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

- Rogue Medic

Protecting Systemic Incompetence – Part I

 

We demand the lowest standards, because we are willfully ignorant and we do not want to understand. The surprise is that so many of us survive our devotion to incompetence. The loudest voices tend to dominate the discussions and the loudest voices demand that their excuses for incompetence be accepted. The rest of us don’t oppose incompetence enough.

A nurse was told to give 2 mg Versed (the most common brand of midazolam in the US) for sedation for a scan, intended to give 1 mg Versed, but actually gave an unknown quantity of vecuronium (Norcuron is the most common brand in the US). The patient was observed to be unresponsive and pulseless by the techs in the scan. A code was called. The family learned the details from a newspaper article, not from the hospital.
 

A Tennessee nurse charged with reckless homicide after a medication error killed a patient pleaded not guilty on Wednesday in a Nashville courtroom packed with other nurses who came in scrubs to show their support.[1]

 

The nurse intended to give a medication that should be limited to patients who are monitored (ECG and waveform capnography), because different patients will respond in different ways. This is basic drug administration and deviation from that basic competence may even have been common in this Neuro ICU (Neurological Intensive Care Unit). We demand low standards, because we do not want to understand.

We don’t need to monitor for that, because that almost never happens.

Except these easily preventable errors do happen. And we lie about it. We help to cover it up, because we demand low standards, regardless of how many patients have to suffer for the benefit of our incompetence.

This is a common argument used by doctors, nurses, paramedics, . . . . It makes no sense, but we keep demonstrating that we don’t care.

The people in charge should act responsibly, but they delegate responsibility and we reward them.

Back to the hospital, Vanderbilt University Medical Center (VUMC) is a university medical center, so the standards should be high. VUMC was founded in 1874 and is ranked as one of the best hospitals in America.

There is a drug dispensing machine, from which less-than-killed nurses can obtain almost anything and administer almost anything, without understanding enough to recognize the problem. This is an administrative problem. This was designed by someone with no understanding of risk management.

The over-ride of the selection is not the problem, because emergencies happen and it is sometimes necessary to bypass normal procedures during an emergency. Ambulances are equipped with lights, sirens, and permission to violate certain traffic rules for this reason.

Some of the many blatant problems are:

* The failure of the nurse to have any understanding of the medication supposed to be given

* The failure of the nurse to recognize that the drug being given was not the drug ordered.

* The failure of the nurse to monitor the patient being given a drug for sedation.

* Most of all, the failure of the hospital – the nurses, the doctors, the administrators, to try to make sure that at least these minimum standards are in place.

* How often do nurses in the Neuro ICU give midazolam?

* Why is a nurse, who is clearly not familiar with midazolam, giving midazolam to any patient?

* How is a nurse, working unsupervised in a Neuro ICU not familiar with midazolam?

* What kind of qualifications are required for a nurse to give sedation without supervision?

* Since this nurse was orienting another nurse, what qualifies this nurse to orient anyone?

* Given the side effects of midazolam, why was midazolam ordered without monitoring?

* Given the side effects of midazolam, was it the most appropriate sedative for use in a setting where monitoring is going to be difficult?

* Was it the more rapid onset of sedation, in order to free up the PET scan more quickly and/or avoid having to reschedule the scan, that led to the choice of midazolam?

* How well do any of the doctors understand the pharmacology of midazolam if they are giving orders for a nurse to grab a dose, take it down to the scan, give the drug, and return to the unit, abandoning the monitoring of the patient to the techs in the PET scan?

* This is not a criticism of the techs in PET scan, but are techs authorized to manage sedated patients?

* Even though they will often scan sedated patients, are the techs required to demonstrate any competence at managing sedated patients?
 

The nurses being oriented apparently thought that it is customary to give sedation:

1. without even looking at the name of the medication

2. without confirming by looking at the name again, it before administration

3. without double checking with a nurse, or tech, that the label matches the name of the drug to be given
 

How many of the doctors, responsible for the care of ICU patients, would agree to be sedated, without being monitored, and to have their care handed off to PET scan technicians?

Why didn’t the doctors and nurses see this as a problem before it made the news?

