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

- Rogue Medic

More on Lasix in EMS

Tue, 28 Sep 2010 06:24:51 -0400 by
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Some people may think that I am crazy for claiming that we should not use Lasix (furosemide). For a slightly different perspective, here is an emergency physician describing the appropriate treatment of unstable hypertensive acute pulmonary edema patients.

EMCrit is an excellent podcast blog with nice short podcasts. More important than being nice and short, the podcasts are science-based and address many of the issues that EMS treats. The first podcast from EMCrit is 10:33.

How important is furosemide?

Is the furosemide drug shortage important?

So, the first thing you do is get your Lasix . . .

Only

1:50

into

the

podcast.

–

OK,

maybe

I

was

thinking

of

a

different

podcast.

–

Maybe

I

was

wrong.

So, the first thing you do is get your Lasix and you throw it in the trash.

No.

I was right.

This is the podcast for me.

It’s not going to help you and it’s very potentially going to hurt you. No Lasix in these patients. Now, I’m sure your EMS providers have already given it. Well, that’s just fine, but you don’t have to exacerbate the problem. Most of these patients will end up volume depleted, not volume overloaded when you look at their intravascular space. You’re probably going to end up giving fluid to these patients, not trying to diurese them. The problem is not fluid overload.

Most of these patients will end up volume depleted,

Go listen.

10 minutes 33 seconds of somebody who understands CHF(Congestive Heart Failure)/ADHF (Acute Decompensated Heart Failure). And he isn’t subtle. 🙂

–

PS – Dr. Weingart, why not try to get those of us in EMS to improve our care of these patients, too?

High-dose NTG and CPAP are also treatments that can be given by EMS. In some places, these are given by EMS.

With sublingual NTG (NiTroGlycerin) we probably cannot give too much to these patients.

We should be using NTG by IV in EMS. In Pennsylvania, IV NTG is an optional drug for 911 services.

–

EMCrit’s page of references supporting this aggressive approach.

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Updated 02/08/11 to reflect the new blog address for EMCrit. http://emcrit.org/ The old links did not redirect appropriately.

.

Filed Under: Critical Judgment, Drug Shortages, EMCrit, Heresy, Lasix, NTG Tagged With: , ,

EMS Garage Rant – Prehospital Pain Management

Fri, 24 Sep 2010 14:20:06 -0400 by

On BYOT: EMS Garage Episode 105 we discussed 2 things that I wanted to rant about – here is some of the second rant.

The second topic was prehospital pain management. I think that Chris Montera saw my post A Prehospital Pain Management Discussion at the NAEMSP Site and wanted to discuss it. There is a lot of excellent material at the NAEMSP discussion site.

There are a lot of ideas discussed on the podcast.

Listen to it.

Why are there so many doctors discouraging appropriate patient care?

What can we do to convince them that prehospital pain management is safe, effective, and necessary?

This is not directed at Chris, since he is aggressive with pain management. He was only repeating one of the arguments against aggressive prehospital pain management – actually, it is an argument against all prehospital pain management.

I scared Chris a little bit with my response, when he repeated what some people claim about pain – Pain never killed anyone!

If anyone wishes to provide some evidence, please do so.

If there is no evidence to support this claim, then prove it. Let me deliver some extreme pain to you, just for a while. I won’t break anything or burn anything, but I will see if I can cause enough pain to kill you.

If Pain never killed anyone!, it won’t kill you either.

What have you got to lose?

You will have experienced some memorable pain. You may have nightmares and other PTSD (Post Traumatic Stress Disorder) symptoms, but since you have already made it clear that you don’t take pain seriously, why should you mind?

We’ll strap you to a chair, so that you don’t injure yourself by thrashing around. Safety first. We’ll hook you up to a monitor to see just how much stress your body is experiencing. We’ll even get a medical director, who believes in Mother-May-I protocols, to supervise. What could be safer – if you are right?

Pain is not dangerous, this is completely safe – Right?

If pain does not need to be treated, then there is no medical problem created by just causing a bit of pain – OK – a lot of pain. Or is pain dangerous?

–

Pain never killed anyone!

I dare you to prove to me.

Put up or shut up.

I can be reached at the email below or in the comments.

roguemedicblog@gmail.com

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Filed Under: Critical Judgment, EMS Garage, Heresy, OLMC Requirements, Pain Management Tagged With: , , , ,

EMS Garage Rant – Kenneth Stokes

Fri, 24 Sep 2010 13:17:03 -0400 by

On BYOT: EMS Garage Episode 105 we discussed 2 things that I wanted to rant about – and rant I did.

