Risk Management

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

- Rogue Medic

2016 – Amiodarone is Useless, but Ketamine Gets Another Use

Sat, 31 Dec 2016 03:10:47 -0500 by Rogue Medic

I didn’t write a lot in 2016, but 2016 may have been the year we put the final nail in the coffin of amiodarone. Two major studies were published and both were very negative for amiodarone.

If we give enough amiodarone to have an effect on ventricular tachycardia, it will usually be a negative effect.^[1]

Only 38% of ventricular tachycardia patients improved after amiodarone, but 48% had major adverse cardiac events after amiodarone.

There are better drugs, including adenosine, sotalol, procainamide, and ketamine for ventricular tachycardia. Sedation and cardioversion is a much better choice. Cardioversion is actually expected after giving amiodarone.

For cardiac arrest, amiodarone is not any better than placebo or lidocaine. What ever happened to the study of amiodarone that was showing such wonderful results over a decade ago? It still hasn’t been published, so it is reasonable to conclude that the results were negative for amiodarone. It is time to make room in the drug bag for something that works.^[2],^[3]

On the other hand, now that we have improved the quality of CPR by focusing on compressions, rather than drugs, more patients are waking up while chest compressions are being performed, but without spontaneous circulation, so ketamine has another promising use. And ketamine is still good for sedation for intubation, for getting a patient to tolerate high flow oxygen, for agitated delirium, for pain management, . . . .^[4],^[5]

Masimo’s RAD 57 still doesn’t have any evidence that it works well on real patients.^[6]

When intubating, breathe. Breathing is good. Isn’t inability to breathe the reason for intubation?^[7]

–

Footnotes:

–

^[1] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

–

^[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

–

^[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

–

^[4] What do you do when a patient wakes up during CPR?
Tue, 08 Mar 2016
Rogue Medic
Article

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^[5] Ketamine For Anger Management
Sun, 06 Mar 2016
Rogue Medic
Article

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^[6] The RAD-57 – Still Unsafe?
Wed, 03 Feb 2016
Rogue Medic
Article

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^[7] Should you hold your breath while intubating?
Tue, 19 Jan 2016
Rogue Medic
Article

Filed Under: ACLS, Airway Management, CPR, Critical Judgment, Evidence, Excited Delirium, Heresy, Intubation, Ketamine, Masimo, Mythology, Pharmacology, Risk Management, Sedation, Toxicology

‘Narcan by Everyone’ Does Not Seem to be Such a Good Idea

Thu, 22 Dec 2016 22:45:48 -0500 by Rogue Medic

Now that we have almost everyone giving naloxone (Narcan) to suspected heroin overdose patients, the fatality rate must have dropped. The panacea must have worked. My criticism of the Narcan by Everyone programs must have made me a laughing stock.^[1],^[2],^[3],^[4]

No.

Does that mean that I am a prophet and that you should worship me?

No.

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H.L. Mencken.

I have been pointing out that the plans assumed that there would not be any unintended consequences. I explained what some of the unintended consequences would be. Many people used logical fallacies to justify ignoring the likelihood of unintended consequences. The reasonable thing to do would have been to study the implementation, so that problems would be noticed quickly.

Misdiagnosis – giving naloxone to people who have a change in level of consciousness that is not due to an opioid (heroin, fentanyl, carfentanyl, . . . ) overdose.

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.^[5]

Bold highlighting is mine.

Failure to ventilate – not providing ventilations to a patient who is not breathing. These patients are often hypoxic (don’t have enough oxygen to maintain life) and hypercarbic (have too much carbon dioxide to maintain life). If the patient is alive, ventilation should keep the patient alive, even if naloxone is not given or if the naloxone is not effective. If the patient is dead, giving naloxone will not improve the outcome.^[6]

But . . . But . . . But . . . Narcan is the miracle drug!

Image credit.

In Akron, a small Ohio city, medical examiner Dr. Lisa Kohler has seen over 50 people die of carfentanil since July. Police Lieutenant Rick Edwards says his officers are “giving four to eight doses of [naloxone] just to get a response.”^[7]

“Every day our paramedics start CPR on someone surrounded by empty naloxone vials… people give the naloxone and walk away,” she (Ambulance Paramedics of BC president Bronwyn Barter) said in an interview.^[7]

Where should we start?

