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6 ways to avoid ketamine pitfalls

Communicating with law enforcement and following these clinical guidelines will help to keep patient safety first and foremost

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How can we keep our patients and clinicians safe in the field, and maintain good working relationships with law enforcement?

AP Photo/Teresa Crawford

The in-custody deaths of persons who had been administered ketamine for agitation have brought controversy and questions about the use of the drug in EMS. Supervisors and leadership are faced with having to make tough decisions about what to do when the roles of law enforcement and patient care collide. In some areas, politicians and leaders with little medical understanding have made decisions about the use of medications, instead of physicians and EMS leaders.

This is a problem that we must face head-on in EMS.

Ketamine is a medication that can provide rapid control of dangerously disruptive patients, allowing further assessment and treatment. It is a dissociative anesthetic that can be administered in a variety of ways, and at higher doses (4-5 mg/kg) will allow a violent, disruptive patient to be controlled to provide care.

Ketamine also is touted for having a wide safety profile, and there are cases where patients have been given large doses of it in error, with no documented ill effects.

However, the cases of Elijah McClain and others show that there is a risk to using ketamine as a chemical restraint, especially when the patient is in, or attempting to be brought into law enforcement custody. EMS agencies have come under fire in some areas for relying on ketamine to control patients, sometimes at the behest of law enforcement officers who may not understand the risks of using this drug fully.

The results can be devastating, and for the most part; avoidable.

How can we keep our patients and clinicians safe in the field, and maintain good working relationships with law enforcement? Following are 6 strategies to avoid ketamine pitfalls and emphasize patient safety.

1. Engage law enforcement leadership. As leaders, we have to be able to discuss with them the goals of assisting law enforcement safely for all. The paramount goal of EMS needs to be patient care, first and foremost. That needs to be communicated to police leadership. This is where we need to share the additional research needed into excited delirium, which is not recognized by the World Health Organization, and is not included in the Diagnostic and Statistical Manual 5th Edition, the authoritative work on mental disorders.

Share what we can do for patients in police custody, and what you will not do, and develop plans to respond to agitated patients. At the least, any call where an agitated patient in police custody leads to EMS response, this warrants both EMS and police supervisors to respond to the scene, to coordinate and make sure lines do not get crossed. Open lines of communication will help to prevent decisions made ad hoc in the heat of the moment.

2. Put patient care first. Educate your staff and first-line supervisors as to their role in these incidents. EMS needs to stay in their lane as caregivers, and not be police. We are there for the patient first. Their safety and health are our responsibility, and when we forget that in the heat of the moment; that is where the problems begin. We need to educate and develop the culture in our agencies that we are patient advocates, and that a patient’s custody status has no bearing on their treatment.

3. Teach CRM to help medics communicate in high-stress encounters. Make crew resource management skills part of your training program so that clinicians can communicate effectively under stressful situations. Use the PACE format (Probe, Alert, Challenge, Emergency) to train paramedics and first-line supervisors how to talk in these situations.

4. Develop strong policies in accordance with your medical director, and make sure they are based on current science.

5. Avoid flat dosages. Every patient should receive a weight-based dose consistent with recommendations. This does not have to be calculated at the scene, you can incorporate a card or reference with patient weights, milligrams and volume that can lower cognitive load at a stressful time.

6. Monitor patients closely after administering ketamine. Every patient who receives medication for sedation or restraint should at a minimum be regarded as a medical patient who requires monitoring and transport to a hospital ED for further care. The patient should be placed on a cardiac monitor, including pulse oximetry, and end-tidal carbon dioxide waveform capnography should be used without exception.

EtCO2 gives you a breath-by-breath measurement of how the patient is oxygenating, and ventilating, and will alert you to a problem with the patient well before the pulse oximeter or ECG will. Once we’ve given a drug, we can’t take it back; and our responsibility is now that patient’s overall safety.

These ideas are only a start, but hopefully, by engaging law enforcement leadership, developing policies and culture, and placing the patient first and foremost; we can minimize the risk and do better for the people we serve.

Crowe Myers

Listen for more:

Ketamine and EMS: Educating the public and ourselves

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Daniel Schwester has been a paramedic since June 2000. He has served in a variety of roles, including education, field training, clinical supervision and active practice as a paramedic.

He is the managing partner of Overrun Productions, LLC, and a co-host of The Overrun, a podcast focused on progressive issues in prehospital medicine. A goal of The Overrun is to bring cutting-edge topics to the prehospital community in all areas, including clinician mental health.

He is married to Jennifer, and is father to Caroline and William. He resides in Toms River, New Jersey.