As state and federal inquiries widen into the case of Elijah McClain, a young Black man who died last summer after Colorado police placed him in a chokehold, the decision by paramedics to inject him with a powerful sedative while he was handcuffed has raised questions about its use during police calls and whether such medical treatment violates a person's rights.
Fire and emergency medical services officials in the Denver suburb of Aurora have said a preliminary review found that medics' actions on the night police detained McClain, 23, were "consistent and aligned with our established protocols." But some medical and legal experts worry that ketamine — or any form of an anesthetic — raises too many unknowns and that it should not be used to subdue someone in a police action.
"Why anyone would be giving ketamine in that circumstance is beyond me," said neuroscientist Carl Hart, chair of Columbia University's psychology department. "The major problem here is we should never be ordering any medication, and no one should be taking or given it against their will."
McClain's death has drawn new attention amid high-profile fatal encounters involving law enforcement against Black Americans, leading to protests. Colorado Gov. Jared Polis has appointed a special prosecutor to re-evaluate the case.
Just after 10:30 p.m. on Aug. 24, McClain, a massage therapist, was buying iced tea from a corner store, his family said. They said he wore ski masks because he had a blood condition that made him feel cold.
Three Aurora police officers were called to the area on a report of a suspicious person wearing a mask and waving his arms.
Bodycam video showed officers ordering McClain to stop. He responded that he was an introvert and to "please respect the boundaries that I am speaking."
After questioning him, the officers grabbed McClain. Then one of them said he believed McClain had reached for one of their holstered guns, and McClain was brought to the ground. Police said in a statement that he "resisted contact, a struggle ensued, and he was taken into custody."
The officers took McClain to the ground using a carotid control hold, a type of chokehold meant to restrict blood to the brain to render a person unconscious. Aurora police banned carotid control holds last month, and chokeholds have been prohibited by police departments across the country in the wake of the death in May of George Floyd, a Black man pinned by his neck while in Minneapolis police custody.
McClain "briefly went unconscious," according to a report the local district attorney, Dave Young, completed last fall. McClain could also be heard in the police video telling the officers, "I can't breathe, please," and he vomited while he was on the ground.
A medic told officers that "when the ambulance gets here, we're going to go ahead and give him some ketamine."
The officers responded, "Sounds good," and they told the medic that McClain appeared to be "on" something and that he had "incredible strength."
An Aurora Fire Rescue medic injected McClain with 500 milligrams of ketamine, according to the district attorney's report.
The coroner found that McClain's death was due to "undetermined causes," and according to Young's report, the "evidence does not support the prosecution of a homicide." McClain had marijuana in his system along with the ketamine, which the coroner suggested was a "therapeutic level."
But the coroner did not rule out that the chokehold, in addition to the ketamine, might have contributed to his death.
"Although there is no evidence to support ketamine overdose," according to Young's report, the coroner "could not exclude the possibility that Mr. McClain suffered from an unexpected reaction to the drug."
The medic at the scene estimated that McClain weighed 220 pounds, Young's report said. But the coroner said he was 5 feet, 6 inches tall and weighed 140 pounds.
According to documents shared by Aurora Fire Rescue, the standard dose of ketamine is 5 milligrams per each kilogram of a person's weight. That would mean that instead of 500 milligrams of ketamine, McClain should have received about 320 milligrams.
The ketamine was given via syringe into his right shoulder, according to Young's report.
"After approximately two to three minutes, Mr. McClain calmed down," the report said. "He was placed on a gurney, his handcuffs were removed, and he was placed into soft restraints ... and loaded into the ambulance."
About seven minutes after he received the ketamine, McClain had no pulse in the ambulance and went into cardiac arrest, the report said. Medics were able to revive him, but he was later declared brain dead, and he was taken off life support less than a week later.
Young declined to press charges.
"Under the circumstances of this investigation, it is improbable for the prosecution to prove cause of death beyond a reasonable doubt to a jury," Young wrote in a letter to Aurora's police chief.
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Mari Newman, an attorney for McClain's family, said that the ketamine was unnecessary and that she wants a thorough investigation.
"The Aurora medics had no right to inject Elijah with ketamine at all," she said. "He was handcuffed, crushed against the ground by officers much larger then he was, and he was not fighting. He was begging for his life, vomiting and trying to breathe. And they certainly had no right to involuntary inject him with a dose intended for someone over twice his size."
City officials in Aurora on Thursday announced an independent review of the McClain case, and it is expected to include "a team of experts who will thoroughly examine the actions of Aurora police, firefighters and paramedics in the case."
According to a news release, Mayor Mike Coffman said "it is imperative that the city moves forward quickly and urgently with this investigation to provide answers to the community."
What does ketamine do?
Ketamine, if administered properly, can be safe, said Jason Varin, an assistant professor at the University of Minnesota College of Pharmacy.
In lower doses, it can be used to treat acute pain, Varin said, while at higher doses, it becomes a dissociative anesthetic, which means that not only does it help physically, but that a person's reality — feelings, thoughts and understanding of what is occurring — is also "disconnected" and he or she may have limited memory of what is happening.
