The McClain Case: What Went Wrong?

EMS and law enforcement function best as a team. When they don’t actively practice teamwork on difficult joint calls, outcomes can go desperately wrong. A good example of that is the death of Elijah McClain. 

McClain was a 23-year-old Black man who died following a confrontation with Aurora, Colo. police in 2019. He was given ketamine, which doctors believe was not related to his death, but the fallout from his case got the drug banned in Aurora, restricted in Colorado, and both police officers and paramedics criminally charged. 

What went wrong? The official cause of McClain’s death was undetermined; the coroner cited possibilities including a drug reaction, cardiac arrhythmia, asthma attack, aspiration of vomit, or homicide via the banned carotid hold police used on him. But young people don’t typically die after police encounters, even ones that turn violent, and there was no damage to McClain’s carotid artery or hyoid bone. 

David McArdle, MD, FACEP, an emergency physician in Colorado, chair of the International Association of Chiefs of Police’s Police Physicians Section, and a certified police officer in Colorado, has followed the case closely. 

“There are two components of the same issue that happened here,” he says, “the agitated combative state, generally known as excited delirium, and positional asphyxia. Together these represent an acute medical emergency masquerading as a law enforcement problem.”

Who’s in Charge? 

McClain came to the attention of a 9-1-1 caller when he was wearing a ski mask and heavy jacket and acting strangely on a warm August night. He was not suspected of a crime but was uncooperative when police detained him, and things turned physical. An officer briefly used the carotid hold as police took McClain to the ground because he said he feared McClain was reaching for another officer’s gun. A second officer applied the hold again once they had him down. 

The police held McClain handcuffed on the ground for 15 minutes as he apologized, vomited, and said he couldn’t breathe. When medics from the Aurora Fire Department arrived, they ultimately gave him 500 mg of ketamine and moved him to the ambulance. There a medic noticed McClain’s lack of chest movement and that he didn’t have a pulse. He was pronounced brain dead three days later and died three days after that. 

“The first thing that should happen with cases like this is that medical care should be summoned immediately,” McArdle says. “The big problem is that patients like this are in a hypermetabolic state, which has to be recognized and treated promptly. And while we’d like to see all agencies function in high-performing, pit-crew kinds of ways, like some do for CPR, that did not happen in this case. 

“What I primarily see in the video of this is the firefighters getting there and then just kind of standing around, as is also seen in so many other cases of combative agitation that do not turn out well. The police have put the individual in the lateral position, which is the safest position for him to be in. Then four guys in bunker gear arrive and kind of stand next to where the cops are. They don’t put oxygen on him, they don’t reach down and touch him. But this guy’s been struggling and creating a tremendous amount of CO₂. 

“When we breathe, everybody assumes that’s to get oxygen in. That’s important, but actually the drive at the brain stem level to breathe is dependent on your pH and your CO₂ level. So really, the drive to breathe is a drive to blow off carbon dioxide. And carbon dioxide is being generated by all the muscular activity of people who are fighting and struggling. When they say they can’t breathe, that’s their brain sensing something is wrong. What they’re really saying is, ‘I can’t blow off my CO₂’—that’s the reality we have to drive home with both police and EMS first responders. 

“But in this case the medics aren’t doing anything. He’s not being preoxygenated, nobody’s taking vital signs. They give him the ketamine, and he goes unconscious. Well, the assumption is the drug is working. But we don’t really know that. Is he losing consciousness because of the drug or because his severe agitated state is not yet adequately controlled and he’s now hypoxic or too acidotic? What is his blood glucose now? Those questions aren’t being asked. 

“The problem is not that ketamine was given. The problem was the ketamine was given too late. The sedation should have occurred much sooner and been a prelude to very aggressive medical therapy.”

There are lots of things that can go wrong in these transitions, and this is just one case, but if there’s a general lesson to extract, it involves who’s in charge. At what point does a prisoner become a patient? And is that equally clear to everyone? 

“This gets into the fact that we don’t train well for interagency transfer of command,” McArdle adds. “The firefighters are looking at this as ‘Well, this is a police emergency. Are they going to give over control or not?’ And the police are kind of assuming the medics are going to take control. And for whatever reason they don’t reach out and touch him. I think that’s a common thread in many of these excited delirium deaths.”

