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

- Rogue Medic

New Series of Rants Second follow up

Wed, 03 Sep 2008 06:05:00 -0400 by
The last post was a response to 2 sentences by Bostonian in NY. This time he wrote a bit more, so I am alternating responses with his comments. His comments are indented and not followed by a footnote. Footnote links are at the bottom of the post.

Bostonian in NY said…

You know, I’ve come back a few times to think about this case since I rendered my hasty gut reaction. I keep coming to the same conclusion: If EITHER of his responsibilities had been successful, the patient is alive.

Maybe. When you are working in surgery, you have much more control over the way things will turn out, than EMS will. Sometimes the patient survives to the hospital in spite of what we do – not because of what we do.

Even vital signs can be misleading at times. Abdominal injuries with uncontrolled bleeding are less likely to exhibit tachycardia, than other sources of uncontrolled bleeding.[1] There is not complete agreement on this anymore than there is in the rest of trauma.[2]

One study stated –

CONCLUSIONS: Tachycardia is not a reliable sign of hypotension after trauma. Although tachycardia was independently associated with hypotension, its sensitivity and specificity limit its usefulness in the initial evaluation of trauma victims. Absence of tachycardia should not reassure the clinician about the absence of significant blood loss after trauma. Patients who are both hypotensive and tachycardic have an associated increased mortality and warrant careful evaluation.[3]

It can be tempting to trivialize signs of hemorrhage, because the patient is not demonstrating the typical vital signs of major hemorrhage. In print the patient will present quite differently from in person. This is part of the problem of the Monday morning quarterbacking we are participating in, here. This is a part of the problem with the way that we are taught in EMS. This is a part of the problem with the way QA/QI/CYA (Quality assurance/Quality Improvement/Cover Your A@#) departments work.

Now, to get back to your comment about tachycardia. While he probably was tachycardic, and that does seem to be associated with worse outcome in all of the studies I mentioned above, and his death makes it quite clear that he was unstable, does that mean that an IV and a liter of 0.9% saline would have improved things? At the point of death, preferably just before, is when I think there is the least likelihood of harm from fluids. So, in his case, yes. The addition of fluid might have improved things. Does that mean he survives? If he is so low on blood, that he is on the verge of death, his problem might be more of a lack of hemoglobin, than a lack of serum. Before that point, the fluid may cause other problems, such as diluting blood to the point where it does not clot in the body.

I keep wondering what Casper’s vitals were and what he looked like. If he’s sitting there all obtunded in his barca lounger with a pulse in the 120’s and a BP in the 80’s, and a couple pints soaked into the shag carpet I’d probably want to have some IV access to dump a liter of LR in while I sit on his femoral artery for the remainder of the ride. Hell, have BLS driver guy hold hemostasis while you get the stick and then get rolling. A simple thought outside of the adrenaline rush of pre-hospital care would have saved a life.
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I believe that the blood was not making it to the floor, due to the ever increasing blob of bandages as the blood continued to soak through, but was being contained by this knee diaper. A diaper is all that it was, since a diaper does not keep the fluid from coming out, just from making an unsightly mess. Gravity was probably all that was helping to keep him alive. That and a low blood pressure – a pressure low enough to not be forcing all of the blood out through the available perforations.

Direct pressure is one method of attempting to control bleeding. It may not be successful. Running fluid into someone with uncontrolled bleeding is not, in my opinion, a good idea. What pressure to start at is debatable, but there is not good research to suggest that being aggressive is good for the patient until the pressure is lower than where we currently recommend opening the lines to high flow of saline, or whatever is the fluid of choice. Saline, and most other fluids, dilute the clotting ability, raise the pressure without necessarily improving the effectiveness of the circulation, and may force more blood out of the body – since bleeding is not yet controlled.

You suggest waiting on scene to start an IV, with the partner applying direct pressure during the IV attempt(s). The problems with this are there might not be effective control of the bleeding. The pressure may only be slowing the bleeding. If the bleeding is being controlled by the direct pressure, transport is more important than an IV and fluid through that IV, in my opinion. That is assuming the paramedic is successful with the IV. Since we do not know what the outcome will be, at that time, how do we know that the fluid is a good idea? Has the body achieved homeostasis, on its own? If PMS were assessing the patient, keeping the leg elevated, or applying direct pressure, there might be a reason to believe that PMS understands what is going on with the patient. How effective is the assessment of someone who does not believe in controlling bleeding. Even the NR (National Registry of EMTs) would not encourage putting the IV before direct pressure.

The title of the original post by ParaCynic is a reference to tourniquets. This is one situation, where the tourniquet appears to be indicated. This is something that requires judgment. I would prefer to apply a tourniquet and, if it appears to be controlling the bleeding, then attempt an IV, but I would not take time on scene with this patient to start an IV. I have had a patient, with uncontrollable bleeding from his head, where I did as you suggest. The bleeding could be slowed by direct pressure and it appeared to be something that we could stop when we were not moving. The site of bleeding was an artery under the scalp, so the pressure was not as direct as I would have liked. While the patient was still, since we were apparently able to control the bleeding, it did seem like a good time to get an IV in place – but this was a patient who presented as stable, except for the bleeding. His vital signs were not indicating significant blood loss. The bleeding appeared to be very slow when we were moving him. There appeared to be less than a pint of blood on scene, but that is a very rough estimate. I have never taken containers of blood (or something looking like blood) and measured them, then spread the blood on the ground to see what that volume really looks like. I have never had anyone measure an amount of blood and spread it on the ground to test my ability to estimate accurately. Anyway, this patient appeared to be stable, in spite of his incompletely controlled bleeding. I also contacted OLMC (On Line Medical Command) to request permission to use epinephrine on the site, if he dramatically deteriorated, as a means of helping to slow the bleeding. OLMC said OK, just don’t inject into the patient. No. I do not want to perform intracerebral epinephrine injections.