All patients considered to have opioid intoxication should have a stable airway and adequate ventilation established before the administration of naloxone.^[8]

We keep making excuses for solutions that are neat, plausible, and wrong. Why don’t we start acting like responsible medical professionals and do what is best for our patients?

Thank you to Gary Thompson of Agnotology for linking to this for me.

Go read Response: ‘What happens when drugs become too powerful for overdose kits’

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Footnotes:

–

^[1] The Myth that Narcan Reverses Cardiac Arrest
Wed, 12 Dec 2012 20:45:29
Rogue Medic
Article

–

^[2] Should Basic EMTs Give Naloxone (Narcan)?
Fri, 27 Dec 2013 14:00:22
Rogue Medic
Article

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^[3] Is ‘Narcan by Everyone’ a Good Idea?
Tue, 03 Jun 2014 23:00:38
Rogue Medic
Article

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^[4] Is First Responder Narcan the Same as First Responder AED?
Wed, 18 Jun 2014 17:15:43
Rogue Medic
Article

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^[5] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]

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^[6] The Kitchen Sink Approach to Cardiac Arrest
Mon, 16 Feb 2015 16:00:53
Rogue Medic
Article

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^[7] What Happens When Drugs Become Too Powerful for Overdose Kits?
Dr. Blair Bigham
Oct 4 2016, 12:11pm
Article

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^[8] Naloxone for the Reversal of Opioid Adverse Effects
Marcia L. Buck, PharmD, FCCP
Pediatr Pharm. 2002;8(8)
Medscape (free registration required?)
Clinical Uses

Filed Under: Airway Management, Assessment, Critical Judgment, Fentanyl, Heresy, Heroin, Naloxone, Narcan, Pharmacology, Research, Risk Management

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

Sun, 03 Apr 2016 14:30:32 -0400 by Rogue Medic

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

How typical is this medic?

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

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:

–

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

–

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

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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

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

Should Universities Avoid Sensitive Topics Because of Guns in the Classroom?

Thu, 25 Feb 2016 10:00:18 -0500 by Rogue Medic

There is paranoia over having guns on campus at state schools in Texas, but where is the evidence to support the fear that armed students will suddenly resort to violent disagreement? Professors are being encouraged to avoid sensitive topics if there are armed students in the classroom. Has discussion of sensitive topics previously resulted in attacks on professors with knives, clubs, chairs, or fists?

With students potentially carrying weapons after Aug. 1, University of Houston faculty members may want to avoid sensitive subjects or drop certain topics from their curriculum altogether, a forum of professors suggested recently.

A slide shown at a recent discussion of a new state law, which will allow licensed individuals to carry concealed handguns on campus, says faculty may want to “not ‘go there’ ” to avoid creating a tense situation. This echoes concerns voiced by professors across the state that allowing guns into the classroom will limit academic freedoms and inhibit discussion of sometimes touchy subjects.^[1]

We do need to know more about the causes of shootings, but Congress has prohibited studying this because the research often reflect the biases of the researchers, whether pro-gun or anti-gun. Researchers on the topic have not done a great job, but that is a reason to improve the research, not to prohibit research.

While there have been a lot of school shootings, is there anything to suggest that these shootings have had anything to do with discussions of sensitive topics?

No.

Will this change if students are allowed to carry firearms on campus?

Probably not.

Research would be nice, but Wayne LaPierre (executive vice president of the National Rifle Association) appears to be convinced that guns are the cause of all of the problems in America. He is the main opponent of research, which he seems to expect to uncover his secret. LaPierre is also the person who seems to profit the most from every mass shooting that makes the news.

News coverage of a mass shooting is a fund raiser for Wayne LaPierre and the NRA. While LaPierre fights to keep guns in the hands of criminals, most NRA members are more reasonable.

Section 2: Opinions of Gun Owners, Non-Gun Owners^[2]

Gun ownership is a topic that many people approach emotionally, rather than logically. People want guns for protection, even though there is no valid reason for the average person to feel safer with a gun. There are plenty of reasons to feel less safe with a gun.

