We have an opportunity for change. Our own Olympia City Council member Jim Cooper is now a new member of the Western Regional EMS & Trauma Care Council, covering five counties: Grays Harbor, Lewis, N. Pacific, Pierce and Thurston Counties. Keoki Kauanoe, chair of the Washington State Progressive Caucus, has asked him about talking with this council about our concerns about Thurston County EMS protocols and use of midazalom (Versed), the drug that led to the death of Vaneesa Hopson when she was chemically restrained on February 7, 2018. Chemical restraint is the medication of a patient to restrict their freedom or movement.
- Mail: Jim Cooper, Olympia City Council, PO Box 1967, Olympia, WA 98507-1967
- Phone: 360.753.8447 (City Council office)
- Email: firstname.lastname@example.org
Please let Jim know EMTs should not be applying chemical restraint at a time when we have an opioid epidempic — especially on individuals they suspect of under the influence of drugs — with a medication that includes this warning:
“Using midazolam with opioid medications (such as codeine, hydrocodone) may increase your risk of very serious side effects, including death.”
Even if we do not entirely eliminate chemical restraint, local standards must be brought up to date with national model EMS guidelines by the National Association of State EMS Officials (NASEMSO). Model guidelines require de-escalation and calming measures are taken and involvement of family, if appropriate, prior to chemical restraint. NASEMSO also specified lower dosages than the Thurston County protocol. It forbids chemical restraint if the patient is face down and requires cardiac monitoring as soon as possible, among other important differences.
Keep in mind chemical restraint by EMTs in non-clinical settings with agitated, unfamiliar patients is inherently more dangerous than chemical restraint in nursing homes, psychiatric wards, hospitals or oral surgery clinics. In those applications, the condition and the history of the patient is generally known and proper medical staff and equipment are available.
Please also let Jim know revising the protocol must be combined with EMT training and other measures to ensure best practices are implemented. Most importantly, EMTs should never be coerced by law enforcement into applying chemical restraint. The Thurston County EMS Protocol must be revised to remove the provision that allows law enforcement assisstance/direction to substitute for physician oversight.
Other countries have other methods of safely, physically restraining agitated patients when they need to be transported in an emergency. In Japan, for example, agitated patients are wrapped to physically restrain them comfortably without sedating them against their will. Keep in mind to apply chemical restraint the patient must already be physically restrained.
In Thurston County, the drug used for chemical restraint by EMTs is 10 mg of midazalom or Versed, a “potent sedative agent” used in hospital settings as a “pre-anesthesia”. According to drug manufacturer’s instructions, midazalom should be used only in a clinical setting with “continuous monitoring of cardiac and respiratory function”, yet in Vaneesa Hopson’s case the EMT applied the sedative and then walked away leaving her face down on the pavement and unattended. EMTs should not be allowed to apply this medication in non-clinical conditions settings without physician supervision and without the medical equipment necessary to follow drug manufacturer’s instructions.
I would like to note that we oppose forcible medication in any setting — nursing homes, psychiatric wards, schools for the disabled and by EMTs. This is a very big issue and its use is very entrenched. We are focusing right now on its use by EMTs because recent events provide us with an opportunity to make progress on this front. Because chemical restraint by EMTs is inherently more dangerously than in the other settings, so it is a place we can move forward in a significant way. I hope we can get it eliminated entirely. Please feel free to strengthen my letter and add the breadth of the issue that I am leaving out as I focus on EMTs.
Thurston County EMS Protocol Is Inconsistent with Model Guidelines
The Thurston County EMS protocol (pages pages J-51-52 ) is not consistent with the NASEMSO National Model EMS Clinical Guidelines, September 2017, Version 2.0 (See pages 67 to 70). The drug used for chemical restraint is 10 mg midazalom, injected either intramuscularly (IM) or intravenously (IV). See drug info here and here, for example.
Recall Vaneesa Hopson was sedated lying face down on the pavement. Thurston County EMS protocol has no provisions against this, while the NASEMSO national standard expressly forbids chemical restraint in this position, stating:
The following restraint techniques should be expressly prohibited by EMS providers: restraint or transport in a prone position with or without hands and feet behind the back (hobbling or “hogtying”), “sandwiching” patients between backboards, techniques that constrict the neck or compromise the airway, or EMS provider use of weapons as adjuncts in the restraint of a patient.
The Thurston County EMS Protocol also does not include these features:
- The NASEMSO Standard specifies to first establish patient rapport by the following methods: (a) attempting verbal reassurance and calm patient prior to use of chemical and/or physical restraints, (b.) engaging family members/loved ones to encourage patient cooperation if their presence does not exacerbate the patient’s agitation, and (c.) continuing verbal reassurance and calming of patient following chemical/physical restraints.
- The NASEMSO Standard defines treatment goals, requires patient assessment and continuous monitoring of the patient, and includes exclusion criteria. A cardiac monitor must be applied as soon as possible.
