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

- Rogue Medic

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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Spinal Immobilization – You Make the Call

Kelly Grayson of A Day in the Life of an Ambulance Driver asks what we would do with an unimpaired ambulatory nursing home patient with a day old cervical spine fracture that has been confirmed by CT (Computed Tomography) scan. Well, what would you do?

Now here’s the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.[1]

Here is a very important part of this presentation.

alert and able to follow commands appropriately

Not necessarily alert and oriented to person, place, time, events, and the completely irrelevant question about who is President.

Alert (not sedated).

Able to follow commands.

Is a disoriented person able to localize pain? If we are to believe the Glasgow Coma Scale (GCS), then following commands indicates higher function than just localizing pain.

We should expect the ability to localize pain to be what best protects the patient from further injury.

Best Motor response
1 – None
2 – Inappropriate extension to pain
3 – Inappropriate flexion to pain
4 – Withdraws from pain
5 – Localizes pain
6 – Obeys commands

We should also expect that the GCS will be replaced by something simpler, but more accurate, such as just the Motor response. There have been several papers written on this. I will address them in other posts.

Suppose this is a patient with dementia – can’t remember the day of the week, the month, the year, the President, or any other information we seem to believe is essential for being able to identify/clear a spinal injury. We already know he has a spinal fracture. What we care about is whether the patient can protect himself from injury.

Can I tell you that I have an injury?

Will I permit movement that will make my injury worse?

These are completely different questions.

There is no reason to apply spinal clearance criteria to this patient. We already know that the patient has a spinal injury.

Spinal clearance criteria are only to identify potential spinal injuries. This spinal injury was identified before we were even dispatched. The known spinal injury is the reason for the dispatch.

Do spinal clearance criteria have anything to do with the ability of the patient to protect his injured spine during transport?

Absolutely not.

All that matters with these criteria is whether they identify a spinal injury, not whether that spinal injury would be made worse by transport without spinal immobilization or made worse by transport with spinal immobilization. It is assumed that transport of a patient with a spinal injury with spinal immobilization will protect the spine from further injury. There is no good evidence to support this. To make such a huge assumption in research is a fatal flaw, but we ignore that, because we don’t want to admit that we are practicing voodoo.

Have spinal immobilization methods demonstrated any ability to prevent worsening of an injured spine during transport?

Absolutely not.

What about nice slow transport with a cervical collar and no backboard?


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

During transport, is a cervical collar, especially a hard plastic cervical collar, going to help?

During transport, is a cervical collar going to hurt?

Can you prove it?

I have been fortunate in receiving orders to not wrestle patients, with potential spinal injuries, into restraints. Why force an injury to get worse?

I had one fall patient with compression fractures and kyphosis that caused her back to take almost a 90° turn. When I contacted medical command, his immediate response to this information was, Please tell me that you do not have this patient on a backboard.

Some medical command doctors are smart enough to realize that the best protection against malpractice is to not injure the patient.

Here is an imaginary scene from a court room. While this is imaginary, it is definitely not impossible and not even improbable.

Doctor – I know that my orders/protocol caused permanent injury to this patient, but I have to follow the standard of care or else I will be sued for malpractice.

Lawyer – Since your orders/protocol resulted in the injury to this patient, do you regret your actions that harmed this patient?

Doctor – Yes, but please understand that I have to injure my patients to protect myself from my patients.

First read the You Make the Call post, then read the Conclusion.[3]

What kind of harm will we cause our patients just to avoid having to call medical command, or to avoid having to explain our actions to QA/QI/CYA, or to avoid the possibility of being written up/suspended/fired?

If I have to injure one patient a year, is my job worth it?

If I have to injure one patient a month, is my job worth it?

If I have to injure one patient a week, is my job worth it?

If I have to injure one patient a shift, is my job worth it?

“The maxim is ‘Qui tacet consentire’: the maxim of the law is ‘Silence gives consent’. If therefore you wish to construe what my silence betokened, you must construe that I consented.”
—Thomas More in A Man For All Seasons – play and screenplay by Robert Bolt

Does harming patients protect us from liability?

Does a failure to contact command for at least an attempt to protect the patient in any way protect us from liability?

