Dr. Bryan Bledsoe

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

- Rogue Medic

Is EMS a Trade or a Profession?

Sun, 31 Jul 2016 23:59:08 -0400 by Rogue Medic

In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.^[1]

In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.^[1]

Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.^[1]

The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?

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Footnotes:

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^[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)
Article

Filed Under: Assessment, Critical Judgment, Dr. Bryan Bledsoe, Education, Ethics, National Registry

Can EPs Fix the Helicopter EMS System?

Wed, 30 Dec 2009 13:06:14 -0500 by Rogue Medic

Over at Emergency Physicians Monthly, Dr. Bryan Bledsoe writes Can EPs Fix the Helicopter EMS System?

Dr. Bledsoe, an EP (Emergency Physician), starts with the following paragraph that puts things in a perspective quite a bit different from what we think of, when we think of helicopter EMS –

Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab accident in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient.

The only other category of medical personnel that has had a higher fatality rate than their patients is the military medic. That is because the opposing military views killing/disabling the medic as an important way to demoralize the troops served by that medic.

The difference is that nobody is intentionally trying to kill flight crews, are they?

Unintentionally, there is a lot done that does increase the danger for flight crews. Dr. Bledsoe is trying to decrease the unnecessary risks of being a flight medic, flight nurse, flight physician, or EMS pilot.

So why do so many of those he is trying to help view him as the enemy?

Ignorance is the only answer I can think of.

Dr. Bledsoe speaks all over the world about EMS and the things we need to improve for our patients and for ourselves. While there are some out there who understand what he is doing, most seem to automatically oppose anything that does not fit in with the way they want to do things.

Their motto seems to be, Screw the patients – this is about our egos.

We put the safety of flight crews in the hands of the most ignorant providers in EMS – those who think that it is cool to call for a helicopter, or those who are not comfortable taking care of unstable patients, or those who want a shiny pin to put on their shirt, or just those who do not want to drive 20 minutes to a trauma center. After all, the patient will be the one paying for this, so what do they care?

Why are the most irresponsible people in EMS encouraged to make these mistakes?

We should be treating fight crews as if they are valuable. They are supposed to be specialists, but they are called for every little thing that might be twisted into an excuse to call a helicopter.

We should not be defending this abuse of patients. We should not be justifying this abuse of flight crews.

I did make a bit of a misrepresentation, the article is written by Michael Abernethy, MD, Bryan Bledsoe, DO & Dale Carrison, DO. This is not just Dr. Bledsoe. There are other emergency physicians aware of HEMS abuse and willing to speak out about HEMS abuse.

Filed Under: Dr. Bryan Bledsoe, Helicopters, Heresy Tagged With: Dr. Bryan Bledsoe, Helicopters, Heresy

Helicopters and Bad Science

Thu, 09 Oct 2008 03:00:00 -0400 by Rogue Medic

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There is an article in the Baltimore Sun about the recent MSP (Maryland State Police) helicopter crash. Advantages of medevac transport challenged.^[1] The crash killed one pilot, one trooper, one EMT from one of the ground ambulances, and one patient who only appeared to have minor to moderate injuries. The other patient, with similar injuries survived.

If the patients are seriously injured, why is a patient surviving, when a physically fit trooper is killed by the same crash? There are differences in the way they are restrained in the helicopter.

Yet, the whole idea behind HEMS (Helicopter EMS) for evacuation of critically injured trauma patients is they are not expected to be able to survive for very long without treatment at a trauma center.

Patients, who are appropriate for HEMS certainly should not be capable of surviving a helicopter crash on the way to the trauma center, then continue to the trauma center, and still survive. This method of transport is for people who are already trying to die. If they are that stable, that a helicopter crash won’t kill them, then transport by ambulance – without a crash – shouldn’t kill them either.

The article mentions the lack of supporting research for flying patients.

This response comes from the doctors –

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?'”^[1]

Apparently, Dr. Scalea does not include HEMS crew members in his concern.

Where is there any evidence to support this childish scare tactic. There is good reason to believe that HEMS does help, but only in very limited circumstances. Dr. Scalea is encouraging the indiscriminate use of helicopters. Dr. Scalea’s unscientific promotion of HEMS on trauma scenes is part of the problem. Many people have seen what Maryland has done and they are trying to emulate Maryland’s system.

Maryland does do some things well.

But these do not include –

1. Risk management.

2. Interpretation of research.

Where is the research that shows a benefit from transporting patients with minor injuries by HEMS?

Where is the research that shows a benefit from transporting patients with moderate injuries by HEMS?

Where is the research that shows a benefit from transporting patients by HEMS, when ground EMS will get them to the trauma center sooner?

Where is the research that shows the fatality rate of HEMS transport is outweighed by improved survival of patients transported by HEMS?

Why are we putting flight crews at risk flying patients who will not benefit from the HEMS transport?

Dr. Scalea’s point appears to be – the flight crews are expendable.

Similar to ancient Sparta. If you don’t come back with a patient on your stretcher, you’d better be on a stretcher, yourself.

The flight crew only exists for the glorification of HEMS.

The flight crews are expendable.

The patients are expendable.

The HEMS system is what matters.

The fear must take precedence over all else.

What if . . . ?

how many people can die next year to make that worthwhile?^[1]

Anyone, who suggests that HEMS is not the answer – and the question is one that is constantly expanding – is then asked, “What if it were your mother/daughter/sister/father/son/brother? You would want them flown by HEMS.”

This is especially powerful to try to convince parents. What if it were your child?

