Speakers Take a Close Look at Prehospital Ketamine Use at EMS World Expo

Prehospital ketamine administration is a hot topic these days. Experts say it makes a great alternative to opioids for pain and also has advantages for use in chemical sedation and even seizures. At the same time, the high-profile trial of the police who assaulted Elijah McClain kicked off with their lawyers blaming the young man's death on the paramedics giving him too much ketamine.

EMS World Expo brought several experts together to take a "deep dive" into the topic of ketamine in prehospital care. The speakers entertained and educated the audience for more than two hours, addressing everything from indications and dosing to side effects and legal concerns.

Michael Bernhardt, a veteran paramedic and EMS educator from Germany, kicked off the session with a brief history of ketamine, starting with its development in the 1960s and its early use as an analgesic. He also acknowledged that while ketamine's use by prehospital providers in the United States is relatively new and growing, that isn't the case in Europe.

"I never had to roll out ketamine," he said in response to conversations about how ketamine was recently introduced in many US agencies, "because when I got there it was already there."

He also tackled several of what he described as "myths" about ketamine, saying that adverse effects like increased intraocular pressure, cardiac ischemia, and frequent laryngospasms are rare and dose-dependent.

"Side effects? Yes, there are some, but they're all minor and they are controllable," he explained.

Kris Thompson, a critical care flight nurse and paramedic, addressed ketamine's dose continuum—in other words, the different effects ketamine has depending on what dose is administered.

"This is one of the most important parts of understanding ketamine and using ketamine," he said.

The continuum ranges from analgesia (low doses) to full dissociation or anesthesia (high doses). In between are what he called the "recreation" dose, which comes with euphoria and amnesia, and the partial dissociation dose. Those middle doses are what should be mostly avoided in the prehospital setting and could lead to unpleasant, and perhaps even traumatic circumstances.

The potential for trauma was highlighted by New Orleans EMS paramedic Jessica Barbour. Barbour, who worked as an advocate and caseworker for sexual abuse and human trafficking survivors with PTSD prior to her career in EMS, acknowledged that ketamine can be a very effective medication in certain situations. But, she said, it comes with dangers.

"Ketamine creates an acute psychosis in healthy brains that almost perfectly mimics schizophrenia," especially when underdosed, she explained. "But the other thing we realize is that specifically in schizophrenic patients, it exacerbates their signs and symptoms."

Barbour's point wasn't to scare paramedics from using ketamine, but to make sure they realize that the drug—especially if the dose ends up putting the patient in the middle, partial dissociative state—may also enhance fear memory consolidation. In other words, it could increase the trauma of the event for the patient. Barbour suggested that paramedics consider whether ketamine is truly needed, or an alternative approach—from verbal de-escalation to alternative sedatives—could be considered first.

"Don't treat you—treat your patient," she said. "Does your patient need the ketamine, or do you need [to administer] the ketamine because you don't want to deal with it?"

Considering alternatives to ketamine was also one of the ten principles for safe chemical restraint presented by Eric Jaeger. Jaeger, a paramedic, educator, and former attorney out of New Hampshire suggested that while ketamine, if properly administered, is a safe drug, there are special considerations when using it, especially for agitated patients when law enforcement is present. The principles he presented are part of a new chemical sedation protocol being developed in the state of New Hampshire.

Jaeger emphasized the importance of being prepared to treat the patient immediately after administering ketamine. That means having airway equipment out and ready to go, and making sure to position the patient properly—not prone—to avoid asphyxiation. And perhaps most importantly, EMS clinicians must remember that "monitoring a patient's airway" is not something to just write in a patient care report, but something to actively do from the second sedation is administered.

"From that moment on, you must be laser-focused on that patient," he explained.

Other principles Jaeger presented included only using chemical restraint if the patient is an active threat to themselves or others, not giving ketamine at the direction of law enforcement, identifying and treating any medical or organic causes of combativeness (e.g., hypoglycemia), and being aware of your own unconscious or cognitive biases that might be influencing treatment decisions.

“Implicit bias occurs when our unconscious assumptions negatively impact the care we provide,” he explained. “It is most likely to influence us in ambiguous situations when we are under stress, such as when we are dealing with an agitated patient.”

Brooke Burton, quality improvement and controlled substance manager for Unified Fire Authority in Salt Lake City, Utah, stressed the importance of documentation and continuous quality improvement. In her agency, every use of ketamine is reviewed at the individual call level. In addition, system-wide ketamine use is tracked to see if there are any concerning trends. For example, the agency noticed ketamine wasn’t being used very much and, after some digging, realized that due to the legal cases and media attention surrounding the drug, paramedics were avoiding it–even when indicated. That led to additional training to ensure paramedics felt comfortable using ketamine when appropriate.

The agency also reached out to its law enforcement partners and brought them in for interagency training.

“When we started training, we invited in the police departments that were all around us … and we did this training together,” Burton said. “So we made it clear: This is a medic decision to … give these drugs…. But we also want to be as hands-off as possible with these patients as we can until the medics can get there until they can assess what's going on with the situation.”

The session wrapped up with some comments from Doug Wolfberg who, like Jaeger, is both an EMS clinician and an attorney. Wolfberg, a partner with the EMS law firm Page, Wolfberg, and Wirth, emphasized the point made earlier by Burton and Jaeger that decisions about medical care are solely in the hands of EMS clinicians, not the police. Which seems obvious, he noted but is sometimes “easier said than done,” especially when police are “the people with the badges, the guns”--and the ones EMS might be relying on for their safety later that shift.