If the problems were reported, nothing appears to have been done to address the problems beyond the usual – Nothing to see here. Move along. or That’s above your pay grade.

That is the primary point I am trying to make.

The problem is well above the pay grade of the nurse.
 

Here is the part that experienced nurses have jumped on immediately:

Why did the nurse think that midazolam needs to be reconstituted?

Vecuronium (most common brand name is Norcuron) is a non-depolarizing neuromuscular-blocker, which comes as a poweder, that needs to be reconstituted.
 


Image source
 

1. Read label instructions?

This nurse has repeatedly demonstrated a need to be supervised, but those responsible for that supervision have apparently ignored their responsibilities in a way that far exceeds any failures by this nurse.

Is it possible that this is a one time event and that the nurse has behaved in an exemplary manner at all times while around doctors and other nurses before this day? It is possible, but the number and severity of the failures on the part of the nurse strongly suggest a pattern of not understanding, not caring, or both. I suspect that any lack of caring is due to a lack of understanding, because I have not yet lost all hope in humanity.

Footnotes:

[1] Nurse charged in fatal drug-swap error pleads not guilty
By Travis Loller
February 20, 2019
Associated Press
Article

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Flag burning, patriotism, and reality

flagburningtrump2a

Tweet by President-elect Donald Trump on flag burning
 

Is appearance more important than reality?
 

Why do people burn the American flag?

There may be many reasons, but the essence appears to be an attempt to shock people to recognize what the flag burners see as hypocrisy.

What is the purpose of prohibiting burning of the American flag?

Some people place more value in this symbol of America (the flag), than they do in what makes America great (the Constitutional protections of the rights of Americans).

Is President-elect Trump an opponent of the American Constitution? Is President-elect Trump just engaging in a politically correct theatrical display for people who do not seem to understand that the American Constitution doesn’t care if their feelings get hurt?
 


 

In 1798, Congress passed, and President John Adams signed, the Alien and Sedition Acts.[1] These restricted eligibility to vote, restricted immigration, allowed for increased deportation of aliens considered dangerous, and made criticism of the federal government illegal. This is one example of Founding Fathers acting in a way that is contrary to what many consider their original intent.

Recently deceased Supreme Court Justice Antonin Scalia voted in the majority to protect flag burning in 1989.[2] Did Justice Scalia hate America, hate the American flag, or is it more complex than an early morning tweet can express?

In 1943, during World War II, the Supreme Court decided on a variation of this concept. Is it Constitutional to force people to demonstrate patriotism?
 

To believe that patriotism will not flourish if patriotic ceremonies are voluntary and spontaneous instead of a compulsory routine is to make an unflattering estimate of the appeal of our institutions to free minds.[3]

 

Real patriotism is not a politically correct compulsory display.
 

But freedom to differ is not limited to things that do not matter much. That would be a mere shadow of freedom. The test of its substance is the right to differ as to things that touch the heart of the existing order.[3]

 

The American Constitution does not authorize thought crimes.
 

If there is any fixed star in our constitutional constellation, it is that no official, high or petty, can prescribe what shall be orthodox in politics, nationalism, religion, or other matters of opinion or force citizens to confess by word or act their faith therein. If there are any circumstances which permit an exception, they do not now occur to us.[3]

 

What about those who claim that Americans have risked their lives, and even died, to protect the sanctity of the American flag? Does service in any branch of the American military contain any oath to protect the American flag?
 

(a) Enlistment Oath .-Each person enlisting in an armed force shall take the following oath:
“I, ____________________, do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; and that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations and the Uniform Code of Military Justice. So help me God.”
[4]

 

The So help me God is optional, since there is no truth to the myth that there are no atheists in foxholes and the American Constitution prohibits all religious requirements for service.

The oath is to protect the American Constitution, which protects flag burning. The oath is not to protect the American flag.

Even Jesus stated opposition to this kind of political theater.
 

5 “When you pray, you are not to be like the hypocrites; for they love to stand and pray in the synagogues and on the street corners [a]so that they may be seen by men. Truly I say to you, they have their reward in full. 6 But you, when you pray, go into your inner room, close your door and pray to your Father who is in secret, and your Father who sees what is done in secret will reward you.[5]

 

What does it say about America that we reward theatrical patriotism, rather than respect for the Constitution which makes America great?

