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People injected 4,000 times with sedative by SF fire department since 2018

Kareim McKnight poses for a portrait at their home in Vallejo, Calif., on Tuesday, August 23, 2022. McKnight says they were sedated against their will by San Francisco Fire Department personnel after protesting against the overturning of Roe v. Wade during Game 5 of the NBA Finals between the Golden State Warriors and Boston Celtics at Chase Center. | Jungho Kim for The Standard

San Francisco fire officials have administered more than 4,000 injections of a sedative to people who were in custody of a paramedic and physically restrained since the beginning of 2018, according to records obtained by The Standard.

The department’s use of midazolam—a pre-surgery anesthesia that slows breathing and in some cases causes memory loss or even death—came under scrutiny this month when a protester sued the city, the fire department and the police after a paramedic allegedly drugged them following a protest of the Supreme Court’s impending decision on Roe v. Wade.

Data suggest that SFFD paramedics have been administering midazolam (also known as Versed) an average of two to three times a day for the past several years, and the practice seems to be far more widespread than many might realize. It’s unclear how this compares with other major cities.

Tia Paneet, a registered nurse with the San Francisco Department of Public Health, told The Standard she was “concerned” after learning about the thousands of sedative injections SF fire personnel have given out in recent years.

“No, I was not aware of that. It’s news to me,” said Paneet, who has extensive experience working in homeless shelters and providing medical treatment to people on the street. “I think there is the issue of consent.”

Fire officials declined to provide The Standard with information on exactly when, where and why individuals under restraint have been receiving sedatives, citing a lack of compiled data and privacy concerns shielded by the Health Insurance Portability and Accountability Act (HIPAA). But the 4,000-plus injections were likely given to “someone who is a danger to self or others,” said Lt. Jonathan Baxter, a fire department spokesperson.

The total number of injections does not include those administered by two private emergency medical service companies in San Francisco: King-American and American Medical Response (AMR). King-American did not respond to a request for comment, while AMR declined to disclose how often it administers sedatives in the city.

One possibility for giving a person midazolam would be to slow someone’s breathing and heart rate if they are suffering from a drug overdose or heart condition, Baxter said. In 2020, a year in which overdose deaths in San Francisco spiked to more than 700, fire department paramedics administered a high of 970 injections.

San Francisco Fire Department ambulances outside of Zuckerberg San Francisco General Hospital on August 22, 2022. | Justin Katigbak for The Standard

But this surge also occurred during the first year of the pandemic, when many people were staying indoors and avoiding large gatherings—outside of attending protests against police violence following the killing of George Floyd.

The lack of answers on why people are being medically sedated in San Francisco has raised concerns that protesters expressing their First Amendment rights could be targeted with midazolam if they’re seen as too agitated or unwilling to stay quiet.

Civil rights attorney John Burris, who filed the lawsuit against the city in response to the incident involving the Roe v. Wade protester, told The Standard he was “shocked” to learn how pervasive midazolam injections are in San Francisco, and he worried that the sedatives could be used against other protesters like his client.

“It’s almost like it’s routine,” Burris said. “That strikes me as almost like a weapon—a weapon of choice. I would like to know how many of those circumstances relate to people who were protesting.”

‘He Approached Me With the Needle’

Kareim McKnight and a friend planned to steal a bit of the spotlight the night of June 13, when the Golden State Warriors were scheduled to face off against the Boston Celtics in a pivotal Game 5 matchup after splitting the first four games.

Of the 18,000-plus people in attendance, the question of which team would move one step closer to a championship couldn’t have been further from their minds.

A little more than a month earlier, an opinion on the landmark abortion case Roe v. Wade was leaked. The Supreme Court’s decision would roll back women’s health and reproductive rights in the U.S. and spark global protests.

McKnight, a longtime Bay Area activist, and their friend entered Chase Center and chanted objections to the court’s opinion while unfurling a banner that read, “Overturn Roe? Hell No!”

