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If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

Let the drug shortages help us make better patient care decisions

Sun, 19 May 2013 08:00:11 +0000 by

Image credit.[1]
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Maryland made smart changes to their protocols because of the drug shortages.[2]

50% dextrose is not as good as 10% dextrose at treating hypoglycemia.[3],[4],[5]

Switching to 10% dextrose is an obvious solution, but not used by everyone.
 

Sedgwick County EMS workers administer about 80 doses of the stuff (50% dextrose) a month, but the county has only received 30 pre-filled doses so far this year through its normal vendor, Braithwaite said.[6]

 

We have research that shows that 10% dextrose is a better choice for EMS, but we continue to use the inferior treatment.

We have trouble obtaining the inferior treatment, but we refuse to change to the better treatment.

Is there a state law that prevents the use of different concentrations of dextrose?

If so, go to the government, explain the problem, and get the law changed. If that does not work, go to the press and point out that the failure to act by the legislature is endangering patients.
 

“We’re now looking at compounding of those medications,” he said.

But that’s an expensive alternative. A pre-filled dose of dextrose costs $6.99. A vial costs $1.81. Pre-filled doses are preferred, Hadley said, because there is one less step for emergency personnel.

Compound dextrose costs $14 per dose and has a much shorter shelf life, 90 days compared with two years.[6]

 

50 ml of 50% dextrose contains 25 grams of dextrose.

A 250 ml bag of 10% dextrose contains 25 grams of dextrose.

The cost of the bag of 10% dextrose is about $2.50, which is much less than the $7 cost of and amp of 50% dextrose.

Is there a difference in shelf life? If they are giving 80 doses a month, how much does that matter?

The only advantage to the 50% dextrose is familiarity, which is due to our failure to change to a better treatment when it becomes the right thing to do.

The drug shortages do not affect 10% dextrose.

Isn’t it time we cut costs, improved safety, improved care, and eliminated 50% dextrose?

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Footnotes:

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[1] 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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[2] Drug shortages leading to better EMS protocols
Fri, 19 Oct 2012
Rogue Medic
Article

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[3] Dextrose 10% or 50%: EMS Research Episode 10
Tue, 05 Jul 2011
Rogue Medic
Article

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[4] Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.
Moore C, Woollard M.
Emerg Med J. 2005 Jul;22(7):512-5.
PMID: 15983093 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central

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[5] A review of the efficacy of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycaemia
Ziad Nehme, Daniel Cudini
2009; Volume 7 : Issue 3; Article Number: 990341
Journal of Emergency Primary Health Care
Free Full Text with link to PDF Download

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[6] Sedgwick County EMS warns of national drug shortages
By Deb Gruver
The Wichita Eagle
Published Tuesday, May 14, 2013, at 8:41 p.m
Article

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Filed Under: FDA, Heresy, Risk Management

Does experience matter – Part II

Wed, 08 May 2013 16:30:57 +0000 by
ResearchBlogging.org
 

In spite of the evidence to the contrary and a lack of rationality in the claim, we continue to be told that increasing the number of people with a title, such as paramedic, will result in better care.

Here is more evidence that dividing the skills among more people leads to less skilled care.

The authors begin by referring to other studies that demonstrate the high failure rate of doctors performing procedures on children.

How is that relevant to EMS? We have a low frequency of use of critical skills – and that is with our adult patients. With children, our absence of experience is even more of a problem. When we do use our infrequently used skills, we often use them inappropriately.[1],[2]
 

Emergency physicians must be competent in the performance of critical procedures associated with pediatric resuscitation. It has traditionally been assumed that the clinical practice of pediatric emergency medicine is sufficient for the acquisition and maintenance of these skills. If the relative low acuity of the pediatric emergency medicine patient population provides inadequate opportunity, there is a risk that procedural skills will not be acquired by trainees or maintained by faculty. An accurate description of the frequency with which faculty and trainees perform critical procedures in a pediatric ED would allow for more informed discussion and targeted interventions to reduce this risk.[3]

 

We need similar examinations of what we do in EMS.
 

We hypothesized that even in a high-volume pediatric ED, the overall frequency of critical procedures would be very low and the exposure of individual providers to critical procedures negligible.[3]

 

Would that be any different from a busy EMS system with a lot of paramedics?
 

