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

- Rogue Medic

Gathering of Eagles 2014


 

Here is a look at some of the presentations (and brief comments on what to expect) that are scheduled for this weekend’s Gathering of Eagles.[1]

Friday –
 

Indoctrination?
 

11:00 am-11:10am
Indoctrinating the Docs:
Training All First Year Medical Students to be NREMTs
– Thomas H. Blackwell, MD (Greenville)

 

That should be a negative presentation, since indoctrination is a means of changing minds when reason does not work. I am a fan of reason.
 

Ketamine (Ketalar)?
 

1:15pm-1:25pm
Another Way to Break the Ache:
Using Low Dose Ketamine for Pain Control
– Melissa W. Costello, MD (ACEP)

 

There seem to be a few reasons medical directors are hesitant to adopt ketamine (laryngospasm, which is manageable; vomiting, which is manageable; unfamiliarity, which is manageable; diversion, which is manageable), even though it is probably the most versatile EMS drug available.
 


EMCrit – Practical Evidence 014 – ACEP Procedural Sedation Update for 2013[2]
 

We endanger our patients with our contortions of extrication, when we could improve conditions for EMS and for the patients by decreasing the amount of screaming and thrashing about.

How does it help to protect the patient’s potentially injured spinal cord if we are providing intermittent stimuli of extreme pain and the patient is reacting by moving – including movement to the neck and back, far more than any capability of a collar and board might restrict movement.

We use backboards, which do not appear to be beneficial, while we avoid ketamine, which is beneficial.
 

Intranasal?
 

1:45pm-1:55pm
Care Ease Through the Nares
Nasal Fentanyl for Kids
– Peter P. Taillac, MD (NASEMSO)

 

IV (IntraVenous) is not the only route available for administration of medications, so why do we artificially limit EMS at the expense of our patients?
 

Too many medics?
 

3:00pm-3:10 pm
Are More Paramedics Elemental or Detrimental?
Lessons Learned from an ALS Expansion Program
– Andrew J. Harrell, MD (Albuquerque)

 

Because dilution of experience improves quality? 😳
 

EMS Palliative care?
 

4:30pm-4:40pm
Raising Questions about a Pain-Full Subject:
Survey Results Regarding Palliative Care Processes
–Arthur H. Yancey II, MD (Atlanta)

 

The patient is dying this year, so I have an excuse to ignore the patient’s pain.

No ethics for us, we’re EMS.
 

Saturday –
 

Airways in Cardiac Arrest?
 

8:30am-8:40am
Tracheal Deviants:
The Effect of Airway on Cardiac Arrest Outcomes
– Jason T. McMullan, MD (Cincinnati)

 

Using airways to treat cardiac arrest is not supported by any evidence, but maybe there is something that has been found to support our favorite mythology – or is it our second favorite mythology, after backboards?
 

EMS ECMO?
 

9:15am-9:25am
A Change in Scene-ery:
Re-Thinking On-Site Management of Cardiac Arrest
– Paul R. Hinchey, MD, MBA (Austin)

 

The idea of transporting dead people may have justification as a bridge to ECMO (ExtraCorporeal Membrane Oxygenation), but do we have any evidence that this improves outcomes?
 

Ketamine and ketamine analogues not perfect together?
 

10:15am-10:25am
Epidemic Proportions:
Dosing Ketamine in the Era of Mamba Dramas
– Christopher B. Colwell, MD (Denver

 

Methoxetamine (Mexxy), O-desmethyltramadol (an ingredient in Krypton), and synthetic cannabinoids (ingredients in Black Mamba and Annihilation and others may produce excited delirium and may not be best treated with ketamine, due to possible combined toxicity. Ketamine and methoxetamine suggest similarities and if it is a genuine chemical dosage problem, and the dose does make the poison, could we be contributing to the problem?

How might we ruin Reese’s Pieces?
 

Two opioids in one?
 

10:30am-10:40am
Double-Duty Dopers:
Managing Fentanyl-Laced Heroin Abuse
– C. Crawford Mechem, MD (Philadelphia)

 

Is it any surprise that the ingredients of street drugs are a surprise?
 

BLS naloxone (Narcan)?
 

10:45am-10:55am
Drugs Falling into the Wrong Hands – or Not ?
Naloxone Use by Non-EMS Personnel
– Jeffrey M. Goodloe, MD (Tulsa and OKC)

 

What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera?

What are the outcomes for these patients in systems that make naloxone a BLS treatment, or even just an advanced first aid treatment?
 

Repeated EMS-worthy inebriation?
 

