In Colorado, Ketamine Becomes Political

In September, amid swirling political controversy surrounding a death in police custody and other high-profile cases, the city council of Aurora, Colo., did something the EMS community might find bewildering: It banned the prehospital use of ketamine.

The resolution, driven by council member Curtis Gardner but passed unanimously, prevents paramedics with Aurora Fire Rescue and Falck Rocky Mountain from using the drug pending completion of a review prompted by the August 2019 death of Elijah McClain—a case that drew intensified scrutiny following the 2020 killings of George Floyd and Breonna Taylor.

Officers in the case responded to a 9-1-1 report of a “sketchy,” possibly agitated subject wearing a ski mask and ended up struggling with McClain, a 23-year-old Black man, ultimately using a carotid hold that knocked him out. When he regained consciousness, paramedics sedated him with ketamine. McClain then went into cardiac arrest on the way to the hospital and died a few days later. He was not armed or suspected of a crime.

An autopsy report didn’t determine a cause of death, noting it could have resulted from natural causes, the carotid hold, or an accident. “Most likely the decedent’s physical exertion contributed to death,” the report concluded. “It is unclear if the officers’ actions contributed as well.” McClain also had asthma.

Of ketamine, the report noted McClain’s blood concentration was at a therapeutic level, “but an idiosyncratic drug reaction cannot be ruled out.”

For prehospital treatment of extreme agitation, however, ketamine is generally a very safe option.

“When you really extract the data on ketamine, the safety profile is incredible,” says E. Stein Bronsky, MD, who provides medical direction for several Colorado agencies outside the Denver region (Denver-area EMS physicians aren’t commenting on the issue). “You can give doses in a very wide range, and it remains statistically very safe. It’s not a medication where if you’re off by 10% because of a weight miscalculation, you run the risk of causing an adverse effect. That is absolutely proven not to be the case with ketamine.”

Thus even at 140 pounds, with appropriate follow-up care, the 500-mg dose McClain got shouldn’t have harmed him. But that hasn’t kept ketamine in the hands of Aurora medics.

Two Other Cases

And there’s pressure to reconsider the drug on more than just one suburban town. Citing concerns about ketamine’s use around cases of excited delirium, the Colorado Society of Anesthesiologists has pushed the state Department of Public Health and Environment to suspend the waiver program that allows EMS medical directors across the state to authorize its use. More than 100 Colorado EMS agencies have such waivers; ketamine is outside Colorado’s standard regulations and can’t be used without one. The DPHE is weighing things.

McClain’s death also drew attention to two other nonlethal cases where surviving patients questioned the use of ketamine to sedate them. Elijah McKnight fought police and was Tased in Arapahoe County in August 2019 but was handcuffed and cooperative with paramedics before being given the drug; he ended up intubated in a hospital for several days. Jeremiah Axtell got it in Lakewood in January 2020 after yelling and cursing at police, but video also showed him appearing to cooperate once handcuffed before sedation.

The cases have prompted concern the drug is being given not only for true cases of excited delirium but also potentially just to make subjects easier for police to handle. The American Society of Anesthesiologists suggested as much in a July position statement that said it “firmly opposes the use of ketamine or any other sedative/hypnotic agent to chemically incapacitate someone for a law enforcement purpose and not for a legitimate medical reason.”

There’s excerpted presedation video from both cases available on YouTube—McKnight’s via a TV report and Axtell’s from a local activist. Both reach their own conclusions, but judge for yourself.

While specific details of certain cases are not always clear-cut, there’s no EMS protocol anywhere that is dictated by law enforcement or that permits sedative use solely to make patients more compliant for police.

“When someone’s in excited delirium, that person isn’t wearing a sign with the diagnosis written on it,” says Bronsky. “There is definitely an element of clinical judgement to decide what may be happening. You have to take into account many different signs and use your assessment skills to decide if this patient is meeting a threshold to consider giving ketamine or any other sedative medication.

“But what I’ll say as a medical director is that with this being a waivered medication, it’s something paramedics are trained on specifically, it’s monitored very closely, and we really do our best—nothing being perfect in the world—to make sure ketamine is used only in appropriate circumstances.”