Footnotes:

[1] Spinal Immobilization: You Make the Call
A Day in the Life of an Ambulance Driver
Article

[2] Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA.
J Trauma. 2010 Aug;69(2):447-50.
PMID: 20093981 [PubMed – indexed for MEDLINE]

[3] Spinal Immobilization: The Conclusion
A Day in the Life of an Ambulance Driver
Article

.

In Defense of Intubation Incompetence – Part I

In response to If We Were Really Serious About Intubation Quality, PA_Medic writes –
 

I’m getting really bored of your anti-intubation posts.

 

If you are bored, then don’t read my blog. Go be coddled elsewhere.

My posts are not anti-intubation posts.

My posts are criticism of bad intubation.

Why do you defend bad intubation?
 

Other then a misplaced tube which should be recognized immediately by auscultation and waveform, a standard in PA, show me the statistics that are for or against placing an airway in an acute CHF or respiratory arrest patient who can no longer support their own airway using a BVM vs an ETT.

 

Intubation is more complex than OK/Not OK. Patient care is more complex than OK/Not OK.

You really do not appear to see intubation as a complex treatment with many side effects – all of which can affect the patient.

Airway management is more complex than just intubation and OK/Not OK.

Show me the data that suggest that any CHF or respiratory arrest patient benefits from bad intubation.
 

Show me data that says a BVM keeps vomit out of the lungs with a decreased LOC.

 

Where is the data that says that incompetent intubation keeps vomit out of the lungs with a decreased LOC (Level Of Consciousness)?

If you work in Pennsylvania, then you are not limited to intubation or BVM. This is one of the benefits of looking at all of airway management, not just whether the tube is in AHole or in BHole.

You seem to be concerned that you might be intubated by someone who is dangerous with a laryngoscope. You don’t seem to care that these medics are harming patients, but when it comes to harming you, that is where you draw the line.

This is not about your patients.

This is about your ego.
 

Several patients are difficult to maintain a proper seal due to facial features combined with movement and transport. In a cardiac arrest I agree the first thought shouldn’t be intubation and that has been statistically proven.

 

Even in the hospital, the doctors who understand resuscitation are using extraglottic airways.
 

If a medic misplaces a tube and they can’t recognize it then maybe that is not the person we should have performing the skill or doing the job.

You criticize me for writing the same thing. 😕
 

There are a lot of procedures medics can perform that aren’t done on a regular basis and that goes for ER doctors/residents and Anesthesiologists. How many emergency tracheotomies are performed by them and have they recertified to someone every year to prove they still can do it and can they perform the same skill

 

I don’t know the answer to your question, but the anesthesiologists I know do need to regularly demonstrate competence in many areas of airway management.
 

if they were called out to perform the same skill laying on a floor of a bathroom with no immediate access outside while the family is yelling over their head to save their baby?

 

That is not what anesthesiologists do.
 

Can I perform an emergency tracheotomy, needle decompression, EJ, intubation, KingLT, or pacer capture on you once a month to make sure I’m up to your standards of proficiency?

 

These are procedures with a very wide range of indications and varying degrees of complications.

Tracheotomy is not in my scope of practice, and if you are a Pennsylvania medic, it is also not in your scope of practice. Crichothyrotomy is only indicated for a can’t intubate/can’t ventilate situation. The complication rate is high. Crichothyrotomy is not like intubation, in a can’t intubate/can’t ventilate situation, the alternative is death. With intubation, there are many alternatives.

There is research on crichothyrotomies that I will address in later posts.
 

Needle decompression is performed so poorly that there is a need to teach medics how to actually get the needle into the lung.

I wrote about this problem in –

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
 


Click on the image to make it larger.
 

From this study we cannot tell if the number that should be in the place of the double question marks is 42. Maybe it is 32. Maybe it is 22. Maybe it is 12. Maybe it is 2. Maybe it is zero. We don’t know and this study cannot tell us, which is not a fault of the study.
 

The same problem exists for trying to figure out the number that should be in the place of the single question mark.

We know that of the patients treated for claimed tension pneumothorax, 26% were treated by paramedics so poorly that the needle never even made it to the lung.

Should we assume that all of the patients treated with needles that actually reached the lung did have tension pneumothoraces?

There is nothing in this paper to suggest that.

