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

- Rogue Medic

Is it Ethical to Treat a ‘Bad’ Person?


Image credit. If you are not upset by this image, you are much better at compartmentalizing than I am.

A question was posted on Facebook a while ago.

Suppose that you are dispatched for burns. Your patient is reported to have burned some children and burned herself while setting the children on fire.

Some of the children have died, but others are alive and are in severe pain.

The surviving children are already being treated appropriately. There are more than enough people and pain medicine to treat the children. There is only your patient for you to deal with.

Your patient even states, I did it.

Do you withhold treatment?

Do you provide any pain management?

Do you treat the person who admits to burning these children?



Why not?


Three Children Dead, Four Hospitalized After Houston Daycare Fire

Anybody who doesn’t think this is going to be one of the worst days of the lives of everyone involved does not understand.

First. Not knowing anything more than what is in the headline, don’t be surprised if the number of dead increases. The original title of the article was, One Dead, Seven Rescued In Houston Daycare Fire. These stories are not the kind that get better with time. Burns and pain and little kids do not make for good memories.

Reading the article, there are several things that grab my attention.

HFD Executive Assistant Chief Rick Flanagan said CPR was being performed on four of the children as they were being taken to a hospital. The ages of the children range from 18 months to 3 years.[1]

People will talk about CISM/CISD and other forms of coping attempting to cope, but they do not work any* better than just talking this out with coworkers and/or family.[2] My home family is different from my work family.

I could never talk about these things with family members that do not have patient care experience.

How do we get them to understand?

If we do get them to understand, how can we ever apologize for bringing that pain into their lives?

Why would we want to bring that kind of pain into the lives of those we love?

Sandy Sawyer, who has lived in the neighborhood for five years, said she saw firefighters rushing children to ambulances.

“I saw them running down the street holding babies, running, because there wasn’t enough room for the emergency vehicles to get through,” Sawyer said.[1]

The more people are screaming about things being out of control, the more we need to slow down and remain in control.

When we pull up to the scene, do we park so that others will be able to get by?

The police are in charge of traffic, but that does not mean that the police cannot be the biggest problem in obstructing traffic. Parking a short walk from the scene to allow fire trucks to get in is going to make everyone’s life easier and might make some lives longer.

EMS is supposed to transport people from the fire, but the same rule applies as for police. We do not need to drive up to the front door. Stretchers have wheels and small children are very light. We need to park where we will be able to get out of the scene when it is time to leave.

Fire truck do need to get close enough to put water/foam in the places necessary to put out the fire, but that does not mean that they should not park in a way to allow other vehicles as much room to get around them as possible.

This is not New York City on September 11, 2001. We do need to work together. None of us are unimportant.

Five of the children were trapped inside the facility and were rescued by Houston firefighters, while the other two children were found outside the home.[1]

Thank you.

A year ago today, the operation, registered as a “child-care home,” was cited by the Texas Department of Family and Protective Services’ Child Care Licensing division for not having a fire extinguisher on hand.

She later corrected the problems, according to Gwen Carter, a DFPS spokeswoman.[1]

Fire extinguishers are important, but much more important is knowing how to use one and using it appropriately.

A fire extinguisher is a tool and tools are only useful when used appropriately.

Would that have made a difference?

I don’t know if the fire extinguisher was used. I don’t know anything about the fire.

I do know that aggressive use of a fire extinguisher before a fire spreads can be the difference between apologizing to the fire department for calling them to a fire that is already out and losing everything.

There is no substitute for actually using a fire extinguisher. It is worth the cost of having to replace an extinguisher.


The things described in the video should all be known before hand if you are at home. If you are not, slow down, take a breath, check the type of extinguisher, et cetera.

How not to put out a fire. Point the fire extinguisher at the base of the fire has never felt right to me. Aim below the fire, but not straight at the fire, works better for me.


With the video below, because the fire is in a very light container, aiming below the fire will only cause it to tip over and spread, so think about where to aim, what you are aiming at, and how far away to stand.