1:30pm-1:40pm
Re-thinking the EMS ”Response” to Serial Inebriates:
Sobering Reflections from an EMS Medical Director
– S. Marshal Isaacs, MD (Dallas)

 

What do we do with the people who go out and have such an intoxicatingly good times, that they end up with us?
 

IO BP? IO PaO2?
 

2:00pm-2:10pm
New Skills From Drills:
Using Intraosseous Systems for Hemodynamic Monitoring
– R.J. Frascone, MD (St. Paul)

 

Interesting, but does it just make us more likely to treat surrogate endpoints and harm our patients?
 

Respect the Mythology?
 

3:15pm-3:25pm
It May Send Shivers Up Your Spine:
Taking Aim at Removing the Backboard Altogether
– W. Scott Gilmore, MD (St. Louis)

 

Pulling the board out from beneath the feet of the EMS myth makers.

Superstition vs. Reality?
 

3:30pm-4:00pm
The Great Debate
The Long and Short of It Being: To Spine Board or Not
The Bony Debaters Will Each Be Asked to Bring a Disc and then Back up Their
Statements with Pithy Remarks and Avoid Assertions that May Lead to Re-Tractions
of some Radicular Idea. They Must Follow Every Facet of the Debate Process
Carefully and take Precautions to Stay Neck and Neck with Their Opponents and
avoid Distracting Activities

– Raymond L. (“Sugar Ray”) Fowler, MD — the PRO (& ex-Con)
VS.
Terence D. (“The Terminator”) Valenzuela, MD, MPH — the CON (& ex-Pro)

 

Let’s hope they pay more attention to the absence of evidence – there is no evidence that justifies using Spine Boards to transport patients – than the abundance of puns they are so fond of.[3]

Footnotes:

[1] Gathering of Eagles – The EMS State of the Sciences Conference
Friday, February 28 and Saturday March 1, 2014
Dallas, TX
Agenda in PDF Download format.

[2] Practical Evidence 014 – ACEP Procedural Sedation Update for 2013
EMCrit
Dr. Scott Weingart
Written analysis of position statement and podcast.

[3] EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed – as supplied by publisher]
 

The backboard has been a component of field spinal immobilization despite lack of efficacy evidence.

 

Just like blood-letting and every other superstition-based treatment.
 

The ambulance stretcher is in effect a padded backboard and, in combination with a cervical collar and straps to secure the patient in a supine position, provides appropriate spinal protection for patients with spinal injury.

 

Why not just leave out the harmful device that cannot be demonstrated to improve outcomes or even to be safe?

.

Japanese man dies after 25 hospitals reject him

ResearchBlogging.org
 

In January, in Japan, 25 hospitals refused to permit an ambulance to transport a man who was pronounced dead when he finally arrived at a hospital.

Were the patients already in the ED (Emergency Department) less stable than this patient?

Was this patient going to be the straw that breaks the camel’s back and result in the deaths of other patients already in the ED?

What kind of evidence do we have to justify diversion?
 

Paramedics rushed to his house but were told in turn by all 25 hospitals in the area that they could not accept the man because they did not have enough doctors or any free beds, a local city official said, adding some institutions were contacted more than once.[1]

 

We do not know if he would still be alive if he had been transported to the first ED, or to the second, or to the third, . . . . We do not even know the cause of death. However, this is a good way to introduce the topic of diversion.

Diversion is not just a problem in Japan, but also in the US and other countries. It has become more convenient for many people to go to the ED than to wait to see a primary care physician. Until that problem is fixed (assuming that it ever is fixed), is diversion appropriate?

There have been a couple of studies in San Diego of what happens when diversion is minimized, or eliminated.

Even though volume went up, diversion dropped to almost zero.
 


 


 
Click on images to make them larger.

The authors acknowledge that the main limitation of this study was the short time frame of the analysis, comparing one week to another.[2]

 

In a longer study, diversion decreased and the need for transfers between hospitals dropped. There did not appear to be any negative consequences of minimizing diversion.
 


 

 

In summary, a community-wide effort to improve getting patients to requested EDs and decreasing ambulance diversion hours can be successful in a large community with an urban, suburban, rural, and remote population distribution. The success of such a process had the additional effect of decreasing the need for ED interfacility transfers for payer request reasons.[3]

 

In this month’s Annals of Emergency Medicine is a study looking at what happened when Massachusetts banned diversion.

 

 

 

 

 

Figure 1. Changes in ED length of stay by hospital among A, admitted patients and B, discharged patients. C, Changes in ambulance turnaround time by hospital. D, Changes in total hospital volume before and after a ban on ambulance diversion by hospital.[4]

 

It seems that the benefits of diversion are just another medical myth.
 

