“Experts” call for conversation about forced ketamine use/ forced sedation

[deleted128562]

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[Arch Guillotti]

As a side note, I’d suggest that our MDA colleague Dr. Doyle (from the first article) consider spending a little time on the street with EMS before opining from the safety of her operating room. Well or perhaps the safety of her break room where she’s available by phone to “assist” the CRNA’s doing the actual work in the OR.

I won't go there since this not my "home" forum but suffice it to say that "MDA" is a very insulting term.

 

[TwoHighways]

If someone wants to get on PCP, meth, cocaine and act a fool and potentially cause harm to themselves, I have no f’s to give. If they are a harm to others as a result of their actions, do what’s necessary to subdue that threat. Reasonable force for the amount of threat they actually are. No qualms about use of sedatives by EMS. Cops need to secure the patient first for the IM K-train administration. 4 mg/kg does wonders. If there are safer alternatives, I’m not against their usage either. Haldol? Etomidate? Benadryl for synergism?

 

[NYEMMED]

Maybe the Anesthesiologist should spend a few hours in the Psych region of the ED or with EMS, would he rather tie the patient down and let them get rhabdomyolysis, or assault staff/ hurt them, or hurt themselves? Is he also advocating that if a mentally unstable patient is violent we would be protected from lawsuits if they should hurt themselves/others, or be completely covered against malpractice if we let them just leave the ED?
To bring back a old slogan, Maybe he should "stay in your lane"

 

[WilcoWorld]

I love ketamine for undifferentiated agitated delirium and I love haloperidol for slightly-differentiated agitated delirium.

That said, the use of restraints - be they physical or chemical - is serious business and should never be taken lightly, as we are stripping a person of their liberties in about the most severe way possible. I think conversations about their use should be ongoing and whenever I use them I accept that my decision may be scrutinized.

If you believe in freedom of speech and preservation of liberties it seems obvious that you should support ongoing conversations about restraining people against their will.

 

[Birdstrike]

Anesthesiologist calls for 'national conversation' about forced ketamine use following McClain case

"I hope this brings about a national conversation about forced sedation and marginalized groups.”

www.google.com

Elijah McClain's death puts focus on ketamine injections during police calls

Ketamine, a powerful sedative, might be given by paramedics to calm people who appear agitated. But some medical and legal experts question its use during police calls.

www.google.com

Anytime someone starts a conversation with "We need to have a 'national conversation'" you're about to fall into a trap. That's code for, "I'm about to stir the pot and create a problem where no real problem exists, because I have an ulterior motive," usually sociopolitical, that has nothing to do with the original topic. They bait you with a topic to catch your attention, in this case, "sedation." Sedation is the topic that interests you. Adding the term "forced" is the bait that brings you in, because it's provocative and one sided. Then, once you're pulled in, you're knee deep in an argument, in this case "marginalized groups," that has nothing to do with the topic they baited you with (sedation). It's actually Grade A+ persuasion technique and unless you're aware of the technique, you're going to get baited into arguments repeatedly and you'll always lose because of how they've framed the conversation. In this case, you think you're arguing for "sedation" but they've framed the subject in such way it appears you're arguing in favor for "forced" sedation against "marginalized groups," which is an unwinnable argument.

Keep an eye out for that phrase: "We need to have a national conversation." It's a trap.

Study the art of persuasion. You'll never view life the same again. It's sort of like looking behind the curtain and seeing all the levers being pulled. Influence, by Cialdina, How To Win Friends And Influence People, by Dale Carnegie, and How To Fail At Everything And Still Win Big, by Scott Adams, are greater starter books on this.

 

[MediMike]

However, a paramedic giving a 7-8 mg/kg dose of Ketamine In the back of an ambulance is concerning. Especially to a patient that was just placed in a choke hold experiencing a syncopal episode. I completely agree that the dose of 500 mg for a 140 lb. individual is way to high. Dose should have been 3-5 mg/kg IM (~190-320 mg). How do you estimate a 63 kg individual as 100 kg? I’m not great at guessing weight, but this isn’t even close. I agree with the anesthesiologist that the patient should have been given around half the dose that they received.

