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

- Rogue Medic

Weird Nursing Karaoke – A Beverage Free Zone

With my fondness for modifying the words of famous quotes or famous songs, I don’t know how I could have not noticed this Weird Al Yancovic of Emergency Medicine. Tex is an ED nurse. A transplant from Texas to North Carolina, he has a way of expressing himself that is hilarious. Do not consume beverages while watching. If you are expecting the chorus to be the same every time and think it might be safe to take a sip, I warned you.

One of his favorite people in the medical world is Dr. Deborah Peel. Not that she does anything medical – unless you count mass diagnosis and prescription of people she never met. I have written about her several times. He also mentions where a lot of the Deborah Peel stuff all started – WhiteCoatRants. He sings about her below to the tune of Helen Wheels, by Paul McCartney’s band Wings.

He has a lot of YouTubes at texicannc’s Channel. His blog is Weird Nursing Tales – excellent stuff! Hook him up with LawDog singing Dirty Deeds Done Dirt Cheap in a Pink Gorilla Suit and we could solve most of the problems facing law enforcement and medicine.


Will Atlanta be the next city to switch to Fire Department EMS?

There is a story about cuts to funding of EMS in Atlanta at The Atlanta Journal-Constitution. The article Fewer ambulances, longer waits for Fulton residents? suggests that there will be continuing funding problems for EMS in the area and that the fire department is chomping at the bit to take over.

In a recent letter, Pamela Stephenson, CEO of Grady, which furnishes ambulances to the central part of the county, asked the commission to reconsider its vote and appoint a panel of residents and medical experts to look at the EMS issue.

Without public funds, she wrote, Grady would have to cut the number of ambulances and attendants on duty, which would mean response times “greater than thirty (30) minutes for all life threatening emergencies.”

According to the quote, it would take longer than half an hour to arrive on scene for emergencies. Not just some of them, but all of them. That is just plain ridiculous. How is it going to take that long if there are available units, for example during off-peak hours or on slow days.

Is she threatening a policy of deliberately slow responses?

Or is it just another example of someone who is incapable of communicating in English?

Or is there a mistake in the quote from her recent letter?

In their vote, Fulton commissioners relied on a document prepared by Alfred “Rocky” Moore, director of the county’s Emergency Services Department. It recommended that the commission eliminate public funding and settle for a countywide standard response of up to 12 minutes in 90 percent of emergency calls.

But with fewer vehicles to handle what is expected to be the same, if not an increasing, demand, calls would back up and response times would grow “far beyond just 12 minutes,” said Dr. Patrick O’Neal, director of the Office of Preparedness in Georgia’s Department of Human Resources.

A response time of 12 minutes, or less, on 90 % of calls does not sound like over 30 minutes for all emergencies, but they appear to be talking about the same thing.

The EMS cuts are hitting Atlanta when the city faces its own projected shortfalls of about $65 million for the budget cycle ending June 30, and $120 million for 2009. Officials cite the increased costs of pensions, health care and fuel, decreasing revenues, and budgeting errors.

Budgeting errors?

That does sound interesting.

Here is where it becomes even more entertaining.

One possibility for Atlanta would be to have the city’s fire department take over ambulance service. Already firefighters are first responders to 911 calls, usually beating the ambulance there by at least a couple of minutes.

“If you’ve got a guy who’s a fireman and an EMS, he can do both jobs,” said Chief Mike Beckman of the Atlanta Fire Department’s EMS service.

There’s one big problem. The fire department has no ambulances.

Grady has about 26 in the field at peak times, stationed throughout the city. Grady officials estimate start-up cost for an ambulance system based in the fire department would be about $20 million.

The fire department has to be prepared to step in, Beckman said, even if that means using Grady ambulances.

“It’s a logistical nightmare, that’s what it is,” said Beckman. But, he added, “If they threw the keys in the parking lot July 1, we’d pick them up and make it work. … We would do what we have to do.”

There is only one big problem?

Maybe I am a bit of a cynic, but if the fire fighters are on the ambulances treating patients and there is a fire, do they treat patients or fight fire?

If the problem is a lack of ambulances, having the ambulances less available, because the personnel are fighting fires, is not a sensible answer.

How many paramedics does the fire department have?

The chief of EMS describes “a guy who’s a fireman and an EMS.”

What is an EMS?

I believe that Georgia uses the classifications of EMT (Emergency Medical Technician), EMT Intermediate, and EMT Paramedic. EMS is Emergency Medical Service. Does he think that one guy is going to be all of EMS?

How much will the skills of paramedics be improved by having to be cross-trained as fire fighters?

“Sorry, I didn’t provide good care, but you should see me fight fire!”

Not exactly the condolence that you might want to hear after a medical error.

Will they send a bunch of fire fighters to medic school and have a whole cluster of inexperienced paramedics?

Will they hire experienced paramedics, but send them to fire fighter school, so that they can dilute their skills?

After all, paramedics have a problem of being too good at their jobs. They are so good that they need to find other things to train in to keep them from going in to the hospitals and taking jobs away from those foolish doctors.

