Where law and medicine collide

Depending on the day, Jeffrey Ho's work attire may include a doctor's white coat or a badge and .40-caliber Glock with high-capacity magazines.

Ho transitions between head of paramedics at HCMC, where he oversees the response to tens of thousands of 911 calls every year, and a part-time sheriff's deputy in rural Minnesota.

He draws on his expertise in health care and law enforcement for a third job. He is a paid advocate for the Taser stun gun, one of the most popular police weapons in North America.

Ho's dual allegiances to medicine and policing collided last summer, when investigators from the Minneapolis Department of Civil Rights discovered that police officers were urging paramedics to sedate emotionally disturbed people in the field with the powerful sedative ketamine. Some patients were then enrolled, without their consent, in an HCMC study of ketamine, on which Ho was a lead researcher.

These revelations outraged some community members and elected officials, set into motion several investigations and ultimately were a factor in the resignation of HCMC's chief executive in February. As the city and HCMC work to regain public trust, City Council Member Jeremiah Ellison said Ho's other loyalties raise troubling questions about the hospital's independence from police interests.

"We are trying to clean up a culture that really enabled escalations of force. It feels like this doctor works against that," said Ellison. "If we're going to move forward in a way where we're building trust with the community — and we're not just approving and condoning escalations of force — then maybe we don't need to have a doctor who also advocates for the use of these weapons."

Ho, who declined to be interviewed but agreed to answer questions via e-mail, said he sees no conflict between his two professions. Police and doctors both want to help save lives, he said.

"I very much view my careers in emergency medicine, law enforcement and research as parallel pathways to public safety," Ho said in an e-mail. "It is my life's work to develop these areas of intersection for the benefit of public protection."

Publicly, HCMC officials have supported Ho. In a private meeting with paramedics at the hospital last December, Ho said that he'd been asked to resign, according to a recording of the meeting obtained by the Star Tribune.

"Why would I resign?" Ho told paramedics. "I didn't do anything wrong."

Ho blamed political pressure and an "overzealous" police oversight staff for the negative attention.

Ho and HCMC declined to address why he'd been asked to resign or any aspect of the ketamine issue, citing a pending lawsuit. A former patient is alleging malpractice and civil rights violations for sedating her against her wishes. Federal regulators are still investigating HCMC's ketamine research and whether the hospital took proper precautions to keep patients safe.

The delirium theorem

Ho has spent 14 years investigating a niche of science that resides in the intersection of medicine and policing: the study of why people die in interactions with law enforcement.

In 2005, with funding from Axon Enterprise, Inc., the Arizona-based Taser manufacturer, Ho wrote an article for Police Magazine disputing claims from human rights groups that its stun guns were killing people. "It has never been scientifically proven that a Taser has directly caused an in-custody death," Ho wrote.

He offered another explanation for these sudden deaths: "Excited delirium."

Ho didn't invent the term, but he's among a small group of doctors who specialize in researching it. A 2016 article in the medical journal Frontiers in Physiology defined the condition as a constellation of symptoms including extreme agitation, shouting, paranoia and violence with great physical strength and hyperthermia. It can lead to fatal cardiac arrest.

The American Medical Association, American Psychiatric Association and World Health Organization don't recognize excited delirium as a medical or psychiatric condition. Some human rights groups call it a way to blame the victims of police brutality, often in cases involving stun guns.

"This is not a medical diagnosis," said Homer Venters, former chief physician at Rikers Island jail in New York City. Venters, who now works for a nonprofit studying health in the criminal justice system, said he's been alarmed to see corporations like Axon promoting this term in recent years. "I think there's still an open question as to the scientific legitimacy of excited delirium," he said.

Ho argues that excited delirium is real, widespread and deadly. He said his research interests come from a desire to reduce the threat it poses.

Axon spokeswoman Carley Partridge concurs, saying in a statement, "There is no longer a true debate among knowledgeable medical professionals on whether excited delirium syndrome is a valid diagnosis."

Some emergency medicine specialists who don't work for Axon agree, including Dr. Christine Hall, a Canadian doctor who also studies excited delirium. She said Ho's conclusions align with what other researchers have found.

"What people love to say is: 'Excited delirium doesn't exist. We shouldn't be training officers about it,' " she said. "I say, cool, that's great. Then don't judge them later for not recognizing it when someone dies."