From April 1, 2009, through March 31, 2010, 3,067 evaluations were performed on medical and trauma patients in the resuscitation bays. Two hundred sixty-one critical procedures were performed during 194 evaluations, representing 6.3% of all resuscitation bay evaluations and 0.22% (2.2/1,000) of all ED patient evaluations during the study period.[3]

 


Click on images to make them larger.
 

That does not look bad.

147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions in a year.

Except – that is for the entire hospital.

When broken down by the doctor actually performing the procedure
 


 

Only 39% were able to try to perform any procedure during a year when there were 147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions.

Look at the range for all critical procedures combined –

0 to 6, with a median of 0.

The white clouds were most of the doctors. Zero critical procedures for the year.

The busiest of the black clouds[4],[5],[6] were only averaging performing one critical procedure every two months.

How much experience do paramedics get when there are a lot of paramedics available to deprive them of experience?

Do we track this and post it for all to see?

What is the level of inexperience in an EMS system that has a paramedic in every seat of every piece of apparatus?

What kind of daily, or even weekly training is required to make up for this absence of experience?
 

Nearly two thirds of our faculty did not perform a single critical procedure during the 12-month study period.[3]

 

Does experience matter – Part I

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Footnotes:

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[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]

Free Full Text from J Ultrasound Med.

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[2] Low quality is identified by inability to use critical thinking
Mon, 20 Aug 2012
Rogue Medic
Article


Click on the image to make it larger.
 

The chart is for all patients treated with needle decompression for suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Did any patient have a tension pneumothorax?

We do not know.

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[3] The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view.
Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS.
Ann Emerg Med. 2013 Mar;61(3):263-70. doi: 10.1016/j.annemergmed.2012.06.021. Epub 2012 Jul 27.
PMID: 22841174 [PubMed - indexed for MEDLINE]

Free Full Text from Annals of Emergency Medicine.

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[4] Quantification and perception of on-call podiatric surgical resident workload.
Meyr AJ, Gonzalez O, Mayer A.
J Foot Ankle Surg. 2011 Sep-Oct;50(5):535-6. doi: 10.1053/j.jfas.2011.04.035. Epub 2011 Jun 11.
PMID: 21652228 [PubMed - indexed for MEDLINE]
 

The results of these data suggest that all residents shared a similar workload during the study period without a clinically significant “black cloud” or “white cloud.” However, a difference was found in the perception of which resident was a “black cloud” or “white cloud.”

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[5] Black clouds. Work load, sleep, and resident reputation.
Tanz RR, Charrow J.
Am J Dis Child. 1993 May;147(5):579-84.
PMID: 8488808 [PubMed - indexed for MEDLINE]
 

A reputation for difficult on-call experiences was strongly associated with few hours of sleep (r = -.77; 95% confidence interval, -0.49 to -0.91), but not with actual work load measured by the number of admissions, patients, deaths, or other variables. Sleep was the major predictor of reputation (multiple R2 = .567 using multiple linear regression analysis).

CONCLUSIONS:
Some residents did have a black cloud; they slept less, perceived that they worked harder than average, and had a reputation for having difficult on-call experiences. Residents with a black cloud function differently from their colleagues; for example, some may be inefficient, while others may create extra work for themselves. Residency program directors must recognize these functional differences to effectively evaluate and counsel house officers.

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[6] Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets
(Google eBook)
Nassim Nicholas Taleb
Random House Digital, Inc.,
Oct 14, 2008
316 pages
Google Books

Believing in black clouds, or other personifications of random occurrences is being fooled by randomness. Dr. Taleb does a good job of describing these errors of judgment.

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Mittiga, M., Geis, G., Kerrey, B., & Rinderknecht, A. (2013). The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View Annals of Emergency Medicine, 61 (3), 263-270 DOI: 10.1016/j.annemergmed.2012.06.021

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Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183

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Tanz RR, & Charrow J (1993). Black clouds. Work load, sleep, and resident reputation. American journal of diseases of children (1960), 147 (5), 579-84 PMID: 8488808

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Meyr, A., Gonzalez, O., & Mayer, A. (2011). Quantification and Perception of On-call Podiatric Surgical Resident Workload The Journal of Foot and Ankle Surgery, 50 (5), 535-536 DOI: 10.1053/j.jfas.2011.04.035

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Filed Under: Experience, Heresy, Research Blogging, Risk Management

Bad Recipe for EMS Event Laughter

Tue, 07 May 2013 12:00:04 +0000 by

 

EduMedic has a post about making public relations more entertaining, but he seems to be entertaining his crews and only scaring the children.

