in
most cases (Strote & Hutson, 2006); therefore, it may be
fair to consider pre-existing cardiac conditions as potential
triggers for death following a use-of-force incident more
generally, rather than a CEW incident specifically (causes
and triggers of sudden unexpected death and sudden incustody death are discussed in more detail in Chapter 6).
Internal Co-Factors — Implantable Medical Devices
Electromagnetic interference is known to affect the
functioning of implantable cardiac devices such as
pacemakers and implantable defibrillators (Vanga et al.,
2009a). In general, pacemakers maintain heart rhythm
when it gets too slow, whereas implantable defibrillators
detect rapid rhythms and deliver an electric shock to reset
the electrical activity of the heart (NIJ, 2011). Although
potential interactions between CEWs and implantable
cardiac devices has been recognized, it is based on a few case
reports, none of which resulted in adverse health outcomes
(Haegeli et al., 2006; Calton et al., 2007; Cao et al., 2007).
Animal studies have not found any evidence that CEWs
have harmful effects on pacemakers and implantable
defibrillators following standard five-second discharges
(Vanga et al., 2009b). Although implantable cardiac devices
may sense the electrical activity of CEWs, they do not
actually deliver an abnormal shock or change native cardiac
rhythm following a short discharge (Lakkireddy et al., 2007;
Khaja et al., 2011). Upon sensing an abnormal rhythm, an
implantable defibrillator begins charging its capacitors,
and then reconfirms that the arrhythmia is present before
delivering a shock. Extended exposures that persist beyond
the charge and re-detection phases of an implantable

40

defibrillator may result in shock delivery (Calton et al.,
2007; Vanga et al., 2009a). Computer modelling studies
have similarly suggested that although CEWs likely would
not cause irreversible change or damage to implantable
cardiac devices, they may transiently interfere with the
function of these devices (Leitgeb et al., 2012a, 2012b).
Internal Co-Factors — Body Type
Although research has not been conducted on children,
the elderly, or subjects with low body weight, these groups
have been identified as populations that may be more
likely to suffer adverse effects following CEW exposure
than adults with larger weights (Panescu & Stratbucker,
2009; NIJ, 2011). To date, the only evidence that subjects
of smaller stature have a higher probability of ventricular
fibrillation comes from animal studies that have suggested
a lower body weight and a shorter distance from the probe
to the heart (dart-to-heart distance) correlate with a higher
likelihood of ventricular fibrillation (McDaniel et al., 2005;
Wu et al., 2008; Sun et al., 2010; Leitgeb et al., 2011). A
single case study describing the death of a seven-month-old
infant following the application of a CEW by a guardian
has been reported. The small size of the infant and the
location of CEW discharge (near the heart) suggested the
CEW injury was responsible for the infant’s death (Turner &
Jumbelic, 2003). While a higher body weight may protect a
subject from the electrical effects of CEWs, if an individual
is overweight or obese this may pose an increased risk for
other adverse effects during a use-of-force encounter, such
as a greater likelihood of experiencing compression of
veins carrying blood to the heart when prone positioning
is used (Brodsky et al., 2001; Ho et al., 2011b).

The Health Effects of Conducted Energy Weapons

5.3.4	 Summary of the Evidence
When considered as a whole, the research literature shows
that electrical stimulation of the heart by CEWs is unlikely
to disrupt cardiac rhythm and rate. Although the risk is
low, however, animal studies clearly support the idea that
it is biologically plausible for a CEW to induce a fatal
cardiac arrhythmia. These animal studies indicate that the
characteristics of a CEW deployment event, such as where
the probes land on the subject, how deep they penetrate,
and how long the device is discharged, affect the likelihood
of ventricular fibrillation. There is a very low probability
that, in a single discharge event, each of these variables
will be at the right value to cause a fatal cardiac episode;
however, an additional aspect of real-world CEW incidents
is the multitude of co-factors (e.g., illicit substances and
pre-existing cardiac conditions) that impact the probability
of adverse health effects. Experimental human studies
are performed primarily on healthy, physically fit men
and thus fail to capture these co-factors. In addition,
human laboratory studies often use discharges into the
back or exposure methods that do not involve probe
penetration, making these models less useful for studying
cardiac effects. Current field data, in the form of a few case
studies, support the existence of a temporal link between
CEWs and fatal cardiac arrhythmias, but a causal link can
neither be confirmed nor excluded at this time. Further
epidemiological evidence that provides information on the
role of co-factors involved in use-of-force events would help
elucidate the potential mechanisms of cardiac disruption
associated with CEW deployment.

Role of Conducted Energy Weapons in Sudden In-Custody Death

6
Role of Conducted Energy Weapons in Sudden In-Custody Death

•	

Potential Causes and Triggers of Sudden Unexpected Death

•	

Potential Causes of Sudden In-Custody Death

•	

Relationship Between CEWs and Sudden In-Custody Death

•	

Impact of Co-Factors

•	

Summary

41

The Health Effects of Conducted Energy Weapons

42

6	

Role of Conducted Energy Weapons
in Sudden In-Custody Death

Key Findings
•	 Sudden unexpected death is a rare event typically involving
various behavioural, environmental, and genetic factors.
It may result from numerous interactions of multiple
physiological systems, including the cardiovascular,
respiratory, and neuroendocrine systems.
•	 Sudden in-custody deaths resulting from use-of-force events
are complicated scenarios that may involve agitation,
physical or chemical restraint, disorientation, stress or
exertion, pre-existing health conditions, and drugs or alcohol,
all of which can potentially contribute to the death. This
makes it difficult to isolate the contribution of a single factor.
•	 Although evidence shows the electrical characteristics
of CEWs can potentially contribute to sudden in-custody
death, no evidence of a clear causal relationship has been
demonstrated by large-scale prospective studies. In a few
coroner reports, however, CEWs were ruled as the primary
cause of death in the absence of other factors and when
excessive exposure was present. Given the limited evidence,
a clear causal relationship cannot be confirmed or excluded
at this time.
•	 If a causal relationship does exist, the likelihood that a CEW
will be the sole cause of a sudden in-custody death is low.
The extent to which the device would play a role in any
death is unclear and dependent upon the co-factors involved.
Sudden in-custody death (also known as arrest-related
death) refers to “rapid, unexpected death during detention
of individuals by law enforcement or public safety personnel”
(Stratton, 2009). Sudden in-custody death can occur at
the scene of detainment, when the individual is being
transported, or at the detention facility (Wetli, 2009). These
fatalities typically involve complicated scenarios that include
agitation, physical restraint, disorientation, physical and
psychological stress, pre-existing health conditions, and/
or drugs or alcohol. Scenarios often initiate speculation as
to whether law enforcement agents may have precipitated
death by using excessive force in the detainment of the
subject (Ho et al., 2009c). In contrast to sudden cardiac
death and sudden death more broadly, literature discussing
sudden in-custody death is scarce (Stratton, 2009) and, even
after an autopsy has been performed, the cause of death
often remains inconclusive. Research suggests associations
between sudden in-custody death and individuals who are:

•	 in states of acute psychiatric agitation, hyperactivity,
or paranoia;
•	 unusually aggressive, strong, unresponsive to pain,
or sometimes acting destructively; and
•	 not responding appropriately to rational reasoning
or commands.
(Robison & Hunt, 2005)
Other features may also be present, and the precise
combination of characteristics can vary for each individual
and the context and circumstances of their involvement
with law enforcement. Figure 6.1 is a representation of the
most common factors discussed in the literature on the
health effects of conducted energy weapons (CEWs) and
the complex relationships among various factors and sudden
in-custody death.
This chapter begins with a summary of the evidence on the
causes and triggers of sudden unexpected death in general,
before focusing more specifically on sudden in-custody death
and the potential role of CEWs in those deaths. The Panel’s
discussion also focuses on two key co-factors often discussed
in the relationship between sudden in-custody death and
CEWs: mental illness and excited delirium syndrome.
6 .1 	

Potential C auses and Triggers
of Sudden U ne x pected Death

Sudden unexpected death describes death occurring within
a short timeframe after the onset of acute symptoms
(Stevenson et al., 1993). The term sudden cardiac death is
used when “a person dies suddenly and unexpectedly from
a suspected [primary] cardiovascular cause” (George, 2013).
Each year, up to 40,000 Canadians die of sudden cardiac
arrest (Heart and Stroke Foundation, 2012). The annual
incidence of sudden cardiac death in North America and
Europe ranges from 50 to 100 per 100,000 persons (Fishman
et al., 2010). Although often unexpected in otherwise healthy
individuals, it is usually related to a structural abnormality of
the heart or its blood vessels, which leads to fatal ventricular
arrhythmias. In adults of more than 40 years of age, the most
common cause of sudden unexpected death is coronary artery
disease (Tan et al., 2005). Diseases of the heart muscle (called
cardiomyopathy), defects in heart valves or ion channels, and
other congenital or genetic disorders may also lead to cases
of sudden unexpected death (Huikuri et al., 2001). Because
the prevalence of coronary artery disease increases with age,
the incidence of sudden cardiac death similarly increases
(Zipes & Wellens, 1998). In older individuals, sudden
cardiac death may be less sudden than the term suggests,
frequently occurring in people with a history of documented
heart disease and following symptoms that last for at least
two hours (Muller et al., 2006).

43

Role of Conducted Energy Weapons in Sudden In-Custody Death

Physiological Systems

Respiratory and Metabolic
Cardiovascular
Neuroendocrine

Sudden
In-Custody
Death
Internal Co-Factors
(Underlying Susceptibility)

External Co-Factors
(Situational Factors)

Intoxicants and Medications
Pre-Existing Physical and Mental Conditions
Body Type

Restraint
Trauma
CEW Use Characteristics
Mental Stress
Physical Exertion

Figure 6.1
Potential Factors Associated with Sudden In-Custody Death
Sudden in-custody death refers to rapid, unexpected death during detention of individuals by law enforcement or public safety personnel. It is a rare
event that may result from interactions of multiple physiological systems, including the cardiovascular, respiratory, and neuroendocrine systems. Sudden
in-custody deaths resulting from use-of-force events are complicated scenarios that may involve various genetic, behavioural, and environmental factors,
all of which can potentially contribute to death. This figure demonstrates some of the most common internal co-factors (intrinsic to individuals) and
external co-factors (inherent to the situations in which CEWs are deployed) represented in the literature on the health effects of CEWs; additional factors
may also be relevant. The complex relationships among all factors involved in CEW deployment scenarios make it difficult to isolate the contribution of
any single factor in a sudden in-custody death; more research will help to resolve this complexity.

In those younger than age 40, although the majority
of unexpected deaths are still cardiac related, other causes
such as respiratory (e.g., asthma) and neurological (e.g.,
epilepsy) diseases may be common (Vaartjes et al., 2009).
Other conditions associated with sudden unexpected death
include hemorrhage in the brain or another internal organ;
blood clots in major arteries supplying the brain, heart, or
lungs; and side effects or overdoses of drugs (Stratton, 2009).
In comparison to adults (age 19 or older), sudden cardiac
deaths in children and adolescents (age 2 to 18), although
rare occurrences, are more likely to occur during moderate
to vigorous exertion (Pilmer et al., 2013). This finding may
be relevant for adolescents involved in physically demanding
use-of-force encounters with law enforcement. Many sudden
unexpected death cases in young individuals, however, remain
unexplained because medical history and autopsy results are
absent or fail to provide a probable cause (Tan et al., 2005).

Even in cases where an underlying cause of death has been
identified (e.g., pre-existing coronary artery disease), it
is important to determine the event that precipitates or
triggers the cause in an otherwise healthy individual (Rubart
& Zipes, 2005). Researchers need to unravel the complex
interactions among various environmental, behavioural,
functional, structural, and genetic factors affecting both
the susceptibility to, and initiation of, sudden cardiac death
(Rubart & Zipes, 2005). Restriction of blood flow to the
heart is considered the most common triggering factor for
fatal arrhythmias. Other triggers can include alterations
in metabolism or neurotransmitters, and effects of drugs
or toxins (Huikuri et al., 2001). Causes of sudden cardiac
death, however, are determined after the fact by autopsy,
and factors that are able to predict an increased risk of
sudden cardiac death are largely unknown.

The Health Effects of Conducted Energy Weapons

44

The flow of ions (e.g., calcium, sodium, potassium,
and hydrogen) across the membranes of heart muscle
cells is ultimately responsible for electrical activation of
the heart. Therefore, proper ionic balance is essential
for coordinated contraction and relaxation of the
heart muscle (Rubart & Zipes, 2005). As demonstrated
in Chapter 5, the cardiovascular system is closely
linked with other physiological systems, such as the
respiratory and neuroendocrine systems. Disturbance
of any of these systems can trigger ionic imbalance and,
eventually, fatal arrhythmias. For example, excessive
exertion and elevated temperature, which may occur
during prolonged struggle, can both enhance carbon
dioxide production and promote the development of
respiratory acidosis. Acidosis elevates the incidence of
cardiac arrhythmias through various mechanisms such
as fluctuations in ions and increased catecholamine
(e.g., adrenaline) release (Epstein & Singh, 2001).
Physiologic stress (caused by exercise, emotion, arousal,
etc.) also activates the neuroendocrine system, leading
to release of catecholamines by neurons that innervate the
heart (Volders, 2010). Although the mechanisms are not
fully known, stress hormones can affect cardiac function
by disrupting ion flow and inducing myocardial ischemia.
Ischemia can further upset ionic balance and enhance the
likelihood of sudden cardiac death (Rubart & Zipes, 2005).
All of these factors, combined with genetic predisposition
and conditions such as obesity, coronary artery disease, and
diabetes, elevate the possibility of sudden cardiac death
during a physically or emotionally stressful situation.
Changes within each of the neuroendocrine, respiratory,
and cardiovascular systems have the potential to individually,
or in combination, act as mechanisms leading to sudden
unexpected death. During the investigation of a use-of-force
associated fatality, when co-factors such as health status of
the individual, presence of drugs or alcohol, occurrence
of a prolonged struggle, and use of restraint all need to be
considered, it becomes extremely difficult to determine the
contribution of each individual element involved in the
sudden unexpected death event. Ultimately, the effects of
CEW discharge within the complex interplay of physiological
changes are challenging to accurately determine.
6 . 2	

P otent i al Causes of S udden
In- C ustody Death

One of the most significant issues preventing a better
understanding of sudden in-custody death in Canada is the
lack of accurate, uniform, publicly available information,
along with any central database (see Section 2.3) to track

this phenomenon. Drawing conclusions about the role
of any single element in sudden in-custody death is further
complicated by two main factors:
•	 Low incidence: The low incidence of sudden in-custody
death in the real world of police use-of-force (Hall et al.,
2012) makes it difficult to set up prospective studies to
examine potential causes.
•	 Complexity of use-of-force events: The complexity and
uniqueness of each use-of-force event means it is often
impossible to collect enough useful data on arrest scenarios
to explore one particular factor consistently (NIJ, 2003).
For example, assessing the role of a pre-existing cardiac
condition in sudden in-custody death would, ideally,
involve a comparison of two groups with similar risk factors
and arrest circumstances (e.g., alcohol-intoxicated, obese,
highly agitated individuals who undergo one five-second
CEW exposure) that can only be differentiated based
on the presence or absence of a cardiac abnormality.
Although there is much evidence related to the causes and
triggers of sudden unexpected death more generally, largescale studies need to be carried out to unravel the causes
and triggers of sudden in-custody death. Of the limited
evidence available, some research points to the potential
contributions of various health conditions, behaviours,
circumstances, and methods of restraint. These factors,
discussed in this section, must be considered to understand
the potential role of CEWs in complex sudden in-custody
death scenarios. These potential causes/triggers, however,
are not exhaustive; natural diseases or physical injuries
resulting from use-of-force encounters may also play a role.
It is probable that each case of sudden in-custody death is
caused by several of these factors acting in combination. The
relevant factors, and their levels of involvement, are likely
different for each individual and each use-of-force event.
6.2.1	 Chemical Restraint
Law enforcement officers use oleoresin capsicum (OC)
spray (i.e., pepper spray) to facilitate control of a subject
by irritating the skin, eyes, or — if inhaled — the mucous
membranes of the airways. Respiratory symptoms can
include a burning sensation in the throat, coughing, and
wheezing (Smith & Greaves, 2002). Several sudden incustody deaths have occurred following the use of OC
spray. An examination of 63 of these cases by the U.S.
NIJ (2003) concluded that although OC spray was not
the sole cause of death in any particular case, it has the
potential to aggravate underlying airway disease, which can
lead to death. Several cases of severe respiratory distress
requiring intubation have also been observed in children
following accidental exposure to OC spray (Winograd, 1977;

