Hot Topics in EMS

Written by Eric Jaeger, JD, NRP, EMS IC, July 2024

AP News and PBS Frontline Lethal Restraint Reporting

Over the last several months, the AP News and PBS Frontline have published a series of stories, linked below, on death in custody and the role of EMS sedation. In a multi-year investigation, they uncovered over 1000 deaths across the United States due to lethal restraint involving police and, in some cases, EMS. Chemical sedation by EMS was involved in nearly 100 of these deaths. I encourage you to review these stories; they demonstrate increasing attention on this issue by the public and they reveal that the scope of the issue is larger than previously realized.

PBS Frontline: Documenting Police Use of Force

(note this links to the story where it discusses EMS sedation; for the full documentary click here).

AP News: How the medical syringe became a tool of control when police restrain people

AP News: Dozens of deaths reveal risks of injecting sedatives into people restrained by police

AP News: At least 15 people died in Texas after medics injected sedatives during encounters with police

AP News: At least 16 people died in California after medics injected sedatives during encounters with police

Key Takeaways
 

Large Number of Deaths
This reporting expands significantly the number of individuals who are known to have died after EMS sedation. (Note: We have no reason to believe that sedation was a cause of death in all of these cases; only that the individuals received sedation prior to death.)

Criminal Charges & Civil Liability for EMS Providers

Two paramedics have been found guilty in a criminal trial involving use of ketamine. Prosecutors seem more willing to hold paramedics and police officers criminally liable for their conduct. In addition, dozens of EMS providers and agencies have been the subject of civil lawsuits arising from deaths in custody, with payouts of over $100 million.

Increased Public Attention and Scrutiny

While the AP News and PBS Frontline stories are the largest reporting project on this topic, many other reporters across the country are now focusing on issues related to death in custody and the role of sedation by EMS.

It's NOT the Ketamine; The Problem is the Overall Approach to Prehospital Sedation 
While 20% of the deaths involved ketamine, nearly 50% involved midazolam. This leads to the conclusion that the problem is not ketamine per se, but rather our overall approach to prehospital sedation.

I strongly believe that to address these issues, we must radically reframe the approach to prehospital chemical sedation. Protocols for physical restraint and chemical sedation should be rewritten (not just tweaked). And all EMS providers should receive updated training that focuses on prehospital sedation as a deliberate, protocolized procedure, following the model of RSI or ED procedural sedation. While classroom training is helpful, in my experience hands-on simulations are key to helping EMS providers relearn the approach to this important topic.

I'm continuing to focus on this topic, including providing virtual and in-person training at agencies and EMS conferences across the country. Please let me know if you are aware of speaking opportunities that might be appropriate. And please reach out if I can be helpful in any way.

For more on this topic check out Dr. Jeff Nusbaum’s talk here.

IV Nitroglycerin CPG

IV Pump CPG

https://useagles.org/teammembers/robert-lowe-3/

Protocol Link

Dextrose

https://www.ncbi.nlm.nih.gov/pubmed/2029097

https://www.ncbi.nlm.nih.gov/pubmed/17763842

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415309/

https://www.ems1.com/cardiac-care/articles/prove-it-administering-dextrose-during-cardiac-arrest-improves-outcomes-9FP6hslyU2OFNrCX/

https://www.foamfrat.com/post/hypoglycemia-in-cardiac-arrest

Ketamine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9014273/

https://www.sciencedirect.com/science/article/abs/pii/S0300957217300394

https://pubmed.ncbi.nlm.nih.gov/35586308/

https://www.cfp.ca/content/64/7/514.short

https://pubmed.ncbi.nlm.nih.gov/15928464/

https://www.webmd.com/heart-disease/what-to-know-agonal-breathing

https://www.mdpi.com/1660-4601/20/4/3654

Click below to see:

What the hospitals see

MCFRS 5-minute drill

Guide for the EMS Duty Officer