Another of the possible ways to deal with this is by keeping the leg elevated. Sometimes complicated with EMS stretchers, but there is no rule that requires the patient to be facing the normal way on the stretcher in order to raise the legs. Raising the legs is generally referred to as Trendelenburg position, which is one of the four topics ParaCynic promised to address in his post Tourniquets, Trendelenburg, Tampons, Toilet Paper. His post on Trendelenburg is Standing Trendelenburg on it’s Head. I don’t know how controversial the last two will be EMS-wise, but the first two are important and we are often taught that the good one is bad, while the bad one is good. We are taught these backwards. We are taught that tourniquets are bad – might cause damage that is insignificant compared to keeping a patient alive. We are taught that Trendelenburg is good, even though there is no evidence to support it. Ain’t EMS great?

Anyway, raising the legs can be done by using the stretcher’s Trendelenburg adjustment, which does not raise the legs very high. Another way of dealing with this patient is to turn him around on the strtcher. Trust my hunch that he does not want to sit up. Put the back of the stretcher up to keep the injured leg elevated. This is not for blood return, as Trendelenburg would be – if it worked, but this is to use elevation to prevent more loss of blood. This provides more elevation than the standard stretcher Trendelenburg setting. Or the method used by those, who might not know how the stretcher works – drug bag/box under the legs.

It is Monday morning quarterbacking, since we know what the outcome of the patient was without these interventions. We do not know what the outcome would be with any, or all, of the interventions we would have preferred. My treatment choices, in the order they would be attempted, not in the order of importance, would be:

1. Leg elevated.

2. Direct pressure.

3. Tourniquet, if the direct pressure is not working (or to allow me to free up my hands to start an IV).

4. Direct pressure in addition to the tourniquet and elevation, if the tourniquet is not controlling the bleeding.

Which to use is determined by reassessment. The IV could be added to all of these, but I think it is only something that should be considered after appropriate measure have been taken to control bleeding. The IV/fluid administration should not be a substitute for bleeding control if bleeding control is possible.

In response to your above post:

Protocols are written by people sitting in offices who know nothing of what a sick patient looks like. So are job descriptions. People who follow them to a T need to be re-educated

I am not one to make an informed statement about job description scribblers. However, it pains me to come to the defense of those, who write protocols. Generally EMS protocols are written by medical directors. They may leave the specific wording, formatting, and printing up to others, which can lead to errors of typography and translation. Medical directors should be very experienced with sick patients. I am often critical of medical directors for policies that allow bad medics to mistreat patients. A lot of medical directors did start out as EMTs/paramedics and have an idea of what EMS is like. Things have changed significantly since many were working the streets. I believe that most people working in EMS have a poor understanding of EMS, even a dangerous approach to EMS. I do not have any numbers to back this up, just my experience working and teaching EMS in 4 states, dozens of jobs, and several EMS forums. My criticisms of medical directors are of the lack of understanding, in spite of this experience (when they have EMS experience).

Too many medics, nurses, and doctors have unreasonable beliefs about the amount of benefit of EMS treatments. Benefits that are not supported by research. Some of the EMS treatments have never been studied. Some studies have only produced negative results. The studies most commonly cited in EMS often have such clear violations of the scientific method, that the results are worthless, except to suggest further research and to demonstrate the ways not to do research. Few medical directors seem to recognize this.

If I, as a physician in training, refused to put in an IV because “that’s a nurse thing”, or refused to bag a patient because “that’s a technician thing” or refused to wheel a patient around because “that’s a transport thing, or refused to hold a retractor because “there’s a big frame to do that for me” I’d be crucified on the spot. Every day in the hospital, I get to stuff my education in my back pocket and do work that is far below my capability…but the bottom line is that shit needs to get done so might as well do it yourself.

I completely agree. I think that my point was more that some paramedics will develop the attitude that their ALS treatments will be able to fix everything and that BLS treatments are not important. I certainly have encountered paramedics who have refused to do stuff that they feel is beneath them.

The attitude problem is a huge one and one that seems to exist even in places with very humble medical directors. Why Maybe they just do not believe that their people have that kind of attitude. I don’t know. I do know of plenty of basic EMTs, who go to paramedic school specifically so they do not have to waste their time on any of that EMT stuff any more.

One solution to this is improved research. Teaching research from the very beginning of EMS training. Teach the scientific method and introduce treatments, one at a time. Introduce the research that has been done on the treatment. Let the students teach themselves, with the assistance of the instructor, what works, what has not been studied well enough to come to any conclusion, and what does not work. I think this would require a dramatic remodelling of EMS education, but would produce much better providers. It is about understanding what works, more than what the current theory is. Maybe the theory will be shown to be accurate, but often we end up discarding these theories as we learn more. We may learn more form people performing research that runs counter to the accepted theories. As we learn enough to discard these bad theories, we are able to build on the confirmed theories and truly understand more.

I will write about the research on prehospital treatment of hypovolemia due to hemorrhage, but that will be another post, but these are some of the points that need to be addressed.

We are addressing a surrogate end point. This is something that we can measure, but that we cannot prove makes a difference in survival.

We need to keep the patient from becoming pulseless, but how high does the systolic BP need to be for that to happen?

I think that it will be much lower than just about everyone is comfortable with – maybe 50 to 60 systolic, with the exception of head injuries, but the research is not yet persuasive enough for any particular vital sign goal. Will the systolic pressure be the most appropriate prehospital indicator of when to start treatment? Radial pulses? Something else? Capnography?

We need good research by doctors good enough to make the study large enough and well enough controlled that the results are meaningful. Something that has been ignored too much in favor of expert opinion. I feel that this reliance on experts – who refuse to perform the necessary research – should, in Catch-22 fashion, disqualify these doctors as experts.

We need good research to improve our care. Otherwise, it is just a bunch of people making the vital signs less annoying and convincing themselves that what they are doing is making all of the difference. Surrogate end points will have to be covered in several posts. It is probably the most misunderstood aspect of research.