I have always responded the same way. I would want Rogue Medic Junior transported in the most appropriate way for RM Junior’s condition, and to the most appropriate facility. RM Junior doesn’t bounce any better than anyone else.

Why do we feel the need to increase the risk to our children by playing on fear?

Another question that gets put to EMS crews that are not gung ho for HEMS, is –

You can’t be sure that there isn’t a Zebra Syndrome waiting to pounce on this child, drag him/her off into the underbrush, and leave horrible hoofprints all over the poor pathetic little innocent corpse.

The answer to that is clear. Doctors miss stuff, too. Even trauma centers miss stuff. If the problem is that there might be something missed, we need to fly everyone to only the very best hospital in the world. Nothing else is acceptable. We can’t trust those local ED physicians, who hear hoofbeats and think horses. No. We must react to anecdotal information, ignore science, and return to the dark ages.

Of course, we need the science of medicine to help the injured patients and the science of aerodynamics to get the helicopters to fly.

Quite the conundrum. Do we pay attention to science?

Should we encourage panic attacks when making important decisions?

No. Science has dramatically increased the life expectancy in this country. Life expectancy has approximately doubled over the last 200 years. This is due to good science. This is not due to scaring people about Zebra Syndrome.

Maryland officials are unswayed by the research, which they say is evolving and unclear.^[1]

Evolving?

Science is always evolving. That is not a reason to ignore science.

Unclear?

Where is the science to demonstrate that this overuse of HEMS is good?

There isn’t any.

There is science to show that this abuse is bad.

This is like listening to homeopaths babbling about the memory of the diluted water they use. This is not science.

“If it’s my family or my patients, and there’s no definitive research, then I want to have a paramedic and a helicopter available,” said Dr. Robert R. Bass, director of the Maryland Institute for Emergency Medical Services Systems.^[1]

What does the research say?

It is true that the research is not clear that HEMS is harmful, but when abused anything is harmful.

If it is my family or my patients, then I want to protect them from the extra risks.

Where is the benefit?

Consider, I am not opposed to all use of HEMS, just the abuses of HEMS. There is no reason to believe that a drive of even 40 minutes puts a trauma patient at greater risk. MIEMSS (Maryland Institute for Emergency Medical Services Systems) uses a 30 minute cut off. Why?

Yes, it is a dramatic show. The fire department shows up and sets up a landing zone. The helicopter can be heard approaching, you can see the flashing lights, you step back from the rotor wash. Everybody has to talk at the top of their voices, because of the noise. Yelling makes everything more dramatic – just look at reality TV. Then you give report to the flight crew.

Maybe you could have been at Shock Trauma already, but you called for HEMS, because the magic wand on top sends out healing rays as it spins. And it would be bad form to leave after calling for HEMS.

Why do doctors think that delaying arrival at the trauma center is better for the patient?

Why should we take the patient out of the helicopter to the obviously inferior care of Dr. Scalea and the others at Shock Trauma? If HEMS is the cure to everything, then we should take the patients from the hospital to the helicopter, fly around the parking lot for a bit, and come back for the next patient.

If the patient’s arrival at Shock Trauma was delayed only for the purpose of getting the patient in the helicopter, maybe the helicopter is the magic bullet. On the other hand, we are probably only playing Russian Roulette. Even with magic bullets, Russian Roulette isn’t safe.

“The accident victim who’s staggering and slurring his words: Is he drunk or does he have a brain injury? If the pre-hospital guys had X-ray vision, then they could diagnose every injury at the scene. But as a medical community, and as a country, we’ve made the decision that over-triage is preferable to the alternative,” he (Dr. Scalea) said.^[1]

Overtriage can be acceptable.

The question is how much overtriage will result in better outcomes?

How much overtriage will result in more crashes and more fatalities?

These two questions need to be looked at together.

Anyone looking at only one of these questions should be ignored.

Does the patient appear to have a life threatening injury?

Will HEMS make a significant difference in transport time, that is likely to make a difference in survival?

Should anyone using mechanism alone, to determine if a patient should be flown, have their medic card shredded in a public ceremony?

Yes.

Should the doctor (medical director), who is responsible for teaching the medic this inappropriate use of mechanism, have his medical license disposed of in the same way, at the same public ceremony?

Absolutely.

It isn’t the individual medic, who sets dangerous policy. It is the medical director who sets dangerous policy.

We need research that looks carefully at enough patients, with enough control of variables, that we actually can conclude something definitive from the research. Where is the research from Shock Trauma that supports transporting these patients by helicopter?

In Maryland, apparently they do not have paramedics on many of the ground ambulances, so they fly the paramedic to the scene. This is insane. They are telling the local community – Don’t worry about paramedics, we will fly one in. There is a significant problem with too many medics in some places. So, why is it that a half hour from the White House, you don’t get a medic unless you call for a helicopter?

MIEMSS must be doing something to discourage medics. I did consider working in Maryland for a while, but not for what medics get paid there. A significant increase in the cost of living and a significant decrease in pay. Maybe they use the savings to buy helicopters. They sure don’t spend it on continuing education, because the medics can’t do much of anything on standing orders – except call for a helicopter.

Today, October 7, 2008, MIEMSS sent out a letter to everyone involved in HEMS – dispatch, ground providers, emergency departments, . . . . The letter states –

Please be advised that effective at 8:00 a.m. Thursday, October 9, 2008, all scene medevac requests for trauma patients that have only Category “C” or Category “D” trauma triage indicators will require medical consultation with the receiving trauma center for helicopter dispatch.^[2]

So, what is this mysterious lettering system of trauma patients? If you refer to the state protocol,^[3] you will see the explanation on page 142 of the pdf. The counter at the top of the page is easy to use. Type in 142 in the rectangle before /348. Yes, that does mean 348 fun filled pages to skim through otherwise. I realize that I am not the best person to make this comment, but they are writing too much. They are also trying to eliminate provider discretion.