Role of Conducted Energy Weapons in Sudden In-Custody Death

Billmire et al., 1996), but controlled laboratory studies do
not support a role for it in compromising the respiratory
function of healthy adults (Chan et al., 2002). Although
evidence is limited, because there may be instances where
OC spray and CEWs are both employed in use-of-force
events and because these two methods of restraint have the
potential to influence similar physiological systems, it can
be complicated to unravel the individual effect of each.
6.2.2	 Physical Restraint
The physical restraint of subjects, particularly placement in
the prone (i.e., face-down) position or the use of specific
forms of neck restraint or compression, may have a role in
sudden in-custody death (Robison & Hunt, 2005; Hall et al.,
2012). In these instances, the cause of death is believed to
be positional asphyxia, where the position of the body does
not allow for adequate breathing. Obstruction to the airway
can also occur if individuals are unconscious and cannot
adjust their heads or necks to facilitate the exchange of air
(Stratton, 2009). The literature examining the outcome of
prone positioning has usually focused on autopsy studies
of small groups of individuals who died suddenly in police
custody. Researchers must investigate the different forms
of restraint used in fatal and non-fatal outcomes, however,
to determine the effects of positioning on sudden incustody death, and the phenomenon cannot be understood
through retrospective examinations of subject deaths alone
(Hall et al., 2012).
Statistically significant changes in respiratory parameters
have been measured in experimental studies as individuals
move from sitting to supine (i.e., face-up), prone, or hogtie positions, but none are clinically worrisome (Chan
et al., 1998), even in heavily exerted subjects with up to
100 kilograms of applied weight force (Chan et al., 2004;
Michalewicz et al., 2007). Because CEWs are often used
to temporarily incapacitate subjects so that they may be
restrained by law enforcement, restraint and CEW exposure
commonly occur together, further complicating the ability
to discern the role that either might play in contributing
to, or increasing the risk of, death.
6.2.3	 Pre-Existing Cardiac Disease
Similar to sudden unexpected death in general, cardiac
disease is the primary suspected underlying cause of sudden
in-custody death in middle-aged or older individuals,
although there are several other potentially relevant natural
diseases including epilepsy and intra-cranial hemorrhage
(Wetli, 2009). Cardiac abnormalities are frequently
observed during autopsies of sudden in-custody death
cases. In multiple studies, approximately half of the subjects
classified as sudden in-custody death victims had cardiac

45

abnormalities, including fibrosis and/or enlargement of
the heart (Stratton et al., 2001; Strote & Hutson, 2006;
Swerdlow et al., 2009). These conditions may be caused
by an underlying disorder such as coronary artery disease
(narrowing of the vessels that supply the heart with blood
and oxygen) or cardiomyopathy (weakening of the heart
muscle) (Zipes & Wellens, 1998). Coronary artery disease
and cardiomyopathy are also common abnormalities in
cardiac structure or function that can eventually lead to
sudden cardiac death (Zipes & Wellens, 1998; Dosdall &
Ideker, 2009). In addition, ventricular fibrillation can occur
with exposure to stimulants such as cocaine, alcohol, and
methamphetamines (Stratton, 2009). Several of these factors
acting in combination with other aspects of a use-of-force
event, such as stress or CEW exposure, could heighten the
risk of sudden in-custody death.
6.2.4	 Drugs and Alcohol
The use of illegal drugs, particularly stimulants such as
cocaine and amphetamines, is strongly associated with
sudden in-custody death (Stratton, 2009) and is common
in individuals who are exposed to CEWs (NIJ, 2011).
The literature is quite consistent, with both small and
larger-scale studies (ranging from fewer than 20 to greater
than 150 cases) indicating that 60 to 80 per cent of sudden
in-custody deaths involve drugs and/or alcohol; of these cases,
approximately 80 per cent or more involve stimulants (Stratton
et al., 2001; Strote & Hutson, 2006; Southall et al., 2008;
Ho et al., 2009c). Evidence of chronic drug use is also
common (White et al., 2013).
Many studies have identified an association between adverse
cardiovascular effects and illicit drug abuse. Medical
examiners frequently report cocaine as the cause of drugrelated deaths (SAMHSA, 2012); it induces restriction of
blood flow to the heart by narrowing the coronary arteries
and can produce or exacerbate cardiac arrhythmias (Lange
& Hillis, 2001). Cocaine toxicity can also reduce the ability
of the heart muscle to contract (Morcos et al., 1993) and can
cause coronary artery spasms (Stephens et al., 2004). The
effects of amphetamines such as MDMA (known as Ecstasy)
are similar to those of cocaine. Following amphetamine
use, excessive catecholamine activity, vasoconstriction, high
blood pressure, and spasms of arteries in the brain can
lead to brain hemorrhage, particularly in the presence of
pre-existing vascular abnormalities (Pilgrim et al., 2009).
In addition to their individual effects, drugs may act in
combination to trigger sudden unexpected death. For
example, amphetamines and cocaine can interact with
antidepressants to induce serotonin syndrome, a “potentially
life-threatening condition caused by excessive serotonergic

46

activity in the central nervous system” (Malik & Kumar,
2012). Alcohol also alters the biotransformation of cocaine,
so that the combination of alcohol and cocaine is associated
with a greater risk of death than cocaine alone (Harris
et al., 2003). Drugs may also alter behaviour such that an
individual will continue to resist law enforcement, resulting
in extreme physical exertion that likely plays an essential
role in a sudden in-custody death incident (White & Ready,
2009). Furthermore, individuals under the influence of
drugs may be less likely to comply following CEW exposure
due to a decreased ability to feel pain, a situation that could
lead to prolonged or multiple discharges (NIJ, 2011).
Withdrawal from drugs and alcohol can also increase the
risk of severe health complications and death. Alcohol
withdrawal syndrome (AWS) begins with symptoms such as
nervousness and increased heart rate and may progress to
a stage that is characterized by cardiovascular, respiratory,
and metabolic abnormalities, ongoing agitation, and
delirium (Carlson et al., 2012). Although the risk of
mortality from AWS has declined over the past few decades,
a significant risk remains, particularly if other conditions
such as liver disease are present (Carlson et al., 2012). It
is conceivable that AWS could be a contributing factor
when an agitated, disoriented individual dies in custody.
Drugs taken for medicinal purposes may also play causal
roles in cases of sudden unexpected death and sudden incustody death, due to their abilities to alter the electrical
properties of the heart. Drugs such as some anti-arrhythmics,
anti-psychotics, and anti-infectives have the potential to
disturb the repolarization phase of the cardiac cycle,
resulting in prolongation of the QT interval (see Figure 3.1),
which can eventually lead to increased vulnerability for
ventricular fibrillation (van Noord et al., 2010).
6.2.5	

Exertion and Intense Physical
and Psychological Stress
During law enforcement encounters that end in sudden
in-custody death, suspects are typically non-compliant,
highly agitated, physically aggressive, and sometimes act
in bizarre manners that include delirium and paranoia
(Ho et al., 2009c; Vilke et al., 2009a). Their behaviour
indicates they are experiencing states of extreme, acute
stress far beyond reason and beyond the distressed states
that police usually encounter (Robison & Hunt, 2005); as
a consequence, their behaviour results in intense physical
exertion and thus the psychological and physical stress

The Health Effects of Conducted Energy Weapons

they experience is likely an important element in the
sudden unexpected death equation. As discussed in
Section 5.1, stress leads to the release of catecholamines
(e.g., adrenaline). These hormones can affect cardiac
function by restricting blood flow to the heart, and a
sudden decrease in blood flow relative to the need at the
moment can upset the ionic balance essential for proper
contraction of the heart (Rubart & Zipes, 2005).
While researchers have demonstrated the link between stress
and cardiac arrest, the risk is relatively small in individuals
with normal cardiac function and no coronary heart
disease (Chugh et al., 2000). High levels of catecholamines
can trigger a potentially lethal syndrome called stress
cardiomyopathy, however, where the left ventricle of the
heart contracts abnormally. This syndrome is typically
initiated by acute physical or emotional stress in patients
with no pre-existing coronary artery disease (Steptoe &
Kivimaki, 2012). Although some researchers speculate that
sudden in-custody death cases in young men with bizarre
or violent behaviour and recent physical exertion could
be explained by stress cardiomyopathy (Otahbachi et al.,
2010), this hypothesis has yet to be adequately tested.
Another mechanism that may contribute to sudden incustody deaths involving excessive physical exertion is
metabolic acidosis, which can cause depressed myocardial
function, arrhythmias, and cardiovascular collapse (Ho et al.,
2010). Struggle against restraints used by law enforcement
may result in a build-up of lactate and, subsequently,
acidosis. Although physical exertion, even in athletes,
does not normally lead to fatal acidosis, several other
factors may come into play during a use-of-force event.
Stimulants such as cocaine can worsen acidosis and alter
pain sensation, resulting in exertion far beyond normal
physiologic limits (Hick et al., 1999). During metabolic
acidosis, the body attempts to compensate with increased
respiration, which reduces acidosis by excretion of carbon
dioxide from the lungs (Swenson, 2001). Certain restraint
positions, however, may prevent this compensation by
impeding respiration (Hick et al., 1999). Many of these
encounters may also involve less-lethal weapons such as
CEWs or OC spray (Ho et al., 2009c). The combination
of emotional stress, extreme agitation, physical exertion,
drug intoxication, and less-lethal weapons may culminate
in a fatal cardiac event.

Role of Conducted Energy Weapons in Sudden In-Custody Death

6 .3 	

R elat i onshi p B etween C E W s
and S udden In-C ustody D eath

Since CEWs are deployed to aid in detaining, incapacitating,
or physically restraining individuals who are demonstrating
resistance, agitation, or violence, they need to be considered
as possible factors in the complex etiology of sudden
in-custody death. When used as recommended, there
have been no studies demonstrating electrical effects of
a CEW as the primary cause of death in the absence of
other contributing factors. Although there is no universal
guideline for proper CEW usage and no definition of
prolonged exposure (NIJ, 2011), in the few cases where a
CEW has been ruled the primary cause of death, excessive
exposure was used (Fox & Payne-James, 2012; White et al.,
2013) (see details below). Death due to secondary trauma
induced by a CEW, such as fatal head injuries caused by
CEW-induced falls or fatal burns caused by CEW-ignited
fires, have also been documented in rare cases (Fox &
Payne-James, 2012). Despite being infrequently ruled as
a primary cause in the absence of other factors, coroners
have at times noted a CEW as a contributing factor or as the
primary cause of death in the context of several contributing
factors. The extent to which a CEW contributes to death
across these types of cases is not known.
A recent review did not find any cases where sudden incustody death was due “directly or primarily to the electrical
effects of [CEW] application” (NIJ, 2011); however, the
timing of death in some anecdotal cases with no other known
risk factors suggests that CEW exposure may have been the
cause (NIJ, 2011). For example, one of the only field studies
designed to examine the possibility that sudden in-custody
death could be caused by immediate disruption of cardiac
rhythm by a CEW analyzed a population of 56 subjects
who collapsed (and subsequently died) within 15 minutes
of CEW exposure. The authors concluded that one death
analyzed in the study fit the profile of electrically induced
ventricular fibrillation since this rhythm was successfully
recorded on an ECG, the CEW current was delivered across
the heart, the subject collapsed immediately, and there was
no evidence of drug use or cardiac disease (Swerdlow et al.,
2009). It is therefore a possibility that CEW exposure was
the cause of death in this subject, but this possibility could
neither be confirmed nor excluded.
CEW exposure was listed by medical examiners as the
primary cause of death in 2 of 213 sudden in-custody death
cases investigated by White et al. (2013). Methamphetamine
intoxication was a contributing factor in one case while,
in the other case, no contributing factors were listed but
the individual was subjected to more than four minutes of

47

CEW exposure during the incident (White et al., 2013). At
the time of this report’s publication there was an ongoing
coroner inquest in Ontario, Canada into the death of a
suspect exposed to a CEW, where a pathologist attributed
the death to cardiac arrhythmia primarily caused by the
CEW. Despite this attribution, the coroner’s jury overseeing
the inquest ruled the cause of death as a cardiac arrhythmia
due to excited delirium syndrome and schizophrenia,
with CEW deployment, an enlarged heart, and genetic
vulnerability as contributing factors (OCC, 2013). The
results of the inquest shed further light on the complicated
nature of implicating CEW exposure as a primary cause of
death. In a study analyzing characteristics of 26 Canadian
fatalities proximal to CEW deployment, researchers noted
that certain characteristics were common among CEWproximal fatalities including history of drug use, poverty
status, and male gender (Oriola, 2012).
In most other sudden in-custody death studies, CEW exposure
is listed as a contributory (but not a primary) cause in a low
frequency of cases (~10 per cent) (Strote & Hutson, 2006)
or in no cases at all (Southall et al., 2008). Two of the more
common causes of death appear to be illicit drugs and preexisting cardiac conditions, but, in many cases, the manner
of death remains undetermined (Strote & Hutson, 2006;
Southall et al., 2008; White et al., 2013). Prolonged, forceful
struggle is frequently associated with sudden in-custody
deaths but rarely identified as a cause (Stratton et al., 2001;
White & Ready, 2009; White et al., 2013).
Despite the challenges apparent in determining cause of
death, some researchers have attempted to use sophisticated
statistical techniques to determine causality. For example,
one study used a modified version of the Naranjo algorithm,
which was originally developed to assess putative adverse
drug reactions. When this algorithm was adapted to
determine cause of death in 175 CEW-associated fatalities
occurring in North America and internationally, CEWs
were considered a probable or definite cause in 21 (12
per cent) of them (Fox & Payne-James, 2012). Of these 21
fatalities, however, CEW exposure was stated as the official
cause of death (as a result of cardiac arrest) in only one
case, which involved multiple and prolonged exposure
(nine discharges within 14 minutes), whereas CEWs played
an indirect role (e.g., by causing falls that resulted in fatal
head injuries, influencing pre-existing cardiac conditions,
igniting fuel on subject’s clothing) in the others.
During a use-of-force event, numerous subject and
situational factors may play roles in enhancing the risk of
death (Hall et al., 2012). These factors lead to dysfunction

The Health Effects of Conducted Energy Weapons

48

Box 6.1 	
CEWs and Risk of Fetal Death
Although most of the published case reports describing fetal
death following electric shocks involve exposures to higher
amounts of electricity than those delivered by CEWs, risk factors
for fetal injury following electrocution include the magnitude
of the current, the pathway along which the current travels,
the duration of the current in the body, the body weight, and
whether or not the mother was proximal to water at the time
of exposure. High-voltage currents, and those that pass from
hand to foot through the uterus, increase the risk of fetal
death (Goldman et al., 2003). In one of the only prospective
studies following women who received an electric shock
during pregnancy, most received electric shocks of 110 volts
or 220 volts while using home appliances. Of the 31 pregnant
women, 28 delivered healthy newborns. One spontaneous
abortion may have been related to the electric shock injury;
however, the study concluded that low-voltage electric shock
does not pose a major risk to the fetus (Einarson et al., 1997).
The Panel’s review of the literature identified one case report of
a pregnant woman who was exposed to a CEW, with the path
of the current travelling through the uterus. She began spotting
after one day, and received medical attention after seven days,
when an incomplete spontaneous abortion was diagnosed.
The conclusion was that because the uterus and amniotic fluid
are excellent conductors of electric current, the fetus may
have been vulnerable, depending on the contact points of the
CEW probes (Mehl, 1992). Contact points that facilitate the
passage of current through the fetus may, therefore, increase
the risk for adverse outcomes. Since no studies have explored
this question to date, the risk remains unknown.
of various physiological systems, which likely act in concert
to ultimately produce fatal outcomes. The introduction of
CEWs into this milieu makes it even more challenging to
determine cause of death. For example, it is not known
if a CEW discharge against an individual resisting arrest
adds to the high levels of stress already being experienced
by that individual, or if this combination of stressors
elevates catecholamine levels enough to increase the risk
of dangerous cardiovascular or cerebrovascular events.
Conversely, CEWs can also potentially act as protective
factors in terminating situations that may otherwise
culminate in sudden in-custody death (Ho et al., 2007b),
although no evidence exists to confirm this speculation.
Although further research is needed, current studies show
that within the complexity of law enforcement encounters,
CEWs have the potential to act as contributory factors in

sudden in-custody deaths. A few coroner reports have
ruled a CEW as the primary cause of death in the absence
of other factors when excessive exposure was present. No
evidence of a causal relationship has been demonstrated,
however, by large-scale prospective studies — and given
the limitations of the evidence, such a relationship can
neither be confirmed nor excluded. The strength of a
CEW’s contribution may vary from case to case and be
based on other contributory factors.
6 .4 	I mpact of C o-Factors

