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

- Rogue Medic

Do Emergency Physicians Intubate Often Enough to Maintain Competency?

Sat, 30 Nov 2019 23:55:16 -0500 by
 

    There is a study of the frequency of intubation among emergency physicians in the current Annals of Emergency Medicine. This study is accompanied by a discussion, which unfortunately does not question the assumption that intubation improves outcome. There is very little evidence to suggest that intubation improves outcomes. That evidence is only using paramedics with the highest success rates – much higher than your average paramedic.

 
Greater intubation experience in paramedics is associated with improved patient outcomes2; does a similar relationship exist for emergency physicians?[1]
 


Image credit.

The unquestioned assumption is that excellent intubation performance improves outcomes, rather than that excellent intubation performance causes less harm than average intubation performance, or below average performance. We do not have any good evidence to support the wishful thinking that paramedics, or even much more experienced emergency physicians, improve outcomes by intubating patients. We just assume this, because we don’t really want to know. If we decide to be honest and actually find out the effect of intubation, how will we handle it if the results show that we are harming more patients than we are helping?

The Cardiac Arrhythmia Suppression Trial was only started because the proponents of the different antiarrhythmics (encainide, flecainide, and moricizine) wanted to prove that their drug was better than all of the rest. They even agreed to include a placebo arm, although the doctors did not like the idea of depriving patients of such beneficial treatment.

 
CONCLUSIONS: There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide.[2]
 

People who had frequent ectopic heart beats – PVCs (Premature Ventricular Contractions) after a heart attack were more likely to die than people who did not have frequent PVCs. The obvious solution – the equivalent of intubation and blood-letting – was to give drugs that will get rid of the PVCs. The problem is that the PVCs were not the problem. The PVCs were just a sign of the problem. The drugs made the actual problem with the heart worse, while making the heart appear to be better. The same is true of blood-letting and may be true of intubation. Abundant evidence for the obvious benefits of blood-letting are quoted in the footnotes.[3]

If intubation is harmful, do we want to know?

If intubation by the average paramedic is harmful, do we want to know?

If intubation by the average emergency physician is harmful, do we want to know?

It isn’t as if we take intubation seriously. If we did take intubation seriously, we would practice much, much more than we do. In stead, we make excuses for failing to practice something that we claim is life-saving, because we are too arrogant to admit that practice is important to develop and maintain any skill.

Practicing on even the most basic mannequin should be done before every shift, whether you are a paramedic or an emergency physician. Unless you have a 99%, or better, success rate on hundreds of patients.

Footnotes:

[1] Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364

The article above is commentary on the article below:

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101

Free Full Text from N Engl J Med.

[3] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.
 

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Filed Under: Airway Management, Bougie, Cardiac Arrest, Critical Judgment, Ethics, Evidence, Experience, Heresy, Intubation, Physician Oversight, Waveform Capnography

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

Sun, 03 Apr 2016 14:30:32 -0400 by
 

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?

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Footnotes:

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[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

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

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[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

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Filed Under: Malpractice, Management, Physician Oversight, Public Relations, Risk Management

Sign the Refusal Form, Ask Them To Leave, and Drive Him To the Hospital – EMS Patient Perspective

Thu, 07 Nov 2013 14:00:28 -0500 by
 
At The EMS Patient Perspective, Bob Sullivan writes about one great example of EMS incompetence. Unfortunately, it is a personal one.
 

She had called 911 for my grandfather, who was entering his later stage of dementia, and had passed out. In the background I heard a paramedic from the company I used to work for explain that his blood pressure and EKG were normal, that he did not need to go to the hospital in an ambulance, and that it was safe to drive him themselves or follow up with his doctor on Monday.[1]

 

But if we tell them to go away, what happens if something changes on the way to the hospital?

Unless the bad outcome is something as blatantly obvious as a cardiac arrest, these less than competent people are probably only going to make things worse.

Even if it is a cardiac arrest, they might not treat the patient appropriately. I have had a very experienced medic (been around for a long time, but apparently only had a single day of experience thousands of times over) ask me why I was defibrillating a patient with obvious ventricular fibrillation on the monitor.

Another decided to move the patient to the ambulance to intubate after he placed the tube in the esophagus and the patient began vomiting. No suction. No ventilation. Just carry the patient with the obstructed airway out to a place where he felt more comfortable.

Would this EMS squad be any better?