Ketamine is known as the street drug "Special K" because of how it induces a trancelike state, which is often referred to as a "K-hole." Variations of ketamine have been approved by the Food and Drug Administration to treat depression.
"It is, like many drugs, quite mysterious as to how it works in some cases," Varin said.
Ketamine may be dangerous to people who suffer liver failure, he added, and it can affect blood pressure, cause rapid heart rate or an irregular heartbeat, prompt seizures or muscle twitching, and induce extreme anxiety or hallucinations as a person comes out of it.
Ketamine is most commonly used by veterinarians on animals and as an anesthetic in some surgical procedures on people. During police-related calls, however, medics may not have the full scope of a person's medical history to anticipate how they will react to it.
"Since it is highly unlikely they can tell the state of health of the individual or if they have non-prescribed drugs, alcohol or prescription medications ... these combination of risks could cause any number of problems, including respiratory depression and cardiac arrest," Varin said.
The department began using the medication in January 2019, KDVR-TV of Denver reported in October.
Sherri Jo Stowell, a spokeswoman for Aurora Fire Rescue, told NBC News on Friday that ketamine had been used 18 times in 2019 and at least twice in 2020. She said the use of any medication is reviewed by trained professionals.
"Aurora Fire Rescue is sympathetic to the pain that members of Aurora's community, especially Elijah's loved ones, are experiencing," the department said in a statement last month. "For the sake of progress and healing, our department welcomes the attention the incident is receiving including the forthcoming independent investigation."
In Colorado, EMS providers are permitted to use ketamine for pain management and to treat a syndrome known as "excited delirium," but they must first obtain a waiver from the state health department.
It is not uncommon for medics to use ketamine outside hospital settings to treat patients who appear agitated and may harm themselves or others, according to the state.
In the same month McClain was provided ketamine, a 25-year-old man in another Denver suburb was given a 750-milligram, two-dose injection of the drug during a police encounter, KDVR reported. The state health department said last week that it is investigating the case.
Aurora police spokeswoman Faith Goodrich said officers are not involved in ordering or administering ketamine, which is left to the discretion of a medic.
Hart, the neuroscientist, said that given the amount of ketamine McClain is known to have received, "I am certain that he thought he was losing his mind."
Ketamine use for excited delirium
McClain's "sudden collapse after an intense struggle" with police is referred to in the coroner's report as an example of excited delirium.
The medic who authorized the use of ketamine had told investigators that he could not gather information from McClain about his medical history because he was acting combative and "appeared to be" exhibiting signs of the syndrome, which may be triggered by drug use or stimulants and is broadly considered to be a state of agitation or aggression.
State health department guidelines note that the use of ketamine for excited delirium "is an emerging treatment" and that "across the country, many physicians question the existence of an excited delirium syndrome."
While it can be controversial to diagnose someone with excited delirium, because many medical professional associations do not recognize it, Dr. Deborah Mash, a professor of neurology at the University of Miami, told NPR that the phenomenon is "definitely real."
"And while we don't know precisely what causes this, we do know it is the result of a neural chemical imbalance in the brain," she said.
Excited delirium has been mentioned in connection with dozens of cases of excessive force and police-involved deaths, including cases in which police eventually used stun guns to shock people into submission, according to Amnesty International.
One of the four Minneapolis officers charged in the death of Floyd had said, "I am worried about excited delirium or whatever," according to the charging document.
Ketamine has also been linked to other excited delirium cases. In 2018, the Minneapolis Star-Tribune reported that Minneapolis police officers asked medical responders to use ketamine on people — at times over the objection of those being drugged and, in some cases, when no crime appeared to have occurred — more than 60 times in 2017, up from three in 2012.
Hospital officials had argued that ketamine helped manage people with excited delirium. The uptick, however, led Minneapolis Police Chief Medaria Arradondo to prohibit officers from recommending medical treatment to EMTs.
Kenneth Udoibok, a Minneapolis lawyer who specializes in civil rights and police misconduct cases, filed a federal lawsuit in 2017 on behalf of a man who said police mistook him for a suicidal man in the parking lot of a hospital. The man was handcuffed and then eventually injected with ketamine by a paramedic against his will, according to the lawsuit. Officials described the man as exhibiting "erratic" behavior, but he said he was agitated because police detained him on the ground in the rain for an hour.
The lawsuit's case against the police was dismissed before trial, and the case against the hospital was resolved out of court.
Udoibok said sedation lawsuits are hard to win, because without video recording, it is difficult to prove that an officer coerced a paramedic to sedate a person.
"It's a complete violation of an individual's rights," Udoibok said. "And it's the perfect crime. You can never prosecute it."
Carl Takei, a senior staff attorney for the American Civil Liberties Union who focuses on police practices, said ascribing a person's actions to excited delirium can create a shield for officers who use excessive force.
Then to "stick a needle into somebody" who is considered physically threatening only makes an already fraught situation involving police that much more dangerous, Takei said.
"Any time that an EMT is administering a medication against a person's will, that raises medical ethics issues, as well, that are not resolved simply because a police officer wanted them to do it," he said. "That goes into the underlying question: Was this invasion of a person's body justified?"