The two co-factors most discussed in the literature related
to the role of CEWs in sudden in-custody death are
mental illness and excited delirium syndrome (an acute
hyperarousal state).
6.4.1	 Mental Illness
Most of the published data on the effects of CEWs on
subjects with mental illness appear to be usage data
suggesting that individuals living with mental illness
are more likely to receive a CEW discharge when
apprehended by police officers than those with no mental
illness. That being said, almost 20 per cent of the Canadian
population will experience a mental illness during their
lifetime, and there are many types of mental illness (GC,
2006). The proportion of those with a mental illness who
actually come into contact with the police and CEWs
is very low. Individuals with some types of mental illness
(e.g., severe psychoses) may be confronted with CEW discharge
when the unique behavioural, emotional, or cognitive states
associated with their illness bring them to the attention
of law enforcement.
Studies have indicated CEWs are 2.7 times more likely to
be discharged during mental health emergencies than
during criminal arrests (O’Brien et al., 2011). Some reports
have focused on the beneficial effects of CEW use in this
population, suggesting CEWs may effectively prevent deadly
force or facilitate the prevention of self-harm (Ho et al.,
2007b). Others have speculated that people with mental
illness will be disproportionately impacted by CEWs,
since police may view this population as dangerous and
thus be more likely to respond pre-emptively with a CEW
in situations involving mentally ill individuals (O’Brien
et al., 2011).
One study indicated death was nearly twice as likely to occur
following CEW exposure when the subject was emotionally
disturbed or mentally ill (White & Ready, 2009). The
study’s findings are called into question, however, because
it compares media reports of fatal and non-fatal CEW

49

Role of Conducted Energy Weapons in Sudden In-Custody Death

incidents and does not differentiate between transient
emotional disturbance and underlying mental illness.
Although there is evidence that individuals with mental
disorders are at greater risk of experiencing the discharge
of a CEW when involved in a use-of-force encounter, the
vast majority of individuals with mental illness do not
exhibit the severe behavioural disturbances that result in
contact with first responders and possible CEW discharge.
Overall, there is little evidence that individuals with mental
disorders are at greater risk of experiencing the discharge
of a CEW when involved in a use-of-force encounter, unless
other factors, such as the exhibition of agitated or violent
behaviours, are present (CPC RCMP, 2012).
There is some speculation that, for the physiological reasons
associated with a mental disorder or the pharmacologic
treatment of some mental disorders, individuals exhibiting
aggressive or violent behaviours in the context of a mental
disorder may be at greater risk for sudden in-custody death
(Robison & Hunt, 2005). As discussed by O’Brien et al.
(2007), others have argued people taking anti-psychotic
medications are already at an increased risk of sudden
cardiac death (Straus et al., 2004), and CEW intervention
may increase this risk. There is no evidence to support or
refute these speculations.
O’Brien et al. (2007) also speculate that CEWs discharged at
individuals with a mental illness may reduce the likelihood
that they will seek subsequent mental health care, but
no relevant data support this claim. People with severe
mental illness are more likely to experience post-traumatic
stress disorder (PTSD) irrespective of CEW use, but the
underlying reasons for this association are unknown
(Alvarez et al., 2012). Although it is clear that chronic
stress leads to adverse health outcomes, a single, acute
trauma exposure may also have negative consequences
for physical and mental health (D’Andrea et al., 2011). It
is possible that a use-of-force intervention may be more
likely to elicit a PTSD-like disorder in a person with severe
mental illness and may cause persistent mental health
problems in a previously healthy individual; however, these
ideas remain speculative.
The limited data available on this topic do not allow any
substantial conclusions to be drawn about the impact of
CEW use in individuals with a mental disorder, nor do they
allow any causal relationship to be identified between the use
of CEWs on individuals with a mental disorder and negative
mental or physical health (such as sudden in-custody death).
Given the speculations discussed above, especially on the
potentially greater negative interaction between CEWs and

compromised health status of some individuals with mental
disorders, this area is a priority for research. The possible
use of CEWs by law enforcement called into therapeutic
settings to elicit compliance or provide restraint in specific
situations also deserves future study.
6.4.2	 Excited Delirium Syndrome
Excited delirium (ExD) syndrome is a highly controversial
condition often associated with sudden in-custody death
and CEW use (Strote & Hutson, 2006; Southall et al., 2008;
White et al., 2013). The term excited delirium is a syndromal
classification used to denote a physical and mental state
characterized by a range of signs and symptoms commonly
including paranoia, hyperactivity, agitation, restlessness,
speech incoherence, numbness to pain, extraordinary
strength, profuse sweating, elevated body temperature,
disorientation, aggression, and combative behaviour (Di
Maio & Di Maio, 2006; ACEP, 2009; NSDOJ, 2009) (See
Box 6.2). Not all individuals with ExD syndrome exhibit the
full spectrum of signs and symptoms, and varying degrees
of the same symptoms can be found in different cases.

Box 6.2	
Controversy over Diagnosis of Excited
Delirium Syndrome
Recent debates about whether excited delirium (ExD) syndrome
is or is not a medical diagnosis may be of little value in
bringing better understanding to this phenomenon (NIJ, 2011).
For example, organizations such as the American Medical
Association and the American Psychiatric Association do not
recognize ExD as a diagnosis, whereas groups such as the
National Association of Medical Examiners and the American
College of Emergency Physicians have both formally endorsed
ExD as a medical diagnosis (Vilke et al., 2012b). The World
Health Organization (WHO), while not officially recognizing
ExD in the International Classification of Disease, did affirm
the right of medical examiners to use their own parlance
and clinical judgment to make informed pronouncements of
causes of death without any constraints from approved lists
of conditions (WHO, 2000). In Nova Scotia, a recent provincial
task force review of this issue concluded that ExD syndrome
and the syndromes identified by numerous other labels or
diagnoses were likely similar and suggested that, in the
absence of an as-yet-agreed-upon diagnostic classification,
the term autonomic hyperarousal state be used to describe
the syndrome (NSDOJ, 2009).

50

The phenomenological presentation of ExD syndrome
has been described historically in the psychiatric literature
beginning in the mid-1800s and has been variably labelled
as acute exhaustive mania, acute behavioural disorder,
Bell’s mania, fatal catatonia, acute lethal excitement, acute
exhaustive syndrome, acute delirium, and manic-depressive
exhaustive death (Adland, 1947). A 1947 study noted greater
incidence in women and individuals aged 18 to 35 than in
other populations, and that it resulted in death in about
75 per cent of cases (Adland, 1947). Historically, scientific
reports on this state decreased substantially when
phenothiazine medications were introduced in the treatment
of acute psychiatric illnesses (Cancro, 2000). Reports appeared
again in the 1980s where ExD syndrome was described in
association with ingestion of illicit substances, especially
cocaine (Wetli & Fishbain, 1985), methamphetamines (Vilke
et al., 2012a), and phencyclidine (PCP) (Yago et al., 1981).
Additionally, a number of other conditions associated with
adverse effects arising from side effects of anti-psychotic
medications (Neuroleptic Malignant Syndrome) (Caroff &
Mann, 1993) and anesthetics (Malignant Hyperthermia) (Ali
et al., 2003) present with similar symptoms. Other definitions
of similar phenomena known in the psychiatric literature
include malignant (fatal) catatonia (Francis, 2010) and acute
delirious mania (Lee et al., 2012). The well-documented state
of acute alcohol withdrawal, delirium tremens (DT), also
includes similar signs and symptoms (Carlson et al., 2012).
While various hypotheses exist about the cause of the above
states, no simple explanation of their cause or progression
has been conclusively demonstrated. In all of the above
states, death as an endpoint is commonly reported. There
is no definitive cause attributed to ExD syndrome, although
some research suggests it may result from the complex
relationships involved when a number of factors are present,
including psychiatric illness (such as schizophrenia or
mania), intoxication with illicit substances (such as cocaine
or PCP), head trauma, and alcohol withdrawal (Samuel et al.,
2009). Some research has also suggested chronic abusers of
illicit substances may be more predisposed to ExD syndrome
(Mash et al., 2009). Autopsy studies of chronic cocaine
abusers who died with or without symptoms of ExD have led
to the suggestion that ExD victims may represent a special
sub-group of cocaine users who have different neurological
responses following long-term use of the drug (Mash et al.,
2002, 2003). ExD syndrome-related deaths are commonly
clinically associated with rhabdomyolysis, hypoxia, agitationrelated acidosis, and pre-existing heart conditions (Strote
& Hutson, 2006). The condition has also been linked to an
overstimulation of the sympathetic nervous system and an
abundance of hormones including catecholamines, such
as adrenaline and dopamine (Mash et al., 2002; NIJ, 2011).

The Health Effects of Conducted Energy Weapons

A number of these factors are also found at increased
frequency in cases of sudden in-custody death (Stratton
et al., 2001). Further complicating the matter is the
observation that sudden in-custody death can occur
following a struggle with law enforcement officers where
the subject is placed in a restraint position that may impair
his or her ability to breathe (restraint asphyxia) (Di Maio
& Di Maio, 2009). The relationships between restraint
asphyxia, ExD syndrome, and sudden in-custody death
are currently not well understood.
Because ExD syndrome involves violent, erratic, unpre­
dictable, and combative behaviour, it is often associated
with a struggle and physical restraint of an individual applied
by law enforcement or medical personnel (Di Maio & Di
Maio, 2006; Hall et al., 2013). This restraint is sometimes
supported by the use of CEWs. When cases of ExD syndrome
coupled with CEW use have culminated in in-custody death,
some researchers have argued CEWs could not serve as a sole
reason for death but may play contributory roles in concert
with a number of other risk factors (Jauchem, 2010). Others
have argued that the death of individuals who experienced
both ExD syndrome and CEW exposure was a coincidence
(Di Maio & Dana, 2007). This argument is founded in
the notion that death occurring during an ExD state (or
other similarly described states labelled with different
diagnostic terms) in the absence of CEW deployment
was well recognized for a century or more before the
introduction of CEWs (Adland, 1947; NSDOJ, 2009).
Simultaneously, however, concerns have been expressed that
CEW deployment may result in undue or additional harm
in cases of individuals experiencing ExD syndrome (Miller,
2007). Questions have been raised around the deployment
of CEWs on individuals who may be experiencing ExD
syndrome, particularly in mental health settings (O’Brien
et al., 2007). Some authors have called for guidelines
prohibiting the use of CEWs on mentally ill individuals
(SCJC, 2006), and others have questioned whether the
deployment of CEWs on individuals with psychotic disorders
is ethical (Erwin & Philibert, 2006). These concerns have
been raised in the absence of substantive data to allow
determination of the relationship between ExD syndrome,
CEW use, and sudden in-custody death. Additionally, these
analyses have not addressed the comparative difference
between rates of sudden in-custody death in ExD syndrome
with CEW use and rates of sudden in-custody death in ExD
syndrome with other forms of restraint. It is also possible
that CEWs discharged in the presence of ExD syndrome
may have protective effects, since the CEW discharge could
result in allowing law enforcement or medical personnel

Role of Conducted Energy Weapons in Sudden In-Custody Death

to more rapidly provide needed therapeutic interventions
that could actually decrease the risk of death associated
with the ExD syndrome.
Given the nature of the available information, it is not
possible to determine if, and to what degree, the use of
CEWs increases or decreases the probability of sudden
in-custody death in the presence of a state of ExD (or an
acute hyperarousal state). The literature also does not
present any conclusive knowledge on the proportional
risk of using CEWs versus other forms of restraint in the
context of ExD syndrome.
6 .5 	 S u m m ary

Sudden in-custody death refers to rapid, unexpected death
during detention of individuals by law enforcement or public
safety personnel. These fatalities typically occur during
complicated scenarios that may include agitation, physical
or chemical restraint, disorientation, stress or exertion,
pre-existing health conditions, and the use of drugs or
alcohol, all of which can potentially contribute to the
death. This makes it difficult to isolate the contribution of
any single factor. Although evidence shows the electrical
characteristics of CEWs can potentially contribute to sudden
in-custody death, no evidence of a clear causal relationship
has been demonstrated by large-scale prospective studies.
In a few coroner reports, however, CEWs were ruled as the
primary cause of death in the absence of other factors and
when excessive exposure was present. Conversely, it has
been argued that CEWs could potentially play protective
roles in stopping situations that may otherwise culminate in
sudden in-custody death. Given the limitations and scarcity
of the evidence, a clear causal relationship between CEW
use and sudden in-custody death cannot be confirmed
or excluded at this time. In addition, there is insufficient
evidence to determine whether the use of CEWs increases
or decreases the probability of sudden in-custody death in
the presence of co-factors such as mental illness or ExD
syndrome. If a causal relationship does exist, the likelihood
that a CEW will be the sole cause of a sudden in-custody
death is low. The extent to which the device would play
a role in any death is unclear and dependent upon the
co-factors involved. Further research is needed to better
define these relationships.

51

The Health Effects of Conducted Energy Weapons

52

7
Gaps in the Evidence on the Physiological and Health Effects
of Conducted Energy Weapons
•	

Confidence in Establishing Direct Causal Relationships

•	

Identifying Length of Time Needed to Establish Probability

•	

Understanding Health Effects on Varying Populations

•	

Lack of Standardization of Reporting and Record-Keeping Practices

•	

Insufficient Funding of Independent CEW Research

53

Gaps in the Evidence on the Physiological and Health Effects of Conducted Energy Weapons

7	

Gaps in the Evidence on the
Physiological and Health Effects
of Conducted Energy Weapons

Key Findings
•	 It is difficult to establish the extent to which CEW exposure
could act as the primary cause of severe adverse health
effects in real-world settings due to the challenge of
weighting the contribution of the multiple factors.
•	 The length of time between discharge and health effect
necessary to suggest a probable CEW-related injury or
death is unclear, although probability diminishes over time.
•	 There is a lack of knowledge about the health effects
associated with CEWs outside controlled settings and within
varying, potentially vulnerable populations. CEW research
typically involves healthy, physically fit volunteers.
•	 Use-of-force record-keeping and reporting practices
are currently not standardized across varying agencies.
This means detailed and consistent information on the
characteristics of the subject and the events surrounding
a use-of-force incident are not collected in a comparable
manner, if at all, leading to a lack of large-scale populationbased field studies and surveillance.
•	 There is a lack of transparent, independent research on a
range of CEW devices and their health implications.
The Panel’s review of the evidence in previous chapters
has demonstrated that many key issues have not been fully
explored across varying populations or in the operational
settings in which conducted energy weapons (CEWs) are
actually deployed, thus pointing to several priorities for
future research:
•	 To what extent can the electrical characteristics of CEWs
cause cardiac arrhythmia `and sudden in-custody death in
humans when deployed in real-world operational settings?
•	 Are certain groups or individuals with particular
conditions at increased risk for adverse outcomes related
to CEWs, and if so, what are the key co-factors?
•	 What CEW design and deployment features could
minimize the risk of adverse health effects?
The Panel has outlined various suggestions for the specific
types of research studies needed to address these questions
more fully in the relevant chapters presented thus far.
This chapter identifies and explores five overarching
gaps in knowledge and evidence concerning the healthrelated effects of CEW use, along with related challenges
in funding, conducting, and interpreting CEW research.
The Panel feels the following gaps are of equal importance

for understanding the state of the literature and places no
emphasis on one over another. In addition, these gaps and
other research questions related to appropriate testing,
approval, and use of CEWs, and appropriateness of CEWs
in relation to other use-of-force interventions, need to
be considered to make informed decisions about public
health, policing, and CEW policy.
7 .1 	

