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

- Rogue Medic

New Series of Rants follow up

Bostonian in NY said…

Wow, that’s a sad oversight by PMS . . . someone should revoke his ACLS privileges.

Doesn’t hemorrhage control fall under C of your ABC’s?

Yes. Hemorrhage control does fall under the C of ABCs. Yes, hemorrhage control is the thing that would have provided this patient with the best chance of watching Casper on TV, rather than playing Casper in the ED.

Maybe someone should never have allowed PMS to have ALS (Advanced Life Support) privileges.[1]

This is one part of the problem with the way that risk is managed in EMS.

A. OLMC (On Line Medical Command). Call for permission from someone who can only rely on you for assessment. If you know what you are doing, is the call necessary? If you don’t know what you are doing, should the doctor even take the call? The doctor cannot trust the information from someone who does not have a clue. Rather than get rid of the problem medics, this facade is maintained.

B. Chart review. By placing the protocol along side the chart and comparing to see if the chart contains all of the items in the protocol. The way many ALS protocols are written, the BLS (Basic Life Support) is skipped over to get to the ALS. There is a mention of following BLS protocols, refer to appropriate BLS protocol, but they are in a separate binder and that stuff is not used to evaluate paramedics, so why bother? It is no surprise what some medics have learned from this –

Skip over the BLS, because paramedics do ALS.

Paramedics are too good to waste their time on BLS.

Whether someone was applying direct pressure is difficult to confirm from the chart. I can write that I was alone in the back, applied direct pressure, started 2 large bore IVs, and intubated the patient. There is the commonly used phrase, If it wasn’t documented, it wasn’t done. This is used to remind us that the chart is a legal document. If we do not treat it seriously, it can cause us a lot of trouble. If we did something, we need to document that it was done. Sometimes this will be the only way of showing that it was done. Not documenting something suggests that it was not done. It does not prove that something was not done, but it becomes harder to prove that you took an appropriate action.

What happens when there is not somebody there to confirm the specifics from your chart? Is everything documented accurately?

Are things innocently forgotten? If you are in a system that requires you to leave a copy of the chart in the ED prior to taking another call, maybe dispatch is rushing you to finish your chart and take a call. This is not the kind of environment that encourages an accurate recreation of the relevant details of a call. If you are in a system that only has computers back at base for writing charts and then faxing them to the ED, how many calls in a row can alter your memory of details?

I have had to rely entirely on my notes to write some charts, because I could not even remember the patient, chief complaint, or what treatment I had delivered. If I hadn’t made notes, it would be almost impossible to document accurately. The notes are written in the ambulance on the way to the ED, in the ED while giving report, and in the ambulance on the way to the next call, and include whatever my partner or an ambulance crew handed me (that I may have to photocopy so everyone has a copy). Using a comparison of the dispatch times, the times from the ECG printout (helpful to be able to hit record and have it document the time, then make a brief note on the printout, such as fifth NTG x 3, or 1st epi, or tube in, or . . . ), and the actual time to arrange events accurately. An ECG printout that includes vital signs can be a wonderful aid to documentation – if the vital signs are accurate.

Are things forgotten, but not so innocently? I certainly do not document every single thing that happens on the call. I am documenting what happened that is relevant to patient care. Not being documented does not mean that it did not happen, but that it was not relevant to patient care, in my opinion. So, not everything that does happen is documented.

Are things left off of the chart, because they might make the medic look bad? This is the part that so many people seem to have trouble with. For example, let us suppose that you know that the staff of the QA/QI/CYA (Quality assurance/Quality Improvement/Cover Your A@#) department will be cracking down on the use of a certain description of patient care, so you describe it differently. You haven’t changed what you do, but because of the approach of QA/QI/CYA, you have changed the way you document it.

You are treating a diabetic and spill orange juice on the glucometer and the strips. At the hospital, you are not able to restock and you are called for syncope. Protocol for syncope includes a check of BGL (Blood Glucose Level). The patient is now awake and alert, agrees to go to the hospital, and is demonstrating absolutely no signs of hypoglycemia. Do you document that you did not obtain the BGL? Do you have a genuine fear of the retaliation of the QA/QI/CYA department, even though this clearly has no relevance to the care of this particular patient?

Once you start making exceptions to the chart like this, where do you stop?

Not all QA/QI/CYA is draconian. Some are excellent, but not all of these departments are made up of people who thoroughly understand patient care. They may not know what is relevant, only what is in the protocol. In this state, the ALS coordinator for this ambulance service was a basic EMT. A clown who once insisted that a crew obtain a refusal from the owner of a car that had been stuck by another vehicle. The owner was not in his car when the car was hit. He was not anywhere near his car.

This ambulance service would hire paramedics as ALS coordinators and then force them out for not doing things the way the elected members of the department felt paramedics should do things. Not my favorite of the places where I have worked.

