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

- Rogue Medic

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19 – April 9, 2020

All of the revised guidelines are at the end.

Treatment of cardiac arrest in the time of a pandemic requires changes to the ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), and NRP (Neonatal Resuscitation Program) guidelines. These were written specifically for COVID-19, but would apply just as well to any other pandemic with the possibility of aerosolized respiratory transmission.

Who is making these recommendation?

From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians[1]

Why are these recommendations being made?

Hypoxemic respiratory failure secondary to acute respiratory distress syndrome (ARDS), myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest,5-8 as do some of the proposed treatments, such as hydroxychloroquine and azithromycin, which can prolong the QT.9 With infections currently growing exponentially in the United States and internationally, the percentage of cardiac arrests with COVID-19 is likely to increase.

Healthcare workers are already the highest risk profession for contracting the disease.10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of approximately 1 hour and be inhaled by those nearby.11 Second, resuscitation efforts require numerous providers to work in close proximity to one another and the patient. Finally, these are high-stress emergent events in which the immediate needs of the patient requiring resuscitation may result in lapses in infection-control practices.[1]

Will the changes decrease chances of successful resuscitation?

Yes. That is unavoidable, but DNRs (Do Not Resuscitate orders) and POLSTs (Physicians Orders for Life Sustaining Treatment) also decrease the chances of successful resuscitation. These changes are still the right thing to do.

How do these changes decrease the chances of successful resuscitation?

There is more focus on successful intubation – at the expense of continuous chest compressions. Chest compressions definitely improve outcomes, while there is no evidence that intubation improves outcomes – and there is evidence that intubation decreases successful resuscitation.

Prioritize oxygenation and ventilation strategies with lower aerosolization risk

● Use a HEPA filter, if available, for all ventilation
● Intubate early with a cuffed tube, if possible, and connect to mechanical ventilator, when able
● Engage the intubator with highest chance of first-pass success
● Pause chest compressions to intubate
● Consider use of video laryngoscopy, if available
● Before intubation, use a bag-mask device (or T-piece in neonates) with a HEPA filter and a
tight seal
● For adults, consider passive oxygenation with nonrebreathing face mask as alternative to bagmask device for short duration
● If intubation delayed, consider supraglottic airway
● Minimize closed circuit disconnections[1]

The AHA is now telling us to stop compressions to help minimize the number of intubation attempts, but not because intubation is going to improve outcomes for the patient. This is to protect everyone near the patient from aerosolized infectious material. An endotracheal tube with a HEPA filter is not an absolute protection, but intubation with a HEPA filter is probably best at preventing spread of aerosolized infectious material than other methods of ventilation and probably even better than passive ventilation (compression only resuscitation with a mask over the patient’s mouth).

Because our patients will now have a lower chance of a good outcome (being resuscitated with good brain function), we should also be more selective about whom we attempt to resuscitate. Too many of us have only been going through the motions, because we have refused to recognize futility, or our medical directors have refused to let us recognize futility.

Even though this lower chance of a good outcome is still better than before we focused on chest compressions, more patients should not have resuscitation attempted.

Consider resuscitation appropriateness

● Address goals of care
● Adopt policies to guide determination, taking into account patient risk factors for survival [1]

The other import consideration is the transport of family members.


o Family members and other contacts of patients with suspected or confirmed COVID-19 should not ride in the transport vehicle.
o If return of spontaneous circulation (ROSC) has not been achieved after appropriate resuscitation efforts in the field, consider not transferring to hospital given the low likelihood of survival for the patient,17 balanced against the added risk of additional exposure to prehospital and hospital providers.[1]

Unfortunately, footnote 17 is to page 16 of CARES (the Cardiac Arrest Registry to Enhance Survival), which is about using CARES in Ohio. I suspect that this was meant to refer to something else, so the wrong citation was provided in the rush to get new guidelines on line quickly.

17. CARES: Cardiac Arrest Registry to Enhance Survival. 2018 Annual Report.


Below are all of the new AHA algorithms (they are also available in PDF format at

AHA – COVID-19 Recommendations – BLS Healthcare Provider Adult Cardiac Arrest Algorithm [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – ACLS Cardiac Arrest Algorithm [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – PALS Pediatric Cardiac Arrest Algorithm [1]

Click on the image for full size.


[1] Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians.
Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, Berg RA, Bradley SM, Brooks SC, Cheng A, Escobedo M, Flores GE, Girotra S, Hsu A, Kamath-Rayne BD, Lee HC, Lehotzky RE, Mancini ME, Merchant RM, Nadkarni VM, Panchal AR, Peberdy MAR, Raymond TT, Walsh B, Wang DS, Zelop CM, Topjian A.
Circulation. 2020 Apr 9. doi: 10.1161/CIRCULATIONAHA.120.047463. [Epub ahead of print]
PMID: 32270695

Free Full Text from the American Heart Association in PDF format

This page is the abstract from the American Heart Association. It has a tab for PDF/EPUB, but the link only provides the PDF link above.


Honoring a Do Not Resuscitate tattoo in an unconscious patient

Also to be posted on ResearchBlogging.org when they relaunch the site.