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Footnotes:

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[1] Relative bradycardia in patients with traumatic hypotension.
Demetriades D, Chan LS, Bhasin P, Berne TV, Ramicone E, Huicochea F, Velmahos G, Cornwell EE, Belzberg H, Murray J, Asensio JA.
J Trauma. 1998 Sep;45(3):534-9.
PMID: 9751546 [PubMed – indexed for MEDLINE]

–

[2] Relative bradycardia in patients with isolated penetrating abdominal trauma and isolated extremity trauma.
Thompson D, Adams SL, Barrett J.
Ann Emerg Med. 1990 Mar;19(3):268-75.
PMID: 2310066 [PubMed – indexed for MEDLINE]

–

[3] Does tachycardia correlate with hypotension after trauma?
Victorino GP, Battistella FD, Wisner DH.
J Am Coll Surg. 2003 May;196(5):679-84.
PMID: 12742195 [PubMed – indexed for MEDLINE]

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Filed Under: ALS, Heresy, Physician Oversight

New Series of Rants follow up

Tue, 26 Aug 2008 10:29:00 -0400 by
Bostonian in NY said…

Wow, that’s a sad oversight by PMS . . . someone should revoke his ACLS privileges.

Doesn’t hemorrhage control fall under C of your ABC’s?

Yes. Hemorrhage control does fall under the C of ABCs. Yes, hemorrhage control is the thing that would have provided this patient with the best chance of watching Casper on TV, rather than playing Casper in the ED.

Maybe someone should never have allowed PMS to have ALS (Advanced Life Support) privileges.[1]

This is one part of the problem with the way that risk is managed in EMS.

A. OLMC (On Line Medical Command). Call for permission from someone who can only rely on you for assessment. If you know what you are doing, is the call necessary? If you don’t know what you are doing, should the doctor even take the call? The doctor cannot trust the information from someone who does not have a clue. Rather than get rid of the problem medics, this facade is maintained.

B. Chart review. By placing the protocol along side the chart and comparing to see if the chart contains all of the items in the protocol. The way many ALS protocols are written, the BLS (Basic Life Support) is skipped over to get to the ALS. There is a mention of following BLS protocols, refer to appropriate BLS protocol, but they are in a separate binder and that stuff is not used to evaluate paramedics, so why bother? It is no surprise what some medics have learned from this –

Skip over the BLS, because paramedics do ALS.

Paramedics are too good to waste their time on BLS.

Whether someone was applying direct pressure is difficult to confirm from the chart. I can write that I was alone in the back, applied direct pressure, started 2 large bore IVs, and intubated the patient. There is the commonly used phrase, If it wasn’t documented, it wasn’t done. This is used to remind us that the chart is a legal document. If we do not treat it seriously, it can cause us a lot of trouble. If we did something, we need to document that it was done. Sometimes this will be the only way of showing that it was done. Not documenting something suggests that it was not done. It does not prove that something was not done, but it becomes harder to prove that you took an appropriate action.

What happens when there is not somebody there to confirm the specifics from your chart? Is everything documented accurately?

Are things innocently forgotten? If you are in a system that requires you to leave a copy of the chart in the ED prior to taking another call, maybe dispatch is rushing you to finish your chart and take a call. This is not the kind of environment that encourages an accurate recreation of the relevant details of a call. If you are in a system that only has computers back at base for writing charts and then faxing them to the ED, how many calls in a row can alter your memory of details?

I have had to rely entirely on my notes to write some charts, because I could not even remember the patient, chief complaint, or what treatment I had delivered. If I hadn’t made notes, it would be almost impossible to document accurately. The notes are written in the ambulance on the way to the ED, in the ED while giving report, and in the ambulance on the way to the next call, and include whatever my partner or an ambulance crew handed me (that I may have to photocopy so everyone has a copy). Using a comparison of the dispatch times, the times from the ECG printout (helpful to be able to hit record and have it document the time, then make a brief note on the printout, such as fifth NTG x 3, or 1st epi, or tube in, or . . . ), and the actual time to arrange events accurately. An ECG printout that includes vital signs can be a wonderful aid to documentation – if the vital signs are accurate.

Are things forgotten, but not so innocently? I certainly do not document every single thing that happens on the call. I am documenting what happened that is relevant to patient care. Not being documented does not mean that it did not happen, but that it was not relevant to patient care, in my opinion. So, not everything that does happen is documented.

Are things left off of the chart, because they might make the medic look bad? This is the part that so many people seem to have trouble with. For example, let us suppose that you know that the staff of the QA/QI/CYA (Quality assurance/Quality Improvement/Cover Your A@#) department will be cracking down on the use of a certain description of patient care, so you describe it differently. You haven’t changed what you do, but because of the approach of QA/QI/CYA, you have changed the way you document it.

You are treating a diabetic and spill orange juice on the glucometer and the strips. At the hospital, you are not able to restock and you are called for syncope. Protocol for syncope includes a check of BGL (Blood Glucose Level). The patient is now awake and alert, agrees to go to the hospital, and is demonstrating absolutely no signs of hypoglycemia. Do you document that you did not obtain the BGL? Do you have a genuine fear of the retaliation of the QA/QI/CYA department, even though this clearly has no relevance to the care of this particular patient?

Once you start making exceptions to the chart like this, where do you stop?

Not all QA/QI/CYA is draconian. Some are excellent, but not all of these departments are made up of people who thoroughly understand patient care. They may not know what is relevant, only what is in the protocol. In this state, the ALS coordinator for this ambulance service was a basic EMT. A clown who once insisted that a crew obtain a refusal from the owner of a car that had been stuck by another vehicle. The owner was not in his car when the car was hit. He was not anywhere near his car.

This ambulance service would hire paramedics as ALS coordinators and then force them out for not doing things the way the elected members of the department felt paramedics should do things. Not my favorite of the places where I have worked.

