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

- Rogue Medic

Zero Tolerance III – Star of Life Law second comment

In the comments to Zero Tolerance II – Star of Life Law comment, there is another comment from Star of Life Law:

I just returned from a weekend fishing trip, so I am only now catching this post.

It is good to get away from everything for a while.

By “strict adherence to the protocols” I was intending that to refer to the strict adherence of the protocols for the administration of controlled drugs. In re-reading my comment, I did not effectively make that clear.

I see differentiating, between controlled substances and the rest of the medications we carry, as only a political difference. I do not see politics as something that should affect patient care. I do realize that politics will always influence patient care, but that does not make it right. We should behave responsibly in the use of all of the medications we carry.

Furosemide is not a safer drug than fentanyl. We need to stop acting as if controlled substances are any more dangerous than any other medications. Controlled substances are actually very safe – unless put in the hands of dangerous medics, but then everything else is safe – unless put in the hands of dangerous medics.

Is the purpose of the protocol to protect the patient or to protect the organization? At some point you have to chose one over the other, because these are incompatible goals.

I respectfully disagree with this statement. I believe that both can be done. Protocols are often being revised to reflect advances in patient care, and/or to provide medics with increasingly advanced tools. This both improves patient care and protects the organization by ensuring that they are adhering to the emerging standards for patient care.

Further, protocols protect the organization by complying with the requirements set forth by the State EMS Regulatory Agency.

And that is just one place where the protection of the patient disappears. The organization that is protecting itself is the State EMS Regulatory Agency. They are the ones causing the incompatibility between protocols and protecting the patient.

Your medical director has no clue about EMS pain management.

I think my system’s medical director does the best job he can considering the available resources and the economic and political realities he faces. I have no doubts about his commitment to our mission and his commitment to patient care.

Additionally, I should have mentioned that even if my medical director wanted to allow the administration of pain meds without OLMC orders, he is prohibited by SC State Law from doing so.

The SC State EMS Formulary lists 5 drugs that REQUIRE OLMC orders: Diazepam, Fentanyl, Midazolam, Morphine Sulfate, and Nalbuphine.[1]

So in my State, this is not a Medical Director problem, it is a requirement of the State EMS Regulatory Agency.

I apologize for the comment about your medical director. Your state medical director has no clue about EMS pain management. This is a state medical director/agency failure.

For example,

Lorazepam MAY BE initiated by Standing Order or Protocol. It is RECOMMENDED – where feasible – that On-Line Medical Control be obtained prior to initiation – but this should not supercede the appropriate care of the patient[2]

Diazepam, lorazepam, and midazolam do not require OLMC for the initial dose. They are schedule IV.

For the opioids, there appears to be no possibility of a standing order.

This Schedule CII Controlled Substance may be administered:
1. ONLY WITH ON-LINE MEDICAL CONTROL ORDER IN THE PRE-HOSPITAL SETTING![3]

In other words, this OLMC requirement should supercede the appropriate care of the patient, they just dropped that wording. This wording probably does not give the impression they were looking for, but the wording does rephrase what they wrote about schedule IV medications. This approach to pharmacology only seems to reinforce my earlier statement – Is the purpose of the protocol to protect the patient or to protect the organization? At some point you have to chose one over the other, because these are incompatible goals.

RSI (Rapid Sequence Induction/Intubation) is a standing order, but no amount of opioid is permitted without OLMC permission. I couldn’t find any disrupted communication provision. It appears that those patients in areas with bad communications just have to suffer, until a doctor can be reached, assuming the doctor gives permission.

How can medics competent to perform RSI, not be competent to give opioids on standing orders?

How can medics not competent to give opioids on standing orders, be competent to perform RSI?

Nalbuphine (Nubain) is not a good drug for EMS. There are a bunch of mixed agonist/antagonist opioids available. These mixed agonist/antagonist drugs do not appear to be of benefit in the EMS setting. At least not of benefit to the patient.

Nalbuphine hydrochloride may produce the same degree of respiratory depression as equianalgesic doses of morphine. However, nalbuphine hydrochloride exhibits a ceiling effect such that increases in dose greater than 30 mg do not produce further respiratory depression in the absence of other CNS active medications affecting respiration.[4]

an equianalgesic doses of morphine?

Nalbuphine hydrochloride is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis.[4]

And yet, the initial dosing of nalbuphine is 5 to 10 mg, while morphine is 2 to 5 mg[5].

Then there is the whole concept of there being any one dose that leads to respiratory depression. A person with severe pain, but pain that is very responsive to morphine, may have respiratory depression at less than 20 mg of morphine. While another person with severe, but pain not very responsive to morphine, may not have respiratory depression until well over 100 mg of morphine.

When people tell me a dose and the effect that it will have on the patient, I distrust their grasp of pharmacology. Pharmacology requires some kind of context, at least if you believe that the dose makes the poison.[6] Paracelsus was not just referring to numbers.

And you have a protocol for flumazenil. If only I had just written a post on the subject of flumazenil.[7]

It appears that I shouldn’t rush out to the get mail, to see if I will be invited to speak at the next SC EMS convention.

Is this situation ideal? No. Is it “placebo oversight?” Likely. But then again, we haven’t exactly been great stewards of the responsibility we seek. Somewhere along the way we lost the trust that we could independently handle these drugs responsibly or appropriately. Thus, the hoops are set into place.

I don’t think that I would use the word ideal.

Who did what, in South Carolina, to lead to the removal of appropriate protocols for the use of controlled substances? Did this removal of the existing standing orders have to do with bad medical oversight, or was it something out of the control of the medical director? Was the medical director not noticing signs of abuse by one medic? So all EMS patients are punished? Was the medical director not picking up on signs of diversion?

I agree with you that we need more training in EMS. I think that, at a minimum, Paramedic should be an Associate Level Degree, and fully believe that a Bachelor Level Paramedic Degree could be established on par with BS RN’s. Further I would love to see a Paramedic to PA bridge program. But those are topics for another day, over good beer.

You are mistaking time in the classroom for understanding. Our EMS education system is broken. We need to eliminate organizations, such as the National Registry, that encourage teaching to the test. EMS education needs to be overhauled before we start requiring more-of-the-same as the solution. Our biggest problem is not time in the classroom.

I would say that we have 2 equally big problems – the quality of instruction in the classroom and the pressure to churn out graduates. Even good instructors can be significantly handicapped by the teach to the test curriculum. The administrations that focus on numbers destroy quality, too.

We have too many paramedics, but we do not have enough good paramedics

At the BS level in an EMS program, do you lose the ability to use instructors who do not have a BS?

As for your suggestion of having a debate over good beer, I cannot find anything to dispute in that suggestion. 😉

Footnotes:

^ 1 SC EMS Formulary
Free PDF

^ 2 SC EMS Formulary
Page 53 in pdf counter (page numbers match the pdf counter).
Free PDF

^ 3 SC EMS Formulary
Page 37 in pdf counter.
Free PDF

^ 4 nalbuphine hydrochloride (Nalbuphine Hydrochloride) injection, solution
[Hospira, Inc.]

FDA label
Free PDF – automatic download . . . html from DailyMed

^ 5 SC EMS Formulary
Pages 58 and 60 in pdf counter.
Free PDF

^ 6 Paracelsus
Wikipedia
Article

^ 7 Flumazenil and EMS – A Box Pandora Should Not Open
What I coincidentally wrote about flumazenil a few weeks ago.

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