C onf idence in Establishing
Direct C ausal R elationships

Establishing causality is not a simple task in any situation
without an experimental research design, and the concept
and definition of causation elicit continuing debate among
philosophers, scientists, and medical experts alike. While
some evidence demonstrates an association between CEW
exposure and certain health effects, and other research does
not, the effects of chance, error, bias, or confounding factors
may provide a number of possible explanations regarding
those relationships (or the lack thereof). An observed
association does not necessarily mean one variable causes
the other, and the lack of an association does not necessarily
mean a causal relationship is absent. Laboratory-based
experimental study designs can help establish causation
because of their ability to control the context in which
the study is taking place. For example, in a randomized
controlled trial using study participants who are reasonably
healthy and mentally sound, the circumstances surrounding
the CEW exposure can be as controlled as possible and
the experimental measurements can be made immediately.
This kind of study would, however, have questionable
real-world relevance.
In the real world, because many factors are usually present,
it becomes much more complicated to establish the extent
to which one specific cause may contribute to an event.
What is identified as a cause will sometimes only operate
under conditions where numerous other conditions are in
effect. Or, there may be several factors, each of which has
the potential to act as a cause for a particular effect when
they coincide in time and space (Rothman & Greenland,
2005). It is highly unlikely that a CEW will be the only
factor having the potential to lead to adverse outcomes
in a use-of-force scenario. There may also be complex
interactions between CEW exposure and co-factors such
as drugs or restraint characteristics. For example, many
investigations have focused on the ability of a CEW to induce
a potentially fatal cardiac arrhythmia. Although not fully
investigated, it is also possible that, rather than directly
causing death, the CEW may interact with an existing cofactor, such as a cardiac condition or intoxication with a
stimulant, which could contribute to the arrhythmia. If
this is the case, although the cause (CEW exposure) may

The Health Effects of Conducted Energy Weapons

54

not be sufficient to induce death on its own, removal may
result in prevention of death. Similarly, it is also possible
that the CEW has no adverse influence, and the subject’s
death still occurs in a similar situation when the CEW is
not present. In that case, removing the CEW from the
equation may not prevent death; instead, death may
be completely attributable to one or more co-factors, such

as drug intoxication. The ability to distinguish between these
two cases represents a major challenge for CEW research.
Simply put, when so many potentially harmful factors are
present during a CEW incident, it is challenging to weight
the relative effect of each. Box 7.1 further illustrates the
complicated nature of establishing causality and this degree
of uncertainty.

Box 7.1
Establishing Causal Inference for Conducted Energy Weapons
Consider a hypothetical randomized controlled trial, whereby researchers are able to control a range of factors, allowing the
researchers to directly assess the relationship between CEW discharge and an outcome, as demonstrated by the following diagram:

CEW			Death
Consider a co-factor that is common to CEW incidents, such as drug intoxication. This co-factor could increase the probability of
someone being exposed to a CEW, and is also associated with morbidity and mortality irrespective of CEW exposure. The diagram
of the causal pathway would change to the following:

Intoxication		

CEW			

Death

In this relationship, controlling for the effects of the co-factor (intoxication) is relatively straightforward using standard regression
techniques to get an estimate of the causal effect of the CEW on death. But, imagine that this same co-factor could change the
threshold for induction of ventricular fibrillation, in which case intermediate variables are introduced along the potential causal
pathway. The diagram now changes to the following (VF represents ventricular fibrillation):

Intoxication		

CEW			

VF 		

Death

Imagine adding another potential co-factor, such as receiving multiple CEW exposures, which make the intermediary variables now
dependent on time:

Intoxication		

CEW1		

VF1		

CEW2		

VF2		

Death

In these cases, it is no longer appropriate to apply standard regression techniques. Instead, estimating the causal link of CEW exposure
to death, in the context of time-dependent exposures in the presence of time-dependent covariates (that may be simultaneously initial
co-factors and intermediate variables), requires marginal structural models, which use inverse probability weighting (Robins et al.,
2000), or other sophisticated methods (Petersen et al., 2006). A further complication is that these diagrams are largely incomplete
because they do not include the full range of potential co-factors and the time dependencies. With so many factors at play over a
given time period, it becomes challenging to weight the relative effect of each factor, including CEW exposure.

Gaps in the Evidence on the Physiological and Health Effects of Conducted Energy Weapons

7 .2 	Identi fy i ng L ength of T i m e
N eeded to E stabl i sh P robab ility

Currently, no guidelines are in place to specify the length
of time needed between CEW discharge and a health effect
in order to suggest the CEW was likely responsible for that
effect. CEW-induced collapse due to ventricular fibrillation
illustrates this ambiguity. The prevailing opinion in the
review literature and various studies is that for a temporal
relationship to exist, collapse should occur within seconds to
several minutes of a CEW discharge in order for the CEW to
be a factor in the collapse (Brewer & Kroll, 2009; Swerdlow
et al., 2009; NIJ, 2011). The medical reasoning behind
the exact cut-off times used in this research is, however,
not fully clear. Although several theoretical mechanisms
for delayed onset ventricular fibrillation following CEW
exposure have been suggested, they are considered unlikely
(Dosdall & Ideker, 2009).
Rather than consider the issue of timing in a dichotomous
manner (that is, there is a time beyond which ventricular
fibrillation and subsequent collapse can no longer be
attributed to a CEW), it may be beneficial to consider a
probability continuum based on the time of the outcome
post-discharge. As time of outcome moves farther away
from time of deployment, the probability that a CEW was
directly responsible for collapse decreases, but does not
suddenly decrease from high to low probability at a certain
cut-off point. This probability continuum would also be
influenced by the various co-factors involved in the situation,
which may themselves have time dependencies (e.g., the
effects of drug intoxication may affect the body longer
than effects of physical restraint). Although a particular
cut-off point may exist, the evidence does not allow for a
realistic point to be established at this time.
7 .3 	

Understand i ng H ealth E ffects
on Vary i ng P opulati ons

7.3.1	 Ethical Considerations
There are many ethical principles and guidelines that
have been established for medical research involving
human subjects (WMA, 2008; HC, 2009) and research
in general (Tri-Council, 2010). However, there is little
ethical guidance for research involving weapons deployed
on human subjects and little academic discussion of this
topic. Ethical challenges and lack of guidance on how to
deal with them have created a gap in evidence related to
laboratory-based experimental research on the health
effects of CEWs across varying populations.

55

A central ethical challenge in researching the health effects
of CEWs is the balancing of risk and potential benefit (TriCouncil, 2010). For research to be ethically sound, the
potential benefits must outweigh the potential harms of
conducting that research (HC, 2009). For animal studies,
experiments must be designed to minimize pain and distress
and, if they cannot be minimized, the value of the study must
be determined by independent external evaluation (CCAC,
1989). In human studies, although precise policies vary from
country to country, the widely held view is that very small
or minimal risks can be considered acceptable even if the
experimental intervention is not intended to benefit the
individual; however, for risks that are considered greater
than minimal, the prospect of direct therapeutic benefit
to the participant must exist (HC, 2009; Bos et al., 2012).
There are no clear rules for assessing minimal risk, potential
benefits, and their relationship to each other in a reliable
way. Evaluating the level of risk is a difficult task because
identical protocols and related risks can be interpreted
differently across review mechanisms and because there is
a subjective element in determining risk and benefit that
can lead to varying individual experiences of identical
protocols (Bos et al., 2012). In addition, both the severity
(e.g., ranging from no danger to possible irreversible
damage) and the probability (e.g., ranging from cannot
be excluded to probable) must be considered in assessing
risks and benefits (Helmchen, 2012). From limited CEW
research involving healthy individuals, available studies
suggest the severity of potential harm would be considered
high, but the probability of experiencing an unintentional
adverse health outcome would be low (although it should
be noted that a painful, unpleasant outcome will always
be experienced due to the nature of CEW field research).
An individual will likely not directly benefit from CEW
exposure in an experimental trial because it is not an
intervention aimed at treating a pre-existing condition.
The benefit of conducting CEW research where the
device is deliberately applied to a subject exists only
on the social or community level (i.e., advancement of
knowledge regarding the possible adverse health effects
of CEWs to prevent injuries or fatalities). Such research (i.e.,
the intentional application of a CEW for the specific reason
of evaluating related health outcomes) in a population
with a potentially higher probability of experiencing an
adverse health outcome would not be acceptable.
In addition to assessing risk and benefit, the ability to
obtain informed consent from research subjects is another
important ethical consideration. Informed consent refers to
an ongoing indication of agreement by an individual with
the capacity to participate in a research project, after the

56

individual has been provided with all of the information
necessary for making an informed decision. In addition,
research participants must be free from undue influence or
manipulation that may arise when subjects are recruited by
individuals in a position of authority (Tri-Council, 2010). In
the context of CEW research, obtaining informed consent
could be challenging when dealing with populations who
might not have the capacity to provide consent. Even
with populations consisting of healthy law enforcement
volunteers, there could be pressure to participate in order
to fit in with colleagues.
Considering these ethical challenges in conducting
experimental laboratory-based human studies, CEW research
has generally focused to date on healthy anesthetized pigs
and healthy human volunteers (Adler et al., 2010). This has
created a gap in knowledge related to physiological and
health effects among varying, and potentially vulnerable,
populations often involved in use-of-force encounters.
Some population-based epidemiological field studies have
attempted to fill this gap and hold promise for identifying
health effects across varying populations (Jenkinson et al.,
2006; Bozeman et al., 2009b; Strote et al., 2010a). These
studies face a range of technical challenges, however (see
Section 7.4), and must abide by other ethical considerations
such as provincial laws and the federal Personal Information
Protection and Electronic Documents Act (PIPEDA), which place
limits on the collection and use of anyone’s personal and
medical information. PIPEDA (and most provincial privacy
laws) does allow for the collection and use of personal
information for the purposes of research without that
person’s consent if certain conditions are met, such as: it
is for research purposes; the research cannot be conducted
without that information; the use of the information ensures
confidentiality; and it is impractical to obtain consent (DOJ
Canada, 2011). Although currently lacking, well-designed
population-based studies on the health effects associated
with police use-of-force events — a part of which involves
CEW deployment — could easily meet all of these criteria
and will be discussed in more detail in Chapter 8.
Defining and Ethically Researching 		
Vulnerability
The gap in knowledge related to physiological and
health effects of CEWs among vulnerable populations
is further exacerbated because defining vulnerability is
not a straightforward task. It is difficult to agree on a
definition of vulnerable populations that is applicable to any
given situation, and many populations may be considered
vulnerable based on physical, mental, social, cultural,
or economic differences (HC, 2009). In the context of
CEWs, vulnerability can be considered across a number
of dimensions. Certain groups may be more likely to have

The Health Effects of Conducted Energy Weapons

interactions with police than others, or may be more likely
to experience a CEW discharge during those interactions.
Specific groups may also be more susceptible to the
occurrence of certain health effects or to more severe health
effects than other groups. Depending on which dimension
is explored, socio-economic, psychosocial, or physiological
aspects may take precedence in determining vulnerability.
The populations that are over-represented in real-world
CEW use statistics include young men (average age in the
low 30s), those with a history of alcohol use or drug use,
and/or those with a mental illness (Bozeman et al., 2009b;
Strote et al., 2010b). Almost 50 per cent of individuals who
are subjected to CEWs have a psychiatric history, and more
than 70 per cent have a history of drug or alcohol abuse (Strote
et al., 2010b). There is also speculation that these groups
may face an increased risk of harm following CEW exposure,
compared to other adults. One study comparing media
reports of fatal and non-fatal CEW incidents suggested
death was nearly twice as likely to occur following CEW
exposure when the subject was emotionally disturbed
or mentally ill and four times as likely when drug use
was present (White & Ready, 2009). Because the study
combined emotional disturbance and mental illness, it is
difficult to isolate the effect of each condition. Another
retrospective study indicated that CEW-proximate deaths
typically occur in subjects who are under the influence of
drugs or alcohol (53 per cent), show evidence of chronic
drug use (87 per cent), or are described as mentally ill
(20 per cent) during the incident (White et al., 2013). A
caveat for both of these studies is that source data may be
inconsistent because media reports were used to generate
many of the statistics. Furthermore, it is not surprising
that emotionally disturbed, mentally ill, or intoxicated
individuals are over-represented in a sample of people who
die following CEW exposure, since it has been demonstrated
that these groups are also more likely to be exposed in the
first place (O’Brien et al., 2011) and that they have greater
risk for sudden unexpected death, even in the absence of
any CEW discharge, compared to other groups (White &
Ready, 2009).

7.3.2	

A common theme in the CEW review literature is the
speculation that certain groups — such as pregnant women,
the elderly, children, and individuals with implantable
cardiac devices — are potentially vulnerable during
exposure to electrical impulses (Hancock & Grant, 2008;
Adler et al., 2010). Although CEW literature often speculates
on potentially vulnerable populations, no risk assessment
structure, data, or methods seem to be in place to quantify
the nature or magnitude of the putative increased risk
faced by these populations. CEW research on vulnerable
populations in a laboratory setting is unlikely to be approved

Gaps in the Evidence on the Physiological and Health Effects of Conducted Energy Weapons

by an ethics committee for a number of reasons related
to informed consent from certain populations, lack of
direct therapeutic benefit to an individual, the presence
of pain (which could be considered a harm) and an
unacceptable risk-benefit ratio. These types of studies
would also not represent the actual circumstances that
make up a dynamic police use-of-force encounter. One
alternative involves simulating the vulnerable condition,
such as alcohol intoxication, in the laboratory on healthy
subjects who are able to give informed consent before
reaching a vulnerable state.
For populations whose vulnerability cannot be simulated,
such as mental illness, it will likely be necessary to perform
large-scale population-based field studies that involve
detailed and consistent collection of information on the
characteristics of the subjects and the events surrounding
the CEW incidents. Data collection for population-based
studies requires a lot of time and study across a large
population of interest to correctly identify risk profiles.
However, difficulties in spotting certain characteristics in
field settings and privacy restrictions prevent access of data
on certain populations (e.g., minors), particularly in cases
of police interaction, and this hinders epidemiological
studies. In addition, some individuals, particularly those
with implantable cardioverter defibrillators (ICDs) and
those who are pregnant, represent a small segment of
those involved in use-of-force incidents and an even
smaller subset of those experiencing CEW deployment;
therefore, it will be challenging to collect enough data for
population-based analyses. For these reasons, populationbased studies capturing real-world CEW scenarios and
subject characteristics, including vulnerable populations,
are lacking.
7 .4 	

Lack of S tandard i z at i on of
R eport i ng and R ecord -K eep ing
P ract i ces

Since municipal, provincial, and federal agencies in Canada
do not use a standard definition of a use-of-force event, it
is impossible to compare these events and related health
effects among police agencies and challenging to develop
population-based studies. There is also little standardization
in the characteristics and features recorded after use-offorce interventions and there are few central registries
with standardized recording of CEW incidents by law
enforcement or medical personnel. Records are therefore
inconsistent in how they distinguish an intervention as a
use-of-force event, the type and duration of force used, the

57

circumstances leading to the intervention, the outcomes
of the intervention, and the characteristics of the subjects
involved. These inconsistencies make it difficult to evaluate
the characteristics within or surrounding the use-of-force
event that may be associated with specific health outcomes.
Inconsistent and non-standardized reporting arises in
Canada partly because the governance of law enforcement
agencies is split across municipal, provincial, territorial, and
federal governments. Within this oversight structure, each
individual law enforcement agency has its own use-of-force
reporting structure and content, which may be different
from agencies in other jurisdictions. For example, in some
provinces the definition of a use-of-force event can involve
hard physical control (i.e., physical force above a simple
joint lock application), and these events are routinely
recorded even if no additional use-of-force measures are
used or if no injury results from the encounter. In contrast,
this same intervention (hard physical control) is only
recorded in other provinces if an injury results from the
encounter. In addition to country-wide inconsistencies,
complications may also arise within a single province. For
example, recent efforts by the Solicitor General’s Office
in Alberta to standardize police use-of-force reporting
across the province (GOA, 2011) has been met with varied
responses, with some agencies participating and others
opting out (C. Hall, personal communication, 2013).
At the federal level, the Royal Canadian Mounted Police
(RCMP) collects routine information on use-of-force events
on an ongoing basis using the Subject Behaviour/Officer
Response (SB/OR) Reporting System — a standardized
method for recording subject behaviour and the use of
interventions (CPC RCMP, 2012). The information collected
includes details on force modalities, the nature of the
event, and the characteristics of the subject involved.
RCMP data for a province, however, are not comparable
with data collected by municipal and provincial agencies
in that province. Scientifically robust comparisons are
limited by these reporting differences.
This lack of standardization is not unique to Canada. In
the United States, some information is available from
the U.S. Department of Justice (USDOJ) Bureau of
Justice Statistics report on arrest-related deaths; however,
reporting of U.S. CEW-related incidents, injuries, or use is
not standardized. The reasons for this appear to be many.
There is no centralized controlling agency that regulates or
authorizes these weapons to be used nation-wide. Decisions
about deployment are left up to individual police agencies.