The best way to protect yourself is to stay away from violent people, such as gangsters, but that is not always possible.

What is a gun supposed to protect you from? Being killed –

All homicides
Number of deaths: 16,121
Deaths per 100,000 population: 5.1

Firearm homicides
Number of deaths: 11,208
Deaths per 100,000 population: 3.5 ^[3]

What is the greatest risk of owning a gun?

All suicides
Number of deaths: 41,149
Deaths per 100,000 population: 13.0
Cause of death rank: 10

Firearm suicides
Number of deaths: 21,175
Deaths per 100,000 population: 6.7

Suffocation suicides
Number of deaths: 10,062
Deaths per 100,000 population: 3.2

Poisoning suicides
Number of deaths: 6,637
Deaths per 100,000 population: 2.1 ^[3]

People with guns are almost twice as likely to intentionally kill themselves as they are to intentionally kill someone else, so why the fear?

Then there are 505 unintentional firearms deaths, 281 firearms deaths in the undetermined category, and 467 firearms deaths in legal intervention/war category. Even the accidental (unintentional) deaths outnumber the appropriate deaths.

This does not mean that there is no good reason to own a gun. There are many, but just for the feeling of protection in a low crime area, like some who are prepared for a home invasion, is like buying a lottery ticket. Your odds of winning do not change, regardless of how many tickets you buy. Estimating the home invasion rate, since it is not usually a specific part of crime statistics, is a guess at what is just a tiny part of the violent crime rate, which has been decreasing for a quarter of a century.

Perhaps a gun is not just supposed to protect you from being killed, but from being attacked, or just from being anxious about being attacked. The suicide statistics do not suggest that guns provide an effective psychological benefit.

The NNT (Number Needed to Treat to produce a benefit) is almost impossible to measure, because of the prohibition on research and the difficulty in identifying cases where a gun might have prevented something vs. when having a gun may have contributed to a bad outcome, vs. the many other difficult to measure possible outcomes. Outcomes of even positive reports might have been better without a gun, since we generally have no way of knowing what the outcome would be if a person did not have a gun.

The NNH (Number Needed to Harm) is easier to measure. Add the accidental injuries, the accidental deaths, and the suicides and divide by the number of guns. Even this will have some difficult to measure possibilities. The difference is that the majority of this number is unambiguous, while the benefit is almost entirely speculative.

The bad outcomes are only going to be a fraction of one percent. They are like dealing with terrorism, which is like mass shootings – rare, dramatic, and emotional. We are not good at making these decisions rationally.

But how dangerous are guns?

Actual Causes of Death^[4]

Some of the death rates, such as due to motor vehicles and firearms, have decreased since 2000, while others, such as illicit drug use have increased.

The full image shows more dramatic changes since 1979, but I edited it to show only the changes since 1999.^[5]

Guns are much less dangerous than tobacco, obesity/inactivity, or alcohol, but more dangerous than terrorism. We don’t worry much about tobacco, obesity/inactivity, or alcohol, but we panic about terrorism. Risk management is not something we do well. We evolved a fight, flight, or freeze response to threats. These are reflexive and emotional responses. Universities are supposed to promote reasonable discussion of diverse and sensitive topics, but they have encouraged political groups to shout down the ideas they do not want to hear.

Professors are supposed to think clearly about things, and educate students to think clearly. Avoiding sensitive topics, because students might not be reasonable, is not reasonable.

–

Footnotes:

–

^[1] UH faculty suggest steering clear of some topics if students armed
By Benjamin Wermund
Updated 8:30 am, Wednesday, February 24, 2016
Houston Chronicle
Article

–

^[2] Section 2: Opinions of Gun Owners, Non-Gun Owners
March 12, 2013
Why Own a Gun? Protection Is Now Top Reason
Perspectives of Gun Owners, Non-Owners
Pew Research Center
Study

–

^[3] Deaths-Final Data for 2013
Jiaquan Xu, M.D.; Sherry L. Murphy, B.S.; Kenneth D. Kochanek, M.A.; and
Brigham A. Bastian, B.S., Division of Vital Statistics
National Vital Statistics Reports
Volume 64, Number 2
February 16, 2016
Free Full Text in PDF format