Because for a long time paramedic education has been taught by people who either burnt out of the field or failed out of the field who then pass on their pearls of knowledge, such as "everyone's 100kg at 0300".

Or it came in a 500mg vial. Another classic dosing strategy if you don't want to try math.

 

[larpleston]

This case may well have been poorly handled. But the purpose of starting this thread was to highlight the fact that it is now being used as a vehicle by some to second guess or try to take away sedation options in general

Both articles you posted are questioning the use of ketamine by EMS and police, not doctors. Is there another article that you meant to post that references its use by physicians (which nobody in either article you linked questions or ‘second guesses’)? If you’re advocating for police to give these drugs then congrats, you just made the argument for NPs to administer conscious sedation exponentially easier.

 

[TwoHighways]

Because for a long time paramedic education has been taught by people who either burnt out of the field or failed out of the field who then pass on their pearls of knowledge, such as "everyone's 100kg at 0300".

Or it came in a 500mg vial. Another classic dosing strategy if you don't want to try math.

truth

 

[AMEHigh]

As a non-EM person it seems like you EM people (and anesthesia) would agree that in general police and EMS shouldn’t be using these medications, which is what these articles are talking about. It’s not talking about using these medications in a medical setting by highly trained physicians.

You all have specific training to be able to do this safely and I don’t believe that EMS and police officers in general do. If the use of such sedatives are absolutely necessary out in the field then it seems like there needs to be pretty clear protocol about when it can be used, how it’s done, appropriate dosing and then getting the go-ahead from a physician.

 

[xaelia]

Since when is ketamine being used to sedate/restrain? When tJC comes around, the answer is always “oh, we are just treating their acute agitation to ensure their safety and enhance their timely recovery”.

 

[TwoHighways]

As a non-EM person it seems like you EM people (and anesthesia) would agree that in general police and EMS shouldn’t be using these medications, which is what these articles are talking about. It’s not talking about using these medications in a medical setting by highly trained physicians.

You all have specific training to be able to do this safely and I don’t believe that EMS and police officers in general do. If the use of such sedatives are absolutely necessary out in the field then it seems like there needs to be pretty clear protocol about when it can be used, how it’s done, appropriate dosing and then getting the go-ahead from a physician.

That’s typically how it works

As Birdstrike said, this thread is a nothingburger.

 

[NYEMMED]

Since when is ketamine being used to sedate/restrain? When tJC comes around, the answer is always “oh, we are just treating their acute agitation to ensure their safety and enhance their timely recovery”.

Its pretty common in the ED, EMS is starting to use it...

 

[NYEMMED]

As a non-EM person it seems like you EM people (and anesthesia) would agree that in general police and EMS shouldn’t be using these medications, which is what these articles are talking about. It’s not talking about using these medications in a medical setting by highly trained physicians.

You all have specific training to be able to do this safely and I don’t believe that EMS and police officers in general do. If the use of such sedatives are absolutely necessary out in the field then it seems like there needs to be pretty clear protocol about when it can be used, how it’s done, appropriate dosing and then getting the go-ahead from a physician.

In order for a paramedic to give any medication it has to be in a protocol, and everything you described is in that protocol. Depending on the EMS agency, usually sedation requires online medical control

 

[alpinism]

For these patients I typically give 5mg/kg IM with repeat doses Q5min as needed. Its pretty common for some patients to need multiple doses before they're completely sedated especially if they have any past medical history of alcohol or drug abuse. Due to this patients will often receive high doses of as much as 500mg-1,000mg within a very short timeframe. This is pretty much in line with standard practice and has also been shown to be extremely safe in psych patients with proper airway management techniques.

 

[GeneralVeers]

I'm often astonished at how much Ketamine paramedics are giving to agitated patients. I've had a few abdominal pain patients with agitation get massive doses of Ketamine.

