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

- Rogue Medic

ABQ to Pay $.3 Million More for Bad Oversight of Bad Medic

 

It appears that bad management tolerated, and promoted, bad patient care – right up until it affected one of their own. Now the residents have to pay a lot of money for this failure of oversight.

How typical is this medic?
 

Throughout the litigation, Tate denied any wrongdoing. He maintained his work behavior was part of the “culture” of the Fire Department.[1]

 

AFD_logo
 

The AFD (Albuquerque Fire Department) disagrees and convinced at least one “hearing officer” that it is only because the rest of the paramedics are better than Tate that his patients did not have worse outcomes.

Does that make any sense?

I discussed the complaints at the time of an earlier article about Tate and AFD.[2]

If you work with a dangerous paramedic, and you do not report any problems, does that make you better than the problem paramedic?

How does such a dangerous paramedic get promoted to lieutenant?

Is it likely that competent management remained unaware of these problems for a decade, or that this was a sudden onset of an unprecedented problem, or that in some other way this is not an example of bad management?
 

Other organizations have had to deal with criticism after their management of the corruption was exposed –
 

The Vatican revealed Tuesday that over the past decade, it has defrocked 848 priests who raped or molested children and sanctioned another 2,572 with lesser penalties, providing the first ever breakdown of how it handled the more than 3,400 cases of abuse reported to the Holy See since 2004.[3]

 

For hundreds of years we have been told that priests don’t rape children, because they are more moral than the rest of us. Evidence has demonstrated otherwise, but the corrupt culture still discourages reporting these crimes to the police.

Is there some reason to believe that Tate is just one rotten apple?

No.

This appears to be another example of a corrupt culture, that will end up costing a lot more money and setting bad standards of care.

Are the patients surviving to the emergency department because of the care provided or just because most people will survive what EMS does to them?
 

Cadigan told the Journal in 2014 that he was confident Tate would be “vindicated when he has a neutral judge to review the city’s unfair and arbitrary action. The taxpayers will likely have to pick up the tab for this absurd witch hunt.”[1]

 

Vindicated for treating the family of a fellow AFD lieutenant the same way he would treat other patients?
 

Tate claimed his conduct was consistent with what he learned at the Fire Department and argued that even if he did commit the alleged acts, he should be given corrective training.[1]

 

Maybe Tate did receive corrective training.

Repeated reminders to fit in with the culture is how corruption works.

If the culture is not the problem, why did an investigation only begin after a complaint about Tate treating one of his own the same way he is reported to treat other patients?

Footnotes:

[1] $300K settlement keeps paramedic from getting job back
By Colleen Heild / Journal Investigative Reporter
Saturday, April 2nd, 2016 at 11:45pm
Albuquerque Journal
Article

[2] How Do We Stop Dangerous Paramedics From Harming Patients?
Sat, 02 Nov 2013
Rogue Medic
Article

[3] Vatican says it’s punished over 3,400 priests since ’04 for raping or molesting children
The Associated Press
Published: 06 May 2014 03:56 PM
Updated: 06 May 2014 04:04 PM
The Dallas Morning News
Article

.

Giving New Meaning to Carpe Diem

 

On facebook, Jon Kuppinger describes the following situation –
 

So what made you decide to call now given your patient has been in full tonic-clonic seizures for over three hours now?

 

Maybe their washing machine was broken.
 


Image credit.
 

The response by the nurse?
 

The nurse was out and we don’t have access to any meds and it just seemed worse than it was earlier and we weren’t sure what to do about it so we decided to wait until she got back to call.

 

Paging Nurse Gilligan! Paging Nurse Gilligan!

The nurse was out for over three hours and . . . .
 

Just sit right back and you’ll hear a tale,
A tale of an endless fit
That started at a nursing home
Then went straight to $#!†.

The patient was a flailing man,
The aide had not a clue.
The patient’s brain was fried that day
In a three hour spaz, a three hour spaz.

The seizure started getting rough,
The patient quaked and tossed,
If not for the callousness of the staff,
The seizure would be stopped.
The seizure would be stopped.

 

Maybe they were engaging in a modern Tuskegee experiment.

Maybe they were using homeopathy or some other form of alternative medicine and were waiting for for the scam treatment to work.

Maybe three hours of seizure was getting boring and they thought that a few more hours of this might be life-threatening. If the patient dies, what will they do for entertainment tomorrow?

Unlike Robin Williams’ character in Dead Poets’ Society, I guess that we can be glad that they did not decide to let the patient seize the whole day. This is not what carpe diem means.

