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

- Rogue Medic

Comment on ALS is Oxygen, IV, Monitor, and Transport – Part I

In response to my post, ALS is Oxygen, IV, Monitor, and Transport, there is a comment from Prmedc.

Quite a few of the problems I see in the local ED come from the ED doc “practicing medicine”. Hey, I’m a doctor! Let’s just drop ten of Versed on this patient and try to intubate, instead of following my well established RSI protocol developed by ACEP.

There are appropriate reasons to deviate from any protocol – even one written by an ACEP committee.

There are many different RSI (Raped Sequence Induction/Intubation) protocols. One protocol does not fit all patients.

The 10 mg midazolam decision does not appear to make sense, but there may be legitimate reasons for using midazolam alone. It would be a mistake to assume that just because research has consistently shown that midazolam alone leads to worse outcomes, midazolam alone is never appropriate.

This is why protocol deviations should be reviewed afterward, rather than automatically punished.

Or, hey, I’m a doctor! Let’s shock sinus tach at 140 instead of giving fluids and pain meds for that fractured femur!

 

This

 


Image source.

 

Plus this –

 


Image source.

 

Is NOT an example of THINKING!

 

Anyone who thinks that shocking sinus tachycardia is a good idea should not be a doctor, should not be a nurse, and should not be a medic.

Sinus tachycardia is a symptom, rather than an arrhythmia to treat. We treat sinus tachycardia by treating the underlying cause(s) – the underlying cause(s) could be hypovolemia, fever, pain, inappropriate vasodilation, stimulant medication, physical exertion, et cetera.

Shocking sinus tachycardia seems to be an example of not thinking.

Shocking sinus tachycardia seems to be an example of trying to make the protocol fit the patient.

Thinking should prevent this.

We should not be memorizing faulty and nonsensical rules, such as over 150 cannot be sinus tachycardia. Or that over the maximum calculated heart rate cannot be sinus tachycardia.

These overly simplified tachycardia rules are neat, plausible, and wrong, but they are to be expected of some EMS cardioversion protocols.

Someone who thinks should not make this mistake. Someone who thinks should not obey such a protocol.

The protocol monkey does not know what to think.

The protocol monkey follows the dumbed down protocols that say to shock whatever is too fast.

The protocol monkey cannot be trusted to do anything else.

We “require” ED docs to think,

Yet you give an example of a doctor not thinking as a reason to prohibit medics from thinking.

“requiring” medics to think won’t fix the legal system or increase our knowledge base or skill level.

Let’s take a look at these suggestions:

 

1a. Will requiring medics to think fix the legal system?

 

No. Why would anyone think that it would? Medics do not run the legal system. Requiring medics to think will also not fix the banking system.

 

1b. Will preventing medics from thinking fix the legal system?

 

Of course not. This is not relevant to what I wrote.

 

2a. Will requiring medics to think increase our knowledge base?

 

Requiring medics to think can be expected to force medic programs to do a better job of teaching, which should increase our knowledge base.

 

2b. Will preventing medics from thinking increase our knowledge base?

 

No. I believe that it has the opposite effect in the places where medics are prohibited from thinking.

 

3a. Will requiring medics to think increase our skill level?

 

Probably. As medical directors have seen the ability of competent medics to handle several limited emergency conditions, they have generally expanded what paramedics are permitted to do and the medical directors have increased what paramedics are permitted to do on standing orders.

The medical directors most involved in EMS keep showing us that they want us to think.

What kind of medical director is foolish enough to prohibit medics from thinking?

 

3b. Will prohibiting medics from thinking increase our skill level?

 

No.

Why would these medics, who are prohibited from thinking, need any skills other than skill at not thinking?

To be continued later in Part II and even later in Part III.

.

Comments

  1. If that was a human strip I *would* shock it, it’s insanely fast (but I think its from a dog)! That’s running at 50 mm/sec instead of 25 mm/sec.

