Racial bias in policing and emergency response is a critical issue that deserves our concern. With that in mind, the Star Tribune’s reporting on the Hennepin Healthcare ketamine situation has overlooked several critical points, in particular the potential of sedation research and ketamine to save the lives of some of our most marginalized and underprotected citizens.
In “Hospital suspends ketamine study” (June 26), state Sen. Jeff Hayden and Hennepin County Commissioner Peter McLaughlin said in a statement that “an urban hospital that treats a large number of people of color and low-income Minnesotans must take extra care.” In the same report, they refer to the studies on prehospital sedation as “unconscionable and unethical.”
As an emergency physician and a medical toxicologist, I routinely see the power of ketamine when those with mental health and substance use disorders are profoundly agitated. While there are many aspects of this scandal that should be addressed, I want to urge the Star Tribune and its readers to consider that ketamine is a lifesaving drug and that research on its use in emergency settings is critically important.
Patients who are profoundly agitated (that is, are distressed to the point of escalating physical aggression) are at substantial risk of sudden death. Most are under the influence of excitatory drugs (such as cocaine) or have an untreated mental illness. Additionally, research suggests these patients are more often young, male and African-American — a pattern that may have as much to do with race-based stressors and racial profiling as any inherent difference.
Mortality is estimated to be between 8 percent and 16 percent. During periods of severe agitation, patients have an excess of excitatory chemicals that together cause an increase in heart rate, blood pressure and temperature. This hyperthermia is further exacerbated by increased muscle activity (fighting against physical restraints), leading to seizures, unstable heart rhythms and multisystem organ failure. Deaths in this manner have been reported for many years.
Therefore, in the profoundly agitated, restraint without sedation is not only poor patient care — it can also be a death sentence. Research at Hennepin Healthcare has helped to show that ketamine quickly and safely improves severe agitation when compared with traditional medications.
Prehospital medicine is a messy and dangerous field. Paramedics respond to unfamiliar places and frequently to unsafe scenes, and they must rapidly assess the condition of individuals who are often under the influence of drugs or alcohol or who are suffering from untreated mental illness. Decisions must be made quickly to protect the patients, bystanders and the emergency providers themselves.
And while racial bias can and does play a role and should be addressed through training, it is (to borrow a phrase from Commissioner McLaughlin) unethical and unconscionable to wait to provide potentially lifesaving treatment to patients because they are unable to provide informed consent. In the same way, a patient who suffers a cardiac arrest at the grocery store should not have CPR withheld until consent is obtained.
Over the next several months, we undoubtedly will be presented with stories of police officers appearing to act outside their scope of practice and encouraging the use of sedatives in the profoundly agitated. We may also hear stories of medics giving sedatives to individuals who even experienced physicians may feel never needed sedation in the first place. In the same way, we have all heard of bad doctors, bad politicians, bad kindergarten teachers and others doing reprehensible things in the course of their work.
In response, as a community, we need to decide whether to implicate ketamine as well and thus take away a vital tool for prehospital providers, a tool used to protect the lives of those who often are the most overlooked and underprotected members of our society — those with mental health and substance use disorders. Instead of rolling the issue up into the simmering discontent surrounding the Minneapolis Police Department, we should be recognizing the research that has been done at Hennepin Health that has already saved innumerable lives.
Sean Boley, of St. Paul, is an emergency physician.