We have no reason for confidence in their abilities or judgment.
 

Syncope is a true emergency.

A lack of arrhythmia does not mean that it is not an emergency.

A lack of abnormal vital signs does not mean that it is not an emergency.

Many patients will not end up with a definitive diagnosis after treatment in the ED (Emergency Department).

Did the medic(s) apply the San Francisco Syncope Rule to determine that this patient does not need to go to the ED?
 

Clinical decision rule

Five risk factors, indicated by the mnemonic “CHESS,” were identified to predict patients at high risk of a serious outcome:

  • C – History of congestive heart failure

  • H – Hematocrit < 30%

  • E – Abnormal findings on 12-lead ECG or cardiac monitoring17 (new changes or nonsinus rhythm)

  • S – History of shortness of breath

  • S – Systolic blood pressure < 90 mm Hg at triage

Note: ECG = electrocardiogram.[2]

 

I doubt that the medic(s) ever even heard of the San Francisco Syncope Rule, but even if aware of it, here is how it should be applied.
 

The San Francisco Syncope Rule should be applied only for patients in whom no cause of syncope is evident after initial evaluation in the emergency department.[2]

 

Only
 

   after
 

       evaluation
 

           in the ED
 

               should we even begin to consider syncope to be a non-emergency.
 

If I search in the dark, with no light, for a black cat and cannot find the cat that really is there, does that make the cat disappear?
 


Image credit.
 

To proclaim that it was safe to leave my grandfather home after a five minute assessment and one set of vital signs was negligent.[1]

 

That should be obvious to everyone.

To every medical director.

To every medic.

To every basic EMT.

To every police officer.

To every mail carrier.

To every drunk not yet passed out on the corner.

This is a failure of EMS education, management, and medical oversight.

The easiest way to get rid of the dangerous people who do not understand this is to sign the refusal form and get them as far away from people they may harm as possible.
 

What if the patient (or family) do not want to go to the ED? That is entirely different and would require several posts to cover.

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Footnotes:

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[1] Sign the Refusal Form, Ask Them To Leave, and Drive Him To the Hospital
November 6, 2013
The EMS Patient Perspective
Article

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[2] San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review.
Saccilotto RT, Nickel CH, Bucher HC, Steyerberg EW, Bingisser R, Koller MT.
CMAJ. 2011 Oct 18;183(15):E1116-26. doi: 10.1503/cmaj.101326. Epub 2011 Sep 26. Review.
PMID: 21948723 [PubMed – indexed for MEDLINE]

Free Full Text from CMAJ.

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Filed Under: Assessment, Heresy, Management, Physician Oversight

You had me at ‘Controversial post for the week’ – Part II

Wed, 23 Oct 2013 08:00:57 -0400 by
 
In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?
 

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]

 

Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.
 

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]

 

We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.
 


Image credit.
 

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.
 

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]

 

PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. 😳

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.
 

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.

 

We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.
 

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]

 

The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.

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Footnotes:

–

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

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Filed Under: ACLS, Atropine, Heresy, Physician Oversight, Science, Unicorn Medicine

You had me at ‘Controversial post for the week’ – Part I

Tue, 22 Oct 2013 08:00:11 -0400 by
 
What kind of trouble would an Ambulance Chaser be up to?

 

Time to stir up some controversy here.

I would no longer require any resuscitation “card courses.” No more ACLS, CPR, or PALS.[1]

 

The saddest part about this is that this is controversial.
 


Image credit.
 

First, I disagree with some of the points about how slow the AHA (American Heart Association) is. The AHA is not as bad as portrayed, but much of this is the failure of the AHA to communicate effectively.
 

Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.[1]

 

To protect against unrecognized esophageal intubation, confirmation of tube placement by an expired CO2 or esophageal detection device is necessary.[2]

 

That is from the 2000 ACLS (Advanced Cardiac Life Support) guidelines.

Necessary is not an ambiguous word, but the guidelines were not taught this way by many people.

If our attitude is that unrecognized esophageal intubation is only a problem for our patients, then we can get away with lesser means of tube confirmation.
 

The following is from the 2005 ACLS guidelines.
 

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.[3]

 

The AHA guidelines did not stress continuous waveform capnography until 2010. Maybe the attitude of the AHA was unrecognized esophageal intubation is only a problem for someone else’s patients.
 