In most cases paramedics are just glorified Uber drivers. Why can't they restrain someone and wait a few minutes until they get to the ED to decide if people really need chemical restraints?

As a Libertarian I find any cases of chemical/physical restraint when not committing a violent crime concerning.

 

[AMEHigh]

In order for a paramedic to give any medication it has to be in a protocol, and everything you described is in that protocol. Depending on the EMS agency, usually sedation requires online medical control

Thank you for explaining that.
So in the case of Elijah McClain, how/why was he given such a high dose?

I guess it seems like maybe there needs to be stricter protocols then? To be honest, I haven't watched the video because I can't bring myself to do so, but from what I've heard is people said he wasn't even acting like a threat when the ketamine was given. What is the current threshold for when it absolutely needs to be given?

 

[HoosierdaddyO]

So coming from the EMS perspective... just how would you all like the Paramedic to transfer a patient that is bat**** crazy in the back of an ambulance. I also take it most of you never were or even spent more than 4 shifts on the back of a rig lol!!! Just like everyone was saying. I don’t want to get hurt and I don’t want my staff to get hurt. Well EMS is the same way. Ketamine when trained properly in the hands of EMS saves lives, prevents accidents to both people on the road and is something that I will support. Asterisk of course is that there needs to be proper training and Medical oversight by the medical director that they know who needs and who doesn’t need chemical sedation!!

 

[AMEHigh]

That’s typically how it works

As Birdstrike said, this thread is a nothingburger.

Ahh ok got it.
Well I just typed a reply below, but it seems like the protocol that those EMS followed needs to be updated. Does not seem like a very good protocol to give such a high dose to someone who isn't a huge threat and just was in a choke hold.

 

[nexus73]

What alternatives are there to ketamine in this situation? Should the patient be restrained to the ambulance gurney as they thrash about violenty, potentially seriously hurting themselves or others? Is there an alternative medication that is safer? Is there a protocol where ketamine could be used more safely in a similar situation?

I thought ketamine was considered a relatively safe drug for use in the field due to low incidence of respiratory depression.

If a patient isn't giving calming medication, would we be hearing arguments they're "strapped down like animals"...

 

[MediMike]

So coming from the EMS perspective... just how would you all like the Paramedic to transfer a patient that is bat**** crazy in the back of an ambulance. I also take it most of you never were or even spent more than 4 shifts on the back of a rig lol!!! Just like everyone was saying. I don’t want to get hurt and I don’t want my staff to get hurt. Well EMS is the same way. Ketamine when trained properly in the hands of EMS saves lives, prevents accidents to both people on the road and is something that I will support. Asterisk of course is that there needs to be proper training and Medical oversight by the medical director that they know who needs and who doesn’t need chemical sedation!!

The patient should be restrained by PD with hard restraints, transferred to the cot with chemical restraint added in as necessary.

You can definitely agree that anyone administering a medication, particularly in the prehospital arena should be doing it at the appropriate dosing, for the right reason in the right situation.

Too often EMS gets a pass for some of the ridiculous BS they do.

 

[MediMike]

What alternatives are there to ketamine in this situation? Should the patient be restrained to the ambulance gurney as they thrash about violenty, potentially seriously hurting themselves or others? Is there an alternative medication that is safer? Is there a protocol where ketamine could be used more safely in a similar situation?

I thought ketamine was considered a relatively safe drug for use in the field due to low incidence of respiratory depression.

If a patient isn't giving calming medication, would we be hearing arguments they're "strapped down like animals"...

Many agencies have Haldol, Geodon and benzos at their disposal as well. And this situation was not one where someone was thrashing about violently.

 

[AMEHigh]

What alternatives are there to ketamine in this situation? Should the patient be restrained to the ambulance gurney as they thrash about violenty, potentially seriously hurting themselves or others? Is there an alternative medication that is safer? Is there a protocol where ketamine could be used more safely in a similar situation?

I thought ketamine was considered a relatively safe drug for use in the field due to low incidence of respiratory depression.

If a patient isn't giving calming medication, would we be hearing arguments they're "strapped down like animals"...

