The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Up To, and Including, DEATH – The Anguish of Happy Medic


 

Happy Medic explains that in reviewing refusal of transport charts, he comes across this magical invocation repeatedly.
 

This is a phrase I see a lot in my line of work. There are a number of variations including another favorite “seizure, coma, death” that are designed to cover the hind quarters of the author in some half cracked attempt at documentation.[1]

 

Even Sylvester Stallone correctly ridicules seizure, coma, death reasoning, so evil it must only be be spoken of in the most reverent terms.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Happy Medic has a question for those who use either murder, death, kill seizure, coma, death or Up To, and Including, DEATH as a part of their documentation of a refusal for minor injuries.

I confess that I was trained to do this and it took me a while to realize how ridiculous it is.
 

Funny part is that this blanket statement calls into question the rest of your document most times. Do you really believe the hand abrasion will lead to death? In what fashion? If it is such a risk, why isn’t the patient being transported?[1]

 

Please, explain how this laceration will lead to death.

This must be a death that would be prevented by immediately taking a magical trip to the ED (Emergency Department) by our magic carpet ambulance.

In the ED, they are able to use stronger spells than seizure, coma, death. :oops:

What we are trying to state is I am not responsible.

This seems to be the motto of the least competent in EMS.

If I follow the protocol, I am not responsible for the harm I cause the patient.

If I follow medical command orders, I am not responsible for the harm I cause the patient.

If I follow orders, I am not responsible for the harm I cause.

Is that really what we aspire to?

If people enter EMS with this attitude, we should do our best to get rid of this attitude.

If people enter EMS without this attitude, we should do our best to get rid of those of us encouraging this attitude.

EMS is not magic. We are not magicians, sorcerers’ apprentices, or flying monkeys.

We are pretending that magic is a solution to ignorance and/or incompetence.

The I am not responsible attitude is dangerous to us and dangerous to our patients.

Please stop being dangerous.
 

Go read Happy Medic’s solution to this magical incantation.

-

Footnotes:

-

[1] Up To, and Including, DEATH
Jan 23, 2014
Happy Medic
Article

.

What Can EMS Expect From 2014? #1 Ketamine Again


 

What changes need to be made in 2014, if they have not already been made?

Ketamine – for those of you who already have ketamine, great work. Continue to improve patient care. Do not let the rest of us slow you down.

Excited delirium – ketamine is the fastest way to sedate a violent patient.

Pain management – ketamine dissociates without respiratory depression.

RSI (Rapid Sequence Induction/Intubation) – ketamine dissociates without respiratory depression.

Asthma – ketamine opens the airway.

Awake intubation – ketamine dissociates without respiratory depression.

Sedation for extrication – ketamine dissociates without respiratory depression.

Seizures- ketamine stops seizures.
 

Safety – ketamine is safe.
 

Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.[1]

 

Is any other sedative that safe?
 

Here are some podcasts to explain in more detail.

Dr. Mel Herbert on ketamine.
Ketamine Update.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Baruch Krauss on ketamine.
Ketamine in the Emergency Department.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Sergey Motov on ketamine.
Ketamine for Everything.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Scott Weingart on ketamine.
Podcast 104 – Laryngoscope as a Murder Weapon Series – Hemodynamic Kills
Page with a link to the free mp3 download, but watch the video first – it is excellent.

More from Dr. Weingart.
EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)
Free mp3 DownloadFrom EMCrit.

-

Dr. Jim DuCanto on ketamine.
Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD
Page with a link to the free mp3 download, but watch the video first – it is excellent.

-

Dr. Minh LeCong on ketamine myths –

PHARM Podcast 75 Ketamine MythBusters
Part 1 – Blowing your mind

PHARM Podcast 76 Ketamine MythBusters
Part 2 – Take the pressure down

PHARM Podcast 77 Ketamine MythBusters
Part 3 – Are you mad enough?

PHARM Podcast 78 Ketamine MythBusters
Part 4 – A fitting end?

 

Would you prefer to have something to read about ketamine?
 