The DNR (Do Not Resuscitate) tattoo is the kind of problem that leads doctors, nurses, and EMS to pretend to be lawyers, lawyers to pretend to be ethical, and patients to be treated against their wishes.

EMS transports a patient to the emergency department. The patient has a chest tattoo of Do Not Resuscitate and what appears to be a signature.

Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level.[1]


It appears that they have access to the patient’s history, but they do not have information about a DNR in the history.

Because he presented without identification or family, the social work department was called to assist in contacting next of kin. All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.[1]



The patient does not currently appear to need an invasive airway, or anything else that would be prohibited by a DNR, so there is time to consult with others.

This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested.[1]


Do we honor the stated, although perhaps not letter of the law until after a court decision, DNR?

If you want to be resuscitated, do not tattoo DNR, or Do Not Resuscitate, on your chest.

But what if he did it while drunk?

There was a case of a patient doing that.

When asked why his tattoo conflicted with his wishes to be resuscitated, he explained that he had lost a bet playing poker with fellow ancillary hospital staffers while inebriated in his younger years; the loser had to tattoo “D.N.R.” across his chest.[2]



They are called Darwin awards for a reason.

Hold my beer and watch this is not usually the start of a tale of wisdom, but of providing a learning opportunity for others.

It was suggested that he consider tattoo removal to circumvent future confusion about his code status. He stated he did not think anyone would take his tattoo seriously and declined tattoo removal.[2]


After driving to the bar, while sober, an individual decided to drive home, while drunk.

The person should clearly not be held accountable for a decision made while drunk.

A person puts a mask on and uses a cap gun to hold up a store where a friend works, because that kind of thing is funny. Someone calls 911, or . . ., and the humor loses something in translation to reality.

I can be very silly, but I take the wishes of the patient seriously.

If a DNR tattoo was a joke, well, that was may be a bad decision, because you don’t know who is going to be deciding how to treat you when you are not capable of expressing your wishes competently.

The EMS laws tell me that I should always start CPR (CardioPulmonary Resuscitation), while calling a doctor for permission to stop, because the wishes of the patient are less important than the wishes of the doctor on the other end of the phone.

I know too many immoral doctors, nurses, and EMS personnel.

For example, a patient who has a clear DNR, clearly states that intubation is not wanted, but is deteriorating. The doctor occasionally returns to ask the hypoxic patient, Do you want to breathe? The patient keeps indicating that intubation is not wanted. Finally, the patient, through surrender to the harassment or disorientation secondary to hypoxia, says, Yes.

The doctor gets to perform a procedure and satisfy himself that the right thing was done, because it is what the doctor wanted.

Is that an extreme example? It was not seen as extreme a couple of decades ago. Maybe today it is recognized as abuse, because we recognize that the purpose of patient care is to take care of the patient, not the doctor, not the nurse, not EMS, not the supervisors, and definitely not the lawyers.

But you have to obey orders. If the military did not obey orders, we would have chaos.

Even the military does not require that anyone obey any unlawful order.

Any person subject to this chapter who–

(1) violates or fails to obey any lawful general order or regulation;
(2) having knowledge of any other lawful order issued by any member of the armed forces, which it is his duty to obey, fails to obey the order; or
(3) is derelict in the performance of his duties;

shall be punished as a court-martial may dire(ct.)[3]


Refusing to follow unlawful orders is not easy.

People in EMS will often state that the reason they did something wrong (as in something bad for the patient) is that they did not want to get yelled at by the doctor and/or nurse.

Clearly, our integrity is not what it should be.

Should we only go out of our way for the patients we like? No. My objection to using the guy who obtained the tattoo while drunk, abd does not want to remove it is nothing to do with his drinking or his bad decision, but with his lack of concern for others. My concern is for people who do care what is done to them, regardless of the lack of concern of this uncaring patient.

Of course, the uncaring patient has had the opportunity to have this explained to him and he has decided to live with that risk. He may not have made the best decision, but it is his decision and it probably will not affect him.

But the person with just a tattoo does not have a legal tattoo!

Maybe it is not legal.

Maybe it is legal.

That is for a lawyer to decide.

As the article states, this patient has gone to extraordinary effort to make a statement with this tattoo.

In the absence of something to show that the tattoo does not express the patient’s informed decision, I accept it as expressing the patient’s wishes.

If I am there it is to take care of the patient, not the medical command physician, not the protocol, not the quality control department, not the legal department, not the supervisors, not the doctors, or nurses, in the emergency department, . . . .

When our medical and legal systems are so broken that we feel that we are forced to harm our patients to be able to do our jobs, we need to stop making excuses and start to change things.


[1] An Unconscious Patient with a DNR Tattoo.
Holt GE, Sarmento B, Kett D, Goodman KW.
N Engl J Med. 2017 Nov 30;377(22):2192-2193. doi: 10.1056/NEJMc1713344. No abstract available.
PMID: 29171810

Free Full Text from NEJM.