He creates a game of Russian Roulette with each child holding a wire connected to the defibrillator and the appearance of the defibrillator delivering a shock through only one of the wires.

No shock will be delivered to anyone, but the children do not know this. The children are told the opposite.

The defibrillator is charged. Capacitor whining until it stops. Dramatic tension for the children.

The defibrillator is discharged. Since everyone is only ECG leads, nobody is shocked, but the presenter is supposed to give the appearance of having been shocked.
 

9. Immediately scream in agony, drop your limb lead, and run/jump/cry as you feel is appropriate to convey that you were “shocked.”

10. After catching your breath, thank them for being brave and invite them to bring their friends back for additional demonstrations on the half-hour for the duration of the event. With their full attention at your disposal, it is also the ideal time to discuss relevant public safety messages for your organization.

11. Repeat procedure for the rest of the day, or as long as you can keep a straight face.[1]

 

Look at the picture that accompanies this. The medics are laughing, but the children are not.

This could be a set up for explaining to children the dangers of playing with a defibrillator/AED (Automated External Defibrillator), or any other electrical device.

This could be justified as a way of teaching children about the dangers of electric current, or the benefits of electricity when used appropriately. This could be used for explaining that everything has risks, no matter how beneficial it might be.

I do not see any reason for not explaining that nobody was shocked, but nowhere is that suggested. Nowhere in the responses to my comments is that suggested.

What is provided is a series of logical fallacies.

 

Ahh, mounting opposition for anything in EMS that isn’t evidenced-based. True to form for you, Rogue![1]

 

Nowhere did I criticize this for not being evidence-based.

Logical fallacies have to do with confusion, misdirection, deceit, . . . , but not with anything good.[2] This is just one of many logical fallacies that will be used by EduMedic in his responses to my comments.
 

“You do not appear to have provided them with any education to justify this.”

1. Re-read the title post. It’s a recipe for laughter. The kids laugh, parents laugh, we laugh. Laughter needs no justification.

2. After this demonstration, I have their undivided attention because they had fun. This is when we talk about what EMS personnel do for the sick & injured and when to call 911.[1]

The bold type is EduMedic’s.
 


Download Video from YouTube | Convert YouTube to MP3
 

We have laughter.

The video shows a way to produce laughter. Nobody really had their fingers cut off. Should we be teaching children to laugh at the misfortune of others?

Laughter needs no justification, because nervous laughter is the same as amusement?

 

Nervous laughter is a physical reaction to stress, tension, confusion, or anxiety. Neuroscientist Vilayanur S. Ramachandran states “We have nervous laughter because we want to make ourselves think what horrible thing we encountered isn’t really as horrible as it appears, something we want to believe.”[3]

 

Having the opportunity to talk to the children afterward is important.

Explaining the difference between a real danger and this fake electrocution is more important. Where does he explain, or even suggest explaining that the electrocution was not real?
 

“You do appear to have taught them that EMS encourages taking unreasonable risks.”

1. At no time is there any risk to anyone involved, only the suggestion of it for the sake of teaching. The same thing is done routinely in HazMat Technician classes with adult students when jars of colored water are presented to the students as something highly toxic. Suddenly the presenter has their full attention.

2. The teachable moment occurs when they quickly realize that there really was no shock. I have yet to see a group of children fail to realize it was purely theatrical. It is at THAT moment when they smile, they laugh, and their minds are open to a new idea… that ambulances and the paramedics on them are not scary after all.[1]

 

Nowhere did I suggest that there was a real risk of shock. My objection has been to the lack of explanation to the children.

Even in adult education, we should tell the students that there was no actual dangerous chemical in the container. Otherwise, we are suggesting that the chemicals are safe enough to keep in a classroom.
 

Where is there any suggestion that it should be made clear to the children that there was no real risk at any time?

