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

- Rogue Medic

Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians

Fri, 25 Jan 2013 08:00:37 -0500 by
 

 

Jamie Davis (the man behind the camera for this show and the man behind the MedicCast), Chris Montera (the man behind the EMS Garage), Kyle David Bates (Pedi-U and First Few Moments), Kelly Grayson (A Day in the Life of an Ambulance Driver and Confessions of an EMS Newbie) and I were on a video podcast from the 2012 EMS Expo in New Orleans.

None of the participants seem to feel that this discussion topic is a form of personal attack and the discussion is calm and thoughtful.
 

Chris Montera Assembles a Crew of EMS Leaders at EMS World Expo
November 19th, 2012

You can watch the video podcast at the ProMed Network page here.

Advance the video to the 10 minute mark for the beginning of the discussion.
 


 

Before the podcast I was at David Page’s presentation on how we educate EMTs and medics to kill. I had been trying to hear Dr. Keith Wesley’s presentation on the harms of oxygen, but the room was overcrowded, the crowd was spilling out into the hallway, and the microphone was not working. Why was Dr. Wesley put in a small room? I don’t know, but I could not hear, so I left.

I was very disappointed – until I saw the title of David Page’s presentation. That is a great topic. When I heard his presentation, I was even happier.

If you are an educator and you get a chance to attend this presentation – do not miss it.[1]

In our talk, we discussed the one thing on which I did disagree with David Page – the value of multiple choice test questions on a certification exam.

Multiple choice questions provide the person taking the test with limited information and no opportunity to obtain further information. Then the examinee is supposed to choose, from among several selections, the one best answer.

The idea of one best answer is a fraud.

Limited information.

No opportunity to gather more information.

Must choose one of the selections.

This just teaches bad decision making skills.

The multiple choice question on a certification exam is an excellent example of Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians.[1]

That was the only disagreement I had with David’s presentation.

We come up with ridiculous ways to artificially limit the learning of our students. For example – why not have the students create their own scenarios after reading the material for the class? No lecture. No guidance from the instructors. The students run it with only occasional feedback from the instructors.

The objections came from the instructors –

What do you mean, we are not necessary?!?!?

They were not thinking of the students and how this may be better for the students. They were only thinking of how this devalued their input and overturned their dogma.

If you are big on dogma, you are probably more harmful than beneficial.

This is another excellent example of Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians.[1]

We discuss several problems with education.

Why do we assume that the amount of time we spend on education is just right?

If our certification exams are any good at assessing for adequate education, why do we have any kind of classroom attendance requirements to get in?

I think that we just figure the completion of the class means that it doesn’t matter who passes the test, since the certification test is not a valid assessment.

Here is an example of the problem with multiple choice questions –

Worst test question ever! – Maybe
 

You can watch the video podcast at the ProMed Network page here.
 

The first 10 minutes is an advertisement, but it is for an interesting product that looks as if it can dramatically cut down on the risk of needlestick injuries and cut down on the cost of disposal of needles.

If you regularly have problems getting needles into the sharps container, because people who inexplicably passed a multiple choice exam esteemed colleagues have stuffed bandages and other non-sharps into the sharps container, the Sharps Terminator by Medical Safety Solutions should prevent that dangerous situation. I do not receive anything from the company.

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Footnotes:

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[1] Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians
Nov 1 2012 11:00AM
David Page, MS, NREMT-P
Thursday Schedule

This controversial look at safety and medical errors in EMS explores the role of education in preprogramming future clinicians to make deadly mistakes. Is it time for EMS education to embrace its role in creating cultures of safety? Or is it all up to the employers?

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Filed Under: Education, EMS Expo, Heresy

Optimizing Outcomes in Cardiac Arrest

Mon, 10 Dec 2012 23:55:05 -0500 by
 

One more of the great presentations at EMS Expo was on improving outcomes from cardiac arrest.[1]

Lake Sumter EMS does not follow the AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) guidelines.
 

 

One member of the audience kept asking about the threat of law suits – the mediocrity response.

But you’ll get sued!

Tell me what to do to avoid getting in trouble.
 