When the funding problems hit the hospitals, why not have the fire department take over and cross-train the nurses and doctors as fire fighters to improve the system?

I wouldn’t even be surprised if JCAHO, sorry, make that TJC (The Joint Commission) approved of this. After all, they are named for what they appear to be smoking.

There are some people who do well at both jobs, when cross-trained. They are not common. Cross-training may be effective if the jobs do not require much skill.

If the EMS chief of the Atlanta Fire Department does not recognize that the bigger problem with EMS is competence – not a lack of a fire department uniform – then things will only get worse with him in charge. Then, maybe a 30 minute response time would save lives by encouraging patient to seek their own transportation to the hospital.

They mention a $20,000,000 start up cost. Yes, we can save you almost $10 million, but the down payment is going to be $20 million.


There is no estimate of how high the costs could go with the fire department in charge.

There are plenty of medics who have to work hard to maintain their level of education and skills. If you cross-train them, they now have to divide their time between maintaining fire fighting education and skills and maintaining paramedic education and skills. It is only in a fairy tale world that you get competence at both for less money.

Therefore, I am expecting that within a year there will be plans to have Atlanta Fire Department take over paramedic service for the city.

If costs do decline, it will only be at the expense of patient care, but that’s OK. I do not live in Atlanta.

Chief Mike Beckman of the Atlanta Fire Department’s EMS service will be a much more powerful man, but it is cynical for me to suggest that has anything to do with his comments. He probably means well, just as Dr. Deborah Peel means well.

But Mom, all the other cool cities are doing it. It must be better than crack!


OLMC For Good Medics

You claim that
requiring OLMC (On Line Medical Command) permission to treat patients does not work and actually lowers the quality of medic in a system. You state that Medic X, the example of the dangerous medic, is made worse by OLMC requirements. But, at least, OLMC requirements help the good medics. Let’s call this one Medic A.

Even better, let’s call this example of a good medic – Medic AD – everybody should be able to trust that Medic AD provides excellent care.

OK. Then why wouldn’t OLMC requirements help Medic AD?

You’re asking the wrong question.

The question should be How would OLMC requirements help Medic AD?

Consider it asked.

First – the goal of Quality Control, Quality Improvement, and all other CYA stuff is to improve the quality of the care the patients receive, or to create the appearance of controlling, or improving, or assessing the quality of the care the patients receive.

Focusing QC/QI/CYA on the medic is missing the point – it is about the patient.

How the medic does the job is not the important thing compared to the effect on the patient.

So, how does the need to get permission from OLMC to treat the patient benefit the patient?

The medic, even Medic AD, is not a doctor. He doesn’t know as much as a doctor.

Yes and No.

There are plenty of physicians who just do not understand all areas of emergency medicine.

What ? ! ?

The most obvious example is pain management, such as aggressive fentanyl administration on standing orders.

But these are powerful drugs!

Are there any drugs that a medic carries that are not powerful?

Maybe, but I think I see your point – if all, or almost all, of the drugs a medic uses are powerful, why treat these differently?

That is a good question.

So, what is the answer?

Gosh, I would have to be a psychiatrist – like Dr. Deborah Peel – to be able to diagnose a bunch of physicians without ever having met most of them.

So, you think the problem is psychological?

Not entirely, but there is more than a bit of paranoia about pain medication.

I believe that a lot of this is paranoia and due to a lack of understanding of the medications.

Let me give an example that is typical of what I hear from physicians defending OLMC requirements. The following comments are not at all unusual for conversations I have with medical directors. This written communication just did a wonderful job of bringing so many of them together.

It seems you DO have an opinion, and a sarcastic one at that. But that is beside the point.

Yes, I have an opinion.

Yes, I express it with more than a hint of sarcasm.

You see, you feel comfortable bashing the med control doctors out there because its not YOUR license on the line, and the med control MD hasn’t even seen the patient yet.

So, if I make a mistake the doctor’s license is on the line?

Please, somebody comment about any case where a doctor lost their license because of bad care by a medic. Anyone.

You see what I mean about paranoia?

So, if I make a mistake my license is not on the line?

Why does the doctor need a phone call for permission when it is pain management, but not arrhythmia, or cardiac arrest, or anaphylaxis, or respiratory distress, . . . ?


Its not YOUR so-called “deep pocket” that the lawyer for the patient who, in so much pain that EMS felt the need to give repeated boluses and later respiratory arrested, are going to go after. While I’m sure in your jurisdiction this doesn’t happen, even in the best of EMS systems there are those few EMS personnel that are either new, inexperienced, or just plain too ignorant to know the dangers of too much analgesia.

Sounds as if I found one of those physicians who is comfortable authorizing medics to treat patients, while knowing that these medics are not safe to treat patients.

OLMC to the rescue!

That will fix everything.

After all, just because they are too stupid to deal with pain management without a magical phone call doesn’t mean they can’t handle life threatening emergencies safely.

If they can’t handle something as simple as pain management – relatively simple if you are well trained – how will they handle a difficult airway?

But, maybe he isn’t the medical director for all of the medics in the system and he just doesn’t trust medics from other organizations.

