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

- Rogue Medic

Why are We So Afraid of Our Patients

Fri, 10 Feb 2012 09:15:23 -0500 by
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WANTYNU asks –

We all know EMS can be dangerous, so if you could carry a weapon, would you and which would it be?[1]

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Better to be judged by 12 than carried by 6.

This is the kind of reasoning used by the people who think they need to have a weapon to provide patient care.

This is not a valid choice this is just paranoia.

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How many EMS personnel are shot on calls each year?

How many EMS personnel are stabbed on calls each year?

How many EMS personnel are attacked with any other lethal force on calls each year?[2]

The armed and dangerous EMS people would have us believe that the number is large.

In how many years is the number not zero?

Are we more likely to be shot or stabbed by our paranoid coworkers, by our family members, by our patients, or never to be shot or stabbed?


In the Standing Orders podcast on armed EMS,[3] the only real defense of EMS carrying weapons was as tactical medics. That is appropriate. You do not go on a raid without a weapon, but what does that have to do with going into someone’s home to provide medical treatment and carrying a weapon?

Not a thing.

How bad do our communication skills have to be for us to make people want to shoot, or stab, us?

I annoy a lot of people, some of whom carry weapons, but I do not feel any imminent threat.

Why are so many people in EMS so afraid?

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Better to be judged by 12 than carried by 6.

The reasoning behind this seems to parallel the reasoning behind a lot of other bad decisions in EMS.

I am afraid of responsibility. I need extreme protection.

Flying everyone who might be seriously injured. Learning to assess patients competently is too much to ask.

Immobilizing everyone because they might sue us.

We need our endotracheal tube to save lives. We need to be able to pretend that we know more than nurses, just because of this one little used part of our scope of practice – something that we do very poorly, but why bring reality into this?[4] [5]

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Maybe, if we want to be viewed as a profession, we should start thinking, rather than panicking.

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Footnotes:

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[1] We all know EMS can be dangerous, so if you could carry a weapon, would you and which would it be?
WANTYNU
02/09/2012
FaceBook page

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[2] Surviving the Next Shift – Part I
Rogue Medic
Fri, 16 Dec 2011
Article

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[3] Surviving the Next Shift
Standing Orders
Dec 13, 2011
Podcast page

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[4] Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

Even though the flight crew success rate was dramatically better than the ground EMS intubation success rate, it is still unacceptably low. What is the difference between the flight crews with 82% intubation success and the ground crews with 95+% intubation success or the flight crews with 95+% intubation success?

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

Free Full Text PDF

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.

In spite of these studies, and others, few medics will admit that they are poor at intubation. We are all above average. At least, more of us do seem to be above average in deceiving ourselves. It seems to be an EMS job requirement.

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Filed Under: Ethics, Heresy, Mythology, Standing Orders

Surviving the Next Shift – Part II

Sun, 18 Dec 2011 06:30:59 -0500 by

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Continuing from Part I of the discussion about what we need to do to go home safely at the end of our shifts.

On Surviving the Next Shift, Brad Buck, Matt Fults, and Dr. Chris Russi D.O. are joined by Eric Dickinson (author, police officer, EMT, and author of the article Tactics to Survive Your Next Shift) and Art Hsieh (of EMS1.com and author of the article On self defense and being a medic).

When is the scene safe?

The scene is NEVER safe.

Scene safety is just another EMS myth.

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What can we do to make the scene more safe?

Awareness of the environment.

Anyone who has been violent can should be expected to be violent again.

If you are an abused spouse and you want to believe that your abuser really loves you because they say they really love you with the same sincerity that they say they will never hit you again – that is your fault. Wake up and call 911.

If you are EMS and you believe some violent person who says I won’t do that again, with even more sincerity than a drunk saying he won’t drink again – it is your fault when you get attacked, again. Wake up and call for police right away.

The best predictor of violence is a history of violence.

The best protection from violence is not a weapon, not body armor, but awareness.

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Image credit. Alex is so fond of ultraviolence, he even attacks his droogies.

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The best protection from violence is not a weapon, not body armor, but awareness.

Weapons can be used against you. If you are not an expert with the weapon, expect to be donating your weapon to the violent person.

Body armor slows you down. The police will be using body armor to protect themselves from the weapons you gave to the violent people.

The most dangerous weapon is whatever can hurt you, that you don’t think can hurt you.