There is a great scene in The Eiger Sanction. Clint Eastwood (Dr. Jonathan Hemlock) is an art professor and a pretty student wants to flirt her way to a passing grade. Eastwood responds to the suggestion with –
 

Dr. Jonathan Hemlock: Are you busy this evening?
Art Student: No.
Dr. Jonathan Hemlock: You live alone?
Art Student: My roommate’s gone for the week.
Dr. Jonathan Hemlock: Good. Then… go on home, break out the books and study your little ass off. That’s the best way to maintain a “B” average. Don’t study it all off.[2]

 

We have too many people in EMS who think a magic pill will keep them out of trouble. The right connections or some magic phrase. Scene safe! BSI!

They don’t want to have to be competent at patient care. They just want to stay out of trouble. Perhaps the best way to avoid trouble is to provide competent patient care.

If they don’t know what competence is, they should stay out of EMS to stay out of trouble.
 

Dr. Banerjee responded politely to mediocrity fan boy. His results are better than what the ACLS guidelines would produce. You need to show evidence of harm to win a law suit. Evidence of non-conformity is irrelevant.
 

 

Fewer than 10 systems produce better than 20% VF (Ventricular Fibrillation) survival to discharge.

We need to stop listening to the defenders of mediocrity and stop killing so many patients.

If we are more worried about the lawyers, than we are about our patients, then we should not be making patient care decisions.
 

 

Do these numbers suggest that Dr. Banerjee has any reason to worry about law suits for not following the ACLS guidelines?

No. His only concern would be if he were to start following ACLS guidelines.
 

No ventilations until resuscitated. Eventually, removing ventilations will the ACLS recommendation, but they part with voodoo tradition slowly. Ventilations are not based on research.

Dr. Banerjee is a fan of pressors (epinephrine and vasopressin), but he is also not going to go against the research if research ends up showing that epinephrine is harmful.

The PEA (Pulseless Electrical Activity) protocol is interesting – treat for many of the potentially reversible causes automatically. I do not remember if it is already part of their protocol, but if it is not, they might want to add bilateral needle decompressions to rule out tension pneumothorax.
 

Why do the defenders of mediocrity fight so hard against progress?

Maybe they just don’t want progress.

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Footnotes:

–

[1] Optimizing Outcomes in Cardiac Arrest
Nov 2 2012 1:15PM
Pushpal (Paul) Rocky Banerjee, MD, Medical Director, Lake EMS, FL; Assistant Medical Director, Aviation One – Medical Transport Services
Friday schedule

Cardiac arrest is a medical emergency that is potentially reversible if treated early. With fast, appropriate medical care, survival is possible. Administering continuous chest compressions, along with early defibrillation, can improve the chances of survival until emergency personnel arrive. Lake EMS has developed an innovative approach to cardiac arrest care. Dr. Banerjee will demonstrate why the cardiac arrest resuscitation rates at Lake EMS are among the highest in the world.

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[2] The Eiger Sanction
IMDb.com
Movie quote at IMDb

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Filed Under: 2010 AHA Guidelines, EMS Expo, Heresy

Improving the Quality of Medical Care and Other Topics on the EMS Garage from the 2012 EMS Expo

Fri, 23 Nov 2012 08:00:07 -0500 by
 

 
Chris Montera (the man behind the EMS Garage), Pat Songer (Director of EMS at Humboldt General Hospital, Winnemucca, NV), Matt Womble (Principal at Womble Consulting), and I were on a video podcast from the 2012 EMS Expo in New Orleans.

You can watch the video podcast at the ProMed Network page here.

There may have been some sort of plan for an initial topic, but as Chris mentions, the EMS Garage wanders.

We started by discussing Burning Man.[1] I am the only one who has not been there.

We switched to patient satisfaction scores.[2]

But the most important topic was improving the quality of patient care by being able to discuss errors without fear of punishment.[3]

 

Image credit.
 

Some people keep trying to get rules that have been set up to prevent lawyers from being able to troll for torts by having access to this privileged information.

Would lawyers feel the same way about having to divulge their conversations with clients, rather than have it considered privileged information?

