The Curious Case of the Final Calm

We can fix how we handle hyperactive delirium. We can’t fix assholes.

I’ve been lecturing on hyperactive delirium for nearly a dozen years. It’s a fascinating evolving topic with small amounts of research finally coming to light into this condition. This will help us reduce morbidity and mortality of this condition, and to finally put a stop to patients dying in police cars, ambulances, front lawns, and roadways. But no matter how much we learn and educate, it only applies to those who want to learn and be better. Mr. Edward McClure does not fit in this category. I have given my most recent lecture “The Curious Case of Bruce Banner: A New Lens on Severe Agitation” at various conferences around the continent and continue to deliver it in the hopes that one day we reach zero deaths of this type. This situation however goes well beyond knowledge and education.

The death of Jesus Lopez Barcenas on December 29, 2024, two days after an encounter with law enforcement and Emergency Medical Services (EMS) in Boulder, Colorado, was not an unavoidable tragedy. It was the direct, foreseeable, and preventable result of a catastrophic cascade of clinical failures by American Medical Response (AMR) paramedic Edward McClure. An analysis of the events of December 27, 2024, reveals a series of reckless actions that constituted a gross deviation from established medical protocols and the fundamental standard of care. These actions transformed a medical intervention into a fatal assault, culminating in manslaughter and forgery charges against the paramedic.

This report provides an exhaustive analysis of these clinical failures. It will deconstruct the incident into its core components of error, demonstrating how each misstep compounded the last, creating an inescapable physiological trap for Mr. Barcenas. The analysis will proceed through five distinct phases of failure:

1. The foundational failure to perform any medical assessment and the abandonment of professional de-escalation in favor of a punitive and contemptuous approach.
2. The administration of a sedative that never comes without risk, and failure to perform any safety checks.
3. The physical assault through the use of explicitly prohibited and lethal restraint techniques that are known to cause positional asphyxia.
4. The complete dereliction of the duty to monitor a high-risk patient following sedation and restraint, eliminating any chance of identifying and reversing his rapid decline.
5. The systemic and legal context, including institutional accountability and the clear precedent set by a similar case in Colorado, which should have prevented this tragedy.

This case, echoing the 2019 death of Elijah McClain in nearby Aurora, Colorado, serves as a critical and painful inflection point for prehospital medicine. It highlights the grave dangers at the intersection of law enforcement action and emergency medical response. Most importantly it underscores the non-negotiable, non-delegable duty of every medical clinician to act, first and always, as an independent patient advocate whose sole responsibility is to the preservation of life and the alleviation of suffering. The actions of paramedic McClure represent a complete abdication of that sacred trust.

The Foundational Failure: Abandonment of Patient Assessment and Professionalism

Every subsequent clinical error that contributed to the death of Jesus Lopez Barcenas stemmed from a single foundational failure: the paramedic's decision to forgo the most basic principles of patient care: assessment, communication, and monitoring. By immediately resorting to chemical and physical force, Edward McClure abandoned his role as a clinician and acted instead as an agent of control, setting in motion a fatal chain of events.

In the practice of prehospital medicine, patient assessment is the bedrock upon which all treatment decisions are built. National, state, and local EMS protocols universally mandate that a thorough assessment must precede any intervention, particularly an invasive one. For a patient presenting with altered mental status or agitation, this initial assessment is not a formality but a critical diagnostic step to identify and reverse potentially life-threatening conditions. Standard of care requires the clinician to rapidly evaluate for organic causes such as hypoxia, hypoglycemia, head trauma, stroke, sepsis, or other metabolic derangements, as these conditions frequently manifest as agitation or bizarre behavior. The Boulder County EMS protocols, which McClure was bound to follow, specifically direct providers to "Consider other causes of AMS" and to check a blood sugar level. As somebody who lectures on this topic I wholly understand in a case of hyperactive delirium, assessment and vital signs does become difficult, bordering on impossible. It doesn’t mean we don’t attempt.