Your pen can be used to kill you. Do you get signatures from violent people? If you do, you are asking to be hurt.

You carry a knife. Do you know where it is? You should probably leave it where it is, but do you know what part(s) of you equipment includes a knife?

One of the weapons mentioned is the monitor, because of its size. The older monitors had the defib paddles and these can be great for stopping someone dead in their tracks. Hit the charge button and most people will not come any closer. My boss was left alone with a prisoner, but thought the police were still behind him. When the prisoner came after him and he realized that he was about to have some quality cellmate time, he grabbed the paddles, pressed charge, and said, Come and get it. Defib pads probably do not have the same effect.

There is also the possibility of oxygen therapy. A portable oxygen bottle can be swung very effectively in a confined space. Most regulators can provide a good grip, but even a two-handed grip can allow you to do enough damage to allow you to get away.

Our goal is to be as violent as necessary for anyone attacking us to change their minds and let us go. The police would much rather have us out of the way before they come in with weapons drawn. We will probably be back after the violent people have been disarmed and cuffed. Somebody has to patch up their injuries.

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Do not play with the emergency panic button on your radio, or on the radio of someone from another agency on scene. I used to work with some clowns who would stand beside you and get their thrill for the day by pressing that emergency button on our portable radios. Since we work in EMS, nobody takes this seriously and there was never any punishment. Boys will be boys was the attitude. That is fine – after they have left EMS for the exciting world of fast food order fulfillment.

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Another thing that is mentioned is the foolishness of medical command permission requirements for EMS.

 

A treatment for a true emergency should never require medical command permission.

 

If we get into a situation where we feel the need to use violence, we probably did something wrong.

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Go listen to the podcast.

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If you do not believe me about the knives in our equipment, here are two examples –

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Image credit. For BLS (and ALS), an OB (OBstetrical) kit has a scalpel, which is a knife.

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Image credit. For ALS, many cric (crichothyrotomy) kits contain scalpels.

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Filed Under: Heresy, Mythology, Risk Management, Standing Orders, Standing Orders Podcast

Surviving the Next Shift – Part I

Fri, 16 Dec 2011 06:30:06 -0500 by

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The most recent Standing Orders podcast, the discussion is about what we need to do to go home safely at the end of our shifts.

Should EMS carry firearms?

Brad Buck, Matt Fults, and Dr. Chris Russi D.O. are joined by Eric Dickinson (author, police officer, EMT, and author of the article Tactics to Survive Your Next Shift) and Art Hsieh (of EMS1.com and author of the article On self defense and being a medic).

Of course, I don’t have an opinion on this, but if I did –

There are several things to consider.

How many EMS personnel are shot on calls each year?

How many EMS personnel are stabbed on calls each year?

How many EMS personnel are attacked with any other lethal force on calls each year?

We do not have good data on these.

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Do we include brandishing a weapon in the same category as being in danger of being killed?

No. If the armed person is allowing us to leave and not chasing after us, we leave, contact the police, and there is no reason to believe that we are any less likely to go home safely.

If EMS refuses to leave, that is a problem, but not one that justifies arming EMS. We need to be smarter than the paper target at the firing range and smarter than the stab mannequin. If someone in EMS does not leave, that is not someone I want to have any access to any weapons. The person is dangerous. And that person should not have any access to any drugs.

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Do we train at drawing a gun while starting an IV?

Do we train at drawing a gun while carrying a patient in a stair chair?

Do we train at drawing a gun while carrying a monitor, drug bag, and oxygen bag?

Are we good enough at drawing and firing a weapon in a confined space with coworkers, family members, and maybe a gunman in hiding to ambush us, but a gunman who is stupid enough to let us come in, put down our gear, draw our weapons and shoot before he shoots?

Are we more likely to shoot our coworkers than whatever original threat might have been there?

How much training on clearing a room do we need before we can secure the room so that it is safe for police to enter?

Can we provide patient care and follow Four Rules of Gun Safety?

RULE I: All guns are always loaded.

RULE II: Never let the muzzle cover anything you’re not willing to destroy.

RULE III: Keep your finger off the trigger until your sights are on the target.

RULE IV: Be sure of your target, and what’s beyond it.[1]

In EMS can we be sure of our target and what is beyond our target?

Are we working with the partner who insists that he does not need to practice intubation, because he is that good?

Is this partner really that good at intubation?

Would you let him intubate you?