The first was the foolish suggestion that EMS should not wait for police to declare an active shooting scene under control before EMS enters. I wrote a bit about the background of City Councilman Kenneth Stokes in Mississippi Councilman Kenneth Stokes is Reckless and Irresponsible.

City Councilman Kenneth Stokes claims that it took over 20 minutes for EMS to get on scene because they were waiting for police. If that is the case, then maybe the problem is with the availability of police (hire more unless you are trying for the highest unsolved homicide rate in the country), not with EMS.

The odd thing is that the claim by City Councilman Kenneth Stokes does not agree with the dispatch times. 23 minutes per Stokes vs. less than 7 1/2 minutes from the EMS dispatch data.

Trust the dispatch data recorded at the time or trust a guy being investigated for repeated abuses while in office?

Maybe City Councilman Kenneth Stokes is honestly an idiot, but the articles I found about him suggest that there is nothing honest about him. If you feel that he should be given the benefit of the doubt, here is the way to reach him.

On Dave Statter’s blog, he wrote this in the comments, which is not normally where Fire and EMS go to sing Kumbaya together.

dave statter says

Kenneth Stokes is my hero. He has been successful where I have been a failure. In fact, I plan to nominate Mr. Stokes for the Nobel Peace Prize. Send him to the Middle East, for he has been able to inspire peace and harmony where no one else has, the STATter911.com mailbag. Finally something we can all agree on and not tear each other apart (just check the recent PGFD video comments).
For that Mr. Stokes, you will always have my gratitude.

Statter

on September 22, 2010 @ 3:12 pm.

The office of City Councilman Kenneth Stokes contact information from the Jackson, Mississippi government web page.

http://www.city.jackson.ms.us/government/citycouncil/

http://www.city.jackson.ms.us/government/ward3
Term Expires:
July 6, 2012

Committees:
Planning (Chair)
Rules (Vice-Chair)
Budget
Legislative
Water/Sewer Ad-Hoc

Mailing Address:
Post Office Box 17
219 South President Street
Jackson, Mississippi 39205-0017

Telephone:
(601) 960-1090

FAX:
(601) 960-1032

Email Address:
kstokes@city.jackson.ms.us

Administration:
Ms. Magnum

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Filed Under: Critical Judgment, EMS Garage, Fraud, Heresy Tagged With: , ,

The Real Gold Standard Of Airway Management at 510Medic

Fri, 24 Sep 2010 06:30:31 -0400 by
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510Medic has a nice post about The Real Gold Standard Of Airway Management.

The way he started out, I expected a riff on Nixon taking us off the Gold Standard – $35 an ounce due to price control then – now just under $1,300 an ounce. Last week, there was this – Gold Bet: $2500 Over/Under 2012. Even I am not cynical enough to take the over on that.

The Gold Standard 510Medic is writing about should be just as dead as the monetary gold standard.

There are some similarities. Both are inflexible and artificial limitations on change.

The idea that intubation is a gold standard only demonstrates an inability to adapt to what is best for the patient.

The gold standard is supposed to mean what is best for the patient, but does it?

In the emergency department, cardiac arrest patients are only intubated in the old fashioned Bretton Woods style of treatment. I expect the new guidelines to continue to de-emphasize intubation as a method of airway management.

In the operating room, intubation has become much less common.

If the emergency physicians and anesthesiologists are switching to more appropriate airway management methods, why isn’t EMS?

Because we are EMS. It sometimes seems as if you have to kick us in the head to get us to use our heads for anything.

As with helicopter abuse, we are not doing what is best for patients.

As with restrictive protocols, we are not doing what is best for patients.

As with on line medical command permission requirements, we are not doing what is best for patients.

As with cardiac arrest drugs, we are not doing what is best for patients.

As with spinal immobilization, we are not doing what is best for patients.

As with restrictions on prehospital pain management, we are not doing what is best for patients.

Are we surprised that, when it comes to airway management, we are not doing what is best for patients?

Let’s put an end to the Gold Standard terminology.

Airway management is about Ventilation – not Intubation.

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Filed Under: Critical Judgment, Heresy Tagged With: , ,

Appropriate Morphine Dosing for Opioid Tolerant Patients

Wed, 22 Sep 2010 22:20:40 -0400 by
What do we do, when treating a patient already taking opioids? When the patient is already taking a large dose of an opioid and has a valid prescription for the doses of opioid being taken?

Remember that there is no maximum dose for morphine. There is no maximum dose for any opioid – as long as there are no adverse effects, such as depressed respirations, altered mental status, hypotension, or bradycardia.

What do we do when this patient has something like a femur fracture that produces severe pain?