We’ve schedule you for a three hour high colonic tonic/clonic today. Ordering activities using drop down menus can cause some real problems.
 

Out of 205 patients, only 19 died in a study comparing using diazepam (Valium), lorazepam (Ativan), or placebo by EMS to treat seizures.[1]

Most of those who died were in the placebo group, even though the placebo group was only one third of the patients. Over 15% of the placebo group died during their hospitalization.

NNK = 6.4 (for untreated seizures)

NNK = Number Needed to Kill. NNH (Number Needed to Harm) is the actual term. These seizures were only untreated for about 15 minutes – not for three hours.

NNH = 3 1/3 (for untreated seizures).

Even an inadequate dose of benzodiazepine would lower the death rate. None of those received IM (IntraMuscular) medication. All received IV (IntraVenous) medication.

Half of the lorazepam group received only one 2 mg dose of lorazepam. The other half of the lorazepam group was given a second dose of 2 mg of lorazepam.

With such low doses, over 40% of the lorazepam patients were still seizing when they arrived at the ED (Emergency Department).

The FDA (Food and Drug Administration) recommends 4 mg lorazepam as the initial dose for seizures.
 

For the treatment of status epilepticus, the usual recommended dose of Lorazepam Injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional Lorazepam Injection is required. If seizures continue or recur after a 10- to 15- minute observation period, an additional 4 mg intravenous dose may be slowly administered.[2]

 

A slightly smaller percentage of the diazepam patients were given a second 5 mg dose of diazepam, so it is not surprising that well over half were still seizing when they arrived at the ED.

A low dose means continuing seizures. My brand new protocols ignored the evidence from the recent IM midazolam (Versed) vs IV lorazepam study and have us continuing to use inadequate doses.[3]
 


 

Only 1 mg – 2 mg lorazepam?

Only 1 mg – 5 mg midazolam?

Holy Continuing Seizures, Batman!

Even the FDA recommends 4 mg.

4 mg was the initial dose in recent study that was safe, but not as effective as 10 mg IM midazolam
 

Does anyone take the adverse effects of seizures seriously?
 

After three hours of seizing, the patient might end up as brain damaged as the staff who decided not to treat him, but maybe not.

Brooks Walsh asks Although I’ve read the study before, I am only wondering now how the IRB for Alldredge 2001 thought there was “equipoise” between placebo and benzos.

Equipoise and Ethics and IRBs, Oh My! is my answer.

Footnotes:

[1] A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH.
N Engl J Med. 2001 Aug 30;345(9):631-7. Erratum in: N Engl J Med 2001 Dec 20;345(25):1860.
PMID: 11547716 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med.

[2] Lorazepam (lorazepam) Injection, Solution
[Baxter Healthcare Corporation]

DailyMed
NLM
FDA label

[3] Seizure
7007– ALS – Adult/Peds
Statewide ALS Protocol
Pennsylvania
Page with link to Full Text Download of Full Protocols in PDF format.

[4] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.
 

All adults and those children with an estimated body weight of more than 40 kg received either 10 mg of intramuscular midazolam followed by intravenous placebo or intramuscular placebo followed by 4 mg of intravenous lorazepam.

 

The relationships among benzodiazepine dose, respiratory depression, and subsequent need for endotracheal intubation are poorly characterized, but higher doses of benzodiazepines may actually reduce the number of airway interventions. Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.11

.

Excited Delirium, Sedation, and Comments – Part III

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

Why do I write so much about excited delirium?

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

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

Some people continue to tell us that sedation is evil.

This is from kindofafireguy

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

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

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

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

The only legal advice that makes sense to me is –

Do what is best for the patient.

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

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

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

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

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

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

How… quaint.

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

Let me repeat that: MUCH prefer to sedate.

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

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

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

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

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

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

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

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

 

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

 

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


Image source.

See also –

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

Excited Delirium, Sedation, and Comments – Part I

Excited Delirium, Sedation, and Comments – Part II

Footnotes:

[1] Extrapyramidal symptoms
Wikipedia
Article

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

.

Excited Delirium, Sedation, and Comments – Part II

Others responded to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

CombatDoc wrote –

Why are medics so scared of sedation?

This is the main problem.

Ignorance leads to fear.

But this does not lead to Yoda quotes.

We should not be arrogant, assuming that we know everything about the drugs we use. That can be just as dangerous as ignorance, but we need to learn more about the medications we use.

Too many people tell us that sedatives and opioids are dangerous. These are probably the safest drugs we use. They have well known side effects, but the side effects are not remotely as common as the Just say No people would have us believe.