I’m really trying to understand your preoccupation with the disclosure of an imaginary risk. Remember the context of most any public safety PR event. Law enforcement typically comes with a buckle-up “convincer” or a talking DARE car. However, there are no multi-page waivers to sign prior to riding the convincer, nor are there counselors on hand to debrief children who may have been frightened by an unoccupied vehicle that suddenly comes to life.[1]

 

Even more logical fallacies, but they don’t end there.

EduMedic provides clear statement that he does not understand that children do not look at the world the same way adults do.

Should we teach children to take risks, but not teach them the difference between real risk and pretend risk?

By the way, the D.A.R.E. program is an example of a myth. D.A.R.E. has been shown to have the opposite effect of what is intended. I would provide evidence, but EduMedic might claim that by citing research I was justifying some of his use of logical fallacies.
 

A large part of education is about perception.

We are trying to change the way students perceive the world.

Being vague, or omitting information, is not good education. These may be good reasons there are so many myths for me to debunk.

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Footnotes:

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[1] Photo Phriday: Recipe for PR Event Laughter
May 3, 2013 9:00 am
Brian Lilley
Article and comments

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[2] Fallacy
Wikipedia
Article

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[3] Nervous laughter
Wikipedia
Article

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Filed Under: Education, Ethics, Heresy, Risk Management

Tubes and Guns and Training, Oh No – Part II

Wed, 01 May 2013 08:00:26 +0000 by
 

EMS concealed carry of firearms has become a topic of discussion, again.[1]

One of the comparisons made was that firearms are like condoms. I don’t think that person understands the proper use of a condom.

A condoms is an effective tool for problems that might arise from something that is pretty common (sexual activity). There is no judgment about how to use the condom, while how to use a firearm during an EMS call is the most important part of carrying a weapon on the job in EMS.

Weapons are not effective tools for EMS to use, since too few of us seem to be capable of providing competent basic EMS care.

The most important weapon we have is our judgement. We regularly demonstrate that we do not have good judgment.
 

One example is needle decompression, which is used appropriately much more often than any weapon would be (if the weapon were used appropriately).

However, when needle decompression is used, the use appears to be almost always inappropriate.

Needle decompression does save lives when used appropriately.
 


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

The chart is for all patients treated with needle decompression for suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

We do not know.
 

It is the responsibility of the EMT to make sure that his shooting skills – and decisions – are up to par better than par. Right?

Is it the responsibility of the EMT to make sure that his intubation skills are better than par?

No. It is the responsibility of everyone – the medical director, the employer, the supervisors, and the EMT. The life threatening skills we use on the job (intubation, needle decompression, cricothyrotomy, . . . ) affect much more than the individual, the individual’s reputation, and the individual’s income.

When I am at work, my First Amendment rights are limited.
 

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.[3]

 

The rights described above do change at work. The same is true for many of our other rights.
 

Tell your employer that you wish to participate in a public assembly on the job in uniform.

Tell your employer your unsolicited opinion of exactly what you think of the way things are run.

Tell your employer that you will share this unsolicited opinion with the press.
 

Our rights as citizens and our rights as employees are not the same.

This is not about protecting the Second Amendment.

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Footnotes:

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[1] Facebook discussion
Chance Gearheart
Facebook
Web page

After reading some of the EMS Forums and groups, I can safely say that I want to be nowhere near some of these people if they’re allowed to carry a handgun on the unit. They’ll be more of a danger to themselves than anyone else around them.

Barney Fife with a bullet in their pocket. Christ man.

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[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]

Free Full Text from J Ultrasound Med.
 

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article
 

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

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

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[3] Bill of Rights to the US Constitution
National Archives
Web site.

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Filed Under: Heresy, Risk Management

We cater to the most stupid people out of fear of . . . whatever

Sat, 06 Apr 2013 08:00:05 +0000 by
 

What do I mean by stupid?

This is an excellent example of stupid.
 

Florida country radio morning-show hosts Val St. John and Scott Fish are currently serving indefinite suspensions and possibly worse over a successful April Fools’ Day prank. They told their listeners that “dihydrogen monoxide” was coming out of the taps throughout the Fort Myers area.[1]

 

dihydrogen monoxide?
 