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^[4] Actual causes of death in the United States, 2000.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
JAMA. 2004 Mar 10;291(10):1238-45. Review. Erratum in: JAMA. 2005 Jan 19;293(3):298. JAMA. 2005 Jan 19;293(3):293-4.
PMID: 15010446

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^[5] QuickStats: Death Rates* for Three Selected Causes of Injury†— National Vital Statistics System, United States, 1979–2012
Morbidity and Mortality Weekly Report (MMWR)
November 21, 2014 / 63(46);1095
Edited to show only the changes since 1999
Free Full Image with footnotes from CDC.

Filed Under: Critical Judgment, Guns, Heresy, Risk Management

The Most Misleading Medical News of 2014

Sat, 27 Dec 2014 23:05:19 -0500 by Rogue Medic

The media are horrible at reporting medical stories, or any other science stories. They regularly report that some recent study shows a cure for cancer, as if cancer is just one illness. What were the media worst at covering this year?

Ebola.

They said Ebola was easy to catch, that illegal immigrants may be carrying the virus across the southern border, that it was all part of a government or corporate conspiracy.^[1]

Image credit.

The part of that quote that affects EMS is the claim that ebola is easy to catch.

Ebola does require isolation precautions – and we are not good at using, or understanding, isolation precautions. Just watch your coworkers putting everything on. Even worse, watch them take them off. Much worse, watch yourself in a mirror.

We are far from good at using isolation precautions.

Ebola spreads through direct contact with bodily fluids such as blood, vomit and diarrhea. Coughing and sneezing are not symptoms.

Airborne viruses, meanwhile, have the ability to travel large distances propelled by a sneeze or cough. In those cases, people breathe in virus particles without even realizing it. Scientists say there is no evidence Ebola works like that.^[1]

Back in August Dr. Anthony Fauci described how we should expect this outbreak to progress. Looking back, we should have ignored the news media and reread this article.

Although the regional threat of Ebola in West Africa looms large, the chance that the virus will establish a foothold in the United States or another high-resource country remains extremely small. Although global air transit could, and most likely will, allow an infected, asymptomatic person to board a plane and unknowingly carry Ebola virus to a higher-income country, containment should be readily achievable.^[2]

Dr. Fauci predicted that in August (print edition September 18). His prediction was more accurate than the media reported it as it happened a month later (a week later than the print edition).

Perhaps we should pay as much attention to what Dr. Fauci wrote about our optimism in favor of inadequately studied treatments.

Among the therapies in development is a “cocktail” of humanized-mouse antibodies (“ZMapp”), which has shown promise in nonhuman primates. ZMapp was administered to two U.S. citizens who were recently evacuated from Liberia to Atlanta, and both patients have had clinical improvement. However, it is not clear whether ZMapp led to the recovery, and with only two cases, conclusions regarding its efficacy should be withheld.^[2]

Perspective is important and we should apply it more often.

For example –

1. Restricting travel from Ebola-outbreak countries to the United States is the best way to prevent the spread of Ebola to our shores.

FALSE

There is no evidence that restricting travel will prevent spread of Ebola to the U.S. Exposed and infected persons might reach our country undetected and thereby escape essential public health monitoring, which could worsen transmission risk. The key to controlling this epidemic is to stop Ebola at its source in West Africa.^[3]

If we won’t take the risk of caring for these patients, we should not interfere with those who do understand appropriate treatment and do treat these patients.

–

Footnotes:

–

^[1] 2014 Lie of the Year: Exaggerations about Ebola
Politifact
Tampa Bay Times
By Angie Drobnic Holan, Aaron Sharockman
Monday, December 15th, 2014 at 3:08 p.m.
Article

PolitiFact editors choose the Lie of the Year, in part, based on how broadly a myth or falsehood infiltrates conventional thinking. In 2013, it was the promise made by President Barack Obama and other Democrats that “If you like your health care plan, you can keep it.”