58

With many thousands of U.S. police agencies, including
multiple agencies in the same city often attending the same
incident, there is no routine standardization, sharing, or
even reporting of use-of-force statistics. Collection of this
data requires resources, and there are no predetermined
funding mechanisms to support this activity, though the
USDOJ has supported this kind of research through the
National Institute of Justice, albeit limited in scope and
scale (Smith et al., 2010; NIJ, 2011). The perception seems
to be that collection and subsequent reporting of data that
may suggest an injury is the result of a police agency’s CEW
use could lead to civil liability.
In the United Kingdom, the Home Office in England and
Wales has collated data on the use of CEWs since the original
operational trial of the TASER® M26TM in 2003. Limited
data are captured after every CEW incident (i.e., the device
is drawn, aimed, laser-sight activated, arced, drive stunned,
or fired in probe mode) and returned to the Home Office
and the Association of Chief Police Officers. These data do
not currently include detailed medical data, although calls
have been made to establish such a process (Payne-James
et al., 2010). A 2011 decision to transfer the collection
and collation function between Home Office units,
and simultaneously update the database software, resulted
in the stoppage of the quarterly publication of these data,
with the last figures being published up to March 2010
(Home Office, 2010). More recent data were expected to
be published in 2013, and periodic updates were supposed
to then re-commence (G. Smith, personal communication,
2013). In addition, comparing U.K. and North American
policing is challenging because of the differences in
police agency scope and practices, along with definitions
of use-of-force.
Across police agencies worldwide, differences also exist in
how a CEW deployment is defined and which characteristics
of the deployment are recorded. For example, some
agencies record a CEW deployment as having occurred as
soon as the laser light sighting beam is activated, since that
alone may engender subject compliance. Other agencies
record it only when a subject receives an actual charge.
Most police agencies do not record the actual location
of the CEW contact points on the subject’s body, which
is important information for assessing the potential link
between probe placement (e.g., transcardiac deployment)
and certain health complications.
The current recording of sudden in-custody deaths in
Canada does not enable focused evaluation of the situations
in which deaths have occurred, whether a CEW was or
was not involved; this limits the ability to interpret these

The Health Effects of Conducted Energy Weapons

events. The current Statistics Canada method of reporting
all custodial deaths does not allow for an evaluation of
police use-of-force events that do and do not culminate in
sudden unanticipated death of the subject. This is because
of the lack of discrimination between natural, suicidal, and
unexplained deaths in penal institutions and those that
occur unexpectedly on the street during a use-of-force
encounter. Instead, reporting focuses solely on providing
an annual count of all custodial deaths.
Device testing is also currently not standardized in Canada.
Even if the characteristics of use-of-force events are recorded
consistently, health outcomes may still not be comparable
if researchers are unable to assess whether the CEWs used
in these events were functioning in a similar manner and
according to the intended specifications. Research indicates
the potential for varying operating and performance
parameters between devices of the same model, especially
pulse repetition rates. Parameters such as the type of
battery used in the device and the load resistance that
the device is fired into can significantly alter the results
obtained during a CEW test (Adler et al., 2013). Weather
conditions and temperature can also lead to CEWs misfiring
and variable testing results that do not meet industry
operational specifications (NDC, 2013). Some research
has attempted to define and articulate testing protocols for
CEW devices (Adler et al., 2013), yet there is little evidence
of regular and standardized testing of CEWs across agencies
in Canada and other countries. Although it would likely
still be challenging to account for different circumstances
surrounding individual use-of-force events, a systematic
protocol for testing the electrical output of CEWs would
help to ensure that each event involves devices that are
performing according to intended standards.
7 .5 	Insuff icient Funding of
Independent C EW R esearch

In any research study, a potential conflict of interest occurs
if a profit-seeking organization with a vested interest in the
outcome of a particular study is providing funding for the
study. For individual researchers, a conflict of interest may
arise when the responsibilities related to research are in
conflict with the personal, business, or financial interests
of a researcher. When researchers investigate products
for which they receive payment or other benefits, their
judgment surrounding ethical design and conduct of
the research and the interpretation of its results may be
distorted (Tri-Council, 2010). It is therefore important
for researchers to ensure transparency and disclose the
funding source for a study as well as information on their
connection to any relevant organizations. Declaration of

Gaps in the Evidence on the Physiological and Health Effects of Conducted Energy Weapons

such a conflict does not nullify study findings, but additional
scrutiny on the part of the reader is warranted to evaluate
the objectivity of the study and to detect possible biases
that affect the interpretation and application of the results.
Much of the CEW research has been performed using two
devices manufactured by TASER® International: the X26TM
and the M26TM. Other devices, such as the TASER® X2TM
and X3TM, the Karbon MPIDTM manufactured by Karbon
Arms®, and the Mark 63 TridentTM made by Aegis® Industries,
are also used by law enforcement or civilians in jurisdictions
around the world, but technical specifications and health
effects are not evident for these models. Literature reviews
have noted that TASER® International, the manufacturer of
the popular TASER® CEW models, has funded a number of
the studies on the effectiveness of the devices (Adler et al.,
2010). Some researchers have specifically examined the
phenomenon, reporting that 23 of the 50 studies (46 per
cent) in their literature sample were disclosed as TASER®funded or TASER®-affiliated, and that these studies had 17.6
times greater odds than independent studies to conclude
that a TASER® is safe (Azadani et al., 2011). While this
does not necessarily indicate that the results of any given
TASER®-affiliated study are biased, it could reflect selective
publishing of research supporting the safety of the devices
by TASER® International. Similarly, research indicating
possible harmful effects of CEWs may be preferentially
authored by those who stand to benefit from criticizing
manufacturers (financial gain through legal consultancy,
building academic careers, speaking engagements, etc.),
although there is no scientific evidence available to confirm
such allegations. Furthermore, any bias could be the result
of the framing or shaping of the actual research questions,
which may be more likely to lead to certain conclusions
even if the integrity of the research is sound.
Regardless of whether bias is present, an author who has
any relationship or perceived relationship, including an
adversarial one, with manufacturers does have a potential
conflict of interest that should be disclosed to improve
transparency and allow readers to interpret the results
of the work. In the Panel’s review of the literature it was
often difficult to ascertain whether a conflict was present,
and this lack of transparency made interpretation of study
findings challenging.
Declaration of funding is also beneficial when industry
funds are donated to agencies that support research
initiatives, a less likely but still indirect source of possible
conflict. For example, the International Association of
Chiefs of Police has supported and released a number of

59

reports involving the appropriate selection, procurement,
and use of CEWs, but has also received large donations
from CEW manufacturers (Johnson, 2012). These sources
of funding must be declared to allow interpretation of
studies completed with agency support. While industryfunded studies are important and can still be accepted
when scientifically robust, there is a gap in the CEW
evidence related to independent CEW research from
organizations without financial or other ties to the CEW
industry, as well as from researchers who do not profit
from criticism of the CEW industry. Transparency and
independence in the creation of questions and the
exploration of those questions will be important to build
a strong body of knowledge related to CEWs in the future.

The Health Effects of Conducted Energy Weapons

60

8
Integrated Strategies to Address Gaps in the State of Evidence
on Conducted Energy Weapons
•	

Standardizing and Centralizing the Recording of CEW Incidents

•	

Enabling Comprehensive Medical Assessment Following CEW Exposure

•	

Improving Access to, and Sharing and Integration of, Knowledge Across Fields

•	

Supporting Large-Scale, Multi-Site, Population-Based Studies

•	

Improving Understanding of CEW Risk Relative to Other Use-of-Force Interventions

•	

Understanding Specifications of CEWs Manufactured by a Range of Companies

•	

Furthering Ethical Laboratory-Based Experimental CEW Research

61

Integrated Strategies to Address Gaps in the State of Evidence on Conducted Energy Weapons

8	Integrated Strategies to Address
Gaps in the State of Evidence on
Conducted Energy Weapons
Key Findings
•	 CEW research gaps can be addressed through a series of
integrated strategies that support increased surveillance and
large-scale, prospective population-based epidemiological
study, as well as continued ethically conducted laboratorybased experimental research.
•	 Standardized and centralized recording of CEW incidents,
underpinned by comprehensive and innovative medical
testing immediately following an incident, would improve
the quality of future research on the health implications
of CEW exposure.
•	 CEW evidence would be strengthened by ethically
and responsibly improving access to, and sharing and
comparability of, information related to CEWs and other
use-of-force interventions. Emphasis on better understanding
of the risk of CEWs in relation to other interventions would
also help.
•	 More robust and objective research on varying device
specifications and performance standards of CEWs would
improve understanding of their health effects.
The Panel was challenged to identify research that would
address the knowledge gaps related to the physiological
and health effects of conducted energy weapon (CEW) use.
As demonstrated in previous chapters, although current
research indicates an association between CEWs and various
physiological and health effects, a number of possible
explanations may exist to explain these relationships
due to the limitations of the research and the effects of
confounding factors. Subsequently, the Panel identified
specific research questions and overarching gaps in
Chapter 7. The Panel feels that answering these questions
can be achieved through a series of integrated strategies
underpinned by improved surveillance, monitoring, and
reporting as well as population-based epidemiological
study. This chapter proposes a number of considerations
that could form the basis of this integrated response.
8 .1 	

S tandardi z i ng and C entralizing
the Record i ng of C E W Incidents

Standardizing Reporting
The first step in understanding and comparing use-offorce events generally, and CEW use more specifically,
would be to establish a common definition of a use-offorce event. Then, implementation of a standard method

of reporting, to enable police and medical personnel to
record a minimum level of information, would ensure the
same details were recorded for each event and make it
possible to compare various parameters at the population
level. In Canada this process would need to engage law
enforcement, public safety, and medical personnel working
at federal, provincial, territorial, and municipal levels,
and could only be achieved through collaboration and
cooperation. Standard forms for both law enforcement and
medical personnel to complete, and a method of linking
the information about the CEW incident and the health
status of the subject, would enable investigators and improve
the quality of information produced. Standardization of
reporting would also help improve the knowledge base of
other jurisdictions outside of Canada.
Creating a Central Repository of Use-of-Force
Events in Canada
Understanding the prevalence of, and the specific factors
that predict, health complications requires the capability
to evaluate police use-of-force events that do and do not
culminate in adverse health conditions such as sudden
in-custody death. This capability would be supported by a
Canada-wide registry of use-of-force events, which would
quantify the number of health complications. This would
enable focused evaluation of the situations in which adverse
health effects occur whether or not a CEW was involved,
and limit the effects of reporting and recording bias in the
interpretation of use-of-force events. A data sample across
a large cohort of consecutive and consistently recorded
events would capture adverse events and be adequately
powered to evaluate scientific connections by co-factor or
event characteristics (e.g., number of discharges, subject
characteristics) and outcome (e.g., sudden in-custody death,
major injury) if those connections consistently existed.
8 .2 	

Enabling C omprehens iv e
Medical Assess ment
Following C EW Ex posure

Engaging Medical Personnel in Assessing Effects
Not all individuals exposed to a CEW or other use-of-force
intervention require medical care or treatment following
the event. Nonetheless, when subjects are brought to the
hospital for evaluation, health care professionals most
likely to engage with these subjects (e.g., emergency
room physicians) would benefit from guidance on the
effects of CEW deployment characteristics and the specific
physiological changes and injuries most relevant to assess
as part of providing patient care (e.g., the presence of
metabolic acidosis, rhabdomyolysis, cardiac arrhythmia,
spinal injury, musculo-skeletal punctures). With knowledge
of the relevant co-factors and potential complications of

62

CEW exposure, health care professionals could more
routinely perform detailed medical examinations relevant
for evaluating physiological effects of CEW exposure, such
as tests that capture medication or drug use, medical history,
imaging of musculo-skeletal injury, or electrocardiography.
Beyond potentially improving the quality and responsiveness
of patient care, more consistent medical testing would
have the added benefit of improving surveillance efforts
involving the effects of CEWs more broadly.
Using New Technologies to Aid
in Testing Procedures
If a CEW is responsible for inducing certain health outcomes
such as cardiac arrhythmias, the prevailing opinion in the
literature is that these conditions should occur within
seconds to a few minutes of discharge. In the field, cardiac
monitoring usually occurs several minutes after the last
CEW discharge (Swerdlow et al., 2009). A technology that
allows for instant, automatic recording of heart rhythm
following CEW exposure would help establish whether
the CEW was responsible for any rhythm disturbances. For
example, it would be useful if the CEW darts themselves
were able to record electrocardiography data once they
had been deployed and lodged into a person’s body. In
addition, video recording technology could be built into
the device to capture circumstances involved in the CEW
deployment (such video attachments are already in use in
certain devices (NSWO, 2008)).
8 . 3	Im pro vi ng Access to, and
S har i ng and Integrati on of,
Knowledge Across F i elds

Improving Access to Records
Access to medical and law enforcement records is guided
by privacy regulations. Exploring the relationship between
CEWs and health outcomes requires examination of law
enforcement records and pre-hospital, emergency room,
and other medical records. Research protocols and review
processes that are respectful of the need for privacy, yet
still enable research of use-of-force events and health
effects, would be helpful for the research community. For
example, current restrictions do not allow researchers to
access the records of minors, an important sub-population.
To establish associations or cause-and-effect relationships
between CEWs and health outcomes, and to lend support
to further population-based studies that would advance
understanding, researchers would benefit from access to as
much information as is ethically and reasonably possible.
Data should be presented in aggregate form to respect the
privacy of individuals.