[2] DNR tattoos: a cautionary tale.
Cooper L, Aronowitz P.
J Gen Intern Med. 2012 Oct;27(10):1383. Epub 2012 May 2. No abstract available.
PMID: 22549297

Free Full Text from J Gen Intern Med.

[3] UCMJ 892. Article 92—Failure to obey order or regulation.
Uniform Code of Military Justice
Subchapter 10
Punitive Article


Comment on Why Did We Remove Atropine From ACLS? Part I


In the comments to Why Did We Remove Atropine From ACLS? Part I is this from BLS in Wichita

Another important question…why are we even attempting resuscitation on many of the patients we encounter in sudden cardiac arrest. Many of these lives are not savable, yet it’s all hands on deck for a wasted heroic effort. We dump tons of resources in to a futile effort.


We do.

The AHA (American Heart Association) continues to try to come up with better answers for these problems, but they are often not easy to solve.

Shouldn’t we be applying our resources where they are needed most, rather than on an octogenarian with multiple medical problems and stage 4 cancer?


That raises some important questions.

If ACLS is for hearts too good to die, then why apply it to people who are dying from other causes?

It now seems possible that with an adequate program of prevention, continuous monitoring and with a prompt aggressive approach to the prevention and ablation of serious cardiac arrhythmias, fewer acute coronary patients will be dead with “hearts too good to die.”[1]



This is from 1967, so there is mythology that has been discarded, such as the need to give atropine with morphine to avoid arrhythmia.

However, they do describe their rate of successful defibrillation to some sort of improved outcome.

What is the improved outcome?

ROSC (Return Of Spontaneous Circulation)?

Survival to non-arrhythmic death?

Survival to discharge?

We do not know.


13% survival to discharge would be good for 1967, especially since the expected alternative would be death, but is it 13% survival to discharge?

One reason we try to resuscitate far more people than just the hearts too good to die is that arrhythmia is not the only reversible cause of cardiac arrest.

Another reason is that we refuse to differentiate between quantity of life and quality of life.

We also are not good at recognizing our limitations.

What about a DNR (Do Not Resuscitate) order?

Some patients do not have the kind of DNR that EMS is permitted to follow, so we are required to call medical command for orders to follow a legal document that says don’t do all of the things that we do.

We can be a very destructive force once we are set in motion, because we are required to do things that we would be prohibited from doing to other people outside of EMS – and we are not good at recognizing this.

Some EMS providers will decide that it is more important that they attempt resuscitation, than respect the legally valid decision of the patient – and EMS rules do not discourage this.

The patient knows why he does not want to be resuscitated, but some of us only respect a patient when the patient makes the decision we want him to make.

A couple of EMTs from the local ambulance company responded to a call I was dispatched on for difficulty breathing. The patient was about 50 years old and had a DNR. The DNR did not affect care on that call, but both EMTs (older than the patient) stated that they would refuse to honor the DNR, because He is too young to have a DNR.

We have people who think they are helping, but are making things worse.

These are people who should not be in EMS.

EMS is not about taking care of the patient not taking care of our egos.

If the patient’s wishes do not match our desires, we need to grow up and provide patient care.

Resuscitating an octogenarian is something that is not bad. An 80 year old male is expected to live for 8 more years, while an 80 year old female is expected to live for 10 more years.

Quality of life is important. Having stage 4 cancer and being resuscitated to be able to have another painful death is not good patient care, unless that is what the patient wants.

We need to pay attention to quality of life and patients’ wishes and stop trying to force patients to live according to our prejudices.


[1] Hearts too good to die–problems in acute myocardial infarction.
Johnson JB, Cross EB.
J Natl Med Assoc. 1967 Jan;59(1):1-6. No abstract available.
PMID: 6038580 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.


The Living Will and Senate Testimony From Terry Read

Terry Read sent me an email with a scan of his father’s living will and a link to the Texas Senate Hearings (the link is also in the comments to Terry Read Comments on the Death of His Father and the Living Will).

Rogue Medic,

I say that I know what happened based on the fact that I was there and went through it.

My point is that this is a very emotional experience. People regularly make mistakes in describing events. For example, in the testimony given by you and by your mother, you contradict each other. Does that mean that one of you is telling lies?

No. It means that our observations depend on many different things, as do our memories.

You are basing your comments on your speculations. So anything that I say certainly has more weight than what you say.

Yet, I can show that your statements are inconsistent, even though I was not there.

Eyewitness testimony is unreliable.

As far as the San Antonio Fire Department not initially cooperating, why do you think this has been going on for so long?

Please provide some evidence to support your conclusion.

You claim that this took a long time. Compared to what?

You claim that the SAFD did not cooperate with someone. Whom did they not cooperate with and what evidence do you have that they did not cooperate?

The investigation took a long time because the Fire Department was not answering the DSHS investigator.

Do you have any documentation to support that claim?

Have you read HB 577. It says “
SECTION 1. Section 166.102(b), Health and Safety Code, is
amended to read as follows:
(b) When responding to a call for assistance, emergency
medical services personnel:
(1) shall honor only a properly executed or issued
out-of-hospital DNR order or prescribed DNR identification device
in accordance with this subchapter; and
(2) have no duty to review, examine, interpret, or
honor a person’s other written directive, including a written
directive in the form prescribed by Section 166.033.”