According to the Boulder County District Attorney's investigation, McClure "injected Mr. Barcenas with a sedative before doing a proper medical assessment". This act represents the "original sin" of the encounter. By failing to perform even a basic assessment like obtaining vital signs, checking a blood glucose level, examining for signs of trauma, McClure could not possibly know the underlying cause of Mr. Barcenas's behavior. He could not know if the agitation was a symptom of a brain injury that would be worsened by a sedative, a diabetic emergency, or severe hypoxia. Instead of treating a patient, he treated a behavior. This is a profound violation of the most fundamental tenet of medicine: first, diagnose the problem, then treat it.

Compounding the failure to assess was the complete disregard for verbal and environmental de-escalation, the established first-line treatment for agitated patients. EMS guidelines and Colorado state law emphasize the use of communication techniques to build rapport, calm the patient, and reduce the need for physical or chemical force. These techniques involve respecting personal space, speaking calmly, validating the patient's feelings, and creating a less stimulating environment. The goal is to establish a therapeutic relationship, however brief, to ensure the patient's safety and cooperation.

There is no evidence McClure attempted any form of de-escalation. On the contrary, his documented statements, captured on law enforcement body cameras, reveal a mindset of contempt and coercion, the very antithesis of a therapeutic approach.

●      Upon preparing to restrain Mr. Barcenas, he stated, "Now let's strap the crap out of him".

●      When directing the dangerous prone positioning, he was heard saying, "Just keep him face down I don't care".

●      After injecting the sedative through a hole in the patient's jeans, he reportedly laughed and commented to an officer, "I love holes in the pants".

These are not mere unprofessionalisms but are diagnostic of a complete psychological shift from clinician to antagonist. The language is dehumanizing, punitive, and mocking. It demonstrates that McClure had ceased to view Mr. Barcenas as a patient deserving of care and instead saw him as an object to be subdued. This "contempt of patient" mindset is the root cause of the entire catastrophic outcome. When a clinician views a patient with contempt, objective assessment becomes impossible. The decision to forgo assessment was not a simple oversight; it was a direct consequence of a pre-existing hostile attitude. McClure had already decided Mr. Barcenas was a "problem" to be managed, not a human being to be treated.

EMS providers have a non-delegable duty to perform their own independent medical assessment and cannot sedate or restrain a patient solely for the convenience or at the direction of law enforcement. The clinician's primary responsibility is to the patient, not to the custody situation. In a crucial exchange documented in the District Attorney's decision letter, Boulder Police officers on scene explicitly told McClure they were "not allowed to be a part of administering a sedative," and that the decision was "McClure's" alone.

This moment created a clear and unambiguous "handoff" of medical authority. Law enforcement deferred to the clinician. McClure was now the sole medical decision-maker on the scene. A competent paramedic would have used this authority to begin providing medical care: stopping any ongoing struggle, ensuring the patient was in a safe position, and initiating a medical assessment. Instead, McClure used his medical authority to immediately apply force, both chemical and physical. He functioned not as an independent clinician but as an instrument of law enforcement, prioritizing control over care. He accepted the "problem" as defined by the circumstances of the police struggle and proceeded directly to a punitive solution, abdicating his duty to redefine the situation as a medical emergency requiring medical care.

The Chemical Hit: Inject and ignore

Following the initial failure to assess the patient, paramedic McClure compounded his errors by administering a medication that has risk. Whether it is droperidol like in this case, midazolam, ketamine, or something else, it needs to be properly selected for the situation at hand and understand no medication is without risk. The choice of drug, the dose, and the lack of any safety precautions created a synergistic effect that significantly contributed to Mr. Barcenas's death.

The act of administering the medication was itself a violation of safe practice. Standard medical procedure requires, at a minimum, obtaining a patient's weight or a reasonable estimation to calculate a weight-based dose, a baseline set of vital signs to assess stability, and a review of contraindications. For high-risk medications, consultation with online medical control is a common and prudent step. McClure performed none of these safety checks. As I alluded to at the beginning of this article, this class of patients do not make it easy to perform such. But there still has to be some type of baseline effort which was blatantly missing in this case.

