Controversies abound concerning the treatment of people of color and marginalized populations by the police. The extent to which the excited delirium assessment in the prehospital setting is the result of disparate treatment by the police in Colorado cannot be presently quantified. The panel had no data available to establish whether, or the extent to which, for example, “the [excited delirium] diagnosis is … used by law enforcement to legitimize police brutality and to retroactively explain certain deaths occurring in police custody.”[33] Nevertheless, the panel acknowledges that law enforcement actions may sometimes impact prehospital setting medical assessments by EMS providers. Anecdotal evidence exists to establish that police officers have sometimes invoked the term “excited delirium” in the prehospital setting, and that persons in police custody who did not require the drug as an appropriate medical necessity for chemical restraint purposes may have received ketamine. Comparable anecdotal evidence exists to demonstrate that law enforcement has periodically relied upon and cited the excited delirium syndrome to justify its use of excessive force (i.e., physical restraint by taser, carotid hold, and neck and back compression resulting in hypoxia or asphyxia) against the patient.[28(p.6)],
Marginalized populations that are victimized by these biased practices are burdened with resulting physical, mental, social, and economic harms. When the justification for ketamine use in the prehospital setting is motivated by law enforcement reasons rather than by legitimate EMS assessments, the prehospital patient will not have received medication for appropriate medical necessity for chemical restraint purposes.
While most paramedics do not consciously administer disproportionate ketamine doses by race/ethnicity after responding to law enforcement calls for medical assistance, this fact remains: EMS providers are asked and expected to intervene in potentially avoidable custodial situations that may be suffused with explicit or implicit bias before EMS ever arrives on the scene. Such a situation may ultimately involve the administration of ketamine. How EMS should respond to these prehospital encounters is a difficult question that, in the panel’s view, will ideally require EMS agencies and law enforcement authorities to undergo joint education and training in order to avoid ongoing miscalculations and, ultimately, any further harm to patients.
As explained in this report, the panel concludes that ketamine is a safe medication when properly administered and monitored by trained paramedics. While the recommended protocols, indications, monitoring, training, and verbal de-escalation tactics will improve the drug’s safety profile, ketamine is not the root problem that has given rise to the societal issues that we now confront. The panel believes that the structural bias inherent in the ongoing use of the ExDS diagnosis in the prehospital setting will continue to allow ketamine to be disparately used against people of color and marginalized populations for non-medical reasons.
PANEL RECOMMENDATIONS
CDPHE should reject “Excited Delirium Syndrome” as a medical condition that warrants waivers to allow for the administration of ketamine by paramedics in the prehospital setting.
CDPHE and EMPAC should incorporate a Racial Equity Impact Assessment in the ketamine waiver process in line with best practices to ensure that the process minimizes implicit or institutional bias that may affect the ketamine waiver application and approval process.
CDPHE should revise its regulations on continuing education requirements concerning the certification/licensure of EMS providers to include minimum hours in the areas of racial equity and explicit/implicit bias, verbal de-escalation, and patient hand-off protocols.
CDPHE should engage with the national organizations that develop paramedic education standards and advocate that the standards include education in the areas of racial equity, explicit/implicit bias, verbal de-escalation, and law enforcement-to-EMS hand-off protocols. In the meantime, CDPHE should develop training programs in these areas and make them available to all EMS medical directors for the purpose of providing training to EMS medical directors and their providers. Completion of these training programs should be required of EMS medical directors and their paramedics as a condition of obtaining a ketamine waiver.
CDPHE’s data collection processes should capture race/ethnicity and zip code information so that the data can be routinely analyzed to determine whether there is disproportionate use of chemical restraint for marginalized persons and communities of color in Colorado.