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

- Rogue Medic

Flipping the Patient the Bird

There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.

vs.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.

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The Bird is the Word – Coma Toast

At Coma Toast, there is a thorough thrashing of the EMS addiction to flying uninjured patients just because we can. The Bird is the Word.

Now, there are a lot of arguments out there about the use of medical helicopters. It’s in the dispatch criteria….it’s in the protocols…..patients can get to the hospital faster. However, most of these arguments can be debunked by actually looking at patient statistics of those transported by ground ambulances verses those who were flown.

Another problem with helicopter abuse, perhaps the most deadly abuse of the helicopter, is to excuse the employment of medics and basic EMTs who cannot competently assess patients.

We don’t need to know what is going on – just put them in a helicopter.

We don’t need to be able to treat patients – we only need to be able to immobilize, get 2 large bore IVs, and hook up the ECG before the helicopter arrives. And don’t forget the non-rebreather mask with 25 liters per minute of oxygen flow.

Why think about patient care, when we have already decided what we are going to do to the patient – before we even see the patient?

We say – Look! The patient we flew the day before yesterday is driving a new car today. The helicopter saved him! We are so awesome!

No.

We should hang our heads in shame at flying uninjured people.

If we overloaded the cath lab with patients who do not have STEMIs, we would be the laughing stocks of EMS.

But put a patient with a bruised fender and a mangled bumper in a helicopter and nobody will criticize a thing.

A large percentage of the people we inflict perform needle decompression on, do not have even simple pneumothoraces, yet we treat them for life threatening tension pneumothoraces. We even document the rush of air escaping from the needle that never even reached the lung.

The needle wasn’t in the lung, so where did the air come from? A brain fart?

We immobilize even the witnesses to car crashes, because we are that bad at assessment.

We do a pathetic job of educating people to perform trauma assessment (of patients – not cars) and we do not remediate those who regularly demonstrate incompetence at trauma assessment. Maybe we need a White Paper on the abuse of patients by EMS.

We justify these treatment errors that injure and kill patients with, You can’t be too safe!

Injuring patients with incompetence is safe?

Killing patients with incompetence is safe?

Compared to what?

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EMS Garage Rant – Prehospital Pain Management


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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EMS Garage Rant – Kenneth Stokes


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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Appropriate Morphine Dosing for Opioid Tolerant Patients

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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First Few Moments – Mechanism Of Injury or Idiocy


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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Too Much Information and Risk Management

Steve Whitehead discusses the problem of Too Much Information the problem of people avoiding learning by claiming that they are being presented with Too Much Information.

He gives 3 examples:

1) We like to keep the bar low.

2) We fear the limitless and undefined.

3) We are inherently insecure.

These are all genuine problems.

I do not want to be treated by someone who embodies these three problems.

I know too many people who do make these mistakes and they are scary.

The people, who complain about Too Much Information, let’s call them TMIs, for the purposes of this post.

If the topic were TMI‘s favorite team, he would hardly be complaining that there is Too Much Information.

If the topic were TMI‘s favorite centerfold, he would hardly be complaining that there is Too Much Information.

The problem seems to be that TMI doesn’t care enough to obtain more information. Why have such a person in a job that involves caring.

A different problem with Too Much Information is in the ability to prioritize that information. This is not deciding that there is Too Much Information, rather determining how much information is important right now.

When we are on scene with a stable patient, how much information do we obtain before transport? What if the only source of the information is a family member – someone who cannot accompany the patient?

How much is too little information?

How much is enough information?

How much is too much information?

Are there other ways of obtaining the information? Can a nurse call from the hospital to gather more information after the patient is in the ED (Emergency Department)? How long do we delay transport to obtain more information?

Part of this can be dealt with by asking questions in a way to best obtain the most relevant information. However, we don’t always know what that way is. Which of the patient’s chronic illnesses – each with repeated complications that end with ED admissions – which of these do we not obtain a thorough history about with this stable patient?

We can come up with all sorts of BS excuses for not obtaining information, such as the need to get back in service quickly, but should we do an incompetent job just to keep to some imaginary schedule?

What about when we are on scene with an unstable patient? A lot of the information we would like is only available on scene. What do we do?

How much is too little information?

How much is enough information?

How much is too much information?

Since the patient is unstable, the option of camping out until we have all of the information we would like, is not one that will lead to the survival of the patient. We need to make certain decisions about how much is enough information right now.

What will a TMI do in that situation?

How would a TMI possibly understand?

TMIs are not understanding people.

TMIs are the people who should be working at jobs that do not require any decision making skill or any understanding of risk management, because TMIs are dangerous when permitted these responsibilities.

On what do TMIs base their decisions, if they have intentionally limited their preparation for the job?

Risk management has a lot to do with making decisions based on limited information.

Risk management requires an understanding of what is enough information given the limitations of the job.

Risk management for EMS involves working with limited equipment. limited personnel, and limited information.

Risk management for EMS cannot work with arbitrary traditional restrictions on the ability to exercise critical judgment, not if we are interested in doing what is best for the patient.

Some of us believe in luck.

Some of us pray to luck.

I prefer to make my own luck.

How do we make our own luck?

We don’t just prepare, we over-prepare.

That is luck?

No. That is preparation. That is having more than the lowest common denominator amount of information.

We do not know what we will be presented with on each call, so how do we know which information we will not need? How would we know, ahead of time, what is not necessary – what is too much?

Some people like using the 5 Ps to describe how to approach this.

Proper Planning Prevents Poor Performance.

Some extend it to 6 Ps.

Proper Planning Prevents Piss Poor Performance.