The Physical Assault: Application of Prohibited and Lethal Restraint Techniques

After administering the chemical agent, paramedic McClure proceeded to physically restrain Mr. Barcenas in a manner that is explicitly forbidden by national standards and his own employer's protocols. This physical assault was a direct and primary cause of the patient's death from positional asphyxia.

The most egregious physical error was placing Mr. Barcenas in the prone (face-down) position on the gurney while his hands were cuffed behind his back. The dangers of this position are not obscure or controversial; they are a fundamental concept in EMS and law enforcement training. For well over a decade, EMS providers have been admonished not to transport patients prone on a stretcher. National organizations like the National Association of EMS Physicians (NAEMSP), numerous training bodies, and local protocols universally and explicitly prohibit this practice. The Boulder County District Attorney's Office and AMR itself both confirmed that transporting a handcuffed patient in the prone position was a direct violation of AMR's own policies.

McClure's action was not an oversight. Body camera evidence captured him insisting on this dangerous positioning, stating, "Just keep him face down I don't care". This statement demonstrates a willful disregard for a known and life-threatening danger.

The pathophysiology of positional asphyxia is well understood. Restraining an individual, particularly an agitated one, in the prone position can lead to death through a multifactorial process:

1. Mechanical Restriction of Breathing: The weight of the body on the chest and abdomen prevents the diaphragm from descending and the chest wall from expanding normally. This severely limits tidal volume and leads to hypoventilation (inadequate breathing).
2. Increased Oxygen Demand and CO2 Production: A person struggling against restraints has a massively increased metabolic rate, demanding more oxygen and producing more carbon dioxide.
3. Impaired Venous Return: Pressure on the abdomen can compress the inferior vena cava, drastically reducing the amount of blood returning to the heart (cardiac preload). This can lead to a precipitous drop in cardiac output and cardiovascular collapse.
4. Severe Acidosis: The combination of anaerobic metabolism from struggling (producing lactic acid) and hypoventilation (retaining carbon dioxide) creates a severe mixed metabolic and respiratory acidosis.
5. Fatal Arrhythmia: The "toxic triad" of hypoxia, hypercarbia (high CO2), and acidosis is a potent trigger for lethal cardiac arrhythmias, leading to sudden cardiac arrest.

McClure's deviations from safe practice did not end with prone positioning. He further compounded the danger by positioning the gurney at an "upright angle so that Mr. Barcenas' upper torso and head were in a more elevated, prone position" and by placing a "spit sock" over the patient's head.

This "elevated prone" or "jack-knife" position has no clinical justification and is uniquely dangerous. By raising the head of the gurney while the patient is prone, gravity forces the abdominal organs up against the diaphragm, further impeding its movement and making breathing even more difficult. The addition of a spit sock to a sedated, improperly positioned, and unmonitored patient is another reckless act. It obscures the airway, preventing the clinician from seeing if the patient is vomiting, choking, or becoming cyanotic (blue from lack of oxygen). It can also trap exhaled air, leading to the rebreathing of carbon dioxide, which worsens the already developing hypercarbia and acidosis.

The Final Failure: Dereliction of the Duty to Monitor

Even after the reckless treatment, opportunities still existed to save Jesus Lopez Barcenas's life. These opportunities were lost due to the final and complete clinical failure: the dereliction of the duty to monitor a critically ill patient.

National standards and established best practices in emergency medicine are unequivocal: any patient who has been physically or chemically restrained requires continuous and vigilant monitoring. This is not optional; it is an integral part of the intervention itself. Standard monitoring for such a high-risk patient includes:

●      Electrocardiogram (ECG): To detect arrhythmias, especially given the administration of a known arrhythmogenic drug like Droperidol.

●      Pulse Oximetry (SpO2): To measure the oxygen saturation of the blood.

●      Waveform Capnography (ETCO2): To provide a real-time measurement of ventilation by analyzing the carbon dioxide in exhaled breaths.

