Public Health

Out-of-hospital pharmacologic intervention by nondoctors poses risks

Sara Berg, MS , News Editor

News media discussions about police brutality and the use of conducted electrical devices have referred to the term “excited delirium,” which is controversial because it lacks a defined set of behavioral signs and symptoms that allow for the identification of a person who is perceived to be in distress and in urgent need of medical or psychiatric help, according to an AMA Council on Science and Public Health report adopted at the June 2021 AMA Special Meeting.

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Several news reports have also highlighted the use of ketamine and other sedative or hypnotic and dissociative agents in the out-of-hospital setting. These drugs are often used in these instances to incapacitate a person for a law-enforcement purpose and not a legitimate medical reason.

The report notes that the people most likely to be disproportionately identified as experiencing “excited delirium” and to die from resulting first-responder actions—or as a consequence of administration of a pharmacological intervention—are otherwise healthy Black males in their mid-30s who are viewed as aggressive, impervious to pain, displaying bizarre behavior and using substances. These are characterizations that may be based less on evidence and more on generalizations, misconceptions, bias and racism.

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Additionally, the council report notes that new crisis-intervention team models should be used. In such models, medical and behavioral health specialists are deployed first to respond to behavioral emergencies in the community—instead of the police. Such an approach can help ensure “that administration of any pharmacological treatments in a nonhospital setting is done equitably, in an evidence-based, anti-racist and stigma free way,” according to the council report.

“For far too long, sedatives like ketamine and misapplied diagnoses like ‘excited delirium’ have been misused during law enforcement interactions and outside of medical settings—a manifestation of systemic racism that has unnecessarily dangerous and deadly consequences for our Black and brown patients,” AMA President-elect Gerald E. Harmon, MD, said in a statement.

“As physicians and leaders in medicine, it is our duty to define the medical terms that are being used to justify inappropriate and discriminatory actions by non-health care professionals. The adoption of this policy represents an urgent step forward in our efforts to remove obstacles that interfere with safe, high-quality medical care—and makes clear that the AMA will continue to aggressively confront all forms of racism or police violence against our patients in marginalized and minoritized communities.”

To address pharmacological intervention for agitated individuals outside of hospital settings, the House of Delegates adopted policy stating that the AMA:

  • Believes that current evidence does not support “excited delirium” or “excited delirium syndrome” as a medical diagnosis and opposes the use of the terms until a clear set of diagnostic criteria are validated.
  • Recognizes that the treatment of medical emergency conditions outside of a hospital is usually done by a subset of health care practitioners who are trained and have expertise as emergency medical service (EMS) practitioners. It is vital that EMS practitioners and systems are overseen by physicians who have specific experience and expertise in providing EMS medical direction.
  • Is concerned about law enforcement officer use of force accompanying “excited delirium” that leads to disproportionately high mortality among communities of color, particularly among Black men, and denounces “excited delirium” solely as a justification for the use of force by law enforcement officers.
  • Opposes the use of sedative/hypnotic and dissociative agents, including ketamine, as a pharmacological intervention for agitated individuals in the out-of-hospital setting, when done solely for a law enforcement purpose and not for a legitimate medical reason.
  • Recognizes that sedative/hypnotic and dissociative pharmacological interventions for agitated individuals used outside of a hospital setting by nonphysicians have significant risks intrinsically, in the context of age, underlying medical conditions, and also related to potential drug-drug interactions with agents the individual may have taken.

Additionally, the new policy urges:

  • Law enforcement and front-line emergency medical service personnel, who are a part of the “dual response” in emergency situations, to participate in appropriate training, overseen by EMS medical directors. The training should minimally include de-escalation techniques and the appropriate use of pharmacological intervention for agitated individuals in the out-of-hospital setting.
  • Medical and behavioral health specialists, not law enforcement, to serve as first responders and decision-makers in medical and mental health emergencies in local communities and that administration of any pharmacological treatments in the out-of-hospital setting be done equitably, in an evidence-based, anti-racist and stigma-free way.

Read about the other highlights from the June 2021 AMA Special Meeting.