Perhaps, instead of the QA/QI/CYA department, it should be called the emPHAsis on the wrong sylLAble department. As with the NR (National Registry of EMTs), they seem to look for things that will be, in their eyes, good test questions. These are things where the text book contains 3 or 4 different points that are emphasized, although rarely relevant to patient care. Then the NR turns that into a question, the which of these does not apply kind of question.

The same is true for the QA/QI/CYA people. They look for something that they feel is important in patient care, such as an IV, then they create a gig sheet that lists all of these criteria and they go hunting for witches. They do not need to demonstrate that the witch is made of wood, just that the QA/QI/CYA procedures found witchcraft. Paramedics learn what is considered witchcraft and document in a way that makes them seem to be as little like a witch as possible.

Once called before the inquisition, the only defense is to confess your sins and beg for clemency. Not really true, but many are intimidated by anyone who wields power so brutally. Most will not stand up to them.

If the paramedic is too good to waste his time on BLS, the basic EMT is there to do that scut work for him. When the the basic EMT is driving the ambulance, it is up to the paramedic to do both the BLS and the ALS, unless there is another person in the back with the paramedic. We should hope that the other person is a basic EMT, so that some BLS will be done.

Clearly, this is the wrong approach to patient care. The paramedic is just as obligated to provide the BLS care as they are to provide the ALS care. If a paramedic does not provide the BLS care that is indicated for the patient, the patient is not likely to benefit from any of the ALS that the paramedic is providing. But you can’t tell that to some paramedics. They are paragods – too good to be wasted on BLS stuff.

This attitude is not limited to EMS. ACLS has long been one to put way too much emphasis on the ALS treatments, even though they admit –

For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.[2]

What is taught in ACLS?

What is covered on the tested in ACLS?

Drugs (which are ALS), dosages, routes of drug administration, rates of drug administration, ALS procedures, the proper order for these drugs and procedures.

I admit that, for the potentially reversible causes of cardiac arrest, there are drugs and ALS procedures that make a difference. Contrariwise, for the generic dead person the drugs don’t do diddly.

Phrases that used to be common at the scene of a cardiac arrest –

Stop compressions, so that I can start an IV.[3]

Stop compressions, so that I can intubate.

Stop compressions, while we move the patient.

As if relocating dead people does anything other than interfere with traffic. OK, some rare potentially reversible causes are reason to move the patient. Other than specific potentially reversible causes, if they are still dead after treatment, Mr. Toad’s Wild Ride will not be therapeutic. If ALS does not change the outcome, transporting the patient to a higher level of ALS, or even an all-BLS service transporting to ALS, will not make a difference. Well, it will increase the number of motor vehicle crashes. It will increase the number of injuries of unrestrained people performing compressions. So, is there a benefit from routinely transporting corpses as emergency patients? Even the ACLS guidelines recognize this and discourage it.

This situation creates the following dilemma: if carefully executed BLS and ACLS treatment protocols fail in the out-of-hospital setting, then how could the same treatment succeed in the emergency department? A number of studies have consistently observed that of patients transported with continuing CPR survive to hospital discharge.[4]

By example and by action, the bosses – medical directors, ALS coordinators, QA/QI/CYA staff, . . . – make clear the kind of behavior they want. IV on any patient who might receive an IV in the ED. Or. IV only as appropriate for care of the patient. Or. IV prior to giving any medication, even aspirin. Or. The protocol states that hemorrhage is part of trauma. Unstable trauma needs 2 large bore IVs. Any failure to complete this part of the protocol will be taken seriously.

What? So the BLS protocol was not followed? We’ve got enough to deal with in the QA/QI/CYA of the paramedics. We can’t worry about the EMTs.

The paramedics need to follow the BLS protocols, too.

Maybe, but we don’t have the people, or the time, to worry about that stuff. That’s just BLS.

Footnotes:

^ 1 ACLS (Advanced Cardiac Life Support) is only recognition of completion of a specified course, that does not permit any privileges itself, but may be a prerequisite to being granted ALS privileges. These terms are often used interchangeably, but they have significant differences. ALS for a medic does not generally include all of the drugs and skills in ACLS. OTOH, there are things that are ALS, that are not even mentioned in ACLS, which focuses on the causes of cardiac arrest and the prevention or treatment of cardiac arrest.

^ 2 (Circulation. 2005;112:IV-58 – IV-66.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 7.2: Management of Cardiac Arrest

^ 3 Stopping compressions to make it easier to start an IV was never a good idea. The veins should be a bit more pumped up during compressions. One problem is that the person may raise the arm a bit and let the blood drain out by gravity. With IO (IntraOsseous) needles being used more often, there is less of a temptation to do this, but people still ask questions that demonstrate they place too much importance in the ability of IV access (the route of most ALS administration) to make a positive difference in the outcome. What I hear sometimes is, “How do we do compressions with a sternal IO in place?” If the IO needle is going to interfere with compressions, do not even think about using it. Anything, other than defibrillations and assessments, that causes compressions to be interrupted is bad. There has been research suggesting that interrupting compressions for defibrillation is unnecessary, but there are too many things left out of this study to recommend anyone try this with a real patient.

Circulation. 2008 May 13;117(19):2510-4. Epub 2008 May 5.
Comment in: Circulation. 2008 May 13;117(19):2435-6.
Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation.
Lloyd MS, Heeke B, Walter PF, Langberg JJ.

^ 4 (Circulation. 2005;112:IV-6 – IV-11.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 2: Ethical Issues

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By Rogue Medic
Filed Under: ALS, Heresy, NTG, OLMC Requirements, Physician Oversight

New Series of Rants – ParaCynic

Sun, 24 Aug 2008 19:00:00 -0400 by

Here is another Normal Sinus Rhythm post. The topic this week is themeless. Read the rest of the NSR Blog posts at NSR Week 10.