Have you watched the video?
As I admitted above I can’t bring myself to watch it, but from what I’ve read it does not seem like he was a violent threat. But I guess you’re saying that you disagree? Even if there are protocols it seems like protocols do need to be changed, so it does seem worthy of a discussion in my opinion.

I think in another post someone mentioned how ketamine is packaged it’s easy to give a higher dose. So even if people agree that at times giving a sedating dose is the right protocol, what is the protocol about the correct dose? It seems like start low and go slow might be something that should be considered since people are saying he was given a too high dose for his weight.

 

[nexus73]

Have you watched the video?
As I admitted above I can’t bring myself to watch it, but from what I’ve read it does not seem like he was a violent threat. But I guess you’re saying that you disagree? Even if there are protocols it seems like protocols do need to be changed, so it does seem worthy of a discussion in my opinion.

I think in another post someone mentioned how ketamine is packaged it’s easy to give a higher dose. So even if people agree that at times giving a sedating dose is the right protocol, what is the protocol about the correct dose? It seems like start low and go slow might be something that should be considered since people are saying he was given a too high dose for his weight.

I didn't watch the video, so admittedly may be basing my perspective on inaccurate assumptions about this particular situation.

I was starting from the assumption EMTs wouldn't give tranquilizers to someone who was calm...which is really another discussion entirely from whether ketamine is appropriate to treat acute agitation.

 

[AMEHigh]

I didn't watch the video, so admittedly may be basing my perspective on inaccurate assumptions about this particular situation.

I was starting from the assumption EMTs wouldn't give tranquilizers to someone who was calm...which is really another discussion entirely from whether ketamine is appropriate to treat acute agitation.

Yeah I don’t think the discussion is about if it should ever be given by any doctor.
For this specific case he was handcuffed, had been in a choke hold, there were several police officers and a medic there, so from what I’ve read he wasn’t posing a huge threat. He had also vomited. The medic mentioned the ketamine even before the ambulance arrived.

So it does seem like a conversation about protocol/indications and appropriate dose needs to be had.

And thanks for sharing. I’ve learned new info!

 

[Apollyon]

"Back in the old days", on the ambulance, we didn't have anything like Ketamine, Haldol, or anything else (we only had Valium for benzos, and morphine for opiates). For the REAL violent psychs, it was mechanical restraint. The stretchers had what we called the "top deck". This was an aluminum frame with a pad on it, like a portable stretcher. It did not flex or bend. Real violent psychs were rare; for me, rare enough that I never had to do the following. What this implies is that a lot of EMS people make things worse. I know that that was true with our service. Anyways, the mechanical restraint was a "top deck sandwich" - the pt was wrapped in a bed sheet, and either strapped to the top deck, and placed upside down on the stretcher, and strapped into place, or put on the stretcher, and the top deck over top, and strapped in place. If they got a B52 (or a 10-4 Good buddy), that was at the ED. People didn't die from our mechanical restraint.

 

[thegenius]

If someone wants to get on PCP, meth, cocaine and act a fool and potentially cause harm to themselves, I have no f’s to give. If they are a harm to others as a result of their actions, due what’s necessary to subdue that threat. Reasonable force for the amount of threat they actually are. No qualms about use of sedatives by EMS. Cops need to secure the patient first for the IM K-train administration. 4 mg/kg does wonders. If there are safer alternatives, I’m not against their usage either. Haldol? Etomidate? Benadryl for synergism?

I'm kind of against law enforcement injecting ketamine in someone to calm them down. It's not even that they aren't trained to use it. Basically I give ketamine to anyone that I want to and there are no real substantive contraindications to it (and it does not increase ICP). I guess there are some airway considerations although they are quite rare.

I oppose it because they don't have the proper rescue equipment or training when they actually do have a problem with it. When I use it, patients are on a monitor and I have lot of help around me.

 

[larpleston]

I'm kind of against law enforcement injecting ketamine in someone to calm them down. It's not even that they aren't trained to use it. Basically I give ketamine to anyone that I want to and there are no real substantive contraindications to it (and it does not increase ICP). I guess there are some airway considerations although they are quite rare.