We need to base our treatments on understanding, not fear.

If we understand what we are doing, we will continually reassess our patients, but we should do this with every treatment, not just the treatments portrayed as evil.

My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient.

Exactly.

The purpose of sedation is to sedate.

That is a description of a sedated patient. We are not supposed to be producing awake and alert and cooperative patients. That is asking the impossible.

We are supposed to be sedating the patient to the point of both no longer being a danger to himself and no longer being a danger to others. Awake and alert have nothing to do with that.

I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

I would prefer to use IV (IntraVenous) midazolam over IM (IntraMuscular), because it wears off pretty quickly when given IV, especially with the exaggerated metabolism of excited delirium patients. The reality of excited delirium is that an IV is usually not practical, so I have to settle for longer duration and less predictable absorption.

I like the idea of the sedative wearing off quickly, because some patients just need to have their excited delirium interrupted. After a period of sedation, some are able to be reasoned with. Some will ask for more sedation, because they realize they cannot control they way their body is acting. This can be like a panic attack. The patient would like to control it, but does not do well without sedation. It should not be a surprise that benzodiazepines are commonly used for panic attack.

How have your results been with IN (IntraNasal) midazolam for excited delirium?

I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that.

If a medic cannot handle respiratory depression, or apnea, by BLS (Basic Life Support) methods, should that person be allowed to use any ALS (Advanced Life Support) treatments?

We can’t handle simple cases of respiratory depression, but we should still be allowed to play paramedic?

No.

Absolutely not.

I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

I was wrong about bath salts. I did not think this would become a big deal. Maybe I am just getting old and do not understand how stupid people will be to get a high. Maybe I need to chase some kids off of somebody’s lawn, somewhere. 😳

I guess the doctors just don’t have enough faith in the power of leather restraints./

Maybe someday my medical director will give us Ketamine….

That would be great.

Sedation has so many uses, that we our patients are really missing out on an excellent treatment for a variety of conditions.

Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

The people who deny excited delirium exists are not the people who work in EMS, emergency medicine, or the police.

The people who deny excited delirium exists are the people who deal with patients who have already been sedated by EMS and the ED (Emergency Department).

If we do not sedate these patients, we may miss the last opportunity to save their lives.

All for a lack of understanding of sedation.

.

Excited Delirium, Sedation, and Comments – Part I

It isn’t my birthday. Still, Shane decided to provide me with plenty of giggles in his response to ‘Hog-tying’ death report faults Fla. medics.

Shane wrote –

I think you might want to review your comments and think before making some statements.

I already made the statements, so I cannot review the statements again before making those statement, unless I repeat the same statements. Based on what you wrote, I will have to repeat some comments. I should probably strengthen, and add to, other comments, because you do not appear to understand.

At first, I thought this comment was a joke. After thinking about it for a while, I suspect that you work for the QA/QI/CYA department of an EMS agency (or maybe you are an absentee medical director). Those are positions that seem to be filled with the most blatant promoters of misinformation. You comment is full of misinformation.

99% of the time, Chemical Sedation is NOT a good practice or recommended to control your patient.

According to whom?

Based on what?

You make bold statements, but you do not provide anything, not even a note from your kindergarten teacher, to support your uninformed assertion.

There are many underlying factors to consider, as you should know, and there are a reason hospitals, medical units and such carry leather restraints and other such devices including police handcuffs with an officer accompanying you in the truck.

There is no requirement for leather restraints on my ambulance, but my state medical director has written protocols with a variety of options for sedation for excited delirium.

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

By protecting my patient, I am protecting everyone else, too.

Please explain the justification for the legal advice that you are giving. Did you stay at a Holiday Inn Express last night?

You should be a patient advocate,

I am being a patient advocate.

You are advocating putting the employer and the medic first, because of some imaginary legal risk.

this does not mean “knocking them out” to better control them. Unknown medical history, allergies, head trauma… all these contribute and should be considered. By doing so could result in a medic induced code due to your actions to use drugs to control a patient.

We do not need to knock the patient out, but we do need to knock them down – we need to sedate excited delirium patients.

I provided a link to the ACEP White Paper. You should have used that opportunity to learn about excited delirium syndrome. Rather than learn, you decided to be an evangelist of ignorance. You wag your finger at me based on what?

You mention Unknown medical history, allergies, head trauma…. How would we make any of these better by increasing metabolic stress?

Fighting against restraints will only make the metabolic stress worse.

What do the experts state in that White Paper?