Terrifying.

di = Two
hydrogen = H
mono = One
oxide = O

Two Hs and One O.

We can rearrange these into the familiar chemical expression of H2O.

Danger! There is H2 in the drinking water!

I hope so. Water is not water, if there is no H2O.

So, some people were worried and called the water company. The water company should have stated –

Dihydrogen monoxide is just water.

Today is April Fools’ Day.

You have been fooled.

Have a laugh at yourself and get on with your day.

But no.

That would have been too reasonable.

This was the response – and threats of felony charges.
 


Click on images to make them larger.
 

Don’t tell people that there is dihydrogen monoxide in the water! Tell them that the reported problem is just a prank, but do not use the opportunity to educate people about what you sell them.

Feed their ignorance.
 

the two hosts could face felony charges for, again, reporting that the scientific name of water was coming out of the pipes. “My understanding is it is a felony to call in a false water quality issue,” Diane Holm, a public information officer for Lee County, told WTSP, while Renda stood firm about his deejays: “They will have to deal with the circumstances.”[1]

 

There is water in the water. – That is not a false water quality issue unless you are an idiot.

There are idiots making threatening to bring felony charges to try to deflect attention from the stupidity of the idiots. – That is a real water quality issue.
 

 
This is dihydrogen monoxide –
 


 

 

 

 
This is water –
 


 

 

 
Do you understand the difference?

What we call it has nothing to do with what it is.

Water is dihydrogen monoxide is H2O.

Water has also probably had every deadly disease in it for as long as there has been water. People, and other animals defecate in that water. The water company cleans the water that they provide to us.

The result is that tap water is almost always much cleaner than the bottled water you buy in a store.

We also fluoridate water in many places. fluoride protects teeth. The result is that the water is healthier with fluoride than without fluoride.

Some people make the mistake of thinking that a complicated name means that something is dangerous.

Or they think that a chemical is more dangerous than something that is natural.

Or they think that something man made is more dangerous than something that is natural.

That is not just wrong, it is Jenny McCarthy wrong, it is Creationist wrong, it is climate change denialist wrong, it is homeopathy wrong, it is just plain stupid, but too many of us are afraid to tell stupid people to stop spreading their stupidity, because we think that is not nice.

By that niceness, we lower ourselves to their level of stupidity.
 

How many scientists support Jenny McCarthy’s anti-vaccine conspiracy theories? Only a handful – and they seem to make money off of it.

How many scientists support Creationism’s anti-evolution conspiracy theories? Only a handful – and they seem to make money off of it.

How many scientists support climate change denialists’ conspiracy theories? Only a handful – and they seem to make money off of it.

How many scientists support homeopathy’s anti-medicine conspiracy theories? Only a handful – and they seem to make money off of it.
 

We give these con men equal time out of some distorted sense of balance between reality and their even more distorted misunderstanding of reality. Maybe these nuts should go hug a unicorn and leave sensible people alone.

Stupidity is not a virtue.

The cure is education, not denialism.

 


 

I do not know the origin of the Deadly Facts About Water poster. If you know, please send me the link and I will give credit. This poster is great.

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Footnotes:

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[1] Florida DJs May Face Felony for April Fools’ Water Joke Worse Than Rubio’s
By Alexander Abad-Santos
April 2, 2013
The Atlantic Wire
Article
 

Update, Wednesday: St. John and Fish were back on the air Wednesday, and officials with the local health department tell The Atlantic Wire that felony charges are not expected.

 

Maybe somebody did point out that criminal charges would be stupid and open them up to ridicule, but I had already written this when that update was posted.

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Filed Under: Creationism, Denialism, Heresy, Risk Management, Science

Free Ambulances For Everyone – Just Hop In And Drive Away!

Fri, 29 Mar 2013 14:00:53 +0000 by

 
Today in stolen ambulance news.

We are not getting any better at keeping people from stealing ambulances.[1]
 

What does it take to lock an ambulance?
 

This should not be a trick question.
 


Image credit.
 

Those keys have about as many buttons as my 12 lead ECG monitor.

If the buttons do not lock the ambulance, I remember bening able to put the key in the door lock, turn the key, and lock the ambulance.

Does the ambulance need to keep running?

If it does, that appears to be a maintenance issue that should not become a safety/security issue.
 