[1] Three Children Dead, Four Hospitalized After Houston Daycare Fire (Videos) – CPR was being performed on four of the children as they were being taken to a hospital.

[2] Critical Incident Stress Management (CISM): Benefit or Risk for Emergency Services.
Bledsoe BE.
Prehosp Emerg Care. 2003 Apr-Jun;7(2):272-9. Review.
PMID: 12710792 [PubMed – indexed for MEDLINE]

Free Full Text PDF from Dr. Bledsoe’s website http://www.bryanbledsoe.com/

* Corrected from and to any as pointed out by russ reina of EMS Outside Agitator.


Who Carries Enough to Manage Severe Pain from Burns?

Happy Medic has a series of posts on the 12 Days of Christmas. On the 10th day – #HM12DOC 10MGS OF MORPHINE.

But is that a lot?

How do we know what a lot really is?

I have been told that some of the patients I have treated have received a lot of morphine, or fentanyl, or midazolam, or lorazepam, or diazepam, or some combination of these.

When doctors/nurses/medics have stated that I have given a lot of pain medicine, my responses have not been what they expected. I did not agree with them.

How painful is it to have a large body surface area burned, not a little bit burned, but second degree and third degree burns?

How much do you carry? Assume that you have standing orders for all that you carry or assume that you are able to persuade medical command to give you orders to give as much as you have, if the severe pain continues.

How much do you carry?

Assume a 100 kg patient with 50% of his body burned. No burned airway. No burned genitals.

Has anyone ever seen a patient like this get to tthe level of pain that could be described as tolerable with any amount that would not be described as a lot?

That is the wrong question.

Has anyone ever seen a patient like this get to tthe level of pain that could be described as tolerable with any amount that would make what is usually described as a lot seem small?

1/2 mg per kg of morphine?

Most people would consider this to be a lot. I have heard comments about a lot, when I have given much smaller doses than this.

2nd degree and 3rd degree burns on half of the body.

Should any of us expect 0.5 mg/kg of morphine to make the pain tolerable?

For a 100 kg (220 pound) patient, this would be a dose of 50 mg morphine.

Should any of us expect 50 mg of morphine to make the pain tolerable?

How many of us carry enough to give 50 mg morphine (or 500 mcg fentanyl or 7 mg Dilaudid)?

How many people have seen severe burn pain, such as I described, made tolerable by a dose as small as 50 mg of morphine, except in a very small patient?

How many of us carry even carry 50 mg of morphine?

How many of us would be able to give all of it?

How many would expect this to make the pain tolerable?

I started by asking if 10 mg of morphine is a lot. Since I have moved on to 50 mg, is 10 mg likely to be a lot?


You just don’t understand my chronic pain!

Nurse K at Crass-Pollination (in her sidebar, read the definition) writes Saturday morning CRAYZEE!!!!!!!!!!!!!! about a response to an old post of hers What do you do when you start to feel like a drug dealer at work?

First, Nurse K works in the ED (Emergency Department).

Let’s think about that. Chronic pain is something that is long term, so it should not generally result in a trip to the ED. Emergencies are the kind of injuries or illnesses that lead to acute pain. There should be a method, for the patient with chronic pain, to deal with break-through pain. The method should not be to go to the ED. The method should not be to procrastinate on refilling a prescription, until the weekend, so that your doctor is not available. This is manipulative and self-destructive.

The problem patients Nurse K describes are patients who are abusing the system. Legitimate chronic pain patients should be just as upset with these patients as Nurse K is.

The abusers of the system only make it more difficult for those with legitimate chronic pain to receive appropriate pain management.

Legitimate chronic pain patients should hate these people who make a mockery of genuine chronic pain. Those who put on an act to receive their pain medications.

How we deal with pain tells a lot about who we are.

I’ve had patients with extremely bad injuries. Injuries so bad that I feel very uncomfortable not giving them something for pain.