So Rogue Medic, treatment by the paramedics may still be terminated, but not by not by the Living Will.

That is not true.

EMS may still contact medical command, as they did in the case of your father, and follow medical command orders. Even the person reading the bill in the video states that specifically.

Resuscitators’ efforts can still be stopped if the patient’s personal physician is present and approves it. If the physician is not present, the medical director of EMS can make the decision.[1]

HB 577 does not state that EMS may not honor a living will.

It is offensive that you would prevent people with living wills from having their wishes followed just because of one unusual, but personal, case.

The State EMS Director admitted the person on the other end of the phone may not be a doctor during the House Committee hearing in which I testified.

An out of context description of a comment is useless. What did the person say? What did the person mean? What was the context?

If a movie reviewer describes a movie as “A tremendous waste of time.” Advertisements for the movie could quote the reviewer as calling the movie “Tremendous.”

That would be tremendously out of context and not at all helpful. You misinterpret HB 577, but you expect me to accept your interpretation of something else? Why?

Through the Open Records Act, I have requested minutes of the meeting, but have not gotten them yet. I am not sure how detailed the minutes are. But you are certainly welcome to make the same request. It was the House Public Health Committee Meeting for April 20, 2011 – for HB 577.

That would be nice.

The lead paramedics stated it would be against the law to continue when I told the paramedics not to stop treatment. Then when I tried to get to my father, the paramedics ganged up on me, wrestled me down, and threatened to have me taken away in handcuffs.

Criminal law, civil law, EMS law, company policies, something else?

Plenty of people will tell you that treating a patient in violation of a doctor’s order is practicing medicine without a licence. I disagree with that interpretation of violation of a doctor’s orders, but that may have been what the paramedic meant, assuming the paramedic actually made that statement.

As far as the Living Will, I can ask WOAI to post. But in the meantime, what would you like me to do, scan it and shoot it to you? Would you like me to photocopy it and mail it to you? If you provide a mailing address, I will do that. Would you like to meet in person and have me show it to you personally? If you do, I am sure we can arrange a meeting.

Below is the living will.

This is a scan of Samuel Read’s living will sent to me by Terry Read. I have edited it to remove the Social Security Number and to convert it to JPEG format. Click on the image to make it larger.

But I am a little curious. Will any of this satisfy you? Also, if you watch the story, what do you think that I was showing to Mireyea Villarreal? I was going over the Living Will with her.

How would I know what you were showing her?

Why would I jump to any conclusions about what you were showing her?

If they had the document, competent journalists should have provided at the very least the wording of the document, but that was not done. In the absence of evidence, the most reasonable conclusion is that the document does not support your claims.

You seem to think I have been hiding something when I have not.

I have only been asking for evidence to support your claims and making the most reasonable conclusions about the evidence available.

As far as a patient not wanting resuscitation, they still have the option of a DNR.

The rules affecting advance directives need to be dramatically rewritten.

What you mean to state is that they still have the option of an Out-Of-Hospital DNR.

If they have a standard DNR, which is not an Out-Of-Hospital DNR, the rules are the same as for a living will.

This is abusive and unfair to patients.

You are supporting abuse of patients with wishes different from your father’s.

The link below will take you to the 82nd Legislatures Senate Committee on Health and Human Services Sessions. Our Testimony is on the May 17, 2011 session. HB 577 is the second bill being testified on. My mother and I begin testimony at about the 7:40 mark.


You can hear my mother and myself both testify that the Living Will called for examination by two physicians, and my mother had power of attorney. None of those things happened. This is what we testified to before a Senate Committee. Do you think both my mother and I committed perjury?

You and your mother gave different descriptions of the events of that day. Not just slightly different, but contradictory. Does that mean that either, or both, of you committed perjury?

You still do not understand how unreliable eyewitness testimony is. You and your mother were eyewitnesses to the same event and provide descriptions that do not agree.

Do you think that a copy of the Living Will was not supplied to Representative McClendon’s office in their investigation?

Should I assume that Rep. Ruth McClendon has any understanding of advance directives?

Absolutely not. Look at the wording of this bill. This is written so that lawyers will be involved. As I stated before, in Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas,

Also, do you think that the Living Will was not provided to the Department of State Health Services in their investigation?

Did the Department of State Health Services find any fault with SAFD?

Chief Grenato says paramedics on scene reviewed Sam Read’s living will with a medical expert over the phone; then decided to stop treatment. The state has reviewed this case and cleared the department of any wrong doing.[2]

The state has reviewed this case and cleared the department of any wrong doing.

If my mother and I both committed perjury on what was in the Living Will, all of these parties would know it.

Why do you assume that anything that is not perjury is the truth?

You can make the statement that you have not perjured yourself, but that does not mean that what you stated is the truth, the whole truth, and nothing but the truth.

Truth and falsehood are not clear black and white issues. Otherwise, you and/or your mother have perjured yourselves by giving different testimony.

