DENVER (KDVR) — The state health department is investigating whether the actions taken by paramedics at the scene of a police altercation last August were appropriate when they sedated an intoxicated man with a 750 mg, two-dose injection of the drug ketamine.
“After reviewing the information that you sent, our department is going to conduct an investigation,” said Peter Myers, a spokesperson for Colorado’s Department of Public Health and Environment (CDPHE), in response to a series of questions from the FOX31 Problem Solvers about the proper use of ketamine in similar situations.
A spokesperson for South Metro Fire Rescue said the department is also investigating whether the actions of its paramedics fall in line with the training and protocol they received.
“South Metro Fire Rescue is reviewing the case and we expect the review to last several more weeks. We will provide answers to your questions after the review is complete,” said Eric Hurst, a public information officer for SMFR.
The incident in question involves a man named Elijah McKnight, 25, who spent several days in a hospital intensive care unit, intubated, after his encounter with paramedics last summer.
“I was in the hospital for a week and a half, but I was unconscious for three days,” he said. “I woke up on the third day, and they took the tube out. And I couldn’t walk for those two days. I couldn’t eat.”
Ketamine is not FDA approved for the sedation of extremely agitated patients who experience a condition called excited delirium, but medical directors at agencies around the state can apply for a state waiver from the health department to use it for that purpose.
The state has approved 106 waivers for ketamine for excited delirium, according to CDPHE.
Excited delirium, according to Dr. John Riccio, the medical director of SMFR, is life-threatening.
“Basically, the patient is hyper-aggressive, markedly agitated, combative, (and) can be delusional,” he told the Problem Solvers in the fall. “These are patients that you cannot reason with or talk down. These are patients that are totally out of control.”
Paramedics said McKnight “appeared to be in excited delirium” when they arrived on the scene.
Prior to their arrival, McKnight, who was sleeping and drunk at a bus stop, scuffled with a sheriff’s deputy who tried to approach him.
The deputy took McKnight to the ground, tased him and handcuffed him. During the altercation, the deputy reported that McKnight kicked him in the face.
When medics arrived, they conducted an alcohol evaluation on McKnight.
Body-camera footage obtained by the FOX31 Problem Solvers shows McKnight was shouting but also coherently and accurately answered several questions from SMFR about the president of the United States, the year, the city and how many quarters were in a dollar. A paramedic later referred to him as “alert,” and a first responder said he did not need to be transported to the hospital.
The footage raises questions about how much influence law enforcement officials have on paramedics and whether McKnight received an appropriate dose.
According to the state’s Ketamine Waiver Guidance, “EMS providers should not engage in restraining people for law enforcement purposes.”
Michael Porter, the chief officer involved with medical care at South Metro Fire Rescue, told the FOX31 Problem Solvers in the fall that unequivocally, law enforcement personnel have no influence on a medic’s decisions.
However, after medics declared McKnight as “alert,” the body camera footage shows a deputy asking them, “You guys can’t give him anything, can you?”
To which a paramedic responded, “We can give him ketamine, and he’ll be sleeping like a baby.”
The footage shows McKnight was laying face down. The first responders referred to him as strong and “bucking” the three people who were holding his body and legs.
Within minutes, the paramedics injected the first dose of the drug.
“They shouldn’t have injected me with ketamine. That shouldn’t have happened,” said McKnight.
In the fall, Riccio told the FOX31 Problem Solvers that the medical crew handled the situation with McKnight properly.
He, like many physicians, called the drug, ketamine, “very safe.”
However, the FOX31 Problem Solvers have since learned Riccio never looked at the body-camera footage from the incident when reviewing the case.
According to Colorado’s Ketamine Waiver Guidance, developed by the state’s Emergency Medical Practice Advisory Council, ketamine may be used for “management of patients exhibiting such severe agitation that they are placing themselves and/or their providers in imminent danger. However, ketamine may be associated with high in-hospital intubation and ICU admission rates; therefore the use of ketamine should be approached with caution. Ketamine should not be used for patients who can be managed safely with traditional therapies.”
McKnight received a second dose of the drug almost nine minutes after the first administration. He ended up receiving a two-dose total of 750 mg.
As we previously reported, department protocol shows combative patients should receive a dose based on their weight: 5 mg per kilogram. The crew estimated McKnight weighed about 210 pounds (95.2 kg) when they gave him an initial 500 mg dose. They said he did not immediately calm down, so they consulted a physician and injected him a second time, with a 250 mg dose.
The Problem Solvers asked Riccio whether the total 750 mg dose followed protocol or whether it would be more appropriate for a 330-pound (150 kg) patient.
“I feel comfortable the crew did the right thing,” said Riccio in the fall. “Ketamine has a long-term…record of efficacy and also of safety. It’s used every day in the emergency room.”