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

- Rogue Medic

DC Fire and EMS Being Sued for Retaliation After Problems Were Reported

 

Big city EMS departments like to brag about how good they are, but are they good?
 

“If you think about how much progress we’ve made in the last two years, I’m very pleased with the deployment we have now. Are we 100 percent yet? No, but we’re working on it,” Miramontes said. [1]

 

No sensible person should argue with progress, but –

How bad were things?

How bad are things now?

How much work needs to be done to get to the level of competent?

What are the problems?
 


If this does not play, it is available at the link in the first footnote.
 

According to D.C. paramedic Gene Ryan, there has been mismanagement, but according to David A. Miramontes MD, FACEP, NREMT, Assistant Fire Chief, things have dramatically improved. Dr./Asst. Fire Chief Miramontes is management.

Whom should we believe?
 

“If you’re a burn patient with agonizing pain I could fix that, I could take your pain away, but hopefully you live in the right neighborhood,” Ryan said. “Hopefully it’s the neighborhood that carries that medication, and that’s hit or miss.”

In response, Assistant Fire Chief David Miramontes told News4 control drugs are deployed to more than 90 percent of the department’s units.[1]

 

Well, morphine and diazepam (Valium) are probably hard to come by, so the problems are to be expected, right?

No.

DCFEMS also carries fentanyl (Sublimaze) and midazolam (Versed) according to their protocols from 2012.[2] Why the failure to provide these basic ALS (Advanced Life Suopport) medications on the ALS ambulances?

Is there any reason why any fire department EMS service should not have excessive amounts of pain medicine on every ALS ambulance? If there is one thing fire departments should be familiar with, it is burns.

Burns mean pain – a lot of pain.

Anyone who has dealt with significant burns knows that more than 100 mg of morphine or more than 1,000 mcg (more than 1 mg) of fentanyl is not an unreasonable dose.

How can a medical director who is also an Asst. Fire Chief tolerate that? Or is the medical director the problem?
 


 

The dose for burns is half of what is permitted for every other painful condition.

What possible legitimate reason is there for not adequately stocking overstocking pain medicine?
 

Half a year ago, there was a problem with ambulances catching fire and running out of fuel. Management blamed the employees and claimed to be unaware of problems. In other words, management was failing to manage. The job of management is to help the employees to do their job well, not to make excuses.
 

Fire officials say they are trying to address various problems in the department. They hired a private consultant for $182,000 to audit the fleet after the inspector general found that they had lost track of reserve vehicles, listing many fire engines as ready for duty when they had, in fact, been stripped and sent to scrap yards.

After more than 60 ambulances had mechanical issues last month, including many with broken air conditioning during a heat wave, . . . .[3]

 

More than 60?

Out of how many ambulances?
 

Ambulances and Medic Units

  • 14 ALS Medic Units
  • 25 BLS Ambulances[3]

 

More than 60 out of 39 in just one month.

Time to replace some ambulances.

But ambulances are expensive. We can’t afford them.
 


 

14 Heavy Mobile Equipment Mechanics plus 3 foremen in the top 25 DCFEMS overtime earners.[4]

Maybe the heavy mobile equipment they work on does not include ambulances, but this suggests that there is a problem with the management of equipment. Is the equipment too old. Is the department understaffed? Is there some other reason for these employees being over-represented?
 

But top fire officials have accused the rank and file of contributing to the breakdowns and staffing shortages through neglect or incompetence,[3]

 

Our employees are out of control and we are powerless to do anything?

That excuse does not appear to be valid.

DCFEMS has gone through a bunch of medical directors, but adequate stocking of ambulances is still just something to dream about? Is the medical director able to make decisions independently, or is he being not able to exercise authority?

I do not know the answers, but the more people keep failing to fix the problems, the more it looks like DCFEMS needs to be scrapped and remade from scratch with new management. The duct tape is not working.

Mismanagement and retaliation vs. out of control employees?

Management is not making a persuasive case.

Footnotes:

[1] D.C. Paramedic Plans to Sue Fire Department
By Mark Segraves
Saturday, Feb 22, 2014 | Updated 5:00 AM EST
News4 NBC Washington
Article

[2] Emergency Medical Services Manual and Pre-hospital Treatment Protocol
David Miramontes, MD FACEP, Assistant Chief, Medical Director
Kenneth B. Ellerbe, Fire & EMS Chief
Effective Date: September 14th, 2012
Revision Date: September 24th, 2012
Version: 1.1
Page 146/303
Protocols at DC.gov in PDF Download format.