Other researchers may be more skeptical of Ho's work because of his ties to the manufacturer, but that doesn't nullify his conclusions, said Hall.

"Dr. Ho's work is saving lives and making our patients safer," said Dr. James Miner, chief of Emergency Medicine at HCMC who has authored Taser research with Ho.

Taser defender

Today, Axon Enterprise retains Ho as its contract medical director, a job to which he dedicates 32 hours per month at HCMC. In exchange, Axon pays the hospital about $140,000 per year. Ho's annual salary at Hennepin Healthcare is currently $460,000.

Ho's position with Axon is not disclosed on HCMC's website. He's also not the first doctor whose ties to the company have raised ethical questions.

In 2005, a previous Axon medical director, Robert Stratbucker, was removed from a University of Wisconsin study of Taser safety after it came out that he was on Axon's payroll.

Around this time, Ho came into the orbit of Axon, then called Taser International. It started when Axon reached out to a colleague at HCMC regarding consulting work, said Ho. The colleague couldn't make the date work and recommended Ho, he said.

Ho had been working at HCMC for 10 years as an emergency room doctor. Even early in his medical career, Ho took on work outside the hospital. He directed medical services for Edina's fire department, worked alongside Minneapolis police SWAT and consulted for a private medical product company. He enlisted in the National Guard, and he's been teaching at the University of Minnesota's medical school since 1996.

In 2003, Ho returned to school to pursue a two-year degree in law enforcement — a requirement to pass the police licensing board in Minnesota — from Inver Hills Community College.

Axon came to him with the consulting offer in 2004, he said.

The Taser was becoming an essential weapon for law enforcement, but Axon faced dozens of lawsuits alleging the weapon was hurting or killing people, according to securities filings. The company later told investors that it had found a solution: employ a group of "world class medical experts" to defend its product.

In 2007, Axon hired Ho to defend a Las Vegas officer accused of killing a man by stunning him repeatedly with a Taser, even after he had been restrained to a gurney. A coroner's jury had concluded that the Taser played a role in the death. Ho knew the Vegas police; two years earlier he had taken a course with the Las Vegas police department on excited delirium, according to documents the Star Tribune obtained through a data request. In court documents, he cited symptoms of excited delirium to explain how the man had died, saying the Taser wasn't a cause. The judge agreed, ruling in favor of the police and Axon.

In 2008, Axon enlisted Ho again when the company sued a medical examiner in Ohio for citing Taser as a factor in three deaths. Ho said the weapon could not have killed them, suggesting excited delirium was to blame in all three cases. A judge ruled in favor of Axon, forcing the medical examiner to scrub Taser from death records, and leading to a police officer being exonerated of murder charges in one of the cases.

Ho has provided his expert opinion in more than two dozen lawsuits in 14 states and a Canadian province, according to court records. In addition to his pay as medical director, Ho bills up to $400 an hour for his services to Axon or the law enforcement agencies that retain him, records show.

Ho has also traveled the world to give more than 100 presentations on Taser technology, from Austria to Australia, Barbados to Berlin and all over the United States, according to his curriculum vitae. In 2006, he spoke to medical officials in France as police in that country prepared to start using stun guns. In 2011, he gave presentations on arrest-related deaths and use of force in U.S. embassies in Serbia and Turkey. In 2017, he traveled to London and Ireland to talk about Taser technology.

By C.J. Sinner, Star Tribune

Axon also contracts with HCMC's security force, of which Ho is the medical director. The arrangement requires HCMC to make its security personnel available for conferences and other appearances promoting its use of the stun gun to protect patients, staff and guests.

Today, Axon boasts that the Taser is now used by 18,000 law enforcement agencies around the world, and that it has been discharged more than 4 million times in the field. Axon cites Ho's research under claims on its website that its stun gun is not only safe, it's responsible for saving more than 216,000 lives. Ho defends his employer's tally.

"The reason I am certain that lives have been saved by Taser weapons is that there are many cases I am aware of (including some I have personally been involved in) where an officer would have been legally authorized to use their firearm in defense of themselves or another but opted to use a Taser weapon instead," he told the Star Tribune. "Had the Taser weapon not been available, the result would have been a seriously injured or dead officer or subject, or both."