This patient is opioid tolerant, so the standard doses of opioid are unlikely to produce a satisfactory effect. By standard doses, I mean doses that would be appropriate for a patient who is not currently taking opioids. That would be a starting dose of 0.05 mg/kg morphine to 0.1 mg/kg morphine – repeated as necessary until the pain is managed to the patient’s satisfaction or until side effects interfere with treatment.

The patient will probably receive more relief by releasing some flatulence than he will from 2 mg morphine. The flatulence may even provide more benefit than 10 mg morphine for an opioid tolerant patient.

Standard doses are not going to work, so do we just ignore this patient’s pain?

Do we tell this patient that our medical director does not trust us to give larger doses of morphine/fentanyl/hydromorphone than standard, because the medical director either has not really considered this possibility or doesn’t think that patients, who are legally prescribed high doses of opioids, deserve to have their severe pain treated effectively. Or maybe the medical director is just so irrationally afraid of opioid medications that he is not interested in understanding opioid tolerance.

It isn’t necessarily the medical director who is the obstacle to treatment. I know of plenty of medics who would not even start treatment of this patient’s pain. Maybe out of fear of causing respiratory depression. Maybe out of fear of causing addiction, in which case they really need to work on their response time, because it is a bit late to be considering addiction or tolerance.

What do you think are the chances of causing dangerous respiratory depression for this patient:

With 10 mg morphine?

Low Medium High

With 20 mg morphine?

Low Medium High

With 30 mg morphine?

Low Medium High

With 40 mg morphine?

Low Medium High

With 50 mg morphine?

Low Medium High

With 60 mg morphine?

Low Medium High

With 70 mg morphine?

Low Medium High

With 80 mg morphine?

Low Medium High

With 90 mg morphine?

Low Medium High

With 100 mg morphine?

Low Medium High

Why?

What would be considered dangerous respiratory depression for this patient?

Why?

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Filed Under: Critical Judgment, Heresy Tagged With: , , ,

A Prehospital Pain Management Discussion at the NAEMSP Site

Tue, 21 Sep 2010 23:27:41 -0400 by

Also posted over at Paramedicine 101. Go check it out at the new location at EMS Blogs.

–

I would have also posted this at Research Blogging, but this discussion is not the kind of research blog post that they are looking for.

Well, what needs to be said about prehospital pain management?

Drug Seekers.

Fentanyl vs. Morphine.

Fractures dispatched BLS vs. ALS.

Standing orders vs. Mother-May-I?

Nitrous oxide, etomidate, ketamine, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), relaxation, ice, acupressure, et cetera. If it might be used by EMS for pain, it is fair game for the discussion.

Legal issues – when will the lawyers start going after medical directors/medical command physicians for withholding appropriate treatment/neglect/malpractice?

Pediatric Pain Management by EMS.

And more.

There is a discussion of Prehospital Pain Management on the NAEMSP (National Association of EMS Physicians) discussion site on Google Groups. NAEMSP Dialog. Anyone can read the discussions. They are there to be a kind of reference for people working in EMS. This is what some of the top doctors, administrators, educators, street providers, and even the occasional blogger have to say on a topic.

Here is a summary of the rules on participation:

Trying to facilitate a higher level of discourse on contemporary issues in EMS. Most of the list members are physicians, managers, and educators – along with street level EMTs and paramedics with an interest in academics and policy issues.

Everyone who wants to join the list has to provide their name and affiliation; all posts are reviewed by a moderator before being allowed to circulate; and all posts must be ‘signed’. There is some descriptive language about the Dialog on the home page of the Google Group (http://groups.google.com/group/naemsp-dialog).

Go read. If you want to comment, sign up, but don’t try to push the envelope on what you can get away with. The envelope has already been pushed.

Some familiar bloggers are also participating – Adam Thompson, EMT – P from Paramedicine 101, Tom Bouthillet from Prehospital 12 Lead ECG, Mark Glencorse from Medic999, and a couple of doctors from the EMS Garage – Dr. Bryan Bledsoe and Dr. Keith Wesley. Some of the other top medical directors in the country are participating as well.

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Filed Under: Critical Judgment, EMS Garage, Heresy, Ketamine, OLMC Requirements, Pain Management, Paramedicine 101 Tagged With: , , ,

First Few Moments – Mechanism Of Injury or Idiocy

Mon, 20 Sep 2010 19:26:35 -0400 by

On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.

Mechanism of Injury or Idiocy?

Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.

Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.

–

One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.

Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently transport the patient.

Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient and manage the airway.

50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.

Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?

The alternative is to limit EMS to effective treatments.

Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

It is important to train/educate EMS well enough to be able to provide this competent assessment.

It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.

Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess and manage the patient’s airway.

Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?

The alternative is to have competent EMS.

–

The answer seems to be that we need to improve EMS and EMS education – a lot.

Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.

Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.

If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.

If we do not understand what is going on medically with the patient, we should not be making patient care decisions.

Calling for a helicopter because I am too stupid to assess my patient is bad medicine.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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Filed Under: Critical Judgment, EMS Garage, Ethics, First Few Moments, Fraud, Helicopters, Heresy Tagged With: , , , , ,

Merit Badge Courses: Who Benefits? 1

Thu, 16 Sep 2010 23:24:25 -0400 by
At EP Monthly, there is an interesting article – Merit Badge Courses: Who Benefits?

I will address this in several parts. First is the quality of the merit badge courses.

Why do we object?
After years of residency training and days of grueling written and oral boards, many EPs find ACLS and BLS to be kindergarten-level courses. The classes address an aspect of clinical practice that we handle on an almost daily basis. When somebody from The Joint Commission asks for your updated ACLS card, but ignores your board certification, it is at very least out of order in importance and frankly insulting to the effort required to obtain the latter. Certainly, ABEM and AAEM agree on this and both organizations have position statements indicating that ACLS or ATLS certification should not be required of board certified Emergency Physicians.

I disagree about the kindergarten-level. That depends on the instructor. If all you are getting is a memorization of guidelines, then it is kindergarten-level, but that is not the way ACLS should be.

That is not the way I have taught ACLS. I certainly did not fit in at every hospital where I taught, but I fit in very well at others. The administrator of the program has a lot to do with that.

If you read much of my blog, you should realize that you would leave my course with more questions than when you arrived at the ACLS class. That is the way it should be. We are faced with guidelines based on expert opinions of inconclusive research, or even based on expert opinion without research.

Anyone who tells you that there are more than a handful of definite answers to be drawn from the research is lying to you. Or they don’t know what they are talking about.

The guidelines are based on thousands of studies.

A lot are animal studies, which are important, but more often than not do not work out as well when applied to real human patients. One of the obvious reasons is that the human patient has a cardiac arrest due to underlying medical conditions, that are not easily recreated in a mouse, pig, or dog. The surrogate arrests we create in animals are no more relevant than the surrogate endpoints that are promoted as answering questions about survival.

A cardiac arrest due to ligation of an otherwise healthy coronary artery in a pig is not the same as a cardiac arrest due to an occlusion of a diseased coronary artery in a human.

The Return Of Spontaneous Circulation (ROSC) is not any better than the animal studies at indicating that a treatment will improve survival to discharge.

Both are necessary intermediate steps in arriving at a treatment that works.

–

What we know:

1. Chest compressions are important.

2. Fast compressions and deep compressions.

3. Interruptions to compressions are bad.

4. Defibrillation is important.

5. Therapeutic hypothermia also seems to be good.

–

If I try to tell you that anything more than that is definite, I am telling a lie.

We may even have to revise some of what I have listed as definite.

Revise, not remove.

We may have to revise something, but I don’t think we will have to remove any of it.

Some people will tell you about information that goes well beyond this. They will present it as certain.

They will be either lying, ignorant, or both.

Does epinephrine improve survival to discharge?

We need much larger placebo controlled studies to answer that question. If can’t tell without these extremely large studies to show an effect, then the effect is not large.

–

Why are we forcing the use of epinephrine?

If we are doing something, we convince ourselves that we are helping.

It is hard to have a bunch of us stand around and just watch someone doing chest compressions, especially if we are trained to give drugs and to do invasive procedures.

We can’t have doctors, nurses, and medics not using their ALS (Advanced Life Support) skills. There has to be something we can do that is better than what a 70 year old spouse can do. There has to be. Something other than those sweaty compressions – that’s what techs are for.

F*&# the research – I’m doing something! Give me an epi!

Look! A pulse! I did it!

–

If you feel like you are taking a kindergarten course, you should look at the way instructors are taught, hired, and paid.

Most of the ACLS teaching I have done has been for less per hour than what I would make working as a paramedic. Not only that, but it is for fewer hours. Never mind overtime, this is less than straight time. This is great for a single parent, which is a big part of why I did so much teaching, but it is not a way to get people who are not limited by daycare hours (or school hours). If I am making less per hour as a medic, what incentive is there for someone who makes more than a medic?

How many residents are mandated to teach ACLS as part of their program requirements? How many of them are any good at teaching in a classroom? If you want a kindergarten environment, put a mandated resident, with no interest in teaching, in front of a class with a PowerPoint. Ativan does more for your memory.

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Filed Under: Critical Judgment, Heresy Tagged With: , ,
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