Ketamine is a dissociative anesthetic, given in the prehospital emergency medical setting for pain management, as an induction agent for intubation, and where permitted, as a sedative for non-compliant patients who become a danger to themselves or others. At too high of a dose, ketamine can cause a patient to go into respiratory arrest and if left untreated, death can result. In the past year, two prominent cases involving the misuse of ketamine tragically resulted in the deaths of two patients, Elijah McClain in Aurora, CO and Gwendolyn Doner in Murray, UT. Now, EMS agencies and providers must reflect on and, most importantly, learn from these cases in order to prevent them from happening in the future.
Both of these calls made national news headlines, and are being put under extreme scrutiny and detailed investigation into the role that ketamine played in the patient outcomes. Because of these cases, and other cases like them, ketamine is currently sitting in the hot seat in the EMS world. The public is left wondering why paramedics continue to use this “controversial” drug while providers still recognize that when given at the proper dose, ketamine is not harmful and provides positive pharmaceutical value.
In its intended use, ketamine provides a dissociative effect that puts patients in a state of sedation and comfort. It’s a fast-acting, weight-based drug that calms down patients enough to make it easier for providers to perform treatments. Across the nation, agency protocols dictate if providers are allowed to use it for sedation of agitated patients, pain management, or both. Protocols vary from agency to agency, but generally ketamine doses for sedation of agitated patients are 1 to 2mg/kg via IV and anywhere from 1 to 4.5mg/kg when given IM. At these doses, the patient should feel the intended effects, while still being able to breathe on their own through their mouth and nose (1).
In the case of Elijah McClain, two paramedics were found guilty of criminally negligent homicide. For context, the police were called on McClain for an alleged civil disturbance. Police detained McClain and once paramedics arrived, Paramedics determined McClain was in a state of excited delirium and gave ketamine in order to sedate him. It’s important to note that “neither the Panel, nor the coroner, found conclusive evidence that the ketamine administered to Mr. McClain was a direct cause of, or even contributed to, his death.” (2) The court ultimately found the paramedics guilty not for administering too much ketamine, but for failing to assess McClain thoroughly before administering the drug and then failing to closely monitor him after administration. Now, the EMS industry, in an attempt to never let this happen again, needs to look beyond what happened in the courtroom, and into what happened on the call, as it relates to patient care and drug administration.
On this call, it is noted that the paramedic administering the ketamine estimated Elijah McClain’s weight to be anywhere between 85-100kg. Aurora Fire Rescue’s (AFR) protocol for excited delirium at the time dictated that the drug should have been given in the dose of 5 mg/kg (3). The paramedic’s weight estimation that McClain weighed around 100kg therefore justified his dose of 500mg. Unfortunately, the paramedics weight estimation was inaccurate and McClain actually only weighed 63.5kg, per the autopsy report (2). Under AFR protocol, McClain should have only been given 317.5mg of ketamine. Again, no coroner or investigative panel was able to determine that a ketamine overdose was the cause of Elijah McClain’s death, but it is worth noting that the inaccurate guess made a glaring difference in the dose of ketamine prescribed versus the dose of ketamine given.
Guessing patient weight is a hard thing to do, and wrong guesses are made every day in EMS, and unfortunately with drugs like ketamine, with the side effect of respiratory arrest, a wrong guess can have a very dangerous, even deadly, consequence. In order for mistakes like these not to happen, it’s important to take the guesswork out of EMS wherever possible. Innovation is needed now – so poor patient outcomes are prevented. The OneWeight™ Patient Scale was made for this reason. It brings accuracy to scenes and the back of ambulances, and it eliminates the need to guess patient weight so proper doses of medication can be given. In cases like that of Elijah McClain, we see that having the patient’s accurate weight is a critical tool for providers and is a tool in achieving a better patient outcome.
Gwendolyn Doner’s case was much different than McClain’s. Doner was involved in a head-on collision and was being treated by EMS for her injuries. Ketamine was administered in order to manage her pain. In short, providers on scene drew up 500mg of ketamine and administered the entire 500mg IV, in error. Doner went unresponsive after the dose was given, was not ventilated for the next 7-9 minutes and the medication dosage mistake was not reported during hand off to the hospital staff4. This case has not been taken to trial yet, nor has it been investigated and no autopsy has been released with the official determination of cause of death.
Based on the details that are known about this call, Doner was given a 500mg IV dose in error. Salt Lake protocols for ketamine for pain management are 0.1-0.3mg/kg IV, with a max dose of 30mg. Doner weighed less than 60kg and by protocol should have only been administered 18mg of ketamine IV. Since providers have not testified yet, or even shared their side of the story, it’s unknown why 500mg of ketamine was drawn up, as opposed to something much less, like the max dose of 30mg. Hospital doctors speculated that by mistake, the IM dose was drawn up rather than the IV dose.
Even though it is not yet known why this mistake happened, it exposes the chaos that happens on so many EMS calls – a patient in distress, trapped in a car, needs medication while a loud, chaotic extrication is taking place, all on a busy road – that can contribute to negative patient outcomes. In these hectic environments, EMS providers need to manage what can be managed in order to maintain control of the scene. The OneDose™ Protocol Management Tool is meant to bring clarity amidst this chaos, giving quick access to protocols and medication calculations so that administration errors can be caught before they happen. It’s meant to set up clearer on-scene communication and ultimately, it’s made to minimize the amount of things providers have to think about on scene. Once providers leave the scene, the call log created by OneDose makes patient handoffs go more smoothly, setting patients up for better care in the hospital. As providers log their interventions and medications, a real-time call log is created, doubling as a quick reference for providers as they give their ED handoffs. This can prevent providers from forgetting and leaving out pertinent call information, as was the case in the handoff of Gwendolyn Doner.
So where can EMS providers go from here? How can the industry learn from these calls in order to prevent these patient outcomes in the future? There is no one correct answer, but one critical answer is to better set providers up for success on calls. This means departments need to invest in giving their providers the best tools to help them perform their jobs at the highest level, even during the highest-intensity calls.
SOURCES
1 Rosenbaum SB, Gupta V, Patel P, et al. Ketamine. [Updated 2024 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470357/
2 Smith, Jonathan; Costello, Melissa, Dr.; Villasenor; Elijah McClain Investigation Report and Recommendations. (2021). Accessed via: https://www.washlaw.org/wp-content/uploads/2021/03/Investigation-Report-and-Recommendations-Accessible.pdf
3 Aurora Fire Rescue Protocols. (2019). Accessed via: https://cdnsm5-hosted.civiclive.com/UserFiles/Servers/Server_1881137/File/Departments/Fire/AFR%20Protocols%2008012019.pdf
4 Bell, Lloyd N; Holloway, Daniel E; Gonzalez, Mauricio A; et al. (2023). Doner v. IHC, et al Plaintiff Complaint and Jury Demand. Accessed via: https://www.belllawfirm.com/wp-content/uploads/2023/04/Doner-Complaint-2023-04-10.pdf