Roundtable: Media report should drive EMS agencies to review ketamine protocols
EMS leaders respond to Star Tribune report of administering ketamine to agitated, restrained patients in Minneapolis
By EMS1 Staff
The restraint and sedation of extremely agitated patients is a high-risk, low frequency procedure for EMS and police. It is extremely dangerous for public safety personnel and the patient. One of the ways to keep a patient from violently fighting against restraint – and until they die from exhaustion – is to sedate the patient with ketamine.
The Minneapolis Star Tribune recently reported the findings of an investigation conducted by the Office of Police Conduct Review, a division of the city’s Department of Civil Rights, citing multiple reports of Hennepin Healthcare EMS workers, in the presence of police, injecting “suspects of crimes and others who already appeared to be restrained” with ketamine, which “caused heart or breathing failure, requiring them to be medically revived,” or required intubation.
Hennepin County EMS ALS protocol 3420 (Behavioral Emergencies) authorizes personnel to administer ketamine if a patient “is profoundly agitated with active physical violence to himself/herself or others evident, and usual chemical or physical restraints may not be appropriate or safely used.”
We asked a panel of EMS leaders, educators and field providers to respond to the mainstream media reporting of ketamine use for sedation, and how EMS agencies should respond. Here’s what they had to say.
Report paints lifesaving drug as unsafe/irresponsible
What is unfortunate about the Star Tribune article is that it unfairly paints a very useful drug as an irresponsible or unsafe medication, when the reality is, it saves lives. Ketamine is extremely versatile for prehospital use in pain control, airway management for severe asthma attacks, and safe mitigation of excited delirium syndrome, to name just a few applications.
I would also caution that watching an edited or partial video of an encounter as a passive observer is far different from the reality of our EMS and police personnel who must perceive, process and rapidly interpret information on a dynamic scene while simultaneously formulating a plan of action to effectively and safely manage a volatile situation. Thus, making judgement calls or formulating opinions about the appropriateness of any such action must take the sum totality of the circumstances into consideration.
While managing public safety emergencies should be a collaborative effort among police, fire and EMS personnel, I would agree that everyone should maintain their professional roles, in that medical interventions should be decided upon by EMS crews and law enforcement actions should be determined by police officers.
—David Tan, MD, EMT-T, FAAEM, EMS1 Editorial Advisory Board member; associate professor and chief
Restraint not a contraindication for ketamine sedation
As usual, there is a deep lack of understanding on the part of the reporter who wrote this. For example, the anecdote about the asthma patient illustrates ignorance of actions of ketamine and its use in asthma.
There is also slight mention of the fact that the EMS MD found the cases reviewed to have been within medical indications. Until the whole case documents are reviewed, including the patient’s vital signs and behaviors at the time, no conclusions can be drawn. The mere fact that the patients were restrained is not, in itself, a contraindication for ketamine or other sedating drugs.
—William "Gene" Gandy, paramedic and EMS educator
A team approach to patient sedation is safer
When a restrained person has a mental health or drug crisis, they continue to struggle, no matter how well law enforcement has bound them up. While this protects the cops, bystanders and patient from trauma, the patient is at risk for metabolic derangement, hyperthermia and death.
To the cops’ credit, they have learned that restraints can kill their detainees and that sedation can be safer for someone that is excessively agitated from a mental health or drug emergency.
Ketamine is probably (the science is still being developed) the best medication for this. Ultimately, the paramedic is responsible for making the decision whether or not to sedate a patient and with which medication.
I have been in many situations where law enforcement has asked me to do something, and most of the time I find their request to be in the best interest of the patient and I do it. When I've refused (and done something different) I have not had any problem with the cops. I respect their opinion and they respect mine. Working together is not a bad thing.
In the case of sedating agitated suspects, a team approach is safer and law enforcement should be recognized for recognizing they had a medical problem and requesting help from paramedics.
—Rocco Altobelli, flight paramedic and EMS educator
Prepare to brief local media on administering ketamine
The New York Times has added its editorial heft and massive circulation to the Minneapolis Police report. When a local news story goes national, it is likely other media outlets will begin to investigate and report – in this case, on the use of ketamine to sedate patients with a behavioral emergency. If I were a service director, I'd put together a briefing packet for when local media calls to include service-specific:
- Behavioral emergency protocol.
- Ketamine indications and dosage.
- Number of times ketamine has been administered for a behavioral emergency.
- Total calls, all types, in that same time period.
- Curriculum for joint training with LE and EMS for patients with behavior emergencies.
—Greg Friese, EMS1 editor-in-chief
Additional ketamine resources
Learn more about the uses and indications for ketamine treatment with these EMS1 resources:
- Inside EMS Podcast: Challenges of using ketamine in the field
- Ketamine for Excited Delirium Syndrome: Results of a 3-year case series
- When overdoses go wild: Protecting the EMS provider
- Excited delirium: Medical emergency – not willful resistance
- Study: Ketamine found more effective for treating highly-agitated patients during transport
- Ketamine: Drug Whys
- 3 reasons to use ketamine for prehospital analgesia
- Treating pediatric patients with ketamine for pain
- Prehospital use of ketamine