DENVER – A panel of medical experts brought together last year to review the use of ketamine outside of hospitals found it “is a safe drug if used properly” by trained paramedics, but recommended changes to when and how it can be used to allay medical risks and disproportionate use on people of color.
The Colorado Department of Public Health and Environment published the ketamine review panel’s recommendations Wednesday more than a year after it announced plans to review the state’s ketamine waiver program on the heels of Elijah McClain’s death.
The panel was led by CDPHE Chief Medical Officer Dr. Eric France and included seven other medical doctors or registered nurses from various areas of the medical field. It started meeting at the beginning of this year to gather and discuss information on ketamine, its use in various settings, excited delirium diagnoses, dosages and more.
McClain died days after Aurora police officers put him in a carotid hold and Aurora Fire Rescue paramedics injected him with a dose of ketamine that was too high for his body weight after saying he had excited delirium.
“The panel agreed that ketamine is a safe drug if used properly and monitored closely by properly trained and qualified paramedics,” the panel found, according to an executive summary of the 126-page report. “However, certain adverse events appear to have arisen primarily from the administration of ketamine and other sedatives to individuals who may not have a medical need for these medications and who could have been managed with a less assertive alternative.
“Further, other societal and systemic factors at play may have allowed chemical restraints to be disproportionately applied to marginalized populations and community of color in Colorado and across the nation,” the panel added. “Although the panel’s scope of review concerned the administration of ketamine in the prehospital setting, the panel agreed that the issues surrounding ketamine administration in the prehospital setting are not exclusively about the drug ketamine.”
The panel made a series of recommendations on ways to adjust the use of ketamine in the field:
- Stop using excited delirium as an acceptable diagnosis to use ketamine on someone – which is something the state already suspended in July for prehospital settings.
- Make policies to determine specific situations when ketamine can be used in emergency settings.
- Create standard doses of ketamine based on a person’s sex and body size – small, medium or large. For men, the recommendations would be 300, 400 and 500 mg for each body size. For women, they would be 250, 350 and 450 mg.
- Ensure ambulances, paramedics and EMTs have a checklist of appropriate dosing and monitoring for people who have received ketamine.
- Change training for emergency medical services responders to include more on how law enforcement transfers patients to medical first responders, including racial equity and implicit bias training, add de-escalation training and up the patient monitoring training.
- Standardize practices among emergency medical services and ambulances across the state, including a recommendation that state lawmakers act to determine whether licensing for ambulances should occur at one single level of government rather than several.
The report comes on the heels of a law passed at the state Capitol this year that requires a much more stringent checklist be met before ketamine can be used on a person in the field, including proving there is a medical emergency, weighing a person or assessing the weight of a person who might receive the drug and banning police officers from directing emergency medical services to use the drug on a person.
Members of the panel who spoke with Denver7 Wednesday talked primarily about the recommendation to stop using the excited delirium diagnosis.
“We did a thorough analysis of the evidence for that diagnosis and how it’s applied, and found it to lack uniform definition and specific validated medical criteria. And we’re not the only ones to reject that diagnosis. We are in line with the American Medical Association, the World Health Organization, and the American Psychiatric Association in rejecting that diagnosis,” said Dr. Lesley Brooks, M.D., a family and addiction medicine physician. “It is incredibly subjective and includes non-medical criteria such as hyper aggression, increased strength and failure to comply with police commands – all of which we believe serve to subjectively disproportionately identify people of color and other marginalized populations.”
France said ketamine use on the basis of excited delirium was “not coming back in the near future” but could still be used as a chemical restraint when a person is at risk for serious, probable and imminent bodily harm to themselves or others – though he said those scenarios “can be found rarely out in the field.”
“The review panel was really clear that the discretion around the use of any drug, whether it’s ketamine, or another sedative, or any other drug, for that matter, is at the sole discretion of the paramedic in the field and the medical professionals who are managing that patient,” Brooks said.
The panel also recommended there be training about how officers hand off a person to emergency medical services to treat the person and training on implicit bias and other things “so that they understand the existing chemical restraint laws and what the criteria are for which a chemical restraint can be used.”
CDPHE Executive Director Jill Hunsaker Ryan said in a statement that the department would take the panel’s recommendations seriously.
“I commend Dr. Eric France for convening and facilitating such a well rounded group of experts,” she said. “The recommendations are thoughtful and will add to the body of knowledge regarding ketamine administration in the pre-hospital setting.”
On Wednesday, Matthew Cron of the Rathod Mohamedbhai law firm shared his thoughts on the report. Cron and his partners represent Sheneen McClain, Elijah McClain's mother.
"Ketamine is a tool of chemical restraint, of chemical detention, of chemical control. It's being used primarily against marginalized communities, including communities of color," he said. "It's a drug that should only be used in dire medical situations, and that's not how it's being used out on the streets."
Cron said another client, Anthony Sleets, was injected with ketamine "for no lawful purpose" on July 7 while handcuffed in Denver police custody after the new law had gone into effect.
"What are you sticking me with?" Sleets can be heard saying on body camera video obtained by Denver7.
According to the video, someone on scene said Sleets was trying to assault paramedics. That same person can be heard saying the ketamine will be used to keep Sleets "calm." Cron said his client never assaulted paramedics and was unlawfully injected with ketamine.
"He [Sleets] saw the paramedics approach him with a needle and he told them, 'Don't give me that. I don't want to be injected,' and they did that anyway," Cron said.
On July 6, Gov. Jared Polis signed HB 21-1251 into law. One of the law's provisions prohibits ketamine from being used to sedate for alleged criminal behavior.
"We believe that the police and the paramedics who responded and made the decision to inject Mr. Sleets and did so, they should be criminally charged," Cron said. "The law is clear what they did is illegal and it's wrong, and they should be held accountable."
Denver7 reached out late Wednesday evening to the Emergency Medical Services Association of Colorado for a response to the report.
Denver7's Jon Ewing and CB Cotton contributed to this report.
