Are Patients Accidentally Tripping on Ketamine in the ER?

As an emergency medicine doctor, Dr. Case Newsom frequently uses ketamine to numb patients’ pain when he has to set broken bones, place dislocated shoulders back into sockets, and perform other emergency interventions.

Dr. Newsom is calm, caring, and steady, making him a natural anchor in even the most panicked situations. Still, early in his career, he encountered numerous bad ketamine reactions. Patients would come out of their ketamine anesthesia agitated, disturbed, and sometimes unhinged. Moving their arms, swinging their legs, sitting up, and trying to bail out of the hospital bed. Nonsensical word salad, petrified, heavy breathing, and racing hearts. 

This is typical. Roughly 15 percent of the time that people get ketamine for emergencies, studies say, they have a notable "reaction" to it. Some say they liked it. More often, patients use words like "bizarre, frightening, or nightmarish." 

The solution to these reactions, in practically every E.R. and ambulance, is simple: give a downer, like a benzo, and knock the patient out. It's the kind of brute-force approach to a challenging situation that emergency medicine often relies on. 

The military influence on emergency medicine is impossible to ignore. Paramedics wear uniforms with rank patches. Leaders are called captains. You bark "copy that" and "10-4" into radios. The whole enterprise feels like a civilian extension of the battlefield, which makes sense: From WWII to Vietnam to the Wars on Terror, many paramedics developed their skills in war zones before bringing them to streets that are only sporadically bloody. 

In 2018, I worked part-time as an ambulance driver in Boulder, Colorado. One day, our captain gathered us in headquarters — a drab conference room with halogen lights — for a training session, which we had often, this time about ketamine. 

I'd never tried ketamine, or given it to patients. Our captain explained ketamine clinically: It's a dissociative — it separates mind from body. Ketamine is a superb painkiller because it doesn't interfere with breathing — unlike opioids. The captain covered dosages, injection sites, and monitoring protocols. Standard stuff. 

Then something unexpected happened. The captain mentioned that when patients emerge from ketamine, "they will be in a different world from you." On the PowerPoint, he displayed what looked like a Magritte painting mixed with magical realism — a top-hatted man with an umbrella floating on rainbow clouds. Other emergency trainings on ketamine, I later learned, show their medics what ketamine looks like using Rick and Morty screenshots. 

Then the captain moved on to other aspects, like ketamine's effect on blood pressure.

And that was it! 

I made eye contact with some co-workers, like, "Did you see that? Is that what ketamine is like!?" I got nothing back. Either no one's curiosity was piqued by the revelation that ambulances possess a medicine capable of transporting patients into a surrealist painting, or they were too afraid to admit it, worried it might lead to a drug test, which the company would administer if they had any suspicions, like if you drove an ambulance into a wall.

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