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Colorado Medics May Have Misdiagnosed 'Excited Delirium' Hundreds Of Times When Dosing People With Ketamine

elijah_mcknight.jpg
Arapahoe County Sheriff's Office
Elijah McKnight, one of two men who told KUNC they were handcuffed by police at the time they were sedated, was tackled to the ground by Arapahoe County deputies after turning away from them in 2019. A medic with South Metro Fire Rescue later dosed him ketamine.

Paramedics unnecessarily sedated hundreds of people with ketamine during confrontations with police officers in Colorado, exposing them to potentially life-threatening complications associated with the drug. That’s according to an estimate from Dr. Mark DeBard, a professor emeritus of emergency medicine at Ohio State University and expert in cases of “excited delirium.”

“It may represent a bit of an undercount, but not a lot, and it seems to me that the problem that you’re facing in Colorado — and honestly, this may be true in the United States — I don't know, it makes me worried, is that it's being highly over-diagnosed in the field,” DeBard told KUNC.

DeBard helped define excited delirium, a rare medical syndrome where people display a long list of possible symptoms, such as hyperaggressiveness, bizarre behavior, imperviousness to pain, and combativeness. In the worst cases, people can be so agitated and out of control that without medical intervention they die. Ketamine is used to sedate people in the aroused state, DeBard said, because it acts quickly.

“All you got to do is stop them from fighting, to calm them down and then their body will slowly return to normal,” he said.

In a prior investigation, KUNC reported that medics sedated people 902 times with ketamine in the last two and a half years, including Elijah McClain, the 23-year-old Black man who died after being confronted by police in Aurora.

READ MORE: Medics In Colorado Dosed 902 People With Ketamine For 'Excited Delirium' In 2.5 Years

DeBard said the incidence rate of excited delirium cases should be about one case per 250,000 people in a given year. For Colorado’s population of approximately 5.76 million people, that would mean medics are administering the drug for excited delirium north of 15 times more often than they should be. Medics should have encountered about 57 cases in that 2.5-year time period.

“If it's not obvious that it needs to be used, they shouldn't use it,” DeBard said of ketamine.

The state’s Department of Public Health and Environment allows medics to administer ketamine for excited delirium through a waiver program. KUNC requested an interview with Jill Hunsaker Ryan, who leads the department, but a spokesperson said the request could not be accommodated by deadline.

Anesthesiologists concerned about use

Amid growing public scrutiny over waivers, the department last month announced a review of the program that issues them. Experts are expected to conduct the review and issue a report in coming months. The department has declined to name the experts involved and how the review will be conducted.

Dr. Randall Clark, a member of the Colorado Society of Anesthesiologists, is seeking a seat at the table for his group, which, in light of the review, is pushing the department for a statewide suspension on medics’ use of ketamine for excited delirium.

"We shared all the concerns that we have about indications for use, the dosing being used, the fact that it does not appear to be monitored in 100% of the uses and how they have received public buy-in of basically incapacitating people in the field against their will,” Clark said.

The society has sent a letter to Hunsaker Ryan’s department highlighting numerous concerns. In a statement to KUNC, the department said it received the society’s letter and is reviewing it.

Clark also raises concern about Elijah McClain’s death last year. Though McClain was already in handcuffs and restrained by officers on the ground, a medic with Aurora Fire Rescue dosed him with ketamine. Clark, echoing statements by other experts, said the dose appeared to be too high.

“He had a cardio, or respiratory arrest, within a few minutes of receiving ketamine in his encounter and the dose he received sounds to me like eight or nine milligrams per kilo, which is far higher than we would typically use to induce general anesthesia in an operating room or procedural area,” Clark said.

The official autopsy was unclear about what caused McClain’s death. It could not rule out the possibility that ketamine, as given, caused an unexpected reaction.

Yet officers said McClain showed signs of excited delirium before he was dosed and the autopsy described McClain’s agitated state as a "likely" factor.

A federal lawsuit by McClain’s family calls what happened “murder,” placing blame for McClain’s death on officers, medics and officials. It contends that McClain did not have excited delirium by any definition.

Excited delirium gets defined

Dr. DeBard first noted excited delirium in the 1990s — before it had a name. He observed puzzling cases in his emergency room. People were unaware of their surroundings, frenzied, sweating, with racing hearts. Often cases emanated from police responding to 911 calls about people acting oddly.

“I managed to start speaking to fellow ER docs from all over the country (and) said, ‘Are you seeing this? You see what's going on in police custody?’” DeBard said. “They all said, ‘Yes. We see it. We don't know what's happening.’”

He eventually brought the issue to his peers, forming a task force. The result was a white paper issued in 2009 through the American College of Emergency Physicians, which represents 38,000 doctors around the country. It not only defined excited delirium, it suggested treatments, including ketamine to sedate people quickly in an effort to prevent deaths.

Appleton, Wisconsin Excited Delirium
Appleton Police Department
In a video used as a police training tool, a man is treated by first responders for excited delirium.

But in McClain’s case, the initial interaction with police doesn’t appear to be excited delirium. When police encountered McClain, he was wearing a ski mask at night and apparently dancing.

“I have a right to stop you because you’re being suspicious,” an officer told McClain, who was not suspected of any crime.

McClain asked officers to let go of him, to “respect the boundaries,” and to “leave me alone.”

Then he told officers, “First off, you guys started to arrest me and I was stopping my music to listen. Now let go of me…”

DeBard said the interaction doesn’t appear to be excited delirium.