- The NASEMSO Standard includes a number of medications that may be used with different dosage levels and also indicates dose may need to be adjusted. The Thurston County EMS protocol specifies one drug at one dose — midazalom 10m IV or IM. Note this is TWICE the dose of midazalom specified by the NASEMSO model standard.
Thurston County’s Protocol is in Conflict with Drug Manufacturer Warnings and Instructions
The Thurston County EMS protocol is unsafe and inadequate, comparing it to drug manufacturer’s literature and also considering the constitutional right we have to refuse medical treatment.
- First, the protocol does not require involvement of crisis response professionals, mental health professionals or family, if available, prior to administering chemical restraint. The involvement of people who can first attempt to calm a patient and adopt voluntary measures is a generally accepted criteria to ensure the constitutional rights of a patient are respected.
- Second, the protocol allows EMTs to administer the drug without physician’s orders. Stunningly, the protocol documentation allows either the “assistance/direction of law enforcement and/or orders from a supervising physician to restrain” – as if law enforcement direction could substitute for physician oversight.
- The drug specified by the protocol is not safe for use in the manner specified in the protocol, which is intravenous injection of 10 mg of midazalom. EMTs do not have the appropriate level of training and do not have the equipment available in the field for safe intravenous administration. For example,
- Drug information recommends midazalom be used in hospital and clinical settings with “continuous monitoring of respiratory and cardiac function” and “immediate availability of resuscitative drugs and age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and personnel trained in their use and skilled in airway management.” This is not the kind of setting available to EMTs in the field.
- Midazolam interacts adversely with many medications, including opioids, other benzodiazepines, and blood pressure medications. Yet the protocol does not call for screening the patient for possible medications they have taken.
- The dose of midazolam requires individualization and may need to be adjusted by a physician considering the patient’s size, age, condition, and other medications they may be taking, yet the protocol specifies a single dosage for all patients.
- None of these warnings or instructions are included in the protocol.
This drug should not be part of the Thurston County EMS protocol.
Revise the Protocol
Citizens Against Chemical Restraint is a group of concerned citizens interested in joining with others to change the protocol EMTs use calling for a moratorium on forcible medication to “chemically restrain” patients by first responders until safe protocols and practices are implemented.
There are safe methods of physical restraint, such as wraps, used elsewhere that we can adopt and chemical restraint by EMTs in the field should be eliminated. If chemical restraint, however, is allowed we suggest a protocol that:
- Requires involvement of mental health and crisis response professionals and, if possible, family members,
- Requires oversight and consultation with a physician concerning the patient’s current condition, (law enforcement direction must not substitute for a physician)
- Specifies medications that do not have serious side effects when combined with opiates and other common street drugs and pharmaceuticals,
- Requires that safe, voluntary, and non-invasive methods are exhausted first.
Traditions Presentation on Chemical Restraint (Begin at 2:00 Minute Into Video)
My prepared remarks begin at about 2 minutes into the video. Thank you.
The Right to Refuse Treatment
The right to refuse medical treatment has been established as a constitutional right based on the right to privacy, equal protection and due process — and this right may be overridden only under specific conditions (Sederer 2013). Another example of this right that is commonly known is that Seventh Day Adventists are allowed to refuse blood transfusions, even when it puts their lives at risk. It is their choice.
Involuntary treatment is warranted only in the case of an emergency, which is defined as “an imminent danger to self or others.” Generally, the following critieria should be met:
1. The treatment is necessary for safety and recovery;
2. All efforts at voluntary treatment have been exhausted;
3. Family and others have been engaged to help persuade the patient to accept care (and were not successful); and
4. The benefits of treatment are likely to outweigh its risks.
In Vaneesa’s case, there was no medical emergency. Family and mental health practitioners were not engaged. And the medication they used has serious side effects if injected too quickly or when combined with opiates — when, as reported, responders thought she was suffering from a “mental health crisis and/or acute effects of substance use”. The risks of treatment were too great to override her refusal of treatment.
Not Just the Protocol…
Talking with family members, I was alarmed to see photos and videos from the night Vaneesa Hopson died. Vaneesa’s face was bruised and swollen, her chin raw and bloody from the police slamming her face into the pavement. She had bruises from head to toe. At the time she was injected, Vaneesa had already been lying quiet for 20 minutes. She was face down with her hands and feet bound and face hooded. Why was a subdued woman chemically restrained?
The EMT pulled her pants down in front of a crowd of 30 or 40 people, injected her and walked away. The EMT gave her the shot of a powerful sedative and then left her unattended! Drug manufacturers warnings state patients require careful watch due to the potential for respiratory problems.
It is reportedly common knowledge among medical technicians that sedatives should never be given when a person is face down. Does Thurston County Medic One have a training problem? Is this EMT unaware of common practice? Was this EMT applying a drug without being aware of manufacturer warnings and instructions? Was he coerced by law enforcement into poor practices?
The actions of this EMT demonstrate either his lack of training or a lack of concern or the negative influence of law enforcement. We not only have a protocol problem, but a personnel and training problem. In addition to revising the EMS protocol, changes must be made to ensure EMTs comply with the protocol and best practices.