Or is President-elect Trump taking initial steps to try to get Citizens United v. Federal Election Commission[6] overturned by expressing that not everything is protected expression? Who can tell with someone who expresses himself in such a vague manner?

Is appearance more important than reality?

Footnotes:

[1] Alien and Sedition Acts
1798
Primary Documents in American History
Library of Congress page

[2] Texas v. Johnson, (1989)
No. 88-155
Argued: March 21, 1989
Decided: June 21, 1989
United States Supreme Court
case

[3] West Virginia State Board of Education v. Barnette (No. 591)
Argued: March 11, 1943
Decided: June 14, 1943
case

[4] §502. Enlistment oath: who may administer
Text contains those laws in effect on November 28, 2016
US Code page

Amended in 1962 – inserted “So help me God” in the oath, and “or affirmation” in text.

[5] Matthew 6:5-6
New American Standard Bible (NASB)
You can go to the site and look up all of the other versions of the Bible or just pick up a Bible and read this.
Bible Gateway
Bible

[6] Citizens United v. Federal Election Commission
2009
case

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Blogging and Anonymity

CCC – Captain Chair Confessions writes anonymously.[1] Is that bad?

Are we so incapable of assessing the content of the blog, that it only becomes relevant when we can attach a normal looking name to the blog, no matter how fictitious that name might be?

I don’t put my name on my blog.

Does that change the validity of the research I write about?

What about when I criticize someone? Is that criticism less valid than if I put a name on my blog?

I criticize some big companies. None of them have contacted me about any kind of libel suit, or any kind of slander suit for any of the podcasts I have been on.

My email is right there in the upper right of the blog. I have always has been.

People think that attaching a name to something gives it accountability.

Oprah Winfrey has made a career of giving a stage to frauds – Deepak Choprah, Jenny McCarthy – even Dr. Oz is promoting nonsense. There are plenty of others.

We know their names, but they are frauds.

Where is the accountability for all of the fraud that has come from her show?
 


 

Deepak Chopra is one of the highest paid entertainers in the US.

There is a lot of discussion of Mitt Romney and Barack Obama. They use their names. Does anyone think that both of them are trustworthy?

What about Michael Moore and Rush Limbaugh? They are both famous liars, who will distort anything to make a political point. Having their names on their lies doesn’t seem to encourage them to behave ethically.

Requiring a name on a blog is like requiring a medic to make the magic phone call to a medical command doctor. It has the appearance of making things better, but none of the substance.

This is a salve for the people who are not capable of determining what is real – people who think that a good argument for something is, What if somebody sues?

Does the blog identify an employer?

Does the blog portray that employer in a negative light?

Is the blog encouraging people to abuse patients?

There are many similar questions that may be asked.

There are a variety of ways of answering some of these questions.

The most important question is does this blog get me to think about what I do, so that I want to be better at patient care?

 

The problem is not anonymous blogging.

The problem is people who want to discourage views, but don’t have any valid criticism of those views.

Medicine and EMS are very traditional. We need to destroy those traditions and start doing what is best for the patients.

Organizations that harm patients in order to do what they think protects them from liability need to be criticized.

During the creation of the United States of America, there were plenty of discussions about the way the government should be set up. The Federalist Papers were written under the pseudonym Publius.[2] We still do not know who wrote some of the essays. The contrary position was taken in the Anti-Federalist Papers, written under the pseudonyms Cato, Brutus, Centinel, and Federal Farmer.[3]
 

If an anonymous blog is not good enough for you, buy some tissues and go whine somewhere else.
 

I am proud of my fellow anonymous and semi-anonymous, bloggers.

I am embarrassed by people incapable of substantive criticism, who resort to sniveling about anonymity.

It is not about agreement, or disagreement, but about getting ideas out there to move medicine, and EMS, forward.

By the way, I seem to have pointed out that anonymity is traditional. Darn, I wrote something positive about tradition.
 

Anonymity IS free speech.
 

Free speech is progress. Obstructing free speech is bad for patients.

Lead, follow, get out of the way, . . . .

