Two men in Colorado were cuffed on the ground. Both were injected with tranquilizers against their will in police stops.

“They are being lazy. I guess they didn’t want to deal with a drunk asshole,” he said.

McKnight is not alone in questioning whether police are influencing paramedics to use the powerful tranquilizer that requires hospitalization for nonmedical reasons.

CNN has found ongoing investigations in multiple states regarding emergency responders’ use of the fast-acting drug to tranquilize people against their will. In some places, such as Colorado and Minneapolis, the use of the drug by paramedics rose sharply in recent years.

Outrage over its use has motivated a city council member in Aurora, Colorado, to propose a temporary ban on the administration of the drug by first responders. In Minneapolis, the police department decided to create a new policy for its officers in 2018.

Sidewalk to ICU

Body camera video shows Arapahoe County sheriff’s deputies approaching Elijah McKnight in 2019 to check on his welfare while he’s passed out on the sidewalk. The conversation is calm and cordial to start, even after McKnight admits unprompted that he has warrants out for his arrest.

Deputies and McKnight go back and forth with McKnight asking them to call his father and deputies taking down his dad’s number. But, eventually, the officers move to detain McKnight and he tries to run.

The video shows officers grabbing him and pulling him down in a struggle. He’s accused of kicking one of the officers in the face. McKnight denies that, but admits he was angry, scared and uncooperative.

The deputies warned him and then use a Taser on him. McKnight is lying face down in the dirt with his hands cuffed behind his back as the two deputies lean on his legs. He screams that his legs are in pain. So when paramedics arrive, he is relieved.

“When they first came on the scene, I was like, please help me,” McKnight told CNN. “Finally, I have witnesses, now the police can’t do something to me.”

Body cameras captured the encounter between McKnight and first responders.

The paramedics assess him. McKnight loudly asks to be lifted up.

Still on the ground, McKnight occasionally yells out but is able to give correct answers when asked what year it is and who is the president.

“You’re a little too hyped up right now, you gotta relax,” a medic from South Metro Fire Rescue says.

“I am being cooperative,” McKnight insists.

“You are. You are. And I appreciate it, man,” the paramedic says.

After about six minutes, paramedics determine McKnight does not need hospital treatment.

But then one of the deputies asks, “You can’t give him anything can you? Unless you go to the hospital, right?”

A paramedic responds, “We can give him ketamine. He’ll be sleeping like a baby, but he’ll have to go to the hospital.”

McKnight objects, yelling: “Don’t give me. Don’t inject anything into my veins.”

It is unclear whether a paramedic or deputy responds, saying, “Just give it to him. I mean he’s bucking the three of us. Just give it to him.”

And they do. After a 500-milligram shot, the paramedics’ post-incident report says McKnight is being “wildly combative.” On body camera video, they say he is still able to “lift” them.

The video shows McKnight cuffed and laying still, yelling out now and then. Paramedics call a physician and get permission to inject him with 250 more milligrams of ketamine — a total dose higher than the drug manufacturer and the state health department recommends for a man of his weight. And finally, McKnight passes out. On the paramedic logs, it says McKnight was suffering from “excited delirium,” a controversial medical diagnosis.

McKnight sees that as simply an excuse to knock him out because police didn’t want to deal with him. Once ketamine is given, the recipient has to be hospitalized.

“They said I didn’t need to be hospitalized. So they definitely wasn’t going to give me ketamine until the police asked for it,” McKnight said. “I definitely wasn’t experiencing excited delirium, I can tell you that.”

A powerful drug

Ketamine is often the strongest sedative in a paramedic’s kit in departments that allow its use. In Colorado, where McKnight lives, the crews need a waiver from the health department to use it. Doctors administer it for pain relief and it can even be a general anesthetic.

In Colorado in the spring of 2013, the state health department’s Emergency Medical Practice Advisory Council cleared the use of ketamine in the field to treat patients with “a presumptive diagnosis of excited delirium,” but EMS agencies need a waiver to use it.

Excited delirium is defined as a condition where a person is so violently agitated that they can essentially exercise themselves to death, two doctors told CNN.

This month, the state health department announced plans to review its ketamine waiver program.

