The recent media report about the use of ketamine in restrained patients contains a few poorly drawn implications and a couple of lessons for line personnel, resulting in a public relations nightmare for the EMS agency involved.
Ketamine is a selective NMDA receptor antagonist. It induces a trance-like mental state quickly. Ketamine has also been shown to help relieve pain and maintain sedation. Unlike many narcotics, ketamine has few clinical side effects, with some patients reporting disturbing sensations when reawakening. Because of its safety profile, ketamine has been effectively used to manage violent patients who pose a risk of physical harm to themselves or to the clinicians who are trying to help them.
Top Takeaways on managing patient, provider risk
Managing violent patients is a challenge under any circumstances. Many EMS system protocols prohibit transporting patients in hand cuffs or other forms of hard restraints, and providers must resort to soft restraints to help keep a violent patient safe. Without sedation, these patients can harm to themselves, up to and including cardiac arrest in significant excited delirium. As a practitioner, I have seen patients who have broken soft restraints, dislocated shoulders and experienced serious derangements of blood pressure and heart rate.
The report provides an alternative view of these situations that, at first read, appears to paint a less flattering view of ketamine use by EMS personnel. Here are my top three takeaways from the report:
1. EMS does not blindly follow LE orders
First, it’s unlikely that EMS professionals blindly follow orders by law enforcement officers regarding a medical procedure. Clinical guidelines provide the framework for the administration of any medication in the out of hospital setting.
2. Ketamine administration is based on clinical, not criminal presentation
Second, ketamine is not administered to individuals because they are suspected of committing a crime. However, if there are stimulants or hallucinogens in the suspect’s blood stream that are causing a highly agitated state during which a crime is committed, the use of ketamine is a safe alternative to more significant, and potentially more harmful methods of control.
3. Restraints may be necessary to administer ketamine
Next, there is an implication that giving a patient ketamine after they have been restrained is somehow unwarranted. In the absence of some type of blow dart mechanism of injection, I’m not sure how else EMS providers are to administer the medication in a relatively safe manner. Hard restraints employed by law enforcement are a rapid and safe method of providing immediate control and helps to render a violent situation safer. Administering ketamine will create a safer approach to transferring a patient from the hard LE restraints to the soft restraints for EMS transport.
Moreover, the inference that somehow patients are suddenly docile or cooperative after being physically restrained is false. Patients continue to struggle, fight and resist efforts to calm down while in an agitated state. What is likely unreported is the dangerously hypertensive and tachycardia clinical state these patients are experiencing and unable to control in these situations.
What we can learn from the media portrayal of ketamine administration
There are other issues with this report. However, there are a few lessons that EMS providers should take from this article:
- Document everything. Documentation in these situations must be extensive. I’m certain that the patient care reports provide adequate recording of the circumstances requiring ketamine administration:
- Why was the patient sedated?
- What was the order of control?
- What were the patient’s observable condition and vital signs before and after restraint?
- What were the reassessment findings?
- What was not/could not be recorded or assessed due to the clinical presentation?
- Maintain professionalism at all times. The increasing use of recording devices by public safety personnel increases the likelihood that comments and actions can be taken out of context. A three-second audio clip does not reflect the 45 to 60 minutes of patient contact time with violent patients. Maintain professional communication and behavior at all times, even under these highly stressful situations.