Is his aim any better with something designed to be more deadly than a laryngoscope and an endotracheal tube?

Where would you feel safest while he is firing?

Behind him?

Beside him?

In front of him (you’ve seen him shoot)?

In the next state?

Behind a bullet proof barrier?

If you answer is Behind him, will you have the opportunity to get behind him before people start shooting?

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[youtube]Mzcgyk62cHU[/youtube]

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Which brings us back to my original questions.

How many EMS personnel are shot on calls each year?

How many EMS personnel are stabbed on calls each year?

How many EMS personnel are attacked with any other lethal force on calls each year?

EMS is a dangerous job.[2]

 

As dangerous as EMS can be, the danger of being shot, or stabbed, or clubbed by a stranger is probably much less than the danger of being shot by your partner.

 

Are we making the environment safer or are we making the environment more dangerous?

Just call in an air strike with high explosives, followed by napalm. A winning combination.

Then there is always the wisdom of the ages – Better to be raped in prison by a dead guy’s friends, than to back away and leave the room to go home at the end of the day, or something like that.

When is the scene safe?

The scene is NEVER safe.

Scene safety is just another EMS myth.

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Go listen to the podcast.

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Continued in Part II.


Original cartoon credit.

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Footnotes:

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[1] maybe some people shouldn’t own guns.
the munchkin wrangler.
Article

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[2] Studies Show Dangers of Working in EMS
Providers should raise awareness about the many hazards of EMS
David Page, MS, NREMT-P
From the November 2011 Issue
Tuesday, November 1, 2011
JEMS.com
Article

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Filed Under: Guns, Heresy, Mythology, Risk Management, Standing Orders

Posteriorly Speaking – A novel use of the pre-hospital 12 lead

Mon, 29 Aug 2011 06:30:53 -0400 by

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On the most recent Standing Orders podcast, EMSSO Episode 6: “Posteriorly Speaking” – A novel use of the pre-hospital 12 lead includes Russell Stine, Brad Buck, Matt Fults, Dr. Chris Russi D.O. and I discuss a case study published by Dr. Russi.

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This is an excellent case study, because it demonstrates a paramedic using his judgment, rather than tryhing to make the patient fit a protocol. This is –

a morbidly obese man (206 kg) with a blood pressure of 104/68 mmHg, a regular pulse of 68 beats/min, and a respiratory rate of 40 breaths/min.[1]

The paramedic, Kevin Steever did a great job of thinking while treating the patient. He did not waste time on scene with this patient, but began moving to the hospital and obtained a posterior 12 lead on the move. The information obtained was useful and relevant to the treatment of this patient.

Here is the timeline for the call. The times I want to draw your attention to EMS-wise is the scene time. 12 minutes may not seem that quick for a scene time with a chest pain patient, but this is a 206 kg patient – that means just over 453+ pounds. This is a case of keeping things moving, but not forgetting about patient care.

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He refused to be placed supine or in the Fowler position (seated) owing to severe back pain and weakness, so he was lifted to the stretcher and transported in the prone position in the ambulance.[1]


Click on the images to make them larger.

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What kind of 12 lead can be expected from a posterior 12 lead?

An atypical 12 lead, but we can still see most of what we are looking for.

What about the size of the patient?

The size and the positioning will probably produce smaller everything on the ECG – including a smaller amount of ST elevation than would be obtained with a standard 12 lead. There is more insulation between the heart and the leads.

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Some people will tell you that you cannot tell anything with a baseline that is not flat, but that is not true. When looking for ST elevation, we tend to ignore the shape of the change at the J point (the point from where ST elevation is measured). There is a noticeable difference between a normal and abnormal 12 lead. That does not mean that this is diagnostic for a STEMI, but it should keep us looking at STEMI as a possibility and encourage involvement of a cardiologist in evaluation of the abnormal ECG.

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A right-sided ED ECG (not shown) did not provide evidence of right ventricular infarct.[1]

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To give an idea of the placement of the electrodes on this patient, they had someone pose for this picture. The leg leads are not on the legs and the arm leads are not on the arms, because the differences are with all of the precordial leads. The arm and leg leads should be placed just as we would place them if the patient were lying on his back.

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Go listen to the whole podcast.