Tourniquets, Trendelenburg, Tampons, Toilet Paper. This is the title of a post that threatens promises to be the beginning of a series of posts about things that irk the ParaCynic. ParaCynic had not been posting for a while. Until somebody irked him. Now he appears to be resuscitated.

Let me tell a story about a Protocol Memorizing Supermedic in a paramedic/EMT system. He arrives to find the patient, Casper, sitting in a recliner, watching the ball game with his leg elevated above the heart (Mom is a nurse), and he has blood soaked bandages piled on top of each other (not supposed to remove the old bandage), yada, yada, yada.

PMS is going to be in the back of the ambulance with the patient. His partner, PMS Basic, will be driving. Family will be meeting them at the hospital. Another medic will be attempting to rendez-vous with our devout acolytes of the Protocol, but since this is EMS, no actual communication takes place between the drivers of these vehicles and therefore no actual rendez-vous happens, either. While this reenactment of a Keystone Cops chase is taking place, PMS is in the back of the ambulance doing what PMSs do.

Alas, he is unsuccessful, so Casper transforms from just a pallid ghost-like appearance to the state of being a true ghost. Being a friendly ghost he doesn’t sue the ambulance company, and everyone else involved in this tragedy. His family sues. Casper is dead and his family doesn’t talk to ghosts. The family sues the fecal matter out of all involved. In this case, that happens to be a lot of fecal matter, since EMS specializes in being full of fecal matter.

PMS is beating himself up over his inability to save Casper’s life because he was not successful in following the protocol. Everybody knows that this was the cause of death. How could he have let down his patient in this time of need?

PMS and Casper are alone in the back of the ambulance and Casper starts channeling Dirty Harry. This is not good for a future friendly ghost.

Casper Eastwood says –

I know what you’re thinking. “Did he lose six quarts or only five?” Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a 14 gauge catheter, the most powerful catheter in the EMS world, and would fill your veins right up, you’ve got to ask yourself one question: Do I feel lucky? Well, do ya, punk?

And PMS did feel lucky.

And PMS gave a prayer to the protocol gods.

And PMS choked.

No IV.

No SAVE!

No kidding?

PMS spent the last minutes of Casper’s life ignoring the blood coming out of his leg and tried to start an IV?

But the protocol says –

Wait, we must all genuflect before a reading from the Holy Book of Protocol.

Thou shalt not arrive at the ER without an IV on all ALS patients!

It is the duty of the Holy Order of Protocol Monks to see that all of the Protocol Monkeys worship at the Cathedral of the Divine Catheter which doth infuse the Blessed Saline of Life.

What about direct pressure?

If there had been another provider in the back, it would have been acceptable to waste time on a BLS procedure, after all – this is ALS.

What about continuing the elevation that seemed to be helpful in slowing down the blood loss?

You need to stop suggesting things that might distract the PMS from the Blessed Application of the Catheter. It puts the Catheter in the body, so it gets the hose.

What about a tourniquet?

Heretic!

Apostate!

Rogue.

OK. ParaCynic may be a bit cynical in mentioning this. TOTWTYTR was discussing Tourniquets recently – also in a way that was supportive of tourniquet use. Oh, what sad times are these when EMS bloggers can say tourniquet at will to medical directors. There is a pestilence upon this land, nothing is sacred. Even those who arrange and design protocols are under considerable economic stress in this period in history.

The horrific idea that it might be more appropriate to keep the oxygen transporting goodness of the hemoglobin in the blood in the body, rather than ignoring the spillage and attempting to hook the patient up to a pressure washer to force what little might remain of the hemoglobin out with the Blessed Saline of Life.

To sacrifice circulating hemoglobin on the altar of Blessed Saline of Life. This marks one as a True Believer. Two more cases of miraculous faith, in the face of negative patient outcome, and PMS will be ready to preach to his own minions.

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By Rogue Medic
Filed Under: ALS, Heresy, Physician Oversight

New Service Rules

Sun, 17 Aug 2008 19:00:00 -0400 by

Here is another Normal Sinus Rhythm post. The topic this week is themeless. Read the rest of the NSR Blog posts at NSR Week 9.

You get a memo from the ALS coordinator (just below the medical director, the person responsible for oversight of the medics) .

We have had a problem with inappropriate triage of ALS patients to BLS care. As of yesterday, all calls dispatched as ALS will have the medic in the back attending to the patient.

Signed ALS Coordinator and medical director.

One of the problems in EMS (Emergency Medical Services), that is present in everything else, is misbehavior. One example of this is in systems that mix ALS (Advanced Life Support – medic, nurse, doctor with needles, tubes, drugs, . . . ) and BLS (Basic Life Support – stuff that really works, except for spinal immobilization) together. Either BLS on the ambulance and ALS responding in a fly car (or whatever terminology you use for a separate ALS response vehicle) or the ambulance crew is made up of a medic and a basic EMT.

One way that misbehavior exhibits itself is when there is a call that appears to be an ALS call, but the medic states it is a BLS call. He refuses to be the person taking care of the patient. We will assume, for the sake of argument, that everybody knows that this patient does have a legitimate ALS complaint. Let’s say chest pain, but the medic claims that the patient just has indigestion.

Never happened.

I’ve seen it happen with doctors, nurses, medics, and basic EMTs. Some people just jump to conclusions without assessing thoroughly, some have such a bias about what a real chest pain patient should look like, that they practically need to be hit over the head with a life threatening arrhythmia to be convinced that the epigastric discomfort is actually cardiac in origin. There is plenty of evidence of health care professionals doing this. Usually it is a doctor, who is documented as being the one to make this mistake, because his gut feeling was that the patient did not have a serious medical condition. One reason nurses and medics do not have so many documented cases is that they do not generally have the final say on treatment.

So the medic decides that the patient with chest pain does not have chest pain, but just indigestion. No ECG, no good history, no real physical exam. They patient just doesn’t look the way the medic expects a chest pain patient to look, at least, if the chest pain were of cardiac origin. Never mind that atypical cardiac presentations may be as common as typical presentations.

