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Doctors recommend paramedics no longer use excited delirium as justification for ketamine sedations

A vial of ketamine sits on a table in front of a needle.
Teresa Crawford
File photo of a vial of ketamine. Colorado's health department says emergency workers should not use a condition involving erratic behavior by people as a reason to inject them with the sedative. Most states and ambulance agencies can use ketamine when people exhibit the condition called excited delirium.

A panel of Colorado medical experts has determined a condition called excited delirium is linked to implicit bias and racism. The finding is part of a report released Wednesday that recommends ways to rein in paramedics’ use of a powerful drug, ketamine, to sedate people, often in situations involving police.

Excited delirium is an emergency medical condition where a person becomes so agitated and distressed that it can result in sudden death. But the diagnosis lacks specificity, Dr. Lesley Brooks of Northern Colorado, a member of the panel, told KUNC.

“It is incredibly subjective with use of non-medical criteria, such as hyper aggressiveness, increased strength, as well as failure to respond to police commands – things that are so subjective that they disproportionately impact communities of color,” Brooks said.

Colorado suspended paramedics’ use of ketamine to sedate agitated people in July, after the passage of a state law. Months before the bill for that law was introduced, the seven-member panel of mostly doctors worked quietly.

It was assembled in 2020 by Colorado Department of Public Health and Environment Executive Director Jill Hunsaker Ryan amid media scrutiny over ketamine sedations, including KUNC investigations that found 902 uses of the sedative for excited delirium and agitation across the state over a two-and-a-half-year period.

Among those 902 cases was Elijah McClain, who died in 2019. Paramedics in Aurora reported that the 23-year-old Black man showed signs of excited delirium and used ketamine to sedate him while he was handcuffed, struggling as police held him to the ground.

Pointing to police body camera footage of McClain trying to communicate with first responders, McClain’s family and supporters say he did not have the condition and should not have been sedated. An independent report to the City of Aurora released earlier this year found that medics appeared to accept officers’ impression that McClain had the condition “without corroborating that impression through meaningful observation or diagnostic examination.”

Three police officers and two paramedics have been indicted on manslaughter and other charges in McClain’s death. An autopsy was inconclusive about the cause.

The panel’s views on excited delirium line up with the American Medical Association’s. The AMA’s House of Delegates issued a statement this year saying that evidence does not support excited delirium as an official diagnosis. The American Psychiatric Association does not recognize it as a mental disorder.

The panel’s 125-page report finds that paramedics should resort to ketamine only when “there are no other means available to safely assess, treat, and transport a patient.”

Such circumstances “are limited to” those who present a “serious, probable, imminent threat of bodily harm to self or others,” according to the report. Luis A. Verduzco, an anesthesiology and critical care doctor on the panel, said new emphasis would be placed on efforts to de-escalate a situation to calm people and to assure that if paramedics use ketamine, they make the decision independently.

“I make that very clear – at the sole discretion of the paramedic, not the passer by who is walking across the street, not the police officer, but the paramedic – that upon his or her discretion, that they feel that the patient needs to be chemically restrained so that we can evaluate the patient to try to obtain a diagnosis, then ketamine is appropriate,” Verduzco told KUNC.

The panel took into account the “Protection of Persons from Restraint'' state law that passed earlier this year, which calls for close monitoring of patients given ketamine. For instance, the panel recommended that all ambulances have a checklist of actions for appropriate dosing and monitoring of patients.

A co-sponsor of the bill, Rep. Leslie Herod, D-Denver, was not available for an interview, but issued a written statement reacting to the panel’s recommendations.

“Ketamine is a powerful drug that can have potentially fatal consequences if used improperly,” she wrote. “I’m heartened to see CDPHE’s Ketamine Review Group establish a careful process for the oversight and administration of the drug and require data collection on its disproportionate use against Black and Brown Coloradans. I am particularly supportive of their rejection of ‘excited delirium’ as a basis for ketamine administration and the panel’s confirmation of what we’ve long known – that the use of excited delirium as a basis for ketamine administration is prone to racism. I’m proud of the work we did in the legislature last session to end the misuse of ketamine by law enforcement, and I expect better outcomes for Coloradans based on these recommendations.”

Colorado Chief Medical Officer Dr. Eric France chaired the panel. He said the next steps will be to circulate the report to state health officials and local medical organizations, including EMS agencies.

“I expect strong communication with these entities, as well as with our communities who are impacted by the policies and practices in paramedic care,” France said. “From there, in 2022, I think we'll be working towards interpreting and defining whether there's a role for ketamine in the future.”

As investigative reporter for KUNC, I take tips from our audience and, well, investigate them. I strive to go beyond the obvious, to reveal new facts, to go in-depth and to bring new perspectives and personalities to light.