    Key changes from the 2005 ACLS Guidelines include

  • Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.[4]

 

What is the key change?

Continuous

or

quantitative waveform

or

recommended

or

confirmation and monitoring

of endotracheal tube placement.

Why was the AHA not stressing this Class I, LOE (Level Of Evidence) A assessment?

There is no good reason.
 

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[4]

 

If a medic, emergency nurse, emergency physician, . . . disconnects waveform capnography from an intubated patient is that a sign of incompetence?

EtCO2 in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.

Probably.

Feel free to disagree, but any such argument should avoid logical fallacies.

What else?

What else will be covered in Part II.

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Footnotes:

–

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

–

[2] Tracheal Intubation
2000 American Heart Association Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control
Free Full Text from Circulation.

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[3] End-Tidal CO2 Monitoring
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Monitoring Immediately Before, During, and After Arrest
Free Full Text from Circulation.

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[4] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Free Full Text from Circulation.

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Filed Under: ACLS, Heresy, Physician Oversight, Science

Protocol Deviation and Mother-May-I Silliness

Wed, 11 Jul 2012 18:00:56 -0400 by
–

–

In response to the conversation David Aber and I had at the end of last week’s episode of EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, David Aber and I discuss the problems with requiring permission to deviate from protocols that cannot possibly cover every patient. I was on a call for the first 45 minutes of the show, but I do get on the show at the end.

EMS Protocol Deviation

–

When is the right time to talk with a doctor for protocol deviation?

Is the protocol badly written?

Before the new protocol is finalized is the best time, but not all of us can attend protocol development meetings.

Next would be after the protocol is written, contacting the medical director(s) to change the protocol.

The best time to change a bad protocol is before the call, but that is not always possible.

–
 

Protocol deviations are NOT a bad thing.
 

The protocols are guidelines and cannot be intended to cover all patient care situations, except in systems where the medical director is discouraging competence.

Rigid protocols are part of the the same idea that is behind on line medical command permission requirements. Both encourage incompetence and discourage competence.

I know he’s incompetent, but he can’t do anything dangerous without calling, so the patients are safe.

I used to regularly hear variations on this from a county medical director as a justification for ignoring incompetence, but requiring rigid protocols and medical command permission for almost everything.

–

What kind of education is required to follow rigid protocols?

Very very little.

What kind of education is required to follow on line medical command permission requirements?

Very very little.

Skills training – IV training, minimal intubation training, an ability to ignore the harm we are causing, a ruthless devotion to the protocol, and not much else.

Assessment?

No.

Really. There is no requirement for an understanding of assessment.

There is no need, since that would suggest that a paramedic is capable of understanding what to assess for without calling command or without reading it out of the protocol.

If a medic understands what to assess for, who knows what kind of things the medic might do next. Assessment involves thinking and we cannot have thinking.
 


Image credit.

This is what our EMS education is geared toward in too many places.

Doctors are encouraging bad EMS care because they do not trust EMS.

They don’t trust EMS for a variety of reasons, but a big one is the low quality of education.

Our education is based on handing down traditional treatments and only discarding treatments reluctantly, and only when told to by someone in a position of unquestioned authority.

Why?

We don’t know and we don’t care. It isn’t going to be on the test.

–

How do we know what works?

Research.

What is the quickest way to scare away medics, nurses, and doctors?

Start talking about research.

This is changing as more understanding of research is required in medical school, but even medical schools are ignoring research and adopting alternative medicine.[1]

–

What are two things NOT supported by research?

Rigid protocols.

Medical command permission requirements.

Where is the evidence to support these dangerous practices?

But that’s the way we’ve always done it.

Put that in a translator and out comes –

But we like being incompetent. You can’t expect us to change now.

–

What is required to get a medic card? A multiple choice written test and a highly structured practical exam. Does this have anything to do with ability to work independently?

We cannot even take the test without first completing a paramedic course, because if we were to allow untrained people to take the test, too many would pass.

A valid test does not need to limit candidates to only those who have taken a full course. If the candidates do not know what they are doing, they cannot pass a valid test.

Well, they sat through all of paramedic school, so how dangerous can they be?

How bad can we be?

Look at how bad we are at treating tension pneumothorax.[2]
 


Click on the image to make it larger.

How dangerous is that?

It depends on which side of the needle you are on.

We are sticking needles in the chests of patients who do not have any reason to be harpooned.