The EMT rides in the back. Or, if the medic responds separately, the EMTs agree to recall the medic, who has not notified dispatch that he is on scene, yet. This way the medic does not need to do any paperwork, other than a recall chart, since he never saw the patient. At least, that is what the documentation will show. So no record of patient contact means no liability for an incompetent workup. That is the way the medic will view this. The patient responded that he did eat a heavy meal before this pain began and that burping (eructation) relieves the discomfort, temporarily. That is enough to convince the paragod that this is not something worthy of his time. It isn’t the pale, cool, soaked with sweat (diaphoretic), crushing substernal chest pressure radiating down the left arm, can’t get the electrodes to stick to the patient, because benzoin is something that other people have to use. In other words, this presentation, that the medic thinks is typical, but is uncommon, is the only thing he is likely to do something about and feel that he isn’t wasting his valuable time. Got more important things to do. Hey, Springer is on.

Nothing about history of diabetes, previous MI (Myocardial Infarction or heart attack), angina, cardiac catheterization, any other history, medication, allergies, because Medic Magoo sees all.

When they get to the hospital, either the medic is not there (released/canceled by BLS) or the medic blames the EMT for not telling him what was going on. In other words, the EMT did not do his job for him. Even though the EMT really was doing his job – taking care of a patient with a legitimate cardiac complaint, because the medic did not want to do anything more than drive.

One medic/EMT system, where the ALS coordinator and the medical director claimed to have a problem with this, chose the wrong solution. There are other wrong solutions. Their solution to the problem?

On any call dispatched as ALS, the medic will provide all care. This will guarantee that the medic does not release care to his partner. It does nothing to get the medic to understand what he is missing in his assessment. It does not require that the medic be competent. It does nothing to differentiate between the medics who appropriately release patients to their partner.

The problem is only with some of the medics.

The solution is to force all of the medics to do things in this thoughtless way.

The problem is that some of the medics do not care or do not understand.

The solution is to ignore the opportunity to use this to remediate those who don’t understand. To ignore the opportunity to find out what the problem is in those who do not care.

There is no discrimination between competent and incompetent.

Ask EMS instructors what the most important ALS skill is. Many, maybe most, will tell you it is a good assessment. This ALS coordinator and medical director have decided that the most important ALS skill is following the direction of dispatch.

Dispatch made the call ALS, because hemorrhage is an ALS call. You arrive on scene and find that it is a paper cut. There is currently no bleeding. There are a couple of drops of blood on a paper towel used to control the hemorrhage.

Dispatch made the call ALS, because abdominal pain is an ALS call. You arrive and treat the patient as having abdominal pain – IV and fluids, per protocol – not performing a good assessment and realizing the patient has epigastic pain as a symptom of a heart attack.

The first case is just making more work for the paramedic. Not really a problem, unless all of the calls are ALS and the medic is spending all of his time treating patients and writing charts. There are places where this is typical.

The second case, just adds an IV to the treatment the patient received, and maybe they are on the heart monitor.

No aspirin. The most effective EMS drug for a heart attack.

No NTG (NiTroGlycerin).

No morphine or fentanyl. The medic would have to get permission to treat abdominal pain with opioids, because the protocols are written by a medical director who is afraid of surgeons and is not familiar with the research on pain management. But that is a different topic.

No 12 lead ECG. That would, in a smart system, lead to a cath lab activation if the medic interprets the 12 lead accurately. There is no good reason why the medic should not interpret the 12 lead accurately.

No beta blockers or other treatments that might be beneficial.

After all, this is just a whiny abdominal pain patient. Probably just ate too much. He should be put in one of the out of sight, out of mind beds.

This is dangerous. If there is a problem with some medics, the solution is to address the problem with those medics. Punishing everyone for the mistakes of a few is not good medicine. It may work in boot camp. If that were the ideal, we would transport patients to boot camp, not to the hospital.

The assessment has not been affected, only the documentation and the addition of the IV lifeline.

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By Rogue Medic
Filed Under: ALS, Critical Judgment, Heresy, Medic X, NTG, Physician Oversight

If it’s not one thing, it’s your mother.

Sat, 05 Jul 2008 05:37:00 -0400 by
Ambulance Driver has another excellent piece on the EMS/Fire Department relationship over at EMS1.com.

Marriage Counseling Part II: The Dysfunctional Fire/EMS Relationship

For the few of you who might not already read everything he writes, this puts things in a different light that may help some to understand some of the problems of dual role/cross-trained people. Read it.

I have written a bunch on the subject and I know that people do care about it. Leave him a comment, so that the people at EMS1.com know that people care enough about the subject to express their views on the subject.

Part III next month?

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By Rogue Medic
Filed Under: ALS, Cross-training, Heresy

Dispatch would have told us if it were something serious.

Thu, 12 Jun 2008 23:45:00 -0400 by
The 911 crew walk to the house with just a little “first in” bag.

Why?

It’s just a syncope call.

No monitor. No thinking. No understanding of patient care. No anticipation of what might be needed.

Why?

Because that is the way things are done in that area.

Tradition.

Certainly Deborah Peel can wait until they go back to the ambulance, get the stretcher, bring the stretcher to Deborah Peel. They were expecting Deborah Peel to walk. He’s not known for being that cooperative. Then they wheel Deborah Peel out to the ambulance, where the heart monitor is waiting, as yet unused.

Now that they are in the ambulance, the assessment and treatment can begin.

This is not much different from the medical command approach of “Just transport.”

Anything that happens outside of the Emergency Department doesn’t count.

Of course EMS has translated that to – Anything that happens outside of the ambulance doesn’t count.

The basic EMT is expecting that the medic will come up with a way to make Deborah Peel appear stable – stable enough to go to the hospital without any ALS (Advanced Life Support) care. In other words, the medic does not have to do anything, except drive.