When the patient says, “I’ve had worse,” and I doubt that I have; or “I’ll wait until I really need something,” and I’m hoping that will be sometime before the surgeon starts cutting; or “I used to abuse drugs and nothing is worth living like that again;” or is lying in bed with a heart rate of 150, pale and sweaty, but discouraging large enough doses to make a significant dent in the level of pain; with that perspective, we are able to see the range of response to pain.

What is 10/10 pain?

For most people, burns seem to be the worst kind of pain. Imagine a red hot frying pan.

Now, reach out and touch the tip of your finger to the frying pan for half a second. What would happen if this were done for real? You have a burn. It hurts. Few people would repeat that experiment any time soon.

Now, imagine having your hand being held against the red hot frying pan, the entire palm of your hand, it doesn’t matter which one.

Think about that pain for a while.

If you have any kind of imagination, and you do not have a psychological illness that isolates you from this kind of empathy, then this should make you uncomfortable, at least.

The pain scale is not from This Is Spinal Tap. It does not go to 11.

Work on a burn unit. These patients have experienced this kind of pain, but now are experiencing severe chronic pain similar to the acute pain they experienced with the initial burn. This is not the only kind of acute or chronic pain worth treating. That is not what I am stating.

I am trying to give an idea of what debilitating pain is.

Fibromyalgia is a way to give a name to a much lower level of pain. If it has a name and a diagnosis, well then the drug companies can sell you a treatment for it. Pregabalin (Lyrica) an anti-seizure, neuropathic pain medication is approved for treatment of fibromyalgia. Here is an interesting view of the effect of pregabalin.

In a study of recreational users (N=15) of sedative/hypnotic drugs, including
alcohol, LYRICA (450mg, single dose) received subjective ratings of “good drug
effect,” “high” and “liking” to a degree that was similar to diazepam (30mg,
single dose).

Pregabalin does not have any studies that show addiction to it. It is interesting that recreational users of drugs would rate it as similar to benzodiazepines (part of the class of drugs these drug users desired). Pregabalin, the only drug approved for the treatment of fibromyalgia, is not an opioid (a natural or synthetic derivative of the opium poppy, related to morphine). The idea of using opioids to treat fibromyalgia is not one the FDA appears to be endorsing.

I am very liberal with pain medicine (when OLMC allows it) and I do not take pain lightly.

Encouraging people to lie there, and to give in to the pain, is just the wrong approach. The more you give in to the pain, the more pain medicine you need, the more you become dependent on pain medication, the less you are able to take care of yourself, the more you become a victim of your own response to the pain.

You become your own victim – not a victim of the chronic pain.

This is tragic. The epitome of tragedy, Hamlet, said –

there is nothing
either good or bad, but thinking makes it so: to me
it is a prison.

O God, I could be bounded in a nut shell and count
myself a king of infinite space, were it not that I
have bad dreams.

That last line confuses many people, not having the ability to understand Hamlet’s “bad dreams,” but it would never work if he were to say, were it not that I have fibromyalgia.”

Hamlet’s dead father would come to him in his dreams and tell him that he was murdered by Hamlet’s uncle, who is now also Hamlet’s step father and the new King. Very unhappy times for Hamlet and this is just the beginning!

Hamlet may have been the prince of despair, the Shakespearean character most likely to whine, but fibromyalgia would never have worked for him.

Maybe it was King Lear with his prove to me that you love me, or Othello with his willingness to let Iago convince him that his wife was fooling around, but Shakespeare knew how to write tragedy. All of these responses to adversity prove to be tragic. And fatal. And whiny.

Was Nurse K being inappropriate?

Not at all. Chronic pain patients would be better off listening to her, than those who say just lie there and suffer, but do it dramatically.


How EMS Manages Pain

In my last post Burns and Pain and Little Kids, I wrote about a case of bad pain management.

The comments included a lot of discussion of how EMS handles pain management.

I was talking with another medic and the topic of pain management came up. Not the first time that has happened.