What kind of remediation was there? None was mentioned in the study.

–

How bad can we be?

Look at how bad we are at intubation.[3]
 

How dangerous is that?

It depends on which side of the endotracheal tube you are on.
 

Go listen to the podcast.
 

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Footnotes:

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[1] Evil Spirits, Shock Trauma, Anecdotes, and Gullibility
Rogue Medic
Sun, 26 Sep 2010
Article

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[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article

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[3] In Defense of Intubation Incompetence – Part II
Rogue Medic
Sun, 21 Aug 2011
Article

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Filed Under: EMS Office Hours, Heresy, OLMC Requirements, Physician Oversight, Risk Management, Unicorn Medicine

What Do You Want From Your Medical Director – Part I

Thu, 19 Jan 2012 06:30:49 -0500 by
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On FaceBook, Dr. Jeff Meyers asked a very important question.

If you had your way, what are the top 3 three things you expect from your medical director? Discuss, discuss!

A surprising (to me) number of people responded with a desire for some respect. I guess that I have been a bit spoiled, because I have not really had that problem. I have had over a dozen jobs in several states. Even when I have completely disagreed with the doctor, or the doctor has completely disagreed with what I have done, there has always been communication. The communication has been been in both directions, up to a point, but all conversations reach an end. Just because I would like to continue the conversation does not mean that the doctor should feel the same way.

I have occasionally been treated rudely by doctors, but usually that is just a misunderstanding. Occasionally, this is just a jerk doctor (we have jerk medics, too), or a topic on which the doctor is a jerk (as medics, we have some topics that we may be jerks about, too), so I do not see this so much as a problem coming from the doctors as much as we are not initiating communication.

My comment was –

I have only rarely had a medical director who would not spend time talking with me – as long as they were not busy. I have also spent a lot of time talking with doctors who are not my medical director. We need to stop being afraid to go up to a doctor and say, “If you have a minute, I would like to talk with you about this patient,” or something similar. Unless I have another call, I can stay with the patient until after the doctor has examined the patient, observe the examination, and ask the doctor what I should have found. Most doctors have taken the time to discuss the care of my patients with me. Is there any GOOD reason we need to leave the hospital immediately? If there is a reason, it is not the fault of the doctor.

In other words, I think that our biggest problem is often ourselves.

Yes, I have worked in Mother May I? systems and I gave more morphine in one Mother May I? system than any paramedic in the neighboring county that had standing orders for morphine.

I had to call to get permission to give even 1 mg of morphine to a 200 kg patient.

I also worked in the neighboring county that had standing orders for up to 0.2 mg/kg morphine for chest pain, burns, and for musculoskeletal pain. For the so called average adult patient of 70 kg (154 pounds), I would not have to call until I reached a dose of 14 mg of morphine. I don’t think that it is common to have adult patients as small as 70 kg, but . . . .

Is the problem that the doctors won’t talk to me?

Is the problem that we won’t talk to the doctors?

Doctors are people. We may chat with them about social topics, but we seem to shy away from discussing medical topics.

Before we start complaining that we do not get any respect from our medical directors, we need to show them that we know enough about patient care to have a conversation.

Maybe as a brand new medic there is a fear that we do not know enough to have a conversation with a doctor. We need to ask the doctors to teach us, so that we do have the knowledge to carry on conversations about medical care.

If doctors teach medics to assess patients better, we can do a better job of treating the patient according the the right protocol – or at least treating the patient in a way that is least likely to cause harm to the patient.

If we learn to just call command and follow orders, why would a doctor think that we know enough to be treated with respect?

I agree that a medical director should reach out to all of the medics that medical director authorizes to treat patients.

Those patients are the medical director’s patients.

But this does not mean that we cannot start a conversation with our medical directors or with any doctors.

When I call for orders for a controlled substance I always try to talk with the doctor afterwards to explain what I gave, what changed, and to thank the doctor for orders, if orders were necessary. With my current protocols, I do not need permission for a lot, but there is still plenty of room for improvement. EMS is continually improving and changing. Our protocols should be as well.

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Filed Under: Heresy, Physician Oversight

A is for airway…also for action.

Wed, 09 Mar 2011 06:30:22 -0500 by
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Yesterday, I wrote about a study that shows that we are not good at assessing the airway, even if we have the right tools.[1] Today, I am writing about the editorial that accompanied that study.