Creative destruction is progress.[4] Without creative destruction we would not be communicating with computers (and your cellular phone is often a computer).

Footnotes:

[1] A blogger outed
Captain Chair Confessions
September 7, 2012
By the anonymous CCC
Article

[2] Federalist Papers
Wikipedia
Article

[3] Anti-Federalist Papers
Wikipedia
Article

[4] Creative destruction
Wikipedia
Article

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Roanoke County Attorney Paul M. Mahoney Caught in a Conspiracy Over Ex-Adult Film Star

Roanoke County Attorney Paul M. Mahoney and Roanoke Fire Rescue Squad Chief Richard E. Burch, Jr. are embroiled in an apparent conspiracy over an ex-adult film star.

Don’t tell anyone. We must protect their reputations, because this is all about reputation.

What did they do?

Never mind what they did – we want pictures –
 


Roanoke County Attorney Paul M. Mahoney.

From the picture, you can’t even tell that Paul M. Mahoney is up to no good.

Paul M. Mahoney is making a mockery of his employer – Roanoke County, Virginia. He is trying to stay out of the spotlight, because Roanoke County Attorney Paul M. Mahoney might be held to a standard of behavior that would result in his termination for bringing ridicule to the County of Roanoke Virgina.

Maybe the standards for Roanoke County Attorney Paul M. Mahoney are not as high as the standards for the volunteer EMTs in Roanoke County.
 


 

Roanoke County Attorney Paul M. Mahoney is assisted in this endeavor by –
 


Roanoke Fire Rescue Squad Chief Richard E. Burch, Jr.

Chief Burch brought his anxieties to the attention of Roanoke County Attorney Paul M. Mahoney.

What anxieties?

Chief Burch was told that a volunteer EMT is not a virgin – how can she work in Virginia? Clearly, she is mocking the whole State of Viginia, or the state of virginity, or the whole attitude of pretending that humans do not engage in intercourse and that we occasionally even enjoy intercourse. 😳

Captain Renault and I are shocked.

I confess that I am not a virgin, either – not that anyone cares.

OK. She is not just not a virgin, but she temporarily made her living being a non-virgin on camera.

Is Roanoke County Attorney Paul M. Mahoney’s job any more legal than acting in adult films?

However, Roanoke County Attorney Paul M. Mahoney seems to be demonstrating that his job is much less ethical than acting in adult films.

Let’s get her fired, but in a way that nobody will blame us. It would be best if her female chief did the firing, because that would be more politically correct than being fired by a bunch of guys who need to take some Ativan and mind their own business.

Have you two ever heard of the Streisand effect?[1]
 


Image credit.

An ex-adult film star can be distracting, but so can a lot of other people.

David Lee Roth, of the band Van Halen, is an EMT. He is not known for an ascetic lifestyle. Would it be inappropriate for David Lee Roth to volunteer?

What about someone with a criminal background? Would it be inappropriate for him, or her, to volunteer? Does it matter is the person has committed a misdemeanor, or a felony, or even worse – been elected to Congress?

As far as I can tell, it has not even been suggested that she is doing anything in uniform, or anything suggesting affiliation with the volunteer squad, that is in any way an inappropriate representation of the rescue squad.

Should she have to wear a scarlet A for Adult film star (retired)?
 
 
 
 

A
 
 

Should each members have to wear a scarlet P for Prude?

Should each members have to wear a scarlet R for Ridiculous?

This does generate a lot of press for Roanoke County, Virginia, just not good press.[2],[3],[4]

Roanoke County Attorney Paul M. Mahoney seems to be providing an excellent example of how to disparage the reputation of volunteer rescue squads using official documents while on duty.[5]

Someone currently getting paid for embarrassing the county is trying to force out a volunteer for previous work in an industry that does not meet his holier than thou standards.

See continuation in Ambulancegirl Makes Unreasonable Accusations in a Comment.

