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September 3, 2020 | View as webpage
Leaders,

Earlier this week, the National Association of EMS Physicians released a statement titled, “Ketamine use in prehospital settings should remain the purview of EMS physicians.”

In response to the recent incidents in Colorado; and a joint statement made by the American Society of Anesthesiologists, the American College of Emergency Physicians and the Colorado Department of Public Health and Environment, the statement noted NAEMSP “firmly believes that the medical direction and supervision of the art and science of prehospital medicine is best practiced by subspecialists in EMS medicine.” The statement further stated ketamine and other pharmaceutical agent administration by prehospital personnel is under the medical authority, supervision and QA/QI programs of a physician.

NAEMSP President, David K. Tan, MD, EMT-T, FAAEM, FAEMS, commented, “The suggestion that ketamine is routinely being used for ‘non-medical’ purposes is dangerously misleading.”

In this briefing, Rob Lawrence and Dr. Craig Manifold take on prehospital ketamine administration policies, politics and police interactions.

Stay well,


Kerri Hatt
Editor-in-Chief, EMS1

 
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Ketamine administration comes under the spotlight
By Rob Lawrence 

The word of the week is ketamine. EMS is the spotlight for its prehospital use of ketamine, for the circumstances that lead up to its use, as well as the clinical outcomes of those in receipt.

Two cases in Colorado brought the situation into critical focus, initially with the administration of two doses of ketamine totaling 750 mg by Colorado-based South Metro Fire Rescue medics in August 2019. The patient, Elijah McKnight, was allegedly intoxicated, struggled with a sheriff’s deputy, was TASERed, handcuffed and subdued by three people. Identifying the patient was experiencing excited delirium, the attending medics administered one 500 mg dose of ketamine and another dose of 250 mg about nine minutes later after consulting with a physician. Clinically, and by Colorado protocols – so far so good. EMS providers in Colorado are permitted to administer ketamine under Emergency Medical Practice Advisory Council Waiver Guidance.

The story elevated to the front-page level as body camera footage identified that deputies asked if the medics could "give him anything," to which a medic replied they can give him ketamine and, "he'll be sleeping like a baby," but would need to be transported.

A further case occurred just last month where another Colorado arrestee, Elijah McClain was administered ketamine, went into cardiac arrest, and was subsequently declared brain dead and died on Aug 30.

The timing of these cases has created a national media story, considerable litigation, an investigation into ketamine administration practices by the State Department of Health and Environment, and a call to ban the use of the drug on excited delirium patients by the mayor of the City of Aurora.

As the issue is still unfolding, I called up Dr. Craig Manifold to help me unpack the issues and takeaways.

A well-known Eagle, Dr. Manifold is an emergency physician with both military and civilian experience of ketamine administration. He noted that ketamine is a very safe medication when used appropriately and under the oversight of an EMS physician. He said, “My experience comes from utilizing it not only in the emergency department but in the field as a military physician and have had truly wonderful experiences with it. It has been extremely valuable to our patients and in the multiple benefits that go along with its utilization.”

He told me, “before, we were seeing patients on cocaine and methamphetamine and now we can manage those patients more efficiently and effectively, and immediately move those patients into the medical care realm and transport to the hospital.” Dr. Manifold highlighted that in informal discussions with EMS medical directors, there is an indication that there has been less death since the incorporation of ketamine for these patients who are involved in these type of scenarios.

Here are the takeaways from my conversation with Dr. Manifold about prehospital ketamine administration.

1. Paramedics and police

Much discussion has involved the on-scene scenario where the police invite the medic to “just give him/her something.” In situations where this direction may have occurred, there is possibly a degree of peer group pressure to conform with a request for sedation based on a non-clinical, lay opinion.

The overarching requirement is to provide appropriate clinical care while considering the safety of both the patient and those on the scene. Dr. Manifold agrees, “it is not a law enforcement decision, but it is certainly the medical provider's responsibility to utilize the medication effectively and safely. Part of that does include input from officers, bystanders, family members and others involved in these scenarios.”

It is very clear that when the paramedic arrives on the scene, a rapid decision must be made on the treatment and transport of the patient as well as the safety of the scene and all those in it. This element can and has been armchair quarterbacked after the fact. The advent of body-worn cameras has added clarity to the decision-making process in review, but also in few, massively promoted cases, laid certain on-scene members open to scrutiny, criticism and litigation.

2. Policy and quality

In the light of the current public focus on the use of ketamine in the treatment of excited delirium, it is probably a good time to examine existing clinical protocols and waivers to ensure they are up to date and the necessary education and training has been delivered. Is the administration of ketamine an immediate flag for QA/QI? Is it passed to the medical director for review? Do we wish to debrief other agencies and partners involved in a hot wash, after-action report or lessons identified session? All may be good ideas.

3. Practice and partnerships

Let’s face it, the police have a hell of a job to do on the streets, and the additional stress and operational pressure of COVID-19 and civil unrest hasn’t made it any easier. Elsewhere in the EMS news sphere, there are suits taken against employers by staff members who have been disciplined for not following the instructions of law enforcement when on the scene, so the matter is very delicate. The discussion into policies, waivers and protocols should not first take place on a dark and stormy night on the ground. A protocol that requires an invasive procedure while the patient is subdued should be discussed clearly and early with jurisdictional partners.

Dr. Manifold believes “The time for these discussions is not in the field. The policies and procedures and the interactions between the medics and the law enforcement officers make for a great opportunity for case-based scenarios – doing the what if? How do we take care of these individuals? What is appropriate? How do we transfer the care of the individual to the medical team? Lots of factors go into this.”

Just because we give the medication, doesn’t mean the arresting officer is no longer involved, and it is a function of leadership to discuss, determine and, if necessary, exercise these actions.