Between 2018 and 2019, there was a 72% increase in ketamine waivers for excited delirium Issued by the Colorado Department of Public Health and Environment. Some 902 waivers were made from 2018 to June 2020, even though the department guidance says the condition is rare and ketamine should “not be considered the standard of care for the management of excited delirium or agitation.”

That increase in usage is “alarming,” said Dr. Mary Dale Peterson, president of the American Society of Anesthesiologists. “It can be fatal, as we have seen in a couple of cases without proper monitoring and attention to detail.”

“Ketamine, or any other drug, you know, should not be given for purely law enforcement purposes. We give drugs to treat medical problems,” Peterson said.

The syndrome of “excited delirium” is not recognized by major medical organizations such as the American Medical Association, the American Psychiatric Association or the World Health Organization. It is, however, recognized by smaller organizations that deal with emergency medicine, such as the American College of Emergency Physicians.

Dr. Walter Dunn, a psychiatrist and UCLA associate clinical professor, says the controversy over “excited delirium” doesn’t mean the syndrome does not exist — but it is tricky to diagnose.

“Even clinicians would have a difficult time diagnosing an excited delirium,” he said. “When you employ ketamine you better be darn sure that this is excited delirium and not something else.”

That is because, aside from being a powerful sedative, when coupled with other medications or substances, the drug can have unintended consequences, Dr. Peterson says.

Excited delirium is what authorities from two different EMT agencies said McKnight and McClain, who had no alcohol in his system, were experiencing when they were injected. Both received doses larger than the state medical guidelines for their size.

The Colorado health department recently determined medics’ actions on McKnight were “independent of police requests” and “warranted.”

His encounter with police ended with him being loaded on to a gurney to be taken to a hospital, where he was hooked up to a ventilator to keep him alive.

Peterson, the anesthesiologist, said that was a known side effect of the tranquilizer. “Depending on what study you look at, 30% to 57% of patients will require intubation,” she said.

That’s also what happened to McClain. But he never woke up.

McClain’s fatal encounter

A resident called Aurora police, saying McClain seemed suspicious because he was moving his hands around and wearing a ski mask in the summer. McClain’s family says he had a blood condition that would make him feel cold.

Elijah McClain died days after his encounter with police.

As police approached, the violin player and masseur was listening to music through headphones. When an officer touched him, he appears startled.

“Please respect the boundaries that I am speaking,” McClain says on body camera video.

Everything happens so fast. There is a struggle when officers decide to arrest him. The slight, 140-pound McClain is cuffed and on his stomach. He says he can’t breathe. Two officers are on him. He is put in a chokehold at least once. He vomits. At one point, an officer says, “Whatever he’s on, he has incredible strength … yeah, crazy strength.”

It turns out he was not “on” any illegal drugs. According to the autopsy, none were found in his system.

Paramedics are on the scene by now; they administer 500 milligrams of ketamine, nearly twice the recommended dose.

“I’ve been in practice 30 years and never given a dose that high,” Dr. Peterson said. She is not involved in McClain’s case.

Mari Newman, an attorney for the McClain family, told CNN: “‘Incredible strength’ is the buzz word police use. It’s an excuse that the person they are dealing with has superhuman strength. They get paramedics to use ketamine to cut corners and quickly sedate people they don’t want to deal with.”

McClain ends up having a heart attack in the ambulance on the way to the hospital. He was intubated and put on a ventilator. He died three days after his encounter with police and paramedics.

New investigations have been opened into the circumstance surrounding McClain’s death.

“He could not breathe. He was fighting for his life,” said his father, LaWayne Mosley. “I wish I was there to fight for him.”

The autopsy report said McClain died of “undetermined causes” but contributing factors were “intense physical exertion and a narrow coronary artery.” The coroner said an “unexpected reaction” to a therapeutic level of ketamine “cannot be excluded” as a factor in his death.

Aurora Fire Rescue determined last November that their paramedics’ actions were “consistent and aligned with our established protocol” and that McClain was showing signs of “excited delirium, a dangerous and often inexplicable condition.”

The district attorney’s office declined to press charges against the officers involved and they were later reinstated after being put on routine administrative leave.