 

Dr. Reuben Strayer on ketamine.

The Ketamine Brain Continuum
December 25th, 2013
by reuben in PSA & analgesia
Article

Awake Intubation: A Very Brief Guide
July 7th, 2013
by reuben in airway
Article

Ketamine as a suicidality reversal agent
June 4th, 2011
by reuben in psychiatry
Article

Taming the Ketamine Tiger
January 27th, 2011
by reuben in PSA & analgesia
Article

Ketamine for RSI in Head Injury
April 3rd, 2010
by reuben in .trauma-general, .trauma-head & face, airway
Article

Another reason to use ketamine for RSI in sepsis
November 24th, 2009
by reuben in airway
Article
 

Is there any good reason to not be using ketamine in EMS?

-

Footnotes:

-

[1] Ketamine Hydrochloride (ketamine hydrochloride) Injection, Solution, Concentrate
[Bedford Laboratories]

FDA Label
DailyMed
Label

.

Should Basic EMTs Give Naloxone (Narcan)?

 
Should basic EMTs be giving naloxone (Narcan) when paramedics do not really understand the drug?

If a patient wakes up after naloxone, does that mean the patient had a drug overdose?

No – but most paramedics do not understand that.[1]

As of January 1, 2014, there will be even more people giving Narcan with little understanding of what they are doing.
 


Peter Thomson.
 

La Crosse firefighters soon could start carrying a life-saving drug for heroin users. The department is applying to be one of the state’s first groups of emergency medical technicians to administer Narcan, the antidote to an opiate overdose.[2]

 

Does naloxone save lives or just make it less work for first responders?

If the basic EMTs are not good at basic ventilation, will they be any better at drug administration?

Are drugs the cure for ventilation problems?
 

The department has witnessed a 53 percent jump in the number of potential drug overdoses since 2009, Chief Gregg Cleveland said.

In 2012, firefighters responded to 98 potential overdoses and 86 so far this year.[1]

 

A 53% increase?

98 last year.

86 so far this year (as of October).

10 months in, so an average of 8.6 per month = 103.2 for the whole year.

Going from 98 to 103 is not a 53% increase.

It isn’t even a 5.3% increase, but only 5.1%
 

Only 5% – not 53%.
 

Bad math.

Correction (13:00 12/28/2013) – the math is not based on the numbers in the article and I did not read the article correctly. The bad math is mine, not Chief Gregg Cleveland’s. Thank you to Christopher Jennison, Jordan L, and Parastocles for pointing out my error.

I apologize to Chief Gregg Cleveland for misrepresenting his statement as bad math, when it was my mistake.
 

Bad decisions.

What kind of time would be saved by having the fire department give naloxone?

What kind of bad outcomes would be prevented?

What kind of better outcomes would be expected?

What is the added cost of implementing this program?

What other programs would be deprived of this money?

Those are just some of the questions that should be asked.

The main question is –

If your fire department is doing such a bad job of managing BLS skills (BVM, positioning, painful stimulus, . . . ), why should we allow you to harm patients with ALS skills?

If your department is not harming patients, then where is the need?

Naloxone does not appear to be the answer to either problem.

Will naloxone cure the math problems of these drug pushing managers?

-

Footnotes:

-

[1] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed - indexed for MEDLINE]
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.

-

[2] Firefighters could be getting medication to save drug users
October 31, 2013 12:00 am
By Anne Jungen
ajungen@lacrossetribune.com
LaCrosse Tribune
Article

.

A Recalled AED is Better Than No AED


 
Cardiac arrest. CPR in progress. Do not use the AED, because it has been recalled!

Wrong.
 


 

HeartStart automated external defibrillators from Philips Healthcare have been recalled.

What does the FDA (Food and Drug Administration) mean by recall?

Well, why was the recall issued?
 

Certain HeartStart automated external defibrillator (AED) devices made by Philips Medical Systems, a division of Philips Healthcare, may be unable to deliver needed defibrillator shock in a cardiac emergency situation, the U.S. Food and Drug Administration said today in a new safety communication for users of these previously recalled devices.[1]

 

A shock might not be delivered.