Of course, that is a big part of the problem. We cannot write protocols that eliminate provider discretion. We can try, but all we do is demonstrate our ignorance. We need to train our people to think independently. Independent thinking appears to be heavily regulated in Maryland. Heavily regulated independent thinking is independent thinking in name only.

In the letter, Robert R. Bass, MD, Executive Director, MIEMSS, writes –

Please be assured that the requirement for medical consultation is not intended to imply or indicate concerns or criticisms of the treatment or triage practices by field providers. Instead, the requirement for medical consultation prior to helicopter dispatch for Category “C” and Category “D” patients is being implemented to provide an additional resource to EMS personnel responding to an incident.^[2]

As the character of Col. Sherman T. Potter, on M*A*S*H, used to say – Bull Pucky!

This just gives you a taste of the way that the state of Maryland handles EMS. Take a look at the protocols. There was an update^[4] sent out just last month. Aspirin for cardiac chest pain no longer requires a medical command order. Woo Hoo! You can clearly see why they want a paramedic to fly in to the scene. Obviously, they have the greatest faith in paramedics – to give aspirin, when clearly indicated, but only for the past month. Sorry, not even for a whole month, yet. Elsewhere in EMS, the bigger problem has been getting medics to get used to giving aspirin to chest pain patients, not in creating obstacles to appropriate care.

What kind of research has been done by Dr. Bass and Dr. Scalea to evaluate their opinion of the need for HEMS? Nothing.^[5], ^[6] OK, there was a comment on a study of HEMS use that was signed by a bunch of trauma doctors. Dr. Scalea was one of them. So was Dr. Norman McSwain. Dr. McSwain is one of the doctors quoted criticizing the abuse of HEMS.

In Air Medical Journal, Ed McDonald writes about the current dramatic increase in HEMS crashes. This was before the September 27 MSP crash –

This can be a hazardous business if we do not exercise good judgment, do not have the proper tools, or push. I was once “10 feet tall and bulletproof” myself. After spending some very uncomfortable and painful moments over the past 39 years pulling what was left of my friends out of a smoking hole, I learned to be vulnerable and teachable. I became teachable enough to understand the value of conservative decision making before every launch and at every moment of every flight. Lose a few close friends who made poor decisions and one sees the value of conservative decision making. The value of “Just Say NO!” became priceless.^[7]

Ed MacDonald is lead pilot for PHI Air Medical in Santa Fe, New Mexico, co-chairman of the AAMS/CORE Safety Committee, secretary of the Air Medical Safety Advisory Council, and safety representative for the National EMS Pilots Association. He is not someone who is opposed to helicopter use, just opposed to abuse.

The loudest voice in opposition to HEMS abuse has been often mislabeled as someone opposed to HEMS use. He is not. He is opposed to HEMS abuse. But read his article, Alright, I’ll Say It, in EMS1.com –

it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.^[8]

Clearly, Dr. Bledsoe is not someone trying to take advantage of a tragic situation, but someone trying to protect flight crews and patients.

Even on the federal level, there are attempts to make HEMS safer.^[9]

Why are Doctors Bass and Scalea opposed to making HEMS safer?

Yes Trooper Medics wear ballistic armor. No, that does not make them “10 feet tall and bulletproof.”

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Footnotes:

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¹ Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

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² MIEMSS Medevac Requests Letter.
October 7, 2008
Free PDF

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³ MIEMSS Maryland Medical Protocols
Effective July 1, 2008
Free PDF

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⁴ Changes/Additions to 2008 Maryland Medical Protocols for EMS Providers
September 9, 2008
Document

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⁵ Articles by Dr. Robert R. Bass
indexed by PubMed

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⁶ Articles by Dr. Thomas M. Scalea
indexed by PubMed

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⁷ Stop pushing.
Macdonald E.
Air Med J. 2008 Sep-Oct;27(5):210. No abstract available.
PMID: 18775382 [PubMed – in process]

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⁸ Alright, I’ll Say It
By Dr. Bryan Bledsoe
ems1.com.
June 12, 2008
Article

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⁹ S. 3229
To increase the safety of the crew and passengers in air ambulances.
Introduced July 8, 2008 by Sen. Maria Cantwell
Link to bill

Updated formatting /25/2011

Filed Under: Critical Judgment, Dr. Bryan Bledsoe, Ethics, Fraud, Helicopters, Heresy Tagged With: Ethics, Fraud, Helicopters

Helicopter EMS – The Starbucks Effect.

Wed, 02 Jul 2008 00:47:00 -0400 by Rogue Medic

Dr. Bryan Bledsoe says, “We are putting patients and flight crews at risk, when there is absolutely no chance for the patient to benefit from the risk.”

Does that sound like a definition of malpractice?

Maybe he was just trying to get some attention after a big accident. Maybe he is just trying to make a name for himself.

He wrote about this recently, before this crash, in Alright, I’ll Say It at ems1.com.

“it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.”

Clearly, not someone trying to take advantage of a tragic situation, but someone trying to protect flight crews and patients.

Back to the video clip at the top of the page. Reporting on this, Tom Costello said, “But the medics on the scene often don’t know how serious the injuries are. And it’s not until the patient gets to a trauma center that those injuries can be assessed.”

Why wouldn’t a medical professional get on camera to say this?