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Footnotes:

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[1] Prehospital diagnosis of ST-segment elevation myocardial infarction using an “all-posterior” 12-lead electrocardiogram.
Russi CS, Myers LA, Kolb LJ, Steever K, Nestler DM, Bjerke MC, White RD, Ting HH.
Prehosp Emerg Care. 2011 Jul-Sep;15(3):410-3. Epub 2011 Apr 4.
PMID: 21463202 [PubMed – in process]

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Filed Under: Assessment, Cardiology, Critical Judgment, Heresy, Standing Orders

What is an Intubation Attempt

Thu, 03 Mar 2011 06:30:51 -0500 by

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The most recent Standing Orders podcast, “A Hot Potato” The Future of Pre-hospital Airway Management, covers a topic that can fill up several podcasts – airway management/intubation.

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I already mentioned the excellent comment on Gold Standards by Dr. Wesley. Another topic mentioned (just over 57 minutes in) is – What makes an intubation attempt?

Several possible criteria are given.

When BVM (Bag Valve Mask) ventilation is stopped.

When the laryngoscope passes the gums.

When the tube passes the gums.

Several different opinions are given.

I think that the important criterion for an intubation attempt is when I approach the patient with the intent to place the tube.

I have interrupted bagging to look in the airway.

I have looked into the airway without having the tube handy, because all I was interested in was – Should I even attempt to tube this patient?

I can look at a patient and be concerned about this being a difficult tube, but should I limit myself to some other form of airway management, just because of doubts? Not always.

I can look at a patient and be concerned about this being a difficult tube, but should I ignore these doubts, just because I cannot come up with an objective reason to avoid intubation? Not always.

Taking a peek is a way to find out more about what I may be dealing with before actually attempting intubation.

In a system that uses RSI (Rapid Sequence Induction/Intubation) or DFI (Drug Facilitated Intubation, or some other acronym for something short of RSI), what do I do after I have knocked out the airway reflexes and respiratory drive and open the airway and find out that my friend the trachea is nowhere to be found?

I am a big fan of using the anatomy to figure out where to place the tube, rather than seeing the cords, but even that may not be helpful. Trauma can rearrange things in the airway. Blood can camouflage things in the airway. Tumors can rearrange things in the airway. Malformations can mean that the airway never looked the way it is supposed to look.

If one of the advantages of being an old-timer is the experience that causes me to want to not just reassess, but assess more thoroughly before committing to intubation, should we be discouraging taking advantage of that experience?

This does complicate the documentation of what an intubation attempt is, but I prefer to encourage judgment on the part of the paramedic, rather than a distinct rule.

Should we trust medics to be honest about intubation attempts?

I hope so, but we should also require much more practice on a much more frequent basis. No that is not redundant. More practice than the minimum needed to satisfy department requirements and doing that amount of practice more often.

As long as we are looking for honesty, we need to admit that we are not as good as we think we are. We each have at least one airway out there that will make us feel as if we have been blindfolded and spun around a few times. If we are not constantly preparing for that possibility, we should not be intubating.

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Filed Under: Airway Management, Critical Judgment, Heresy, Intubation, Standing Orders

You Gave Her 20 Milligrams

Thu, 27 Jan 2011 06:30:12 -0500 by
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There is a great post at StreetWatch on prehospital pain management and one of the obstacles to good patient care.

Peter writes about the way that they finally were able to approve standing orders for pain medicines.

The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.[1]

Peter did not just wait for the doctors to get around to doing what is right for patients. This is pain management. How often do we see doctors going out of their way to do the right thing for the patient? I don’t know what your answer is, but my experience has been that it is not enough.

If I were to use two words to describe the management of pain in EMS, those words would be not enough.

There are some great doctors, who do a lot to improve EMS, but those same doctors are also generally trying to accomplish a dozen different things at once. None of those dozen things may be unimportant, or only a few of them are likely to be unimportant.

We need to do what we can, on our own, to get other doctors to change our protocols to allow us to provide appropriate patient care.

If we continue to rely on whatever the doctors let us do, our patients will continue to be limited to not enough.

Do we want to provide excellent patient care?

Or.

Do we want to keep our heads down and avoid doing anything that might attract attention from an administrator, or from a medical director, or from any doctor at any hospital we might transport to – no matter how much we have to hurt patients do do this?

We can change things, so that we do not have to hurt our patients.

And many prefer not to exercise their imaginations at all. They choose to remain comfortably within the bounds of their own experience, never troubling to wonder how it would feel to have been born other than they are. They can refuse to hear screams or to peer inside cages; they can close their minds and hearts to any suffering that does not touch them personally; they can refuse to know.[2]

There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.