Waveform capnography is the undisputed gold standard for monitoring a sedated patient's breathing. Unlike pulse oximetry, which is a late indicator of a problem (we know that SPO2 levels only drop after a patient has stopped breathing for some time), capnography provides an instantaneous breath-to-breath picture of respiratory status. It is the earliest possible warning of hypoventilation or apnea, allowing clinicians to intervene long before irreversible hypoxic injury occurs. Boulder County protocols specifically call for EtCO2 monitoring after sedation, thus I can extrapolate they carry such capability.

There is no evidence that McClure performed any of these essential monitoring tasks. The charge of second-degree forgery, based on allegations that he made "inconsistent statements and written reports following this incident," strongly suggests that he may have documented vital signs or monitoring that did not actually occur, though I have not seen the run report. This is a common reason for such charges, when body camera footage or other evidence directly contradicts the official patient care report.

Mr. Barcenas's death was a predictable physiological process, not an instantaneous event. He would have progressed along a fatal trajectory: from agitation and struggle, to sedation-induced respiratory depression, to hypoventilation exacerbated by prone positioning, to apnea, to severe hypoxia and acidosis, and finally, to cardiac arrest.

Continuous capnography would have sounded an alarm at the very beginning of this slide, when hypoventilation first began. This would have prompted a competent paramedic to perform simple, life-saving interventions: repositioning the patient off his stomach, opening his airway, and providing assisted ventilations with a bag-valve-mask. These basic actions could have reversed the process and prevented the cardiac arrest. The failure to monitor was a failure to provide the most basic safety net for his own reckless interventions.

The forgery charge is a powerful piece of evidence that speaks to McClure's state of mind after the event. Falsifying a legal medical record is a deliberate act intended to conceal wrongdoing. It demonstrates a consciousness of guilt, undermining any potential defense that his actions were a simple mistake or a lapse in judgment. It suggests an awareness that his clinical conduct was indefensible and would not withstand scrutiny.

Systemic Context: Institutional Failures and Willful Blindness

While the actions of Edward McClure were the direct cause of this tragedy, they did not occur in a vacuum. His conduct must be viewed within the broader context of the legal landscape in Colorado and the institutional responsibilities of his employer, American Medical Response (AMR).

On August 24, 2019, in Aurora, Colorado, a 23-year-old Black man named Elijah McClain died after being forcibly restrained by police and injected with an overdose of the sedative ketamine by paramedics. I use that term loosely as I know the amount of drug given compared to weight based dose was not what killed Elijah, however I use the term in the context of the outcome of that case. It drew international attention and resulted in a landmark legal outcome: in December 2023, two Aurora paramedics, Peter Cichuniec and Jeremy Cooper, were convicted of criminally negligent homicide for their roles in McClain's death The prosecution's case centered on the paramedics' reckless decision to administer a massive dose of a powerful sedative without proper assessment and their subsequent failure to monitor McClain as his condition deteriorated.

The McClain case and the subsequent convictions set a clear and unmistakable legal, ethical, and clinical precedent for every EMS provider in the state of Colorado. It established that paramedics could and would be held criminally liable for deaths resulting from reckless sedation and improper management of patients in police custody. For paramedic McClure to commit a virtually identical series of errors like improper assessment, reckless sedation, dangerous restraint, and failure to monitor, just one year after the McClain verdicts is staggering. It suggests more than mere negligence; it implies a willful blindness to the most significant medico-legal event in recent Colorado EMS history. His actions represent a conscious or reckless disregard of a well-established, highly publicized, and legally reinforced standard of care, elevating his culpability from a simple error to a reckless act.

McClure's status as a newly certified paramedic raises critical questions about the training, supervision, and quality assurance processes at American Medical Response, a major national EMS provider. McClure received his Colorado paramedic certification on September 6, 2024, less than four months before the fatal encounter with Mr. Barcenas on December 27, 2024.

Newly certified providers are expected to be the most "by the book," adhering closely to the protocols they have just learned. McClure's flagrant and multiple violations of the most basic protocols suggest a potential failure in the system designed to support and oversee new clinicians. The possibilities include deficient initial training, an inadequate field training and evaluation (FTO) process, or a corporate culture that did not sufficiently reinforce protocol adherence for high-risk, low-frequency events like managing a severely agitated patient.

