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Forced Sedation

Interesting article on NBC news about the use of ketamine for sedating patients in police custody. 


Elijah McClain was injected with ketamine while handcuffed.  Some medical experts worry about its use during police calls.


The reporter centers the story around the tragic case of Elijah McClain, who was apparently walking down the street, wearing a face mask and listening to headphones when a 911 caller said he was acting strangely.  The police stopped him and ended up taking him down with a chokehold.  He said he couldn't breathe and he vomited.  EMS came.  The officers told them he was on something and was exhibiting inhuman strength.  The medics gave Elijah a large dose of ketamine, and shortly after he was in cardiac arrest.  He was resuscitated, but suffered a brain injury and was unplugged.


In light of today's awareness of cases of brutality, this case has aroused considerable attention and controversy.


The article seems to take the positions that 1) people should not be injected with a sedative during a police action and 2)  they should not be injected against their will.


The reporter talks to two college neuroscientists, a pharmacy professor and two lawyers including  someone from the American Civil Liberties Union.  He doesn't talk to an emergency physician or a paramedic.  An ED doctor or a paramedic would have likely provided insight into the real world conditions where these cases play out.


Here is my take on it.  First, I just want to say, this was a tragic case that should never have happened.  Just because someone is acting strangely or may be mentally ill (unless they are bothering someone or are observed committing a crime), they probably shouldn't be physically restrained.  Where I work in Hartford there are a lot of people who act strangely, but once you know them, you learn they are not acting strangely for themselves.  There are just a lot of strange people out there, and not everyone should be held to the normal person standard. 


In this blog post, I only want to address why a paramedic would give someone ketamine or a sedative like Versed or ativan (benzodiazepines) against their will.  (Note: I do it quite frequently.)  We don't carry ketamine in my section of Hartford, but as an EMS clinical coordinator that oversees several EMS services, we approve ketamine for use in certain circumstances, including to sedate violent patients. 


Our statewide paramedic protocols call for a number of measures to calm someone down and deescalate scenes.  It is not uncommon for us to respond to a violent EDP (emotionally disturbed person).  In many cases, the patient may be on drugs such as PCP and are resisting efforts. They may be naked in the middle of winter walking down the street.  (PCP makes people hot and it is quite common to have them disrobing in public). They may be smashing windows or merely threatening others.  I have had such people jump out of open windows.  They may also be schizophrenic, off their meds and talking about killing themselves or others.  If they are just plain crazy, standing on a street corner talking to themselves, as long as they know where they are, and have no intention of hurting themselves or others, we leave them alone.


Patients may only be restrained under the following indications:


Any patient who exhibits an altered mental status and may harm himself, herself, or others or interfere with their own care may be restrained to prevent injury to the patient or crew. Restraining must be performed in a humane manner and used only as a last resort.


We are authorized to do both physical and chemical restraint.  if someone fights against the physical restraints, I will chemically restrain them.


Continued patient struggling against restraints may lead to hyperkalemia, rhabdomyolysis, and/or cardiac arrest, chemical restraint may be necessary to prevent continued forceful struggling by the patient.


When I arrive on scene, I try to talk to the person, who the police may be holding down, sometimes in handcuffs, sometimes not.  If the person is alert and oriented and can carry on a normal conversation, I will ask the officers to let them up and take off their handcuffs.  If they are still resisting and are out of their minds, I will sedate them per out protocols.  The sedation works wonders.  It takes a few minutes to work, and I will urge everyone on scene to resist agitating them further, and let the medicine take hold.  I get them on the stretcher, we take the cuffs off and they are often sleeping like babies by the time we arrive at the hospital.


Paramedics do not medicate at the request of police.  Paramedics medicate based on their own medical guidelines to protect the patient and others from injury.  If a paramedic medicates a person, they are not transported to the jail, but to the hospital where they receive full emergency evaluation and care.


I try to put myself in the situation of responding to this particular case.  If I show up and if police are fighting with a man and they tell me he is on something and is showing extra human strength I am inclined to believe them (provided their description seems to match what is occurring in front of my eyes) and I would be inclined to sedate the patient if it appeared what the police were saying was true.  


As far as the excessive dose Elijah McClain received, I will say it is not always easy to properly estimate a patient's weight or age in a chaotic setting.  We can't have them step up on a scale as they might in a doctor's office.  The fact that they estimated his weight at 220 pounds is curious because 220 pounds is 100 kilograms, which makes estimating the dose of ketamine much easier than if a patient weighed less.  At 5 mg per kg, the dose would be 500 mg.  Easy math to do in the head.  If the patient weighs 140 pounds, you would have to do the math  140 divided by 2.2 equals 63.6 kilograms.  Then 5 X 63.6 gives you a dose of 318 milligrams, about 2/3s of what he actually received.  A bit more complicated math, harder to do in your head than with the 220 pound/100 kilogram patient.


Maybe EMS should be more cautious of the story they receive when they arrive, but I can say based on experience, when the police say that the patient is violent and has superhuman strength, that is usually the case.  I have seen small women on PCP throw large officers off themselves.  I have seen police officers have the s kicked out of them, all the while employing only defensive tactics against people to avoid hurting them.  I have also seen officers respond back with what I might consider excessive counterattack.  The point is there are many mentally ill patients who are violent and there are a lot of drugged out patients who are also violent.  Sedating them is better than wrestling them or having someone, patient or medical worker, get hurt. 


As far as dosing, EMS needs to improve its weight estimating abilities, and should probably err on underestimating, particularly with a drug such as ketamine.