EMTs should not administer ketamine for ‘excited delirium,’ need bias training, state panel concludes

December 1, 2021
Denver Health Paramedics ambulance on Colorado Boulevard.Denver Health Paramedics ambulance on Colorado Boulevard.Hart Van Denburg/CPR News
A Denver Health Paramedics ambulance on Colorado Boulevard in March 2020.

A Colorado Department of Public Health and Environment committee has released its findings on the state’s ketamine waiver program, which allows paramedics to administer the powerful sedative outside of the hospital settings.

The committee, composed of paramedics, pharmacists, emergency room doctors and others, recommends continued non-hospital use of ketamine, but noted certain “societal and systemic factors” may contribute to its misuse by EMTs.  

“We think that these recommendations will lead to more formal training of paramedics so that they can better manage these situations,” CDPHE chief medical officer Dr. Eric France, who served on the panel, said.

The findings came with several recommendations. Most notably, the committee recommends no longer diagnosing people with “excited delirium syndrome”, a controversial condition that has been disproportionately used to explain the deaths of people of color in police custody. 

According to state data, paramedics have used ketamine 902 times since January 2018 on individuals they said were experiencing the syndrome. 153 of those instances led to complications, such as hypoxia, a lack of oxygen getting to the body’s tissue.

Committee member Dr. Lesley Brooks, a family medicine specialist in Fort Collins, said the diagnosis isn’t recognized by several major medical and psychiatric bodies. 

“Its current criteria is incredibly subjective and nonmedical and includes things like hyper aggression, increased strength and police non-compliance,” Dr. Brooks said. “Our ketamine investigatory review panel very clearly said we reject this diagnosis because of its lack of specificity, its lack of validity and its inherent bias.” 

Scrutiny over use of the drug on people being arrested intensified following the death of Elijah McClain in 2019. Aurora paramedics diagnosed him with excited delirium at the scene and injected McClain with far too big a dose for someone his size. Following the injection, he went into cardiac arrest and died in police custody. An autopsy was inconclusive about the cause of his death. 

Those paramedics are now facing criminal charges in his death.

A new state law already limits how ketamine can be used in emergency settings if the waiver program is restored. It bars police from requesting or ordering emergency personnel to administer the drug.

The committee’s report also touches on the racial justice concerns around the emergency use of ketamine. It recommends the development of implicit bias and racism training programs for paramedics. 

“The goal would be that paramedics have the appropriate formalized training that they need to be able to recognize and understand bias as it comes into play in healthcare,” Dr. Brooks said. 

The CDPHE as a whole will now review the report and decide how to best change the waiver program. Until then, ketamine will continue to be off limits in emergency situations. 

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