DENVER (KDVR) – The use of ketamine to sedate agitated people outside of a hospital setting has been suspended in Colorado with the implementation of a new statewide law that changes how paramedics can use the drug.
“It is of the utmost importance that Coloradans can receive safe and effective medical care from EMS providers,” said Randy Kuykendall, who leads the Health Facilities and Emergency Medical Services Division at the Colorado Department of Public Health and Environment.
“CDPHE responded to national concerns about ketamine administration by convening a comprehensive review panel last year, and we will continue to be responsive by removing and restricting ketamine waivers as a result of this legislation,” Kuykendall said. “We remain committed to a safe Colorado for all.”
The law, which took effect when Gov. Jared Polis signed it on Tuesday, puts significant restrictions on the situations in which paramedics can use the drug on agitated people while law enforcement officers are present.
“You cannot forcefully inject someone with a drug that can kill them without having the proper medical attention right there and supervision right there, and it can never happen at the direction of law enforcement,” said Rep. Leslie Herod, (D-Denver), who introduced the bill during the 2021 legislative session. “These are common sense things that unfortunately, we shouldn’t have to legislate. But unfortunately, we do.”
What’s next for paramedics
Now, medical professionals will have to use alternative methods for calming agitated patients while the state works to come in compliance with the new law.
Some emergency medical services providers say other sedatives are not as effective or as fast-acting as ketamine.
“I think that ultimately, we believe that in certain circumstances — very particular, violent situations — that ketamine is the best medication,” Will Dunn, the senior manager for clinical services Eagle County Paramedic Services, said. “I certainly understand and am sympathetic to the sponsors of the bill and wanting to make sure that’s done in the proper way.”
“I think my concern, and the concern that’s shared by many in the industry, is that you sort of no longer have the use of what we think is the best and safest means of dealing with this particular extreme, unrelenting agitation,” Dunn said.
Scott Sholes, president of the Emergency Medical Services Association of Colorado, said there will be consequences related to this new law.
“This consequences of this bill, likely unforeseen and unintended by the Colorado General Assembly, will dramatically impact our ability to safely treat and transport mental health and other patients experiencing life-threatening emergencies, and EMSAC is working with CDPHE to reinstate those waivers within the parameters of the new legislation,” Sholes said.
Denver Health said its paramedic division is modifying its practices and protocols.
“We are making the changes and also ensuring we continue to provide the best care possible to patients in these emergency situations,” Denver Health spokesperson April Valdez Villa said in an email. “As the waiver recognized, ketamine can be an effective and valuable tool in a crisis situation. There are two other ketamine waivers, which were not affected by this sudden change. As permitted by those remaining waivers, DHPD will continue to use ketamine, as appropriate, for pain management. We will also continue to advocate for our EMS professionals to have access to necessary tools and treatments in the field to do what is in the best interests of our patients.”
State transparency, inaction, in question
Herod said she has been “very disappointed” with the ketamine-related data kept by CDPHE — which oversees the state’s ketamine waiver program — and the lack of action after incidents involving an adverse reaction or a death.
“Honestly, the way that we found out about all of these cases of ketamine abuse has been through the media, and that is not appropriate,” Herod said. “As legislators, we need to know when these certifications (waivers) are given out, and when they’ve been problematic.”
In the last year, CDPHE has denied or ignored at least 20 on-camera interview requests from the Problem Solvers about ketamine policies, regulations and questions on behalf of the public. So the Problem Solvers asked questions of the health department leader at an unrelated press conference about COVID scholarship winners.
The Problem Solvers asked why the state hasn’t been more transparent about its ketamine program and policies during the last year.
“We don’t comment on individual cases that we’re investigating, but as you know, we are in the midst of doing a complete review of our ketamine waiver program,” CDPHE executive director Jill Hunsaker Ryan said. “The review includes several experts. It’s taken many months, but we believe it will be finished in July.”
“It’s very thorough and has very good recommendations to assure the safety of the use of ketamine in the field in the EMS setting. At that time, we will certainly provide information about the review in addition to interviews,” Hunsaker Ryan said.
During Wednesday’s press conference, the Problem Solvers also asked how CDPHE was helping the public by not making health leaders accessible in recent months to answer specific questions about ketamine and state policies as more questionable cases have been revealed.
“I think this review process will prove to be very transparent and very helpful to the entire EMS system and administering this drug, and also in conjunction with the recent bill that passed. It’s going to be a complete revamping of the program, and it’s why we’ve asked EMS agencies to curtail their use of ketamine until we’re able to put the appropriate protocols in the place, and we will be providing information about those protocols within a few weeks,” Hunsaker Ryan said.
The ketamine review
In a signing statement, Polis said CDPHE would begin to act on the review’s findings later this summer.
“Following the release of CDPHE’s findings…the agency will conduct a robust stakeholder engagement process to improve consumer protections in the EMS system and develop other recommendations for consideration,” Polis said.
Polis said he is looking forward the results of the report and is confident it will be released in the coming weeks.
“It’s important to take the time to get it right but not take so much time that it causes additional difficulties and suffering,” Polis said.
Herod said she is encouraged by the progress CDPHE is now making with its review.
“I think that they stalled because of COVID and some other reasons, you know — there’s other priorities that came to the top. … It’s really important that we work in partnership to really look at ketamine abuse and how we want to move forward in Colorado. So, I look forward to what their report says and how we can work together to ensure that ketamine is not being used inappropriately in the field,” Herod said.
Dunn, with Eagle County Paramedic Services, said that while the review is underway, his agency has been doing extensive training on the issue, especially since the 2019 death of Elijah McClain in Aurora. A coroner could not determine McClain’s cause of death but could not rule out the possibility that he had an unexpected reaction to the drug.
“Because we are a pure (emergency medical services) agency, we are able to spend a lot of time on training. And certainly, since Elijah McClain, we’ve done a bunch of training that’s looked at the ethics of restraint and the ethics of using sedation and a number of other things that we probably would not have done had that not come up,” Dunn said. “But I think that’s important that our medics know why we’re doing it and when to do it, and that it’s safe.”
Law enforcement perspective
Meanwhile, the new law also impacts law enforcement officers who unduly influence a paramedic by encouraging them to administer the chemical restraint.
Organizations that represent law enforcement continue to oppose the measure.
“By signing House Bill 1251, Gov. Jared Polis is ignoring the testimony of numerous doctors and emergency medical professionals who said it will chill critical communication among first responders and ultimately hurt patient care,” the County Sheriffs of Colorado, the Colorado Association of Chiefs of Police and the Colorado Fraternal Order of Police said in a joint statement. “This new law creates an unprecedented liability for law enforcement officers and may prevent them from sharing necessary information with EMS for fear it may later be perceived as ‘directing’ EMS’ actions, and result in criminal charges against the officer.”
“Law enforcement should not and does not direct patient care; yet, the ambiguous wording in this law and the new liability it creates provides yet another reason for the best and brightest to choose another profession, further exacerbating recruitment and retention challenges in Colorado,” the statement reads. “Colorado’s leaders should heed the concerns expressed by medical and public safety professionals, not create disincentives for strong communication during emergency life-or-death situations.”