The Health Effects of Conducted Energy Weapons

Sharing of Information
Currently, there is little to no linking of data between law
enforcement agencies and hospitals, and often the data
collected can be of little medical use. No formal linkage
procedure exists for the tracking of police calls that progress
to hospital visits following incidents involving CEWs or
other uses of force. Data are also not linked between law
enforcement agencies or between health care practitioners
(although provincial health card numbers can be used to
confirm health records). A lack of sharing of information
between law enforcement and health provider agencies
limits the examination of physiological and health effects of
CEWs in Canada. Law enforcement agencies in Canada do
not have jurisdictional authority to access medical records
of subjects, and cannot follow up on the specific outcomes
of police use-of-force events or CEW deployments unless
the subject specifically allows such follow-up and provides the
information. Similarly, general duty medical practitioners
do not have access to law enforcement records or information
beyond what is transferred during initial presentation to
a health care facility. Except under the auspices of a research
protocol, the physiological and health effects experienced
by a subject exposed to a CEW cannot therefore be followed
comprehensively by either group.
In other jurisdictions, such as the United States, law
enforcement agencies have medical advisors who participate
in the investigation of subject injuries or complaints and
can gain access to the medical records to facilitate more
integrated record-keeping. Canada could benefit from
these types of initiatives. Linking information about
different use-of-force modalities, and how they affect the
health of individuals, could encourage investigation of a
range of relevant phenomena and increase the number
of high-quality publications.
Improving and Sharing Knowledge
Across Disciplines
Some of the physiological and health effects experienced by
individuals who are exposed to CEWs are not well studied
themselves; therefore, it is difficult to hypothesize why or
how they might play a role in a use-of-force incident. For
example, excited delirium syndrome remains controversial,
and challenges related to diagnosis can also make it
challenging to study its relation to CEW exposure. Research
also demonstrates that individuals with mental disorders
are more likely to experience cardiac complications than
individuals without these disorders, yet the reasons for this
increased risk are unclear (Bensenor et al., 2012; ChauvetGelinier et al., 2013). Acquiring additional information on
these relationships, along with the sharing of this knowledge
across medical fields, would help illuminate the possible

Integrated Strategies to Address Gaps in the State of Evidence on Conducted Energy Weapons

connection between mental illness and CEW-proximal
fatalities. Ultimately, a greater understanding of the causes
of relevant health conditions in the context of CEW use,
as well as risk factors related to these conditions, would
lead to better knowledge of how CEWs could influence
potential physiological and health effects.
8 .4 	

S upport i ng L arge-S cale , Mult iS i te , P opulati on-B ased S tudies

Ensuring Multi-National, Multi-Site Study
The challenges related to CEW deployment and assessing
physiological and health effects are not isolated to one
particular jurisdiction. Our body of knowledge would
benefit from robust, multi-national, prospective populationbased studies, in which a broad range of health care
professionals are trained in the nature and breadth of
CEW injury, and conduct consistent, comprehensive, and
detailed medical examinations of individuals exposed
to CEWs. These collaborative studies would undertake
detailed assessments of the various factors involved in CEW
deployment, and use appropriate statistical methodologies
to evaluate direct and indirect factors and their relative
strength. The inclusion of sites where CEWs are not in use
would also make for useful comparisons in these studies
(for an example see PERF, 2009). Similarly, assessment
of outcomes before and after the introduction of CEWs
within a particular site could prove useful (for an example,
see Smith et al., 2010).
Improving Knowledge on Varying, Potentially
Vulnerable, Populations
Conducting more population-based studies could help build
knowledge of the health effects of CEWs on vulnerable
populations such as the mentally ill, but without the ethical
constraints faced by laboratory-based experimental studies.
It is usually impractical to obtain voluntary, informed
consent for these studies from certain populations, the
risk-benefit ratio is unacceptable, and there is a struggle
between the natural duty to protect the rights of people
who are deemed vulnerable and the need to advance
scientific information.
Population-based studies with appropriately designed
protocols that ensure privacy and confidentiality could also
pose minimal risk to the vulnerable individuals involved.
Because the information would already be part of existing
record-keeping (e.g., law enforcement or emergency room
records), it could be standardized and analyzed for study
purposes without posing any additional burden or legal
risk for the participants. Studies investigating mortality
risk in use-of-force events could rely on information from

63

coroner records, the acquisition of which would pose little
further risk. The anonymity and privacy of the individuals
involved would be further protected by presentation of the
data in aggregate form.
Encouraging Adaptive and Inclusive
Surveillance Research
Well-constructed, multi-centred, population-based studies
often have research protocols that evaluate physiological
and health effects across several communities. If a CEW
event occurs outside of that research protocol (e.g., an
incident occurring in a neighbouring community that
may not record events in a way that is comparable with
the study), information is often not captured in a manner
that would allow the event to be used in a research study.
To enable scientific analysis and reliable comparisons
across events, research protocols would benefit from
dynamic evidence-gathering methods that allow for the
capturing of unforeseen events (and their characteristics)
in neighbouring communities during data collection.
Standardized record-keeping across agencies would also
help improve comparability and inclusion in these instances.
8 .5 	I mprov ing U nderstand ing
of C EW R isk R elativ e to O ther
U se-of -Force Inter v entions

Comparing Sudden In-Custody Deaths Related and
Unrelated to CEW Incidents
To shed light on the issue of whether CEWs are contributing
to sudden in-custody deaths, it would be useful to compare
sudden in-custody death rates in use-of-force events that
involve CEWs with those that do not. Currently, this
information is unavailable. Since these data do not require
unethical experimentation, but rather diligent collection
of the details surrounding use-of-force incidents, this task
should be achievable. If death rates were similar among
similar populations, whether a CEW was involved or not,
this finding would suggest that CEWs do not present a
greater risk than any other factor in a use-of-force event.
Exploring the Risk of Not Using a CEW
The Panel’s charge was to review the physiological and health
effects of CEWs alone; however, as previous expert panels
have highlighted (NSDOJ, 2008b; NIJ, 2011), CEWs exist
alongside many other devices and possible interventions used
by law enforcement and public safety personnel. Thus, the
“risk associated with [CEW] deployment must be viewed in
relationship to the risks of other alternatives, and not viewed
in a vacuum” (NIJ, 2011). Any law enforcement intervention
comes with a certain risk of injury, to both the officer and the
suspect. Some studies have indicated that, in comparison to

The Health Effects of Conducted Energy Weapons

64

other less-lethal uses of force, such as chemical spray, baton
strikes, and police dogs, the potential for suspect injury is
lower with CEWs (Jenkinson et al., 2006). Other studies
have noted consistent decreases in suspect injuries when
CEWs are used as well as evidence of reductions in officerrelated injuries following adoption of the devices (PERF,
2009; Smith et al., 2010). In contrast, researchers have also
found that suspects are more likely to experience injuries
following CEW deployment when compared to the use of
soft- or hard-hand force, and chemical spray. Injuries are
also more likely when CEWs are used in conjunction with
other uses of forces (Paoline III et al., 2012 ). Given these
contrasting findings, some important questions remain:
•	 How does the risk of using a CEW in a given situation
compare to the risk of not using a CEW in that same
situation, in terms of injuries for the officer, suspect, and
other bystanders who may be involved?
•	 When comparing CEWs to other use-of-force interventions,
how do the potential for injury and the possible severity
of these injuries differ?
•	 Is it preferable to promote an intervention that comes with
a higher risk of death but a lower injury rate, or an option
that has a lower risk of death but a higher injury rate?
The answers to these questions are unclear and far
beyond the scope of the Panel, but they are important
considerations nonetheless. To properly assess the risk
of CEWs in relation to other interventions, future studies
should account for jurisdiction and context, the use-offorce techniques and protocols in place, and the related
adverse health effects that include morbidity, its severity, and
mortality. Assessments might also benefit from capturing
morbidity, its severity, and mortality information on the
responding officer and bystanders.
8 . 6	

Understandi ng S pec i f i cat i ons
of C E W s Manufactured by
a R ange of Co m pan i es

Improving Understanding of Varying
Device Specifications
Much of the CEW research has been performed using two
devices manufactured by TASER® International: the X26TM
and the M26TM. Other devices, such as the TASER® X2TM
and X3TM, the Karbon MPIDTM manufactured by Karbon
Arms®, and the Mark 63 TridentTM made by Aegis® Industries,
are also used by law enforcement or civilians in jurisdictions
around the world. Although technical specifications are
not always evident for each of these models, the waveforms
delivered by, and weapon characteristics of, all of these
devices are different, and may elicit different physiological
and health effects. When the specifications among devices

are variable and continually evolving, it is possible that
differences in device characteristics could be significant
enough that safety data for one weapon might not directly
reflect the safety profile of a new or different device. By
studying and comparing these devices, researchers could
better understand how CEWs with distinct outputs are
associated with physiological effects that vary in type and
severity. A useful scenario would consist of a study with a
large sample size, which includes groups that are evaluated
following exposure to various types of CEW devices and
to variable device performance standards.
Establishing Performance Testing
and Approval Protocols
CEWs are designed to provide certain outputs each time
they are used; however, performance parameters may vary
based on factors such as the environment in which the CEW
is used (e.g., in cold weather), the type of power source
used (e.g., NiMH versus alkaline battery cells), and the
device’s ability to stand up over time (NDC, 2013). Some
research has attempted to define and articulate testing
protocols for CEW devices to ensure there are standard
means for assessing device performance over time (Adler
et al., 2013). With protocols such as these in place and
appropriate testing procedures continually undertaken,
law enforcement agencies could ensure devices were
working as intended, and re-test devices involved in any
CEW incident resulting in adverse health effects to assess
whether the device could have inadvertently malfunctioned.
In addition, with appropriate standards in place to ensure
proper functioning, the ability to compare CEW incidents
resulting in adverse health effects within and across agencies
would be improved because researchers could be assured
that devices were performing in a similar manner in
different contexts (Adler et al., 2013). To properly assess
the relationships between CEWs and physiological and
health effects, researchers and law enforcement personnel
would benefit from ensuring the devices are functioning as
intended, and in a similar manner across various incidents,
exposures, and contexts.
8 .7 	

Further ing Ethical
Laboratory-B ased
Ex per imental C EW R esearch

Although there may be more promise and increased
relevance of knowledge gleaned through improved
surveillance, monitoring, and reporting, as well as through
population-based epidemiological study, supplementing
these activities with continued support of ethically
conducted experimental research studies using animal
and human models could provide some value.

Integrated Strategies to Address Gaps in the State of Evidence on Conducted Energy Weapons

Supporting Further Research Using Animal Models
Many of the challenges in applying CEW animal research
to our understanding of how the devices influence human
populations are common to most phenomena studied
using other species. Differences in genetics, anatomy,
and physiology between humans and animals cannot be
remedied, so the applicability of findings will always be
questionable and the current research in this area adds
little to the state of evidence related to CEW devices.
Despite these shortcomings, animal studies can increase
understanding of how certain conditions common to CEW
incidents influence the relationship between CEWs and
health effects. Research involving simulating use of illicit
substances (Lakkireddy et al., 2006) and mimicking the
stress response (Nanthakumar et al., 2006) are examples
of such studies. Any future studies that explore the
relationships between CEWs, health effects, and co-factors
would need to ensure large sample sizes and carefully
designed experiments with proper comparison groups to
improve the quality of the study. They would also need
to be designed to minimize pain and distress in animals,
and, if these cannot be minimized, the value of the study
would need to be determined by independent external
evaluation (CCAC, 1989).
Supporting Further Research with
Human Populations
Studies that imitate field conditions by exposing human
subjects to CEWs following physical exertion (Ho et al.,
2011a) or alcohol consumption (Moscati et al., 2010)
have been conducted. While taking into account ethical
constraints on laboratory-based research and the value of
what can be learned from population-based study, further
development of human research studies that consider less
homogenous study subjects (e.g., varying physiological
states), larger sample sizes, and use of comparison groups
could be beneficial. Furthermore, improved guidance
around the ethics of weapons-related research and testing
with all populations could be useful for researchers engaging
in any sort of future CEW study. In the absence of large
human data sets, alternative techniques that use smaller
sample sizes coupled with effective and robust prediction
models of potential injuries could also be developed. Human
research studies would be complemented by future computer
modelling that applies novel approaches in assessing potential
co-factors (e.g., bi-domain computer models).

65

The Health Effects of Conducted Energy Weapons

66

9
Summary and Conclusions

•	

What Is the Current State of Scientific Knowledge About the Medical
and Physiological Impacts of Conducted Energy Weapons?

•	

What Gaps Exist in the Current Knowledge About These Impacts?

•	

What Research Is Required to Close These Gaps?

•	

Final Reflections

Summary and Conclusions

9	

Summary and Conclusions

This chapter synthesizes the main findings that emerged
from the Panel’s review, deliberations, and assessment
of the evidence on the physiological and health effects
of conducted energy weapons (CEWs). It organizes
the findings by answering each of the three questions
comprising the charge and concludes with the Panel’s final
reflections on moving forward in this field. The answers
provided are based on the Panel’s collective judgment of
the evidence, and represent the most accurate responses
the current state of knowledge permits.
9 .1 	

W hat Is the C urrent S tate
of Sc i ent i f i c K nowledge
A bout the Med i cal and
P hys i olog i cal I m pacts of
C onducted E nergy W eapons?

Since their introduction in the late 1990s, CEWs have
become one of the many use-of-force options available to
law enforcement and public safety personnel across Canada.
Currently, there are approximately 9,174 CEWs in use
in Canada and although the number varies based on
jurisdiction, all federal, provincial, and territorial jurisdictions
use the device in some capacity. In addition to causing pain,
CEWs influence the peripheral nervous system in a way that
causes temporary, involuntary, and uncoordinated skeletal
muscle contractions. This incapacitation is achieved through
the delivery of short, repeated pulses of electricity to the
skin and subcutaneous tissues through two metal probes.
The principle guiding the functioning of the CEW is that
the short-duration electrical discharges it delivers are highly
effective in stimulating motor and sensory nerves, causing
incapacitation and pain, but are much less effective in
stimulating the heart muscle and thereby inducing potentially
fatal disruptions to the heart’s rhythm and pumping ability.
The available information on the electrical design and
output characteristics of a limited number of CEW devices
shows that they are sufficient to cause the intended pain
and incapacitation through stimulation of the peripheral
nervous system. Specifications among CEW devices are
variable, however, and may change with use and under
different conditions. CEW devices and the variations among
them are also constantly evolving, so knowledge based
on any particular model does not necessarily translate to
other devices and the characteristics of newer devices are
unknown. Evaluating the intended and unintended effects
of CEWs requires testing each device on its own merit and
understanding the context and conditions under which
it is used.

67

Decision-making about selecting, acquiring, and using
CEWs, and record-keeping related to the outcomes of using
the devices, are largely undertaken by local law enforcement
agencies and officers and vary across municipal, provincial/
state, and federal/national jurisdictions in Canada and
internationally. This has resulted in little ongoing systematic
and standardized documentation capturing comparable
information on the use of CEWs and related injuries, health
complications, or deaths.
Despite the lack of surveillance activity, there has been
a range of scientific inquiry focused on the potential
unintended physiological and health effects associated
with CEWs. Several population-based and single case studies
suggest superficial physical injuries are often associated
with CEW deployment, which are mainly caused by the
weapon’s probes, but also from severe muscle contractions
and related falls. Although the occurrence of superficial
physical injury is high, these types of injuries rarely pose
significant risk for morbidity and mortality, and case studies
indicating more severe physical injuries are rare. Keeping
in mind that all law enforcement interventions come with
a certain risk of physical injury to the suspect involved, the
Panel chose not to focus on physical injury in great detail.
Other health effects associated with CEW electrical
discharges are not as well documented or studied. In its
assessment of the limited evidence available, the Panel
agreed the physiological and health effects of most concern
in the context of CEW deployment were those effects that
could be considered potential mechanisms for sudden
unexpected death. These include activation of the human
stress response and build-up of related stress hormones
such as catecholamines, disruptions in breathing and the
potential for metabolic and respiratory acidosis, and the
risk of disruption to the heart’s natural functioning and
the potential for arrhythmias.
From the Panel’s review of the limited available literature
on each of these potential effects, the majority of which
focus on cardiac effects, several findings emerged:
•	 Although limited studies suggest CEW exposure can
induce the stress response and increase hormone levels,
these increases are of uncertain clinical relevance. It is
also unclear to what extent the discharge of a CEW adds
to the high levels of stress already being experienced by
an individual in an arrest scenario.
•	 Studies of animals subjected to prolonged or repeated
CEW exposure indicate the potential for respiratory
complications (e.g., pronounced acidosis). Although
published experimental data identify respiratory changes
in healthy human subjects typical of vigorous physical

The Health Effects of Conducted Energy Weapons

68

exertion, studies involving more heterogeneous groups
or humans subjected to prolonged or repeated exposure
have not been conducted.
•	 Some animal studies suggest CEWs can induce fatal
cardiac arrhythmias when a number of discharge
characteristics, either alone or in combination, are in
place: probe placement on opposite sides of the heart (i.e.,
current is delivered across the heart), probes embedded
deeply near the heart, increased charge, prolonged
discharges, or repeated discharges. These studies indicate
the biological plausibility of adverse health outcomes
following CEW exposure.
•	 A small number of human cases have found a temporal
relationship between CEWs and fatal cardiac arrhythmias,
but available evidence does not allow for confirmation or
exclusion of a causal link. If a causal link does exist, the
likelihood of a fatal cardiac arrhythmia occurring would
be low, but further evidence is required to confirm the
presence and magnitude of any risk.
•	 The roles of co-factors common to real-world CEW
incidents (e.g., intoxication, exertion, struggle, restraint)
and other co-factors (e.g., body type, existing health
complications) that may increase susceptibility to adverse
effects have not been adequately tested to properly establish
an understanding of vulnerability in humans.
Sudden in-custody death resulting from a use-of-force event
typically involves a complicated scenario that includes
agitation, physical or chemical restraint, disorientation,
stress or exertion, pre-existing health conditions, and
the use of drugs or alcohol, all of which can potentially
contribute to a death. This makes it difficult to isolate
the contribution of any single factor. Although evidence
shows the electrical characteristics of CEWs can potentially
contribute to sudden in-custody death, no evidence of
a clear causal relationship has been demonstrated by
large-scale prospective studies. In a few coroner reports,
however, CEWs were ruled as the primary cause of death in
the absence of other factors and when excessive exposure
was present. Conversely, it has been argued that CEWs
could potentially play protective roles in terminating
situations that may otherwise culminate in sudden incustody death. Given the limitations and scarcity of the
evidence, a clear causal relationship between CEW use and
sudden in-custody death cannot be confirmed or excluded
at this time. In addition, there is insufficient evidence to
determine whether the use of CEWs increases or decreases
the probability of sudden in-custody death in the presence
of co-factors such as mental illness or excited delirium
syndrome. If a causal relationship does exist, the likelihood
that a CEW will be the sole cause of a sudden in-custody

death is low. The extent to which the device would play
a role in any death is unclear and dependent upon the
co-factors involved. Further research is needed to better
define these relationships.
These conclusions are limited by a number of challenges
presented by the available laboratory-based experimental
research studies, including translation of findings from
computer and animal model studies to humans, human
studies with mainly healthy subjects that do not represent
the varying populations involved in CEW events, the absence
of adequate control groups, lack of diverse and robust
experimental designs and monitoring (e.g., biased samples),
and small sample sizes. Large-scale population-based studies
that better capture the complexity of real-world CEW
deployment scenarios, along with a range of potential
co-factors, are lacking.
9 .2 	

What Gaps Ex ist in the C urrent
K nowledge About These Impacts?