Kareim McKnight poses for a portrait at their home in Vallejo, Calif., on Tuesday, August 23, 2022. McKnight says they were sedated against their will by San Francisco Fire Department personnel after protesting against the overturning of Roe v. Wade. | Jungho Kim for The Standard

It didn’t take long for security to descend on them and have them removed from the arena. The lawsuit alleges security put a knee in McKnight’s back and handcuffed them. As McKnight continued to chant, a police sergeant allegedly threatened to have them sedated. City officials have declined to comment on McKnight’s lawsuit.

Baxter said that the fire department’s paramedics are the only people involved in a decision to sedate someone. But an investigation into the in-custody death of a man in 2017 found that a police officer called for a paramedic to sedate the man during a struggle. Carlos Margo would later die with the sedative, methamphetamine and amphetamines in his system, but the San Francisco Medical Examiner ruled the death an accident. No charges were ever filed.

McKnight said they were sitting in front of a vehicle outside of the arena when a paramedic brought out the needle.

“As he approached me with a needle, I started saying, like, ‘I could be allergic, I could be allergic.’ You know, I didn’t know what to do,” McKnight said. “And he stuck it in me. I was like, ‘Oh, my God.’

“I felt really vulnerable and just sort of physically depressed. I didn’t feel like I was going to fall asleep or anything, but I did notice I was moving slowly and kind of stuttering a bit.”

Later in an ambulance ride to the hospital—which resulted in McKnight receiving a $2,537 bill from the fire department—the protester wondered if they were the first or one of many to be sedated as a result of their activism.

McKnight, who is Black, believes the color of their skin was a factor in why they were drugged and punished.

“I asked them in the vehicle, ‘Are you doing this to other people? Are you doing this to protesters?’” McKnight said. “And I specifically said, ‘What about all the people who came out for George Floyd (protests)? You know, children who came out. I cannot even imagine.”

An Unclear Investigation

While the fire department’s data suggest that paramedics regularly inject midazolam into people who are restrained, few activists appeared to be aware of this when contacted for this story.

Burris said he had never encountered the practice before McKnight’s case. The National Alliance on Mental Illness’ local chapter told The Standard that it had no knowledge of such actions. A local leader of the CodePink movement also said she was unaware. 

Cleve Jones, a veteran LGBTQ+ activist in the Bay Area, told The Standard he was “pretty shocked” to learn of the practice.

“I think the risk of doing something like that is just enormous,” he said. “A responding officer has no way at all to determine the medical history of the person they’re detaining.”

A photo of Midazolam taken on Wednesday Feb. 15, 2010, in San Francisco, Calif. | Michael Macor/The San Francisco Chronicle via Getty Images

Politically, midazolam has often proven controversial—but not for its usage by paramedics. It is also part of a cocktail of drugs used in lethal injections. 

On the rare occasion when midazolam has received media attention as a tool of law enforcement, experts have often expressed surprise to learn about its usage. In 2008, Nashville TV station WSMV found that the city’s largest mental health advocacy organization, its mental health judge, and the local ACLU chapter were all unaware that law enforcement used the sedative—even though it had been allowed to for nearly two years.

Paramedics administering Midazolam first sparked controversy in San Francisco in 2019, when NBC Bay Area reported that the state’s Emergency Medical Services Authority (EMSA) was launching an investigation into the fire department’s use of sedatives following the death of two men who were drugged while in custody of paramedics. 

An official for the EMSA said the agency has no record of a department-wide investigation, and Baxter said the fire department was not aware of any probe by state officials over the last three years.

When administering midazolam, the fire department is required to monitor the patient’s heart rate, oxygen saturation and blood pressure. But the rules also note that patients on narcotics or with certain health conditions should be given smaller doses of Midazolam.

Additionally, the policy recommends discontinuing the medication infusion if the patient has hypertension, hypotension, “partial airway obstruction (especially when combined with narcotics),” or several other conditions.

Craig Smollin, a toxicologist and professor of emergency medicine at UCSF, said that encountering patients who have been given midazolam is not uncommon for emergency room doctors.

When a patient is severely agitated, doctors often don’t have time to figure out “what other preexisting medical conditions exist or what other medications the patient might be taking,” he told The Standard. 

“So it’s a balance between what are the risks of leaving the person who’s very agitated in that state versus giving them a medication that has potential risk,” he said. “Both of those scenarios have risk.”