Either way, you get the idea. This is completely incompatible with claiming, Oh no. That is Too Much Information.

How do we know which information we will not need?

We don’t.

Only a fool would believe that he is smart enough to know what information he does not need, when he is still learning. Because of this prejudice, some never learn.

The problem seems to be that TMI doesn’t care enough to obtain more information. Why have such a person in a job that involves caring.

How do we know what we need to know?

Can someone, especially someone who intentionally limits the information he has, ever know?

From the quotes I have in the sidebar –

In the fields of observation chance favors only the prepared mind. – Louis Pasteur.

What these TMIs are saying is that they are too good to prepare to take care of patients, because the patients are not important to the TMIs.

EMS is not about the First Responder.

EMS is not about the EMT.

EMS is not about the Medic.

EMS is not about the Nurse.

EMS is not about the Doctor.

EMS is about the patient.

Competent EMS personnel insist on being prepared with more than enough information, in order to be best prepared for as much as is practical.

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A Conversation on Mechanism of Injury


I was talking with one of the long time, weekend, night shift nurses. The people I count on to do what is right for the patient, because the administrators are not around.

Well, I mentioned in passing – I thought it was going to be just in passing – about the recent comment kerfuffle about MOI (Mechanism Of Injury criteria for trauma triage, or just mechanism). This is the assessment skill substitute for assessment that people use as a justification for flying uninjured patients in helicopters.

As if that is safe.

All of a sudden, the nurse started a little tirade about a medic who brought in a patient to this non-trauma center ED (Emergency Department) because he did not bother to report on the MOI when calling for medical command destination decision.

I do not remember what the mechanism was, but it was something vehicular and must have sounded bad, because that’s what MOI means –

The 911 call sounds bad!

or

That dent looks like it is going to cost a lot to repair!.

That has nothing to do with the patient, except that the mechanism suggests things to be more careful in assessing for.

This is all that mechanism means.

You might want to pay extra attention to these things suggested by mechanism.

Mechanism is not assessment.

Mechanism is the equivalent of stereotype, or prejudice, or bias, or racism.

Mechanism is not about understanding.

Mechanism is a shortcut that encourages ignorance.

Mechanism is just a superficial substitute for a patient assessment.

Mechanism is for those who cannot assess real patients.

Anyway, being the blunt person that I am, I interrupted the nurse’s rant, because my shift is only 12 hours long and her rant was looking like a filibuster. I didn’t even have to ask the obvious question about what a simple assessment showed, because the nurse mentioned over a dozen rib fractures and a flail chest.

Clearly, this is not a patient who should have been transported to the local ED with several trauma centers less than 20 minutes away by ground. This is a case, if reported accurately, of an incompetent medic. And not just a little bit incompetent.

Back to mechanism.

What does mechanism add to the assessment of a patient with a flail chest?

A flail chest is a portion of the ribs acting like a trap door. The ribs are broken in so many places that there is no resistance to pressure, except when the patient exhales.

Breathing is not very complicated. The diaphragm creates negative pressure. On inhalation, the diaphragm pulls away from the chest and the accessory muscles also cause the chest to expand. This sucks air in.

On exhalation, the diaphragm and accessory muscles relax and create pressure. This forces air out.

With a flail chest segment, breathing mechanics are mostly normal for everything except the flail segment. The rest of the chest is creating a pressure difference that moves the air. As long as the ribs are intact, they will all move together. When there is a flail segment (2, or more, ribs broken in 2, or more, places is the textbook definition) that broken part of the ribs will move the opposite direction from the rest of the ribs. The flail segment will move in the opposite direction from the intact part of the ribs.

When the ribs are expanding out to create negative pressure, the negative pressure is pulling air into the chest, but the negative pressure is also pulling the broken ribs inward.

When the ribs are relaxing and creating positive pressure, the positive pressure is  forcing the air out of the chest, but the positive pressure is also forcing the broken ribs outward.

This is one of those assessment findings that is hard to miss. The patient may be trying to keep you from assessing that part of the chest, because . . . well . . . it hurts. It doesn’t hurt a little bit. This isn’t just a hairline fracture that hurts a lot. This is a bunch of broken bones that are moving around – a lot – with every bit of breathing.

Not – It only hurts when I laugh.

Not – It only hurts when I move.

But – It only hurts when I breathe.

The normal response to the first two is pretty easy. If it hurts, when you do that, don’t do that.

That doesn’t work very well for breathing. Go ahead. See how long you can hold your breath. Now take a hammer and break a bunch of your ribs. Now, how long can you hold your breath? Not the same thing, at all.

The only time that a flail chest should be missed is when the ribs are not completely broken, in which case, it is not really a flail chest, except for the textbook definition of 2, or more, ribs broken in 2, or more, places. That is the textbook definition. The textbook definition should include the paradoxical movement. Paradoxical movement is what everyone is supposed to be looking for.

Paradoxical means the opposite of what we would ordinarily expect. We would ordinarily expect the ribs to all move together. With a flail chest, the flail segment is moving in the opposite direction from the rest of the ribs.

If the patient is conscious and not disoriented, the pain should be a clear clue to examine the part of the chest being protected. The patient’s arm may act as an excellent splint. Expect to use a lot of morphine/fentanyl/Dialudid. Pain will interfere with breathing more than the opioids will. Fentanyl is less likely to affect cardiac output (blood pressure), so that is my preference.

If people are missing flail chest, we need to ask Why?

We don’t need to complain that the person is ignoring mechanism.

Focusing on mechanism just ignores everything we understand about assessment.

Or do we just not understand assessment?

Mechanism Of Injury criteria for trauma triage encourage incompetence.

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