The release said when officers asked him why he stole the ambulance, he said “he took it because he wanted to find a police car and wreck into it so that we would shoot him.”[2]

 

Isn’t that one of the ways a terrorist might use an ambulance?

All we have to do is get the terrorists so high that the only thing they can do with the ambulance is drive it into a bunch of unoccupied cars.

Then there are some possibly more sober, and maybe less destructive people.
 

Three Houston men have been charged with stealing an ambulance and trying to sell the emergency vehicle for scrap metal recycling.[3]

 

Today in stolen ambulance news.

We do not learn.

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Footnotes:

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[1] How Long Until a Stolen Ambulance is Used in a Terrorist Attack?
Tue, 19 Mar 2013
Rogue Medic
Article

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[2] Cops: Man stole ambulance, crashed into cars – Police say the man took bath salts, other drugs
Updated: Friday, 29 Mar 2013, 10:57 AM EDT
Published : Friday, 29 Mar 2013, 10:57 AM EDT
Wishtv.com
Article

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[3] 3 Texans allegedly tried to sell stolen ambulance
March 29, 2013 | Updated: March 29, 2013 9:35am
Houston Chronicle
Article

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Filed Under: Heresy, Risk Management

How Long Until a Stolen Ambulance is Used in a Terrorist Attack?

Tue, 19 Mar 2013 14:30:11 +0000 by

 
Image credit.
 

FireGeezer wrote about this yesterday in Another Stolen Ambulance.[1]

How difficult is it to lock an ambulance?

How difficult is it to lock any vehicle?
 

While paramedics were still inside the hospital, someone jumped into the ambulance shortly before 3 a.m. and drove away. The paramedics hadn’t set a lock that secures the ambulance while it is idling.

“The patient was in such critical condition they wanted to get her into the hospital quickly,” said Tim Brown, Medstar operations manager.[2]

 

What if the driver had not put the ambulance in park and it started to drive away with the unstable patient and the crew in the back?

What will cause the ambulance to stop?

Hitting something? Being thrown into park? Stomping on the brake?

How will that affect the care of the unstable patient in the back?

Will that dislodge IVs, or an endotracheal tube?

The more unstable the patient, the slower we need to go and the more deliberate we need to be about our actions.

Unstable patients are not an excuse to cut corners. Unstable patients are a reason to be slower and more careful in all of our actions.
 

The ambulance was found three hours later at 15th Street and College Avenue. Brown said the ambulance did not appear to have been damaged or ransacked, and the keys were left on the driver’s seat.[2]

 

Nothing bad happened, therefore it must be safe.
 

At least we don’t have to worry about a fire truck being used in a terrorist attack, because fire trucks require a lot of training to drive.

Oopsy – That argument implies that terrorists would not be able to fly even one plane into a building, never mind three planes in one hour fifty minutes. :oops:

 
8:13 – Flight 11 has its last routine communication with air traffic control.

8:14 – Flight 11 does not follow instructions from air traffic control.

8:19 – Call from flight 11 reporting stabbings – I think we’re getting hijacked.

8:20 – FAA considers Flight 11 to be hijacked.

8:46:30 – Flight 11 flies into WTC 1.

8:52 – Phone calls from several people on Flight 175 reporting that it has been hijacked.

8:54 – Flight 77 changes direction toward DC.

8:56 – Flight 77 turns off its transponder and is out of sight (and possibly out of mind) for 36 minutes.

9:03:02 – Flight 175 flies into WTC 2.

9:24 – FAA notifies NORAD of possible hijacking of Flight 77 and adds Flight 93 to the possible hijackings soon after.

9:28 – Hijackers attack the cockpit on Flight 93 with air traffic control listening.

9:32 – Dulles Terminal Radar Approach Control notices Flight 77 approaching DC.

9:37:46 – Flight 77 flies into the Pentagon.

9:45 – US airspace closed to traffic.

9:57 – Passengers begin to fight with hijackers on Flight 93. The only effective action taken by anyone to stop these attacks.

10:03:11[3] – Flight 93 flies into the ground.
 

Would we be any better prepared if a bunch of ambulances/fire trucks/police vehicles were stolen and used in attacks?