I oppose it because they don't have the proper rescue equipment or training when they actually do have a problem with it. When I use it, patients are on a monitor and I have lot of help around me.

Not only do they not have rescue equipment they aren’t regularly using a medical command and even things that aren’t adverse effects like emergence reactions aren’t going to be identified by them. How many cops even know the word ‘contraindication’ and why would they? Where I did residency the cops had to do about two months of training. Probably less than 10% of that was focused on medical care. We denigrate our own profession if we claim they are adequately trained to give ketamine (or hell, anything beyond maybe Tylenol).

 

[AlmostAnMD]

zyprexa would be a better choice imo

also a good choice for altered demented old people, unlike ketamine

 

[TwoHighways]

I'm kind of against law enforcement injecting ketamine in someone to calm them down. It's not even that they aren't trained to use it. Basically I give ketamine to anyone that I want to and there are no real substantive contraindications to it (and it does not increase ICP). I guess there are some airway considerations although they are quite rare.

I oppose it because they don't have the proper rescue equipment or training when they actually do have a problem with it. When I use it, patients are on a monitor and I have lot of help around me.

Cops have no business administering ketamine or any drug beyond an epi pen belonging to the actual patient, which can be plenty dangerous if the epi isn’t warranted. Should have made my post more clear. Cops provide the muscle for EMS to safely deliver the appropriate IM dose of ketamine.

 

[MediMike]

"Back in the old days", on the ambulance, we didn't have anything like Ketamine, Haldol, or anything else (we only had Valium for benzos, and morphine for opiates). For the REAL violent psychs, it was mechanical restraint. The stretchers had what we called the "top deck". This was an aluminum frame with a pad on it, like a portable stretcher. It did not flex or bend. Real violent psychs were rare; for me, rare enough that I never had to do the following. What this implies is that a lot of EMS people make things worse. I know that that was true with our service. Anyways, the mechanical restraint was a "top deck sandwich" - the pt was wrapped in a bed sheet, and either strapped to the top deck, and placed upside down on the stretcher, and strapped into place, or put on the stretcher, and the top deck over top, and strapped in place. If they got a B52 (or a 10-4 Good buddy), that was at the ED. People didn't die from our mechanical restraint.

I dunno man. While I didn't start until around 2003 I still remember the backboard sandwich and prone restraints...I also remember how those things were eradicated from the vast majority of systems due to the risk of positional asphyxia.

 

[Apollyon]

I dunno man. While I didn't start until around 2003 I still remember the backboard sandwich and prone restraints...I also remember how those things were eradicated from the vast majority of systems due to the risk of positional asphyxia.

As it was a rare thing, I think we just got lucky that we didn't kill that many. However, also, the psychs weren't as fat in the 90s, because the new meds that are better, but chunk you up, just weren't available.

And, as you say, eradicated. I'm talking 1993.

 

[MediMike]

Ahhh...it was your generation that took it away from me.

I agree though, can count on one hand how many times I felt the need to knock someone down with meds over a 10 year career.

 

[southerndoc]

If an anesthesiologist or any physician for that matter doesn't believe in prehospital chemical sedation, I invite them to spend 10 minutes alone in the back of an ambulance with a violent patient. I bet the majority would change their opinion.

Chemical sedation has its place. Physically restraining a combative or delirious patient causes more harm than chemically sedating them. Now that doesn't mean that a 100 pound person needs 500 mg of ketamine. I believe the 5 mg/kg IM dose is too high. One of the agencies near me does 500 mg for EVERY patient regardless of weight. I believe that is dangerous.

My paramedics have standing orders for ketamine 2-5 mg/kg IM for agitated delirium with recommendation for smallest dose possible. I am notified within 30 minutes of its administration by a battalion chief. Every case is thoroughly reviewed (including bodycam footage of police officers). This is not something I take lightly, but it's also something I don't want paramedics and police officers fighting with someone for an extra 5 minutes while a paramedic calls for orders.