Since all of these parties did not come to the same conclusion, there must be more to this than you understand, which is what I have been stating from the beginning.

For example, let’s compare the testimony given by your mother, where you were not handcuffed and your testimony, where you were handcuffed.

They then threatened to handcuff him and take him away and stated that that would not bother him at all.[1]

and I tried to get to my father to continue treatment myself. They wrestled me down and had me taken away in handcuffs, so I had to give up at that point.[1]

Whom should I believe? Is this perjury? Did you just make a mistake?

The state has reviewed this case and cleared the department of any wrong doing.

Also, note that the State EMS Director was not at the Senate Committee Meeting after having gotten questioned at the House Committee meeting.

OK, but what does that mean? Does it mean anything? Does it signify anything other than the person having limited time and many responsibilities?

One more thing, I am almost 49 years old and have a 4 year old son that my wife and I prayed many years for. And like you, I have other interest as well. Do you think I would have devoted the tremendous amount of time, energy, and emotion to this effort, as I am still doing, if I did not know that the wrong thing had really happened? I have gained nothing from this financially. The only thing I have gained is recognition that the wrong thing happened. And even now, I am still dealing with people like yourself.

Terry Read

I repeat that you are very emotionally involved in what happened and that has affected your actions. I do not know what a daughter, prayer, or time have to do with this. People do plenty of things voluntarily, but that does not mean that they are right. You are comparing things that are completely unrelated.

If the paramedic contributed more of his energy, more of his free time, and spent more of his money contradicting you, would that make him more reliable than you? He was there. What if he has half a dozen children? Would that affect what is true?

On political issues, people on differing sides contribute a tremendous amount of time, energy, and emotion to this effort, but that does not mean that both sides are right, or that one side is right and the other side is wrong.

You ask me to read your mind. Mind reading is what scam artists do. I look at evidence.

Time, energy, and emotion do not determine the truth.

Your justifications only discourages trust in your judgment.

Is it true that EMS personnel are not capable of interpreting a simple document?

Or is it that the lawyers write unnecessarily complicated documents to discourage others from interpreting these documents.

What if we educated EMS personnel (and nurses and doctors) about the application of advanced directives and simplified them. For example, my suggestion for a living will clearly state at the top of the page what minimum requirements need to be satisfied (based on those from Samuel Read’s living will). This is just one possible way of improving the communication of the patient’s wishes.

All of this could have been prevented by requiring that these documents be written much more clearly, not by arbitrarily assuming that more treatment is better.

Click on the image to make it larger.

If EMS is incapable of interpreting well written advance directives, then EMS clearly cannot provide complicated treatments to any patients. The most complicated EMS treatment algorithms are used for treating cardiac arrest.

Should we only provide treatment that is simple and easy?

Would patients be better off with less treatment, so that we don’t have to think? Mr. Read, in his testimony, states that more treatment is better.

That is not true. What we need is more appropriately applied treatment.

Defending the incompetence of the legislature in writing rules for advance directives is not good for patients.

We need to stop lowering our standards to accommodate those who least understand.


[1] Video of May 17, 2011 testimony
Texas Senate
Page with link to video in Real Media format

[2] EMS workers stop medical treatment after reading will in the field
Mireya Villarreal
July 27, 2011


Terry Read Comments on the Death of His Father and the Living Will

Over at Medic Madness, Terry Read responds to some of my comments on the handling of his father’s death. Since when is it not our responsibility?

Rogue Medic,
By your definition of “unreliable”, all witnesses would be unreliable. Military people being interviewed on the History Channel about a battle could not be trusted.

All witnesses are unreliable.

It is only by comparing the different descriptions of the same events that we are able to determine what is closest to the truth.

Take a look at the Rashomon effect. The story and film, Rashomon, are 94 years old and 61 years old, respectively. This is not something new. Even ancient Solomon had a memorable way for evaluating the accuracy of witness accounts. Solomon’s sword is memorable, but rarely helpful.

Witnesses are unreliable.

Believe me, I know what happened.

This is what I often hear as justification for not examining facts. Perhaps with an offer to buy something that is too good to be true.

So does the San Antonio Fire Department. That is why they were so reluctant to cooperate with the Department of State Health Services (DSHS) in the investigation.

Please provide some evidence that they were reluctant to cooperate.

In defending the DSHS decision to clear the Fire Department and the Paramedics, The State EMS director said the “policies are locally determined”. Representative Zerwas said “If that is the policy, that concerns me more”.

Yet the law the Texas Legislature passed does nothing that would change what happened.

EMS called medical command. EMS would still call medical command for orders to discontinue CPR in the case of anything that is not a Texas Prehospital DNR. This is the same as the rules in Pennsylvania, which need to be overhauled to prevent patients from being treated against their will.

Representative Susan King got the state EMS director to admit that the person at the other end of the phone may not even be a doctor.

Please provide some documentation to support that claim. If any such statement was actually made, the context in which it was made.

When asked about the paramedics stating that it would be against the law to continue, the state EMS Director said, “that was a misunderstanding”

It may be against EMS policies to continue, but not against criminal law. Did anyone actually state this? If someone did say this, in what context was that statement made?