So, they take a blood pressure, but there are problems obtaining the number. They can only get occasional beats. When you are letting the pressure out of the cuff quickly, there can be a bit of a “inaccuracy,” especially if the beats are not cooperating by being close together.

Well, they know that the number can’t be right because that would be really bad.

Why don’t we hook up the monitor? Oh, yeah, good idea. Then we can find out what his heart rate is. The monitor is the keeper of the heart rate on ALS calls, just as the pulse oximeter is the keeper of the heart rate on BLS (Basic Life Support) calls. For some reason the pulse oximeter malfunctioned on Deborah Peel, even though they spent a lot of time trying to troubleshoot it. The best they could get was a sat in the low 80s and a heart rate in the upper 20s.

Now, you are probably already experiencing more than a little frustration reading this. I was watching this as we were returning from the hospital to our station. We had heard the call dispatched and I asked my partner why the crew was coming out of the house with a syncope patient, but without the monitor. The response – “None of the medics do that. You and Jeff are the only ones who bring monitors in on this kind of call.”

Great Googly Moogly, I done died and went the wrong way.

As we are wandering over to lend a hand, which my partner says is a bad idea (not the first time I’ve heard that), we overhear the blood pressure confusion. They are hooking up the monitor and have a nice wide complex bradycardia* on the monitor. The medic automatically grabs the IV kit and tells his partner to get the atropine out.

Since I am just helping, I put an oxygen mask on Deborah Peel. I even turn the oxygen on. I ask about blood sugar and they actually did that inside. The blood sugar is in the normal range.

I suggest, in my helpfulness, that pacing might be a good idea, since Deborah Peel is clearly unstable. As in unconscious, hypotensive, and bradycardic. That atropine is not helpful for ventricular bradycardias. But, they don’t approach ACLS that way. Pacing is something they do not use. Why? I do not recall the response to that question, maybe I never got a response, maybe I was just doing a better job of keeping my mouth shut at that point – to avoid letting out the screaming that is going on in my mind.

The hospital is two minutes away, otherwise we would not have been driving by this call. Do they start driving? No, the EMT has to help the medic with the IV start, spike the bag, cut the tape, hand the tape to the medic, . . . .

The atropine does not make things worse. Then they drive lights and sirens to the hospital.

Everything is already done, as far as the protocol is concerned. Chart review on this should earn the medic brownie points for being so diligent in care. The medical director can rest easy. This officer is one of the good ones, making sure that the others are kept in line. Passing on the right way to take care of patients.

But the chart and reality do not have anything to do with each other. Do they?

For a different perspective, what if this had been something that fell into the significant trauma category?

Well, we would drive to the hospital and meet the helicopter there at the landing pad.

How far of a drive is it to the trauma center?

15 to 30 minutes.

So, to save a few minutes of drive time, you fly the patient?

We have to. We can’t deprive our service area of our excellent patient care. If we aren’t here, mutual aid from the next town over might have to come in and treat our patients.

This reasoning almost makes sense. These guys have seen the neighboring EMS and don’t trust those guys.

Those guys are dangerous!

Of course, the only difference between them is the uniforms. When not working their full time job as these guys, most of these guys work part time as those guys, many of those guys work part time as these guys, but some of those guys work part time as other those guys. This keeps the overtime down.

These guys and those guys probably even pass the National Registry of EMTs paramedic test without any problems.

If you don’t purchase the program on the way into the ball park, you aren’t going to know who the players are.

* Bradycardia means s l o w. In this case to the point of not circulating enough blood to the brain to remain conscious. Wide complex means that even the electricity in the heart is moving very slowly. The heart is slow and the electricity is not connecting efficiently. This may mean that the lower part of the heart is causing the heart to beat. Normally a group of heart cells in the top of the heart (the sinus node) are in charge of causing the heart to beat, if they fail, then farther down the conduction system, where the upper part and the lower part of the heart meet, there is a back up to the sinus node (the AV junction), but even that is not working for Deborah Peel.

Not really a big problem. He just needs a ________.

Even those of you not big on cardiology can probably figure out the word that goes in there. The word is pacemaker. Deborah Peel will receive one in the hospital.

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Helicopter EMS – The Starbucks Effect.

Safety über alles!

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By Rogue Medic
Filed Under: ALS, Atropine, Ethics, Fraud, Helicopters, Heresy, Medic X, National Registry, Physician Oversight Tagged With: , ,

Raising the Standards for Rock Ridge EMS

Thu, 05 Jun 2008 02:09:00 -0400 by
Vince commented on the post “Rock Ridge Hospital and EMS.“:

“Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.”

Bad medic are only bad medics when they fail to have the integrity to realize “these are other people’s lives I am playing with and I better make sure I get my shit together.” A bad OLMC physician may allow medics to continue to deliver substandard care, an issue that needs redress to be sure, but he certainly did not force anyone to be a bad medic.

Medic X, who cannot imagine what a 52 card deck looks like, is responsible for his misbehavior.

BUT

The medical director is responsible for allowing this paragon of EMS to work in EMS.

Medic X is irresponsible and incompetent and reckless.

BUT

He cannot grant himself the authority to treat patients.

The medical director is supposed to protect the patients from Medic X.

Otherwise, what do we need the medical director for? Not much.

Personal Responsibility.

Exactly. Why excuse the medical director from personal responsibility?

This is why it is outrageous to me, in principle, to focus on ways to make bad medics ‘less dangerous’ by any means other than those discussed above (remediation, counseling et al)

When there is the possibility to improve the care delivered, we should look into that.

You know that I am not a fan of fancy gadgets. Waveform capnography is one gadget that is extremely useful, and improves the care delivered by competent medics. CPAP is a treatment that helps to avoid intubation. CPAP should be used, not because we are afraid of the medic missing the tube, but because CPAP is better for the patient.

I realize your motivation is patient care and, after all, that is what this is all about. I also concede that these are not mutually exclusive ideas.