–

^[2] Ebola–underscoring the global disparities in health care resources.
Fauci AS.
N Engl J Med. 2014 Sep 18;371(12):1084-6. doi: 10.1056/NEJMp1409494. Epub 2014 Aug 13. No abstract available.
PMID: 25119491 [PubMed – indexed for MEDLINE]

Free Full Text from New England Journal of Medicine.

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^[3] Ten Key “Facts” About Ebola: True or False?
Kristi L. Koenig, MD, FACEP, FIFEM
November 7, 2014
JournalWatch Emergency Medicine from NEJM
Article

Filed Under: Critical Judgment, Heresy, Journalism, Public Relations, Risk Management

Is ‘Narcan by Everyone’ a Good Idea?

Tue, 03 Jun 2014 23:00:38 -0400 by Rogue Medic

Image credit.

My friend Jonathan Blatman asks the following question about naloxone (Narcan) on Facebook –

I’ve heard that PA (Pennsylvania) is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone.^[1]

The problem is not that basic EMTs, or first responders, or police are stupid people.

The problem is that all people are stupid people.

Doctors, nurses, and paramedics do not understand naloxone, so we need to improve the understanding of pharmacology among doctors, nurses, and paramedics, before we increase the ranks of ignorant people inappropriately administering the drug.

Naloxone itself is very safe.

A quack once challenged me to take 1,000 times the dose of any medicine I chose, while he would do the same with some natural product. I accepted and chose naloxone, with the condition that he first take 1,000 time the daily recommended dose of one of something he considered completely safe and natural – water.

The quack had it pointed out to him that this dose of all natural water would be deadly. The quack backed out. Whether naloxone’s standard dose is 0.4 mg (it should not be more than this) or the dose more popular in areas with frequent fentanyl overdoses (2.0 mg) does not matter. Naloxone has been demonstrated to be relatively safe at massive doses.

Adult Patients
In one small study, volunteers who received 24 mg/70 kg did not demonstrate toxicity.
In another study, 36 patients with acute stroke received a loading dose of 4 mg/kg (10 mg/m2/min) of naloxone hydrochloride injection followed immediately by 2 mg/kg/hr for 24 hours. Twenty-three patients experienced adverse events associated with naloxone use, and naloxone was discontinued in seven patients because of adverse effects. The most serious adverse events were: seizures (2 patients), severe hypertension (1), and hypotension and/or bradycardia (3).^[2]

400 mg (0.4 mg dose x 1,000) or 2,000 mg (2.0 mg x 1,000) would be higher than the doses tested in these patients, but would still be much safer than 1,000 times the recommended daily dose of water, even though water is safe and essential for life. It does not matter if there is fluoride in the water for it to be lethal, but we should fluoridate water, because only conspiracy theorists think that fluoride is dangerous in drinking water.

We engage in magical thinking about the drugs we give.

The problem is not with the drug. The problem is with the actions of the people giving the drug – us.

We still have a big push for giving fibrinolytics (tPA – tissue Plasminogen Activator) to patients with acute ischemic stroke, even though most of the improvement may be due to the transience of stroke symptoms in some stroke patients (TIS – Transient Ischemic Attack). Fibrinolytics do not appear to be beneficial for acute ischemic stroke and there is no reason to give them for a TIA.

There is weak beneficial evidence in only two out of eleven studies (only 18% of studies) – and increases in death in most studies of fibrinolytics for acute ischemic stroke.^[3] The problem is not with the drug. The problem is with the actions of the people giving the drug. Most of the evidence shows death increased, but we ignore that.

Naloxone and tPA are both given based on a rush to treatment and a fear of not giving the standard of care – the Yuppie Nuremberg Defense.

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.^[4]

Will this be a matter of providing naloxone, rather than providing ventilations?

An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007.^[5]

What about people who take more than one drug?

If the opioid is reversed, will there be problems?

All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.^[6]

Will we identify the patients who have other medical conditions that may respond after naloxone, but not because of naloxone, such as hypoglycemia, stroke, seizures, clonidine overdose, arrhythmia, head trauma, dehydration, syncope, et cetera?