Also, if you actually listened to my story, you would know that I have stated all along that the lead paramedic went into the other room and got on the phone with someone. Then came out and said “Stop!”. So I never claimed that the paramedics were not in contact with another party. But the lead paramedic did have a key role in interpreting by reading the Living Will over the phone. And obviously he did not read the entire Living Will. Have you gone to the WOAI website to read the Living Will in its entirety?

I have read the full story. I have only seen what you put in the comments. I have not seen the actual document anywhere.

You have demonstrated that you are clearly the one who is unreliable. You were asking why I did not produce the Living Will when I had posted the Living Will on the WOAI website just a couple of days after the story. If you read the Living Will, you will clearly see that the Living Will was not followed.

There is no document posted on the web site, only a comment in which you state that what you are copying is the living will.

It is interesting that you now appear to recognize that a living will is not a will.

Not trusting all of the comments on a story does not make me unreliable. Until I have seen the document, I have not seen the document. You are the one with connections to WOAI. Get them to post it.

That fact alone puts the weight of the evidence on my side.

I could claim that your reluctance to post the actual document does exactly the opposite, but I’ll wait until I can see the actual document.

It is fascinating that when I testified before Committees in both the Texas House and Senate, no one questioned my story.

They are politicians. Their job is to create the impression of reacting to a public interest story.

But you do.

I am not a politician.

I am only interested in improving patient care and in finding out the truth.

I do not know if you are intentionally misrepresenting the events, if your recollection is colored by emotion, or if you are presenting mostly accurate statements.

You really do need to go to the WOAI website and go through all of the postings if you are really interested in the facts, which I suspect that you are not.

Comments on an article are not facts. If you want to provide facts –

Provide a link to a transcript, or other recording of hearings addressing this.

Provide the actual living will to someone who will confirm its authenticity before posting it.

Image credit.

DNR (Do Not Resuscitate) orders are flawed and always will be. We need to encourage those writing the laws to clarify the wording of these documents, not to come up with more complicated ways of presenting them. The Texas legislature passed a law that does not really change anything except to complicate things.

If the Texas (or Pennsylvania) legislature had any idea of what they are doing they would simplify the documents so that a doctor is able to read these documents at a point when time may be critical in determining what to do.

We should not presume that everyone would want to be treated. We should encourage people to clearly express their wishes, so that their treatment follows their wishes as closely as possible.

There will always be cases where things do not go as planned. EMS (Emergency Medical Services) would not exist if everything went as planned. We are the Help, something went wrong with . . . people.

People should not try to change the rules on living wills to invalidate the wishes of all of those who are conscientious enough try to make their wishes known ahead of time.

Representative Ruth McClendon does not appear to have any idea of how to do this, but she did create the false impression of caring about patients’ rights.

Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas

If we want some living wills to be interpreted by lawyers, then we need to have that written in big letters across the top of each page, otherwise it is the job of EMS to contact medical command to determine what to do. If the document is worded to be interpreted by a doctor, then EMS is doing that by contacting medical command.

The legislature is at fault for creating documents that are not easy for a doctor to interpret.

Legislatures exist to write complicated documents that require the interpretation of lawyers, but that is not surprising, sine they are mostly made up of lawyers. They take what should be simple and complicate it.

End of life decisions, CPR/no CPR, intubation/no intubation, blood transfusions/no blood transfusions are going to be different for different people. We need to respect the decisions of those people. We should not impose our wishes on them.


Reducing Unnecessary Hospitalizations of Nursing Home Residents

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Today in the New England Journal of Medicine there is a perspective piece on something near, and dear, to all of our hearts – unnecessary hospital admissions from nursing homes.

A lot of nursing home patients could be treated on site, without calling an ambulance to take them to the ED (Emergency Department) to produce large bill, but maybe not any better care.

More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days.1 Several studies suggest that many of these hospitalizations are inappropriate, avoidable, or related to conditions that could be treated outside the hospital setting — and they cost more than $4 billion per year.1-3 Avoidable hospitalizations are also common among long-stay residents of nursing homes (see graphs Unavoidable and Potentially Avoidable Hospitalizations of Nursing Home Residents Eligible for Both Medicare and Medicaid, 2005.).2-4[1]

Click on the image to make it larger.

In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid.4[1]

I knew it.

I knew it.

I knew it.

I knew it.

I . . . .

Two caveats are critical. First, not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable. Second, given fiscal constraints and the dearth of health care professionals trained in geriatrics and long-term care, not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population.[1]

Inother words, the patient may be a stable transport to the hospital for a stay of a couple of days, but if the nursing home is not prepared to provide the necessary care, the patient could be unstable by the time an ambulance is called.

Unstable means that we will want to see a valid prehospital DNR (Do Not Resuscitate) order in Pennsylvania. Anything that is not a prehospital DNR and we are supposed to call medical command to receive permission to obey the patient’s wishes clearly documented on a valid legal document. Of course, this is presuming that the nursing home is able to provide any documentation at all.