What evidence backs this up? Yes, there are low standards for EMS. I have been very critical of the medical oversight that encourages this incompetence. The medical directors need to stop allowing anyone with a card to go out and inflict their incompetence on patients. Patients are not in a position to know who is competent and who is not. It is the job of the medical director to determine this before signing the paper that says this person is safe to treat patients with all of the life threatening drugs and equipment they carry.

In stead, medical directors write liberal protocols for helicopter transport. These liberal protocols are often violated egregiously, yet the medical director ignores this. Why? He probably does not know, because he is probably never going to see the patient and will never know that the patient chart is largely a work of fiction.

Some examples of bad flight decisions:

An adult with a lower leg fracture, about 20 minutes from trauma centers in two directions by ground. The idiots called for a helicopter for this stable patient, because that is what they do. They are too stupid to appropriately assess and treat the patient. But wait, some of the idiots who do this are the same medics who work on the helicopters on their other job. Why would anyone trust them with a patient, just to try to save a little time? Good pulses, sensation, and movement. No other injuries – at least according to the report that was given to the flight crew. Who knows how incompetent the assessment was that led to this report.

A child with his foot caught under the seat of a car that struck the guard rail. No intrusion into the patient compartment, everyone restrained, the driver was sitting in the seat that was on top of the child’s foot. The driver had an ankle injury (possible fracture) and was flown. Once one person is flown, usually everyone goes by air. So the five occupants of this car, of which the ankle injury was the most serious, were all flown. We had our own little air shown because somebody can’t treat an ankle injury. My patient was the child. I called the trauma center to get permission to drive him to the local hospital, since he is uninjured, but his parents want him checked out. Medical command at the Ivy League trauma center insists that this child must go by air to the pediatric trauma center. The parents are no longer on scene – they were not in the car, but were far from attentive to their child. Had the parents been on scene, maybe I would have been able to get them to sign a refusal for the helicopter transport and transport to the appropriate hospital with pediatricians on staff.

A stabbing to the chest 8 minutes by ground to the trauma center. The first in medic doesn’t quickly move the patient to the stretcher and transport. He calls for a helicopter. 40 minutes later the now pulseless child is placed in a helicopter to fly to a different trauma center. The patient was still alive 30 minutes after the arrival of the first medic. The patient would have arrived at the trauma center alive and had a chance to live – if he had not been flown.

Since the patient was a child the helicopter flew this dead patient and the trauma center worked the code for almost an hour. Nothing can bring back the wasted half hour that might have made the difference between a casket and an ICU bed. The child might have died anyway, but why call the helicopter to delay transport?

As for the Starbucks Effect, the number of medical helicopters has expanded similar to the way Starbucks have exploded across the countryside, but Starbucks does not explode the same way helicopters explode across the countryside. If you look at the chart it does look like the price of SBUX (Starbucks stock symbol), over the past 5 years, has taken off and flown pretty high, only to take an plunge reminiscent of Icarus, or a crashing helicopter. Today Starbucks announced that they are closing 600 stores – the customers are not flying in to buy their scuppie coffees. When will the flight programs put patients first and do something similar? We are creating bogus excuses to put patients in helicopters to satisfy the growing need for paying customers (patients).

And for anyone reading, who might be offended by what I wrote – if it does not apply to you then you know who I’m talking about; if it does apply to you stop being part of the problem and don’t complain that I pointed out your incompetence. Have I gone too far with crash and burn metaphors? I doubt it. Idiots will still be flying minor trauma after reading this.

Dr. Bledsoe says, “We are putting patients and flight crews at risk, when there is absolutely no chance for the patient to benefit from the risk.”

Words worth repeating.

Maybe we should start requiring competence from medics, so that we can protect patients and flight crews.

Here is a link to the abstract of the study mentioned in the video:

Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF.
Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Review.
PMID: 16766969 [PubMed – indexed for MEDLINE]

Another blog to read on the same topic, from a different perspective, is Too Old To Work, Too Young to Retire. His post is Helicopters in EMS. Ambulance Driver also writes about this and gives it more of a human touch in Gut Check….

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Dispatch would have told us if it were something serious.

Safety über alles!

Filed Under: Assessment, Critical Judgment, Dr. Bryan Bledsoe, Ethics, Fraud, Helicopters, Heresy, Malpractice, Medic X, Physician Oversight Tagged With: Ethics, Fraud, Helicopters

RSI, Intubation, Medical Direction, and Lawyers.

Mon, 28 Apr 2008 19:35:00 -0400 by Rogue Medic

There has been a discussion of the article High-risk EMS procedure gets a low level of oversight^[1] on TexasEMT.com. The forum on RSI (Rapid Sequence Induction or Rapid Sequence Intubation) has been very active. It presents a variety of views, including mine.

One of the physician/medics on the list included some posts from another site. The posts provide a lot of good evidence for the safety of RSI. I will eventually review a lot of the intubation research. There will be special places for the examples of research from Dr. Wang and Dr. Yealy that are discouraging good airway management.

The gist of the discussion between me and another person has been the level of medical director responsibility. He does not see the problem with medical directors as serious.

I see bad medical direction as the essence of airway problems.

His most recent post finishes up with this statement.

So, if you’re right, and failed tubes are the fault of bad medical directors, then the studies quoted above represent incontrovertable evidence of excellence in medical direction. After all, a 95% success rate and only 3 surgical airways in over 1500 attempts shows that they clearly have in-touch doctors.^[2]

The 95% success rate refers to intubation success. The airway management success rate was 99.7% and it improved with the addition of capnography.^[3]

I agree with him. The problem is that these are only some of the systems that intubate. Dr. Wang and Dr. Yealy will find you places with much lower success rates.

