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EMS policy may be to blame for inmate's death after ketamine sedation

Daniel Taylor.jpg
Taylor family
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Daniel Taylor in a family photo with sisters NaTasha, top left, and Noel, bottom right, along with mother Colleen and dog Mojo.

A Duval County man, injured in a confrontation with officers at the county jail, died after emergency medical workers gave him a powerful sedative without fully monitoring his reaction.

Unlike other departments in Florida, many emergency medical services on the First Coast don't require extensive safeguards after the use of ketamine, a review by WJCT News found.

Medical professionals and other EMS departments advise robust monitoring of patients for complications like clogged airways in the minutes after administering the drug. But local departments — including the Jacksonville Fire and Rescue Department, St. Johns County Fire Rescue and Clay County Fire Rescue — have comparatively relaxed standards.

Daniel Taylor arrived at UF Health Jacksonville unresponsive after a jailhouse fight with 10 corrections officers Aug. 13. Taylor was still conscious and aware when paramedics arrived and first became unresponsive after being given the maximum dosage of ketamine allowed under department rules, according to a JFRD EMS report obtained by WJCT News.

Within five minutes of receiving the dosage, Taylor was no longer breathing and his heart stopped beating as he was being transported to the hospital. Despite being resuscitated, he never recovered brain function and was taken off life support a week later.

After 10 months, the State Attorney's Office continues to investigate and has not stated whether prosecutors will press charges related to Taylor’s death. Officers and paramedics have faced manslaughter charges in similar situations elsewhere in the country.

The EMS report

Taylor had been awaiting paperwork for his release from jail for misdemeanor trespassing in the early morning hours on Aug. 13. A witness said Taylor was confused about why he still had not been released several hours after his court appearance, leading to an argument with a guard that escalated into a confrontation with 10 officers.

The fight left Taylor with an inch-long cut above his eyebrow, but he was still responsive.

A pre-hospital report from UF Health Jacksonville describes what EMS personnel told doctors led to the patient's condition before they arrived. According to that report and a witness's account, 10 guards held Taylor on the ground as he bled from his forehead.

Taylor's family says the Jacksonville Sheriff's Office told them he was too combative to be evaluated by a nurse, so officers called JFRD paramedics to evaluate him.

The EMS report says the same: that paramedics found Taylor "laying on the floor combative and unable to be restrained by corrections officers" as he was being held down. Taylor was placed in handcuffs, with his hands and feet chained together as he was placed onto a stretcher and forcibly sedated.

Records show a discrepancy, however, in how much Taylor weighed, which would dictate how much ketamine would be appropriate.

Jail records, family comments and a witness say Taylor weighed about 160 pounds, and hospital records put him at 80 kilograms, or roughly 176 pounds.

In the EMS report— signed three days after Taylor's hospitalization — paramedics listed his weight as 100 kilograms, or 220 pounds, the minimum weight for a patient to receive the maximum dosage of ketamine under JFRD policy.

Crash scene
The Florida Times-Union

Taylor was sedated at 6:10 p.m., and an assessment conducted by paramedics immediately afterward showed his vital signs were normal. By 6:15 p.m., paramedics noticed he was no longer breathing as they loaded him into the ambulance and conducted CPR to revive Taylor before intubating him to provide oxygen.

UF Health's pre-hospital report says Taylor's vitals were lost on the way to the hospital.

A narrative section of the EMS report did not mention the usage of ketamine or that Taylor was sedated at all. It notes he was "carried to the stretcher restrained in handcuffs" and then "went into cardiac arrest upon entering [the ambulance]." Ketamine is mentioned once in the document under a section outlining treatment, providing the dosage but not why it was used.

NaTasha Taylor, Daniel's sister, arrived at the hospital with his immediate family three days after the incident. According to her, doctors told the family that Taylor had arrived functionally brain dead from prolonged lack of oxygen due to the ketamine, something she says a detective and other officers echoed when speaking with the family.

Taylor was in the hospital for a week before his family made the decision to take him off life support. For the duration of his hospital stay, NaTasha Taylor said, JSO maintained in repeated discussions with the family that JFRD had followed all protocols.

The circumstances of Taylor's death mirror the death of Elijah McClain in Colorado. The 23-year-old's death in 2019 death was widely evoked during the 2020 national protests against police brutality. Officers had forcibly arrested McClain before paramedics responding to the scene sedated him with ketamine.

In McClain's case, the 140-pound man was also estimated by paramedics to weigh 220 pounds, allowing them to give him the maximum dosage of ketamine under their department rules

Paramedics in McClain's case, similar to Taylor's, noticed he was not breathing and had lost vitals in the ambulance, seven minutes after he had been given ketamine. McClain was revived, but, like Taylor, had no brain activity and was taken off life support a week later.

The three officers and two paramedics in that case were charged with manslaughter last year and are awaiting trial.

Ketamine policy

Emergency personnel both inside and outside hospitals favor ketamine. It's used in therapeutic settings to assist with intubation, stop seizures and provide mild sedation before other medical procedures. Its primary use has also been to sedate combative patients, or those suffering from "excited delirium," a controversial diagnosis where symptoms include agitation, aggression, distress, sudden death and hyperthermia.

The existence of excited delirium syndrome, or just excited delirium, is not supported by the American Medical Association, American Psychiatric Association or American Academy of Emergency Medicine. The latter released an official statement in April that it opposes "the use of the terms as they are based on unproven assertions" and that ketamine sedation should not "be dictated by law enforcement."

