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

- Rogue Medic

Immobilization or not that is the question – EMS Garage Episode 156

Chris Montera, Scott Keir, Dr. Dave Ross, Sam Bradley, Patrick Lickiss, and I discuss the lack of evidence of any benefit from spinal immobilization.

Immobilization or not that is the question: EMS Garage Episode 156


Any standard of care that does not have evidence of benefit needs to have an expiration date.


What do we do that causes the most stress on an unstable spinal fracture?

Placing a cervical collar on the neck and strapping the patient to a board increases the stress on any unstable spinal injury.

Why do we let a superstition become the Standard Of Care?

Because we can’t tell the difference between superstition and medicine.

There is no evidence that spinal immobilization ever provided any benefit to anyone.

There is evidence that spinal immobilization doubles the rate of disability among people with spinal injuries – exactly the people it is supposed to protect.[1]

Spinal clearance protocols do cut down on the pain and suffering of those without spinal injuries.

Spinal clearance protocols make it more likely that the people with spinal injuries will be endangered by manipulating their spines into rigid EMS collars and onto rigid boards.

Making the patient fit the board, rather than making the board fit the patient, is not good medicine. It does not even make sense.

Without evidence of safety, spinal immobilization should be stopped.

Without evidence of benefit, spinal immobilization should be stopped.

Go listen to the podcast.

Also listen to – A Change of the Dogma – If spinal immobilization helps only one . . .


[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]


Community and International All in One – EMS Garage Episode 150 and Fentanyl

This week’s EMS Garage covered several topics. Community and International All in One: EMS Garage Episode 150. Chris Montera, Gary Wingrove, Pat Songer, Russell Stine, and I discuss these topics –

International Roundtable of Community Paramedics and Community Paramedic – Community Paramedic is something that is inevitable. Many people do not like the idea, but there is no practical alternative. The main question is how to best set up a Community Paramedic program.

International Paramedic – We need to stop using the infantile excuse of That’s not the way we do it here. This attitude kills patients. Imagine if everyone decided that they would freeze their thinking at some point in time and never make any progress beyond that point unless it came from their own people. That is the opposition to International Paramedic. We need to recognize that we have a lot to learn from the way the rest of the world implements EMS. We need to stop ignoring what others are doing and start learning from others. Go sign up at International Paramedic.

Image credit.

Ultrasound in EMS“Machines made by Sono-Site Inc. will be put on 12 ambulances. The company provided the devices, which cost $60,000 to $70,000 each, and about $52,000 in training, Knapp said.” According to Pat Songer, his service is using different devices that only cost $6,000 to $6,700 each – less than 10% of the cost listed in the article. They have a lot of support from the hospital, which is very important. This has a lot of potential to improve care. We need to pay attention to the research and see what the advantages and disadvantages are. I am hesitant to suggest that this be used to encourage refusals, but triaging patients to community hospitals seems to be an area where this cuts costs and improves care.

Legal Medicine – We assume that we know how not to be sued or how not to lose a law suit, but this is just another EMS myth.

And fentanyl

A little bit on fentanyl. I mentioned that the most important advantage in using fentanyl is that it wears off quickly. This means that a patient who receives enough fentanyl to tolerate an ambulance ride (a bouncy truck ride lying on top of the rear axle as it hits pot holes) should already have the fentanyl wearing off when we arrive at the ED (Emergency Department). Time from administration and total dose will affect how quickly it wears off.

Why is fentanyl wearing off quickly important?

If the patient has enough fentanyl on board to tolerate the ambulance ride, then lying in a much better padded hospital bed that does not bounce around may result in oversedation and the main complication we wish to avoid – respiratory depression. In the ED they can assign one nurse to take care of this patient until the patient is breathing more deeply or they can give naloxone (Narcan).

Unfortunately, in some EDs they will quickly whip out the naloxone and will not titrate it to the desired effect – adequate respirations. A standard dose of naloxone can result in complete reversal of the pain management and increase the pain to much more than it was when we began treating the pain. Not titrating naloxone results in reversal of all of the endorphin effects – all the things that a person is able to do on their own to manage their pain.

Not titrating naloxone is torture.

Image credit. Ouch! Don’t be stingy with the fentanyl.