The Panel’s review of the evidence demonstrated that
many key issues have not been fully explored across varying
populations or in the operational settings in which CEWs
are actually deployed, thus pointing to several priorities
for future research:
•	 To what extent can the electrical characteristics of CEWs
cause cardiac arrhythmia and sudden in-custody death in
humans when deployed in real-world operational settings?
•	 Are certain groups or individuals with particular
conditions at increased risk for adverse outcomes related
to CEWs, and if so, what are the key co-factors?
•	 What CEW design and deployment features could
minimize the risk of adverse health effects?
The Panel further identified and explored five overarching
gaps in health-related CEW research and knowledge:
Confidence in Establishing Direct
Causal Relationships
It is highly unlikely that a CEW will be the only factor having
the potential to lead to adverse physiological and health
effects in a use-of-force event involving many factors. It is,
therefore, difficult to establish the extent to which CEWs
could act as a primary cause of adverse health effects in
real-world settings given the available study designs and
the complexity of assessing the multi-factorial situations
in which CEWs are deployed. When so many potentially
harmful factors are present during a CEW incident, it is
challenging to weight the relative effect of each. This greatly
reduces the ability to reach definitive causal conclusions.

69

Summary and Conclusions

Identifying Length of Time Needed
to Establish Probability
Presently, the length of time between a discharge and a
health effect necessary to suggest a probable CEW-related
injury or death is unclear. Rather than consider the issue of
timing in a dichotomous manner, it would be beneficial to
consider a probability continuum based on the time of the
outcome post-discharge. That is, as time of outcome moves
farther away from time of deployment, the probability that
a CEW was directly responsible for that event decreases, but
does not suddenly decrease from high to low probability
at a certain cut-off point.
Understanding Health Effects
on Varying Populations
Ethical constraints are associated with CEW laboratory
studies, including unacceptable risk-benefit ratios, lack
of direct therapeutic benefit to an individual and the
presence of pain, and obtaining voluntary informed consent.
These concerns are exacerbated for potentially vulnerable
individuals. In this context, vulnerability is challenging
to determine and no risk assessment structure, data, or
methods seem to be in place to quantify the nature or
magnitude of the putative increased risk of adverse health
effects faced by these populations.
To date, experimental laboratory-based CEW research has
generally focused on healthy anesthetized pigs and healthy
human volunteers. These types of studies do not represent
the actual circumstances that make up a dynamic police
use-of-force encounter, thus limiting their generalizability.
Large-scale population-based field studies involving
detailed and consistent collection of information on the
characteristics of the subject and the events surrounding
the CEW incident hold promise for addressing ethical
constraints, but currently these studies are lacking. This
has led to a gap in knowledge related to physiological and
health effects among varying, and potentially vulnerable,
populations often involved in use-of-force encounters.
Lack of Standardization of Reporting
and Record-Keeping Practices
The ability to carry out adequate surveillance and
population-based study is hindered by a lack of
standardization and consistent reporting and recordkeeping practices related to use-of-force events. There are
few central registries with standardized recording of CEW
incidents by both law enforcement and medical personnel.
The gap in surveillance efforts and population-based
study severely hinders the ability to form evidence-based
conclusions about the relationship between CEW use and
adverse health effects.

Insufficient Funding of Independent Cew Research
Many of the available studies appear to be affiliated with,
or receive support from, CEW manufacturers or individuals
with perceived conflicts of interest, and funding sources
are not always transparent. Although these studies may be
scientifically robust, there is a perceived conflict of interest
that limits their widespread acceptance. There is insufficient
funding, creating, and conducting of independent research
by organizations without financial or other ties to CEW
manufacturers or with other perceived conflicts of interest.
9 .3 	

What R esearch Is R equired
to C lose These Gaps?

The Panel was challenged to identify research activities
and mechanisms that would address the knowledge gaps
related to the physiological and health effects of CEW use.
The Panel determined the need for a series of integrated
strategies underpinned by surveillance, monitoring,
reporting, and population-based epidemiological study.
The following considerations could form the basis of this
integrated response:
Standardizing and Centralizing the Recording
of Cew Incidents
Establishing common definitions of use-of-force and CEW
use would ensure that record-keeping efforts in Canada
and internationally could support population-based
monitoring and study. Implementation of a standard
method of reporting to enable police and medical personnel
to record a minimum level of information would then
ensure the same details were recorded for each event,
making it possible to compare various parameters at the
population level. Further study would also be supported by
the creation of a central repository of use-of-force events
in Canada.
Enabling Comprehensive Medical Assessment
Following Cew Exposure
When subjects are brought to the hospital for evaluation,
health care professionals most likely to engage with these
subjects would benefit from guidance on the co-factors
and specific physiological changes and injuries most
relevant to assess for patient care. With this knowledge,
health care professionals could more routinely perform
detailed medical examinations relevant for evaluating
physiological effects of CEW exposure. Beyond the
treatment of individuals, these more routine practices
could aide in surveillance efforts more broadly. Innovative
technologies could also be integrated into CEW devices
to allow for the instant and automatic recording of health
and circumstantial information.

The Health Effects of Conducted Energy Weapons

70

Improving Access to, and Sharing and Integration
of, Knowledge Across Fields
Researchers would benefit from improved access to law
enforcement and medical records, based on what is ethically
and reasonably possible. Respecting privacy concerns,
a process could be established to anonymously share and
link this information across disciplines, institutions, and
jurisdictions. Linking information about different useof-force modalities, and how they affect the health of
individuals, could encourage investigation of a range
of relevant phenomena and increase the number of
high-quality publications examining these associations.
Ultimately, a greater understanding of the interconnections
and etiology of health outcomes relevant to CEW use
would lead to improved knowledge of how CEWs influence
potential physiological and health effects.
Supporting Large-Scale, Multi-Site,
Population-Based Studies
Our body of knowledge would benefit from robust multinational, prospective population-based studies, in which
a broad range of health care professionals are trained
in the nature and breadth of CEW injury and could
therefore conduct consistent, comprehensive, and detailed
medical examinations of individuals exposed to CEWs.
To enable scientific analysis and reliable comparisons
across events, research protocols would benefit from
dynamic evidence-gathering methods that allow for the
capturing of unforeseen events (and their characteristics)
in neighbouring communities.
Improving Understanding of Cew Risk Relative
to Other Use-of-Force Interventions
CEWs exist alongside (and can be used in conjunction
with) many other devices and possible interventions used by
law enforcement and public safety personnel. To properly
assess the risk of CEWs in relation to other interventions,
future studies should consider comparing sudden in-custody
deaths (and other injuries) both related and unrelated
to CEW incidents. Future studies would also benefit from
exploring the risks of not using a CEW in a given situation
and accounting for jurisdiction and context, the use-offorce techniques and protocols in place, and the related
adverse health effects that include morbidity, its severity,
and mortality.

Understanding Specifications of Cews
Manufactured by a Range of Companies
By studying and comparing a broader range of devices
beyond those manufactured by TASER® International,
researchers could better understand how distinct outputs
(waveform specifications and deployment modes) from
CEWs are associated with a range of physiological effects that
vary in type and severity. Properly defining and articulating
testing protocols for CEW devices would impose standard
methods for assessing device performance over time.
Enhancing knowledge in this area would help establish
more robust information surrounding the safety parameters
and technical specifications of the devices.
Furthering Ethical Laboratory-Based Cew Research
Despite the limitations in the generalizability of
experimental research using computer, animal, and
human studies, there are several advantages in conducting
further laboratory-based research. Future computer and
animal modelling would benefit from the application of
novel approaches (e.g., bi-domain computer models) and
larger sample sizes with proper comparison and control
groups. Human studies would benefit from mimicking
certain characteristics typical of subjects in the field
(with appropriate ethical and safety constraints in mind),
using more heterogeneous and larger study samples, and
exploring extrapolation techniques.
9 .4 	

Final R eflections

This report provides an overview of the state of knowledge
concerning the physiological and health effects of CEWs.
The conclusions reached by the Panel are based on its
interpretation of the best available evidence, which is
provided throughout the report. The Panel recognizes
that gaps exist within the literature and undoubtedly this
poses challenges when assessing the physiological and health
effects of CEW exposures. The Panel also recognizes that as
advancements in scientific understanding occur, perspectives
may need to evolve to recognize any new body of evidence.
Currently, there are numerous chances to rethink how
we assess and communicate the safety of CEWs and useof-force interventions more broadly. Opportunities exist
for redesigning and improving research methodologies,
standardizing collection of information, and developing
partnerships across disciplines, jurisdictions, and
professional practices.

Summary and Conclusions

Educating the public, health care providers, popular media,
and law enforcement will be essential to advance research
and knowledge related to CEW use. To ensure that the
public, media, and law enforcement are receiving and
communicating the most up-to-date and robust scientific
evidence, it may be beneficial to work on the development
of standard ways for communicating about CEWs, risk, and
health implications. Drawing on the fields of public health
and stakeholder engagement and management, along with
literature related to risk perception, risk management,
and safety assessments, standards for effective mechanisms
for knowledge translation and communication could be
established and ultimately improve transparency related
to the health effects surrounding CEW use.
Although there are potential risks associated with CEWs,
the devices may also have positive effects (e.g., reducing
injuries) not only among those who are exposed to the
devices, but also among the public and law enforcement
officers. It will be important to assess outcomes if CEWs are
not used in a given situation and to take into consideration
broader socio-political factors and risk assessments beyond
the potentially negative health effects of the devices.
This final assessment report is meant to provide an in-depth
and authoritative statement on the state of knowledge
about the relationship between CEW use and a range of
health effects. In addition, the Panel acknowledges there
are a number of factors that go into decision-making
related to CEWs that are beyond assessing health effects
and that these factors must also be considered in any largescale assessment of their use. This report must therefore
complement other work on testing and approval procedures,
motivations and protocols for appropriate use, safety and
effectiveness standards, appropriateness of the devices
compared to other use-of-force interventions, and other
socio-political considerations that make up the broader
package of information needed to make sound decisions
about policing and CEW use in Canada.
This assessment presents an opportunity to inform
municipal, provincial, territorial, federal, and international
law enforcement practices and provides a platform to
encourage improved communication among these
jurisdictions. It is the Panel’s hope that the report will be
used to continue dialogue among a variety of stakeholders
on a science-based question of public health importance.
Ultimately, public perception and emotion, while important
considerations, should not lead the debate — a range of
scientific inquiry, risk assessment, and evidence must guide
policy surrounding the use of CEWs in Canada.

71

The Health Effects of Conducted Energy Weapons

72

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The Health Effects of Conducted Energy Weapons

85

Appendices

Appendices 

•	

APPENDIX A	 Summary of Main Findings from Past Evidence Assessments

•	

APPENDIX B	 Physical Injuries Following CEW Exposure

•	

APPENDIX C	 Summary of Animal Studies Examining Respiratory Dysfunction

•	

APPENDIX D	 Summary of Animal Studies Examining Variable CEW Characteristics
	
and Cardiac Dysfunction

The Health Effects of Conducted Energy Weapons

86

APPENDIX A
Summary of Main Findings from Past Evidence Assessments
Almond Report, Report of Advisory Panel to Minister of Justice on Use of CEWs by Law Enforcement in Nova Scotia (NSDOJ, 2008b)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.

Health Outcomes
Death, bodily injury.

Key Health-Related Findings
•	 Risk of death or serious injury associated with CEW use
on healthy individuals is low, but may not reflect the risk for
vulnerable populations, such as those suffering from mental
or physical health conditions or who are under the influence
of drugs/alcohol.
•	 No medical research established causal link between CEW use
and death, though the science is still evolving.

Conclusions
Panel of medical/scientific
experts should review evidence
(with a separate panel of
mental health experts to
address the issue of excited
delirium syndrome); advise
Minister of Justice, policymakers, and police annually.
Policy formation hindered
by lack of central CEW case
data repository.

2011 DOMILL Statement on TASER M26 and X26 and Children and Vulnerable Populations (DOMILL, 2011)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.

Health Outcomes
Death, injury, cardiac/
drug interactions,
excited delirium
syndrome, stress,
mental illness.

Key Health-Related Findings
•	 Possible increased risk of harm for children, adolescents, low-body-weight persons: harmful cardiac
arrhythmia; physiological harm from intense muscle contraction, pain, and stress induced by CEW;
skin and soft tissue injury from CEW probe darts.
•	 Risks to pregnant women and fetuses are not well-documented but could include injuries from
uncontrolled falls and intense muscle contractions, which may lead to increased rate of caesarian
section delivery and/or low birth weight babies.
•	 Equivocal evidence indicating increased risk of CEW-induced seizures in individuals with epilepsy.
•	 CEW interaction with pacemakers and implantable devices is not harmful.
•	 Serious cardiac harm may be possible in presence of underlying cardiac disease or chemical
intoxication.

2005 DOMILL Statement of the Medical Implications of the Use of the M26 Advanced TASER (DOMILL, 2005)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.
•	 Lab research.

Health Outcomes
Death, injury, cardiac/
drug interactions,
excited delirium
syndrome.

Key Health-Related Findings
•	 Possible hypersensitivity to CEW from interaction with
illegal drugs.
•	 Probability of damage to implanted devices/pacemakers
is very low.
•	 Small human data sample sizes are an impediment to research.

Conclusions
Risk of life-threatening or
serious injuries from the
M26™ TASER® appears to
be very low.

House of Commons Report, Canada, Study of the Conductive Energy Weapon – TASER (House of Commons of Canada, 2008)
Evidence
•	 Expert testimony.

Health Outcomes
In-custody deaths,
excited delirium
syndrome, ventricular
fibrillation, bodily
injury.

Key Health-Related Findings
•	 Witnesses’ testimony: 962 field deployments of CEWs,
0.3% severe injuries, 99.7% mild or no injury.
•	 20 deaths following TASER® application in Canada as of 2008.
•	TASER®-induced ventricular fibrillation only documented in
animal models.

Conclusions
No established causal link
between CEW application
and death.
Need government
commissioning/funding
of independent, scientific,
peer-reviewed CEW research.
continued on next page

87

Appendices

Kiedrowski Report, An Independent Review of the Adoption and Use of Conducted Energy Weapons by the RCMP (Kiedrowski et al., 2008)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.
•	 Police records/
other police
documents.
•	 Interviews with
RCMP/other police
services.

Health Outcomes
Key Health-Related Findings
Death, injury, cardiac
•	 Human studies: no clinically significant changes in recordable
capture and arrhythmia,
cardiac electrical activity, body temperature, or serum markers
neuromuscular function,
of muscle injury/acidosis.
excited delirium
•	 Pig studies: lengthy transcardiac TASER® X26™ discharges could
syndrome.
result in ventricular fibrillation or tachycardia.

