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

- Rogue Medic

New Series of Rants – ParaCynic

Here is another Normal Sinus Rhythm post. The topic this week is themeless. Read the rest of the NSR Blog posts at NSR Week 10.

Tourniquets, Trendelenburg, Tampons, Toilet Paper. This is the title of a post that threatens promises to be the beginning of a series of posts about things that irk the ParaCynic. ParaCynic had not been posting for a while. Until somebody irked him. Now he appears to be resuscitated.

Let me tell a story about a Protocol Memorizing Supermedic in a paramedic/EMT system. He arrives to find the patient, Casper, sitting in a recliner, watching the ball game with his leg elevated above the heart (Mom is a nurse), and he has blood soaked bandages piled on top of each other (not supposed to remove the old bandage), yada, yada, yada.

PMS is going to be in the back of the ambulance with the patient. His partner, PMS Basic, will be driving. Family will be meeting them at the hospital. Another medic will be attempting to rendez-vous with our devout acolytes of the Protocol, but since this is EMS, no actual communication takes place between the drivers of these vehicles and therefore no actual rendez-vous happens, either. While this reenactment of a Keystone Cops chase is taking place, PMS is in the back of the ambulance doing what PMSs do.

Alas, he is unsuccessful, so Casper transforms from just a pallid ghost-like appearance to the state of being a true ghost. Being a friendly ghost he doesn’t sue the ambulance company, and everyone else involved in this tragedy. His family sues. Casper is dead and his family doesn’t talk to ghosts. The family sues the fecal matter out of all involved. In this case, that happens to be a lot of fecal matter, since EMS specializes in being full of fecal matter.

PMS is beating himself up over his inability to save Casper’s life because he was not successful in following the protocol. Everybody knows that this was the cause of death. How could he have let down his patient in this time of need?

PMS and Casper are alone in the back of the ambulance and Casper starts channeling Dirty Harry. This is not good for a future friendly ghost.

Casper Eastwood says –

I know what you’re thinking. “Did he lose six quarts or only five?” Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a 14 gauge catheter, the most powerful catheter in the EMS world, and would fill your veins right up, you’ve got to ask yourself one question: Do I feel lucky? Well, do ya, punk?

And PMS did feel lucky.

And PMS gave a prayer to the protocol gods.

And PMS choked.

No IV.


No kidding?

PMS spent the last minutes of Casper’s life ignoring the blood coming out of his leg and tried to start an IV?

But the protocol says –

Wait, we must all genuflect before a reading from the Holy Book of Protocol.

Thou shalt not arrive at the ER without an IV on all ALS patients!

It is the duty of the Holy Order of Protocol Monks to see that all of the Protocol Monkeys worship at the Cathedral of the Divine Catheter which doth infuse the Blessed Saline of Life.

What about direct pressure?

If there had been another provider in the back, it would have been acceptable to waste time on a BLS procedure, after all – this is ALS.

What about continuing the elevation that seemed to be helpful in slowing down the blood loss?

You need to stop suggesting things that might distract the PMS from the Blessed Application of the Catheter. It puts the Catheter in the body, so it gets the hose.

What about a tourniquet?




OK. ParaCynic may be a bit cynical in mentioning this. TOTWTYTR was discussing Tourniquets recently – also in a way that was supportive of tourniquet use. Oh, what sad times are these when EMS bloggers can say tourniquet at will to medical directors. There is a pestilence upon this land, nothing is sacred. Even those who arrange and design protocols are under considerable economic stress in this period in history.

The horrific idea that it might be more appropriate to keep the oxygen transporting goodness of the hemoglobin in the blood in the body, rather than ignoring the spillage and attempting to hook the patient up to a pressure washer to force what little might remain of the hemoglobin out with the Blessed Saline of Life.

To sacrifice circulating hemoglobin on the altar of Blessed Saline of Life. This marks one as a True Believer. Two more cases of miraculous faith, in the face of negative patient outcome, and PMS will be ready to preach to his own minions.



  1. 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?

  2. You. Ain’t. Right.But I love the way you think.

  3. Hey look, someone reads my crap.You mean BLS is supposed to precede ALS? I thought that was just a trite little cliche…

  4. Bostonian in NY,You are correct. At least that is the short answer. I’m working on a more comprehensive post on this comment. AD,Isn’t “not being right” a prerequisite for survival in EMS? When thinking right appears more interesting I may try it, but don’t count on it.ParaCynic,A lot of people read your droppings. I thought you were hibernating, or something. As far as BLS preceding ALS – I thought you started this. 🙂

  5. Well, I take your point that this person is overlooking the obvious in search of the perfect. But I’ll wager that the protocol says direct pressure, yaddayaddayadda, first. So the protocol, nor the following of same, is not the problem. The problem is craniorectal inversion, and willful and wanton stupidity.

  6. Patrick,The protocols are broken up into BLS protocols and ALS protocols. While they do not say that medics should not follow the BLS protocols, there are no cases that I know of where a medic got in trouble for not following the BLS protocols. Not having an IV, when the ALS protocol states that there should be an IV is the kind of thing that risks your job and your paramedic card. The message, while only written between the lines, is explicit. It isn’t the protocol stating that BLS should not be done, but the way the protocols are enforced. No IV? Do you not want to be a paramedic? Paramedics are strongly encouraged to keep their heads hidden away in the lower part of their colons.

  7. Patrick, I forgot one part. You wrote, “this person is overlooking the obvious in search of the perfect.”Having an IV is not perfect. It is far from perfect. If we would stop trying to wash out the hemoglobin with saline, we might have better outcomes. This patient needed bleeding control – not lavage of the arteries and veins.

  8. I agree with AD. You definitely ain’t right. Still, it’s a good post. BLS always has to come before ALS. Which reinforces my belief that good medics are good EMTs before they are medics. Bleeding control is part of C, as bostonian in ny said, bleeding control is part of the ABCs. Sadly, this IV fascination isn’t unusual. Several years ago one our BLS units called for an intercept. That in and of itself was very unusual. What was even more unusual was that they were on scene with an ALS unit from a private ambulance company. The patient was unconscious and in need of some airway control. For some reason the medics decided that an IV was part of that and ignored the airway while trying to start an IV. Harsh words were exchanged and our BLS crew started for the hospital without the private ALS. When we met up with them, they were doing a good job of managing the airway using BLS skills. So good in fact that the patient woke up and never needed to be intubated.

  9. TOTWTYTR,Riiigggtttt. It is called an IV Life Line for a reason. The word Life is in there, because it is used to Save a Life. Line is in there, because it is a Line that is used to Pull the Patient out of the Grip of the Jaws Of Death. The tensile strength of the Life Line is directly proportional to the size of the IV catheter, plus half the size of any additional catheters connected to working Life Lines.For your penance, you must recite the protocol ten times and start seven unnecessary IVs. :-)I love the Tale of the IV Airway Medics. If only this were rare. But then what would I rant about?

  10. I read somewhere and truely believe it. Most priority 1 trauma patients are basic patients. Short scene times, rapid transport, and early access to definitive care are more important to the priority 1 trauma patient than ALS are. JS

  11. JS,I agree with you. I have seen other patients killed by too much attention to ALS at the expense of BLS. Not just by paramedics.Not that ALS doesn’t have its place, but it is not likely to make a difference between life and death.

  12. Did the medical director have any problem with the way the medic mistreated this patient?

  13. first rule of fire,No.PMS was already leaving. I had other priorities of bad patient care at that job, so this was not important to me. I should have learned from his way of handling this that he would not be very much use in remediating/eliminating the incompetent medics.