We want to avoid putting the patient in the situation of having their pain relief reversed. In the ED, one on one observation of patients is not common. The patient is being transferred from EMS, which has several people observing the patient, to the ED, which has several patients per nurse. The ED is just not staffed to provide one on one observation without detracting from the care of other patients. Sometimes staff will over-react to respiratory depression and hurt the patient.

We should not be causing problems for the ED or for the patient by transferring a patient that the ED is not as prepared to treat than we are in EMS.

Not noticing dangerous respiratory depression in EMS is incompetence.

Not noticing dangerous respiratory depression in the ED may be just due to having divide attention among many patients at a time when things change.

Go listen to all of these at EMS Garage.


International Paramedic

What if we tried to improve EMS quality from the outside, rather from within?

What if we had an international organization advocating for higher quality EMS?

This might work.

That is the idea behind International Paramedic.

The most recent EMS Garage looks at International Paramedic. International Paramedic: EMS Garage Episode146. Matt Womble is the featured guest representing International Paramedic. Scott Kier is moderating the discussion, Russell Stine, William Random Ward, and I ask Matt questions about how this works and he gives some excellent answers.

Download the Initiation Document for International Paramedic here.

One great comments from Matt Womble –

The US has to get out of the mentality that these are all of the sandboxes and we have to make everybody happy. Quite frankly, making everybody happy is not doing what’s best for the patient.

The original group of people who gathered to start this is below. Some of these people will be familiar to anyone in EMS.

Joe Acker . . . . . . . . . . . . .Bathurst, NSW AUS
Lyle Blumhagen . . . . . . . . . . Drumheller, AB CAN
Mathias “Matt” Duschl . . . . . . . Ziegelbrücke, SUI
Marty Epp . . . . . . . . . . . . . Oshawa, ON CAN
Dia Gainor . . . . . . . . . . . . Boise, ID USA
Neil Kirby . . . . . . . . . . . . Dubai, UAE
Kevin McGinnis . . . . . . . . . . Hallowell, ME USA
Teresa McCallion . . . . . . . . . Bonney Lake, WA USA
Chris Montera . . . . . . . . . . . Eagle, CO USA
Michael Nolan . . . . . . . . . . . Pembroke, ON CAN
Ian Patrick . . . . . . . . . . . . Diamond Creek, VIC AUS
Pierre Poirier . . . . . . . . . . Ottawa, ON CAN
Penny Price . . . . . . . . . . . . Calgary, AB CAN
Mike Touchstone . . . . . . . . . . Philadelphia, PA USA
“Jay” J. Albert Walker . . . . . . Dartmouth, NS CAN
Gary Wingrove . . . . . . . . . . . Buffalo, MN USA
Matt Womble . . . . . . . . . . . . Hillsborough, NC USA

Go listen to the podcast.

Go read the document.

Go join International Paramedic.


Next EMS Radio Star

There is a contest, Next EMS Radio Star, at the EMS Garage for people who want to start their own podcast – not just start their own podcast, but also be launched by the EMS Garage.

Perhaps you are worried that this will be an opportunity for others to ridicule you. Well, if you have been in EMS long enough to have anything to say that is worth listening to, you ought to have a pretty resilient ego. On the other hand, Chris Montera (the guy in charge of EMS Garage) is not looking to be the Next Simon Cowell. 😯

Chris is looking to find the positives in EMS podcasting.

It is true that we sometimes entertain ourselves at the expense of others in the group emails that go out to the EMS Garage participants mailing list, but we find as much entertainment making fun of ourselves as we do of others.

Do you have some ideas that you don’t hear from any other podcasters?

Do you have some ideas that others have discussed, but you think that some important points have been ignored on podcasts, or you thing that ignored is too strong a word, but you do think that the ideas have not been given the attention they deserve?

Or do you just have the ability to be very entertaining?

Or maybe you just want to be the next Lt. Steven Hauk, who will forever be remembered for the line – Sir, I know in my heart that I am funny.

What do you have to say about EMS?

Can the EMS podcasting world handle a Good Morning, EMS?

Go read the rules and enter and let us see what you’ve got.

Next EMS Radio Star


Bath Salt Abuse – EMS Garage Episode 140 – Part I

This week’s EMS Garage[1] covered paramedics being highly respected in Australia and the abuse of bath salts.