The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]

ExDS is Excited Delirium Syndrome.

Acidosis is not going to get better with continued struggling, but sedation can stop the struggling. Leather restraints do not stop the struggling. Leather restraints do protect others, when secured correctly, but leather restraints also increase the danger to the patient.

ExDS subjects are known to be irrational, often violent and relatively impervious to pain.[1]

An irrational struggling acidotic patient is going to become less acidotic because . . . ?

An irrational struggling tachycardic patient is going to become less tachycardic because . . . ?

An irrational struggling hypertensive patient is going to become less hypertensive because . . . ?

An irrational struggling hyperthermic patient is going to become less hyperthermic because . . . ?

An irrational struggling hypoxic patient is going to become less hypoxic because . . . ?

Sedation decreases the struggling and decreases the cycle of worsening metabolism that the patient exacerbates by fighting against restraints.

Most authorities, including this Task Force, posit the beneficial use of aggressive chemical sedation as first line intervention. As with any critically ill patient, treatment should proceed concurrently with evaluation for precipitating causes or additional pathology.[1]

The experts do not agree with Shane’s fear of over-sedation.

The experts do not agree that the rest of the patient’s history is more important than sedation.

The experts appear to want to protect the patients with head injuries by sedating the patient.

The experts have thoroughly investigated the condition of excited delirium (something police, EMS, and emergency department staff are familiar with) and decided that use of aggressive chemical sedation as first line intervention is the right thing to do.

I think a little more thought should go into your blogs.

Clearly.

Footnotes:

[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

.

‘Hog-tying’ death report faults Fla. medics

An internal investigation by Broward County’s Fire Rescue division concluded that errors by emergency personnel may have caused the death of a Lauderhill man who suffocated after being “hog-tied” by Broward Sheriff’s Office deputies and county paramedics.[1]

This death is from October 15, 2001, so it has been over a decade and everyone in EMS should be refusing to allow patients to be placed in the prone position following restraint. Hog tying should never even be considered.

The responsible way to manage someone who is combative is to chemically restrain the patient. Physical restraint is for the purpose of being able to inject the patient with the chemical restraint.

Should the medics have known better? Yes, but it was a decade ago and there are still EMS agencies that are not aggressive with chemical restraints.

This is the responsibility of the medical director. We are supposed to be trained and equipped to not make things worse. Clearly, we can make things much worse, if we do not have the right education and medication and protocols.

We should not be treating our excited delirium patients like animals in a rodeo. As medical people, we are supposed to be smarter than the patient with the malfunctioning brain.

Diabetes, head injury, stroke, hypoxia, hyperthermia, drugs, psych, et cetera. There are many possible reasons for this behavior. Our job is to sedate the patient with the least harm to everyone involved, including the patient.


Image credit.

Tasers protect everyone, including the patient,[2] so it is safer for everyone if police use a Taser and then EMS sedates the patient. This is not likely to be effective unless aggressive doses of sedative are given.

Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS subject, any LEO interaction with a person in this situation risks significant injury or death to either the LEO or the ExDS subject who has a potentially lethal medical syndrome.[3]

They point out that a perfect outcome is expected every time.

A perfect outcome is not possible every time.

One of the problems in dealing with excited delirium is that it looks easy, but only when it is done right.

Making the treatment of unstable patients look no more eventful than the treatment of stable patients is what good EMS is all about.

When we make it look easy, some people will claim that we over-reacted. We cannot go back and handle things differently, but we should not want to. Some conditions need to be approached as if they arfe life-threatening. Excited delirium is one of them.

Why?

Because it is life-threatening.

Our job is to try to prevent death, not to cause death. If we do not protect our excited delirium patients by aggressively sedating them, we will kill some of our patients.

Footnotes:

[1] ‘Hog-tying’ death report faults Fla. medics
Report cites 9 ‘failures’ that it says cumulatively may have led to man’s death
By Elgin Jones
South Florida Times
April 19, 2012
Article Reprinted at EMS1.com

[2] Joe Lex: Electrical Misadventures – Microwaves, Cords, Plugs, TASERs, and Lightning
Published: August 30, 2010
Free Emergency Medicine Talks
Page with mp3 link to download

Dr. Joe Lex is one of the most sought after emergency medicine lecturers in the world. Listen to this and to the rest of his talks that are at Free Emergency Medicine Talks.

[3] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

.

