Elijah McClain was walking home from a convenience store with iced tea when someone called 911, telling the operator he was wearing a ski mask and had his hands up. “He looks sketchy,” said the caller. When asked for a description, the caller said he thought he was a Black male. It was 10:30 pm on August 24, 2019, in Aurora, Colorado. No more than a half-hour later, McClain, a 23-year-old massage therapist, was put in a now-banned carotid control chokehold, threatened with a dog bite, and injected with 500 milligrams of ketamine. On the way to the hospital, he went into cardiac arrest and was taken off life support six days later.
When restrained by the police, McClain can be heard on a body camera, saying, “My name is Elijah McClain. I was going home. That’s what I was doing, just going home. I’m an introvert, and I’m different. I’m just different, that’s all.”
Debra A. Pinals, M.D., clinical professor of psychiatry and director of the Psychiatry, Law, and Ethics program at the University of Michigan, says that while each incident must be examined on a case-by-case basis—and although the McClain case was not about a behavioral health crisis—the fatal outcome raises serious questions about the crisis response system more generally. Moreover, as Dr. Pinals points out, it opens up dialogue about problems that need addressing, including structural racism, lack of certain standardized practices, insufficient use of de-escalation techniques, and the controversial excited delirium syndrome diagnosis. The latter has caught the attention of the mainstream population and the medical field alike because of the application of ketamine by paramedics as a chemical restraint performed seemingly at the command of law enforcement and the disparity of its use on Black men.
High Stakes and Systemic Biases Are Not a Good Combination
At 10:30 pm, the caller described McClain as a man in a ski mask raising his arms. He told the operator he looked sketchy. “He might be a good person or a bad person,” the caller said. The 911 operator asked if there were any weapons involved or mentioned, and the caller said, “No.” When the operator asked the caller if he or anyone else was in danger, the man said, “No.”
Thirteen minutes later, officer Nathan Woodyard spotted McClain and told him he had a right to stop him for “being suspicious.” The 23-year-old was on his way home, listening to music through his earphones, a white plastic bag holding ice tea in his left hand and his phone in his right. His sister explained to Denver7 that McClain wore a ski mask because he had anemia and would get cold.
Dr. Pinals says how a 911 call about suspicious behavior turns deadly often has a complicated answer. She says that unlike crises in the emergency room, they don’t transpire in a controlled setting on the street. “These are humans responding to humans, often in frightening situations.” First responders’ reactions can be impacted by all of the incidents they’ve experienced beforehand, in and out of the job. “They often go into situations with a lot of adrenaline.”
The three officers—Woodyard, Randy Roedema, Jason Rosenblatt—got closer to McClain, and one officer told him, “Stop tensing up.” As they moved in, McClain responded by saying he’s an introvert and asked them to please respect his boundaries. “I’m going home. Leave me alone.” One of the officers said, “Relax, or I’m going to have to change the situation.”
The interaction between McClain and the three officers escalated quickly as they tried to move him to the grass. Officer Roedema can be heard on the body camera shouting that McClain reached for an officer’s gun, though that’s unclear in the body camera footage. In response, officer Woodyard used a carotid control hold on McClain. In the footage, the officers can be heard discussing whether he passed out as a result. One said he heard McClain snoring, a signature that he likely did briefly lose consciousness.
Still pinned to the grass by the three men, McClain asked, “Why are you attacking me?” The officers didn’t respond. Instead, they talked to each other, with one officer asking, “Do we have anything other than him being suspicious?” Another officer replied, “No.”
The challenge, notes Dr. Pinals, is that, in a crisis, first responders have to make rapid decisions without knowing the whole story. In these quick moments, people’s training, past experiences, and biases can play a role. It’s hard to say what exactly the three first responders thought when interacting with McClain, who was not a large person at 5 feet 6 inches and 140 lbs. What we do know is that Black men are often misperceived as larger and more frightening than White men of the same size. At the scene, one of the officers thought McClain was on a substance that gave him “incredible strength.” He wasn’t. Another officer responds to the first, saying, “Yeah, crazy strength.”
We also know that when Aurora Fire Rescue personnel later guessed McClain’s weight to administer ketamine, they estimated that McClain was 220 lbs—a whole 80 lbs more than his actual weight. As a result, paramedic Jeremy Cooper administered 500 milligrams of ketamine to McClain, far more than what he should have received.
Excited Delirium Syndrome
When emergency medical technicians and paramedics determine that a person is in crisis, they have prehospital intervention protocols and dosing guidelines to manage chest pain, breathing emergency, and behavioral escalation. Dr. Pinals says that early intervention saves lives and, conversely, delays in care for emergencies, like heart attacks and strokes, can be life-threatening. “This is also true for a medical emergency of delirium. You can potentially save a person’s life by getting them hydrated and better medical monitoring.”