If EMS transportation were shut down, as all air transportation was shut down following the hijacking of planes, what would be the outcome for patients?

19 people hijacked 4 planes, attacked 3 targets, and were prevented from attacking a fourth target only by passengers.

What if a dozen, or two dozen people stole a dozen, or two dozen, ambulances and used them in coordinated attacks?

It took less than 1 hour 50 minutes from the first report of hijacking until the final plane crashed.

How long would it take from

Am I giving ideas to terrorists?

No. Terrorists have already thought of this.

We are the ignorant ones.

How much does it take to lock an ambulance?

Who is responsible for safely securing the vehicle when parking it? The driver – in other words, we are responsible.

This seems to be the EMS motto –
 

What can we do to avoid responsibility?
 

We can’t avoid responsibility, but we should protect everyone else by getting out of EMS if that is our attitude.

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Footnotes:

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[1] Another Stolen Ambulance
March 18, 2013
FireGeezer
Article

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[2] Ambulance stolen from St. Louis hospital while medical personnel try to save crash victim
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[3] Timeline for the day of the September 11 attacks
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Filed Under: Heresy, Risk Management

Woman with Risks for Torsades de Pointes Dying within Hours of Leaving the Emergency Department

Wed, 02 Jan 2013 14:00:41 +0000 by
 

I don’t expect to see this as a headline anywhere, but this possible cause of death something we should be aware of.

Abdominal pain in a patient with many comorbidities. She is given medication and later is found dead at her home.

What drugs was she taking?
 

a Potentially proarrhythmic drugs as classified by the Arizona Center for Education and Research on Therapeutics (www.qtdrugs.org).
b Given during emergency department visit.[1]

 

What risk factors did she have?
 

a Risk factors present in case study.[1]

 

The 12 lead obtained in the ED (Emergency Department) shows a bradycardia with a heart rate of 58 beats per minutes. Bradycardia probably should have been included in the risk factors in this case.

What treatment did she receive that increased her risk of TdP (torsades de pointes)?
 

 

Ondansetron (Zofran)
 

On September 15, 2011, the FDA issued a Medwatch Safety Alert for Zofran (ondansetron) in patients with congenital Long QT syndrome, a heart arrhythmia. The FDA further required GlaxoSmithKline to conduct a thorough QT study to determine the degree to which Zofran may cause QT interval prolongation.[1] On June 29, 2012, the FDA issued an FDA Drug Safety Communication Update entitled New information regarding QT prolongation with ondansetron (Zofran).

The 32-mg high dose of ondansetron (Zofran) has been pulled from the market by the FDA because of concerns about cardiac problems.[15][2]

 

The high dose of 32 mg is more than would usually be given by EMS or in the ED.

In this case, the ondansetron was 8 mg given orally in the ED, so this was a much smaller dose.

What is QT segment prolongation?
 


Image credit.

There is a problem with the image. The ventricles contract during the QRS complex, not during the T wave.
 

Let’s see some torsades.
 


Click on images to make them larger.[3]
 

How do we know that it is TdP?

Because of the long QT segment in the beats preceding the VT (Ventricular Tachycardia).

Does all torsades go away on its own, as the above example did?

No.

 

A medical screening examination was conducted and 8 mg of orally disintegrating ondansetron (Zofran) was administered for persistent nausea and vomiting. A 12-lead electrocardiogram (ECG) completed at triage (Figure 1) was remarkable for left ventricular hypertrophy and QT interval prolongation.[1]

 

This is a patient who should be on a monitor, not necessarily because of the proarrhythmic effects of the drugs she is already taking, but because of the combination with the proarrhythmic drug she has been given in the ED.

 

Shortly thereafter, the patient self-discharged from the emergency department before receiving definitive treatment. Upon making a follow-up phone call, it was discovered that the patient had been found unresponsive in bed approximately 4 hours after leaving the emergency depart[1]

 

Was it the Zofran?

Maybe, but if it was, the ondansetron may only be the straw that broke the camel’s back.

Does that mean that the risks should have been ignored?

No.

Many of the patients we see are the most fragile people in society and we are seeing them when they are at their greatest vulnerability to adverse treatment effects.

The FDA has warned about the QT prolonging effects of ondansetron, so we cannot claim that we could not have known. I have written about this before.[4],[5]

We should be looking for reasons why we should not be giving treatments.

