When 23-year-old Elijah McClain was walking home from a convenience store in Aurora, Colorado, that evening in 2019, he had no idea that he would soon be fighting for his life because someone thought he looked suspicious. Despite being unarmed, police put him in a stranglehold by putting pressure on his carotid artery. Then paramedics arrived and gave him an overdose of ketamine based on an overestimation of his weight. According to a report published in July 2020, medics in Colorado dosed 902 people with ketamine for “excited delirium” over 2.5 years, with 17 percent resulting in serious complications, including the death of Elijah McClain.
The two paramedics involved in Elijah McClain’s tragic death were recently found guilty of criminally negligent homicide two months after one of the police officers involved was found guilty of homicide. The paramedics claimed they were following protocols that were in place by their department. They had previously received training on when and how to administer ketamine. While this may be true, the jury still held them accountable for their actions, which resulted in dire consequences. Even before this case was settled, Elijah McClain’s death contributed to significant changes to the care of people in police custody in cities and states around the U.S.
Neck Restraints: Chokeholds and Strangleholds
In 2021, the American Academy of Neurology issued a position statement on the use of neck restraints, which includes chokeholds and strangleholds, in law enforcement. A chokehold is a pressure applied to someone’s windpipe, also known as the trachea, rendering the individual unable to breathe and depriving the brain of oxygen. Likewise, a stranglehold is a pressure applied to someone’s carotid artery, which blocks the blood flow to the brain. Both maneuvers make it so the person can become confused, incapacitated, suffer a stroke or heart attack, and may even die. That is precisely what happened to George Floyd, Eric Garner, and other young unarmed Black men whom police have killed.
“Law enforcement should never place people in chokeholds; Congress should pass legislation to prohibit police chokeholds nationwide,” says Anthony Collier, who serves as the director of criminal justice for the National Urban League. On September 14, 2021, the U.S. Department of Justice took a step in that direction, banning strangleholds by federal agents unless deadly force is authorized. Such an instance would be “when the officer has a reasonable belief that the subject of such force poses an imminent danger of death or serious physical injury to the officer or another person.” Numerous additional cities and states have banned strangleholds for their officers as well.
Chemical Restraints: The Case Of Ketamine
In the case of Elijah McClain, he survived two strangleholds on the night of his death but only to be given an injection of ketamine, which proved to be lethal. Ketamine, and medications like it, is often used by law enforcement as a chemical restraint. Ketamine is known colloquially as a “date rape” drug. It can lead to hallucinations and make the person feel detached from reality. In a joint statement, the American Society of Anesthesiologists and the American College of Emergency Physicians stated they “firmly oppose the use of ketamine or any other sedative/hypnotic agent to chemically incapacitate someone solely for a law enforcement purpose and not for a legitimate medical reason.” It is important to note that for a physician or other medical provider in the clinic or hospital to prescribe or administer ketamine, they must be registered and have a special license from the Drug Enforcement Agency.
“Emergency personnel should not sedate people in police custody against their will, especially considering the number of innocent Black people who are racially profiled and detained by the police,” said Anthony Collier. “Furthermore, paramedics believing Elijah McClain to be almost 100 pounds heavier than he was and involuntarily injecting him with a dose of drugs to match that discrepancy is a stark reminder of how racist stereotypes can have deadly consequences.”
Stereotypes are often rooted in implicit bias, which may play a significant role in cases like this. Implicit bias is unconscious bias based on prior experiences or beliefs about people. These biases often rely on stereotypes and may significantly impact medical decisions. For example, a study at the University of Virginia found that medical students and residents had numerous false beliefs about biological differences between races, and learners with these beliefs were more likely to treat patients of different races differently.
Excited Delirium
Law enforcement has used the unofficial diagnosis of “excited delirium” as a rationale for why they use the neck and chemical restraints described above. “Excited delirium” has been defined as someone who has agitation, aggression, confusion, acute distress, extreme sweating and may result in sudden death of the affected person while in law enforcement custody, often in the pre-hospital care setting. This condition is associated with the use of illicit substances, and the person experiencing this condition is said to have “superhuman” strength.
It is important to note that despite the increased use of this term in law enforcement, it is not listed in the Diagnostics and Statistics Manual for psychiatric diagnoses, and the American Medical Association (AMA) has made clear that there is no such medical diagnosis. They raised concern that this diagnosis has been disproportionately cited in cases of Black men in law enforcement custody. They further explained that to become an official diagnosis, there should be a clear set of diagnostic criteria.
The AMA went one step further and made recommendations regarding law enforcement using chemical restraints. They indicate that there should be a clear medical indication before administering a controlled substance, the person administering the drug should have appropriate training, and there should also be appropriate supervision.
Progress has been made as the term “excited delirium” has since been removed from Aurora Fire Rescue training manuals and all law enforcement documents in Colorado. Additionally other municipalities around the country have also removed this unofficial diagnosis from law enforcement training documents. Importantly, there has been increased interest in engaging mental and behavioral health providers when there is a suspected mental health issue involving a suspect or person in custody.
Lessons Learned
Elijah McClain’s tragic death serves as a reminder of the importance of medical personnel, whether EMS, nursing staff, or physicians doing their independent assessment of the patient’s clinical status. This can be particularly challenging in stressful high-tempo situations; however, the high-stress situations tend to lend themselves to more opportunities for bias in decision-making. Medical providers must remember that law enforcement is independent of the medical provider’s role. The medical providers should rely on their training and expertise to make medical decisions. That distinction is essential, and as was seen in the case of Elijah McClain, the medical providers were held accountable for actions taken that, according to the medical examiner, resulted in the premature death of a young man.
“I hope all EMS workers learn from this tragic situation not to blindly accept the word of law enforcement on the scene, especially when the police have Black people in their custody,” said Anthony Collier. Indeed, it is not just EMS workers who must remember to do their own independent assessment, but it is all medical providers who must remember when they are evaluating a patient in custody, even if the patient has altered sensorium or is unresponsive, that initial relationship is between the medical provider and the patient.