One of the problems in EMS is that medics are trained to believe that morphine is some dangerous, magical drug that will sneak in on little cat paws and steal your patient’s breath away. This is told to us by doctors, nurses, and other medics – even non-medical personnel.

We frequently treat respiratory depression in EMS. And we often overreact when we do.


Read Ambulance Driver‘s article on EMS1.comThe Airway Continuum. The comparison between airway management and police use of lethal force is a useful one. Why do we automatically leap to the most invasive approach to airway management?

Conversely, why do we leap to the paranoid expectation of respiratory depression and respiratory arrest, when dealing with pain management?

This is an EMS version of an Urban Legend.

A site that is devoted to finding the truth about urban legends is Snopes.com. We have some people who provide the EMS version of urban legend debunking. AD does that, but he does not go far enough in this article. Not that he might think he exhausted airway management in this one article. AD could go on for days with only a pause for something to whet his whistle. And it would be entertaining, even if he does occasionally plagiarize himself.

Airway management is far more complex than “Intubate ‘Em All and Let Respiratory Sort ‘Em Out.” EMS protocols often do not acknowledge this.

Another problem with the use of morphine is the rush to use naloxone when there is any uncertainty about the patient’s respiratory status. This questionable nature of the respiratory drive should encourage a much more conservative approach. AD discusses this in Naloxone: The Most Abused Drug in EMS.

Pain management is also a far more complex treatment than “One Dose Fits All.” It is also something where “One Drug Fits All,” does not apply. Morphine is commonly used to manage pain, but it is far from a good drug for EMS. The big thing morphine has going for it is Tradition!

But the worst tradition associated with morphine is the dosing. If you are good, you may receive orders to treat an adult with 2 mg morphine. If you are really good you may receive orders to repeat that dose One Time. At least from some OLMC doctors.

The Danger.

The Peril.

The Horror.

There are some big problems with this approach. Pain management is not about rewarding paramedics with aggressive doses for good behavior. These doses that aren’t really even close to aggressive.

Pain management is about providing appropriate care for the patient.

Why is it that paramedics have to fight with some OLMC (On Line Medical Command) physicians for permission to appropriately treat patients?

Why are some doctors such vigorous opponents of appropriate pain management?

Why are some doctors such vigorous opponents of appropriate patient care?

Opponents of appropriate patient care? How can I say that about doctors?

A patient in moderate to severe pain.

A patient with no real contraindications to morphine (if hypotensive, no real contraindications to fentanyl).

A patient who will benefit from the treatment.

A patient too often denied appropriate pain management.

A patient too often denied any pain management.

Now, back to my talk with my friend.

He had a patient with a probable hip fracture. His partner insisted on calling OLMC for orders, even though they have standing orders. OLMC gave orders for 4 mg of morphine – much less than is available on standing orders.

Here are the standing orders for isolated extremity trauma:

(Choose one)
Fentanyl 50-100 mcg IV/IO 6,7 (1 mcg/kg)
may repeat ½ dose every 5 minutes until maximum of 3 mcg/kg
Morphine sulfate 2-5 mg IV 6,7
(0.05 mg/kg)
may repeat dose every 5 minutes
until maximum of 0.2 mg/kg
Nitrous Oxide (50:50) by inhalation 8

If we assume that the patient weighs 50 kg (110 pounds), then the standing orders would allow for the patient to receive 10 mg of morphine before having to call command for orders to give any more pain medicine. Not that those orders are likely to take into consideration that the patient is still in pain after 10 mg of morphine – only the “recklessness” of requesting to give more than 10 mg. This is the world of EMS pain management. Pain management isn’t about the patient. Pain management isn’t about appropriate care. Pain management is commonly about treating medical command for discomfort.

If only medical command were familiar with research on EMS pain management, such as I described in Public Perception of Pain Management.

Look at the standing orders again. In the system where he works, the medical director does not allow them to carry nitrous oxide or fentanyl. The medical director does not appear to have any plans for EMS to carry these drugs. The medical director does not encourage the use of the pain management standing orders.

One way that the medics are discouraged is by being labeled “Too Aggressive.”