What does the FDA recommend?
 

“The FDA advises keeping all recalled HeartStart AEDs in service until you obtain a replacement from Philips Healthcare or another AED manufacturer, even if the device indicates it has detected an error during a self-test,” said Steve Silverman, director of the Office of Compliance in the FDA’s Center for Devices and Radiological Health.[1]

 

Do not take these AEDs out of service service until a replacement is present.

Why?

What about the lawyers?

But it’s defective!

Thinking is dangerous!
 

“Despite current manufacturing and performance problems, the FDA considers the benefits of attempting to use an AED in a cardiac arrest emergency greater than the risk of not attempting to use the defibrillator.”[1]

 

The benefit is greater than the risk.

There is risk with everything.

Anyone who tells you otherwise is selling something.

There is not benefit with everything.

Since the detection of an error during the self-test does not guarantee that the AED will not deliver a shock when needed, removing the AED without a replacement is more dangerous than leaving the AED in service.

These recalled AEDs are better than no AED.
 

Of course, if needed for use in an emergency, make every attempt to clear the error and use the device normally, as described in the Owner’s Manual.[2]

 

The manufacturer and the FDA agree that, in the case of these AEDs, something is better than nothing.

Are we really going to make a dead patient more dead by using a defective AED?

-

Footnotes:

-

[1] FDA issues safety communication on HeartStart automated external defibrillators from Philips Healthcare
FDA News Release
For Immediate Release: Dec. 3, 2013
Media Inquiries: Jennifer Rodriguez, 301-796-8232, jennifer.rodriguez@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA
News Release

-

[2] Philips HeartStart FRx and OnSite (HS1) automated external defibrillators (AEDs)
Phillips Healthcare
Maintenance Advisory

.

My Response to A Discussion on Evidence from EMS Expo

 

Last week I wrote A Discussion on Evidence from EMS Expo about one of the conversations that I had at EMS Expo about evidence and patient care.

What were the conditions for the treatment being discussed?
 

Everybody knows the treatment works.

If the treatment is not used, the patient dies.

If the treatment is used, the patient lives.

We should ignore demands for evidence, because evidence-based medicine does not exist in this primitive culture.

Who are we to question the ways of this culture?

Isn’t it arrogant to try to impose our values on this culture?

It works for them, so shouldn’t we accept that?

 

The primitive culture being discussed was not EMS, but everything about the discussion does apply to the primitive culture of EMS.

We are Emergency Medical Shamans.
 


Original source of edited image.
 

We choose to ignore evidence and use magic rituals that do not work.

We use these magic rituals to harm patients.

We claim that these magic rituals are so beneficial that we should not deprive patients of the magic, because that would be dangerous.

We insist that intubation saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that spinal immobilization saves lives and protects spines and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that ventilation in cardiac arrest saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that epinephrine in cardiac arrest saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that IV fluid for uncontrolled hemorrhage saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

If the treatment is not used, the patient dies.

If the treatment is used, the patient lives.

Ask for the evidence and the absence of evidence becomes Everybody knows that . . .
 


 

Why do we believe the people who tell those EMS lies?

We are reckless and refuse to look at the evidence that shows how dangerous we are.

We are primitives who pretend that science does not work, because science does not support our biases.

When will we stop killing our patients with this ignorance?

.

EMS Witch Doctors at Work

 


John J. Jankowski Jr./Special to The News Journal[1]
 

Is it really fair to place all of the blame on the people walking patients to the magic backboards?

They are probably doing what their medical directors and quality control departments tell them must be done.
 


John J. Jankowski Jr./Special to The News Journal[1]
 

However, why are medical directors encouraging this charlatanism?

Why is quality control discouraging quality patient care?

Is there any evidence that anyone walking will benefit from laying on a backboard?
 


