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