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

- Rogue Medic

Excited Delirium 2

I expect to be writing a lot about the EMS EduCast – Excited Delirium: Episode 72. It is very important essential for EMS providers.

The first comment in response to my post, Excited Delirium: Episode 72 EMS EduCast, is from Tom Bouthillet of Prehospital 12 Lead ECG.

This was an excellent episode and I applaud Mr. Johnson for sharing his experience so that we can all learn from it. Clearly he has paid a high price and he has my sympathy, but I can’t join you in saying that he “did nothing wrong.”

If my understanding is correct, it sounds like he used a police baton to restrain the patient. While this may not have been the proximal cause of the excited delirium, it was very poor judgment. A paramedic should never use a weapon to restrain a patient unless:

1.) The paramedic’s life or his partner’s life is in danger
2.) There is no opportunity for escape
3.) A weapon (or an improvised weapon) is needed to level the playing field to restore safety

I can hear it now. “Hindsight is 20/20″ and “you’re an arm chair quarterback.” No, I’m simply pointing out that it’s a mistake to say that Mr. Johnson did nothing wrong. Clearly at least one major mistake was made.

Tom,

I agree that using the baton was poor judgment. When faced with an unstable situation, we will make snap judgments. Marty Johnson’s explanation is that he felt it was the only way he could get a grip on the patient. He stated that the patient was sweaty and he had latex gloves on, so the patient kept slipping out of his grasp. I would take the gloves off. Even though the patient is bleeding, you have to assume that the gloves have already lost their much of ability to act as a barrier to transmission of germs, but the gloves are acting as a barrier to being able to manage the situation.

We occasionally have to make important decisions about the appropriate amount of force to use. We should have thought these out, as much as is practical, ahead of time. How many of us have thought these things through?

This is a situation that may initially seem like it is not a big deal. the problem is that things do not get better. They get worse. Not just a little bit worse, but a lot worse. Not necessarily getting a lot worse right away, so that you just step back and re-evaluate or to retreat and call for help, but progressively worse, so that you may not be aware of the way things are spiraling out of control.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
[1]

We expect to be in control.

During EMS education, we are even told the lie that we should be in control.

Because of this, we are frequently able to dismiss the evidence that we are not in control. Having developed this ability to ignore just how out of control things are, we react poorly when things do not go our way. We flail about and panic. Ironically, the patient may be doing exactly the same thing.

Would Marty Johnson do things differently, today. I think that he made that very clear. He is trying to get people to understand how badly things can turn out.

Even more important than the baton is the perception of the baton. Is a baton a weapon, if it is not used to strike?

Is a baton a weapon, if the baton is used to protect the person the baton is being used on?

Is a sedative a weapon?

Is a restraint a weapon?

A physical restraint?

A chemical restraint?

Consider the weaponized fentanyl variant used during the Moscow theater hostage rescue.

How much does the result affect the interpretation of the intent.

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, most if not all deaths were caused by suffocation when hostages collapsed on chairs with heads falling back or were transported and left lying by rescue workers on their backs; in such position, tongue prolapse causes blockage of breathing venues.[53]. Thus, part of casualties can be attributed to accident but at least some to unprofessional rescue efforts.[2]

Even if nobody had died in Moscow, the chemical would have been considered a weapon, but many of the deaths of the hostages would probably have been avoided with basic airway positioning. Some people vomited, aspirated, and asphyxiated. Others were suffocated by a lack of positioning, allowing the tongue to obstruct the airway. Had there been better organization of the evacuation, how many of these people would not have died that day? Had there been better organization of the evacuation, this might not have been a disaster.

How we act helps to show our intent.

When we are prepared, we can act more appropriately, even if the initial impression of onlookers (including medical command) is that we are being inappropriately aggressive.

When we are prepared, we can turn an unstable situation into a non-event, except for dealing with the protocols that discourage/prohibit appropriate care.

We use our hands for many purposes. We can use them to deliver painful stimuli. When done appropriately, there should not be any permanent harm, and the pain should be stopped as soon as there is an adequate response to the stimulus and only repeated if stimulus is again appropriate. The entire point of painful stimulus is to produce a response, and we do this on a regular basis.

Most often, we are using verbal stimuli, but we move to more aggressive stimuli, when the less aggressive stimuli do not elicit a response.

If we omit painful stimuli from our assessment/treatment, then we are neglecting some of our patients.

Was he charged with murder just because he used a baton to attempt to restrain a patient?

I don’t know.

Was Marty Johnson charged with murderous assault, even though he was driving the ambulance at the time the alleged crime occurred?

It does look that way.

If he had showed up and aggressively sedated this patient, would this have been anything other than a routine call?

Probably not.

The doctors may have made a big deal about aggressive sedation, even though it is probably the best thing for the patient.

Acting appropriately aggressively initially will often prevent a lot of bad outcomes. Our goal should be calls that are not memorable, because the patient was protected by aggressive intervention. Unfortunately, we have patients harmed by some protocols that discourage aggressive intervention, because What if . . . ?

I am not cavalier about the aggressive use of sedatives, opioids, or other drugs. I think that aggressive treatments should be treated as sentinel events. RSI Intubation is an excellent example of a treatment that should not be treated as anything other than a sentinel event.

Everything that we do has the potential for harm.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be competent before allowing them to work on their own.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be accountable for all of their actions.

Medical command permission requirements are purely for the psychological benefit of the people who do not understand medical oversight.

Medical command permission requirements are dangerous.

Footnotes:

[1] The Second Coming
William Butler Yeats
Poem of the Week
Poem

[2] Moscow theater hostage crisis – Chemical attack
Wikipedia
Article

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, . . . .

Gemology? – the science dealing with natural and artificial gems and gemstones?

Why is a gemologist, academic or otherwise, giving expert testimony on toxicology?

A better question may be – Why does the gemologist make more sense than everyone else quoted?

Or is it a translation error?

.

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