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

- Rogue Medic

To Restrain or Not To Restrain, But That’s Just the Beginning of the Question – comment

In the comments to To Restrain or Not To Restrain, But That’s Just the Beginning of the Question, jeg43 wrote,

I am astonished that restraint is an issue in this day and age.

Restraint should not be an issue, but it still is. Pennsylvania actually has better protocols than many other states/localities.

Wait! I do see the legal components.

There are many legal components of this, but consider the first footnote I showed in the chemical restraint protocol –

2. Do not permit patient to continue to struggle against restraints. This can lead to death due to severe rhabdomyolysis, acidosis, dysrhythmia, or respiratory failure. Medical command should be contacted for possible chemical restraint with sedative medication.[1]

I think the suggestion that medical command be contacted, is one that appeals to a medical director who does not have to physically get involved in restraining patients. Dr. Kupas is the state medical director for Pennsylvania, the one who has his name attached to these protocols. He was (probably still is) a paramedic. He has to convince a committee of regional medical directors of the appropriateness of these protocols. Or, it could be the other way around.

I have only briefly talked with him about pain management protocols, something that could have progressed into a conversation on sedation. It would be a natural progression of such a conversation. In stead the conversation was quickly terminated by Dr. Kupas. He stated that he was trying to change the pain management protocols to get the regions that prohibit standing orders for pain management, to be more aggressive.

He also stated that he wanted to reign in the more aggressive regions. These regions had standing orders that are only dangerous if the medical directors are authorizing incompetent paramedics to treat patients. Of course, any protocol can be dangerous in the hands of an incompetent paramedic, but these medical directors really, really believe in the magical powers of OLMC (On Line Medical Command requirements for permission to treat). He ended the conversation right there. Then went to stand in the back of the conference room.

I never had the opportunity to ask him the relevant questions.

Why do EMS patients not deserve appropriate pain management in Pennsylvania?

Why do EMS patients not deserve appropriate sedation in Pennsylvania?

Why is this at the whim of the doctor answering the phone?

It all does depend on the mood of the doctor answering the medical command phone, their approach to pain management, the culture at that particular hospital, . . . . Some doctors are great and give appropriate orders for the patient. Some act as if the patient is unimportant and they are doing me a favor by giving me orders to treat the patient appropriately.

My patient vs the doctor’s patient. Is there a real distinction, when I am following the doctor’s orders? Of course, my patient is also their patient. So by doing me this wonderful favor, they are allowing me to prevent them from mistreating their patients. Try getting some of the doctors to understand that.

Eventually, some lawyers will recognize that inadequate prehospital pain management and inadequate prehospital sedation are areas of medical direction malpractice that will probably be gold mines in the courtroom.

The doctor has an obligation to the patient.

The doctor ignores that obligation, perhaps out of some infantile attitude that the patient’s pain does not matter until the doctor sees the patient. Maybe the doctor is overworked. Maybe the doctor just has no competence in pain management. Maybe the doctor just authorizes a lot of incompetent paramedics, and thinks this provides some safety for the patients. It does not.

After reading most of your linked posts I have another reaction: Self, never, never let anyone put you in an ambulance. Wait! Bad idea. I may not be able to make that decision and may need help urgently. Another thought: This is information I really did not want to have. And: Damn. The EMS have issues of clusterf**kedness just like the rest of reality.

Yes, there are many problems, but things are improving. As more physicians have more experience with EMS, and with pain management and sedation, the competence level improves. There are still hospitals that do not allow emergency physicians to use fentanyl or propofol in the management of patients. These are considered anesthesia-only drugs in some hospitals. The research on the use of fentanyl and propofol by emergency physicians is extensive. This research demonstrates the safety of administration by emergency physicians without an anesthesiologist holding their hand.

As there is research to show that emergency physicians can safely administer these medications. Anesthesiologists are becoming much more comfortable with emergency physicians using these drugs.[2] There is less extensive, but similar research showing the safety of aggressive pain management and sedation by EMS. Some emergency physicians are becoming more comfortable with EMS treating these patients without the, OLMC holding their hand, Mother-May-I call.[3]

Both examples are in the interest of improving patient care. Some physicians will use the irrelevant distinction that medics are not doctors. Of course medics are not doctors. If we are treating patients according to EBM (Evidence-Based Medicine, or as some prefer – SBM or Science-Based Medicine), then the critical part is, What is best for the patient?

The question is not, What is best for maintaining the customary hierarchy? The question is not about the status or authority of the emergency physician. Appropriately aggressive oversight requires an involved competent medical director. It does not require polling the local OLMC to see what mood the doctor is in, or to see if Dr. Just Transport is working, or any other random factor, factors that are irrelevant to what is going on with the patient. Factors that are irrelevant to patient care.

The evidence is clear. EMS can aggressively manage sedation and pain without ED doctors holding their hand. This hand holding only serves to delay appropriate care, not to improve it. For these patients, delayed care is worse care. For these patients, delayed care is bad care.

Then: You mean to tell me that there are incompetent medics actually treating emergency patients? And OLMC is in place because no one will fire the incompetent medics thus adding to the problems of timely emergency care/treatment?

Maybe I should phrase it – OLMC is in place, because of a poor understanding of risk management, a poor understanding of EMS, and a lot of other responsibilities. I have spent a lot of time trying to convince medical directors of the safety of standing orders and of the importance of aggressive oversight. They deny that there is a problem. They deny that there is a better solution. They see the problem as other medical directors approving dangerous medics and they have to protect patients from those medics. this only perpetuates the problem. As the state changes to more liberal standing orders – appropriately liberal – medical directors will need to adapt.

Yes, there is a problem of inappropriately liberal standing orders. The medical director, who says, Do whatever you want, yet does not provide aggressive oversight. This does nothing to manage the quality of care, either.

Two things more:
1) Each time I read one of your posts, my respect and appreciation for who you are and what you do increases. Thank you, sincerely, for your effort.
2) Is there anything a civilian, not in any way connected to the field of medicine, can do to help you other than shoot identified incompetents?

Thank you. EMS is a job that appeals to several different types of people. Many of us in EMS would not fit in in a M-F 9-5 world. I am glad there are people, other than me, to do those jobs. I could write a lot of posts on EMS personalities and finding the right niche to fit into.

Unfortunately, as a civilian, there is not much you can do. If there are hearings on any changes in EMS, where you live, go find out what you can. Ask questions. Get involved in the discussions. Unfortunately, even those in EMS have a poor understanding of how to best provide EMS. People in EMS do want to help patients, but we often disagree about what is best.


[1] Pennsylvania EMS Statewide ALS Protocols
Effective November 2008
Pages 100/121 to 102/121 in the pdf page counter
Page with link to the full text PDF of the protocols.

[2] “Poachers and Dabblers?”: ASA President’s Incautious Comment Riles Emergency Physicians
George Flynn
Special Contributor to Annals News & Perspective
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed – indexed for MEDLINE]

[3] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

This is just one example of the appropriately aggressive and safe use of fentanyl in EMS. This is much larger than the rest of the research on the topic combined. I wrote about the study, in more detail, in Public Perception of Pain Management.