Nearly a year after his death, the city, state and health department opened new investigations into his case.

Elijah McClain’s case gained attention again this summer when protesters demanded action.

The FBI and the Justice Department have been reviewing the case since 2019.

A spokesperson for the National Fraternal Order of Police said the idea that police are using excited delirium as an excuse to use excessive force by injecting ketamine on any subject is out of line.

“I push back on that,” Sherri Rowan, the national director for wellness services for the National Fraternal Order of Police, told CNN. “As soon as they respond and recognize what it is, medical personnel are summoned. EMTs and paramedics are called because of the risk that is possible when someone is recognized to be having that sort of condition. Police departments are looking to do the best job that they can.”

A paramedic’s story

There is no national database that tracks ketamine use by EMS workers across the US. CNN found several ongoing investigations into the use of ketamine by first responders across the country.

One completed investigation was in Minneapolis. Ketamine is also used by first responders in nearby communities, such as Woodbury, where Joseph Baker used to be a paramedic.

“I have been pressured by police to administer ketamine,” Baker told CNN, in his first media interview. In August, he filed suit against the city of Woodbury, where he worked until 2019.

Joseph Baker says he was pressured to use ketamine by police when he was a paramedic in Minnesota.

Baker says he had to quit after suffering retaliation and being disciplined for exposing falsified EMS training attendance documents that allowed people to get or keep their certifications to be paramedics, and disciplinary action for refusing to bow to police pressure to use ketamine when he thought it was not medically necessary.

The fight over ketamine was one of the final straws, he said. In 2019, he says he was called to assist with someone having a mental health crisis. Before he even arrived, dispatch was telling him and his crew to “get the ketamine ready,” he said.

“I was met by multiple officers who asked, ‘Do you have your ketamine ready, do you have it drawn up?’ And I said, ‘No. I have it available, but I’d like to evaluate this patient,'” Baker told CNN.

That angered the police officers, he said. But, in the end, he said, talking to the patient worked and no drugs were required.

“The most powerful medication that we have on the ambulance is our ability to speak with patients. Ketamine takes that away.” Baker said. “I don’t believe it should be requested by police. I don’t tell them when to use their mace. They should not tell me to administer drugs.”

In a statement to CNN, the city of Woodbury said it “internally reviewed its Emergency Medical Services training records and protocols and determined the training and protocols were in compliance with all licensing requirements. Contrary to the allegations in the Complaint, no training records were falsified, and Mr. Baker’s complaints were properly addressed.”

It said with regard to the administration of any medications such as ketamine: “No employee of the City of Woodbury improperly administered any such medications.”

The city added, “Mr. Baker was never disciplined or subject to retaliation and we categorically deny the allegations in the complaint.”

Baker’s attorney, Kenneth Udoibok, disputes that and says not a month goes by at his small Minneapolis office without a call linked to administration of ketamine.

“People are not complaining that the paramedic injected them with ketamine. They are complaining that a police officer caused that to happen,” Udoibok told CNN.

Care or improper conduct?

That report also found in some cases, the person being detained was not only handcuffed, but strapped down on a stretcher in an ambulance before receiving ketamine.

Ryan Patrick, an attorney on the Minneapolis Office of Police Conduct Review, said during a public city council meeting that the full picture was complex.

“There is a wide range of involvement in those cases,” he said, “ranging from officers directly suggesting that ketamine in particular be administered to EMS professionals asking MPD officers if they believe they should be sedated.”

Attorney Udoibok calls ketamine use “the perfect crime against citizens.”

“If police are accused of abusing the use of ketamine, the police say it wasn’t their decision to administer it, that was the paramedics’ choice,” he said. “And paramedics are never going to admit they are liable, so they will say ketamine was necessary.”

Due to the McClain case, an Aurora City Council member is pushing for a temporary ban on the use of ketamine by first responders until the investigations in his case are complete.

McClain family attorney Newman said it should not have been used in the first place against Elijah.

“This is just another way to use excessive force against people, especially people of color.”

McKnight said he hopes they ban it all together.

“I woke up choking on a ventilator. This should not happen to anyone else ever again.”