What police agencies are carrying ketamine? I think this is a misrepresentation. They would need licensed paramedics, a medical director, and the medical director must carry a separate DEA registration for the storage of ketamine. I have 3 separate DEA's for EMS agencies. We utilize a tracking system that was actually recognized in Congress several years ago when the Protecting Patient Access to Emergency Medications Act was passed in 2017. Oddly enough, this was signed into law by Trump but the DEA has yet to implement it into regulations. Go figure.

 

[wholeheartedly]

I think one concern is that sometimes police push for its use by EMS when it wouldn’t usually be indicated. That was a big area of concern that blew up involving Hennepin a few years back. I‘ve seen that in our own ED, “Just knock him out already.”

 

[MLNS]

I can’t even keep track of the number of terms that cause people offense and emotional distress any more. But I fixed it for you.

Except this is a term that’s been around and abused for quite some time; purposely slinged by crnas and admin to blur the line between physicians and nurses.

I’m not in anes but it would behoove you to learn about it and realize It’s not one of the flimsy terms that fits into the 2020 imoffendedbyeverything crowd.

 

[Tenk]

The thing that I don't understand about a lot of these policies is that EMS ends up giving huge dosages that are totally inappropriate. If anything they should be giving ~300 mg of ketamine IM on most full size adults and then reassessing how that works and giving more if needed.

I have sedated so many combative patients on ketamine it is honestly insane. Not once did I ever need 500 mg. Lights out usually around 300 to 400 at most. The skinny tweaker usually does fine with about 250.

 

[Southpaw]

Anesthesiologist here. @Mr. Hat doesn't appear to respect anesthesiologists or our field of medicine. "Experts". That's fine. No biggie. This isn't my forum so I'm not gonna make waves. He should read his own articles though. The anesthesiologist in question never said that physicians shouldn't give these meds. She's pushing for proper training, which is what we all push for on this forum constantly. Last I checked you all were for appropriate supervision of PAs or NPs in your department. Do you think EMS should be able to run wild giving whatever whenever?

Also, the article posted by @Mr. Hat says a Fire and Rescue squad has given Ketamine 400-500mg IM 25 times in the past 2 years. Meanwhile, there are physicians on this forum who are prior EMS saying they needed chemical rescue a handful of times in 10 years. Something's not adding up. Either Fire and Rescue is overdosing and overusing, the patients have drastically change, or physicians here have poor recall.

Also, you all should watch the video. He wasn't resisting before being given roughly 8.3mg/kg ketamine IM in an untitrated dose. He was catecholamine deplete after crying, vomiting, and being put in a chokehold by officers before passing out. He was otherwise healthy. He had 2 MIs in route to the hospital and died 2 days later. I don't know what to tell you all - if you think policies over ketamine use, and chemical restraint in general, by Aurora Fire and Rescue don't need review then I'd simply disagree.

 

[Rendar5]

Anesthesiologist here. @Mr. Hat doesn't appear to respect anesthesiologists or our field of medicine. "Experts". That's fine. No biggie. This isn't my forum so I'm not gonna make waves. He should read his own articles though. The anesthesiologist in question never said that physicians shouldn't give these meds. She's pushing for proper training, which is what we all push for on this forum constantly. Last I checked you all were for appropriate supervision of PAs or NPs in your department. Do you think EMS should be able to run wild giving whatever whenever?

Also, the article posted by @Mr. Hat says a Fire and Rescue squad has given Ketamine 400-500mg IM 25 times in the past 2 years. Meanwhile, there are physicians on this forum who are prior EMS saying they needed chemical rescue a handful of times in 10 years. Something's not adding up. Either Fire and Rescue is overdosing and overusing, the patients have drastically change, or physicians here have poor recall.

