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

- Rogue Medic

The Continuum of Care



For his 100th podcast, Dr. Scott Weingart (EMCrit Blog – A Discussion of the Practice of ED Critical Care) gives an explanation of what his blog/podcast is all about. This was the opening lecture of SMACC 2013.

My career goal and the purpose of this blog and podcast is to bring Upstairs Care, Downstairs-–that is to bring ICU level care to the ED, so our patients can receive optimum treatment the moment they roll through the door.


Podcast 100 – What is Critical Care and What is EMCrit?


Should appropriate patient care ever be limited by turf wars or limited by fears of liability or in any other way arbitrarily limited?

There will always be the financial limitation of care that we have always had to deal with. At some point, using all of the resources we have to try to prolong the death of one patient will deprive other patients of those same resources. We cannot have all resources available at all times to all possible patients. We live in a world of limited resources. Anyone who tells you otherwise is selling something, and that something is a lie.

What about joy of turf wars, the liability of providing appropriate care, and the frustration of being expected to provide high quality patient care regardless of arbitrary political boundaries?

Shouldn’t the critical care doctors decide what critical care is delivered and when it begins?

Shouldn’t the emergency physicians decide what emergency medicine is delivered and when it begins?


When I started in EMS, we used to believe that morphine was a horribly dangerous drug that could only be given in ineffective doses of 1 to 2 mg; that morphine should be given only after radio communication with a doctor; that this kind of prehospital morphine administration was pushing the limits of aggressive medicine.

There are still people who will repeat the unfounded warning that giving morphine (or fentanyl) for undifferentiated abdominal pain will kill the patient.

If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the delusive hope.[1]


Dr. Cope was just originating one of the many myths that persist in medicine.[2],[3]

As Dr. Weingart is opposed to interruptions and delay in the appropriate care for emergency patients in the hospital, I am similarly opposed to interruptions and delay in the appropriate care for emergency patients outside of the hospital.

Is there any reason to believe that physicians responsibility for emergency patient care is limited to that which happens only after the patient crosses the EMTALA[4] line?

Paramedics have repeatedly demonstrated their ability to give opioids, such as fentanyl, safely on standing orders.[5],[6]

Emergency physicians have repeatedly demonstrated their ability to provide deep sedation in the emergency department, in spite of being criticized as dabblers and poachers.[7],[8]

There are more examples of the ways we interfere with a smooth continuum of care for our patients. Dr. Weingart does not appear to disagree, but his focus is on improving care within the hospital and he can only do so much.

Those of us in EMS need to keep pushing for better appropriate care for our patients.

The Standard Of Care is the normal care that would be expected.

Why should we accept a Standard Of Care that is bad patient care?

We should be providing exceptional care, not limiting our patients to bad standards.

We need to reform the legal system that encourages coerces us to provide bad patient care.[9]


Go listen to the podcast or watch the video of the conference presentation.


[1] The early diagnosis of the acute abdomen.
Cope Z, Silen W.
New York (NY): Oxford University Press; 1921.

Analgesia In The ED: Habits And Facts
Pain Management In The ED: Prompt, Cost-Effective, State-Of-The-Art Strategies
EB Medicine
Page with quotation from the book.

[2] Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain.
Thomas SH, Silen W.
Br J Surg. 2003 Jan;90(1):5-9. Review.
PMID: 12520567 [PubMed – indexed for MEDLINE]

[3] Analgesia in patients with acute abdominal pain.
Manterola C, Vial M, Moraga J, Astudillo P.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. Review.
PMID: 21249672 [PubMed – indexed for MEDLINE]

ACEP (American College of Emergency Physicians)
News Room
News Media Resources
Fact Sheet

[5] 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]

Free Full Text PDF Download from MSTC.

[6] Safety of prehospital intravenous fentanyl for adult trauma patients.
Soriya GC, McVaney KE, Liao MM, Haukoos JS, Byyny RL, Gravitz C, Colwell CB.
J Trauma Acute Care Surg. 2012 Mar;72(3):755-759.
PMID: 22491566 [PubMed – as supplied by publisher]

[7] The safety of single-physician procedural sedation in the emergency department.
Hogan K, Sacchetti A, Aman L, Opiela D.
Emerg Med J. 2006 Dec;23(12):922-3.
PMID: 17130600 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[8] “Poachers and dabblers?”: ASA president’s incautious comment riles emergency physicians.
Flynn G.
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed – indexed for MEDLINE]

[9] Standard Of Care Project
Emergency Physicians Monthly
Web page.



  1. Hells yeah, I agree brother

  2. “Upstairs Care, Out There!”

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