Sleep quality and fatigue among prehospital providers


ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Even though many in EMS will tell you that EMS stands not for Emergency Medical Services, but for Earn Money Sleeping, sleep deprivation is a problem for many in EMS, many in medicine, and many in other fields. I am a night person, much more awake and alert at 2 AM, than at 8 AM.

In spite of this, some early to bed, early to rise EMS administrators demand that employees adapt their schedule to the personal preferences of the administrator. This is not only an irrational attitude, but demonstrates such a lack of awareness of what others experience, that working in any patient care setting would be contraindicated.

Sleep deprivation produces impairments in central nervous system (CNS) activities from the most basic functions, such as appetite and temperature regulation, to higher functions, such as memory and vigilance. Sleepiness has been linked to increases in unintentional incidents such as motor vehicle collisons and occupational injuries.3–5 [1]

We should not hesitate to give partial credit to those who insist on having everyone else adapt to their schedules.

Shift workers also tend to have to rely on sleep-inducing agents. A survey of emergency medicine residents revealed that 46% used some kind of sleep agent, including alcohol, benzodiazepines, and muscle relaxants, to fall asleep.8 [1]

About half of residents, not just EMS personnel, but there is no problem that needs to be addressed. Just gulp down some coffee and put on your war face.

There is some unintentional humor in the study. Probably due to lack of sleep.

We collected 119 completed surveys. Subjects were 54.0% female, and the largest age group was 40 to 49 years (39.3%; Table 1).[1]

I do consume chocolate to ward off irritability. Maybe that is the 54% of me that is female. Those 40 to 49 years old were the largest group – by weight or volume or something else? I would ask the same about the 54% female, but I know when to not comment. OK, maybe not. 😳

a moderate proportion of subjects reported employment at multiple EMS agencies (34.2%).[1]

While not the only factor, I would expect that this strongly correlates with sleep deprivation and the resultant negative effects.

I am surprised at the low rate of people working multiple EMS jobs, maybe a lot of them have real jobs work outside of EMS.

The majority of subjects were overweight or obese (84.6%) based on body mass index (BMI).[1]

Sleep deprivation produces impairments in central nervous system (CNS) activities from the most basic functions, such as appetite and temperature regulation, to higher functions, such as memory and vigilance.[1]

No connection.

one-fifth reported being told that they have weight problems (22.7%).[1]

More than 4/5 are obese, but only 1/5 have had a doctor notice this.

Nearly half of the subjects (44.5%) reported experiencing severe fatigue while at work (Fig. 2). The proportion of subjects with severe fatigue increased with years of experience (p < 0.0001),[1]

A global score >5 suggests poor sleep quality.[1]

At least this is something that we learn to adapt to, so it should be less of a problem with increased time on the job.

Or not. Maybe the increasing problems at over 20 years indicates an amount of time in EMS that causes more significant damage.

How much of what we do works out as a feedback loop that compounds problems as if we had heart failure?


Image credit.[2] Click on the image to make it larger.

We know the simple treatments for heart failure – high doses of NTG (NiTroGlycerin) and CPAP (Continuous Positive Airway Pressure).

Maybe the solution to sleep deprivation is something equally simple, such as taking naps or being permitted to sleep when not treating patients.

Even though we have known for decades that NTG and CPAP are the best treatments for acute exacerbation of heart failure, few of us seem to use these treatments. When we do use them, we use homeopathic doses of NTG and we make excuses for not using CPAP.

Will there be any faster adoption of sensible approaches to sleep deprivation?

Will people in EMS be able to make enough to not have to work other jobs?

Federal law limits work hours for many sectors of the transportation industry, including commerical pilots (eight hours of flight time per 24 hours), shipboard personnel on tankers (15 hours per 24 hours), and long-haul truck drivers (14 hours per shift, with a maximum of 11 hours driving).29–31 [1]

Will we only respond to rules set by others?

The mature thing to do would be for us to act first.

One of the reasons I work at my current job is the bosses allow the employees to sleep at any time – as long as calls are covered and other work is accomplished during the shift.

Footnotes:

[1] Sleep quality and fatigue among prehospital providers.
Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D.
Prehosp Emerg Care. 2010 Apr 6;14(2):187-93.
PMID: 20199233 [PubMed – indexed for MEDLINE]

Free Full Text at PubMed Central with links to Free PDF Download

[2] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, & Hostler D (2010). Sleep quality and fatigue among prehospital providers. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14 (2), 187-93 PMID: 20199233

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Paramedic struck off for failing to perform full life support on girl, 7

I first wondered what they meant by failing to perform full life support.