The bigger problem is that systems with poor intubation success rates are not hard to find. While we should be encouraging the excellent systems, where is the outrage at the incompetence of systems that do far worse?

If you are Dr. Wang or Dr. Yealy, looking at paramedics in Pennsylvania where every town that has its own traffic light needs to have its own paramedics, why correct the problem of too many ALS services, too many medical directors, and too many bad medical directors? Instead, use this situation to justify criticism of paramedics’ intubation skill.

Why are we not gathering pitchforks and torches and demanding better than the bad airway management encouraged by Dr. Henry Wang, Dr. Donald Yealy, Dr. Robert Kowalski, Dr. S. Addison Beeson, Dr. Cynthia Simmons, Dr. Paul Pepe, Dr. Robert Simonson, Dr. Frankenstein, . . . .

“If you have a good medical director, somebody who’s actively engaged and involved in EMS, you can kind of push the envelope,” said Bryan Bledsoe, a Midlothian emergency physician and the author of several EMS textbooks. “The problem is a lot of these services have someone who just signs the chart.”(article)

Just signing a chart, or just looking at flagged charts, is not medical oversight. These service should not have ALS unless they have a real medical director.

“I’ll say this flat out: There is no excuse for a misplaced tube,” said William E. Gandy, an EMS educator in Tucson, Ariz., who is known nationally for his expertise in airway management. “We have the means to verify that a tube is in the right place. There’s no excuse for not verifying.”(article)

Can anybody make a good case that he is wrong?

I can’t.

Who is responsible for these three cases of, not RSI problems, but intubation confirmation problems?

All of these cases were problems with the confirmation of the placement of the endotracheal tube – not with the use of the medications to paralyze the patient.

Very basic stuff for an ALS airway.

While it is difficult to know how widespread such problems might be, many familiar with EMS issues say the incidents that reach the legal system are likely just the tip of the iceberg.

R. Jack Ayres, an Addison attorney who holds a paramedic’s license and has long been involved in EMS at the state and local levels, said he knows of at least 50 cases in which botched intubations caused death or disability.(article)

People have been saying that this is only a matter of 3 cases.

People have been saying that this is a matter of only RSI problems.

They don’t know what they are talking about. If you have a system that has the ability to check exhaled CO_2, (carbon dioxide), but people don’t check exhaled CO_2,, then this is a huge problem.

Each of these cases would have been prevented by simply checking exhaled CO_2,, and placing an alternative airway if the medic could not get the tube in the right place.

How difficult is it to teach that you check CO_2, continuously on every intubated patient?

How hard is it to make sure, as medical director, that this is done on every intubation?

If you show up at the emergency department and you do not have a device for checking exhaled CO_2,, nobody notices?

Allen was intubated seven minutes before the helicopter landed at the United Regional Health Care center in Wichita Falls, according to records. The tube became dislodged before she was treated in the emergency room, the records indicate.

Both the flight nurse and the paramedic acknowledged in depositions that they did not use carbon dioxide monitoring, even though it was available.

The medical director for Air Evac’s Wichita Falls base at the time was S. Addison Beeson, a Tulsa emergency physician. She did not respond to messages from the Star-Telegram.(article)

It isn’t as if you sneak into the emergency department with these patients and nobody notices. Intubated patients are high priority patients. They require extra staff and equipment.

None of the nurses, doctors, techs, respiratory therapists, janitorial staff, . . . notice this?

One problem is that it isn’t much better in the emergency department. When I bring in a patient with waveform capnography attached, the first thing that staff will tend to do is pull the tubing, because it is “in the way.” Would they go into the ICU (Intensive Care Unit) and do the same? There is a lot more stuff “in the way” in the ICU.

One reason for this is that, in the ICU, more stuff is considered better care. More EMS stuff, even though it is helping EMS to provide a higher level of care than than the emergency department, is viewed as just “in the way.”

What doctor, nurse, or respiratory therapist throws away the best method of confirming tube placement without using it?

OK, that is a bit unfair. I have never seen a respiratory therapist do this. The respiratory therapists are often as interested in this as in any other new gadget, and they understand its value. Why don’t the doctors and nurses? OK, still a bit unfair. It is only some doctors and nurses that do this, but why do any do this? If you do not know what it is, ask before removing it. Hmm, this pin is “in the way” on this hand grenade, better remove it.

What is extremely rare is that the doctor, or nurse, will use the waveform capnography to check tube placement. Instead, they will be running circles around themselves to use all sorts of inferior methods of confirming placement. They will completely ignore the most reliable method of confirming placement.

This is wrong.

This is where EMS learns to not use capnography, or the slightly-better-than-useless color change device.

“If they don’t use this stuff in the hospital, why do we have to use it?”

Clearly, anyone who would say this, does not understand patient care and should not be intubating. In EMS there are too many of these idiots. The medical directors, the essence of airway problems, do not seem to do a good job of removing them.

Simonson said records he has reviewed at CareFlite show that the air medical service regularly has to “bail out” ground EMS crews that fail to intubate paralyzed patients.(article)

So, they couldn’t intubate the patient. This happens. Did they use an alternative method of managing the airway?

That is what matters.

None of these cases in the article were about RSI, they were about airway management.

There are places where the medics have no clue about airway management, but are allowed to intubate. Is this acceptable? Should this be acceptable?

What kind of person knows that his people cannot manage an airway, but allows them to intubate (RSI or no RSI)?

