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.
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?
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?
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?
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?
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.
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.
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