John J. Jankowski Jr./Special to The News Journal[1]
 

This is a legitimate question. If someone has good evidence that placing a walking patient on a backboard has improved the patient’s outcome, please produce that evidence.
 

Even the ACS COT (American College of Surgeons Committee On Trauma) does not recommend a backboard for patients walking on scene. The ACS COT are the authors of the PHTLS (PreHospital Trauma Life Support) guidelines.

The NAEMSP (National Association of EMS Physicians) does not require a backboard for patients walking on scene.
 

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[2]

 

A collar and no board appears to be the standard of care.
 

What kind of defense will work if there is disability to a patient when they were walking on scene before being placed on this backboard that is clearly not recommended?

Something like –

We really really believe in witchcraft!!!11!!!

Annie was walking before we put her on the board, but now she can’t walk.

Is there any reason to believe that does not happen?

should we expect the ACS COT and/or the NAEMSP to defend this use of witchcraft?

Here is what the ACS COT and NAEMSP write about not putting walking patients on backboards –
 

This is the official position of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma regarding emergency medical services spinal precautions and the use of the long backboard.[2]

 

When the experts eliminate some witchcraft, should we continue that witchcraft?

When the experts admit that they were wrong, should we continue doing things the wrong way?

Are we here to try to protect our reputations or to try to protect our patients?

Is EMS a profession with ethical standards?

Are we capable of learning to be better?

-

Footnotes:

-

[1] DART bus crash
delawareonline
John J. Jankowski Jr./Special to The News Journal
Article

-

[2] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed - in process]

Free Full Text in PDF Download format from NAEMSP.

.

Peer Pressure to Mistreat Patients ‘Just to Be Safe’

 

Start a conversation on use of back boards in almost any EMS group and expect someone to say that, based entirely on mechanism of injury, the uninjured patient must be strapped to a back board Just to Be Safe.

Is it safe?

No.

Where is the evidence of safety?

Where is the evidence of benefit?

What we get is just the ignorance-based bias of the person who has no understanding of safety.
 

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).
[1]

 

a <2% chance that immobilization has any beneficial effect.
 

Less than 2% chance of any benefit?

Roulette wheels have better odds playing just one number. It is reckless to bet on a single number in roulette (the only safe bet is to be the house, but that is a different topic). This is being reckless and irresponsible with our patients.

Why do we see gambling on the extreme long shot as safe?

Maybe because we are not gambling with our own disability.

We are betting our patients’ disability on our ignorance.

Is that safe for the patient?

The same study showed that those with unstable spinal injuries were twice as likely to be disabled if they were strapped to back boards.
 


Image credit from Voodoo Medicine Man.
 


 

The study is not definitive, but we are just guessing about what might work, based on an ancient hunch. We have no clue.

It is time we found out what works.

It is time we admit that we do not know what works.

We are clearly demonstrating that we are clueless about what safe means.

The standard of care has changed.
 

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[2]

 

This is from the people who write the PHTLS (PreHospital Trauma Life Support) and ATLS (Advanced Trauma Life Support) guidelines as well as from the NAEMSP (National Association of EMS Physicians).

Do we want to go to court and face experts who will say this about back boards just to be safe –
 

We don’t do that any more.

We learn from our mistakes.

 

Is that safe?

Isn’t it time we stopped encouraging people to make mistakes that harm our patients?

-

Footnotes:

-

[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

-

[2] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed - in process]

Free Full Text in PDF Download format from NAEMSP.

.

Standards Of Care – Ventricular Tachycardia

 

Is it possible to write protocols that are based on good evidence, rather than on GOBSAT (Good Old Boys Sitting Around a Table) rules?
 

The Standard Of Care is what the popular kids are doing because of peer pressure, a lack of understanding of the available evidence, and a fear of law suits.

Peer pressure?

If we don’t do what everyone else is doing, we will harm patients?

Patient care is not a popularity contest, otherwise there would be no need for doctors. A majority of neighbors could come up with the Standard Of Care.

Is there any reason to discourage doctors from challenging the Standard Of Care?

Well . . . .