 

EJs (External Jugular IVs) are rarely used in EMS outside of cardiac arrest and do not appear to offer much benefit over a peripheral IV.
 

Intubation is something I would want to observe you practicing repeatedly on a mannequin before deciding whether to allow you to intubate me. This is something that would teach paramedics a lot about the many complications other than your overly simplistic right hole/wrong hole assessment of success.

He was hypoxic, his oropharynx is cut up, he has some vocal cord trauma, there is also some tracheal necrosis due to overinflation of the cuff that was not even lubricated, but the tube is in the right place and we all know that the tube location at the time of transfer is the only thing that matters.

There are a lot of medics who should not be allowed to intubate. This is just one way of identifying them, because the results of the studies on actual patients make it clear that we do not get rid of these dangerous medics.
 

The King LT is similar to intubation.
 

Go ahead and use the transcutaneous pacemaker on me. I have had medics pace me to gain experience with the transcutaneous pacemaker. Pacing is another skill that is poorly performed by EMS as well as by nurses and by doctors. Medics are not well trained to assess for transcutaneous pacemaker capture. Medics often do not understand the difference between electrical capture and mechanical capture.

It seems that most often the transcutaneous pacemaker works by producing painful stimulus. Too many people use the sternal rub as a painful stimulus. The sternal rub is one of the mythical procedures so common in EMS. If the patient woke up to a sternal rub, I do not see any reason to consider that as anything other than eyes open to voice.

While we are using treatments on medics, where is my dose of fentanyl? What about Versed?
 

We are trained to use skills that we may seldom use or never at all but if we do we are trained to recognize if it was done wrong to correct it if possible.

 

Research shows that medics do not do this well.

Still you defend those who cannot competently deliver patient care.

Why?

What is it about incompetence that inspires you to defend dangerous medics?
 

After years of working in the ER and EMS I have seen many ER attendings and residents miss tubes.

 

I have seen the same thing.
 

I’ve seen them call anesthesia stat and watched them come down and fail as well watching the patient die in the room due to a difficult airway.

 

The only patient I have seen die that probably was due to physician airway mismanagement was an asthmatic infant who died the next day.

I have seen a crichothyrotomy due to inability to intubate, although I don’t think there was an inability to ventilate, but I was not attempting ventilation on that patient.

There are plenty of non-EMS people who are bad at intubation. How does that excuse EMS incompetence?

Your defense appears to be –

I am dangerous, but others are even more dangerous, therefore I should be allowed to continue being dangerous.

That is a bogus argument.

You are making an argument for completely banning intubation.

I have not argued that intubation should be banned, but that we need to remediate those who can be remediated and eliminate those who cannot be remediated.
 

No one can be 100% proficient in medicine, EVER!!! Ever missed an IV on a diabetic? How about twice on the same patient? BGL is 15!!! What do I do??? Try again, transport, should I give Glucagon? Whatever you did may or may not have saved the patient. Guess we have to send you with the IV team in the hospital to make sure you know how start a line because you must be out of practice because you failed.

 

Nobody is perfect, so if I don’t practice and if I complain about high standards, everybody will let me get away with this. Waaa!

That is the problem.

This appears to be a threat to your ego.

You do not appear to care about your patients.

You only seem to care about someone assessing your competence.

You don’t seem think that you are up to it.

Why is extra practice an insult?

Extra practice is good for us and good for our patients.
 

Try for once instead of regurgitating statistics from studies post something you have done as a medic that worked. Show me studies you have been involved in to discount what what you preach against. You discount paramedicine in every post.

 

You have not read much of my blog.

I do write about improving EMS.

I don’t write to make excuses for incompetent EMS.

If you want excuses for incompetent EMS, go elsewhere.
 

Sure I can bag a overdose due to respiratory depression for an hour and take them to the ER or I can give them a small dose of naloxone to reverse the effects and increase respiratory effort. Tell us your latest 911 story where the patient benefited from ALS care and promoted paramedicine. I know I have several. I’ve seen 3 patients this year walk out the door of the hospital post cardiac arrest that I personally coded. Can you say the same?

 

If you want a blog about war stories, there are some excellent ones out there, but war stories is not what I do.
 

If you want to be anti EMS, be a personal injury lawyer, or use your research knowledge as a medic to help move our profession forward instead of dragging it back by showing the short comings of a system that the public barely understands.