4. Data exchange on prehospital ketamine use

Data is an essential element to demonstrating the worth and effectiveness of prehospital ketamine administration and this further highlights the need for bidirectional data between EMS agency and hospitals to identify outcomes for QA/QI and performance improvement.

Dr. Manifolds observed, “we have to look at our utilization of ketamine. This is a relatively new introduction to our profession over the last 5 to 10 years. And we are going to see an increase in its usage and that is just a natural evolution in people adopting and using it. Ketamine is used for multiple processes, such as analgesia, not just for sedation management, and procedural components such as rapid sequence intubation, so there are many factors, such as differences in dosing to look at.”

5. Clinically qualified investigators and direct experience

In 2020, no one in the U.S. is immune to politics, it is just as pervasive as COVID-19. Where investigations take place, those undertaking them must be clinically qualified to comment on actions and activities. They must have direct experience of field provision of ketamine and the environment and circumstances in which this drug is employed. All must resist the “ready; fire; aim” approach that sometimes takes place in these scenarios.

While we acknowledge there may be bad actors in any profession, facts, data, and outcomes must cast the vote and not the opinion of laypersons or search engine operatives!

Listen for more: Inside EMS Podcast: Challenges of using ketamine in the field

Additional resources:
6 ways to improve the exit interview process
By Maria Beermann-Foat, PhD, MBA, NRP 

By Maria Beermann-Foat

The premise behind exit interviews is centered on capturing information to reduce future employee turnover. As business research has shown high turnover rates are linked to increased recruiting costs, decreased worker productivity and an adverse impact on workforce morale, it makes sense that we should find ways to retain employees.

It is expected that exit interviews will bring to light specifics of why an employee is leaving and help identify systemic issues contributing toward the turnover rate. Armed with this type of information, leaders can then enact organizational changes and stem the flow of departing staff.

Institutional knowledge loss is a primary risk factor when high turnover exists. When an employee leaves an organization, they leave with specific knowledge about the organization’s culture, activities, personnel, and – most importantly – why they are leaving. The more tenured the employee, the greater the loss of expertise – gained through their years of work efforts and relationships built – leaving with the employee.

Organizations with low turnover rates benefit from reduced recruitment costs and increased productivity, but also with a greater retention of the organization’s established culture. When personnel stay with the organization longer, they develop a deep understanding of the organization’s core mission/purpose, values and cultural norms. They, in turn, are able to help instill these in newer employees trying to assimilate into the organization.

Organizations with high turnover rates risk cultural expectations becoming “muddy” or rapidly evolving, as new employees are more likely to be mentored by employees not much more tenured than themselves. Having a less established foothold in the organization’s desired culture may translate into personal interpretation of the organization’s mission and values instead of those intended by the organization. While on the surface, this may not seem like a major risk, it can be when policy language is vague enough and those actions that make your organization special (e.g. taking the time to fill the food and water bowls of a patient’s pet, turning off the lights, and ensuring there are no burning candles in the home prior to transport) are passed on from tenured provider to newer provider through daily demonstration and reinforcement.

An insight into competitive advantage

Exit interviews may provide leaders an opportunity for insight into workforce factors impacting retention and may assist in determining an organization’s competitive advantage. In theory, having an open dialogue with a departing employee, may reveal the existence of a problem manager or some other not as obvious issue, identify training gaps, and (if the employee is leaving for another job offer) a comparison of benefits and workplace features to those of a competitor.

However, obtaining this type of information may not be easy. Employees, afraid of burning a bridge or reprisal, may only offer superficial feedback. In contrast, employees leaving on unfavorable terms may overemphasize negative critique.

A study by Feinberg and Jeppeson (2000) examined the consistency between employee reasons for leaving during exit interviews conducted immediately and again 2-years post-departure. The responses differed significantly, with immediate exit interview responses being more careful or positive than those shared once the separation was complete and time had passed.

Additionally, a 2013 review of exit interview programs from 210 organizations in 33 industries revealed that very little positive organizational change resulted from the feedback (Spain & Groysberg, 2016). An ineffective strategy in conducting exit interviews and following up on the information received can limit results.

Here are 6 strategies to formalize the exit interview structure to guide the process, ensure consistency and achieve improvement:

  1. Interviews should be scheduled with the employee to allow ample time for the employee to prepare for the conversation. Let the employee know the purpose of the interview (i.e. what the organization is looking to gain from the conversation) and possibly provide the employee with a list of the questions that will be asked in advance. This will help the employee to reflect on the upcoming conversation and potentially provide more thoughtful responses than off-the-cuff ones.
  2. Communicate the expectations of confidentiality and reinforce this expectation by having a neutral party conduct the interview (some organizations use their HR representative or a manager from a different agency for this role). This can be beneficial in instances when the employee is leaving on negative terms and there’s a risk of increased tension.
  3. The interview itself should take place as the last item for the employee to complete before formally leaving employment. If it can be held just prior to ending the workday, it provides a clean break of employment and eliminates a need for the employee to have to return at a future date.
  4. Use the meeting to provide final paperwork, go over any benefit information or changes, return employer-owned equipment and/or uniforms, and answer questions.
  5. Implement the feedback! Submit a summary of identified organizational key issues or trends to executive leadership and respective managers. Better yet, share these with all staff and ask them to help identify solutions. The best solutions are usually those conceptualized by the people impacted directly by the issue/problem.
  6. Lastly, share these exit interview follow-up successes on a regular basis with all staff. The more accustomed the organization becomes to follow through from exit interview feedback, the more likely current employees will gain confidence in the process. In turn, they may see the benefit of their parting words, increasing the likelihood of conveying useful feedback.
Additional resources:
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