Is Ketamine Really the Most Dangerous Thing in our Drug Bags?

In November of 2017 Philadelphia Flyers defenceman Radko Gudas delivered a savage slash to the head of Jets forward Matthieu Perrault. The incident had the potential to cause serious, permanent injury to Perrault. It was a risky, dangerous act. In December of the same year, Nurse RaDonda Vaught worked a shift at Vanderbilt University Medical Center in Tennessee.  Her fate collided in epic fashion with that of patient Charlene Murphey when Vaught bypassed numerous process safeguards and administered an intravenous dose of the paralytic medication vecuronium bromide instead of the sedative Versed which had been ordered for Murphey. Murphey was paralyzed, but remained alert while she suffocated and died, unable to move, breathe, or call for help. Like Gudas' slash, Vaught's medication error was careless and dangerous. Death resulted in one case and a career-ending inury was narrowly avoided in the other. In the wake of these happenings, Gudas was suspended for 10 games and lost $408,000 in salary, and Vaught was fired and now faces a criminal charge of reckless homicide. Interestingly, neither hockey sticks nor vecuronium bromide were investigated or banned. The individual actors, not the tools, were held accountable for the respective outcomes.

Fast forward to August 2019 in the City of Aurora, Colorado. Police are called for the report of a suspicious person walking down the street wearing a ski mask. Aurora P.D. arrives and encounters Mr. Elijah McClain, an unarmed black man. During the ensuing moments police decide to arrest McClain who struggles with the officers in response. They use restraint tactics including a "carotid hold"  to subdue Elijah, and in the aftermath summon EMS in the form of the City of Aurora Fire Department. At some point the paramedics elect to administer the sedative ketamine to Mr. McClain. He suffers a cardiac arrest in the ambulance and subsequently dies a few days later. The autopsy reports indicate that cause of death cannot be definitively determined, but an adverse reaction to ketamine cannot be “ruled out.” (By definition an undetermined cause of death cannot rule out myriad possibilities, but I digress)

There were numerous police officers and EMS personnel on scene that evening who had contact with Elijah. It is unclear what specifically happened while the police wrestled with McClain other than the previously mentioned "carotid hold" (a Law Enforcement euphemism for "choke-hold”). Any number of factors could have contributed to the tragic outcome and even a medical examiner is clueless as to why McClain died.

To be sure, ketamine has a fairly good safety profile. It is used in operating rooms all around the world as part of the anesthetization process. A 2018 report by the World Federation of Societies of Anesthesiologists sang the praises of ketamine citing:

• Ketamine has specific advantages over some of the other sedative and anaesthetic agents. Airway reflexes and tone are often preserved during ketamine sedation and it has an excellent haemodynamic profile. 
•  Ketamine has a unique role in prehospital, emergency and critical care medicine and is commonly used by anaesthetists all over the world. 
•  Research has suggested that use of optical isomers of ketamine may help reduce unwanted side effects. 
•  Ketamine appears to have beneficial anti-inflammatory, bronchodilatory and neuroprotective properties. 

Based on this, ketamine is exactly the tool one would want when dealing with violent subjects with altered mental status. Yet in a disturbing trend of blaming outcomes on tools rather than the people using said tools, the City Council of Aurora has elected to ban the use of ketamine pending the outcome of McClain's case. This author implores the reader to deeply consider this; a group of politicians is venturing to dictate emergency medical procedures- to people with actual medical training.

Though disappointing and concerning, this probably shouldn’t be surprising in 2020 USA. Aurora's City Council is simply following the spreading creep of "cancel culture," wherein self-righteous virtue signalers make knee-jerk reactions in the name of social justice. Aurora is actually a prime example of virtue signalers in that they collectively have no expertise whatsoever in the industry which is affected by their decision - in this case emergency medicine. 

Expectedly there is not a single physician on the City Council. Not even a nurse or a paramedic. They do boast an architect and "proud cat dad," a member of the National Organization to Insure (sic) a Sound-Controlled Environment (NOISE), and a woman who works with adults with developmental disabilities. In an entertaining stroke of irony they also have At Large member Allison Hiltz whose bio states her "expertise is in the application of evidence-based policy-making."

There is no evidence supporting the notion that ketamine caused or even contributed to McClain’s death aside from the fact that it happened to be administered to him that night. True, the alleged dose (500mg) of ketamine was above the correct dose for McClain’s weight, but even if that dosing was shown to have directly caused McClain’s death, the problem is not the tool, it’s the user. Like vecuronium and hockey sticks, ketamine isn’t the bad guy here.

EMS providers carry a vast array of tools and medications which, if used improperly, could cause injury or death. An overdose of cardizem or epinephrine could easily put a patient into cardiac arrest. A poorly placed airway could result in anoxia and brain-death. Additionally any of the medications we routinely administer can cause untoward effects in certain patients who are sensitive to those medications. We train to look for and deal with both spontaneous and iatrogenic life-threats which makes the administration of medications in the prehospital setting very safe. Combined with protocols and orders provided by actual physicians who are practicing evidence-based medicine, it's very difficult to believe that we've suddenly, after at least a decade of using ketamine to treat extreme psycho-motor agitation, realized that we're carrying a terrifyingly deadly tincture in our ambulances. Again, studies as recent as January of 2020 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081852/) have established ketamine as a very safe agent in the treatment of excited delirium.

Unfortunately the Aurora ban persists unscathed by actual science, and is igniting undue controversy nation-wide over a very useful emergency medication. In the meantime EMS providers in Aurora are now without a sedative agent which, ironically, helps to stop psychomotor agitation - agitation that invariably necessitates an aggressive, hands-on approach to control and restraint by police officers. In the wake of George Floyd et al, you’d think cooler heads would prevail. All evidence to the contrary. 

No, ketamine is not a bullet, but in our current culture facts may not stop politicians from shooting themselves in the foot.