Perhaps, instead of the QA/QI/CYA department, it should be called the emPHAsis on the wrong sylLAble department. As with the NR (National Registry of EMTs), they seem to look for things that will be, in their eyes, good test questions. These are things where the text book contains 3 or 4 different points that are emphasized, although rarely relevant to patient care. Then the NR turns that into a question, the which of these does not apply kind of question.

The same is true for the QA/QI/CYA people. They look for something that they feel is important in patient care, such as an IV, then they create a gig sheet that lists all of these criteria and they go hunting for witches. They do not need to demonstrate that the witch is made of wood, just that the QA/QI/CYA procedures found witchcraft. Paramedics learn what is considered witchcraft and document in a way that makes them seem to be as little like a witch as possible.

Once called before the inquisition, the only defense is to confess your sins and beg for clemency. Not really true, but many are intimidated by anyone who wields power so brutally. Most will not stand up to them.

If the paramedic is too good to waste his time on BLS, the basic EMT is there to do that scut work for him. When the the basic EMT is driving the ambulance, it is up to the paramedic to do both the BLS and the ALS, unless there is another person in the back with the paramedic. We should hope that the other person is a basic EMT, so that some BLS will be done.

Clearly, this is the wrong approach to patient care. The paramedic is just as obligated to provide the BLS care as they are to provide the ALS care. If a paramedic does not provide the BLS care that is indicated for the patient, the patient is not likely to benefit from any of the ALS that the paramedic is providing. But you can’t tell that to some paramedics. They are paragods – too good to be wasted on BLS stuff.

This attitude is not limited to EMS. ACLS has long been one to put way too much emphasis on the ALS treatments, even though they admit –

For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.[2]

What is taught in ACLS?

What is covered on the tested in ACLS?

Drugs (which are ALS), dosages, routes of drug administration, rates of drug administration, ALS procedures, the proper order for these drugs and procedures.

I admit that, for the potentially reversible causes of cardiac arrest, there are drugs and ALS procedures that make a difference. Contrariwise, for the generic dead person the drugs don’t do diddly.

Phrases that used to be common at the scene of a cardiac arrest –

Stop compressions, so that I can start an IV.[3]

Stop compressions, so that I can intubate.

Stop compressions, while we move the patient.

As if relocating dead people does anything other than interfere with traffic. OK, some rare potentially reversible causes are reason to move the patient. Other than specific potentially reversible causes, if they are still dead after treatment, Mr. Toad’s Wild Ride will not be therapeutic. If ALS does not change the outcome, transporting the patient to a higher level of ALS, or even an all-BLS service transporting to ALS, will not make a difference. Well, it will increase the number of motor vehicle crashes. It will increase the number of injuries of unrestrained people performing compressions. So, is there a benefit from routinely transporting corpses as emergency patients? Even the ACLS guidelines recognize this and discourage it.

This situation creates the following dilemma: if carefully executed BLS and ACLS treatment protocols fail in the out-of-hospital setting, then how could the same treatment succeed in the emergency department? A number of studies have consistently observed that of patients transported with continuing CPR survive to hospital discharge.[4]

By example and by action, the bosses – medical directors, ALS coordinators, QA/QI/CYA staff, . . . – make clear the kind of behavior they want. IV on any patient who might receive an IV in the ED. Or. IV only as appropriate for care of the patient. Or. IV prior to giving any medication, even aspirin. Or. The protocol states that hemorrhage is part of trauma. Unstable trauma needs 2 large bore IVs. Any failure to complete this part of the protocol will be taken seriously.

What? So the BLS protocol was not followed? We’ve got enough to deal with in the QA/QI/CYA of the paramedics. We can’t worry about the EMTs.

The paramedics need to follow the BLS protocols, too.

Maybe, but we don’t have the people, or the time, to worry about that stuff. That’s just BLS.

Footnotes:

^ 1 ACLS (Advanced Cardiac Life Support) is only recognition of completion of a specified course, that does not permit any privileges itself, but may be a prerequisite to being granted ALS privileges. These terms are often used interchangeably, but they have significant differences. ALS for a medic does not generally include all of the drugs and skills in ACLS. OTOH, there are things that are ALS, that are not even mentioned in ACLS, which focuses on the causes of cardiac arrest and the prevention or treatment of cardiac arrest.

^ 2 (Circulation. 2005;112:IV-58 – IV-66.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 7.2: Management of Cardiac Arrest

^ 3 Stopping compressions to make it easier to start an IV was never a good idea. The veins should be a bit more pumped up during compressions. One problem is that the person may raise the arm a bit and let the blood drain out by gravity. With IO (IntraOsseous) needles being used more often, there is less of a temptation to do this, but people still ask questions that demonstrate they place too much importance in the ability of IV access (the route of most ALS administration) to make a positive difference in the outcome. What I hear sometimes is, “How do we do compressions with a sternal IO in place?” If the IO needle is going to interfere with compressions, do not even think about using it. Anything, other than defibrillations and assessments, that causes compressions to be interrupted is bad. There has been research suggesting that interrupting compressions for defibrillation is unnecessary, but there are too many things left out of this study to recommend anyone try this with a real patient.

