Closer look at ‘excited delirium’ behavior that first responders say leads to ketamine sedation

West

AURORA, Colo. (KDVR) — The City of Aurora is expected to receive the results of an independent investigation into the death of Elijah McClain next Monday, including an evaluation of paramedics’ use of ketamine to sedate McClain moments before he went into cardiac arrest.

McClain, 23, died in August 2019 after an altercation with three police officers and after being sedated with ketamine. NewsNation affiliate KDVR obtained some of McClain’s medical records revealing medics said he was “suffering from possible initial stages of excited delirium” when he was sedated.

Many physicians “question the existence of an excited delirium syndrome,” according to Colorado’s ketamine waiver guidance, developed by Colorado’s Emergency Medical Practice Advisory Committee.

The committee, also known as EMPAC, decides whether to recommend state ketamine waivers for medical directors. The waivers allow paramedics to sedate extremely agitated patients with the drug, in a prehospital setting.

KDVR discovered state health officials recently started referring to the condition for which they grant ketamine waivers as “extreme agitation.”

“It was decided after the November EMPAC meeting, and as a matter of efficiency, to categorize ketamine waiver use for indications of ‘excited delirium and/or extreme or profound agitation’ to (sic) ‘extreme agitation,’” said Peter Myers, a spokesperson for the Colorado Department of Public Health and Environment, in an email to the Problem Solvers. The “‘extreme agitation’ category is inclusive of excited delirium,” he continued.

Aside from McClain’s case, KDVR has uncovered other controversial cases related to the drug’s use by paramedics, but many emergency medical services providers insist ketamine is an important tool for the safety of the patient and the first responder.

Aurora Fire Rescue declined to comment about its experiences assessing and handling extremely agitated patients in a prehospital setting.

The Problem Solvers filed an open records request for videos and documentation related to cases in which paramedics used ketamine to sedate agitated patients in Aurora in 2019 and 2020.

The city provided dozens of police body camera videos and patient care reports (with identifying information redacted) showing the moments leading up to a patient’s ketamine sedation and the aftermath. In many cases, health officials described patients as experiencing symptoms of excited delirium.

Paramedics described one patient, who received a 400mg dose of ketamine in January 2020, as “yelling and screaming unknown words.” Health documents indicated the patient “was presenting with signs of hyper-aggression, appearing disoriented.” Aurora police officers reported that the patient had been throwing chairs and damaging property prior to the medics’ arrival.

KDVR also found multiple references to patients who had consumed the synthetic drug, “black mamba,” or other drugs or alcohol prior to sedation.

In a February 2019 case, a patient received ketamine after being detained by Aurora police, according to the patient care report. “Patient is acting very aggressive towards EMS and APD.  Patient is disoriented, and hallucinating.  A female who is on the scene stated this patient was smoking black mamba and possibly other drugs,” the records showed.

In a case in May 2020, medics said they believed the patient, who was “acting very erratic and making non-sensical statements,” had ingested “mamba.” The patient care report indicated he was yelling, pouring water on himself, not responding to any questions or commands, and “appeared to be hallucinating about possibly his kids.”

Paramedics approached a patient in April 2019 after he was restrained by police. The patient had been “running around naked yelling at everyone,” according to the patient care report. He “would not calm down and was tased five times before they were able to place handcuffs on him and laying him on his side,” the records showed.

“A person can go from very cooperative to very agitated in, really, seconds, and I think EMS, as well as, police do have to deal with that reality of, you know, they are also put in a dangerous situation,” said Dr. Joshua Solano, an assistant professor at the College of Medicine at Florida Atlantic University.

“There’s no test that we can do in the emergency department or in the hospital that’s going to say, ‘Yes or no, this is excited delirium,’ later,” said Solano, who is also a practicing emergency physician. “The people who are there are making a decision based off their training as well as their own experience, and that’s, I think, the thing that’s very difficult from a lay-person looking at it.”

Solano recently presented preliminary ketamine research at a January National Association of EMS Physicians Conference. 

In a study of approximately 80 patients, Solano and his colleagues found patients who were treated with ketamine for excited delirium in a prehospital setting, who also had cocaine in their system, had a greater risk of intubation — or the need for assistance with breathing — in the emergency department. 

Solano said it is unclear why this occurred.

“Further research is warranted, prehospital providers may wish to consider a dose reduction or alternative agent in these patients,” the study found.

“EMS has the ability — because they are very well trained and very competent — of dealing with that and looking at the airway and deciding to watch very carefully, (and) give oxygen,” he said. “That’s all in their protocols.”

The preliminary research did not find any association between alcohol consumption and the need for an airway intervention after ketamine sedation. However, Solano said not every patient in the study had an alcohol level that was measured.

Despite his findings, Solano referred to ketamine as an “excellent tool” with a “very good safety profile” when it is used within protocols that are established by medical directors.

“It’s very safe. I know it’s a very controversial area right now because of some specific cases,” he said. “These drugs generally allow for the control of agitated or combative patients in a much safer manner. In the past, I think it was one of those things where the other medications take much longer and don’t work quite as well, so this is a little bit more of a safer burden.”

Since ketamine is a relatively new tool for treating agitated patients, Solano said, some medical professionals may be choosing to use it more often. 

“That just has to be looked at, at a departmental level, and that’s part of quality improvement,” he said. “We’re always trying to find out, really, the right patients to be using this medication for, and that’s an ongoing process.”

Solano said there is always room for improvement and more training.

“Whenever you have something new or a protocol, you have to evaluate it and kind of work through a process of quality improvement and look at: what are the cases, where there were issues, and look at what were the factors that maybe contributed to issues in those cases, and then kind of give that feedback and do some education and training to help improve the process along,” he said. 

“The state and EMS is obviously going to be defensive because it’s really hard to look at a few cases when the vast majority of cases go safely and the vast majority of patients do well, and you have, unfortunately, a very high-profile case that is a complete tragedy,” said Solano. 

“We’re all looking to try to make things better. I think when people get defensive, it’s difficult to then work to improve things,” he said.

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