A few years after the Ohio case, Ho began publishing research on another tool he said combats excited delirium — a sedative called ketamine.

Ketamine questioned

Ketamine has long been used by emergency room physicians as a sedative and anesthetic. In 2012, Ho published a paper that concluded that ketamine works more quickly than comparable sedatives, with fewer side effects. He wrote the drug could be "easily administered" by paramedics to combat excited delirium.

Over the next five years, mention of the term "ketamine" in Minneapolis police reports soared from three to 62.

Imani Jaafar, director of the Minneapolis Office of Police Conduct Review, noticed. While reviewing hundreds of hours of police bodycam footage, she and her team observed officers asking paramedics to sedate people and joking about the drug's debilitating effects. Some patients suffered medical complications as a result. One man was hogtied, sedated and put in the back of an ambulance.

One of the paramedics mentioned HCMC's ketamine study to officers, prompting investigators to question whether a need for subjects for Ho's study was driving up use of the drug.

In response to the review board's findings, police leadership ordered officers not to give medical advice to paramedics.

Instead of releasing the report to the public, the city sent the findings to HCMC.

In a written response, Ho and study co-investigator Dr. Jon Cole dismissed the city's findings as a "reckless use of anecdotes, partial snapshots of interactions with police" that drew "uninformed and incorrect conclusions." The conclusions of the report, they wrote, "will prevent the saving of lives."

The report remained secret until two weeks later, when the Star Tribune obtained a copy and published its findings.

In a public hearing afterward, community members filled the City Council chambers to protest police involvement in sedating patients, some calling out Ho by name. "The fact that the director for Emergency Medical Services of HCMC is also an active-duty sheriff in Minnesota is disgusting and appalling and absolutely a conflict of interest and a conflation of two entities that should be completely separate," Minneapolis resident Maddie Harrison told council members.

The city hired former acting U.S. Attorney General Sally Yates to investigate the matter. While the Yates investigation was cut short, her preliminary report found police officers in Minneapolis appeared to have "a high degree of familiarity with the use of ketamine."

Officers were also diagnosing "excited delirium syndrome" on the street, though it was unclear whether they'd ever received training on this condition.

Battle within

By December, frustration had been simmering for months among paramedics when they met with Ho to discuss a death threat from a former patient who had been sedated against his will.

One paramedic called the study negligent for encouraging paramedics to sedate patients who appeared to be "having a bad day," not just those showing dangerous agitation. That meant a higher likelihood of ending up in intensive care with tens of thousands of dollars in hospital bills.

"That's your name that was on that study," another paramedic said to Ho. "We did what we were supposed to."

Ho blamed the civil rights department for dragging paramedics into the controversy. He faulted the hospital administration for failing to understand the jobs of paramedics, city officials for deflecting blame away from police and the media for sensationalism.

"None of the things in the report were accurate," Ho said. "They weren't coming from a person who has any understanding of how a research project [works]."

HCMC executives say Axon did not provide funding for the ketamine research. Records show Axon has given grants to the hospital's nonprofit research arm. The hospital, citing a pending lawsuit, also has denied public records requests that would tell how the research was approved.

In January, HCMC released its own review of the ketamine study, concluding that no patients were harmed. In an internal e-mail obtained by the Star Tribune, Ho and two other EMS leaders characterized this as absolution.

"The leaked [city] report created a narrative that attempted to define us and it will not stand," they wrote to Hennepin EMS employees. "We will create our own narrative, and it will define us with integrity, honor, courage, teamwork, and compassion."

HCMC says it has been working to earn back the public's trust, such as creating a community advisory board to be more transparent about its research studies.

Dr. Eric Campbell, a University of Colorado bioethics professor who specializes in conflicts-of-interest in the medical field, believes that may be difficult given the hospital and Ho's ties to law enforcement.

"It would seem reasonable to me that many patients may not go to HCMC if they knew that there was a doctor there who was also a police officer," Campbell said. He cited the opioid epidemic as one example where the roles of police and doctors conflict.

Ho says those concerns are unfounded.

"People who call my ethics into question don't know me very well," Ho said. "My goal has been to use this work to protect people from injury, save lives in the field and to fairly reimburse my employer for my time spent in this endeavor."

Andy Mannix • 612-673-4036