But as I alluded to earlier, any tool/device etc. that makes it ‘appear’ easier and ‘more foolproof ‘ will likely have the unintended consequence of allowing an already sub-standard paramedic, to rely on them at the exclusion of his underdeveloped assessment skills and judgment.

I am just advocating eliminating the middleman 😉

I am also not a fan of middlemen.

The term foolproof is, at best, an exaggeration. Similar to unsinkable.

Snopes.com has a great page, Sinking the Unsinkable, on the use of the term unsinkable, its relation to the Titanic, and the arrogance of many involved. The current approach to physician oversight is often closer to the arrogance of pretending the Titanic was unsinkable, than it is to any real risk management.

We need to weed out the substandard medics, instead we find ways to accommodate them. That is not what I am trying to do. I am interested in better tools. Tools that will help competent medics provide better care.

Obviously, anything that would improve patient care and eliminate potentially fatal errors are something I think we are all on board with. I am not that arrogant. I just would put more of my ova into the standard raising basket.


Just how arrogant is to be determined. The ale in your most recent post appears to have been drained.

I am in favor of raising standards. We also need to police ourselves and insist that medical directors get rid of those who cannot be remediated.

Instead, we seem to try to defend the bad medics. Until they harm someone. Why shouldn’t we do something before they harm someone?

Just applying standards that relate to patient care would be much better than checking to make sure the prospective medic has a pulse and a license, which seems to be all too common in EMS. We also need to put an end to the distraction of the medics with unrelated tasks, such as janitorial work, landscaping, fire fighting, or whatever else is dreamed up to occupy medics’ time not actually on calls.

If you remember for many many years I have been of the opinion that the paramedic profession take similar steps that nursing did insofar as making itself a profession, i.e. with minimum education requirements. Not only would this serve as a first-line filter to keep out some of the knuckle-draggers with the “Your life is my hobby” attitude, it may make inroads in garnering much deserved respect from other professionals, in particular OLMC physicians, not to say anything about an increase in salary. Perhaps you can post on this idea….


I am not convinced that more school will make a big difference. Appearances may be changed, but look at how overeducated medical directors are. In many cases, these highly educated medical directors still do not get EMS. Otherwise, why would we have OLMC (On Line Medical Command) requirements? We used to have to call for permission to do everything, even to start an IV. As EMS becomes better understood, the need to have medics call for permission has been gradually going away, but there are still places that insist on it.

Why?

As long as there are OLMC requirements, the medical director can point to this fraud and claim that there is physician oversight.

BUT

There is no real physician oversight – the medical director has no idea what is going on with patient care.

Not many people understand medicine and fewer understand EMS. Few realize that OLMC requirements are just a substitute for real physician oversight. And a very dangerous substitute.

Real physician oversight is not cheap or easy. Many do not want to do all of that work. Many services do not want to pay what it would take.

BUT

If you aren’t going to provide real physician oversight, you need to limit care to BLS (Basic Life Support).

How many services will behave responsibly? Pay up for real physician oversight, get a medical director who understands EMS and oversight, or get out of the ALS (Advanced Life Support) business.

It doesn’t matter if you are the volunteers, fire fighters, private ambulance company, third service, National Registry, or anything else.

Do it the right way, or not at all.

By Rogue Medic
Filed Under: ALS, Critical Judgment, Cross-training, Heresy, Medic X, OLMC Requirements, Physician Oversight, Waveform Capnography

Waveform Capnography vs. Hubris.

Wed, 04 Jun 2008 19:50:00 -0400 by

In discussions of confirmation of endotracheal tube placement, some people have suggested that not everybody needs waveform capnography. We have been intubating for decades without waveform capnography.

This is true.

It is also true that we don’t need to intubate. BLS can be good patient care. BLS airway management can be good airway management.

We had been driving cars for decades without seat belts or airbags. The addition of seat belts and airbags is not to be ignored. Few people would want to have a car without these life protecting devices. There is always that idiot who is afraid of being trapped by the seat belt in a burning car, so he refuses to wear a seat belt. Your chances of being trapped in a burning car by a jammed seat belt, and being too stupid to figure out how to loosen the belt are ridiculously small. But, if you are one of these idiots, this misunderstanding actually seems logical – at least to you.

We do have a term for people who crash while not wearing seat belts. They are called patients – if they survive long enough for EMS to arrive. The glass half full approach is to assume that you will not crash. Well, you do not have the ability to control all of the other drivers on the road, all of the animals that eventually decorate the side of the road, or even the ability to control all of the passengers in your vehicle. You may not even have the ability to stay in your seat on a bumpy ride, unless you are wearing a seat belt. Although, if you are endowed with enough hubris, you might think you have all of these abilities.

You may drive for years without having a crash. You may intubate for years without having a tube, where waveform capnography would make a difference. That is, a misplaced tube that would be picked up by capnography, but not by your intentionally limited assessment.

All it takes is one, Killer.

And I call you Killer with all of the appropriate affection and respect for someone who approaches patients with the appearance of competence, the experience that should produce competence, but not the substance of competence, Killer.

What about all of the providers, who lacking your extensive experience, are more likely to miss signs of a misplaced tube, Killer? How long will it take one of them to exceed their capabilities and suffocate a patient with the misguided belief that your limited approach to assessment is acceptable, Killer? What about when your assessment is in error, due to the incorrect assumption that you are too good for waveform capnography, Killer?

Perhaps, I am being too subtle.

Another objection is that waveform capnography is too expensive for small departments to afford. Just put a sign out front that says:

–

No life is worth the cost of doing the job right!

–

For a change of pace from my rant, and for an amusing take on the plastic pieces that change color to indicate the presence of CO2 (carbon dioxide), read this post by JB on the Rocks. This comes with a beverage alert.

Barney, End Tidal CO2, and the Anti-Christ

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By Rogue Medic
Filed Under: Airway Management, ALS, Critical Judgment, Heresy, Intubation, Physician Oversight, Waveform Capnography
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