Conclusion
No necessary and sufficient
causal link between CEW and
death in healthy adults.
Individuals with low body
weight, pre-existing medical
conditions, intoxication, acute
psychosis, or acute stress may
face a higher risk of harm or
death following CEW exposure.
The term excited delirium
“should not be included in
the RCMP operational manual
unless subsequently formally
approved by the RCMP after
consultation with a mentalhealth policy advisory body.”

Manojlovic Report for the Canadian Police Research Centre, Review of Conducted Energy Devices (Manojlovic et al., 2005)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.
•	 Detailed summary
of two reports
by the BC Office
of the Police
Complaints
Commissioner,
which used expert
testimony.

Health Outcomes
Death, injury, seizure,
superficial skin damage.

Key Health-Related Findings
•	 Research gaps: death proximal to restraint, physiological effects
of excited delirium syndrome; effective restraint and treatment of
excited delirium sufferers.
•	 Excited delirium syndrome not a universally accepted diagnosis.

Conclusion
Risk of cardiac harm is very low.
No definitive research evidence
showing causal relationship
between CEW and death.
Excited delirium syndrome
“is gaining increasing
acceptance as a main
contributor to deaths
proximal to [CEW] use.”

Synyshyn Report for Canadian Association of Police Boards, A Select Review of Medical and Policy Review Literature (Synyshyn, 2008)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.

Health Outcomes
Ventricular fibrillation,
cardiac capture, CEW
probe wounds.

Key Health-Related Findings
•	 Human laboratory experiments cannot entirely reproduce
in the field scenarios.
•	 Ethical considerations are main challenge in research on
co-risk factors and vulnerable populations.

Conclusion
Research has not shown
conclusive link between
CEWs and death.
There is still disagreement in the
research community regarding
applicability of pig studies
of CEW risks to cardiac health.

2011 National Institute of Justice, Study of Deaths Following Electro Muscular Disruption (NIJ, 2011)
Evidence
•	Peer-reviewed
literature.
•	 Grey literature.
•	 Expert testimony.
•	 Coroner records.
•	 Police records.

Health Outcomes
Death, serious injury,
cardiac arrhythmia,
excited delirium
syndrome.

Key Health-Related Findings
•	 ”There is currently no medical evidence that [CEWs] pose
a significant risk for induced cardiac dysrhythmia in humans
when deployed reasonably.”
•	 There is anecdotal evidence that CEWs can cause cardiac
arrhythmia in field deployments.
•	 Risk factors include intoxication, excited delirium syndrome,
acidosis, and cardiac pacemakers, but the literature has not
conclusively demonstrated any causal relationships; more
research on the role of these factors in sudden death proximal
to CEW use is needed.

Conclusions
No conclusive medical evidence
indicating high risk of injury or
death from short CEW exposure
in normal, healthy adults.
Risk of death proximal to CEW
use is less than 0.25%; risk of
injury or death is probably less
than 1%.
Drive-stun mode should not be
repeated on subjects exhibiting
abnormally high pain tolerance.
Most deaths proximal to
CEW use involve prolonged
or multiple discharges; law
enforcement should avoid
this type of deployment.

The Health Effects of Conducted Energy Weapons

88

APPENDIX B
Physical Injuries Following CEW Exposure
EPIDEMIOLOGICAL STUDIES
(Bozeman et al., 2009b)
Study Design
Prospective population-based multi-centred
study of individuals exposed to CEWs at
6 law enforcement agencies

Sample Size
1,201

Findings
•	 83% of the cases resulted in superficial puncture wounds
•	 2 cases of head injuries occurred, sustained during falls related to CEW use

Sample Size
100

Findings
•	 20% sustained injuries that were mostly a result of superficial puncture wounds
•	 Less common injuries included superficial abrasions, minor lacerations, and nose bleeds

(Gardner et al., 2012)
Study Design
Retrospective study using information from a
multi-centred database of CEW uses in the field,
focusing on a sample of minors (age 13 to 17)
(Haileyesus et al., 2011)
Study Design
Sample Size
Retrospective study using 2 national databases ~300,000
describing injuries sustained during use-of-force
incidents resulting in emergency room treatment

Findings
•	 Of ~300,000 non-fatal injuries resulting from use-of-force interventions, 11% were
CEW-related injuries that involved probe puncture wounds, contusions/abrasions,
foreign bodies, and lacerations

CASE SERIES/CASE REPORTS
(Chandler et al., 2011)
Study Design
Case report

Sample Size
1

Findings
•	 Probe embedded in the forehead
after CEW deployment from a
distance less than 5 feet

(Le Blanc-Louvry et al., 2012)
Study Design
Case report

Both case reports demonstrate that the length
of a CEW dart can be sufficient to allow
brain penetration

Sample Size
1

Findings
•	 CEW probe penetrated skull
and underlying frontal lobe

Sample Size
1

Findings
•	 Perforating eye injury resulting in retinal detachment

Sample Size
1

Findings
•	 Perforating eye injury resulting in temporary vision loss

Sample Size
1

Findings
•	 Acute trauma (tearing) to certain lower body tendons following CEW exposure in the thigh

Sample Size
4

Findings
•	 Probe penetration into the skull and various injuries resulting from falls including
skull and facial fractures, concussion, and laceration

Sample Size
1

Findings
•	 Subject experienced a mild to moderate pneumothorax (collapsed lung) as a result
of CEW incident; authors suggest it was caused by the CEW probe, but could not
rule out the fall resulting from CEW incapacitation as a potential cause

Sample Size
1

Findings
•	 Compression fracture of a thoracic vertebrae resulting from intense muscle
contractions and consistent with compression fractures resulting from seizure

Sample Size
1

Findings
•	 Subject experienced a seizure as a result of a CEW shot to the head, and showed
evidence of a concussion likely resulting from a fall to the ground

(Chen et al., 2006)
Study Design
Case report
(Han et al., 2009)
Study Design
Case report
(Giaconi et al., 2011)
Study Design
Case report
(Mangus et al., 2008)
Study Design
Non-consecutive case series
(Hinchey & Subramaniam, 2009)
Study Design
Case report

(Sloane et al., 2008)
Study Design
Case report
(Bui et al., 2009)
Study Design
Case report

89

Appendices

APPENDIX C
Summary of Animal Studies Examining Respiratory Dysfunction
Subject and Exposure Time

Measurement

Observations
Pre-Exposure

Observations
Post-Exposure

Conclusions

(Jauchem et al., 2006)
6 pigs exposed to single discharges
for 5-s, followed by a 5-s period of
no exposure, repeatedly for 3 min

pH

7.42

6.95

•	 Blood pH significantly decreased for
1 h following exposure
•	 Acidosis believed to be a result of leg muscle
contractions (which caused increased lactate
and metabolic acidosis) and decreases in
respiration (which caused increased PCO2
and respiratory acidosis)
•	 Lactate was highly elevated, with a slow return
(time course greater than 1 h) to baseline

(Dennis et al., 2007)
11 pigs, two 40-s discharges

(Jauchem et al., 2009b)
10 pigs, 30-s discharge

(Jenkins et al., 2013)
10 pigs, subjected to discharges of
up to 30 minutes

Lactate (mmol/L)

1.05

14.5

PCO2 (mm Hg)

~ 45

~ 100

pH

7.45

6.81

Lactate (mmol/L)

1.6

22.1

PCO2 (mm Hg)

45.3

94.5

pH

7.39

7.04

Lactate (mmol/L)

1.6

14.1 (10 min
post-exposure,
and 8.2 three
hours after
exposure)

PCO2 (mm Hg)

60

113 (immediately
post-exposure)

pH

~ 7.4

~ 6.9

Lactate (mmol/L)

~ 1.25

~ 16

PCO2 (mm Hg)

~ 37

~ 100

•	
•	
•	
•	

Breathing stopped during exposure
Two deaths resulting from cardiac arrhythmias
Significant acid-base disturbances
Unlike Jauchem et al. (2006), animals were
mechanically ventilated (except during 40-s
discharges) so increased PCO2 was believed
to be caused by impaired circulatory function
rather than decrease in respiration

•	
•	
•	
•	

Breathing stopped during exposure
Decrease in pH
Increase in lactate
Increase in PCO2

•	 Inhibition of spontaneous breathing in
the first 60-90 seconds post-exposure
•	 Animals developed mixed metabolic
and respiratory acidosis
•	 Four deaths occurred, likely due to mechanical
cardiac muscle failure (not electrically induced
arrhythmias)
Values represent the average of 8 animals
immediately following 5 min of continuous
exposure, because data were incomplete at
later time points

The Health Effects of Conducted Energy Weapons

90

Varied location
and charge

Varied length of discharge

Varied strength of charge

Varied probe depth

Varied probe location

APPENDIX D
Summary of Animal Studies Examining Variable CEW Characteristics
and Cardiac Dysfunction
Subject

Probe Location

6 pigs (150
discharges
total)

2 positions: one
across the heart
and one across
the abdomen

4 pigs (67
discharges
total)

11 positions (on
front and back),
including some
across the heart

5 pigs

Performed
surgery to place
one probe above
heart and allow
for depth
variation; other
probe on
abdomen

9 pigs
(each
exposed
~26 times)

Across the heart

Probe
Depth
Inserted just
under skin

12 mm

Varied
dart-to-heart
distance

Not specified

Strength
of Charge

Length / Number
of Discharges

Standard

1 X 5-s and
1 X 15-s

Outcome (and Reference)
Cardiac capture only occurred when current was
delivered across the heart but ventricular fibrillation
did not occur. Longer discharge (15-s) more likely
to cause capture (Nanthakumar et al., 2006).

Standard

1 X 10-s

Cardiac capture occurred at a higher rate when current
directly crossed the heart but transcardiac discharge
was not required for capture. Two cases of ventricular
fibrillation occurred, both when current was delivered
across the heart (Valentino et al., 2008a).

Standard

1 X 5-s (each
animal exposed
multiple times at
different
dart-to-heart
distances)

Average distance from tip of dart to heart that elicited
ventricular fibrillation was ~6 mm (range 2–8 mm). In
humans, if probe is fully penetrated and skin-to-heart
distance is small, probe may be close enough to heart
to cause ventricular fibrillation (Wu et al., 2008).

Varied

1 X 5-s (each
animal exposed
multiple times at
different charge
strengths)

A charge 15X stronger than that of a standard CEW
was required to induce ventricular fibrillation even
in smallest pig. Heavier pigs required higher charges
(McDaniel et al., 2005).
Cardiac capture usually occurred with standard charge.
Ventricular fibrillation induction occurred (in less than
half of cases) only when charge was ~4X greater than
standard (Kroll et al., 2009).

2 pigs

Across the heart

9 mm

Varied

1 X 5-s (each
animal exposed
multiple times at
different charge
strengths)

11 pigs
(some
controls)

Across the heart

10 mm

Standard

2 X 40-s

Cardiac capture occurred in all animals. Two cases
of fatal ventricular fibrillation (Dennis et al., 2007).

14 pigs
(some
controls)

Across the heart

12 mm

Standard

2 X 40-s

Cardiac capture occurred in all animals. One case
of fatal ventricular fibrillation (Walter et al., 2008).

6 pigs

Across the heart

One probe
10 mm
from heart

Standard

Varied length
(each animal
exposed multiple
times for different
length of time)

A discharge of ~90-s is required for induction
of ventricular fibrillation (Kroll et al., 2010).

10 pigs
(5 for each
group)

Across the heart

Not specified

Standard

1 X 30-s and
1 X 60-s

No episodes of ventricular fibrillation (Jauchem
et al., 2009a).

10 pigs

Across the heart

Not specified

Standard

20 X 5-s (4 groups
of 5 X 5-s,
5 min apart)

No episodes of ventricular fibrillation (Esquivel
et al., 2007).

Standard

Up to 1 X 30-min

Four deaths occurred (at 4, 4.5, 10 and 10.25 min).
None of the deaths were attributed to sudden cardiac
death caused by electrically induced ventricular
fibrillation (Jenkins et al., 2013).

Varied

1 X 5-s (each
animal exposed
multiple times at
different charge
strengths)

Ventricular fibrillation risk varied depending on
position of CEW darts in relation to heart (but only
occurred with an “enhanced” CEW that delivered
a charge more than 4X greater than standard)
(Lakkireddy et al., 2008).

10 pigs

Across the heart

13 pigs

5 positions,
including 3 across
the heart and 2
on the back

Not specified

9 mm

91

Board of Governors of the Council of Canadian Academies
Affiliations as of June 1, 2013
Elizabeth Parr-Johnston, C.M., (Chair), Former President,
University of New Brunswick and Mount Saint Vincent
University (Chester Basin, NS)

Claude Jean, Executive Vice President and General
Manager, Foundry Operation, Teledyne DALSA
Semiconductor (Bromont, QC)

Margaret Bloodworth, C.M., Former Federal Deputy
Minister and National Security Advisor (Ottawa, ON)

Thomas J. Marrie, FCAHS, Dean, Faculty of Medicine,
Dalhousie University (Halifax, NS)

John Cairns, FCAHS, Professor of Medicine, University
of British Columbia (Vancouver, BC)

Jeremy McNeil, FRSC, Helen Battle Visiting Professor,
Department of Biology, Western University (London, ON)

Marie D’Iorio, FRSC, Executive Director, National Research
Council Canada, National Institute of Nanotechnology
(Edmonton, AB)

Axel Meisen, FCAE, C.M., Former Chair of Foresight
at Alberta Innovates — Technology Futures (AITF)
(Edmonton, AB)

Henry Friesen, C.C., FRSC, FCAHS, (Vice Chair),
Distinguished Professor Emeritus and Senior Fellow, Centre
for the Advancement of Medicine, Faculty of Medicine,
University of Manitoba (Winnipeg, MB)

Lydia Miljan, Associate Professor of Political Science
and Chair of the Arts and Science Program, University of
Windsor (Windsor, ON)
P. Kim Sturgess, FCAE, CEO and Founder, Alberta
WaterSMART (Calgary, AB)

Board of the Canadian Academy of Health Sciences
Thomas J. Marrie, FCAHS (President), Dean, Faculty of
Medicine, Dalhousie University (Halifax, NS)
Catharine I. Whiteside, FCAHS (Past-President), Dean,
Faculty of Medicine, University of Toronto (Toronto, ON)
John Cairns, FCAHS (President-Elect), Professor of
Medicine, University of British Columbia (Vancouver, BC)

Robert Sindelar, FCAHS (Secretary), Dean, Faculty of
Pharmaceutical Sciences, University of British Columbia
(Vancouver, BC)
Jawahar Kalra, FCAHS (Director), Professor of Pathology,
University of Saskatchewan (Saskatoon, SK)
Peter Singer, FCAHS (Foreign Secretary), Chief Executive
Officer of Grand Challenges Canada and Director, Sandra
Rotman Centre, University Health Network, University of
Toronto (Toronto, ON)

92

Joint Scientific Advisory Committee
Affiliations as of June 1, 2013
Tom Brzustowski, O.C., FRSC, FCAE (Co-Chair), Chair of
the Board, Institute for Quantum Computing, University
of Waterloo (Waterloo, ON)
John Cairns, FCAHS (Co-Chair), Professor of Medicine,
University of British Columbia (Vancouver, BC)
Paul Armstrong, FCAHS, Distinguished University
Professor, University of Alberta (Edmonton, AB)
Dale Dauphinee, FCAHS, Former Executive Director,
Medical Council of Canada (Montreal, QC)
Jean Gray, C.M., FCAHS, Professor of Medicine (Emeritus),
Dalhousie University (Halifax, NS)
Stuart MacLeod, Past Executive Director, Child and Family
Research Institute & Professor, Department of Pediatrics,
University of British Columbia (Vancouver, BC)
Susan A. McDaniel, FRSC, Director, Prentice Institute
& Canada Research Chair in Global Population & Life
Course, Prentice Research Chair & Professor of Sociology,
University of Lethbridge (Lethbridge, AB)
Norbert R. Morgenstern, C.M., FRSC, FCAE, Professor
(Emeritus), Civil Engineering, University of Alberta
(Edmonton, AB)

The Health Effects of Conducted Energy Weapons