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.^[7]

The problem is not with the administration of naloxone, but with the faulty assumption that because a patient wakes up after naloxone, the patient woke up because of naloxone.

Doctors, nurses, and paramedics do not do a good job of identifying the difference currently. We need to educate them, rather than encourage others to replicate their mistakes.

Pharmacology is poorly understood by people with medical education.

The documented indication for nebulized naloxone administration was suspected opioid overdose in 70 patients (66.7%), altered mental status in 34 patients (32.3%), and respiratory depression in one patient (0.9%).^[8]

The indication for naloxone is respiratory depression.

The treatment for respiratory depression is to supplement oxygen and/or ventilations. We have decided to give naloxone in stead.

Naloxone was used appropriately in fewer than 1% of patients.

How ~~good~~ bad will our naloxone by everyone education be?

Don’t wait with bated breath – someone my administer naloxone.

Dispatch – Activate Our Honeybee Swarm Removal Plan

Thu, 22 May 2014 13:30:14 -0400 by Rogue Medic

Delaware does have a honeybee swarm removal plan. Up until this week, the plan was probably used more as a punchline for jokes than anything else. The plan was created in 1995, but Yesterday was its first use.

Why have a honeybee swarm removal plan?

If you are dealing with a swarm of bees, your ability to solve problems may not be that good.

Who ya gonna call?

Dispatch.

Whom will dispatch call?

Probably someone who does not know what to do. Unfortunately, that person – the one who does not know what to do – probably will suggest something. Well, I’m not 100% certain, but . . . . This is when you should just disconnect the line, because not 100% certain means I haven’t the slightest idea, but my ego won’t let me admit the truth out loud. This is the equivalent of the guy with a beer in one hand, doing something reckless, and saying, Watch this!

More dangerous than the guy who is not 100% certain is the person who takes advice from him. Maybe pouring gasoline all over the highway and setting it on fire will control the bees, but I would rather get that information from someone who is familiar with bees and can tell me of a specific instance when it has worked, how this scene is the same/different, and how I can get further information about it. Anecdotes can be very dangerous. Experts citing anecdotes may not be any better than the guy who is not 100% certain.

As it turns out, Kill it with fire was not a part of the honeybee swarm removal plan.

What is needed for a plan like this?

A list of several emergency contacts and numbers where they can be reached at night, on the weekends, and during holidays.

Descriptions of how to deal with the variations of the emergency that can be anticipated.

Contact numbers for people outside of the area, who would be needed in the event of a very large disaster of this kind.

Recommendations for first responders who are probably already in the middle of things when the plan is initiated.

Tuesday, a truck carrying bees overturned on I-95. Bees can be a problem. Drivers may not respond to emergencies the way we would like. A swarm of bees may lead people to panic.

How many bees?

16 to 20 million bees.

Am I going to be able to give an accurate estimate of 20,000 bees, 200,000 bees, 2,000,000 bees, or 20,000,000 bees?

First responder – Dispatch, we appear to have a bit of a bee problem. Do we have some sort of disaster plan?

Dispatch – Today is your lucky day. We do have a bee swarm plan.

The plan, which was updated in March, involves a response network of beekeepers statewide. Three beekeepers from New Castle County responded to the scene after Tuesday’s accident. The initial response including using fire hoses to tamp down the swarms.^[1]

This worked well, but having a plan does not guarantee any kind of success. Reality does not come with guarantees, so having people who understand how to adapt to change is important.

No plan survives the first contact intact, but well prepared people produce their own luck.

What number do people call when things go wrong? 911. We deal with what happens when it is worse than expected. We should have some sort of plan, even if only cursory, for the things that cause us to call for help. Rare things happen rarely, but they do happen.

–

Footnotes:

–

^[1] Delaware motorists warned to watch out for bees
By Associated Press
Published: May 20
Updated: Wednesday, May 21, 1:46 PM
Washington Post
Article

Filed Under: Heresy, Management, Risk Management

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

Fri, 24 Jan 2014 10:30:24 -0500 by Rogue 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.

[youtube]gGGDzEWvGRY[/youtube]

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. 😳

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.

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Footnotes:

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

Filed Under: Heresy, Risk Management

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