By definition, delirium means that the person has an underlying medical condition that needs to be treated. That includes intoxication from substances or medication side effects, and it can look like acute psychosis or mania. Diagnostically, says Dr. Pinals, it can be challenging to determine what’s causing the delirium. A paramedic’s goal is to stabilize the person and get them to the hospital for further evaluation and treatment.
While delirium is a medical diagnosis, excited delirium is not recognized as a medical or psychiatric diagnosis in the ICD-10 and DSM-5, respectively. In 2009, the American College of Emergency Physicians (ACEP) formally recognized excited delirium syndrome (ExDS) in a white paper, stating that the “presence of the hallmark clinical findings along with the presence of some type of centrally acting stimulant strongly suggests the diagnosis,” but it notes there is no “gold standard test.”
Paramedics’ role in the crisis continuum has evolved over time, representing the quiet third responder that people in behavioral health services, says Dr. Pinals, often don’t know much about. “They come in, put people on a stretcher, and then they go.” She notes that, as a whole, the three-legged-response system—law enforcement, EMT, and behavioral health—hasn’t been sufficiently examined from the vantage point of what an integrated and coordinated response might look like. Like law enforcement, the emergency medical technician community generally doesn’t know much about behavioral health or behavioral health systems. “Many, if not most, don’t have specific training on behavioral health, and often, in particular communities, no one is pushing for that to change.”
Just like mental health professionals, who are more apt to diagnose Black youth as having a conduct disorder or Black adults as having an antisocial personality disorder, emergency medical technicians aren’t free from systemic racism. In 2018, the Society for Academic Emergency Medicine published a systematic literature review of excited delirium and found that it was disproportionately diagnosed in young Black men.
In a letter from District Attorney Dave Young to the Aurora Police Department, Aurora Fire Rescue medic Jeremy Cooper determined McClain—who was handcuffed and on the ground—showed signs of excited delirium “by his appearance and his aggression.” McClain’s family disagrees, and in a lawsuit said the Aurora Fire Department’s claim that he was experiencing excited delirium was “false, reckless, and intentional.”
Injecting People with Ketamine During Arrests
Minutes after officer Woodyard used the carotid control hold on McClain, he began to throw up. An officer can be heard on the body camera telling him to stop. McClain says, “Sorry, I wasn’t trying to do that. I can’t breathe correctly.” He threw up a few more times before Aurora Fire Rescue arrived on the scene, and paramedic Cooper injected him with 500 milligrams of ketamine. According to an Aurora Police Department press release, after officer Woodyard did the carotid control hold on McClain, the officers requested Aurora Fire Rescue and Falck Ambulance to “render professional medical attention” “due to the level of force applied while restraining the subject and his agitated mental state.”
Before Aurora Fire Rescue arrived, one of the police officers can be heard on the body camera saying, “When the ambulance gets here, we will go ahead and give him some ketamine. Let that sit for a minute.” It’s paramedics who are trained to determine how and when to give medical intervention, yet the officer stated ketamine would be used even before the medic arrived.
The case of Elijah McClain requires its own analysis, but as Dr. Pinals notes, the conversations surrounding what happened with him point to why excited delirium is a diagnosis of controversy. It’s often used as a retrospective explanation for the use of force. “What we see is that someone in a police interaction dies, and law enforcement may later state, ‘The reason I used all that force is because the person had excited delirium. I had to protect myself because these people are pain tolerant and extremely aggressive, and they don’t listen.’” Though there are cases where individuals don’t and can’t respond to verbal de-escalation, more data is needed to understand these circumstances. Speculations surrounding the McClain case are drawing attention to whether during arrests and at the behest of law enforcement, paramedics are injecting ketamine into people for a syndrome that isn’t widely recognized as a medical or psychiatric diagnosis.
In the medical field, ketamine was established as a dissociative anesthetic and has been long considered safe, even for pediatric surgeries. But like many medications, says Dr. Pinals, it has the potential for positive use and misuse. “Ketamine, used in these emergency prehospital contexts, puts people at risk of needing to be intubated. It, therefore, requires adequate medical supervision.”
The Colorado Society of Anesthesiologists recently issued a statement asking that Emergency Medical System personnel in the state no longer use ketamine to treat excited delirium. “The condition is described as one that can include a hypermetabolic state that can lead to death within minutes if left untreated. However, this entity is not recognized by most medical authorities and there are legitimate questions on whether or not it actually exists.” The group said Colorado EMS personnel have used ketamine to treat excited delirium 902 times over the past 2 ½ years, with dosages equal or greater than those used to produce general anesthesia, and a high reported complication rate of 24% in 2019, including at least one death.