In fact, a number of controversial ketamine cases have had similar features. Speaking generally, rather than specifically to McClain’s or any case, emergency physician David Tan, MD, FAAEM, FAEMS, agrees the transfer of command can be a problem. 

“I think we’ve all been on scenes where it becomes clear this is less of a medical case and more of a law enforcement case or vice versa,” says Tan, division chief of EMS and an associate professor of emergency medicine at Washington University in St. Louis, as well as medical director for the St. Charles County (Mo.) Police Department. “Maybe an EMS crew recognizes what seems to be a violent suspect as a frequent hypoglycemic diabetic, and suddenly it becomes a medical case. If you have preplanned and precultivated relationships, that transition of command occurs much more easily—and I’d say more naturally—because there is no turf battle. You’re colleagues on the same team.”

Relationships

Like so many interactions in EMS and healthcare, relationships—established in advance and groomed continuously—fuel success at the EMS/law enforcement interface. Problem is, when EMS and law enforcement train together, it’s typically for the big stuff—terrorism MCIs, active shooters—and not the Elijah McClains, individual cases of altered mental status or something else “routine” that can quietly go dangerously bad if care and handoffs aren’t attentive. Those kinds of incidents are, for the record, more common than mass shootings. 

As a chief or leader, you might consider some joint training on excited delirium and similar murkier types of cases. As a street-level professional, you can help things by working on familiar, friendly relationships with your 5-0. 

“The most important thing is to develop those more informal relationships on calls,” says Tan. “Take the time to communicate with law enforcement and let them know you appreciate them stopping by, making sure you’re safe, and cooperating with information as allowable by HIPAA.”

Needless to say, that does not mean give ketamine to sedate suspects who are abusive or unruly but fall short of excited delirium just to make life easier for the cops or yourselves—that has been suggested in some recent publicized ketamine cases. Like any drug, use ketamine strictly within your protocols. 

Tan cowrote an updated 2020 position statement on the care and restraint of agitated/combative patients led by NAEMSP and cosigned by other major EMS organizations.¹ It’s explicit on this point: 

EMS practitioners must not administer sedating medications to an individual to facilitate arrest or to assist law enforcement to take the individual into custody. EMS practitioners should use the least restrictive restraint techniques to facilitate clinical patient assessment, medically indicated treatment, and safe transport to a hospital. In all circumstances the decision about using pharmacologic management is a healthcare decision that must be made by the EMS practitioner with oversight by an EMS medical director. 

“To me, it matters not whether we’re dealing with an agitated patient, a sick case, abdominal pain, chest pain, what have you—I expect my practitioners to practice medicine as outlined in their standing orders and clinical operating guidelines,” says Tan. “Whether it’s an asthma attack or a bee sting or whatever, I have to presume the credentialing process for their employment ensures they know the standard operating procedures and their standing orders for medical care.” 

One human frailty those orders and guidelines must counteract is diagnostic bias, where an initial characterization by, say, an officer on scene or 9-1-1 dispatcher might carry over without due reconsideration by EMS crews. Take that information as important but evaluate for yourself. 

“It really is incumbent on the medical practitioner to determine the presence or absence of an emergency,” Tan adds. “How do you do that? Well, you talk to the patient yourself, and you do your own history and physical examination. We know when you arrive at scenes and jump off the truck, you can be barraged with information from bystanders and other responders and family members yelling at you, and sometimes the EMS practitioner can kind of get lost in that information and start acting without getting their own side of story. I always remind my practitioners, wherever the patient is able to speak and answer questions, it really is important to get your own story and kind of reassess the situation. A lot can change between the 9-1-1 call and you arriving on scene.”  

Reference

1. Kupas DF, Wydro GC, Tan DK, Kamin R, Harrell IV AJ, Wang A. Clinical Care and Restraint of Agitated or Combative Patients by Emergency Medical Services Practitioners. NAEMSP Position Statement, October 2020; https://nasemso.org/wp-content/uploads/Clinical-Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-Services-Practitioners.pdf.

John Erich is the senior editor of EMS World. Reach him at john.erich@emsworld.com.