Some people just do not understand that the satisfaction of finding out some bit of information now comes at the price of having all similar information kept secret in the future.

Some people just do not understand that the satisfaction of finding out some bit of information now comes at the price of not protecting patients from similar errors in the future.
 

Discouraging isolated episodes of negligent care without lifting institutional performance more broadly would surely be a Pyrrhic victory for tort law’s deterrent effect.[4]

 

The tort system does not lead to a decrease in errors, or in improved protection for patients, but working to identify and eliminate errors does provide the opportunity to protect patients. As Matt Womble keeps stating – We can’t expect other people to do our job for us. We need to educate people about what we do and how to do it better.

We need to fix our own quality problems, because the lawyers certainly are not improving the quality of medicine. If we won’t fix our quality problems, why should we expect non-medical people to fix our problems?

We feel that we have to do something, and the tort system is already in place, but where is the evidence that the tort system improves outcomes for patients.
 

You can watch the video podcast at the ProMed Network page here.

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Footnotes:

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[1] Burning Man
Wikipedia
Article

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[2] EMS Garage on Press Ganey – Should We Reward High Scores
Wed, 27 Apr 2011
Rogue Medic
Article

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[3] What if confidential information, provided to protect patients, were no longer confidential?
Sat, 30 Jun 2012
Rogue Medic
Article

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[4] Relationship between quality of care and negligence litigation in nursing homes.
Studdert DM, Spittal MJ, Mello MM, O’Malley AJ, Stevenson DG.
N Engl J Med. 2011 Mar 31;364(13):1243-50.
PMID: 21449787 [PubMed – indexed for MEDLINE]

Free Full Text from New England Journal of Medicine

Tort theory suggests that litigation induces defendants to be more careful and warns others to take precautions.28 But to be effective, this deterrent function logically requires a degree of precision.

CONCLUSIONS
The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

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Filed Under: EMS Expo, Heresy, Legal Medicine, Risk Management

Stop the Madness! Reducing Unnecessary Spinal Immobilizations in the Field – Part I

Thu, 08 Nov 2012 13:30:26 -0500 by
 

Picture credit from Voodoo Medicine Man.
 

Continuing to review the presentations I attended at EMS Expo. Jim Morrissey covers spinal immobilization and the way they are eliminating conventional spinal immobilization (placing a rigid collar on the neck and strapping the patient to a board) in Alameda County.[1] Alameda County’s medical director, Dr. Sporer, has an article about the reasons for changing the protocol.[2] Attend his presentations if you have the opportunity.

Oakland is the largest city and they have plenty of experience with trauma, so this will be an important place for EMS to watch to see the rate of spinal disability drop.
 

Where is the evidence
 

that spinal immobilization
 

improves the outcome
 

of patients?
 

Even Dr. Dave Ross, who has written some articles critical of spinal clearance protocols, is calling for a study to find out the actual effect of spinal immobilization, because right now there is no good evidence of benefit.[3]

None.

Yes, there are anecdotes of manipulation leading to worse outcomes.

Spinal immobilization is manipulation – no matter how much we try to pretend otherwise.
 

Do we sedate combative patients in order to immobilize them without added manipulation?

If we do not, then their movements fighting immobilization are producing much greater stress on any unstable spinal fractures that they have.

Dementia – I transported a patient with altered mental status and a fall, who would not tolerate being placed flat on a board. The smallest size on the C-collar was still too large to not place significant distracting force on the neck of this very little little old lady.

She had a C2 (2nd Cervical vertebra) fracture.

Would she be paralyzed if I had forced immobilization on her?

Maybe. Maybe not.

Would I have been able to get orders for sedation of a change in mental status patient to immobilize her?

Maybe she would have survived immobilization without the immobilization increasing her injury.

Maybe. Maybe not.

We will never know.

What we do know is that she was fine with gentle transport, sitting up on the stretcher, without any forced manipulation of her injury to “immobilize” her.

She was fine when I dropped her off. She was fine hours later when I asked about the cause of her change in mental status and found out about the C2 fracture.

