Paramedic clinical practice relies heavily on protocols, which are written standards for patient medical assessment and management. In accordance with regulation, EMS medical directors approve and direct paramedic practices through protocols and standing orders. The current EMS agency protocols regarding ketamine use for excited delirium and/or extreme or profound agitation typically describe positive and negative aspects relating to the waivered medication, such as indications for use, contraindications, dosing, and adverse events. Some but not all of these protocols also refer to other related protocols, such as the medical measures EMS providers should take to address behavioral health emergencies.
The panel agrees that CDPHE should require EMS medical directors to incorporate the relevant recommendations concerning different aspects of ketamine administration into protocols. The panel firmly believes that establishing protocols specific to the relevant chemical restraint elements will limit the impact of a paramedic’s assumptions and biases that may negatively affect clinical decision making when working with difficult patients. All of these protocols should be thought of as an integrated set of standards that operate holistically and should clearly cross-reference each other so that paramedics understand how they are interrelated and when to use them. Guidance concerning cross-referencing of protocols can be found at National Model EMS Clinical Guidelines. [63]