Is ketamine a problem lying in wait at your agency?
5 actions EMS leaders should take to ensure ketamine is appropriately administered when indicated and documented correctly
Ketamine is in the news again. A South Carolina woman has filed a lawsuit against Charleston County EMS and four of its providers for negligence in the 2019 death of her husband. She claims the administration of ketamine was "unlawful, unjustified and unreasonable use of force."
You should recall that in early September, two Colorado paramedics were indicted on 10 counts each of crimes including manslaughter, criminally negligent homicide, assault with a deadly weapon, conspiracy and a range of other criminal charges for their administration of ketamine to Elijah McClain, 23, who died in 2019 after an interaction with police and EMS in Aurora, Colorado.
In both cases, ketamine was administered to a patient in police custody with the intent to sedate. Also in both cases, the need for sedation, as well as the paramedics’ actions to properly assess and treat the patient is being called into question.
It seems likely to me that plaintiff attorneys representing families grieving the in-custody death of a loved one are examining police case reports, prehospital care records and hospital medical records to see if ketamine was administered. And if ketamine was administered, determining if there are grounds for legal action based on the patient assessment, ketamine dosing and administration, and ongoing patient assessment.
Rather than waiting for a tragedy to happen or an attorney to file suit, EMS leaders ought to consider the following:
1. Agitated patient protocol review
EMS providers frequently encounter patients experiencing behavioral emergencies. A small percentage of those patients are out-of-control and putting themselves and others at risk of injury or death. As we know from experience, law enforcement is often controlling or restraining the patient, who may or may not have also committed a crime or being suspected of committing a crime, when EMS arrives. These incidents are a major challenge for everyone.
If your service’s paramedics are authorized to administer ketamine to sedate an agitated patient, an important first step is to review the current protocol and update the protocol as necessary. Review the protocol’s indications, dose calculations, administration routes and ongoing patient assessment and treatment after ketamine is administered.
2. Train all personnel
Use a combination of online training videos, classroom lectures, case reviews and high-fidelity simulations to train and verify competency to recognize and treat a behavioral emergency, including the administration of ketamine when its indicated. Make sure training includes:
Patient assessment to formulate a treatment plan
Other relevant treatments for airway management and ventilatory support
Ongoing patient assessment after ketamine administration
In most negligence cases, the litigation reveals inadequate, poor or absent documentation. Make sure training includes a component for participants to review and improve their documentation skills and to make documentation quality part of the competency assessment. Documentation should include, but not be limited to:
Scene size-up, primary assessment and secondary assessment findings
Interactions with other co-responders, such as police officers, other healthcare workers and friends or family of the patient who may also be at the scene
Description of how the patient was restrained, if at all, by police officers when paramedics arrived and how that restraint may have complicated assessment of the patient
Explanation of the dose calculation, how the amount was verified by another paramedic and the route the ketamine was administered
Patient’s specific behavior at the time of administration and the ongoing status of the patient at the time of administration
As part of high-fidelity simulation video, record the actions of the paramedics. If capabilities allow, video record the simulation with two actors. Have one actor, in the role of a police officer with point of view camera, be actively engaged in the patient restraint and collaborate with the paramedics. Have a second actor as an interested but not interfering bystander record the simulation on a smartphone camera. Since it is increasingly likely your encounters with patients experiencing a behavioral emergency will be recorded, you ought to practice with cameras rolling and use that video to improve your personal and team skills.
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3. Document the completion of training
The documentation of the training should match the intensity of the training. It’s not enough to capture the minimum documentation requirements for national registry certification, state licensure or local credentialing. In the case of documenting training on response to and treatment of patients experiencing behavioral emergencies, exceed the minimum requirements by:
Writing a thorough lesson plan for the training session. Include the names of the educators who developed the training session, the administrators and medical director who approved it, and the educators who delivered the training.
If a written examination and/or skills competency check list were created, include an explanation of how those were developed and validated. Preserve the performance results for each paramedic, along with the proctors for their competency check.
Listen to the EMS One Stop podcast: Chemical restraint
4. Review old cases
Gordon Graham, noted risk management expert, lawyer and trainer, uses the term “problems lying in wait” to describe the likelihood of problems existing within an organization but leaders failing to identify and deal with those problems. Too often, leaders fail to address problems lying in wait until they are forced to by litigation. Is ketamine a problem lying in wait in your organization?
At the least, it seems reasonable to review several years of patient care reports to identify cases that meet all or some of these criteria:
Patient with severe agitation or out-of-control behavior
Administration of ketamine or another medication to sedate the patient
Adverse or unexpected patient reaction to ketamine
In-custody injury or death attended by paramedics
Need for airway management and or ventilation after ketamine was administered
You may find countless examples of outstanding patient assessment and care. If that’s the case, make sure to recognize your crews for their diligence, praise your training staff and make sure processes are in place to maintain your organization’s culture of excellence.
If you find potential problems lying in wait, discuss with your organization’s leaders and medical director how you’ll use those findings to update protocols and improve training, documentation and patient care. Use past mistakes, instead of ignoring them, to strengthen the organization and providers.
If your case review surfaces potential negligence or criminal wrong doing, discuss next steps with your legal representation. In my opinion, proactively assessing and acting may take the wind out of future legal proceedings and position the organization for a more favorable resolution or settlement.
Listen to The EMS Educator podcast: Research on ketamine use by EMS
5. Stay vigilant as a field provider
As I review the news reports of accusations of wrongdoing against EMS providers, these are the red flags that I regularly see:
Poor or inadequate documentation
Documentation that tells a different story than video recorded by police or bystanders
A sudden change in patient mental status or behavior that goes unnoticed by EMS providers
Discounting the severity of a patient who says, “I can’t breathe”
Administering ketamine to a patient in-custody without an assessment
Failing to initially assess and continuously monitor the patency of the patient’s airway and ability to self-ventilate
What are the red flags you see most often in accusations of wrongdoing against EMS providers? Remember, your safety comes first and it's critical that you regularly take action to keep yourself safe on scene, as well as safe in the court of public opinion and court of law.