There is no research to support any kind of need for on line medical command permission for any pain medicine.

There is no good reason for us to continually be giving doses that are not enough.

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if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?[1]

This is also important.

Limits on standing orders are not limits on patient care. We can always call medical command for orders to give more.

What’s the worst that can happen?

A doctor tells me that the patient cannot be in pain after that much morphine/fentanyl. Then we transport to the hospital and I get the doctor to come over and assess the patient himself and the doctor learns that a patient can be in a lot of pain after that much morphine/fentanyl. The doctor is then better able to understand what appropriate pain management is.

If the worst that can happen is that the doctors think I care too much about treating pain, is that a bad thing?

It is important to point this out to the doctor. Unless you have some sort of remote medical command system, the doctor is the one who does not believe that the patient is in pain after whatever treatment was given on standing orders.

It is medical command doctor’s job to demonstrate to us that this patient is not still in significant pain.

If this doctor is comfortable denying treatment to this patient, the doctor needs to see what the patient is really like – if we are to change things so that we can provide appropriate pain management.

We should not be disrespectful.

Doctors are generally great about answering questions. When I ask doctors about what is going on with a patient, unless they are extremely busy, they take some time to answer me. By getting doctors to try to explain how patients in severe pain do not actually have severe pain, we should be able to get these doctors to realize that their orders are not enough.

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There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.

There is no research to support any kind of need for on line medical command permission for any pain medicine.

There is no good reason for us to continually be giving doses that are not enough.

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Footnotes:

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[1] You Gave Her 20 Milligrams?!!
StreetWatch
Article

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[2] Text of J.K. Rowling’s speech
‘The Fringe Benefits of Failure, and the Importance of Imagination’
Harvard Commencement 2008
Harvard Gazette
Text

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Filed Under: Critical Judgment, Ethics, Heresy, OLMC Requirements, Pain Management, Research, Standing Orders

OLMC For Good Medics

Fri, 28 Mar 2008 18:37:00 -0400 by


You claim that requiring OLMC (On Line Medical Command) permission to treat patients does not work and actually lowers the quality of medic in a system. You state that Medic X, the example of the dangerous medic, is made worse by OLMC requirements. But, at least, OLMC requirements help the good medics. Let’s call this one Medic A.

Even better, let’s call this example of a good medic – Medic AD – everybody should be able to trust that Medic AD provides excellent care.

OK. Then why wouldn’t OLMC requirements help Medic AD?

You’re asking the wrong question.

The question should be How would OLMC requirements help Medic AD?

Consider it asked.

First – the goal of Quality Control, Quality Improvement, and all other CYA stuff is to improve the quality of the care the patients receive, or to create the appearance of controlling, or improving, or assessing the quality of the care the patients receive.

Focusing QC/QI/CYA on the medic is missing the point – it is about the patient.

How the medic does the job is not the important thing compared to the effect on the patient.

So, how does the need to get permission from OLMC to treat the patient benefit the patient?

The medic, even Medic AD, is not a doctor. He doesn’t know as much as a doctor.

Yes and No.

There are plenty of physicians who just do not understand all areas of emergency medicine.

What ? ! ?

The most obvious example is pain management, such as aggressive fentanyl administration on standing orders.

But these are powerful drugs!

Are there any drugs that a medic carries that are not powerful?

Maybe, but I think I see your point – if all, or almost all, of the drugs a medic uses are powerful, why treat these differently?

That is a good question.

So, what is the answer?

Gosh, I would have to be a psychiatrist – like Dr. Deborah Peel – to be able to diagnose a bunch of physicians without ever having met most of them.

So, you think the problem is psychological?

Not entirely, but there is more than a bit of paranoia about pain medication.

I believe that a lot of this is paranoia and due to a lack of understanding of the medications.

Let me give an example that is typical of what I hear from physicians defending OLMC requirements. The following comments are not at all unusual for conversations I have with medical directors. This written communication just did a wonderful job of bringing so many of them together.

It seems you DO have an opinion, and a sarcastic one at that. But that is beside the point.

Yes, I have an opinion.

Yes, I express it with more than a hint of sarcasm.

You see, you feel comfortable bashing the med control doctors out there because its not YOUR license on the line, and the med control MD hasn’t even seen the patient yet.

So, if I make a mistake the doctor’s license is on the line?

