Anesthesiologist says ketamine protocols need review

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DENVER (KDVR) — The Colorado Department of Public Health and Environment (CDPHE) should review and “perhaps” tighten state policies that allow paramedics to sedate agitated patients with ketamine, according to an American Society of Anesthesiologists (ASA) officer who reviewed two questionable incidents, including the case of Elijah McClain.

“It’s tragic –  in the stories that we have seen,” Dr. Randall Clark, the first vice president of the ASA, said. “Because of that, we wanted to speak up and make ourselves available to make this a better outcome for all involved.”

Clark, who is also a professor of anesthesiology in Colorado, said members of his organization were surprised to learn ketamine was used to sedate McClain and another man, Elijah McKnight, during two separate incidents last August. McClain died days after receiving a 500 mg dose of ketamine from Aurora Fire Rescue paramedics following an altercation with Aurora police.  

McKnight ended up in the intensive care unit after South Metro Fire Rescue paramedics gave him two doses of ketamine, totaling 750 mg.

The doses that were administered, said Clark, were enough to induce general anesthesia.

“I think we all recognize the difficult situations that the police and EMTs find themselves in. It is often fraught with hazard for all concerned,” Clark said. “The question would be, after the administration of the drug and the patient becomes sedated – or in the size of doses being used here are actually in a state of general anesthesia – how quickly they are monitored appropriately so that any complications can be prevented?  And in the two cases that you have reported previously, I think the evidence suggests perhaps that was not done.”

On Friday, Clark sent an email to CDPHE’s Chief Medical Officer, Dr. Eric France, offering to be involved in the state’s review of its own ketamine policies.

“I would like to make myself available for any reviews that CDPHE might undertake on the issue of ketamine use by EMTs in the field, specifically use to treat excited delirium,” he wrote.

Dr. France responded by saying, “I appreciate you offering your time for any reviews that CDPHE might undertake on the issue of ketamine use. As you are probably aware, ketamine is allowed through a waiver program to be used by paramedics for the appropriate medical indications.”

Clark told the FOX31 Problem Solvers the dosing that is being used by paramedics is “concerning” to anesthesiologists. 

 “This is not something we would use in clinical medicine,” he said. “And we do know that ketamine can depress respiration and cause other health problems. The question is whether these patients or these civilians were then treated appropriately, monitored appropriately to be able to manage any complications of this size of drug.”

Although a coroner said McClain could have suffered an unexpected reaction to the drug, Aurora Fire Rescue has previously told the FOX31 Problem Solvers, “There is no conclusive evidence that the care provided by Aurora Fire Rescue contributed to his death.”

South Metro Fire Rescue, meanwhile, is conducting its own review of the case involving Elijah McKnight. The state health department is also investigating.

Clark said the ASA has additional questions about the circumstances for which the drug was used on McClain and McKnight.

Colorado paramedics are allowed to administer the drug to extremely agitated patients experiencing a condition called excited delirium if their agency’s medical director has obtained a waiver from the state health department.

“We have questions whether this condition of (excited delirium) was perhaps as well developed as the people on the scene thought it might be and whether this degree of chemical incapacitation may have been necessary,” Clark said.

Although several emergency physicians have referred to ketamine as one of the safest options to sedate an extremely agitated patient in the field, Clark warned that the drug is only “safe” within a specific context.  

“You have to have the ability to monitor the effects on the patient. You have to have the ability to monitor the patient’s respiratory strength, monitor their oxygen saturation, monitor their EKG, monitor their blood pressure,” he said. “If you have the ability to do all those things, and you have personnel on the scene that are able to manage any derangements of those characteristics, then yes, I think you can use the phrase that, ‘this is a safe drug,’ but to say it’s safe without that context, I don’t believe is appropriate.”

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