Don’t let your imagination get the better of you, here. Too Old To Work, Too Young To Retire is not a naked woman, although he is rumored to do a great impression of Lili Von Shtupp.
However, TOTWTYTR does have a post titled, A Naked Woman. This post was inspired by Flashlights, a post by Burned-Out Medic. Go read both, then come back.
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My thoughts automatically go to the method of restraint – physical, rather than chemical.
Who benefits from having EMS use physical restraints, rather than chemical restraints?
The patient?
No.
EMS?
No.
The police?
No.
The advocates of restrictive EMS protocols?
Bingo.
The avoidance of sedation only benefits those who place protocols ahead of patient care.
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I couldn’t have a post with a title of A Naked Woman and not include at least one picture.
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If we were to inject people with boluses of epinephrine, would the effect on the patient’s body be much different from what happens when we physically restrain agitated delirium patients, but we do not provide any sedation?
This is where aggressive sedation protocols are very important.
How much do we want to increase the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient?
In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the patient?
In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the physical safety of police, EMS, family members, and by-standers?
In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the legal safety of police and EMS?
If limited to midazolam, what really are the difficult to manage problems, if we start with 10 mg IM for this 45 kg patient? 0.22mg/kg IM (IntraMuscular).
Yes, I do realize that this is much higher than the label recommends, but has anyone ever seen an agitated delirium patient respond, even a little bit, to the recommended doses of midazolam?
The recommended premedication dose of midazolam for good risk (ASA Physical Status I & II) adult patients below the age of 60 years is 0.07 to 0.08 mg/kg IM (approximately 5 mg IM) administered up to 1 hour before surgery.[1]
A whole bunch of unknowns vs. an NPO patient being given some sedation for routine surgery (not anesthetic dosing).
0.22 mg/kg midazolam vs. 0.07 to 0.08 mg/kg midazolam.
10 mg midazolam vs 3 1/2 mg midazolam.
I expect that one, or two, people will have anecdotes about the recommended dose of midazolam actually working. Anything is possible. However, why are we so hesitant to protect patients from the dangers of hypermetabolic states?
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PS – TOTWTYTR, are you sure that the feces was from the dogs?
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Continued in A Naked Woman – TOTWTYTR – Part II and later to be continued in A Naked Woman – TOTWTYTR – Part III.
I wrote about how others deal with this, including the death of a patient, in Excited Delirium: Episode 72 EMS EduCast.
Footnotes:
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[1] Dosage and Administration
Midazolam Hydrochloride (midazolam hydrochloride) Injection, Solution
[HOSPIRA, INC.]
DailyMed
Label with link to download of PDF of full FDA Label
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Great thoughts. I wonder how many medics are going to be concerned w/ accidental needle sticks when trying to chemically restrain such a patient.
Personally, I’d consider the nasal administration route, assuming you can hold her head still long enough, but then the same goes for holding a limb still long enough for a needle.
Hey, if you’re gonna hold them still long enough for a needle, why not an IO?
Also something to consider is that Midazolam has a potential 20 minute onset of action if given IM…
There are other drugs out there for us – Haldol & Inapsine just to name a few.
Yes, they have their dangers – just as any other medication we administer. But, as professionals, we are to be expected to know and deal with the potential side effects.
So in a versed only world, lets just give alot? I’ll sedate the *** out of people when needed but feel I should have more options besides versed.
Christopher Smith,
In a world with limited resources, we should use what we have in the way that is best for the patient.
Absolutely.
I am not suggesting that midazolam is the best drug for excited delirium. Midazolam is far from the best.
I’m not a big fan of using chemical restraints on patients, especially since from my experience you have to physically restrain the patient before you chemically restrain them. If we look at in hospital practice, at least in this part of the world, the patient is always restrained before meds are administered.
Practically speaking, it’s not easy to administer any medication to a violent patient. IV requires physical restraint, IM requires some physical restraint before and after administration, IN requires getting way closer to the patient’s mouth than I want to and some amount of physical restraint.
Maybe if we could aerosolize the med, but then that would put everyone at some risk.
Where is Marlin Perkins when we need him?
Too Old To Work,
Yes, some form of restraint is necessary, but why continue physical restraint for a medical condition that is more safely treated with sedation?
That all depends on the way it is done and the agent used. If the chemical used in the Moscow hostage rescue was based on fentanyl, preloading EMS and police with naloxone would be one way of using this. Airing out the scene afterward would be important.
Up in the helicopter.
We are Stan.
A tranquilizer gun is a nice idea – right up until you see some people shoot.
I work with some people who would be more accurate if we spun them around and blindfolded them.