COLORADO, USA — Colorado health leaders released recommendations Wednesday about the use of ketamine in prehospital settings following a review that was conducted when questions about the use of the drug surfaced after the 2019 death of Elijah McClain.
On Aug. 24, 2019, Aurora Police Department (APD) officers contacted McClain, 23, while he was walking home from a convenience store where he'd gone to pick up a drink. Three days later, on Aug. 27, he died at a hospital of undetermined causes, according to the Adams County Coroner's Office.
McClain was given a dose of the drug by paramedics with Aurora Fire Rescue (AFR) during a struggle with Aurora Police. McClain later died and his family recently reached a $15 million settlement with the City of Aurora.
Two paramedics were indicted in McClain's death, and according to the indictment, they overestimated McClain's weight by roughly 57 pounds and administered a dose of ketamine that was appropriate for a person weighing 77 pounds more than him.
The Colorado Department of Health and Environment (CDPHE) is responsible for licensing or certifying those who provide medical care in prehospital environments. CDPHE can issue waivers to EMS agency medical directors who meet certain criteria, and those waivers permit them to administer ketamine.
The review didn't investigate a specific case. Rather, the independent panel conducted a review of the program that allows paramedics to administer ketamine.
“We convened a diverse group of experts to examine the use of ketamine in the field by emergency medical services. We did a thorough review of the latest research and drew on the many years of experience from the committee members,” said Dr. Eric France, chief medical officer, CDPHE.
“I’m truly proud of this committee’s work and am committed to determining what recommendations should be adopted by the state," he said.
The panel found that ketamine is a safe drug "if used properly and monitored closely" but that "adverse effects" have arisen due to the drug being administered when it may not have been medically necessary.
"It is a medication that can really help us get someone from in the field to a hospital where we can provide more definitive care," said Dr. Janetta Iwanicki, a medical toxicologist with the Rocky Mountain Poison Center and a member of this panel.
In the 126-page report, the independent committee recommended first responders shouldn't use the sedative for "excited delirium syndrome." According to the report, the diagnosis has been scrutinized for years for the potential of bias.
"Descriptors such as 'hyper aggression,' 'increased strength,' and 'police noncompliance' are listed as criteria for this assessment and have been associated with racial bias against African American men," the report said.
"We felt it was really important that we described more in detail of what that patient should look like who receives ketamine," said Dr. Iwanicki.
The panel also recommended that ketamine be used in very "limited settings" where there are "no other means available to safely assess, treat and transport the patient." These situations could include instances where the person presents an "imminent threat" of harm to themselves or others.
The panel also suggested CDPHE should analyze whether there is a disproportionate use of ketamine for communities of Colorado.
Scott Sholes, the president of the EMS Association of Colorado, supported the panel's recommendations. He appreciated the suggestion related to a change in oversight. Colorado is one of two states where ambulance agencies are licensed at the county level rather than the state level. The panel suggested CDPHE should request the legislature to consider changing that oversight to allow for more uniform standards and protocols.
"When something happens the state can look at the practice of the individual EMTs and paramedics but there is limited ability to look at the agency," said Sholes. "The situation like we found ourselves in here in the last couple of years with the whole ketamine controversy is a great opportunity to look at the entire state system."
Other recommendations from the report include the following:
- Specifying when the use of ketamine may be needed in emergency settings.
- Rejecting excited delirium syndrome as an acceptable diagnosis.
- Basing the standard dose on body stature (small/average/large): 300/400/500 mg for males and 250/350/450 mg for females.
- Monitoring of a patient who has received ketamine closely. All ambulances should contain a checklist of actions for appropriate dosing and monitoring.
- Augmenting paramedic educational curriculum to add modalities in patient handoff from law enforcement, racial equity and implicit bias training, verbal de-escalation techniques and a stronger focus on patient monitoring practices with sedation.
- Creating more consistent practices among all emergency medical services and ground ambulances through statewide oversight.
In July, the state notified Medical Directors of Emergency Medical Services of the suspension of ketamine for excited delirium and agitation in the prehospital setting. This report does not change the current suspension of the use of ketamine in emergency settings.
"There was, I think, about 100 agencies statewide that had these waivers," said Sholes. "We will see how many want to continue with waivers for this in the future."
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