What if somebody sues?

A judge should throw out a law suit for a lack of evidence of harm caused by the lack of manipulation.

We need to stop claiming that manipulating the necks of patients is protecting them from injury.
 

According to spinal clearance criteria, altered mental status is one of the reasons we must not clear the spine.

If these patients do have spinal injuries, in what way do they benefit from the increased stress on the injury provided by EMS immobilization?

Spinal immobilization does not prevent stress on the injury, but only allows us to pretend it is not happening and that we are not causing the injury.

I will look at what they will be doing in Part II.

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Footnotes:

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[1] Stop the Madness! Reducing Unnecessary Spinal Immobilizations in the Field

Nov 2 2012 9:30AM
Room: 206
Category: General
Jim Morrissey, MA, EMT-P
Friday Conference schedule.

A mounting body of evidence shows that the current approach to spine injury assessment and treatment needs to change, and change radically. Several studies show that EMS is immobilizing far too many patients and may be causing more harm than good in some trauma victims. This presentation examines the inaccuracy of using mechanism of injury as a predictor of injury and how EMS textbooks and past guidelines have led us astray. We review several articles and papers showing the detrimental effects of immobilizing victims of penetrating trauma and other patients, and discuss the multitude of problems associated with cervical collars and backboards. We review and validate several models of spine injury assessment protocols, especially ones that can reliably clear patients from the need for spinal protection. Finally, we will evaluate tools appropriate for patients who do require some degree of spinal protection.

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[2] Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article

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[3] Confessions of a recovering field spine clearance addict — revisited
November 02, 2012
By Dave Ross
EMS1.com
Article

Revisiting the article below –

Confessions of a recovering field spine clearance addict
September 06, 2012
By Dave Ross
EMS1.com
Article

I commented on that article in the link below –

Confessions of a recovering cervical spine field clearance addict – Part I
Mon, 10 Sep 2012
Rogue Medic
Article

I have not yet written Part II.

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Filed Under: EMS Expo, Ethics, Evidence, Heresy, Mythology, Spinal Immobilization

Lasix Kills: Better Therapy for CHF

Wed, 07 Nov 2012 15:30:49 -0500 by
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EMS Expo had several excellent presentations and a lot of good company. One of my favorite topics was covered by one of my favorite doctors, Keith Wesley.[1] Attend his presentations if you have the opportunity.

For emergency treatment of CHF (Congestive Heart Failure), furosemide (Lasix – frusemide in Commonwealth countries) is a bad drug.

If we use Lasix, are we killers?

Maybe.

How much follow up do we get on our patients?

How would we know if we dehydrate a patient and alter his electrolytes to the point of killing him?

How would we know that the increase in blood pressure from Lasix is not making the CHF worse?

What if we give Lasix to someone with asthma, or pneumonia, or a PE (Pulmonary Embolus), are we shortening the lives of these patients?

How many of these patients die and how many might not die if they never received Lasix from EMS or from the ED?

We do not know, but we would have to be insane to think that the number is zero – or even close to zero.
 

Where does Lasix work?

In the kidneys, when there is good circulation to the kidneys – not in the patient who is pale, cool, and sweaty, because that is an indication of catecholamine release.

Some claim that Lasix will cause vasodilation and that this will improve outcomes.
 

Lasix causes vasoconstriction.
 

Vasoconstriction is what kills CHF patients.
 

Does Lasix kill?

Yes. Lasix kills.
 

In patients with chronic heart failure and especially in the presence of generalized edema, prior investigations have demonstrated either increases in intravascular volume17-19 or no consistent changes.20 During acute cardiogenic pulmonary edema, however, blood volume is more frequently reduced. In 16 of the 21 patients herein reported, the initial volume measured or calculated after onset of acute dyspnea demonstrated a lower than normal intravascular volume. To this extent, volume changes during acute pulmonary edema differ from those which were observed during chronic congestive heart failure.[2]

 

Chronic CHF and Acute CHF are not the same and should not be treated as if they are the same.

Lasix is safe for chronic CHF.

Lasix is not safe for acute CHF.

