Medication Was Designed to Treat not Harm

I, like many of you, was horrified by the brutal killing of George Floyd by police officers in Minneapolis, and am glad it has led to real attention and public scrutiny of other equally horrific incidents. The death of Elijah McClain is another such incident. As a mother of three young brown men, and as an anesthesiologist who uses ketamine regularly in my practice, I am appalled that this young man died because of unnecessary use of force and cavalier use of ketamine for chemical restraint. 

Elijah McClain was a 23-year-old young Black man who was anemic and wore a mask in public to stay warm. He was killed last year when officers stopped him for looking “suspicious” on his way home from a convenience store after dark.

The video of this incident is brutal and disturbing. Elijah was thrown to the ground and held down by three police officers as he sobbed and told them he couldn’t breathe, that he doesn’t do violence, and that he is different. The officers told the EMS to give him ketamine to calm him down because he was “clearly on something.” He was put in a carotid chokehold, which led to a brief period of unconsciousness and then a bout of vomiting. He received 8 milligrams per kilogram of ketamine and then went into cardiac arrest in the ambulance and died a few days later. Perhaps Elijah was posing a real threat and perhaps he really did reach for an officer’s gun, although none of that is supported by the video. 

This 5-foot 6-inch, 140-pound young man received 500 milligrams of ketamine because paramedics estimated his weight to be 220 pounds. Most EMS protocols that allow for prehospital use of ketamine to treat excited or agitated delirium recommend 3 to 5 milligrams per kilogram in an intramuscular injection. In many of these situations, paramedics do not have to call to check with a physician prior to administering the drug. In this case, however, there is no evidence in the video that the paramedics carried out an 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 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, and development of these changes over a short time period. But based on the video footage, Elijah did not appear to fit any of those criteria and did not sound delirious.

We know that ketamine can significantly increase a patient’s heart rate and blood pressure, cause hypersalivation, nausea, vomiting, apnea, laryngospasm, and respiratory distress. His catecholamine levels were probably already significantly elevated, and yet ketamine was given in a large dose without medical evaluation, and while he was actively vomiting.

There appears to be a clear need for increased mental health and medical training for law enforcement and EMS professionals. Though 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, rapid sequence induction and intubation, procedural sedation, or sedation and chemical restraint in patients with agitated or excited delirium. While some institutions have these protocols in place, they are not the majority: A survey of over 10,000 nationally certified paramedics revealed that only 32% out of the 3,421 paramedics permitted to administer ketamine had to call for immediate approval prior to using it. Of those who had administered the drug, 14% had experienced adverse events, 1% reported laryngospasm, and 95% considered ketamine to be safe and effective. It was used for 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 most 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.  

Black people are three times more likely to be killed by law enforcement than white people, and one in 1,000 Black males are killed by law enforcement each year. Recent studies have shown that the police-involved killings of unarmed Black Americans have immediate and long-lasting mental health effects on the well-being of Black adults. Adolescents and children are also impacted by police violence in multiple ways that are delineated in an excellent article in Pediatrics: Exposure to racial profiling, police violence, and caregiver encounters with law enforcement can increase the incidence of anxiety, depression, PTSD, migraines, asthma, substance use, and a host of other mental and physical health issues.

Educating law enforcement and EMS on correctly diagnosing anxiety, terror, agitation, or delirium, and on the safe and appropriate use of medications is critically important. The situation with Elijah McClain should never have resulted in his incapacitation or death. The American Society of Anesthesiologists agreed as much in its recent statement on the use of ketamine for nonmedical purposes. Let’s push for improved training on the use of medications as well as awareness of racial biases so that there are no more stories like this one.  

Dr. Rita Agarwal is a pediatric anesthesiologist and pain specialist, and the mother of three boys. She is currently the president of the Society for Pediatric Pain Medicine and former chair of the American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. She believes in health advocacy and equity.

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