I, like most of you, was horrified by the brutal killing of George Floyd by police officers in Minneapolis, and I am glad it has led to real attention and public scrutiny of other equally horrific incidences. As the mother of three brown teenagers/young men, the death of Elijah McClain also chills me to my very core. I am saddened by the seemingly unnecessary use of force that led to his death, and cavalier use of ketamine to provide chemical restraint.
Many police departments across the country are now banning the use of carotid restraints and chokeholds; I think we also need to encourage a much closer look at the use of chemical restraints and determine what sort of training and education is needed by paramedics .
Elijah McClain was a 23-year-old Black, young man. He was a vegetarian and violin player who volunteered at the local animal shelter as well as a massage therapist who was anemic and wore a mask in public to stay warm. He was killed last year when officers stopped him for looking “suspicious” – he was walking home from a convenience store after dark, listening to music, and wearing a mask.
The video of this incident is brutal and disturbing. When the law enforcement officers pulled up to the other side of the street and yelled at him to stop, he did not immediately respond. He had his ear buds in and apparently didn’t hear the request. Early on one of the officers says “dude, he’s going for your gun”. As a result, he was thrown to the ground and held down by three police officers. He sounds terrified, but keeps telling the officers his name, who he is, that he is an introvert, that he doesn’t “do violence” and that he is different. He is heard sobbing, he repeatedly tells them he can’t breathe, while the officers tell him to stop moving and threaten him. Then they tell the EMS to give him ketamine to calm him down because he is “clearly on something”. Perhaps he is posing a real and immediate threat, and perhaps he really did reach for an officer’s gun, although none of that is supported by the video. We CAN hear him talking, telling them he can’t breathe, telling them he’s sorry, that they are phenomenal, that he will do anything to be a better man, asking them why he is being attacked, that he is just trying to go home. He is put in a carotid chokehold, which leads to a brief period of unconsciousness and then starts vomiting. He receives 8mg/kg of ketamine. He then suffers cardiac arrest in the ambulance and dies a few days later.
This 5’6”, 140lb young man received 500 mg of ketamine because paramedics are allowed, by protocol, in some Emergency Medical Services to use ketamine to treat “excited or agitated delirium.” He did not sound delirious. In many of these situations’ paramedics do not have to call to check with a physician as long as they follow protocols.1,-5 There is no evidence on the video that the paramedics carried out any sort of assessment prior to the administration of ketamine. It is unclear how the diagnosis of agitated or excited delirium was made. There are validated and accepted scales such as the Altered Mental Health Scale that can be used to diagnose patients, and there are clear diagnostic criteria for delirium, which include: disturbance of consciousness, disturbance or abnormalities of cognition, development over a short time period.4 Elijah did not sound like he fit any of those criteria.
We know that ketamine can significantly increase a patient’s heart rate and blood pressure and cause hypersalivation, nausea, vomiting, apnea, laryngospasm, and respiratory distress. His catecholamine levels were probably already significantly elevated and yet ketamine was given to Elijah in such a large dose without medical evaluation and while he was actively vomiting; how good were his airway protective reflexes?
There is a clear need for increased mental health and medical training for law enforcement and EMS services, particularly if chemical restraint is an available option for their department. While ketamine is useful when given correctly, it has very real and dangerous side effects. There are guidelines that were developed by the American College of Surgeons and the American College of Emergency Physicians for the use of ketamine by EMS as an analgesic in trauma patients, for RSI, procedural sedation, or for sedation and chemical restraint in patients with agitated or excited delirium .5 While many institutions do have protocols in place that allow for the use of ketamine in the prehospital setting, they are not the majority.3 A survey of nationally certified paramedics revealed that while 1/3 of the over 10,000 respondents were permitted to administer ketamine, 2/3 of those permitted to use ketamine or approximately 2000 reported that they DID NOT need immediate approval prior to its administration.3 Of those who had used the drug, 14 percent had experienced adverse events, 1 percent (22) reported laryngospasm and 95 percent considered ketamine to be safe and effective. It was used to provide chemical restraint in 1,235 patients.
It is essential that we take a more discriminate look at the use of medications to chemically restrain people – and the training that accompanies that power. Seemingly Elijah was stopped was because he was Black, and the only reason he received ketamine was that his behavior was not perceived as normal. Many of us care for “different” people from all races, creeds, and backgrounds. We see their anxiety and fear; we hear their stories; and we know that people do not respond to stress, confrontation, and anxiety in the same way. “Tensing” and struggling are NOT abnormal. This can be a primal and reflexive response, the body trying to protect itself from perceived, and in this case, very real danger.
Recent studies have shown that the police-involved killings of unarmed Black Americans have immediate and long-lasting mental health impacts on the well-being of Black adults. 6-9 Adolescents and children are impacted by police violence in multiple ways that are delineated in an excellent article in Pediatrics “Police, Equity and Health”.6 Exposure to racial profiling, police violence, and caregiver encounters with law enforcement can all increase the incidence of anxiety, depression, PTSD, migraines, asthma, substance abuse, and a host of mental and physical health issues. Black people are three times more likely to be killed by law enforcement than white people, and 1 in 1,000 black males WILL be killed by law enforcement. 9
Educating law enforcement and EMS on correctly diagnosing anxiety, terror, agitation, or delirium, and the safe and appropriate use of medications is critically important. The situation with Elijah McClain should never have resulted in his death. Let’s push for improved training on the use of medications as well as racial biases so that there are no more stories like this one.
- Ketaminefor the Acute Management of Excited Delirium and Agitation in thePrehospitalSetting. Linder LM, Ross CA, Weant KA.Pharmacotherapy. 2018 Jan;38(1):139-151. doi: 10.1002/phar.2060. Epub 2017 Dec 22.PMID:29136301
- Ketaminefor Rapid Sedation of Agitated Patients in thePrehospitaland Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. Mankowitz SL, Regenberg P, Kaldan J, Cole JB.J Emerg Med. 2018 Nov;55(5):670-681
- Ketaminein thePrehospitalEnvironment: A National Survey of Paramedics in the United States. Buckland DM, Crowe RP, Cash RE, Gondek S, Maluso P, Sirajuddin S, Smith ER, Dangerfield P, Shapiro G, Wanka C, Panchal AR, Sarani B.Prehosp Disaster Med. 2018 Feb;33(1):23-28.
- A prospective study ofketamineas primary therapy forprehospitalprofound agitation. Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, Harrington J, Ho JD.Am J Emerg Med. 2018 May;36(5):789-796.
- Police, Equity, and Child Health. Boyd RW, Ellison AM, Horn IB.Pediatrics. 2016 Mar;137(3):e20152711. doi: 10.1542/peds.2015-2711. Epub 2016 Feb 1.PMID:26908673
- Police violence and the built harm of structural racism. Boyd RW.Lancet. 2018 Jul 28;392(10144):258-259. doi: 10.1016/S0140-6736(18)31374-6. Epub 2018 Jun 21.PMID:29937191
- Policekillingsand their spillovereffectson the mental health of black Americans: a population-based, quasi-experimental study. Bor J, Venkataramani AS, Williams DR, Tsai AC.Lancet. 2018 Jul 28;392(10144):302-310. doi: 10.1016/S0140-6736(18)31130-9. Epub 2018 Jun 21.PMID:29937193
- Stolen Breaths. Hardeman RR, Medina EM,Boyd RW.N Engl J Med. 2020 Jun 10. doi: 10.1056/NEJMp2021072. Online ahead of print.PMID:32521156