Circulation. 2008 May 13;117(19):2510-4. Epub 2008 May 5.
Comment in: Circulation. 2008 May 13;117(19):2435-6.
Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation.
Lloyd MS, Heeke B, Walter PF, Langberg JJ.

^ 4 (Circulation. 2005;112:IV-6 – IV-11.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 2: Ethical Issues

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Comments

  1. It is fun to drive my QA people nuts. I believe in the thinking of “Treat the patient, and worry about the paperwork later.” Problem is, do that in the Democratic People’s Republic of New Jersey, and heads roll. God forbid I’m allowed to think like a Paramedic.

  2. Brick City Medic, I certainly didn’t mean to suggest that anybody try this in the People’s Republic. That would be absurd. In the People’s Republic, gravity lifts things up, ice improves traction, and the government does not tolerate corruption. BTW, I love the auto insurance rates.You must move to the United States in order to try this. Since you are smuggling yourself across the Berlin Wall from the Wanna Be People’s Republic, into the true People’s Republic, there may be serious consequences. In the Eastern Block, laughter is not the best medicine, since you are not authorized to intentionally use humor. 🙂

  3. You know, I’ve come back a few times to think about this case since I rendered my hasty gut reaction. I keep coming to the same conclusion: If EITHER of his responsibilities had been successful, the patient is alive.I keep wondering what Casper’s vitals were and what he looked like. If he’s sitting there all obtunded in his barca lounger with a pulse in the 120’s and a BP in the 80’s, and a couple pints soaked into the shag carpet I’d probably want to have some IV access to dump a liter of LR in while I sit on his femoral artery for the remainder of the ride. Hell, have BLS driver guy hold hemostasis while you get the stick and then get rolling. A simple thought outside of the adrenaline rush of pre-hospital care would have saved a life. ===================In response to your above post:Protocols are written by people sitting in offices who know nothing of what a sick patient looks like. So are job descriptions. People who follow them to a T need to be re-educatedIf I, as a physician in training, refused to put in an IV because “that’s a nurse thing”, or refused to bag a patient because “that’s a technician thing” or refused to wheel a patient around because “that’s a transport thing, or refused to hold a retractor because “there’s a big frame to do that for me” I’d be crucified on the spot. Every day in the hospital, I get to stuff my education in my back pocket and do work that is far below my capability…but the bottom line is that shit needs to get done so might as well do it yourself.

  4. Yes, but the actions of a small group of people with the same thoughts overthrows governments. It worked in Poland and the Baltic states……….

  5. Bostonian in NY,I am writing another post to answer a lot of what you wrote. Once I start writing the comment section seems too confined a space to reply in my own idiom. :-)Brick City Medic said… “Yes, but the actions of a small group of people with the same thoughts overthrows governments. It worked in Poland and the Baltic states……….”Yes. We can hope that a form of representative democracy eventually comes to NJ. Should you guys change your name from the Swamp State to the PAC (Political Action Committee) State? NJ home of the Great Swamp National Wildlife Refuge. Eat your bayou loving hearts out Louisiana. 🙂

  6. I don’t live there, I merely let the people who work there pay me.

  7. Brick City Medic, Touché.I lived there for a few years.

  8. If I wasn’t married and wasn’t straight, you would be my love Rogue Medic. In all seriousness… You’ve inspired me to ramble and rant and go off the deep end a little, and thus hopefully I can piss some people off almost half as much as you can!

  9. Cheating Death,

    If I wasn’t married and wasn’t straight, you would be my love Rogue Medic.

    Kind of like the end of Some Like It Hot. [last lines]

    Jerry: Oh, you don’t understand, Osgood! Ehhhh… I’m a man.
    Osgood: Well, nobody’s perfect.

    And then there is this Cheating thing. how am I supposed to overlook that? Not just cheating, but it seems like a bit of necrophilia, too. I suppose I shouldn’t knock it until I’ve tried it – preferably not as the dead one. 🙂

    In all seriousness… You’ve inspired me to ramble and rant and go off the deep end a little, and thus hopefully I can piss some people off almost half as much as you can!

    Nah! I’m just trying to be reasonable. 🙂

  10. What if you bring up just one problem in a post? Do you have to make it 5 or 6?Don’t get me wrong, these are great points and spot on. Just too much to digest at once.

  11. fifth NTG x 3. It must be nice to not have to stop at a total of 3. It must be nice to have protocols that allow you to treat CHF the right way. BTW your ALS coordinator sounds as bad as mine.

  12. first rule of fire,I’ll work on keeping it down to fewer topics per post.The nitro is often something that scares the protocol writers. CHF is generally treated very poorly. With CPAP, high dose NTG, and ACE Inhibitors, many intuabtions could be avoided.My current ALS coordinator is good and quite different from that clown.

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