Further complicating the picture are the allegations of non-cooperation from the Boulder County District Attorney's office. The DA stated that AMR "failed to respond timely to several communications and requests from investigators," necessitating the issuance of search warrants to obtain records and information. While AMR moved quickly to terminate McClure and publicly condemn his actions as being contrary to their values and protocols, the alleged lack of cooperation with a criminal investigation raises serious questions about corporate transparency and accountability. This behavior, combined with a documented history of performance issues and fines for AMR in other Colorado municipalities like Colorado Springs for failing to meet response time standards, paints a picture of potential systemic issues that extend beyond a single "rogue" employee.

Although the term "excited delirium" is not explicitly mentioned in the charging documents, Mr. Barcenas's presentation—extreme agitation, nonsensical statements, unusual strength during the struggle with police—aligns with the classic description of this controversial and now-largely discredited diagnosis. In recent years, major medical organizations, including the American Medical Association (AMA) and the American College of Emergency Physicians (ACEP), have formally withdrawn their support for "excited delirium" as a valid medical diagnosis. They cite its lack of clear diagnostic criteria and its unscientific basis, and they recognize its disproportionate application as a justification for excessive force and in-custody deaths of marginalized individuals, particularly Black men.

McClure's actions, namely bypassing assessment and de-escalation to proceed directly to maximum chemical and physical restraint, are a textbook application of the outdated and dangerous clinical pathway associated with a suspected "excited delirium" presentation. This case tragically exemplifies the lethal consequences of applying this discredited paradigm, which prioritizes rapid incapacitation over careful medical evaluation and patient-centered care.

Conclusion

The death of Jesus Lopez Barcenas was a homicide, as ruled by the coroner, caused by a cascade of reckless clinical actions that were in direct violation of established medical standards. Paramedic Edward McClure's conduct represented a complete and willful abandonment of his duty to his patient. The sequence of failures is undeniable: a contemptuous and punitive mindset led to an abandonment of assessment, which led to reckless chemical sedation with a high-risk drug, which was combined with a prohibited and lethal restraint technique, all compounded by a complete failure to monitor the patient's predictable decline. These were not isolated mistakes but a chain of interconnected, reckless decisions that actively constructed the circumstances of Mr. Barcenas's death. The subsequent charge of manslaughter is directly supported by the evidence of this recklessness, and the charge of forgery underscores a consciousness of guilt.

To prevent such a tragedy from recurring, EMS systems, regulatory bodies, and their law enforcement partners must implement meaningful systemic changes.

Recommendations:

1. Mandatory High-Fidelity Training: EMS agencies must move beyond lectures and implement mandatory, high-fidelity, scenario-based training for managing agitated patients. This training must focus on hands-on practice of verbal de-escalation techniques, the pharmacology of sedation, the immense dangers of positional asphyxia, and the critical importance of post-restraint monitoring.
2. Robust Field Training and Supervision: EMS agencies, particularly large for-profit entities like AMR, must be held to a higher standard for the supervision and ongoing evaluation of their clinicians, especially those who are newly certified. Extended field training periods with experienced preceptors and regular high-risk/low-frequency skill validations are essential to ensure both clinical competence and professional comportment.
3. Formalized Inter-Agency Protocols: Law enforcement and EMS agencies must develop and train on formal, collaborative protocols for managing scenes with agitated individuals. These protocols must explicitly codify the paramedic's role as the final medical authority and an independent patient advocate, empowering and requiring them to direct care and ensure patient safety, even in chaotic or tense situations.
4. Mandate and Audit Capnography Use: The use of waveform capnography must be mandated for every patient who receives chemical sedation or is placed in significant physical restraints. Patient care records for these events must be subject to 100% audit to ensure this life-saving monitoring is being performed and documented correctly.

The death of Jesus Lopez Barcenas was a preventable failure of the most fundamental duties of a medical professional. Clinicians like this hamper the progress of the 99.9 percent of the rest of us who drive to be better on a daily basis. His case must serve as a catalyst for substantive change to ensure that the public can trust that when they call for help, the responding clinician will be a caregiver, not an agent of harm.