Dr. Simonson goes on to say:

Simonson said he has come to believe that RSI “needs to go away” when it comes to ground EMS. To that end, he has removed it from the protocols of all but two of the units under his direction because, he said, only those units had the necessary experience.(article)

Has he taken intubation away from the inexperienced ground services?

Has he done anything to educate them, to improve their experience level?

With only a few sentences out of hours of comments, it is difficult to determine what his approach is.

The problem remains a failure of the most important part of airway management in three cases. The problem was not with the medications that cause temporary paralysis (RSI).

Here are the reasons, given by the medical directors for two large cities, for not using RSI.

Arlington: Short transportation times and the inability to train a large number of paramedics are cited by Cynthia Simmons, the local medical director for the city’s ambulance provider, American Medical Response.(article)

In other words, the medical director can’t train a large number of medics in advanced airway management.

Dallas: Paramedics in a large system don’t have enough opportunities to sharpen their intubation skills, according to medical director Paul Pepe.(article)

He used to be medical director for the state of Pennsylvania, home of Dr. Wang and Dr. Yealy. What kind of illogic is this? If the medics in a large system “don’t have enough opportunities to sharpen their intubation skills,” who does?

What kind of medical oversight do they have that keeps them lacking in “sharp?”

Bad airway management, RSI or not, is a reflection of the quality of the medical director.

Other RSI/airway/tube confirmation posts of mine:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Risk Management, and Rocket Science

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Footnotes:

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^ ¹ RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at JEMS.com

Now apparently only available at Free Republic.

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^ ² TexasEMT.com Forum Index » Open EMS/EMT Discussion » RSI

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^ ³ Wayne MA, Friedland E.
Prehospital use of succinylcholine: a 20-year review.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Filed Under: Airway Management, Critical Judgment, Dr. Bryan Bledsoe, Heresy, Intubation, Physician Oversight, RSI

RSI Problems – What Oversight?

Tue, 22 Apr 2008 03:02:00 -0400 by Rogue Medic

In High-risk EMS procedure gets a low level of oversight,^[1] an article in the Star-Telegram, Danny Robbins writes about problems with airway management in EMS, specifically RSI (Rapid Sequence Induction, sometimes referred to as Rapid Sequence Intubation). Danny Robbins is a reporter who has won a bunch of awards, does his homework, and puts out a balanced piece of journalism. For one thing, he seems to recognize the problem as one of oversight more than skill.

It appears that the AP (Associated Press) has picked up the story and there are abbreviated versions of it turning up all over Texas. The rest of the country may add to the commotion. There is a pretty good Interactive graphic: RSI with the story. One of the other papers to pick up on the AP redistribution is the Houston Chronicle in their abbreviated story Health officials question high-risk intubation procedures. Ordinarily, I would not mention the derivative story, but they have a comment section at the end of the article that is interesting. EMS1.com also has the story and a comment section.

The Interactive graphic: RSI is a bit misleading without the rest of their course to explain the steps and the importance of all parts of the procedure. There are two problems that I have with it. On the slide for RSI step 3, the suggestion that cricoid “Pressure prevents stomach contents from entering the airway,” is not accurate. Dr. Bryan Bledsoe, interviewed in this article, wrote about the shortcomings of Sellick’s Maneuver, or cricoid pressure on EMS1.com. Sellick’s Maneuver — Not the Panacea We Thought.

Then on the slide for RSI step 6, the CO₂ (carbon dioxide) detector is, in my opinion, not appropriate for RSI. There should be a requirement for waveform capnography for all RSIs. The plastic piece stuck on the end of the tube contains some litmus paper that changes color to indicate the presence of an acid – carbon dioxide. It loses its ability to change color, react to CO_2, in the presence of moisture.

Breathe in some dry air and when you breathe out, it will be moist. If you have ever seen a couple fogging up a car, exhaled moisture and cool night air are the reasons for the condensation on the windows. For another example of this, take a color change CO₂ detector, open the package and breathe through the detector. Don’t worry, you won’t be ruining anything of value. How many breaths does it take until the litmus paper stops changing color? In my experience, these detectors fail on real patients – due to moisture – at ridiculously high rates.

If you wish to monitor CO₂, use waveform capnography. A site that explains this in a lot of detail is Capnography for Paramedics. Waveform capnography is capable of providing far more than just information about tube placement. If the patient has a sudden change in cardiac output, waveform capnography will spot that before any other assessment method will. The patient regains a pulse, the CO₂ increases significantly. The opposite is true if the patient arrests. Having trouble differentiating between CHF and asthma, or emphysema? Waveform capnography can be a tremendous help.

But let me just offer my modest opinion. Anyone intubating without waveform capnography is asking for trouble. There are very few exceptions. The printout from waveform capnography is more trustworthy than any other method of confirming placement. Including direct visualization. If anything bad happens to the patient, produce a couple of printouts of good CO₂ numbers and you can be certain that the tube was not in the esophagus at the times the recordings were made.

Or you can use some other method and try to explain that the tube must have moved after it was placed correctly. Almost always this is what medical professionals, in an effort to be accurate, call a lie. Without any form of documentation it is easy to claim that some form of magical intervention caused the tube to move. “Winged monkeys sighted over ambulance after successful intubation. On arrival at the hospital the tube was found to be in the esophagus. News at 11.”

Read this excuse of the paramedic “training coordinator” for AMR (American Medical Response), who committed the one most unforgivable sin of airway management – he did not recognize that the tube was in the wrong place.