However, the condition is referenced in official documents and policy guides for emergency medical services and hospitals throughout the country and is supported by the American College of Emergency Physicians, which released a report on "hyperactive delirium" last year.

Ketamine.jpg
Teresa Crawford
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AP

Both Taylor and McClain were diagnosed by responding paramedics as suffering from excited delirium, justifying the use of ketamine under the policies of their respective departments.

Ketamine's properties are relatively unique compared to other sedatives. It disassociates a patient, making them feel like they are outside of their body, unable to see, move or hear, but under normal circumstances they will continue to breathe and function on their own without assistance from medical personnel.

"Ketamine is an extremely safe drug," Andrew Schmidt, deputy medical director at UF Health Jacksonville's trauma unit, said. "But, there are some adverse side effects to this."

Schmidt, who is also the medical director for Jacksonville Beach Ocean Rescue, says the EMS department he oversees does not use the drug, but at the trauma ward he and other doctors use ketamine at high dosages to sedate combative patients on a daily basis.

"It is hands-down the absolute safest medication we have to chemically restrain someone, without question," Schmidt said, describing alternative sedatives, especially opioids and narcotics, as more likely to cause loss of breathing and heart functions.

UF Health Jacksonville.jpg
UF Health Jacksonville
UF Health Jacksonville.

According to Schmidt, monitoring is an extremely important part of managing ketamine sedation.

"Really, most of your adverse effects you're going to get in terms of respiratory drive are going to happen the first couple minutes, out to 10 minutes, but usually the first couple minutes."

A review of ketamine policies at emergency medical services throughout Florida supports Schmidt's statements.

Fire departments regularly recommend ketamine as the preferred sedative for paramedics to use if they have it on hand, describing it as having a robust safety profile compared to other drugs, and that potential side effects at high dosages — such as hypersecretions (increased saliva production that can clog up airways and cause patients to choke), laryngospasm (vocal cords seize up and prevent breathing) and apnea (breathing stops)— can easily be mitigated with proper monitoring.

When it comes to monitoring, however, EMS protocols surrounding ketamine in South Florida are more robust than some departments on the First Coast.

Nine out of 12 departments in Broward County use ketamine to sedate combative patients. All 12 require the use of EtC02 monitoring, also known as capnography, on sedated patients. Capnography tracks ventilation and monitors carbon dioxide levels. It provides an early warning sign of respiratory failure, especially in cases of oversedation.

Broward fire departments include multiple warnings and reminders in their protocols that using ketamine to sedate a patient can likely cause respiratory depression and that medics must be actively monitoring patients and be prepared to manage breathing for them.

JFRD and SJCFR, in contrast, require only Sa02 and Sp02 monitoring, respectively. These metrics follow the levels of oxygen in the blood. While they're important markers for making sure a patient is breathing properly, in cases of oversedation, they'll often reveal a problem too late for intervention compared with capnography.

"The reason for that is because if you and I are talking right now, your oxygenation stats are probably going to be 98%, and if you suddenly stopped breathing for whatever reason, your oxygenation will actually remain normal for a couple minutes," Schmidt said. "But what our EtC02 tells us is that you've stopped breathing."

Both Jacksonville-area departments only require EtC02 for patients who have been intubated, according to emails from their respective medical directors. Intubation will usually occur after a paramedic determines a patient's breathing is in distress. In the case of patients sedated with ketamine, it may come too late after the point where they've stopped breathing.

Two minutes after sedating Taylor, paramedics got an SaO2 reading of 96%. In a field marked "EtC02" on the EMS report, they put down "unable to complete." Three minutes later, they lost Taylor's vitals, and while they temporarily revived him after intubation, Taylor would never regain brain activity.

The American College of Emergency Physicians, one of the few professional organizations in the world that supports the existence of excited delirium and the preferred usage of ketamine to treat it, states that monitoring for the heart's electrical activity and rhythm, blood oxygenation levels and carbon dioxide through capnography should all be used in tandem for any patient suffering from the condition, especially if sedated.

JFRD's medical director confirmed in an email to WJCT News that the department "does not currently utilize nasal capnography for non-intubated patients" when asked about policies regarding ketamine. When asked if department policy would change after Taylor's death, the department did not respond.

At JFRD, intramuscular injection of ketamine is supposed to be given at a dosage of 4 milligrams per kilogram, with a maximum dosage of 400 mg even if the patient weighs more than 100 kg, or 220 pounds.

Taylor, reported as 80 kg by the hospital, should have received a maximum dosage of 320 mg.

A Duval County medical examiner concluded that Taylor's death was a homicide caused by lack of oxygen to the brain from an irregular heartbeat after a violent physical altercation. His death on Aug. 20 has been investigated by JSO detectives and an assistant state attorney in Melissa Nelson's Office for the last 10 months.

Investigators requested a second coroner's report from an outside medical examiner this year, due to the "complex nature of the medical evidence," according to a spokesman for the the State Attorney's Office.

Reporter Raymon Troncoso joined WJCT News in June of 2021 after concluding his fellowship with Report For America, where he was embedded with Capitol News Illinois covering Illinois state government with a focus on policy and equity. You can reach him at (904) 358-6319 or Rtroncoso@wjct.org and follow him on Twitter @RayTroncoso.