How many of you out there can truthfully say that you haven’t had at least one case in which a big tough guy had apnea after only a minimum of versed or MSO4?

Again, comments please! Has anyone ever had this happen?

I adjust the dose to match the patient’s weight, underlying health, age, and current condition – then I reassess and determine if more is needed. I keep doing this until side effects discourage further treatment, or I run out of medication (or orders), or the patient is tolerating the pain well. I am always limiting the rate of administration, since most side effects are rate related.

I have never seen this miracle apnea, the doctor describes.

Or one of my most “treasured” memories, the call from EMS who had an unconscious victim and after administering the impaired protocol, called med control for morphine orders because the patient had just “come around and he was screaming in pain”.

Hmm. Unconscious “victim?”

I have addressed appropriate use of naloxone elsewhere.

Maybe a cancer patient treated inappropriately with naloxone?

Point is we are only a voice on the other end of the line sometimes. We cannot see what you see, only hear what you have to tell us.

For a moment, just for a moment, there is reality.

Sometimes we know exactly who you are and what you are all about and we can trust your judgement.

Right here, the doctor states that he does not have a problem with Medic AD using his judgment.

He doesn’t go as far as to say that Medic AD would not benefit from OLMC requirements, but he does suggest that he would automatically give Medic AD the orders being requested.

So, what would be the point of having Medic AD call OLMC before allowing the patient to receive treatment?

OLMC can then hear a familiar, trusted voice and relax.

It is all about the paranoia.

But other times you are simply “that voice over the radio”, the volunteer EMS system from “BFE”, the requested order from an RN who runs into the trauma room asking for morphine for EMS while you are trying to intubate someone,

Doesn’t that sound like a system that works well?

Would you like to be a patient there?

and sometimes, albeit rarely, you are simply another EMS provider who likes to give morphine to everyone, regardless of chief complaint.

This isn’t even using the lowest common denominator to justify OLMC requirements.

This is a medic who makes Medic X look good.

So, why is this medic still working?

OLMC requirements allow medical directors to justify keeping this worse-than-Medic X on the street and pushing drugs.

OLMC requirements endanger patients.

Requiring Medic AD to call OLMC to ask for permission to do what he knows how to do is only interrupting assessment and treatment, delaying patient care, and creating the possibility that an OLMC physician does not give orders that are appropriate for the patient.

The objections from most doctors, who are supportive of OLMC requirements, seem to be most focused on the physician’s ability to control things.

The problem with OLMC requirements is that they are barriers to patient care.

This is about patient care, not physicians’ need for control.

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

Fun with explosives – NTG.

Calling Dr. Deborah Peel – Anyone Home?


While looking at Notes from Dr. RW, a good medical site, I found a post (Psychoanalyzing medical bloggers on NPR’s Morning Edition – from March 17, I could not find a direct link, but it is in his archives). I posted the following comment on his site. Dr. Peel had commented on the same post, so I thought she might read it and respond. No luck, yet.

Being a diligent gadfly, I decided to post to Dr. Peel’s blog directly. The problem is that she has not posted anything since February. Apparently, she has more important fish to fry than medical bloggers. So, I posted the same comment after an excellent comment by erdoc85 (from M.D.O.D.) about her on air foolishness on a post from October that is more relevant than her post from February.

Her fan must go crazy waiting for his next exciting Peel Post.

If you search “Deborah Peel” blog the first two results are for White Coat Rants (read his posts) and her blog is all the way down at result number five. Sweet.

She is paving the road to hell (for patients and health care providers) with her oh-so-good intentions.

Let me know what you think of this comment, not enough oomph?

Dr. Peel jumps to the conclusion that the patients being described are individuals and not composites, that they are easy to identify and that the information about the patients has not been changed to make identification essentially impossible.

I dare Dr. Peel to identify any patient from my site. I have been using the pseudonym “Deborah Peel” for all of my patients and for some of my coworkers since her appearance on NPR.

How does a physician mass diagnose people without ever meeting them?

How does a physician prescribe treatment to people based on that fraudulent diagnosis?

Medical professionalism is completely absent from her behavior, yet she accuses others of being unprofessional and inappropriate.

Where does she find any evidence that blogs are any more of a threat to patient privacy than medical books?

House of God, MASH, Awakenings, …

There are many books that have been written on medical topics that do not always put the patient in the best light. Where is her outrage?

Where is the concern for the privacy of these patients?

Perhaps she does not read books and is unaware of the phenomenon of bound volumes of printed pages compiled for entertainment or even education.

What about television? ER has all sorts of information about patients and – horrors – you can see the patients (maybe she does not know they are only actors).

Imagine if any of those patients were to watch the TV show and recognize their own medical case being portrayed on screen.

If you want less than positive portrayals of patients and staff, what about House, MD?

She probably does not understand the sarcasm.

Dr. Deborah Peel should be reported to the state medical board for her on air medical malpractice. She should also be continuously ridiculed for her blatant hypocrisy.

Or, maybe I am wrong and she is the answer to all of the world’s problems.