KIRP Letter to the CDPHE Executive Director

December 1, 2021
Jill Hunsaker Ryan, MPH
Executive Director
Colorado Department of Public Health & Environment
4300 E Cherry Creek South Drive
Denver, CO 80246


Dear Director Ryan,

I would like to present to you the final report of the Ketamine Investigatory Review Panel (KIRP or panel). This is the panel of seven external medical experts that I convened at your direction to review the ketamine waiver program of the Colorado Department of Public Health & Environment (CDPHE).  I asked this panel to provide recommendations on the indications for ketamine use, the safety and dosing of this drug, the patient-side care that should be given to someone who has received ketamine, the education and training of EMS providers necessary to use this drug, and the oversight of the EMS workforce by local ground ambulance agencies and the state.  This review process has led to many new insights regarding the care of the extremely agitated patient in the prehospital setting.    

Imagine for a moment that law enforcement calls EMS to a scene to care for an extremely agitated individual, bleeding from a wound on their head, disoriented, mumbling incoherently, combative and not following the directions of law enforcement.  Attempts by the police to calm the patient through verbal de-escalation have failed. The paramedics are faced with the question of what to do next: the paramedic needs to assess, treat and likely transport this patient to a local hospital, yet the medical/mental condition of the patient is causing their resistance to care.  This is the difficult, tense prehospital care issue that the panel wrestled with.  Some of their findings include:

  • The basic education for an EMS provider is packed with many courses, none of which historically focused on the tools necessary to manage this situation, including verbal de-escalation, formal hand-off from law enforcement, implicit bias, and the appropriate assessment and monitoring of ketamine use for chemical restraint.  
  • The diagnosis of Excited Delirium Syndrome, used by EMS medical directors to describe a medical condition of hyper agitation and increased metabolic output, is rejected by the panel as prone to implicit bias and racism.  
  • The panel reframed the use of ketamine as an important tool for those rare times that verbal de-escalation and physical restraint fail and chemical restraint is required.  Referencing existing Colorado laws and protections to determine when and how to use this drug for chemical restraint, the KIRP feels there will be times when it is needed to safely assess, treat and transport a patient. The panel concludes that ketamine is a safe drug to use for chemical restraint when proper monitoring by adequately trained personnel occurs. 
  • Once a paramedic decides to use ketamine for chemical restraint, the panel recommends a series of precautions and steps to assure the best outcome for the patient.  The panel’s recommendations include defining a standard dose of ketamine to assure the necessary disassociated state is achieved, coupled with the immediate monitoring of respiratory and cardiac functions at the patient’s side, not waiting until the patient is in the back of the ambulance. The use of standard doses can save time and allow the paramedic to concentrate on getting the monitoring equipment in place rather than on estimating weights and calculating doses, two steps that are susceptible to error.   
  • In reviewing the existing oversight of EMS care in Colorado, the panel learned that ours is one of only two states in the nation that do not license ground ambulance agencies at the state level.  The Department is limited in its ability to investigate a complaint or assure consumer protections of medical care in the current Colorado EMS regulatory framework. The panel recommends that CDPHE consider whether licensing at the state level would allow for more uniform standards, protocols and regulatory oversight throughout the state in order to assure appropriate consumer protections.

As you know, all waivers for the use of ketamine for excited delirium syndrome in Colorado have been suspended.  In terms of next steps, CDPHE will need to consider the recommendations by this panel, as well as the legal requirements for ketamine administration, monitoring, and reporting established by HB 21-1251. We will then seek input from the community, other medical experts and EMS providers to determine whether ketamine use should be allowed in Colorado in limited circumstances, with stricter protocols, enhanced training and more oversight. 
Thank you,

Eric K. France MD, MSPH, MBA
Chief Medical Officer
Colorado Department of Public Health & Environment