What will everyone hide behind, if we admit that the Standard Of Care may not be the best available care?

What will everyone hide behind, if we admit that the Standard Of Care may be bad care?

If we admit that, will memorization and application of a bunch of Standards Of Care be good for patients?
 

What about V Tach (Ventricular Tavhycardia)? The AHA (American Heart Association) writes guidelines for treatment, which are generally accepted as Standards Of Care and copied into EMS protocols. To the credit of the AHA, they do continually review the available evidence and revise their guidelines.
 


 

Many devotees of Standards Of Care whine about these changes. How can we be expected to provide care that doesn’t get us in trouble, if the definition of what doesn’t get us in trouble is constantly changing? It is as if we will be expected to understand what we are doing, rather than to just be expected to memorize and apply the Standards Of Care. It is as if we are expected to continue learning because we don’t know everything.

Amiodarone may be the ultimate standard Standard Of Care.

A Fib (Atrial Fibrillation)?

Give amiodarone.

A Flutter (Atrial Flutter)?

Give amiodarone.

V Tach?

Give amiodarone.

Wide complex tachycardia that could be anything?

Give amiodarone.

V Fib (Ventricular Fibrillation)?

Give amiodarone.

Sinus tachycardia (due to sepsis, or hemorrhage, or pain, or epinephrine, or dehydration, or anxiety, or fever, or . . . )?

Some people will still give amiodarone.

Why?

It’s the Standard Of Care. This is the excuse for not being competent. Just memorize some Standards Of Care, sprinkle them around liberally, and everything will be OK – but never, ever question the Standard Of Care.

This is no different from the protocol monkey, who is faced with the multiple choice protocol decision.

Tachycardia problem?

Tachycardia treatment.

Amiodarone vs. adenosine. Tough choice. Narrow = adenosine. Wide = amiodarone.

But does amiodarone do a good job of treating emergency patients?

Different studies show that amiodarone is only 29% effective at terminating V Tach,[1] only 25% effective at terminating V Tach, [2], and only 15% effective at terminating V Tach within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29% effective.[3]

What else is available?

In the 2010 ACLS guidelines, procainamide is listed as Class IIa, LOE B, while amiodarone is only Class IIb, LOE B.

What does that mean?
 

Class IIa
Benefit >> Risk
It is reasonable to perform procedure/administer treatment or perform diagnostic test/ assessment.

-

Class IIb
Benefit Risk
Procedure/treatment or diagnostic test/assessment may be considered.[4]

 

There is much better evidence that procainamide is effective.
 

Procainamide and sotalol should be avoided in patients with prolonged QT.[5]

 

But that is a mistake.

Amiodarone is a potent QT segment prolonging drug.
 

Proarrhythmia
Like all antiarrhythmic agents, amiodarone I.V. may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. Proarrhythmia, primarily torsades de pointes (TdP), has been associated with prolongation by amiodarone I.V. of the QTc interval to 500 ms or greater. Although QTc prolongation occurred frequently in patients receiving amiodarone I.V., torsades de pointes or new-onset VF occurred infrequently (less than 2%). Patients should be monitored for QTc prolongation during infusion with amiodarone I.V. Combination of amiodarone with other antiarrhythmic therapy that prolongs the QTc should be reserved for patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent.
[6]

 

If the only advantage of amiodarone over procainamide is QT prolongation, but that advantage is not real, why should we prefer amiodarone to procainamide?

-

Footnotes:

-

[1] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed - indexed for MEDLINE]

-

[2] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

-

[3] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed - indexed for MEDLINE]

-

[4] Table 3. Applying Classification of Recommendations and Level of Evidence
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 1: Introduction
Table 3

I have modified this table solely for the purpose of clarity of presentation, by modifying color and font. None of the words have been changed.

-

[5] Wide-Complex Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Tachycardia
Free Full Text from Circulation

-

[6] AMIODARONE HYDROCHLORIDE injection, solution
[Bedford Laboratories]

DailyMed
Warnings
FDA Label

.