I once did some ride time with them and was told that they did not want to hire me because some of the medics I rode with said I was too aggressive and others said I was not aggressive enough.

My interpretation of that was that I am Goldilocks’ porridge. Their interpretation was lacking in literary reference. They probably would have labeled me an Upstart.

You can see where the problem is in EMS. When it comes to pain management, it isn’t about patient care. There are several other things that are considered before the well being of the patient is considered. The other things that are considered can all veto the standing orders.

Then there is the problem of pain that is not due to an extremity injury. If the pain is not from an isolated extremity injury, then the pain is categorized as “too risky” to treat.

Not that this is based on research, these are doctors after all, their expert opinion is to “That’s the most foul, cruel, and bad-tempered medicine you ever set eyes on!” and “Look, that morphine’s got a vicious streak a mile wide! It’s a killer!” and “He’s got huge, sharp… er… He can leap about. Look at the breathing!”

It is true, the bunny in Monty Python and the Holy Grail was a killer. At times morphine can produce respiratory depression that can be a killer, too. Just not when well trained medics use it to appropriately treat their patients’ pain. Titrating the dose to the patient’s pain. The well trained medic is the Holy Hand Grenade of Antioch that counters the respiratory depression from a larger than appropriate dose of morphine, or any opioid.

If only the medical director would insist that the medics be competent in the use of the medications that the medics carry, instead of discouraging the use of the unpopular ones.


Burns and Pain and Little Kids

The ambulance is already on scene, bringing the little girl and mother out to the ambulance.

Everyone is looking to see what is going on.

Who could be making so much noise?

The noise is not from the ambulance, not from my truck, not from the police cars, nor from any of the emergency noise makers you would expect.

The noise is from the little girl screaming.

Piercing all sound barriers.

All except one.

We place her in the ambulance ask a couple of questions and then start to the specialty hospital that is both a burn center and a pediatric center. We have too many people on the ambulance – Dad up front, 2 EMTs in back with me, Mom, and our little patient. We’re not really at clown car capacity, but the amount of room is not as comfortable as I would like. Rather than be able to spread out my gear and have easy access to it, I need to pass my bags to the EMTs, so they can pass individual items back to me. On some calls this might be a problem, but this will not be one of them.

Mom is sitting across from me, on the other side of her daughter, holding her daughter’s hand. Looking for someone to ease her daughter’s pain. All of the right people showed up with all of the right equipment to do just that. Everything is working as it should when a well trained group of people, who do this on a regular basis, work together.

Mom is feeling so much guilt for her inability to protect her child. Feeling she has betrayed her child – allowing a curious child, and what healthy child isn’t curious, allowing a curious child to see the handle of a pot calling to her.

The handle is tempting her from over the edge of the stove.

It is making funny noises.

What is going on there?

What child doesn’t want to know?

Well, Mom feels guilt for not being there to stop the inquisitive climbing, the reaching for the pot.

Guilt for not being able to have the scalding, boiling water land instead on Mom and spare her daughter.

Guilt for not keeping up with the developmental progress of her daughter, ever exploring the unknown.

Guilt because today the monster was not just an imaginary one in the closet.

And she was not able to protect her daughter.

The little girl did pull the pot down onto her chest, onto her arms, onto her legs, and onto her diaper.

Mom deserves praise for being smart enough to immediately remove the diaper and prevent far more serious burns from developing. We forget that diapers are designed to trap water. Trapped boiling water on the groin is sometimes overlooked in the panic following a scalding of a child.

The screaming is not likely to be any worse if the child’s groin is being scalded, but the pain she feels could be worse.

Her expression of pain is 10/10, right now. Can her pain get any worse?

Yes, her pain can get worse, but how can she express it any differently, any more clearly?

She probably cannot.

But Mom has prevented the worst part of the scalding through her quick action of removing the diaper. Telling Mom this does nothing to ease her pain or her daughter’s pain.