The paramedic, Jeffrey Dektor, stated in a deposition that he made two attempts to intubate Cannon, the second time with the ambulance stopped at a parking lot.

He testified that he believed his first attempt was successful but tried again with a larger tube when he noticed that Cannon’s oxygen saturation levels continued to decline. During that attempt, he said, the tube became dislodged.

Asked why he didn’t use any form of carbon dioxide monitoring, even though it would have been available on the ambulance, he replied: “I cannot state why I did not.”

Twenty minutes passed from the time of Dektor’s first attempt until Cannon was successfully intubated at Presbyterian Hospital, records show.^[2]

The medical director did not have any problems with this. There are not words strong enough for such indifference. How can a medical director be complacent about a medic who cannot recognize a misplaced tube? Another way of describing a misplaced tube is a suffocation device.

Everybody seems to put the blame on the medic. The medic was doing what he was taught by the medical director. The medical director probably mentioned the end tidal CO2 device, but perhaps did not stress it enough and clearly did not do enough continuing education. The biggest problem with this infrequently performed skill is the lack of competent oversight.

Robert Kowalski, who was the hospital’s director of emergency medicine as well as Hunt County EMS medical director at the time, confirmed in his deposition that he was the physician who finally intubated Cannon.

He stated repeatedly during the deposition that the matter did not cause him any concern.

Kowalski, who now lives in Cadillac, Mich., said recently he doesn’t remember the case well enough to discuss its details.

“It was not a paramedic we had problems with, I can tell you that, because I know the [paramedics] we had problems with, and he wasn’t one of them,” he said.(article)

So, this is not one of the bad medics Dr. Robert Kowalski continues to allow to treat patients, in spite of his knowledge of their danger to patients. This abuse of a patient’s airway was an action that Dr. Robert Kowalski did not have a problem with. Should we blame the medic or the medical director. This is another example of the dangerous Medic X that I wrote about here, here, here, here, and here. Not that I have an opinion on this mistreatment of patients by medical directors.

Dr. Robert Kowalski knows the medics he has problems with, but only seems to know that he did not identify this medic as one of the problem medics. Did Dr. Robert Kowalski know any of his good medics? Did Dr. Robert Kowalski have any good medics?

EMS personnel work in an environment that can be noisy, bumpy, and distracting. Waveform capnography helps you to deal with those problems that interfere with a good assessment. To not use waveform capnography is very bad risk management. To not have a problem with not using waveform capnography is beyond reckless.

There are courses that do an excellent job of teaching medics, nurses, and doctors to use RSI safely. RSI is a tool. A tool can be misused by any tool. RSI is not dangerous. A poorly planned for RSI is dangerous. A poorly trained for RSI is dangerous. Unskilled people performing RSI is dangerous.

Having well trained people, with excellent oversight, perform RSI is not dangerous.

Probably the best known of the courses to teach all aspects of airway management from BVM to RSI is SLAM (Street Level Airway Management). Their courses are not cheap.When it comes to airway management, there is no such thing as cheap. If you do not pay to train your people well (doctor, nurse, medic) you will end up paying more for it in the end. They also have a book available on their site and elsewhere. Danny Robbins interviewed one of their instructors , Gene Gandy, for the article.

The issue of whether RSI should be practiced by ground EMS was underscored by the Cannon lawsuit, which charged that American Medical Response never retrained the paramedic who attempted to intubate Patricia Cannon even after the company, based in Greenwood Village, Colo., became aware of the facts of the case.(article)

When I make a mistake, which happens more often than I would like, I follow up by doing what I can to avoid making that mistake again. According to this article, AMR (American Medical Response) apparently does not see inexcusable mistakes that kill patients as any kind of a problem. It is unfortunate that there were no criminal charges brought against AMR and their medical director – Dr. Robert Kowalski.

Poor performance of RSI is an indication of poor medical oversight. RSI is a tool. As a tool, it can be used properly, or it can be misused. If it is allowed to be misused, that is the fault of the medical director. How can anyone say that the liability should be placed anywhere else?

That is plenty of writing for now.

Safety über alles!

Fri, 11 Apr 2008 00:11:00 -0400 by Rogue Medic

Backboards and Band-Aids: Notre Dame’s

The dynamic duo, with another on the way, over at Backboards and Band-Aids got me started on a bit of a rant. Go to their site to see the video of a line drive to the head.

Anyway this is my perspective on the idea of limiting high school base ball to wooden bats in order to prevent college pitchers from being hit in the head by line drives.

While the speed and mass of the ball are important factors, I will leave that to the physics people.

The type of impact – direct vs glancing vs deflected by a glove or shoulder – will probably have more to do with the impact.

Add to that the type of pitch, the skill of the batter, the comfort level of the batter with a wood bat vs. an aluminum bat, . . . .

There are so many factors that go into such an equation that the type of bat assumes an insignificant place in the whole picture.

The need for people to try to make something completely safe often leads us to profound silliness.”If it saves just one life . . .” is one of the mantras of those who would sacrifice everything else for just the appearance of a little safety.

So how much difference would wood make?

First someone needs to demonstrate clearly that the aluminum bat leads to a more dangerous impact. They might use the term more impactful, but I just shudder at that thought.

Am I connecting two unrelated things? I don’t think so. Made up words and made up solutions are part of their methodology.

But shouldn’t we try to be as safe as possible?

That depends on what we give up.

What could be more important than safety?

Isn’t that for the individual to decide?

People make bad decisions all of the time.

Yes. Forcing your version of safety on everyone else would be a bad decision.

What do you mean? I only want to protect people.

Why can’t we let people make their own minds up about this?