A note, from the nursing home doctor on a prescription pad pretending to be a DNR order, should result in malpractice charges against the doctor. Not that I have any opinion on the matter, but we should expect more responsible behavior from Dr. Conrad Murray.

You’ve never seen a prescription written in crayon? OK, I haven’t either, but a DNR on a prescription pad is no less valid in crayon than in ink, or even in invisible ink. This is a non-DNR. What does the patient not want done? Who authorized this? Based on what consultation with the patient or family or court appointed representative? The incoherent rambling of dementia are no less valid.

Interventions designed to reduce preventable hospitalizations should therefore be directed at facilities that have the infrastructure, leadership commitment, and culture of quality and safety necessary to undertake more acute care.[1]

I have been impressed lately by some of the nursing home nurses. In different facilities, I have been told, The patient needs IV antibiotics. We can do that here. I don’t know why the doctor is sending the patient to the hospital for something we can provide here.

Maybe the nurses are getting a bit rogue and are not feeling that they are providing good care to their patients by just transferring a patient to the hospital every time the patient has a fever that lasts more than a few hours.

If you were the patient, would you prefer to be placed in an ambulance, on a thin mattress, bounced along just over the rear axle in this ambulance truck, to go to the ED. At the ED, the doctor does not know you, generally does not have all of the documentation he would want (DNR, living will, . . . ) to understand how aggressive to be in treatment. Then you may be admitted for a few days to build up strength for the return ambulance ride.

In many areas of the United States, realistic concerns about legal liability, as well as satisfaction on the part of nursing home residents and their families, affect hospitalization patterns. Thus, tort reform that limits liability for poor outcomes unrelated to the quality of care, and education of residents and families about realistic goals for care and advance care planning that considers the risks as well as benefits of hospitalization, can be key to reducing preventable hospitalizations.[1]

Imagine having the patient, the family, the nursing home staff, and the doctor all communicating about what is best for the patient,


[1] Reducing Unnecessary Hospitalizations of Nursing Home Residents
Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D.
N Engl J Med 2011; 365:1165-1167September 29, 2011
Free Full Text from NEJM

Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D. (2011). Reducing Unnecessary Hospitalizations of Nursing Home Residents N Engl J Med , 365 (September 29, 2011), 1165-1167


Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas

But that answer wasn’t enough for Terry Read. He wanted to do more. And for the last two years he’s been working with State Representative Ruth McClendon to keep this from happening to anyone else.[1]

And what is that horrible thing that happened to Terry Read?

His father died. I can relate to that. My father died.

Terry Reid’s father, Samuel, had a living will. Apparently, Samuel Read’s living will stated that he did not want CPR.

My father also did not want CPR.

When my father collapsed, we honored his wishes.

When Samuel Read collapsed, Terry Read wanted him to stay alive, even though Samuel Read appears to have clearly expressed his wishes in writing. We want our parents to stay alive, but that does not give us the right to force medical treatment on them. Especially not when they have documented their wishes in front of witnesses who have determined that they have the capacity and the information to make this decision.

We are not gods. We cannot keep people alive forever. If we try to keep people alive forever, it is called torture.

Most of the relevant information is not included in the story. Because of HIPAA? No. Terry Read should have the authority to release any information he wants.

Most likely, the problem with the information is that Terry Read is not releasing it, because it does not support his story. He claims that the living will was violated, but where is the violation?

Let’s start with the errors in the story.

The Read family spoke with News 4 WOAI Trouble Shooter Mireya Villarreal and says EMS crews didn’t read the will correctly and made a big mistake.[1]


That is not true.

If you disagree, provide some evidence that anything SAFD EMS (San Antonio Fire Department Emergency Medical Services) did was contrary to the wishes of Samuel Read.

Chief Grenato says paramedics on scene reviewed Sam Read’s living will with a medical expert over the phone; then decided to stop treatment. The state has reviewed this case and cleared the department of any wrong doing.[1]

The name of the Chief is Chief Granato, not Grenato.

I spoke with Melissa Sparks, Spokesperson for SAFD (San Antonio Fire Department). She confirmed the spelling of Chief Granato’s name. She also provided some other information that was not in the story.

then decided to stop treatment.

The paramedic did not decide to stop treatment. One of the medical directors for SAFD was contacted by phone. The relevant parts of the living will were read to the medical director. What is relevant is decided by the medical director, not the paramedic.

The medical director decided that stopping CPR was what the patient wanted and had clearly expressed in his living will.


This is the ethical thing to do.


To continue to treat a patient – against the wishes of the patient – is abuse.


It is not the job of EMS to abuse patients.


My condolences go out to Terry Read and the rest of his family, but Terry Read’s grief does not authorize him to deprive patients of their right to make decisions for themselves. Not even his father.

The state has reviewed this case and cleared the department of any wrong doing.

That is the Texas Department of State Health Services. In other words, there was no big mistake.

If anything, SAFD EMS deserves commendation. Could they have handled this more gently? Maybe. Maybe not. This is 2 1/2 years later, but Terry Read is still not responding to reason. Imagine how much less reasonable Terry Read was when he was faced with his father’s death?