Also, you all should watch the video. He wasn't resisting before being given roughly 8.3mg/kg ketamine IM in an untitrated dose. He was catecholamine deplete after crying, vomiting, and being put in a chokehold by officers before passing out. He was otherwise healthy. He had 2 MIs in route to the hospital and died 2 days later. I don't know what to tell you all - if you think policies over ketamine use, and chemical restraint in general, by Aurora Fire and Rescue don't need review then I'd simply disagree.

3 points:
1. Acute chemical restraint with sedating medications of agitated patients would be considered under EM or Psych expertise moreso than anaesthesia expertise. Not saying you guys aren't experts on sedation in general (I would defer to you as higher experts in this regard), I'm just saying he's correct to consider us more expert than you in this particular patient population in which we are practicing chemical restraint more than we are practicing procedural sedation.

2. Completely besides the point, but what do you mean he had 2 MI's en route to the hospital. That doesn't make any medical sense. You either have 1 MI or you have none.

3. I think we all agree that excessive ketamine dosing is inappropriate and there are times when they are too trigger happy in some areas and may need review by the appropriate agencies or directors.

 

[VA Hopeful Dr]

3 points:
1. Acute chemical restraint with sedating medications of agitated patients would be considered under EM or Psych expertise moreso than anaesthesia expertise. Not saying you guys aren't experts on sedation in general (I would defer to you as higher experts in this regard), I'm just saying he's correct to consider us more expert than you in this particular patient population in which we are practicing chemical restraint more than we are practicing procedural sedation.

2. Completely besides the point, but what do you mean he had 2 MI's en route to the hospital. That doesn't make any medical sense. You either have 1 MI or you have none.

3. I think we all agree that excessive ketamine dosing is inappropriate and there are times when they are too trigger happy in some areas and may need review by the appropriate agencies or directors.

It might just be semantics, but let's say you get an acute thrombus at one site and then 10 minutes later get one at a completely different site. I could see calling that 2 MIs.

Now I'm neither a cardiologist nor an EP so this might be completely wrong.

 

[Apollyon]

Either Fire and Rescue is overdosing and overusing, the patients have drastically change, or physicians here have poor recall.

Or, Occam's Razor - I, for example, may have just sucked at my job!

 

[Southpaw]

3 points:
1. Acute chemical restraint with sedating medications of agitated patients would be considered under EM or Psych expertise moreso than anaesthesia expertise. Not saying you guys aren't experts on sedation in general (I would defer to you as higher experts in this regard), I'm just saying he's correct to consider us more expert than you in this particular patient population in which we are practicing chemical restraint more than we are practicing procedural sedation.

2. Completely besides the point, but what do you mean he had 2 MI's en route to the hospital. That doesn't make any medical sense. You either have 1 MI or you have none.

3. I think we all agree that excessive ketamine dosing is inappropriate and there are times when they are too trigger happy in some areas and may need review by the appropriate agencies or directors.

1. Cool. You're the expert.

2. Thought I read an article at some point somewhere saying '2 MIs in route'. That's what I was referring too and yeah it appears layperson misinterpretation. So yeah, you're right.

3. Agree. OP could've concluded that without specialty bashing. To each their own.

 

[TwoHighways]

Arrhythmia isn’t equivalent to MI. Only glanced through the second article, but where the did two MI’s come from? Highly unlikely in a 23 year old to have one, much less two. Y’all really doctors, or I’m a being trolled?

This particular case should be examined closely. Could have been handled a lot better all the way around and the outcome is tragic, but it’s not a reason to broadly ban the use of sedatives by EMS. Why is there always this push to ban stuff?

 

[Southpaw]

Arrhythmia isn’t equivalent to MI. Only glanced through the second article, but where the did two MI’s come from? Highly unlikely in a 23 year old to have one, much less two. Y’all really doctors, or I’m a being trolled?

This particular case should be examined closely. Could have been handled a lot better all the way around and the outcome is tragic, but it’s not a reason to broadly ban the use of sedatives by EMS. Why is there always this push to ban stuff?

Are you EM? In my anesthesia training we were taught about ketamine being terrible in the catecholamine deplete patient. Elijah was certainly that. In my opinion 1) he didn’t need chemical restraint and 2) given what he went through prior to chemical restraint ketamine was a very bad choice.

