Colorado Panel Says Erratic Behavior Not a Reason to Use Ketamine as Restraint

An expert medical panel in Colorado said that "excited delirium," a condition involving erratic behavior, is not a reason to use the drug ketamine as a restraint.

Colorado's health department announced the decision Wednesday to emergency workers. The department announced the expert panel last year, saying it would review the state's ketamine waiver. Emergency medical service directors can get the waivers, permitting their workers to use the drug outside of hospitals.

Excited delirium is associated with habitual drug abuse, mental illness, or both. A majority of states and agencies allow for the use of ketamine to those exhibiting the condition, The Associated Press reported. The drug is used as a sedative, meant to act fast with few side effects.

Ketamine is often used during emergencies when there is a risk of danger involving medical staff or the patient. However, usage of the drug came under scrutiny in August 2019, after the death of Elijah McClain. McClain was injected with ketamine after being diagnosed with excited delirium when he was stopped by police.

The expert medical panel created a report, discovering that deciding if a person is experiencing excited delirium does not have clear guidelines and has been "associated with racial bias against African American men."

"It has subjective and non-medical criteria such as hyper-aggression, increased strength and police noncompliance — all of which are very subjective and inherently biased," said Dr. Lesley Brooks, a family and addiction medicine physician on the panel.

Paramedics are recommended by the panel to only give ketamine when no other safe options to monitor, treat, or transport patients are available. The panel also said it could be used when patients exhibit "serious, probable, imminent threat of bodily harm to self or others."

For more reporting from the Associated Press, see below.

Ketamine, Colorado, Excited Delirium
This photo shows a vial of ketamine, which is normally stored in a locked cabinet, July 25, 2018 in Chicago. Colorado's health department says emergency workers should not use a condition involving erratic behavior by people as a reason to inject them with the drug ketamine. Most states and ambulance agencies can use ketamine when people exhibit the condition called excited delirium. Teresa Crawford/AP Photo, File

The panel's recommendations follow last year's nationwide protests for police reform and racial justice reckoning prompted by the police killing of George Floyd in Minneapolis.

Locally, Colorado advocates also angered by racial injustice took to the streets in the name of McClain, the 23-year-old man who was stopped by Aurora Police officers responding to a 911 call about a suspicious person wearing a ski mask and waving his arms. Police put him in a chokehold twice and multiple officers pressed their body weight on him. Paramedics injected McClain with ketamine, and he died less than a week later.

One focus of the panel was an examination of bias and structural racism that affects paramedics' decision-making leading up to injecting people with ketamine, according to the report.

"Given the dialogue that our country has been having ... we understand that bias exists in a variety of places both implicit and explicit and it exists in health care," Dr. Brooks said.

She added that the panel wanted to ensure that field personnel like paramedics "aren't exempt from needing to understand where bias happens and how it plays out in the care that they deliver."

The recommendations came after the September indictments of three Aurora Police officers and two Aurora Fire paramedics on various charges including manslaughter, second-degree assault and criminally negligent homicide in the McClain case.

The paramedics called to the scene with McClain incorrectly estimated his weight, giving him more than 1.5 times the dose he should have received, officials have said. McClain got 500 milligrams because they thought he weighed 220 pounds (99.8 kilograms).

He was only 140 pounds (63.5 kilograms) and should have received 315 milligrams, the officials said. McClain suffered cardiac arrest and was later declared brain dead and taken off life support.

The panel also addressed dosing requirements for ketamine and suggested paramedics use a standard, fixed dose "based on the patient's body stature rather than a strictly weight-based dose."

The panel's experts also emphasized the importance of immediately monitoring people who receive ketamine with physiological assessments and physical exams.

The report also called on the Colorado Legislature to consider state standardization of emergency medical service programs and training, noting that "in all but two states" ambulance agencies are licensed at the state level — one of those exceptions being Colorado, where agencies are licensed by counties.

Dr. Eric France, the state's chief medical officer said having state licensing authority allows for more oversight of local emergency medical services.

The report also emphasized the need for more training on the interactions and communication between police and emergency workers at the same scenes.

That would involve clear guidance on the roles of emergency workers and police and the ability of paramedics to have authority for medical decisions without input from police.

Elijah McClain, Ketamine, Excited Delirium
Scrutiny over the usage of ketamine was renewed after the death of Elijah McClain. McClain was injected with ketamine after being diagnosed with excited delirium when he was stopped by police and die less than a week later. In this photo, people hold portraits of Breonna Taylor, Philando Castile, and Elijah McClain during a protest demonstration outside the Governors Mansion on March 6, 2021 in St. Paul, Minnesota. Stephen Maturen/Getty Images