We need to lower the blood pressure, but Lasix raises the blood pressure.
 

Two patients became noticeably shorter of breath by 10 to 20 minutes after furosemide administration.[3]

 


 

We need to lower the heart rate, lower the blood pressure, and decrease the amount of work being done by the heart. Heart failure means that the heart is already having trouble.

The solution is not to make the heart work harder.
 

Activation of the sympathetic nervous system by intravenous furosemide treatment in patients with congestive heart failure is a new finding.[3]

 

New?

The paper was written in 1985, but we keep hearing that Lasix is a vasodilator.
 


 

Lasix raises blood pressure in emergency treatment of CHF.

Lasix raises heart rate in emergency treatment of CHF.

Lasix decreases cardiac output in emergency treatment of CHF.
 

Lasix makes acute CHF worse.
 

For the first hour, or more, the effects of Lasix are dangerous to the patient.

Lasix is a stress test that kills.

We should listen to Dr. Wesley and stop killing our patients.

What should we use?

NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) does the opposite of what Lasix does. Higher doses of NTG produce better outcomes.
 

Also read NTG and the Hero Medic at Street Watch: Notes of a Paramedic, for a perspective on high dose NTG for acute CHF.

Would half a bottle of NTG tabs kill an acute CHF patient? No, and that is still much safer than giving Lasix to acute CHF patients.
 
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Footnotes:

–

[1] Lasix Kills: Better Therapy for CHF<
Nov 2 2012 8:00AM
Room: 217
Category: ALS
Keith Wesley, MD, FACEP
Conference schedule for Friday.

This lecture examines our better understanding of the pathophysiology of congestive heart failure and the history of its treatment. Old theories result in old therapies, and current research should guide us in providing better prehospital therapy for this deadly condition. We will explore the role of pharmacologic agents such as diuretics and nitrates, as well as the value of continuous positive airway pressure (CPAP) support.

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[2] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed – indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format.

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[3] Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis.
Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, Cohn JN.
Ann Intern Med. 1985 Jul;103(1):1-6.
PMID: 2860833 [PubMed – indexed for MEDLINE]

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[4] Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure – Bolus, Drip or Both?
Wed, 17 Oct 2012
Rogue Medic
Article with links to plenty of studies on high dose NTG

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Filed Under: CPAP, EMS Expo, Heresy, Lasix, NTG, Pharmacology, Research

Misrepresenting Current Topics in EMS Research from EMS Expo – IMMEDIATE

Mon, 05 Nov 2012 11:30:24 -0500 by
 

At EMS Expo, I was told that Dr. Paul Pepe also did not mention covering Intramuscular versus intravenous therapy for prehospital status epilepticus[1] without mentioning the doses of midazolam (Versed) and lorazepam (Ativan) used in his presentation on the Eagles conference. So John Studnek, PhD has some company in his omission of important information. I don’t know if Dr. Pepe covered the IMMEDIATE trial, too.[2]

If your protocol doses are to start with 4 mg of IV lorazepam or with 10 mg of IM midazolam, then the doses are not important. These large doses of benzodiazepines appear to decrease the need for intubation.[3]

I suspect that 4 mg lorazepam IV (IntraVenous) or 10 mg midazolam (IntraMuscular) will scare a lot of medical directors. They will worry about the need for intubation with large doses of benzodiazepines and switch to IM midazolam, but at a low dose that is less effective and more likely to result in intubation.
 

The second study – IMMEDIATE.

The GIK (Glucose, Insulin, and Kalium [Latin for potassium]) study was undeservedly hyped when it came out and Dr. Studnek continues that misrepresentation.

Should we ignore that the study was originally supposed to be large enough to produce statistically significant results – 15,450 people?[4]

Dr. Studnek points out that there were 911 people in the study. That is the emergency number in the US, so it can help us remember how many patients there were, but that number is before exclusions. There were fewer than 900 patients included in the study. After eliminating almost all of the 15,000 patients who were supposed to be in the study, even 911 patients is a significant disappointment.