Please, somebody comment about any case where a doctor lost their license because of bad care by a medic. Anyone.

You see what I mean about paranoia?

So, if I make a mistake my license is not on the line?

Why does the doctor need a phone call for permission when it is pain management, but not arrhythmia, or cardiac arrest, or anaphylaxis, or respiratory distress, . . . ?

Paranoia.

Its not YOUR so-called “deep pocket” that the lawyer for the patient who, in so much pain that EMS felt the need to give repeated boluses and later respiratory arrested, are going to go after. While I’m sure in your jurisdiction this doesn’t happen, even in the best of EMS systems there are those few EMS personnel that are either new, inexperienced, or just plain too ignorant to know the dangers of too much analgesia.

Sounds as if I found one of those physicians who is comfortable authorizing medics to treat patients, while knowing that these medics are not safe to treat patients.

OLMC to the rescue!

That will fix everything.

After all, just because they are too stupid to deal with pain management without a magical phone call doesn’t mean they can’t handle life threatening emergencies safely.

If they can’t handle something as simple as pain management – relatively simple if you are well trained – how will they handle a difficult airway?

But, maybe he isn’t the medical director for all of the medics in the system and he just doesn’t trust medics from other organizations.

How many of you out there can truthfully say that you haven’t had at least one case in which a big tough guy had apnea after only a minimum of versed or MSO4?

Again, comments please! Has anyone ever had this happen?

I adjust the dose to match the patient’s weight, underlying health, age, and current condition – then I reassess and determine if more is needed. I keep doing this until side effects discourage further treatment, or I run out of medication (or orders), or the patient is tolerating the pain well. I am always limiting the rate of administration, since most side effects are rate related.

I have never seen this miracle apnea, the doctor describes.

Or one of my most “treasured” memories, the call from EMS who had an unconscious victim and after administering the impaired protocol, called med control for morphine orders because the patient had just “come around and he was screaming in pain”.

Hmm. Unconscious “victim?”

I have addressed appropriate use of naloxone elsewhere.

Maybe a cancer patient treated inappropriately with naloxone?

Point is we are only a voice on the other end of the line sometimes. We cannot see what you see, only hear what you have to tell us.

For a moment, just for a moment, there is reality.

Sometimes we know exactly who you are and what you are all about and we can trust your judgement.

Right here, the doctor states that he does not have a problem with Medic AD using his judgment.

He doesn’t go as far as to say that Medic AD would not benefit from OLMC requirements, but he does suggest that he would automatically give Medic AD the orders being requested.

So, what would be the point of having Medic AD call OLMC before allowing the patient to receive treatment?

OLMC can then hear a familiar, trusted voice and relax.

It is all about the paranoia.

But other times you are simply “that voice over the radio”, the volunteer EMS system from “BFE”, the requested order from an RN who runs into the trauma room asking for morphine for EMS while you are trying to intubate someone,

Doesn’t that sound like a system that works well?

Would you like to be a patient there?

and sometimes, albeit rarely, you are simply another EMS provider who likes to give morphine to everyone, regardless of chief complaint.

This isn’t even using the lowest common denominator to justify OLMC requirements.

This is a medic who makes Medic X look good.

So, why is this medic still working?

OLMC requirements allow medical directors to justify keeping this worse-than-Medic X on the street and pushing drugs.

OLMC requirements endanger patients.

Requiring Medic AD to call OLMC to ask for permission to do what he knows how to do is only interrupting assessment and treatment, delaying patient care, and creating the possibility that an OLMC physician does not give orders that are appropriate for the patient.

The objections from most doctors, who are supportive of OLMC requirements, seem to be most focused on the physician’s ability to control things.

The problem with OLMC requirements is that they are barriers to patient care.

This is about patient care, not physicians’ need for control.

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

Fun with explosives – NTG.

By Rogue Medic
Filed Under: Critical Judgment, Dr. Deborah Peel, Fentanyl, Heresy, Medic AD, Medic X, Morphine, Naloxone, NTG, OLMC Requirements, Pain Management, Physician Oversight, Research, Standing Orders

OLMC (On Line Medical Command) Requirements Delenda Est

Wed, 12 Mar 2008 17:38:00 -0400 by

Carthago delenda est.

The secret to appropriate drug dosing is titration. Should a medic who cannot be trusted to titrate opioids, sedatives, and other drugs be trusted to provide ALS care?