Recent Safety Data

In announcing its review of the ketamine waiver, Colorado’s DPHE reported the drug was used 902 times in three years for cases of excited delirium and profound agitation. Its critics have cited complication rates of 16% overall and 24% in 2019. But again, these are—hopefully exclusively but certainly primarily—patients in excited delirium, the most agitated of the agitated. “It’s extremely unlikely it’s the ketamine that’s killing them,” says Bronsky. “It’s their physiologic state.”

A recent NAEMSP webinar examined some recent data to argue for ketamine safety. In Denver, while overall sedations by Denver Health’s paramedic division have risen in recent years (correlating to increases in meth calls and assaults on providers), ketamine has remained a small part of its arsenal: In 2019 it was given for sedation to just 0.11% of patients, all of whom were taken to hospitals rather than jail. Complications included hypersalivation (18%), hypoxia (17%), and apnea (7%).

Recipients were very agitated and very sick: Almost 20% required additional sedation, and of those whose hospital courses and outcomes could be tracked, 15% were intubated in the ED. Ketamine dosages correlated to the onset of sedation but not a need to go to the ICU.

ESO’s database has records of around 15,000 ketamine administrations to about 11,000 patients in 2019, with 99% taken to hospitals. More than half were admitted, and a total of 6% died. But that wasn’t due to the ketamine; among records with available mortality data, there were just six deaths (0.3%) where ketamine could not be excluded as a possible contributing factor—and two of those six also had advanced end-of-life diseases.

Noted ESO Chief Medical Officer Brent Myers, MD, “Ketamine appears to be very safe and not associated with unexpected outcomes very often.”

Find the webinar here. Other findings from ESO included:

• Intubation following ketamine administration for excited delirium seemed more related to cocaine use than the ketamine;
• Among patients experiencing combative behavioral health emergencies, fewer than one in five were sedated, and ketamine was associated with more ventilation and advanced airway assistance but not deaths;
• Ketamine given for sedation resulted in an overall hospital intubation rate of 4.5%;
• Reduced initial doses modestly reduced the need for intubation but were associated with a need for repeat doses;
• No racial disparities were found in rates of EMS sedation of patients in police custody; and
• Ketamine was more effective for pain control than opioids but more associated with alterations in levels of consciousness.

Understand that ketamine isn’t entirely without risk—but that it has a very low complication rate when administered appropriately and followed with attentive clinical management and can be effective where other sedatives fail.

“Our assumption is that our EMS providers are highly trained personnel, and if they’re giving this medication, they’ve decided this patient meets the criteria,” says Bronsky. “So now the issue is less the administration than our need to make sure we’re doing proper monitoring afterward, in case they start going into any kind of collapse or arrest or periarrest situation.”

“We would be foolhardy,” added Myers during the webinar, “to throw out a medication that’s being used appropriately for pain control, sedation in a subset of patients that may be severely agitated, and procedural sedations for those in the prehospital environment who have no room for error as it relates to hypotension.”

Pushing Back

Getting that kind of data out there is only the beginning of how emergency physicians are pushing back. National and local docs have written the DPHE to defend EMS use of ketamine, and the National Association of EMS Physicians both argued for physician control of such decisions in a September statement and in October updated its earlier materials on patient restraint in a joint statement with other EMS groups.

Efforts are also underway to file a complaint with the Colorado Medical Board against the Aurora City Council for unlawfully legislating matters the state leaves to doctors.

“We feel this is a political entity that is instructing physicians and medical providers about what they can and can’t do medically, and I believe that’s illegal,” says Bronsky. The process has been slowed, though, as the board is only set up to receive complaints against medical providers and practices, not political bodies.

That point does, however, get to the key issue here for EMS: However you might second-guess the appropriateness of care in individual cases, decisions about powerful drugs are still best left to physicians, not politicians.

“The biggest concern about everything is the precedent of prehospital medicine actually being legislated by a political body,” adds Bronsky. “I’m not aware of that ever happening in this country. By our state law, medical directors are the ones who get to make medical decisions. The decision of the Aurora City Council is of questionable legality—they designated themselves as having authority to legislate medical practice. And they did it under a very misguided concept, based on inadequate information. There is no data-driven reason to be specifically concerned about ketamine.”

John Erich is the senior editor of EMS World.