Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Excited Delirium: Episode 72 EMS EduCast

I have been trying to figure out a good way to address the risks/lack of risks of following protocols. The EMS EduCast has a podcast that really puts all of this in perspective.

The guest, Marty Johnson, NREMT-P of Medicology™, had a bit of a negative outcome from a patient care situation. He was charged with murder.

He didn’t do anything wrong.

Go listen to the podcast.

How would that work out for you?

We may not take civil rights seriously, but this is what they are for. Every one of the rights in the Bill of Rights is there to make it difficult for the government to lock us up. Is that because the Bill of Rights was written by a bunch of criminals, or a bunch of bleeding heart liberals?

No.

It is because the people who wrote the Bill of Rights had just fought a war to rid themselves of a government that was comfortable searching people without warrants, spying on political groups they did not like, seizing property without due process, et cetera.

The Bill of Rights exists to protect us from the government. Governments will always do these things, because power corrupts.

Does anyone in the government have to worry about where their paycheck will come from while they are prosecuting us?

No.

They are getting paid to prosecute us. They might even get raises.

So. Me against the government?

How will I do?

Will following protocols protect me?

That depends.

If I follow my protocols, will that prevent bad outcomes for my patients?

If I follow my protocols, will that prevent bad outcomes for me?

We all know that bad outcomes happen with even the best treatment.

If I follow my protocols, will that prevent bad outcomes?

No.

What about being too aggressive with treatments?

Is that what led to the murder charge?

No. Quite the opposite.

If the patient had been aggressively sedated with doses large enough to remove every bit of medical director sphincter control, then this patient might still be alive.

But, No!

These doctors are more concerned about the possibility of respiratory depression occurring in hypermetabolic patients, than they are about the actual consequences of the patient’s metabolism being dangerously elevated.

Hypermetabolic = vital signs elevated enough to be dangerous.

Hypermetabolic = in need of respiratory depression.

So, what do these doctors want us to do?

Not sedate the patient and try to correct the dangerous vital signs, but wrestle with the patient and create a much more dangerous situation. Brilliant!

If I take a patient breathing at over 30 times a minute and cut his respiratory rate in half, is that dangerous respiratory depression? Is respiratory depression dangerous? How much midazolam/lorazepam/diazepam, haloperidol/droperidol, ketamine, et cetera would it take to cut his respiratory rate in half? What is considered normal respiratory rate for an adult?

Cutting his respiratory rate in half would probably require a lot more than a protocol permits.

Not to worry. I can always call medical command for more.

Picture riding a bull, while calling command, because however many people we have on scene – we don’t have enough – at least not enough to do this safely. The safest way to manage these patients is to heavily sedate them.

Safest for the people wrestling with the patient – police/fire/EMS.

Safest for the patient.

Safest.

I can’t prove that with any data (no data that I know of), but hundreds of people die in custody every year.

These in-custody deaths are not from over-sedation.

Some of these in-custody deaths may be from aspiration of vomit, but if I am going to sit there and allow a patient to choke to death on his vomit, then everything I do is dangerous. There is no safe way for me to treat patients if I sit back and watch them choke to death.

This is not a reason to avoid sedating patients.

Should over-sedation be a problem for any competent EMS provider?

Only if you accept the National Registry definition of competent, or the absentee medical director definition of competent. For everyone else, this definition can be found everywhere else under the word incompetent.

If I cannot handle an overly sedated person, I should not be working in EMS.

Over-sedation (under-stimulation) is a little, easy to manage problem.

Under-sedation (over-stimulation) is a huge problem complicated by protocols written by doctors who fail to understand these relative risks.

Maybe this is the rhythm –

Maybe this is the rhythm –

Maybe it is some other rhythm.

We don’t know.

We can’t tell.

After sedating the patient, we can measure vital signs and hook them up to monitoring equipment, but the agitated patient in need of sedation will not tolerate assessment. His vital signs are a mystery. His vital signs are elevated, but we don’t know how elevated and we probably don’t have good information about his medical history and what drugs he may have taken. If any sedatives have been taken, the quantity can be described as not remotely enough.

There is much more to write on this, but I am getting too worked up and need a sedative. More on this soon.

Excited Delirium: Episode 72
EMS EduCast
Podcast

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Comments

  1. This was an excellent episode and I applaud Mr. Johnson for sharing his experience so that we can all learn from it. Clearly he has paid a high price and he has my sympathy, but I can’t join you in saying that he “did nothing wrong.”