“It's pretty easy to say he doesn't come close to meeting the criteria for excited delirium,” DeBard said.“Somebody has got to basically be disoriented and unable to make a coherent response and there's no sign of that in this case that I could tell,” DeBard said.

In his opinion, if McClain later developed excited delirium, it was likely caused by the confrontation with police.

In a prior investigation, KUNC highlighted the stories of two more men who were handcuffed by police at the time they were given ketamine. Neither man appeared to be demonstrating excited delirium, but both were sedated by medics anyway. One of the men specifically asked not to be dosed with the drug, raising ethical issues for Clark, who viewed the videos, including body camera footage of McClain.

READ MORE: Coloradans Dosed With Ketamine During Police Confrontations Want Investigation

“If you look at the tape of the interactions they were speaking in whole sentences, speaking appropriately for the conditions that they were in and would not be delirious by the traditional sense of the word in medicine,” Clark said.

Clark said the rate of complications in cases is another concern.

“The thing that stands out to me is the intubation rate,” he said. “I think your own reporting has found, depending on the time period looked at, it varies between 10 and 20%. That's a staggering number of people needing to be intubated from this drug administration and, again, it speaks to the potency of the drug that they're using and the dose they're using.”

An intubation is where a tube is inserted into a person's mouth and down their trachea, and they are placed on a ventilator to help them breathe.

If medics in Colorado are overdiagnosing excited delirium, that would mean people were exposed to such complications as many as 845 times.

Unknown which agencies dose most

Under Colorado’s system, medical directors — typically doctors — can apply for waivers allowing paramedics to administer ketamine for excited delirium. The applications are approved by a little-known state board called the Emergency Medical Practice Advisory Council. The state health department collects data on the program but declined to give the raw numbers to KUNC, citing a confidentiality law.

KUNC tried to learn which Emergency Medical Service agencies had the most cases where people were given ketamine. The department declined to share that information. So we asked which medical directors, who may hold waivers for multiple Emergency Medical Service agencies, oversaw the most administrations of ketamine. The department declined but instead provided a list — without names. It shows that medics overseen by four medical directors accounted for almost 80% of the 454 cases where people were given ketamine in 2019. It was unclear from the data where those administrations occurred in the state.

Each medical director develops their own ketamine-use protocols for the agencies they lead. If medics are over-diagnosing excited delirium, it's on the directors to recognize that as a problem. KUNC reached out to six doctors who hold waivers or are members of the council that approves them. They all either declined to be interviewed or did not respond to our requests.

Black Lives Matter movement draws attention to issue

Over the summer, Black Lives Matter marches placed police and government policies under intense scrutiny. Because of Elijah McClain’s death, even medics and doctors can’t escape the spotlight. Excited delirium hasn’t made many headlines, but it is in the undercurrent of major news stories, including the deaths of George Floyd in Minneapolis and Daniel Prude in Rochester, New York. In both cases, officers invoked “excited delirium” on body cameras.

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Paul Becker / CC BY 2.0
Protesters march at a violin vigil for Elijah McClain in Columbus, Ohio on July 4, 2020.

Yet it is unclear how often officers decide excited delirium occurs, calling medics in to help and perhaps administer ketamine. There is no conclusive data that KUNC could find to show how often police and medics are making the right diagnosis. Dr. DeBard didn’t even want to guess how many EMS agencies use ketamine.

“It seems widespread, but I have no data on that,” he said.

That’s because emergency medical services are decentralized. It’s an even bigger stretch to ask how often ketamine is used on agitated police suspects across the country.

“Basically, we don't know how often excited delirium is claimed and it can be claimed that multiple points in the medical/legal investigation by multiple different parties,” said Justin Feldman, an epidemiologist and a fellow at the Harvard FXB Center for Health and Human Rights. He studies police violence and deaths in custody.

“A coroner, medical examiner can say there was excited delirium involved,” Feldman said. “A prosecutor who's deciding whether or not to bring charges against officers can make the arguments, defense lawyers can make the argument, that there's just many, many different many different places where it can come into play.”

As for the very worst outcomes, like Elijah McClain’s death, the information can sometimes be found, but it’s hiding below the surface.

“You would have to get the autopsy report and the toxicology report, which is not even public record in many states, and is also difficult to get in the first place,” he said.

If McClain’s case hadn’t been revived by Black Lives Matter protesters, it may have simply been obscured.

Dr. Randall Clark also is searching for comprehensive data on excited delirium cases where ketamine is used by medics. Data from the state’s Department of Public Health and Environment is patchy and has come to light in stories like these, but it is better than nothing.

“Relatively few states have a reporting mechanism like Colorado,” he said. “So how in the world would you know what is happening with people across the country who are receiving ketamine for excited delirium, if those agencies aren't required to record uses and look at complications? It's, it's really a stunning statement that this could be going on and not have broader knowledge.”

On Monday, Aurora’s city council ordered a temporary halt of medics’ use of ketamine for all purposes. Among those in support are Mayor Mike Coffman, who said he would look to the results of ongoing medical investigations and would only support its use by medics if it is deemed both “safe and effective.”

And the American College of Emergency Physicians, which issued the white paper in 2009 that is cited by doctors who hold waivers in Colorado, has formed a new working group of medical and patient safety experts. Their job is to revisit the paper. Dr. DeBard won’t be part of the process because he’s retired.

“I hope they'll figure this out, but basically, the police should never be allowed to suggest its use, No. 1,” he said. “EMS should never be allowed to ask the police if they should be using it, No. 2.”

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