Medics, Not Medicine, Killed Elijah McClain
Ketamine had little to do with what happened in Aurora, and our most vulnerable patients are worse off in the rush to take it away from EMS.
Our patient was in trouble, and not the kind he thought.
The sheriff’s office had been called, as they were with any emotionally disturbed person, and like many emotionally disturbed people he was convinced (not without reason1) that they were there to kill him. His breathing was unsustainably fast, punctuated by screams that grew increasingly nonverbal; the pulse oximeter couldn’t hang on long enough to count his pulse or SpO2. Though the family attested to drug use, they couldn’t be sure what it was, and we likely didn’t have the antidote anyway. No amount of cajoling by loved ones or verbal de-escalation could temper his agitation, and the threat steadily rose that his overworked heart would give out. Finally, our lead medic turned to a family member and calmly intoned, “For his safety and ours, we’re going to give him something to calm him down.“
This is not a once-in-a-career war story; for the area, and EMS in general, this is a relatively common occurrence. Possibly the only reason it even comes to mind is that it came within hours of the announcement that two paramedics would be charged with manslaughter in the death of Elijah McClain, who had according to his autopsy received a fatal dose of the drug we were about to give.
What Ketamine Is
Ketamine is a dissociative, a class of drugs that, to sum up several hours of stupor- and/or tears-inducing biochemistry, induce out-of-body experiences. This quality has a number of beneficial uses, but the one we’re concerned with here is its ability to calm patients whose emotional instability becomes a life-threatening runaway train with far less effect on the respiratory drive than other central nervous system depressants. This makes it a drug of choice for treating “hyperactive delirium syndrome with severe agitation,” the terminology adopted by the American College of Emergency Physicians to replace “excited delirium” largely in the wake of McClain’s death2—when you’re two dudes working out of a truck, trying to solve one problem with another is generally not recommended.
“Far less effect,“ however, is not no effect, and ketamine has adverse effects to look out for. When pushed rapidly, ketamine can cause laryngospasm (spasming of the vocal cords that can prevent breathing) and periods of apnea (complete loss of breathing). While serious, these effects are relatively rare, easily detected via even basic life support monitoring (the lowest standard of care in the EMS system), and treatable with BLS equipment. A minimally conscientious paramedic has little to nothing to fear.
What Happened in Aurora
Unfortunately, Elijah McClain didn’t get minimally conscientious paramedics; he got Cooper and Cichuniec.
When Cooper and Cichuniec got on scene, they found a patient restrained in a prone position (on his stomach) with his hands behind his back, who had already vomited multiple times. Either of these is a concern for multiple respiratory and medical issues, and yet neither so much as asked their patient a question throughout the entire incident. Instead, they accepted the police “diagnosis” of excited delirium without so much as speaking to their patient. Police officers are typically trained to the “first responder“ level, a non-standardized level that amounts to little more than naloxone and CPR; deferring to their judgment on their area of expertise would be (another instance of) gross misconduct on its own.
Even with all this, however, and even with the too-large ketamine dose of which much has been made, McClain could and should still be alive. Though their overestimation of his weight led to a massive overmedication by their protocols, it’s on the lower end for an initial surgical dose, which requires much closer and more expert monitoring but is not inherently unsurvivable with rapid transport. And, as mentioned before, the complications of rapid ketamine administration are easily detected and treated.
If you bother to get a set of vital signs. The thing you do for a transfer from one wing of a hospital to another. The thing you can’t close out an EMS report without doing. The thing you can’t pass an EMS testing scenario, at any level, without doing.
Cooper and Cichuniec, before and after giving one of the most powerful drugs in the EMS formulary, did not do even the absolute least that would have saved them, the patient and (perhaps) the system. Instead, they let their patient slowly stop breathing and die, failing to even do a basic assessment until he was already pulseless. Though the competent medical professionals they handed McClain off to would get pulses back and maintain clinical life for a few days, the damage was done.
Ketamine as Scapegoat
Unfortunately, a public that cried out for justice didn’t always look for it in the right direction, and (as is this project’s raison d'être) policymakers and media with little subject matter expertise latched onto the most eye-popping detail, with wide-ranging but little-understood effects.
Colorado, for example, signed new legislation requiring the weighing of any patient before administration of ketamine for agitated delirium—effectively banning it for EMS use, given the restraints of prehospital medicine. This is a disaster in patient care terms: of the drugs suggested to treat life-threatening levels of agitation in the National Model EMS Guidelines3, ketamine has by far the best-known and mildest effect on the respiratory system. The next Elijah McClain may receive a far more dangerous medication because the last one got two more dangerous medics.
Epilogues (Or, “I’m the Guy That Does His Job”)
Our patient seemed to be resting comfortably, unconscious but breathing slowly and deeply with picture-perfect capnography (a respiratory metric much more valuable than pulse oximetry but slightly more complicated to set up, and which I’d insisted on out of Aurora-induced paranoia). We handed off our patient to ER staff without issue, and while like most patients I never saw him again, subsequent contact with the family revealed no bad outcomes.
Cooper and Cichuniec face sentencing in March, a grim reminder of the damage we do when we fail to do our jobs. The damage they’ve done to our profession remains to be seen.
Disclaimer: the deputies on this call acted professionally.
ACEP had been the last man standing on excited delirium for years; the back-and-forth over the diagnosis would take another post at the least.