 

I do write to help move EMS forward, but I am often opposed by those devoted to staying in/returning to the Dark Ages.

You do not seem to be able to recognize that –

When I write about having medics think, I am promoting better EMS.

When I write about medics using judgment in the administration of opioids, sedatives, nitrates, calcium, and others, I am promoting better EMS.

When I write about the recklessness and irresponsibility of on line medical command permission requirements, I am promoting better EMS.

When I write about the things that we need to do better, such as intubation, I am promoting better EMS.
 

Your just an ambulance driver. Maybe I should just be a transport medic and report what the nurse told me to tell the other nurse while taking a set of vitals enroute. Do you think we even need 911? Maybe the hearse can swing by and pick up the patient and bring them to the ER because the care there is better and a medic may not hurt them. I think that’s called a taxi to triage.

 

Thank you for making my point that your comment is just about your ego.
 

To be continued later (with responses to other comments) in Part II and probably in a Part III.

SWG42EUNJUGZ

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Comment on 10% Dextrose vs 50% Dextrose

In response to Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. There is this comment from Can’t say, clowns will eat me –

Ok, I’ve seen this study many times and even referenced it to many people at differing levels of providership. That being said one of the most interesting arguments I’ve heard is that basically the people saying this thought, their blood sugar is critically low and they’re killing brain cells and if we don’t push D50 and push it as fast as possible we’re going to essentially cause a brain injury.

There is no reason to believe that there is any harm to the patient with 10% dextrose.

That brain damage assumes that it takes longer for the patient to be treated with 10% dextrose than with 50% dextrose.

The average time to return to full consciousness with 50% dextrose?
 
 

8 minutes.

 
 
The average time to return to full consciousness with 10% dextrose?
 
 

8 minutes.

 
 
Where is the difference?

Maybe the people making these excuses are the ones with brain damage causing them to see a big difference between 8 minutes and 8 minutes, but those of us without brain damage realize that time does not speed up or slow down depending on the concentration of dextrose.

The brain damage is more likely just operator error. The operator error is bias. The people are biased against something they are not familiar with. This leads them to assume that there are problems with the unfamiliar, even though these problems do not exist.

Also, I’ve heard the argument as to the previous post about the administration guidelines of the approximately 30 minutes it’d take to push it being too long

There is no 30 minutes.

30 minutes is a lie from the biased opponents of better patient care.

. . . as above but also that tied in with the D10 drip to stop rebound hypoglycemia just not being “practical” because we can’t spend that long with the patient, etc. Why is that wrong? Is it better to cause tissue necrosis? rebound hypoglycemia and by their own logic, even further brain damage?

There were differences in scene times between the 10% dextrose and the 50% dextrose groups, but that is to be expected with any new and unfamiliar method of treatment. In this study, a 3 way stopcock was used to draw 10% dextrose from the IV bag into a syringe, then switch the direction of flow to the patient and push the 10% dextrose that had been drawn into the syringe. This is more complicated than the method of giving 50% dextrose, but there are many other ways to give 10% dextrose.

The difference in time was only in the total scene time, not in the treatment time.
 
 

The fastest scene times and the fastest recovery times were in the 10% dextrose group.

 
 
This raises questions about the skills of the people who claim that we cannot give an adequate amount of 10% dextrose in less than 30 minutes –

How drunk and stupid are they?

But they aren’t necessarily drunk, or even stupid. What they are is biased.

Biased people aren’t necessarily bad people, but they are dangerous.

What else do we call refusing to provide better care to our patients just because of bias?

A refusal to provide better care is a demand to provide worse care. This is dangerous.

If this were a National Registry of EMTs testing station, nobody would have any problem with whatever 10% dextrose administration method was being tested, because we would practice until they were able to do it consistently and quickly.

If we cannot consistently wake up hypoglycemic patients with 10% dextrose in the same amount of time as with 50% dextrose, maybe we should not be allowed to use dopamine or lidocaine or amiodarone drips.

Clearly a drip set is more than a little bit beyond our capabilities as paramedics.

And if we can’t manage a simple IV drip set, we certainly can’t manage an endotracheal tube. 😳

Perhaps we do not want to use that argument.