The society followed up by saying that independent of excited delirium, “the use of chemical incapacitation to treat agitation is demonstrably hazardous…”
Another Elijah, Elijah McKnight, had a similar experience to McClain. He was handcuffed by police and given ketamine by a fire department medic. McKnight told the Colorado Sun that the arrest affidavit said the medics determined he had excited delirium. He ended up having to be intubated in the hospital for days. McKnight said he didn’t have excited delirium. What he was experiencing and exhibiting, he said, was fear for his life. “I thought I was going to die,” he told the paper.
Changing the Crisis Response System and 988
Dr. Pinals says that it matters how a crisis call comes in and who comes to the scene. The 911 dispatcher makes decisions based on the information they’re getting from the caller; then, they funnel it and triage. As a forensic expert with vast experience in retrospective analysis, Dr. Pinals has examined numerous police reports and interviewed officers to determine what happened on calls involving an individual with mental illness. At present, if someone calls 911 and is experiencing chest pains, the dispatcher will send out an ambulance. In many communities, if someone is suicidal, police are invoked. Dr. Pinals notes that it’s also possible a mobile crisis team might be called, but that depends on how the call is triaged and what resources and services exist in that community. She hopes that 988 will be a game-changer, increasing people’s access to the help they need and decreasing interactions—and the associated risks that can come along with those interactions—that they don’t. “When there’s a 911 call, a dispatcher decides who to send out, whether an ambulance, paramedic, law enforcement, or the fire department. With 988, maybe a mobile crisis team will come to the scene first and determine what’s needed.”
Dr. Pinals has directly trained law enforcement officers and overseen grants for police diversion and co-responder programs. She oversaw the Crisis Intervention Team grants and some of the CIT development in Massachusetts and has helped train officers in Michigan. She points out that first responders may have a skewed view of mental illness because, for many, their contact with it is crisis. “They don’t get to see the long view of behavioral health and what a person is like when not in crisis.”
Crisis Intervention Team training and other types of targeted mental health training like CIT aim to help change perspectives and make interactions safer for everyone, notes Dr. Pinals. De-escalation skills are part of that training, but the focus isn’t just learning de-escalation techniques. She finds it can be helpful to talk with officers about trauma and recovery: looking at a person in totality, not only at their worst moment. Also, she has seen how improved understanding boosts empathy toward the person in crisis. “With that understanding, it can be safer for everyone involved.”
While law enforcement and emergency medical technicians are not behavioral health experts, they are essential partners. Dr. Pinals says while it’s vital that they can identify when there’s a behavioral health crisis, they do not need to make a psychiatric diagnosis, nor would it be appropriate for law enforcement to do so. “It’s life-saving if everyone knows their role and the person in distress is triaged through the right door, allowing emergency medical personnel and law enforcement to get back on the street or to the next call, while the person with mental illness can access treatment.” She says that safety first also means accepting behaviors from those in crisis that can be incredibly uncomfortable. “We’ve learned a lot in seclusion and restraint prevention on inpatient units about tolerating behavior and not rushing to lay hands on people. Some behavior is not inherently dangerous, like nudity. Someone might remove their clothing when drunk, high, or while having psychotic or manic symptoms. It can create such discomfort that a situation might escalate even though the behavior itself isn’t unsafe.”
What needs to happen next is continuity between first responders, both in using common de-escalation strategies when possible and protocol coordination. Dr. Pinals says that crisis response can be like a dance that hasn’t been adequately choreographed, adversely impacting how scenes are managed and outcomes, or it can be remarkable to see how well it can work. Determining who is in charge can be confusing amidst a crisis, so knowing how roles will play out in advance helps when there’s actually a crisis that requires a coordinated response.
Looking retrospectively at cases that went awry, and without all the facts, it’s easy to point out that police should not determine when ketamine is used since it’s a medication that requires medical oversight to administer. What is less clear is how roles and responsibilities in a particular action were coordinated and how much there may have been a blurring of boundaries of roles. Such a lack of clarity of who is in charge isn’t unique to first responders on the street. In hospitals, clinical staff often work with security, and systems may develop protocols after an incident occurred where there was a disagreement about who was in charge and thereby what protocols to follow—medical or law enforcement. “At the community level, we are in the infancy of developing well-coordinated standardized processes between behavioral health crisis response, law enforcement, and EMTs. The important thing is to take stock and draw lessons from experiences that went well and those that did not.”