Dr. Studnek points out that this was published in JAMA, which is a prestigious journal, so that means that it is of high quality. The week before JAMA hyped this study, they hyped a paper on helicopters in EMS that is garbage.[5]

Being published in JAMA does not mean a study is of high quality.

Should we ignore that the resulting number of patients is only 6.7% of the original and that the error bars on the results are frequently much larger than the possible benefit of treatment?

So what that there is a statistically significant improvement in one, and only one, of the secondary endpoints of the study? This is to be expected when there are that many targets. It is unlikely that everything will come up negative, especially in a study with a small number of patients.

The statistically significant improvement disappears when reassessed one month later.

Is this the epinephrine effect all over again?

Epinephrine increases the return of pulses, but fewer people treated with epinephrine survive to leave the hospital alive. This is less harmful.

The benefit disappears before discharge from the hospital.

Is that what we call success?

We can provide a statistically significant benefit that disappears when you leave the hospital!

Yawn. Let us know about treatments that make a difference in outcomes that matter.
 


Click on the image to make it larger.
 

Even the authors do not make exaggerated claims.
 

Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI.[6]

 

Further studies are needed to assess the out-of-hospital use of GIK as therapy for patients with ACS.[6]

 

Maybe we should listen to the authors encouragement to not read too much into this study. Studies of 20,000 earlier patients did not show benefit.

Further study is needed, not further hype.

This is an interesting treatment idea, but it should only be used as a part of a controlled study.
 

Go read the comments of some astute emergency physicians on this study –

The IMMEDIATE trial: Should EMS give Glucose-Insulin-Potassium? by Dr. Brooks Walsh in Mill Hill Ave Command.

and

Glucose-Insulin-Potassium For MI? By Dr. Ryan Radecki in EM Literature of Note.

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Footnotes:

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[1] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.

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[2] A View From the Eagle’s Nest: A Recap of the 2012 EMS State of the Sciences Conference
Nov 2 2012 9:30AM
Room: 210
Category: General
Paul E. Pepe
Conference schedule for Friday

Current Topics in EMS Research
Nov 1 2012 4:30PM
Room: 219
Category: Educator
Jonathan R. Studnek, Ph.D
Conference schedule for Thursday

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[3] Misrepresenting Current Topics in EMS Research from EMS Expo – RAMPART
Rogue Medic
Fri, 02 Nov 2012
Article

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[4] Should We Start Using a Glucose-Insulin-Potassium Cocktail
Rogue Medic
Wed, 04 Apr 2012
Article

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[5] Flawed Helicopter EMS vs Ground EMS Research – Part I
Rogue Medic
Wed, 18 Apr 2012
Article

Part II

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[6] Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes: The IMMEDIATE Randomized Controlled Trial.
Selker HP, Beshansky JR, Sheehan PR, Massaro JM, Griffith JL, D’Agostino RB, Ruthazer R, Atkins JM, Sayah AJ, Levy MK, Richards ME, Aufderheide TP, Braude DA, Pirrallo RG, Doyle DD, Frascone RJ, Kosiak DJ, Leaming JM, Van Gelder CM, Walter GP, Wayne MA, Woolard RH, Opie LH, Rackley CE, Apstein CS, Udelson JE.
JAMA. 2012 Mar 27. [Epub ahead of print]
PMID: 22452807 [PubMed – as supplied by publisher]

Free Full Text From JAMA

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Filed Under: ACS, EMS Expo, Heresy, Pharmacology, Research

Misrepresenting Current Topics in EMS Research from EMS Expo – RAMPART

Fri, 02 Nov 2012 07:00:06 -0400 by
 

I have been very happy with the EMS Expo in New Orleans. I did some podcasting, made some new friends, attended some great presentations, and had a bit of a New Orleans Halloween. I was anticipating an interesting review of some important research relevant to EMS from the past year.
 

This presentation provides an overview of the most important and impactful EMS research that has been published or presented in the last year. Papers will be reviewed that have been presented at the most recent meeting of the National Association of EMS Physicians or published in such journals as Prehospital Emergency Care, Annals of Emergency Medicine, Academic Emergency Medicine and others.[1]

 

To claim that I was disappointed with the research review would be an understatement.