There are earlier posts in this thread by EM physicians discussing alternatives to ketamine.

 

[TwoHighways]

Are you EM? In my anesthesia training we were taught about ketamine being terrible in the catecholamine deplete patient. Elijah was certainly that. In my opinion 1) he didn’t need chemical restraint and 2) given what he went through prior to chemical restraint ketamine was a very bad choice.

There are earlier posts in this thread by EM physicians discussing alternatives to ketamine.

I’m a lowly MS0. School starts in a couple weeks. The details of this case warrant a great deal of scrutiny from what I’ve gathered. Remediation minimum and perhaps even termination may be warranted, but I wasn’t there and don’t know all of the details. At face value, it doesn’t reflect well on the medic administering the ketamine. That said, the potential for misuse/abuse isn’t grounds to rob all EMS providers of a valuable tool used to sedate actual excited delirium/aggressive/violent patients.

 

[Rendar5]

3. Agree. OP could've concluded that without specialty bashing.

I feel the same.

 

[WilcoWorld]

Arrhythmia isn’t equivalent to MI. Only glanced through the second article, but where the did two MI’s come from? Highly unlikely in a 23 year old to have one, much less two. Y’all really doctors, or I’m a being trolled?

This particular case should be examined closely. Could have been handled a lot better all the way around and the outcome is tragic, but it’s not a reason to broadly ban the use of sedatives by EMS. Why is there always this push to ban stuff?

There is not "always a push to ban this stuff". The physician in the article was calling for their use to be reviewed. Review =/= banning.

I don't mean to pick on you - you're just the latest example to catch my eye - but I see what happened here and in so many other posts on this forum recently as symptomatic of a problem plaguing our national conversations. Out of defensiveness (I think) when one of our positions is questioned we ratchet up the questioner's inquiry into something they never intended, and that destroys the possibility of rational, productive conversation.

 

[TwoHighways]

@TwoHighways do you have a clinical background in EMS, nursing or something else? You offer a lot of opinions on clinical medicine, which could mislead others implying that you have more experience than you do. Although, maybe you do have more experience than the typical individual that hasn’t even started medical school. I just want to make sure you aren’t accidentally misleading others by giving the impression that you have practiced medicine. I don’t mean to be hard on you, but just want you to consider how you post. You do show some humility at times deferring to physicians which I appreciate.

Humility has never been my strong suit. I did stay at a holiday inn last night...

Deflection aside, I do have a bit of experience and a lot of self education that have shaped my views on a variety of matters pertaining to healthcare as it’s practiced in the USofA. I’m not your typically, starry eyed premed straight out of undergrad.

 

[TwoHighways]

There is not "always a push to ban this stuff". The physician in the article was calling for their use to be reviewed. Review =/= banning.

I don't mean to pick on you - you're just the latest example to catch my eye - but I see what happened here and in so many other posts on this forum recently as symptomatic of a problem plaguing our national conversations. Out of defensiveness (I think) when one of our positions is questioned we ratchet up the questioner's inquiry into something they never intended, and that destroys the possibility of rational, productive conversation.

Fair assessment/criticism. I should have at least read both articles before commenting.

 

[Southpaw]

I appreciate both of your input into this discussion from other fields, but more importantly your respect for us as EPs. Outpatient primary care and anesthesia both have skills that we as EPs don’t. There is overlap for sure, but it isn’t exactly the same. Your terminology might not be how we would describe something as an EP or entirely accurate regarding this patient, but that is ok. You aren’t EPs (and with not having to deal with agitated/combative patients frequently aren’t you glad?! ). None of us really know all of the specific details without any medical records. I just respect you acknowledging our skill set and wanted to relay that. We should respect your skills and abilities too. We can learn from both your areas of expertise.

absolutely. I respect like heck what y’all do. Some of my great friends are EPs. You all have an extremely difficult job and just like us, you’re constantly getting pushed around by hospital administrators and corporate medicine. We need to stick together.