    • Agreed… as a real strip I would highly doubt sinus tach there, based on rate alone. Correlate clinically, etc, but…

      • If we assumed the strip was at 25 mm/sec the rate would be ~200-210 bpm. Say this is a 7 yo with a fever…clinical correlation would lean towards no shock.

        • Christopher,

          If we assumed the strip was at 25 mm/sec the rate would be ~200-210 bpm. Say this is a 7 yo with a fever…clinical correlation would lean towards no shock.

          Suppose this is a 20 year old who has been taking stimulants – amphetamines, cocaine, whatever the dealer mixed together that day to cut the amount of real drug in what was being sold – it is still sinus tachycardia.

          Sinus tachycardia is treated by treating the cause.

          The 7 year old is tachycardic because of the fever.

          Cardioversion will not make the fever go away, but it can make the sinus tachycardia go away. Whatever rhythm replaces the sinus tachycardia will be worse.

          The 20 year old is tachycardia due to pharmacologic misadventure.

          Cardioversion will not make the fever go away, but it can make the sinus tachycardia go away. Whatever rhythm replaces the sinus tachycardia will be worse.

          Cardioversion of sinus tachycardia is like hitting the self destruct button in a James Bond movie – nothing good will come of this. Run away!

          The phrases that are spoken after cardioversion of sinus tachycardia are many of the phrases of regret –

          Why did it do that?

          That’s not the rhythm I want.

          Oopsy.

          and –

          Oh, Fudge!

          Ralphie: Oooh fuuudge!

          Ralphie as Adult: [narrating] Only I didn’t say “Fudge.” I said THE word, the big one, the queen-mother of dirty words, the “F-dash-dash-dash” word!

          Link to the quote from A Christmas Story

          .

      • Brandon,

        Agreed… as a real strip I would highly doubt sinus tach there, based on rate alone. Correlate clinically, etc, but…

        There are P waves with a regular PR interval. This is sinus tachycardia. It is true that it is from a dog, but it is also true that it is sinus.

        .

        • My apologies for skimming, Rogue. On closer look I see the P waves. I do hold, though, that at certain rates, when atrial activity is obscured as it often is, it can be reasonable to make presumptive rhythm calls based largely on rate, or at least carefully considering it. What would you say if it were ~300? Still could be sinus? How about irreg. irreg. at ~275? How about very wide and regular at 220?

    • Christopher,

      If that was a human strip I *would* shock it, it’s insanely fast (but I think its from a dog)! That’s running at 50 mm/sec instead of 25 mm/sec.

      Yes, it is from a dog.

      No, I did not think about the print speed when I copied this. I was looking for clear P waves and less than 2 large boxes between QRS complexes, so that it would be clear that it is very fast. I will have to use a monitor while working out to get a good strip of sinus tachycardia from a human (although some might say I don’t qualify) at over 200 beats per minute.

      A heart rate of 200 is much faster than what my maximum calculated heart rate of 170 is supposed to allow, but there is absolutely nothing about the heart that prevents the sinus rate from going that fast. I will definitely need some benzoin to keep the electrodes from coming off. 🙂

      Even at a double the rate, the rhythm I copied is still sinus tachycardia and should not be cardioverted. I assume that you are being sarcastic about cardioverting this just because it is extremely fast.

      The whole point of the strip (which is one of the points that Prmedc was making) is this –

      No matter how fast the rate, it is still sinus tachycardia and cardioversion is never an appropriate treatment for shock sinus tachycardia.

      .

  2. Does your service treat protocols as a floor for the care provided, or a ceiling? Protocols were intended to be a floor, but due to uninvolved medical directors and uninformed/uneducated administrators have become a celing in many places.

    Deviate from protocol with good reason. Tell a physician. Now tell the typical administrator. See the difference in reaction? That’s why much of EMS is in the position it’s in.

  3. Rogue Medic- I wish to quote you warmly and accurately!
    FA

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