You wouldn’t say that if you were the one injured.

I have been injured many times and feel that the ability to choose my own risks is far more important than the comfort of some safety nut, who doesn’t even understand probability.

But, if you don’t take the risk you cannot be hurt.

Not by that risk, but it alters the way you approach risk.

What do you mean?

If your only method of dealing with risk is avoidance, you have only one real solution. You must lock yourself up somewhere that you feel is safe from risk.

That doesn’t make sense.

Everything has risks.

How about some examples. This is a medical blog, so make them medical.

Working in the suburbs, where the trauma centers are spread out a bit more than in the typical big city, I have worked places where the philosophy is to fly anyone who can be misrepresented as critical trauma.

Misrepresented?

Some examples:

Dr. Deborah Peel lost control of a car, side swiped some parked cars, and is acting in a way that could be described as hysterical. There is a laceration on Dr. Peel’s forehead.

Clearly a serious head injury.

On talking to Dr. Peel it was easy to calm the good doctor down. There appeared to be only a small laceration to Dr. Peel’s forehead, but head lacerations tend to bleed a lot. The bleeding is easily controlled. Even Dr. Peel’s behavior is easily controlled – at least in this case.

So where is the problem?

Until Dr. Peel is told that, due to the non-existent critical trauma, transport will be by helicopter. Now Dr. Peel is exhibiting the same hysterical type of behavior again, due to a fear of flying, and Dr. Peel is refusing transport by helicopter.

So the patient has a right to refuse if the patient has the capacity to understand the risks and benefits of the proposed treatment.

The “can’t be too safe” officer on scene decided otherwise.

That’s kidnapping.

Yes, but who is going to press charges? If charges are filed, who will testify against the local EMS people. “Are you saying we shouldn’t fly you if you are seriously injured?”

The patient wasn’t seriously injured!

Here is where the safety misrepresentations really become interesting. They claim that you cannot be sure that the patient does not have a critical injury. If you do not fly this patient, you are putting not just yourself, but all of your coworkers at risk of losing their jobs. If the EMS agencies do not remain open to work people will have no way of getting to the hospital.

Maybe the patient did have a serious injury.

It was a series of low speed side swipe type impacts that eventually resulted in the car stopping. There was no evidence of serious injury. Even the most backward ED or doc-in-the-box clinic could take care of this patient with a scratch.

Maybe the “can’t be too safe” officer had a serious head injury.

Tempting, but I’m not going to go there.

One bad case like that is no reason to scrap the whole system.

I am not suggesting that the system be scrapped, but that it be used appropriately. This patient was 10 minutes from the closest hospital without lights and sirens. There was no reason to use lights and sirens. If the closest hospital were to refuse to accept this patient, then it is just a half an hour to one of the down town trauma centers.

The helicopter will save a lot of time.

And it will cost a lot of money, it will put the patient and crew at greater risk, and it will require the fire department to come out and set up a landing zone. All for someone with a minor injury.

Here is another example. At a construction site, Dr. Deborah Peel is the operator of a piece of heavy equipment with a fully enclosed operator compartment. The equipment rolls over on its side. The equipment was not on firm ground, so it probably rolled very s l o w l y. Nobody reported any dramatic impact. Dr. Peel does not speak English (or does not admit to speaking English). No oriented verbal response (in English) means altered mental status. Again a serious head injury. There is no sign that Dr. Peel’s’s head was injured in any way.

Helicopter?

Yes, we are now using the helicopter for translation. I can’t think of a more appropriate use of resources, can you?

One of the flight medics who works there was adamant that I am putting everyone at risk by suggesting that these patients should not be flown.

The helicopter service that flew these patients. Was it the same one that employs this flight medic and the other flight medics where you worked?

Aren’t you the cynic? Yes. All of the flight medics, who also work as ground EMS people, work for the helicopter service we used.

But those are only two examples.

I could go on and on about minor injuries and uninjured patients flown because of mechanism.

Mechanism is a valid reason to fly patients.

Only very rarely. Mechanism points to areas that should be assessed more thoroughly.

A GSW (Gun Shot Wound) suggests that you should look for other GSWs, that you should consider that the route of travel of the projectile might not be a clear point A to point B, . . . , but if it is in the lower leg there is no good reason to fly someone to save 10 minutes drive time and have your ambulance back in service a little sooner.

But what if you miss something?

That is where this whole conversation was going. You cannot avoid missing things.

The cost to fly everyone, because you might miss something will eventually bankrupt a lot of people and put the helicopter services out of business. So, when you have a patient where helicopter transport can make a significant difference in outcome, no helicopter is available.

You cannot protect against all possible risks.

You have to allow people to use judgment, but teach them to use that judgment well.

These “you can’t be too safe” methods only encourage childish decision making and prevent medics from learning to care for patients. It becomes just a matter of calling for the helicopter and getting the IV and other protocol stuff done before the helicopter arrives. No real patient care, just make it look good for the helicopter crew. Call them enough and maybe they will hire you.

We are becoming a nation of people who are incapable of evaluating risk. We only want to pass the risk on to someone else. How long will we be able to continue this?

In a recent post I linked to an article with an interview of Dr. Bryan Bledsoe about helicopter use in EMS. Dr. Bledsoe has been a vocal opponent of the misuse of helicopters in EMS for a long time. On his site are links to PDF formatted downloads of a bunch of papers he has written.

Other posts about helicopter misuse in EMS:

Helicopters and Airways

Interfactility Helicopter EMS

Helicopter EMS – The Starbucks Effect.

Dispatch would have told us if it were something serious.