    If my understanding is correct, it sounds like he used a police baton to restrain the patient. While this may not have been the proximal cause of the excited delirium, it was very poor judgment. A paramedic should never use a weapon to restrain a patient unless:

    1.) The paramedic’s life or his partner’s life is in danger
    2.) There is no opportunity for escape
    3.) A weapon (or an improvised weapon) is needed to level the playing field to restore safety

    I can hear it now. “Hindsight is 20/20” and “you’re an arm chair quarterback.” No, I’m simply pointing out that it’s a mistake to say that Mr. Johnson did nothing wrong. Clearly at least one major mistake was made.

    Tom

    • I just finished listening to the podcast, and agree that it was excellent. Mr Johnson should be applauded for telling his story and I admire his desire to educate providers about excited delirium.

      In reviewing my notes on the podcast I see that I both circled and underlined the word “baton” followed by a question mark.

      I also noted how he repeatedly described this incident was “high profile” in his community.

      While we may never be able to read the true mind of the commonwealth attorney that charged him, these two factors likely played a significant role in deciding to charge him, especially when he revealed that he drove the ambulance to the hospital and did not ride the call.

      Tom, I would go further and say that a paramedic should never use a weapon to restrain a patient, PERIOD. I do not agree with your exceptions. For example, hitting a patient with an oxygen cylinder is not an appropriate “restraint method” in my opinion.

      From the “White Paper Report on Excited Delirium Syndrome”, American College of Emergency Physicians, September 10, 2009:

      “It is the role of LEOs to control the person with potential ExDS. However, as soon as control has been obtained, it is the role of EMS to recognize that this is a medical emergency and to assume responsibility for assessment and care of the patient.”

      The Appleton, Wisconsin excited delirium video shows an extraordinary level of coordination between police and EMS in dealing with such a patient. I think this type of coordination will be a must in these situations.

      Furthermore, providers will need to be given the proper chemical restraints for these patients so that we can assess and care for the patient, which is what I think RM is advocating here. Do I have confidence that we will be? No.

      • In my mind it boils down to force disparity. For example, EMS is called to the “world’s strongest man” contest. One of the participants is enraged and about to throw an 800 pound anvil on your partner’s head. With only a fraction of second to react, you hit the man in the head with an oxygen cylinder because it’s the nearest hard object. I don’t see this as different from any other “use of force” scenario for a common citizen. If you’re life’s in danger, you have a right to use an appropriate amount of force to defend yourself, and that is calibrated to your attacker. An unarmed 80 year old woman is different from a 20 year old man with a baseball bat. The context changes what is “reasonable” and I don’t see how wearing a uniform forfeits your God-given right to self-preservation.

        Tom

      • I should clarify, if there’s time to use a weapon to restrain a patient then there’s probably time to run away. So rather than get caught in semantics, I would like to amend my first post to say, “Don’t use a weapon unless you’re fighting for your life.” I agree with you insofar as I can’t think of a good reason for an EMS professional to restrain a patient with a weapon.

        Tom

    • Tom,

      I am going to be writing a lot on this topic. I made my response a separate post. Excited Delirium 2.

  2. Not sure how I feel about Paramedics using a baton. Being able to say I’m not the Police (and I won’t act like the Police either) gives me a lot of room with patients.

    Interesting video with a potential ExDS patient.

  3. Wow! Very interesting video. Thanks, Christopher!

    Tom

  4. I should also add that I’m skeptical of all claims regarding “superhuman” strength. It’s not easy to hold down someone who doesn’t want to be held down, especially if the goal is not to hurt them, and especially if they know how to use their legs. Ask any accomplished grappler or martial artist. Calling them “superhuman” is almost like calling them “other-than-human.”

    Tom

  5. I am trying to find a list of services that use Ketamine and/or have specific protocols for ExDs. If anyone can help I’d appreciate it.

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  1. […] This post was mentioned on Twitter by Greg Friese and EMSEduCast, EMS Blogs. EMS Blogs said: From #RogueMedic: Excited Delirium: Episode 72 EMS EduCast http://bit.ly/9QGApr #EMS #Blogs […]

  2. […] first comment in response to my post, Excited Delirium: Episode 72 EMS EduCast, is from Tom Bouthillet of Prehospital 12 Lead ECG. This was an excellent episode and I applaud Mr. […]

  3. […] I wrote about how others deal with this, including the death of a patient, in Excited Delirium: Episode 72 EMS EduCast. […]

  4. […] Excited Delirium: Episode 72 EMS EduCast Wed, 29 Sep 2010 Rogue Medic Article […]

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