Footnotes:

[1] Streisand effect
Wikipedia
Article

[2] Porn star turned EMT could be in trouble over racy past
By EMS1 Staff
EMS1.com
July 16, 2012
Article

[3] My Take on the Whole Porn Star-Turned-Medic Issue…
The Fire Critic
July 12, 2012
Article

[4] Porn Star or Felon …which do you want in your station??
Iron Firemen
June 27, 2012
Article

[5] Re: Cave Spring Rescue volunteer
Official letter to Roanoke Fire Rescue Squad Chief Richard E. Burch, Jr. from Roanoke County Attorney Paul M. Mahoney
June 27, 2012
Document in PDF format

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Another Wonderful Friday the 13th

I love superstitions, so this is another opportunity to point out how ridiculous this example of anecdotalism is.

Anecdotalism?

Absolutely. If we objectively track of what happens on Fridays that are the 13th and compare those bad events with the bad events that happen on the other Fridays, we will see that this superstition is not supported by research, but only supported by our faulty memories.

We selectively remember bad things that happen during a full moon, or on a Fridays the 13th. We associate the bad things with the evil influence of the moon, or the date, or whatever makes us soil our panties.

This is no different from a doctor, nurse, or medic remembering the outcomes that are interpreted favorably and ignoring the bad outcomes, when giving medical treatments. The patients do not even have to have improved. The only thing that matters is that the person remembering the experience has a favorable memory of what happened.

This is why almost every experience-based treatment will be demonstrated to be harmful, unless it is eliminated without evidence.

We convince ourselves that what we are doing is helpful, because we wouldn’t intentionally harm patients, therefore we are helping. We don’t notice the circular logic, because we are fooling ourselves.

An example is a patient I transported to a hospital that claims to be the best hospital in the country/world. It is an excellent hospital. One of their buildings has more than 13 floors, but it does not have a 13th floor. Did somebody steal it? Were they careless and maybe they lost it? No. They are just demonstrating that even an Ivy League university hospital trembles before irrational superstitions. Fortunately, the buffoons in charge are not the people treating patients. Ben Franklin would be embarrassed. This is the kind of foolishness he created the university to oppose.


Image credit.

However –

The patient I transported was receiving a superstition-based medicine tradition-based medicine experience-based medicine. I mentioned that it was unfortunate that this patient had to be harmed by this medication (there were several obvious adverse effects) for no benefit. One of the nurses defended the superstition by stating, I’ve seen it work.

Of course you have, because that is what confirmation bias is. Convincing ourselves that what we are seeing is confirmation that we were right – in spite of the evidence.

No doctor came in while I was there, but doctors do tend to be less superstitious than nurses and medics, so I remain optimistic.
 

Belief in lucky or unlucky things imposes purpose, design, meaning, and significance on otherwise indifferent and purposeless events. Confirmation bias assures that such superstitions will be supported by plenty of validating anecdotes.[1]

The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. – Thomas Henry Huxley.

Some superstitions unsupportable hypotheses are take a long time to die.

Footnotes:

[1] paraskevidekatriaphobia
Skeptic’s Dictionary – A Collection of Strange Beliefs, Amusing Deceptions, and Dangerous Delusions
Robert T. Carroll
Article

.

EMS Week 2012 at EMS Office Hours

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, and I discuss the images we use for EMS Week and what they say about us.

EMS Week 2012 Episode

Click on the images to make them larger.

The image of EMS Week 2012 as seen by FDNY –
 


Image credit.

Is that the way we see ourselves?


Image credit.

Are we the faceless dark misunderstood outlaw character of this poster?

We certainly do not have Bruce Wayne money.

Does the motto for EMS Week 2012 go with the image?
 


Image credit.

Does listening to voices lead to a slightly different calling?

Is it crazy to try to do a good job of caring for patients, when few understand what we do, but many want to tell us how to do it, and few want to pay us well to do it?

Is it even crazier to pretend that we can provide excellent care without continually maintaining and improving our understanding?
 


Image credit.

Maybe we should reconsider EMS recruitment.
 


Image credit.
 

Somebody’s missing out on all the fun.

Is EMS a lifestyle of being accountable for understanding patient care, or some sort of a different lifestyle?

Go listen to the podcast as you bask in the glory of EMS Week.

For a less dark view of EMS Week, read Kelly Grayson’s end of the world version.

Top 10 ways to celebrate the last EMS Week ever

People engage in risky behavior when they believe world is ending, such as telling their supervisors what they really think of them.

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