Bath salts ingestion can lead to rhabdomyolysis, which is primarily a blockage of the kidneys with the byproducts of tissue destruction. What is most dangerous about rhabdomyolysis is the release of large amounts of potassium into the blood stream. A poisonous amount of potassium is called is hyperkalemia and some of us may have a protocol by the names of crush syndrome, rhabdomyololysis, or hyperkalemia.

Management of severe hyperkalemia.[2] Click on the image to make it larger.

Hyperkalemia can be treated quickly with calcium gluconate or calcium chloride. Another treatment that works quickly is albuterol. Some protocols be limited to treatment with sodium bicarbonate (NaHCO3), but this works much more slowly than calcium or albuterol. The difference in time between calcium and bicarb is a lifetime – the patient’s remaining lifetime.

Call medical command for permission to give calcium, rather than bicarb. Delaying bicarb will not matter, while getting permission to give calcium will matter.

If the patient is stable, there is plenty of time for bicarb to work, but if the patient is stable the patient can probably also wait until after arrival at the hospital for treatment. If the patient is unstable and you only have bicarb in your protocol, do not delay at all on scene to give the bicarb, because the patient will be dead before sodium bicarbonate does anything. If the patient is unstable and you have calcium in your protocol, nothing works better or faster.

Patients with renal failure given the selective β2-adrenoceptor agonist, albuterol, by intravenous infusion (0.5 mg over 15 mins) show a significant decline in PK (about 1 mmol/L) that is maximal between 30 and 60 mins (47). Because injectable albuterol is unavailable in the United States, it is encouraging to note that nebulized albuterol in a high dose, administered to patients with end-stage renal disease, has a similar effect: PK declines by 0.6 mmol/L after inhalation of 10 mg of albuterol, and by about 1.0 mmol/L after 20 mg (41, 42, 48, 49).[2]

PK = Plasma concentration of Potassium (K). Added 7/12/2011 at 23:22

Go listen to the podcast.

To be continued in Part II.


[1] Bath Salt Abuse: EMS Garage Episode 140
EMS Garage
Page with links to download Podcast

[2] Management of severe hyperkalemia.
Weisberg LS.
Crit Care Med. 2008 Dec;36(12):3246-51. Review.
PMID: 18936701 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from The University of Tennessee Health Science Center


More on Ambulance Waiting Time at the Hospital – Australian Edition

A different way of trying to deal with the same problem we were talking about on the recent EMS Garage podcast – How Much is that Patient in the Window?[1] – only on the other side of the world.

Ambulance officers across SA yesterday began protesting against “ramping” – keeping patients waiting on ambulance stretchers at the FMC – by giving “free rides” to patients.[2]

On the podcast, Rob Theriault mentioned many of the problems with a punitive-only approach to this problem. Will this work out any better than what is being attempted in Canada?

This also has the potential for dramatic unintended consequences.[3]

“There will always be situations where we have a peak of demand and we have several ambulances which arrive at the same time.”

Ms Hanson said additional nursing staff and three extra barouches had been moved into the ED to help combat the problem.[2]

Barouche? I am not familiar with that word and a search of dictionaries does not help. Unless this is what is meant.

A barouche was a fashionable type of horse-drawn carriage in the 19th century. Developed from the calash of the 18th century,[1] it was a four-wheeled, shallow vehicle with two double seats inside, arranged vis-à-vis, so that the sitters on the front seat faced those on the back seat.[4]

If someone familiar with the Australian use could explain, I would appreciate it. I suppose that the term refers to a bed or chair, but I am only guessing.


[1] How Much is that Patient in the Window?: EMS Garage Episode 135
EMS Garage

[2] $200,000 ambulance officers’ protest hits home
Health Reporter Jordanna Schriever
The Advertiser
June 02, 2011 11:00pm
Article and picture

[3] Unintended consequences

[4] Barouche
Article and image


How Much is that Patient in the Window?

This EMS Garage[1] had nothing to do with the song made famous by Patti Page, other than to provide a catchy title.

Winnipeg hospitals racked up a $60,000 bill last month after more than 400 ambulances were forced to wait upwards of 90 minutes to unload patients at emergency departments.[2]

All stick and no carrot. WWBBD – What Would Bugs Bunny Do?

