So, I wanted to have a level-headed discussion about this case. I’ve been loosely following it since it happened, and I’m curious to see what others think of it, perhaps hear from folks who followed it more closely.
For those out of the loop, here’s the JEMS article on it: https://www.jems.com/patient-care/two-co-paramedics-found-guilty-in-death-of-elijah-mcclain/
The tl;Dr is this: Aurora fire medics are dispatched to assist Aurora PD with a combative patient they believe is in an altered mental state. Aurora FD EMS crews identify this patient as qualifying for their excited delirium protocol based on PD and patient presentation, and administer the maximum dose of ketamine allowed under their weight-based dosing (which was well over what Elijah weighed). Now, there’s other details (this IS a tldr), but after the ketamine, the patient goes into respiratory and cardiac arrest and is eventually declared. The paramedics involved were found guilty of negligent homicide. The FD has stood by their paramedics, saying that they followed their policies appropriately.
Let me lead with this: it seems to me that McClain’s case was a foreseeable (albeit low likelihood) and unfortunate outcome that was the cumulative result of many lesser individual poor choices on the part of both law enforcement and EMS. We lack the personal context to really appreciate those choices, I think, and we’re left to armchair quarterback those decisions with only the information available to us. I do believe that Mr. McClain should still be alive, and likely would be under different systems-level conditions, such as training and clearly defined interdepartmental operations protocols. Personally, I disagree with the conviction based off of my current understanding of the situation. My current understanding of the facts does not persuade me of the presence of gross, nevermind criminal, negligence on the part of the EMS crew. There absolutely is a conversation to be had here about PD leveraging field sedation and integrating field emergency care as a compliance and law enforcement tool as opposed to a healthcare response to a medical emergency. There’s another conversation to be had about systems-level choices that likely influenced this outcome. I think that just throwing these guys in jail fails to accomplish anything on those fronts, and, as such, is a false justice.
So, I’d like to ask you guys for your thoughts. Was it preventable? Was the conviction helpful? What can be done to prevent this in future, if anything, and what’s your take-away?
a: patients shouldn’t be administered ketamine against their will… btw that excited delirium could be from some other drug that interacts.
b: if you’re going to ignore that, don’t go for the maximum dosage per estimated weight… go for say, half of that and see what happens.
c: that drug has some very hallucinogenic properties before knocking you out… and can make you trip out while not being able to move… there’s probably something less psychologically scarring to sedate people with.
Hey, thanks for sharing your thoughts. Just so I know where to meet you at, do you work in EMS? Because we could get into some technical details that might not be helpful or accessible to someone outside the field.
Some quick thoughts, though:
A. It’s fairly common that we have to medicate patients without their consent. For example, someone suffering an opiate overdose is incapable of consenting to getting narcan; there are other times where patients may be in an alert but confused state that necessitates treatment while they’re not competent to assess the risks and benefits or refusing or accepting care. When I worked in a metro area, we got a decent amount of combative patients who were too confused to make their own healthcare decisions, but needed to receive treatment, including physical and chemical restraints, to stop harm to themselves or others. Somebody having a medical event that’s causing them to be confused and combative (I’m speaking generally here, not about Elijah) is usually not someone you’re going to be able to have a rational discussion with about whether they consent to getting some medicine to help them calm down. In my experience, the decision to medicate is not typically done at the request or order of police officers, and is more of a judgment call between the paramedic and the base hospital doctor they call in to; which is where I think Aurora has terrible policy, because it seems like they were deciding to medicate to support the police in their job. There is no room for cops in a provider-patient relationship, imo; the patient needs what the patient needs in order to preserve their life and come to no further harm, nothing more, nothing less, and that definitely shouldn’t be dictated by someone who isn’t a healthcare professional.
B. We don’t have scales in the field, and I don’t know if you’ve ever tried to weigh someone while they try to fight you, but it doesn’t work well. Estimated weights are what we have if the patient can’t/won’t talk to us and nobody else knows, that’s just how it goes. What I will say is that Elijah McClain was 140 lbs (that’s ~65 kg, rounding by fives), and him getting the full weight dose seems wildly inappropriate. I have a hard time imagining how that paramedic looked at a 5’6" 140 lb man and said “yeah, that’s about 100 kgs”; my guess is they either wanted to really knock him on his ass and rounded up (bad), they asked the cops and the cops lied their ass off (why would you ask the cops for a weight?!), or they were just lazy and went with a dose they knew (also terrible). It IS possible they just screwed up and really believed he was that big, but I find that a little difficult to believe because it’s such a huge weight discrepancy.
EDIT: According to this article: https://www.cbsnews.com/colorado/news/colorado-jurors-watch-recorded-testimony-aurora-paramedics-accused-death-elijah-mcclain/ The paramedic makes a few claims that seem a little strange to me. First, that the five CC strangers don’t have adequate markings for delivering a well-measured dose. All of the 5cc syringes I’ve used for drug administration are marked out to 1/5cc precision, which should have been sufficient; and if it wasn’t, they should have used a different syringe or not given the medicine until they felt they could do so appropriately. Then, he claims that they’re taught to give either 300, 400, or 500 mg based on whether the person looks small, medium, or large. That doesn’t seem consistent with any clinical education program I’ve ever been to. Lastly, he reported that he estimated that Elijah was 200 lbs and roughly 6 feet or “big”, and that since he was over the 400 mg mark, he just rounded up to 500. At 5 mg/kg, ~65 kg, an appropriate dose would have been 325 mg, not 400, definitely not 500. The paramedic fucked up here, no bones about it. I still believe that the system never should have put medical providers into this relationship with the police in the first place. If the cops want tactical sedatives, let them take that up with the FDA and DOJ, leave us the fuck out of it. After reading up a little more, though, it’s clear that the paramedic really screwed up the weight estimate. I’m willing to accept some leeway for the fact that the scene was hectic and it may not have been exactly easy to estimate his size, but they nearly doubled the weight estimate, which seems like a pretty extraordinary screw up.
If there’s any basis for convicting the paramedic, this really terrible estimate is it. Now, as for just trying half the dose and seeing what happens, that’s something we can’t do. Paramedics cannot practice medicine except under a doctor’s license, so we have written orders from doctors that indicate what we can do and how we can do it. If we just go wild catting half doses without any kind of physician guidance, that’s practicing medicine without a license and you can get in very serious trouble about that.
C. Ambulances are not ERs. We have a pretty narrow set of choices for treating any given problem, and the way those choices are applied are often firmly dictated by protocols or physician guidance. The crew may not have had other options for chemical restraint.
Broad strokes, I think the crew fucked up by using a weight estimate that should have been obviously inappropriate. However I also think that this is just throwing the crew under the bus to save a system that deserves a kick in the teeth too. Basically giving people ketamine because the cops decided to fight them is terrible practice, and, imo, fire administrative staff, law enforcement administrative staff, and the local medical director (who writes the protocols for Aurora Fire/EMS) bear a share of the blame that is at least as large as the EMS crew’s for even setting up the system to have allowed this to happen in the first place.