Why not just come in and establish a line and administer D10 via a drip. And, the administrators will love this. You won’t be tied up on scene unavailable, you won’t be unavailable going to the hospital after the call without a patient(in which case you oftentimes will be paid little or nothing) and you’ll transport more and make more money for the company. For those in the private sector, wouldn’t that be a boon to reimbursements?

I don’t see any need to change transport for a difference in recovery time that is zero minutes.

There is no important difference in treatment time.

There is a dramatic difference in the potential for bad outcome with the unnecessary high concentration of the 50% dextrose.

Does a surgeon require the greater risk of general anesthesia for something that can be treated under local anesthesia?

Do we fly every patient?

Do we drive everywhere with lights and sirens?

We consider the benefits and risks of treatments.

We use the treatment that provides adequate benefit without unnecessary risk.

50% dextrose provides a greater risk for no greater benefit.

The picture is one I found labeled as being from Annals of Emergency Medicine of 50% Dextrose extravasation, but I do not know anything about which issue it is from or any other details – update – the image credit is below.

Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed – indexed for MEDLINE]

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Agitated Delirium Comment from RevMedic

RevMedic added a great comment to A Naked Woman – TOTWTYTR – Part I.

Great thoughts. I wonder how many medics are going to be concerned w/ accidental needle sticks when trying to chemically restrain such a patient.

Thank you.

I think hope that most medics are aware of the potential for a needlestick injury when wrestling with a violent patient in one hand and a syringe in the other. I can’t imagine covering this treatment without addressing the possibility of needlestick injury prominently. On the other hand, I can’t imagine covering this treatment without encouraging aggressive dosing. OK. I can imagine both. I can’t imagine is just a figure of speech.

Personally, I’d consider the nasal administration route, assuming you can hold her head still long enough, but then the same goes for holding a limb still long enough for a needle.

The concerns I have about nasal administration of midazolam (Versed) are:

1. A. If you are squirting something up my nose, even if I am feeling cooperative, my first instinct is probably going to be to forcibly exhale through my nose.

According to Newton’s Third Law of Motion Violently Combative Patients – For every action there is an equal and opposite re-action. I squirt something up the patient’s nose. The patient sneezes it back at me.

When dealing with combative patients, the equal and opposite re-action is very important. We want the patient making the initial movements, while we just try to get him/her to a safe place for a takedown. Too often we do the opposite. We pick one spot to bring the patient and then the patient puts everything into avoiding that one spot. Not a recipe for success.

1. B. If this forced exhalation of the large dose of midazolam does happen, how likely will it be that the protocols have an allowance for ignoring that dose?

If this does happen, how likely will it be that medical command will make an allowance for ignoring that dose?

If this does happen, how likely will it be that the DEA (Drug Enforcement Administration) will make an allowance for ignoring that dose?

If there is an adverse event, how likely is it that the large dose forcibly exhaled will not be considered to have been given to the patient and considered to have not just contributed to the adverse event, but to be the sole cause of the adverse event, even though the dose that entered the patient’s blood stream would be essentially zero?

Considering that I would use a starting dose larger than most medical directors are likely to be comfortable with as their total dose, this can be an important consideration.

2. Where is the evidence of efficacy?

I have not seen any research on the use of IN (IntraNasal) midazolam with combative patients. While this is not a very common condition, I have not even seen a single case report.

Hey, if you’re gonna hold them still long enough for a needle, why not an IO?

🙂

If you have an already extremely agitated patient, pulling out power tools could be one thing that might make the patient even more agitated.

Also something to consider is that Midazolam has a potential 20 minute onset of action if given IM…

Midazolam is not the drug of choice – not even close.

Midazolam is the default drug for many of us. Of course, there are some who do have to deal with the even more ridiculous limits of only having diazepam (Valium).

And 20 minutes can be a very long time – more than a lifetime.

There are other drugs out there for us – Haldol & Inapsine just to name a few.

Haloperidol (Haldol) and droperidol (Inapsine) are much safer than FDA (Food and Drug Administration) Alert[1] and the FDA Black Box warning[2] suggest.

And then there are the many oddities about these documents. For example –

Because of this risk of TdP and QT prolongation, ECG monitoring is recommended if haloperidol is given intravenously

Haloperidol is not approved for intravenous administration.[1]

We might think that the FDA would at least separate such contradictory statements, but we would be wrong.

