As EMS medical directors in the Twin Cities, we want members of the public to understand all the factors that must be considered — and the care we take in our work.

By Jeffrey Ho, Charlie Lick, John Lyng, Marc Conterato, Paul Nystrom and Kevin Sipprell

June 19, 2018 at 11:00PM

iStock (The Minnesota Star Tribune)

As medical directors of the five advanced life support 911 Emergency Medical Services (EMS) systems operating in Hennepin County, we feel it is important that we respond to recent concerns raised about the use of ketamine in emergencies with law enforcement present (Star Tribune coverage: June 15, 16, 17 and 19; see tinyurl.com/st-ketamine).

The use of ketamine, as a safe and effective option for sedating patients in a crisis state in emergencies, is well-documented in medical and scientific literature. Emergency medicine physicians at Hennepin Healthcare are leaders in the research behind safe medical sedation and ketamine use, and our EMS systems are considered national and international leaders in prehospital sedation for agitation. We all are experiencing higher call volume and responding to an increased level of agitation due to the rise in drug abuse and mental health emergencies. The use of ketamine in emergency situations by EMS professionals has saved lives in our local communities and around the world.

The writers of a recent city of Minneapolis draft report suggest that an issue may exist with how medical sedation is provided to patients experiencing serious distress or agitation. The safety of patients is paramount and foremost in the minds of our paramedics as they respond to what are often very dangerous and difficult situations. The decision to use ketamine in a crisis to stabilize an individual is a medical one that is made by the paramedic to prevent injuries and even save a person's life. Sedation is not, and should never be, used as a consequence of a perceived crime, as implied by the draft report. Any patient who receives sedation is transported only to an emergency department as a receiving destination.

The physical response to a crisis on a person's health and body can be life-threatening. Allowing uncontrolled exertion and agitation to continue can lead to a high-risk situation for the patient called metabolic acidosis — the buildup of waste products in the body. At its most extreme, agitation can become a condition of "excited delirium," which is a life-threatening syndrome recognized by the American Academy of Emergency Medicine and the American College of Emergency Physicians. When left unchecked and untreated, the outcome is often death. Treatment with a sedative is a time-sensitive response.

Of the available sedatives in our EMS system, ketamine is often the best choice based on the patient's behavior, the severity of agitation, the timing, the risk of a patient causing self-injury even after physical restraints have been applied and other medical considerations.

The choice of medical sedation in these challenging situations requires EMS professionals to balance all of the risks and benefits quickly. It is difficult to accurately capture the true state of a patient during an emergency or a behavioral health crisis from only a partial view of the situation. While it may appear that a patient is physically calm at certain points during a crisis situation — even after physical restraints have been applied — the patient may not be fully stabilized and could still be at risk of causing further harm to themselves or others.

As national leaders in emergency medical prehospital care, we are committed to acting in the best interest of the communities we serve and to treating our patients with respect. We understand that the questions raised in this draft report are concerning, and the disparaging statements made by EMS staff and police in no way reflect the values of our local EMS systems and will be addressed. However, the conclusions about ketamine in this draft report were made without consulting medical professionals. Not fully understanding the complex and dynamic decisionmaking by EMS professionals when deciding to sedate someone in a medical crisis can lead to misunderstandings about the circumstances involved. It can also lead to public mistrust of a lifesaving treatment that could hurt the ability of EMS personnel to protect lives in crisis situations.

Therefore, we believe it is critical that an independent review of the use of ketamine is conducted that includes the medical evidence and research in its findings. As EMS professionals who go to work every day to protect lives, we are fully committed to ensuring that our practices are safe and that they meet the standards of care and the protocols that guide us. We are fully committed to working with our public safety partners and providing accurate, verifiable information to the community about how we perform our duties.

Dr. Jeffrey Ho is chief medical director for Hennepin EMS. Dr. Charlie Lick is medical director for Allina EMS. Drs. John Lyng and Marc Conterato are co-medical directors for North Memorial Health Ambulance. Dr. Paul Nystrom is medical director for Edina Fire and EMS. Dr. Kevin Sipprell is medical director for Ridgeview Ambulance.