The first impactful review is the RAMPART study.

There is something that need to be highlighted from this paper.

The more rapid termination of seizures at the doses used in the study.

The more rapid termination was mentioned, but the doses used were not mentioned.

Why not? Who knows?
 

All adults and those children with an estimated body weight of more than 40 kg received either 10 mg of intramuscular midazolam followed by intravenous placebo or intramuscular placebo followed by 4 mg of intravenous lorazepam.[2]

 

These doses may be considered too large by some medical directors.

My protocols do not include IM (IntraMuscular) midazolam (Versed) for adult seizures, but my protocol doses of IV (IntraVenous) lorazepam (Ativan) may only reach a maximum of 4 mg after several repeat doses. This study used lorazepam as a single 4 mg IV dose.

Is there any good study to demonstrate equal efficacy with smaller doses?

Is there any good reason to expect that smaller doses would decrease the rate of intubation?
 [2]

Midazolam in an autoinjector was evaluated in an open-label dose escalation study involving 39 healthy participants. Safety and pharmacokinetic parameters were determined for doses ranging from 5 to 30 mg. No serious adverse events were noted during the study. Two participants (30 mg) experienced changes in their electrocardiogram (trigeminy and prolongation of QRS complex) that met the criteria for dose-limiting adverse events. No significant respiratory depression was noted during the study.[3]

 

Doses of up to 30 mg IM midazolam in healthy subjects did not produce any significant respiratory depression.
 

The adult lorazepam IV doses in the study is the dose recommended by the FDA label –
 

For the treatment of status epilepticus, the usual recommended dose of Lorazepam Injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional Lorazepam Injection is required. If seizures continue or recur after a 10- to 15- minute observation period, an additional 4 mg intravenous dose may be slowly administered.[4]

 

But everybody knows that intubation of seizure patients only happens because of the benzodiazepine! Right?

Probably not with seizure patients.[5]
 

The relationships among benzodiazepine dose, respiratory depression, and subsequent need for endotracheal intubation are poorly characterized, but higher doses of benzodiazepines may actually reduce the number of airway interventions. Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.11 [2]

 

We appear to be giving too much consideration to possible complications that might be related to the medications, but appear to be more likely to be because of a failure to use enough medication.

This is important and our failure to use enough midazolam may be very dangerous to our patients.

If we change from an often ineffective IV dose of lorazepam to an often ineffective dose of IM midazolam, are we making things any better?

We have good evidence of benefit, but we do not have good evidence of harm, so we worry about the harm. This is the opposite of our approach to epinephrine, where we have a lot of evidence of harm, but no good evidence of benefit.

To be continued in IMMEDIATE and Epinephrine parts.

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Footnotes:

–

[1] Current Topics in EMS Research
Nov 1 2012 4:30PM
Room: 219
Category: Educator
Jonathan R. Studnek, Ph.D
Conference schedule for Thursday

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[2] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736

Free Full Text from N Engl J Med.

I have written about this in Intramuscular Midazolam for Seizures – Part I,
Part II,
Part III,
Part IV,
Part V,
Part VI,
Misrepresenting Current Topics in EMS Research from EMS Expo – RAMPART,
and Images from Gathering of Eagles Presentation on RAMPART.

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[3] Human safety and pharmacokinetic study of intramuscular midazolam administered by autoinjector.
Reichard DW, Atkinson AJ, Hong SP, Burback BL, Corwin MJ, Johnson JD.
J Clin Pharmacol. 2010 Oct;50(10):1128-35. Epub 2010 May 13.
PMID: 20466872 [PubMed – indexed for MEDLINE]

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[4] Lorazepam (lorazepam) Injection, Solution
[Baxter Healthcare Corporation]
DailyMed
NLM
FDA label

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[5] A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH.
N Engl J Med. 2001 Aug 30;345(9):631-7. Erratum in: N Engl J Med 2001 Dec 20;345(25):1860.
PMID: 11547716 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med.

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Filed Under: EMS Expo, Heresy, Pharmacology, Research, Risk Management