Cases of QT prolongation and serious arrhythmias (e.g., torsades de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE[2]

If we can get the patient to sit still for a 12 lead ECG, is the droperidol (Inapsine) necessary? We just need to keep telling the patient to keep still for the 12 lead – all the way to the hospital.

Yes, they have their dangers – just as any other medication we administer. But, as professionals, we are to be expected to know and deal with the potential side effects.

Absolutely!

Footnotes:

[1] Information for Healthcare Professionals: Haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate)
FDA Alert [9/2007]

[2] Inapsine (droperidol) Dear Healthcare Professional Letter Dec 2001
Dear Healthcare Professional Letter

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A Naked Woman – TOTWTYTR – Part I

Don’t let your imagination get the better of you, here. Too Old To Work, Too Young To Retire is not a naked woman, although he is rumored to do a great impression of Lili Von Shtupp.

However, TOTWTYTR does have a post titled, A Naked Woman. This post was inspired by Flashlights, a post by Burned-Out Medic. Go read both, then come back.

My thoughts automatically go to the method of restraint – physical, rather than chemical.

Who benefits from having EMS use physical restraints, rather than chemical restraints?

The patient?

No.

EMS?

No.

The police?

No.

The advocates of restrictive EMS protocols?

Bingo.

The avoidance of sedation only benefits those who place protocols ahead of patient care.

I couldn’t have a post with a title of A Naked Woman and not include at least one picture.

If we were to inject people with boluses of epinephrine, would the effect on the patient’s body be much different from what happens when we physically restrain agitated delirium patients, but we do not provide any sedation?

This is where aggressive sedation protocols are very important.

How much do we want to increase the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the patient?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the physical safety of police, EMS, family members, and by-standers?

In what way is increasing the heart rate, blood pressure, respirations, et cetera of a coked out agitated patient considered to be good for the legal safety of police and EMS?

If limited to midazolam, what really are the difficult to manage problems, if we start with 10 mg IM for this 45 kg patient? 0.22mg/kg IM (IntraMuscular).

Yes, I do realize that this is much higher than the label recommends, but has anyone ever seen an agitated delirium patient respond, even a little bit, to the recommended doses of midazolam?

The recommended premedication dose of midazolam for good risk (ASA Physical Status I & II) adult patients below the age of 60 years is 0.07 to 0.08 mg/kg IM (approximately 5 mg IM) administered up to 1 hour before surgery.[1]

A whole bunch of unknowns vs. an NPO patient being given some sedation for routine surgery (not anesthetic dosing).

0.22 mg/kg midazolam vs. 0.07 to 0.08 mg/kg midazolam.

10 mg midazolam vs 3 1/2 mg midazolam.

I expect that one, or two, people will have anecdotes about the recommended dose of midazolam actually working. Anything is possible. However, why are we so hesitant to protect patients from the dangers of hypermetabolic states?

PS – TOTWTYTR, are you sure that the feces was from the dogs?

Continued in A Naked Woman – TOTWTYTR – Part II and later to be continued in A Naked Woman – TOTWTYTR – Part III.

I wrote about how others deal with this, including the death of a patient, in Excited Delirium: Episode 72 EMS EduCast.

Footnotes:

[1] Dosage and Administration
Midazolam Hydrochloride (midazolam hydrochloride) Injection, Solution
[HOSPIRA, INC.]
DailyMed
Label with link to download of PDF of full FDA Label

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EMS Liability What You Should Know: EMS Garage Episode 106



Listen to EMS Liability What You Should Know: EMS Garage Episode 106. Steve Wirth of Page, Wolfberg & Wirth, LLC talks about the recent appeals court reversal in the case in Missouri of the chest pain refusal not being covered by immunity.

There is a lot of good information.

Do you know what your state’s rules are?

Do you know what your employer’s rules are?

Do you know what an informed consent is?

Do you know what an informed refusal is?

EMS Liability What You Should Know: EMS Garage Episode 106

Also on the show were –

Chris Montera

Kyle David Bates

Jamie Davis

Scott Kier

James Warmuth

and me.

I also wrote about this in –

EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights

and

Chest Pain Refusals.

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