“Wait. To the OLMC Batphone, Robin. My Batcompetence will grow 3 sizes on the phone, just as the Grinch’s heart did on Christmas Day.”

Curiously, as the Batmedic completes this OLMC order, his competence disappears like Brigadoon, until he is on the Batphone with OLMC, again – maybe still with the same patient.

When someone is talking on the phone while driving a car, we consider this a dangerous distraction, yet when the same interruption is made in the assessment and treatment of a patient the interruption is expected to have the opposite effect.

Perhaps we should hang up and drive.

Perhaps we should hang up and assess the patient.

Perhaps we should hang up and treat the patient.

Some people learn and develop their abilities. Why is EMS designed to prevent medics from using that improvement in ability to help the patient?

You learn what you do. If you do not learn from this repetition, you are defective and need to be replaced with someone not prone to continually repeating the same mistakes.

The change from OLMC requirements to standing orders has been progressing, like the frog climbing out of the well in the notorious math problem. A little bit of progress, then some recidivism, followed by many repetitions. The progress does exceed the backsliding, but not by a lot.

Medics used to have to call OLMC to get permission to start IVs, then medical directors realized that medics could be taught to make these decisions and we had some early standing orders.

Medics used to have to call OLMC to get permission to give any drug, e.g. “push one amp of the silver box.” Then medics were introduced to pharmacology. After a while, medical directors realized that medics could be taught to make some of these decisions and standing orders were expanded.

There is no demon in opioids or benzodiazepines and these will eventually be administered almost universally on standing orders; administered in doses that would make some of the physicians today blush; administered with few limitations on the conditions to be treated. This is just a predictable continuation of what is already happening. Some choose not to see it.

There will always be places that do not go along, but overwhelmingly the move will be toward more medic autonomy. Not complete autonomy, but changing the physician oversight from the mysticism of OLMC requirements to genuine oversight. Playing whisper-down-the-line with an OLMC physician is oversight in name only. It’s result is an arbitrary denial of care to some patients, a denial of appropriate care to other patients, and permission for only some patients to receive appropriate care. Probably not exactly what Hippocrates had in mind.

There are already places that have the aggressive standing orders that I describe.

It may take ten or twenty years for the rest of the country to catch up.

What is different about those places?

Are the medics with aggressive standing orders killing a greater percentage of their patients than those with OLMC requirements?

More and more medics are becoming doctors and they understand that much can be done for the patient before the patient arrives at the hospital. They understand that making the patient wait until the patient arrives at the hospital may not be consistent with good patient care. Changes in protocols probably do not require any change in the medic scope of practice. This will require a change in the amount and type of standing orders and will require a change to a method of physician oversight that really works.

As increasing numbers of medics become doctors there will be more of a realization that little, if anything, that a medic does is improved by abbreviating the patient assessment and abbreviating the patient treatment to give a hasty report of this interrupted assessment to the OLMC physician.

EMS education needs to be improved significantly, but much of this can be done through remediation. Those who cannot be remediated can be demoted, terminated, or transferred to systems that just don’t get it. Or they could work for the sanitation department – it seems to pay better, has lower quality standards, yet is more important for public health.

The systems that have a bunch of medics showing up on every call will have much winnowing to do. Maintaining skills under those circumstances is impractical. We have been acting as if quantity solves everything. Increasing the quantity of medics makes maintaining the same quality much more difficult. OLMC requirements do not change that.

If the medical directors do not take the lead in directing change in EMS the politicians will. If you want to see that future, just look for the city with the highest concentration of politicians and see if it’s EMS system sets a good example.

The politicians are focused on mainly response times.

If you believe that EMS is primarily a public safety business, then response times may be critically important to you.

If you believe that EMS is primarily a medical business, then taking a little bit longer to get good care to the patient may be critically important to you.

The more we understand about EMS the more we realize that rapid response times are not anywhere near as important as good patient care. Faster response times and scoop and run medical care are not the way to maintain the quality of care or to improve the quality of care.

EMS is presented with many problems.

On Monday, Peter Canning wrote a post about the problems in EMS. Men’s Health: Does EMS Need to Call 911? His comments give you a perspective on many of the problems EMS faces that I do not intend to address.

My other posts on OLMC requirements and Medic X are:

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.

By Rogue Medic
Filed Under: Heresy, NTG, OLMC Requirements, Opioid, Pain Management, Physician Oversight, Standing Orders