[3] Two D.C. ambulances catch fire while on call
By Peter Hermann
Published: August 13, 2013
Washington Post
Article

[4] Response to Questions Asked by the Committee for “Fiscal Year 2011 and 2012 Performance Oversight”
Government of the District of Columbia Fire and EMS Department
Council of the District of Columbia
Committee on Public Safety and the Judiciary
Phil Mendelson, Chair
February 3, 2012
Document in PDF Download format.

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Comments

  1. As long as we don’t think that DC is the only service, large or small with such restriction on pain meds. Whether through protocol (theory) or mother may I medical control (practice). There are many places that I’ve looked at that have both ridiculously low standing order doses and despite statements about wanting to relieve pain in the pre hospital realm they deny deny deny when asked for true pain control.

  2. This worries me, all ALS vehicles should always have fully stocked drugs including full range of pain medications. This is a basic requirement and should not be allowed to continue. I work in UK and this would never be allowed to happen with a clued up management team and strong clinical director. As for the other issues, easy fix with new ideas and maybe a union that will look at change and support rather than obstruct. I could turn things around in 2 years.

    Ron Schanck
    USAR Paramedic UK

  3. “Anyone who has dealt with significant burns knows that more than 100 mg of morphine or more than 1,000 mcg (more than 1 mg) of fentanyl is not an unreasonable dose.” **

    I disagree with the above quote! 100mg of Morphine and/or 1000 mcg of Fentanyl FAR EXCEEDS a safe dose for almost any patient. The therapeutic dose for morphine is often cited at 0.1 mg/kd. 100mg of Morphine would never be a safe starting dose for any prehospital patient in my opinion! Please revise and review this JEMS!!!

    • EMD Physician,

      “Anyone who has dealt with significant burns knows that more than 100 mg of morphine or more than 1,000 mcg (more than 1 mg) of fentanyl is not an unreasonable dose.” **

      I disagree with the above quote! 100mg of Morphine and/or 1000 mcg of Fentanyl FAR EXCEEDS a safe dose for almost any patient.

      That is why I wrote that this is for patients with significant burns.

      The therapeutic dose for morphine is often cited at 0.1 mg/kd. 100mg of Morphine would never be a safe starting dose for any prehospital patient in my opinion!

      Where did I write anything about this being a starting dose? If you think I, did provide some evidence.

      If you look at the protocol they are dealing with, the maximum total dose is 10 mg morphine.

      Are you suggesting that 10 mg of morphine is an appropriate total dose of morphine for severe burns?

      I am contrasting total doses of over 100 mg of morphine, which is an appropriate dose for some patients, with a limitation on the total dose of 10 mg, which is a reasonable starting dose for some patients.

      Recent research suggest that fixed doses of opioids are more appropriate than weight-based doses with repeat doses as needed.

      Here is some recent research suggesting that weight-based dosing is not the appropriate way to dose. They are not suggesting that 100 mg of morphine be the starting dose. Neither am I.

      The concept of weight-based dosing assumes that opioid doses should proportionally increase to match increased body size (thus, enlarged opioid volume of distribution) to reach or maintain a certain opioid plasma concentration. However, pharmacodynamic studies have not found analgesic effect to correlate to opioid plasma concentrations,[26, 27 and 28] perhaps explaining the lack of clinical correlation found with our data.

      In summary, in our sample of ED adults aged 18 to 65 years, we found no evidence that increasing weight adversely affected pain relief after a fixed dose of hydromorphone. This result suggests that there is no advantage to weight-based dosing over simpler fixed dosing.

      EMS treating severe burns with 10 mg of morphine at a time, until a total dose of well over 100 mg of morphine is reached is not inappropriate.

      We should only titrate pain medicine to pain relief, not to some ancient superstition of what is too much.

      I think you know that, since you wrote that this does not exceed the safe dose for every patient.

      Please revise and review this JEMS!!!

      I will write more about this and stress the importance of having access to adequate doses of opioid, no matter how large.

      Whether any dose is appropriate is determined by the response of the patient, with repetition of the dose until pain relief is obtained (appropriate titration).

      I do not work for JEMS. I do not claim to have any affiliation with JEMS. I do not see why you assume that I do, but you also assumed that my reference to a total dose of over 100 mg of morphine was a reference to a starting dose of 100 mg of morphine.

      Edited to add this link to the study –

      Does Initial Hydromorphone Relieve Pain Best if Dosing Is Fixed or Weight Based?
      Xia S, Choe D, Hernandez L, Birnbaum A.
      Ann Emerg Med. 2014 Jun;63(6):692-698.e4. doi: 10.1016/j.annemergmed.2013.10.003. Epub 2013 Nov 7.
      PMID: 24210367 [PubMed – in process]

      .

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