Dealing with a cardiac arrest, regardless of whether we continue treating the patient, is a time of great stress for the family.

After pronouncement can be a great time for EMS to call a trusted neighbor, a pastor/rabbi/imam/priest, other family members, or whomever the family feel most comfortable with at the time of the death of a loved one.

What about State Representative Ruth McClendon?

She appears to be clueless about the EMS regulations and assumes that those of us in EMS are just as clueless.

“EMS personnel do not have the responsibility or the training or the knowledge to interpret legal documents,” Representative McClendon told us.[1]

We cannot understand the patient’s wishes, but we can perform miracles and bring terminally ill people back to full health?

Of course, Representative McClendon is completely misrepresenting what happened. EMS did not interpret the living will, the medical director did. Living wills are written for doctors, and other medical personnel, to interpret. Living wills are about the kind of care a patient wants. Living wills are not about arcane legal minutia.

“Emergency responders, paramedics, are not in the business of interpreting living wills. They’re in the business of doing what they’re trained to do, which is to administer emergency medical treatment,” Terry Read explained.[1]

They contacted medical command for permission to stop CPR and only stopped CPR after receiving orders from medical command.

Why is that so hard for Terry Read and Representative McClendon to understand?

She (Representative McClendon) sponsored House Bill 577, which was passed during this legislative session. It makes it very clear, a first responders’ first priority is to treat a patient.[1]

The only change is the strong suggestion that we should refuse to respect the wishes of the patient, just to put on a show for families who do not respect the wishes of their family members.

SAFD EMS did treat Samuel Read first, then the paramedic contacted medical command and then followed medical command orders.

C.S.H.B. 577 contains a provision not included in the original requiring the emergency medical services system’s medical director or online physician, if a person’s personal physician is not present or does not assume responsibility for the care of the person while the person is receiving emergency prehospital care, to be responsible for directing the emergency medical services personnel who are providing emergency prehospital care to the person and authorizing the director or online physician, under such circumstances, to order the termination of cardiopulmonary resuscitation only under specified conditions.[2]

That is exactly what happened. Everything SAFD EMS did for Samuel Read was in compliance with the new law.

This law is a feel good law, but it may persuade people to abuse patients, rather than treat patients with respect.

This should be titled the Encouraging Abuse of Terminal Patients Bill.

Representative McClendon should be ashamed of her actions. So should everyone else who voted for this.

Patient care is about the patient.

The patient is Samuel Read.

Samuel Read did not want to be resuscitated.

Also read the writings of Medic Madness and The Social Medic on this –

Since when is it not our responsibility?

Are We Encouraging The Abuse Of Terminally Ill Patients And Their Families?


[1] EMS workers stop medical treatment after reading will in the field
Mireya Villarreal
July 27, 2011

[2] House Committee Report Analysis of Bill
HB 577
Authored by Representative McClendon
House Analysis of Bill and a lot of other documents related to this bill at the Texas Legislature information page


Advance Directives

Some more writing on the topic of advance directives.

As with Dr. Boris Veysman,[1] I have begun resuscitation in the absence of awareness of a DNR.

Unlike Dr. Veysman, when I have learned after transport to the ED, I have responded with an apology and an explanation that I did not know and certainly would not have abused their family member if I had known.

Walt Trachim writes about one such situation in DNR’s: Yes or No?.

Dr. Veysman seems to have had the perverse response of – But look at what a great result I produced by abusing your loved one!

In Dr. Veysman’s defense, I do feel that it is important to point out that Dr. Veysman does advocate for very aggressive pain management.[2] I do not believe that he is at all malicious.

I think that one of the big problems with medicine is that so much harm can be done without any malice.

The most important thing mentioned in DNR’s: Yes or No? – after some undeservedly kind words (prolific could go either way), and a few cases relevant to the topic, is the main point.

And now – because of the facts and opinions that I’ve read – I have to think about it. How can I not?


One way of addressing this unintentional harm is with the POLST. Dr. Eric Widera writes about this in POLST: Standardizing End-of-Life Orders rather than Patient Communication.

Twelve states have adopted the POLST paradigm into law (CA, HI, ID, MD, NY, NC, OR, TN, UT, WA, WV), and many more are developing programs. My state (California) has signed the POLST into law, although implementation in San Francisco is spotty at best.

The Coalition for Quality at the End of Life (CQEL) is a link to more information on end of life issues.

National Health Care Decisions Day 2010 is at Pallimed.

From Happy National Health Care Decisions Day! at Asystole is the Most stable Rhythm, I picked up a link to a post by Dr. Grumpy. There are a lot of comments. Checkout time.

Finally, the most recent post, The Arrogance of Hope is the dissection of Dr. Veysman’s article at Movin’ Meat.


^ 1 ‘Shock me, tube me, line me’.
Veysman B.
Health Aff (Millwood). 2010 Feb;29(2):324-6. No abstract available.
PMID: 20348077 [PubMed – in process]

Free Full Text from Health Affairs         Free PDF from Health Affairs

^ 2 Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]