I call OLMC (On Line Medical Command) for orders for some morphine to help ease the baby’s pain. Morphine is not the best drug for this, but it is traditional and medicine is enamored of tradition. Fentanyl is much safer.

Dr. No Narcs answers the OLMC phone. Inside I cry, but even he would not force this patient to continue to suffer extreme pain, would he?

He tells me not only does he not want me to give any morphine, he does not want me to start an IV, but he does want me to keep sterile dressings on the burns. He is board certified in both emergency medicine and internal medicine. All of that education is wasted when it is not used. He doesn’t seem to know a thing about EMS or a patient’s experience of pain.

Calling another hospital for medical command, after you have been refused orders, is discouraged. Since it would be irresponsible of me not to call the destination hospital, where they do not know me, I call. They are no better than Dr. No Narcs.

Unknown Useless Doctor – We’ll manage the pain when you get here.

RM – But she’s in severe pain. Can’t you hear her.

UUD – I do not appreciate medics questioning my orders.

RM – I’m not asking for the orders for me – I’m not the one in pain.

UUD – Bring the child in and leave the medicine to the doctors.

I am having a Richard III moment, but I have no kingdom to offer in exchange for a competent doctor. My patient suffers tragically.

We arrive at the hospital (a burn center and a pediatric hospital). By now the little girl is having periods of unresponsiveness, not that I attempt to awaken her – she is already receiving far too much painful stimulus.

Her periods of unresponsiveness are lasting about 5 seconds at a time. She is exhausted. Whatever energy she had that might have been needed to help her heal, has been dramatically diminished.

The doctor, one of the pediatricians, is going to start an IV personally. The doctor is not exactly trusting the ED staff to do this. I am reminding the doctor about the obvious pain. Should anyone need any reminding with a screaming child?

The doctor states that oral acetaminophen with codeine will be enough.

The area is overflowing with university medical centers, yet physicians who understand pain management are as scarce as hen’s teeth.

The doctor gets the IV on the first try, but the little girl pulls away before it is secured. Two more unsuccessful attempts, then success. Before securing the line, the doctor gives one milligram of morphine. By now, the little girls unresponsive periods have increased to 15 seconds long and about a minute apart.

Now, over an hour after pulling the pot off of the stove, she has some relief. With the morphine she sleeps. How appropriate. How inappropriately delayed.

Oh, don’t pretend you know what is best for this child – what if she stops breathing?

She would have to stop thrashing about violently for respirations to even begin to be a concern. We are having trouble just keeping her on the stretcher, never mind keeping sterile dressings on for even the 8 second bronco riding time.

Stops breathing?

As in the respiratory rate drops down from 60 breaths per minute to 50 breaths per minute?

Or to 40 breaths per minute?

That really would be a problem؟

This child is nowhere near respiratory arrest.

If there should be any question about the respiratory drive, and the medic misses the signs, what would make anyone think that Mom will be anything other than alarmist about any problem with her baby’s breathing?

She is feeling under-protective and feels a need to atone for that. Will she remain silent?

What about the medic, only an arm’s length away from the patient?

How could a competent medic miss dangerous respiratory depression in this child?

The only way this can be justified is if you allow dangerous medics in the system.

Do we knowingly endanger the population of patients by scattering hand grenades with faulty pins among the people they turn to for protection?

That would be completely wrong, but does not seem to be uncommon.

Mom felt guilt for not protecting her daughter from a foreseeable dangerous situation.

I feel guilty for being a good little Nazi and just following orders.

Orders designed to allow medical directors to feel comfortable endangering patients and allowing them to delude themselves that they are protecting those patients.

I have betrayed my patient by following the orders of not one, but two different indifferent medical command doctors who refused to allow for the treatment of a tiny patient – a patient they could clearly hear over the phone.

Hippocrates would never have approved of this.

To have the means of easing a patient’s pain, but to refuse the treatment to the patient.

Why is OLMC sometimes the sound barrier impervious to all entreaties?

I continue this and expand on some of the comments in:

How EMS “Manages” Pain.