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As Mick “Crocodile” Dundee was preparing to go on walk-about through the Outback, he had to ask his best mate what day it was so he would know when to return. His mate commented how lucky Mick was, “Doesn’t know; doesn’t care.” In this issue of Annals, Katz and Falk1 describe a similar problem common to many emergency medical services (EMS) systems. It’s not that they don’t care; they don’t care to know.[2]

What does this say about us?

We claim to be doing everything we can for our patients.

Look at the comments about the death of Curtis Mitchell from people who insist they would dig for hours through the snow just to rescue the one patient we know died. This is after the fact and we know that Curtis Mitchell died, so we insist that we would do everything to save him, while delaying treatment of the other patients. We know the other patients did not die in a way that can be tied to delayed response. Of course, if we do that, then maybe somebody else dies due to delayed response.

What we did not do, as is the case with intubation, is use the right tools to help the patient. The right tool for Curtis Mitchell was not a shovel. The right tool is a 4 wheel drive vehicle.

The right tool for the dead patients with the tube in the esophagus was not a fancier stethoscope. The right tool is waveform capnography.

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Where are we when it comes to doing everything we can to find out which patients we are harming and which patients we are helping?

Usually, we are making excuses. After all, we can always sacrifice someone after the fact, when we have identified someone to point a finger at.

Why not find out before we kill someone?

Why not try to do what EMS is supposed to do – prevent deaths?

No. This is EMS. We don’t do that.

We don’t use information.

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There is always the potential of failure to intubate. Even more disastrous is the potential for failing to intubate the trachea and not recognizing it. In every setting, we focus on avoiding such an eventuality. In the operating room, arguably the most controlled setting possible for ETI, this issue has been addressed decisively.5 Detecting and monitoring end-tidal carbon dioxide is the standard of care for patients who undergo ETI. However, there is no such standard or routine practice for EMS systems or even our emergency departments.[2]

Are emergency physicians that much better at intubation, that they do not need to use waveform capnography?

Better than anesthesiologists in the OR?

Are medics that much better than anesthesiologists in the OR?

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It is nothing short of amazing that physicians use the most reliable technology in the environment that can be the most controlled and is the most conducive to effectively examining the patient to determine the success or failure of the procedure. In contrast, we send EMS providers, often with limited experience, into the most treacherous environments, sometimes to places we would never dare to venture, and expect them to perform under conditions we would never tolerate. There, the ability to clinically determine the success of ETI is least. Additionally, valuable tools are not made available or are not used predictably.[2]

Why worry?

It’s just the airway.

The air hole or the food hole –

Wherever the tube ends up –

What matters is that we care –

We just don’t care enough to use the right equipment.

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In the operating room, most intubated patients never move. Control is at a maximum. End-tidal carbon dioxide is monitored throughout each procedure. In the field, EMS providers, when they use them, often rely on various ETI detection devices for single spot determinations. Have we not placed our priority in the wrong place?[2]

But that is what we are best at – placing our priority in the wrong place (and placing a bunch of our endotracheal tubes in the wrong place, too).

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So, for the EMS system Katz and Falk studied, where were the efforts to monitor patient outcomes, individual providers, and EMS system components (eg, the various participating agencies) and processes? Why was the use of available detection devices “sporadic” and what was being done about that? In short, before Katz and Falk, who cared to know? More importantly, who cares to know in each of our own communities?[2]

How many of us have measured the quality of intubation in our systems?

How many of us just muddle along and make a scapegoat out of the medic who intubates the esophagus of a patient and has it make headlines?

I think the group that muddles is much larger than the group that knows its abilities, or knows its disabilities.

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In the operating room, and in the ED, an unrecognized esophageal intubation would be considered a sentinel event, necessitating extensive documented effort to avoid a recurrence.[2]

In EMS, this is not a sentinel event.

In EMS, we have different terminology – Nothing to see here. Move along. Nothing to see here.

We need to change that.

Our patients deserve better.

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Footnotes:

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[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

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[2] “A” is for airway…also for action.
Delbridge TR, Yealy DM.
Ann Emerg Med. 2001 Jan;37(1):62-4. No abstract available.
PMID: 11145775 [PubMed – indexed for MEDLINE]

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Filed Under: Airway Management, Critical Judgment, Ethics, Heresy, Intubation, Physician Oversight
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