EMS operates under protocols that may state –

If condition X is present, give treatment A, then give treatment B.

ED treatment can be just as protocol driven as EMS treatment.

We have drugs that can be dangerous under certain circumstances.

Should we give any drug without considering the possible drug interactions and adverse events?

If we are not aware of the drug’s possible drug interactions and adverse events, should we be permitted to give the drug?

Ondansetron is one of the drugs I give frequently, but I need to remind myself to consider the possible QT prolonging effects and to look for other QT prolonging drugs and medical conditions.

What other drugs do I carry that can cause QT prolongation?

Amiodarone (Nexterone, Cordarone) is the only drug I carry that is on the Drugs with a Risk of Torsades de Pointes list. Even ondansetron is not on this list. There is less evidence that ondansetron causes torsades, than there is that amiodarone causes torsades.
 

Substantial evidence supports the conclusion that these drugs prolong the QT interval and have a risk of TdP when used as directed in labeling.[6]

 

Oxytocin (Pitocin) and ondansetron are on the Drugs with a Possible Risk of Torsades de Pointes list.
 

Substantial evidence supports the conclusion that these drugs cause QT prolongation but there is insufficient evidence that they, when used as directed in labeling, have a risk of causing TdP.[6]

 

Diphenhydramine (Benadryl) is the only drug I carry that is on the Drugs with a Conditional Risk of Torsades de Pointes list.
 

Substantial evidence supports the conclusion that these drugs prolong the QT interval and have a risk of TdP but only under certain known conditions (e.g. excessive dose, drug interaction, etc.).[6]

 

All of these drugs are generally considered to be safe, because we are ignorant of the adverse events they can cause. TdP is only one adverse event. Amiodarone has other proarrhythmic effects, can cause hypotension,

Then there are the many drugs that may interact with these drugs to prolong the QT segment.

Antibiotics, psychiatric medications (for all kinds of psychiatric conditions – psychosis to depression), erectile dysfunction drugs,

Then why aren’t we seeing large numbers of dead bodies?

These patients have other medical conditions that may lead to death without any TdP or there may not be much TdP caused by these drugs. We do not know.

We do know that thousands, even tens of thousands of patients can die without anyone noticing that the deaths are the effect of a drug.[7]

For example –
 

She was pronounced dead at the scene by emergency care providers. Because of her extensive medical history, the woman’s family declined an autopsy, and her primary physician attributed the death to complications of diabetes mellitus, end-stage renal disease, and hypertension.[1]

 

What was the cause of death?

We do not know.

Given the number of risk factors for TdP, is TdP a likely cause?

Torsades de pointes is no less likely a cause of death than anything listed by the her primary care physician on the death certificate.

This isn’t a multiple choice exam, where someone thinks that there is some mythological one best answer.

This is the real world and all of these conditions probably significantly contributed to her death.

Was ondansetron the final straw?

Maybe.

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Footnotes:

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[1] Woman with Risks for Torsades de Pointes Dying within Hours of Leaving the Emergency Department.
Pickham D, Sickler K.
J Emerg Nurs. 2011 Dec 2. [Epub ahead of print] No abstract available.
PMID: 22137882 [PubMed - as supplied by publisher]

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[2] Ondansetron
Wikipedia
Adverse effects
Article

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[3] Etiology, warning signs and therapy of torsade de pointes. A study of 10 patients.
Keren A, Tzivoni D, Gavish D, Levi J, Gottlieb S, Benhorin J, Stern S.
Circulation. 1981 Dec;64(6):1167-74.
PMID: 7296791 [PubMed - indexed for MEDLINE]

Abstract with link to Free Full Text Download in PDF format from Circulation

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[4] Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part I
Mon, 02 Jul 2012
Rogue Medic
Article

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[5] Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part II
Thu, 05 Jul 2012
Rogue Medic
Article

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[6] TdP drug lists
AZCERT.org is now CredibleMedsTM
Web page with links to all lists as pop ups.

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[7] 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 [PubMed - indexed for MEDLINE]

Free Full Text Article from N Engl J Med.

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Filed Under: Cardiology, Heresy, Pharmacology, Risk Management
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