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

- Rogue Medic

Excited Delirium, Sedation, and Comments – Part III

There are some more responses to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

Why do I write so much about excited delirium?

Few of our patients will have any kind of life-or-death intervention from EMS. These are some of the patients. We can make the difference between life and death.

These are also some of the least likable patients we will deal with – they are often attacking us. How do we protect ourselves and protect our patients?

Some people continue to tell us that sedation is evil.

This is from kindofafireguy

Granted, I’m no lawyer, but it seems to me the greatest potential for liability is when the standard of care is NOT met, as opposed to when it is.

So if you have protocols for chemical restraint (as my region does), to me that would imply greater liability for not restraining a patient in need of it and said patient wreaking mayhem and injuring people.

But that’s just me applying common sense. So it’s probably wrong.

I am not a lawyer, either. I think that we have too many people telling us what a jury will do, when we do not know what a jury will do. The jury determines what is the standard of care and whether that standard was met. Trying to predict what 12 people (or six) will agree on – after listening to very biased, but antagonistic descriptions of the same events and expert testimony that is similarly antagonistic – is not something intelligent people should do.

The only legal advice that makes sense to me is –

Do what is best for the patient.

The problem is that we do not always know what is best for the patient, but –

If the patient is excited, with all other patients, we would be trying to calm the patient down. With excited delirium, we seem to be going out of our way to make them even more sedated. Here are some nice soothing leather restraints.

If we follow the physical restrain promptly with chemical restraint, that is patient care.

If we do not follow the physical restraint with chemical restraint, how is that patient care?

This is from Kelly Grayson of A Day in the Life of an Ambulance Driver

“By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.”

How… quaint.

Don’t know what hospitals Shane is dealing with, but virtually every hospital I take patients to has virtually done away with leather restraints, partly because of Joint Commission requirements, but also because they’d much prefer to sedate.

Let me repeat that: MUCH prefer to sedate.

There are EMS agencies near me that do not aggressively sedate agitated patients.

As our medical protocols become more and more aggressive, that is changing, but we still have to wait for some of the old medics (and old medical directors) to die off. Being treated according to their own protocols may be the best way to do that. If it does not kill them, being treated by their own protocols may convince them that their approach to patient care is not good patient care.

They’d much rather use a B52, or Geodon, or Zyprexa, or increasingly, ketamine, and they’re tickled pink if we get a head start on that before we even arrive.

B52 refers to a mixture of B (Benadryl – diphenhydramine) 50 mg, haloperidol (Haldol) 5 – 10 mg, and lorazepam (Ativan) 2 mg. These doses are not limits, but starting points for sedation. We can always give more, even if we have to make a phone call while in the middle of wrestling with the patient.

The Haldol does not get the recognition it deserves, but that is what is doing the most to knock the patient down – not knock the patient out. Knocking the patient down has little to do with gravity. Knocking the patient down means getting rid of the patient’s combative behavior.

The diphenhydramine is there both as a sedative and as prophylaxis against extrapyramidal symptoms.[1]

This is from an article in Emergency Medicine News on treating excited delirium –

Regardless of one’s choice of medication, the key to success is to use enough drug. Internist- and pediatrician-type doses usually don’t cut it. The PDR is clueless about effective doses for our purposes, and safety caveats in that publication are merely fodder for lawyers, not information for clinicians. The best guideline is to give enough to achieve the intended result.[2]

 

Regardless of one’s choice of medication, the key to success is to use enough drug.

 

Why do so many of us attempt to justify giving an inadequate dose?


Image source.

See also –

‘Hog-tying’ death report faults Fla. medics.

Excited Delirium, Sedation, and Comments – Part I

Excited Delirium, Sedation, and Comments – Part II

Footnotes:

[1] Extrapyramidal symptoms
Wikipedia
Article

[2] Rapid Tranquilization of Violently Agitated Patients
Roberts, James R. MD
Emergency Medicine News:
November 2007 – Volume 29 – Issue 11 – p 15-18
doi: 10.1097/01.EEM.0000298833.70829.ad
Free Full Text from Emergency Medicine News

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Comments

  1. “Trying to predict what 12 people (or six) will agree on – after listening to very biased, but antagonistic descriptions of the same events and expert testimony that is similarly antagonistic – is not something intelligent people should do.”

    Honestly, it’s virtually impossible to predict what TWO people will agree on.

    I think what’s happened is that the litigation-happy culture we’ve found ourselves in has put people in charge in a panic. Some (if not many) are afraid to put their faith in us as first responders because they themselves don’t feel safe doing things they have control over, much less what we do out in the field under their license. And, as bad of a place as that is to be in, and even it sounds like an excues, is just an uncomfortable truth about the nature of medical practice today.

    Again, I’m not speaking for every medical director out there. But I do think it’s happening, at the patient’s expense (both financially and physically).

    • kindofafireguy,

      I think what’s happened is that the litigation-happy culture we’ve found ourselves in has put people in charge in a panic. Some (if not many) are afraid to put their faith in us as first responders because they themselves don’t feel safe doing things they have control over, much less what we do out in the field under their license. And, as bad of a place as that is to be in, and even it sounds like an excues, is just an uncomfortable truth about the nature of medical practice today.

      Again, I’m not speaking for every medical director out there. But I do think it’s happening, at the patient’s expense (both financially and physically).

      We don’t have a good understanding of risk management.

      We do not demand evidence of benefit before making treatments routine.

      We defend treatments because they are traditional.

      We avoid aggressive use of opioids, nitrates, and sedatives – after all, these are the drugs we have been brain washed into fearing.

      .

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