Although papers from the case do not mention Izabelle Easen by name, they show he failed to perform Advanced Life Support on a seven-year-old girl and pronounced her dead after only performing Basic Life Support.[1]

I have pronounced patients dead based entirely on BLS assessment. That is not wrong.

A technician on a second ambulance wanted to take the girl to hospital, which he said would have “given the family some support” but was overruled by Mr McKenna.

Experts did say that the chances Izabelle would have survived if she had been taken to hospital were slim.[1]

“given the family some support”?

This is often claimed as a reason for continuing CPR in futile cases, but nobody appears to have done anything other than pretend that they know what others would want. Based on what? How do we know that parents want to be given false hope? Why do we presume that parents want large hospital bills just to be given false hope?

Why are we so insistent on misleading family members?

ALS (Advanced Life Support) has not been demonstrated to improve outcomes in cardiac arrest.

This is what I was thinking. While I do not know what went on in this case, there is much more detail on some other cases where ex-paramedic James McKenna appears to have really misbehaved, and not just a little bit.

During your employment as a Paramedic with Yorkshire Ambulance Service NHS Trust:
1. on 31 December 2007, you attended a male patient who had suffered five epileptic seizures and you:
(a) did not check the patient’s pulse;
(b) informed the ambulance crew that they were not required to take the patient to hospital;
(c) obtained a signature from the patient, on a form stating that he refused transport to hospital or treatment, whilst he did not have the capacity to make an informed decision;
[1]

This raises some questions about whether the Health Professions Council is more concerned with procedure than with patient care.

They provide some more details about their decisions on these complaints.

8. Mr McKenna admitted that he attended this 25 year old male patient who had a history of epilepsy. Shortly before 9:00pm he had suffered a cluster of five seizures. The Panel does not find particular 1a to be proved. The “Refusal of transportation” document records “P100” which is fairly to be construed as a recording of a pulse rate of 100. Given the ease and speed with which a pulse might be taken, the Panel does not find that the HPC has proved this particular. Particular 1b is proved, the same being admitted by Mr McKenna and in any event supported by the Patient Report Form (“PRF”) completed by the ambulance crew who attended the scene as it records that they were “stood down” at 9:08pm as they were “not required” as a result of Mr McKenna’s call to the Despatch Centre. Particular 1c is disputed by Mr McKenna but the Panel finds it proved. The “Refusal of transportation document” patient signature on this document is illegible and shaky and there is no printed name as required by the form. Furthermore, there is no supporting signature of a witness despite the fact that a number of persons, including Patient D’s girlfriend, were present.[1]

Why do so many paramedics work so hard to refuse to transport patients?

Why do medical directors ignore the refusal forms that are not extensively documented?

Why do medical directors not perform 100% review of refusals?

The same questions apply to the QA/QI/CYA committees that are supposed to be concerned about patient care.

This kind of problem with patient care seems to be the end point of a series of bad decisions made to avoid patient care. How did QA/QI/CYA let it get that bad.

But wait, there’s more –

The patient had more seizures and ex-paramedic McKenna returned to provide more of the lack of care he delivered the first time.

2. on 31 December 2007, you later attended the same male patient who had suffered a further three epileptic seizures and was also suffering from a leg injury and you:
(a) informed a second ambulance crew that they were not required to take the patient to hospital;
(b) argued with the patient’s mother about whether or not he should be transported to hospital;
(c) agreed to transport the patient to his mother’s home and so dragged him to your car using his trouser belt;
(d) muttered “this is ridiculous” in a manner suggesting that the patient was being uncooperative;
(e) failed to assess and/or treat the patient’s knee injury;
(f) transported the patient to the hospital in your car with no additional support if the patient had further seizures;
(g) did not inform the patient’s family that you were taking him to hospital instead of his mother’s home; and
(h) behaved without compassion, feeling or tact towards the patient and his family;
[1]

All of these appear to have been admitted by ex-paramedic McKenna or supported by other evidence.

At some point, he may have been a good medic, but he does not seem to care what happens to patients. There does seem to be undue attention to procedure over patient care, but I don’t see that as the cause of the undertreatment.

There is something else to consider. How many of us work with someone like this?

Footnotes:

[1] Paramedic struck off for failing to perform full life support on girl, 7
A paramedic has been struck off after failing to perform advanced life-saving techniques on a seven-year-old girl who then died.
By Stephen Adams, Medical Correspondent
5:14PM BST 11 Oct 2011
The Telegraph
Article

[2] James McKenna
Health Professions Council
Complaints
Hearings and Decisions
Allegation Number: FTP02654 and FTP02093

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