There is even the possibility of a specialty in hallway medicine to deal with treating patients who never seem to make it into a hospital room.[3]

What can be done to improve the availability of ambulances?

The move is in response to reports that revealed one-third of Winnipeg ambulances are waiting to unload patients in emergency at any given time.[2]

What can be done to address the root of the problem?

Is this likely to backfire?


This doesn’t have any potential for dramatic unintended consequences.[4]

Not even a little bit.


Chris Montera
Rob Theriault
Greg Friese
Scott Kier
Anne Robinson


[1] How Much is that Patient in the Window?: EMS Garage Episode 135
EMS Garage

[2] City hospitals billed $60,000
Paramedic service charges for wait times

Winnipeg Free Press – PRINT EDITION
By: Jen Skerritt
Posted: 05/21/2011 1:00 AM

[3] The emerging subspecialty of Hallway Medicine.
Freeman J.
CJEM. 2003 Jul;5(4):283-5. No abstract available.
PMID: 17472776 [PubMed – in process]

Free Full Text from CJEM with link to Free Full Text PDF Download.

[4] Unintended consequences


Drive Like an Egyptian

This week on EMS Garage there are a few topics.[1]

Driving, which is one of the most common causes of LODD (Line Of Duty Death) and a huge source of lawsuits against EMS agencies.

Why are we so bad at coming up with sensible measures to discourage reckless driving?

Why do we take bad driving for granted?

If we assume that bad driving is inevitable, aren’t we encouraging bad driving?

Why do we rely on mindless rules that discourage critical judgment by the driver (such as a red light requires a full stop)?

What should we do to improve EMS driving?

Can we ever expect to have safe drivers, if we discourage critical judgment?

One problem that is mentioned is that management often thinks that they can only change behavior by punishing bad behavior (bad driving, in this case).

Punishment is not essential to behavior modification.

Management needs to focus on demonstrating good behavior, rather than on punishing what we see management getting away with on a regular basis.

Clearly, management that drives bad does not take bad driving seriously.

Why do we pretend that something that kills us and kills our patients is not a problem?

Buck describes the drive cameras that record just before a crash. This is designed for protection in court. Buck does not support this. I point out the obvious problem with that kind of approach –

What’s better protection from going to court, than changing the behavior of your employees who are behaving badly?

We need to change bad behaviors before they become bigger problems.

We need to recognize that we are only encouraging bad behavior when we tolerate bad behavior.

What kind of social media policies should we have in EMS?

As with driving, we seem to avoid allowing any judgment. We act as if blogs are bad. We use the occasional example of misbehavior on the part of a blogger to prejudice all EMS blogs.

Why do we always seem to abandon using critical judgment, when it comes to making decisions?

Are we really incapable of thinking?

If we are incapable of thinking, should anyone trust us to take care of them in an emergency?

Reference is made to a podcast from December 2009, where Dr. Keith Wesley came on and criticized EMS bloggers for poor content and for anonymity.[2]

Yes. There are some bad blogs out there. There is no way to prevent that.

There are also excellent blogs out there.

The presence of the pathetic blogs does not affect the quality of the excellent blogs. Criticizing the excellent blogs for the flaws of the bad blogs is misguided.

Anonymity is similarly a bogus criticism.

Are we smart enough to read something and determine if it is valid?


Are we too stupid to make any decisions without some authority telling us what to think?

Again, if we are incapable of thinking, should anyone trust us to take care of them in an emergency?

Any authority who has to resort to silencing criticism is not an authority we should listen to.

Any authority who discourages thinking is not an authority we should listen to.

An expert is someone who just hasn’t been embarrassed a lot, yet.

Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

– Richard Feynman.

Trusting experts is only for those of us who are not smart enough to understand what we are reading.

Also on the podcast are:

Chris Montera
Scott Keir
Buck Feris
Russell Stine
David Konig
Chris Kaiser

The articles we started out discussing:

EMS Week. What did you do or what should you do?

Take This Week And Shove It is a blog post that came up in the discussion of what we do wrong when settling for the same old pat on the head for EMS Week.


[1] Drive Like an Egyptian: EMS Garage Episode 134
EMS Garage

[2] Dr. Wesley Versus the Bloggers: EMS Garage Episode 65
EMS Garage