Research has led to the consensus that crowding is largely due to output factors, particularly the practice of boarding admitted patients in the ED2,7-10 because of lack of inpatient capacity. Ambulance diversion, in contrast, is an input factor, which has little effect on ED crowding.4 [2]

 

Very few of the patients coming in to the ED are arriving by ambulance.
 

On July 3, 2008, the department released a policy directive ending the practice of ambulance diversion in the state, except in cases of internal hospital disaster.17 The policy took effect on January 1, 2009, allowing hospitals 6 months to prepare for the changes necessary for its implementation. This policy represented the first statewide ambulance diversion ban in the United States.[2]

 

A lot of the bad things were supposed to occur when diversion was banned.

None of them happened.
 

Preliminary reports from hospitals suggest that the end of ambulance diversion has been a relative success because of operational changes made at individual hospitals in anticipation of the ban.24,28 Early reports from Boston Emergency Medical Services (EMS) suggest that there has not been an increase in ambulance turnaround time as feared, although this has not been formally studied.29 [2]

 

At the Gathering of Eagles conference, this was one of the topics.
 

-It negatively impacts EMS operations and could jeopardize our ability to respond to the next critical patient.

-It often results in patients being transported to ED’s other than where their MD’s or medical records are.

-It negatively impacts patient satisfaction and provider morale.

-It does little if anything to reduce ED overcrowding.[5]

 

In places that use diversion, when all of the hospitals are on divert, the dispatch center is supposed to notify the hospitals that dispatch will be making destination decisions until things improve. I have not seen any explanation for why that was not the case in Japan.

Diversion does not appear to provide any real benefit to anyone, except that it is consistent with the superstitions of many people, and medical people are as superstitious as gamblers.

Footnotes:

[1] Saitama man dies after hospitals reject him 36 times
Japan Today
Mar. 06, 2013 – 02:31PM JST
Article

[2] The effects of minimizing ambulance diversion hours on emergency departments.
Khaleghi M, Loh A, Vroman D, Chan TC, Vilke GM.
J Emerg Med. 2007 Aug;33(2):155-9. Epub 2007 Jun 18.
PMID: 17692767 [PubMed – indexed for MEDLINE]

[3] Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial.
Vilke GM, Castillo EM, Metz MA, Ray LU, Murrin PA, Lev R, Chan TC.
Ann Emerg Med. 2004 Oct;44(4):295-303.
PMID: 15459611 [PubMed – indexed for MEDLINE]

[4] The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.
Burke LG, Joyce N, Baker WE, Biddinger PD, Dyer KS, Friedman FD, Imperato J, King A, Maciejko TM, Pearlmutter MD, Sayah A, Zane RD, Epstein SK.
Ann Emerg Med. 2013 Mar;61(3):303-311.e1. doi: 10.1016/j.annemergmed.2012.09.009. Epub 2013 Jan 24.
PMID: 23352752 [PubMed – in process]

Free Full Text Download in PDF format.

[5] Taking a Turn For The First: Taking Aim at Diversion Practices
S. Marshal Isaacs, MD, FACEP
Gathering of Eagles XV
February 23, 2010
Presentation slides in PDF format

75-year-old Japanese Man Dies After Hospitals Reject Him 36 Times
By Yue Wang
March 06, 2013
TIME.com
Article

Khaleghi, M., Loh, A., Vroman, D., Chan, T., & Vilke, G. (2007). The Effects of Minimizing Ambulance Diversion Hours on Emergency Departments The Journal of Emergency Medicine, 33 (2), 155-159 DOI: 10.1016/j.jemermed.2007.02.014

Vilke, G., Castillo, E., Metz, M., Upledger Ray, L., Murrin, P., Lev, R., & Chan, T. (2004). Community trial to decrease ambulance diversion hours: The San Diego county patient destination trial Annals of Emergency Medicine, 44 (4), 295-303 DOI: 10.1016/j.annemergmed.2004.05.002

Burke, L., Joyce, N., Baker, W., Biddinger, P., Dyer, K., Friedman, F., Imperato, J., King, A., Maciejko, T., Pearlmutter, M., Sayah, A., Zane, R., & Epstein, S. (2013). The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time Annals of Emergency Medicine, 61 (3), 303-3110 DOI: 10.1016/j.annemergmed.2012.09.009

.

Excited Delirium – Episode One of Rogue Medic Rants podcast

 

Matt Fults and Brad Buck are hosting a podcast for me at Standing Orders – The Podcast.

They share a delusions that there is not enough Rogue Medic on the internet. 😕

Their solution is to give me my own podcast on their site. 😎

They mention that they are excited; I point out that they are delusional; so the first podcast is perhaps the best way to combine these into one diagnosis – Excited Delirium. 😯
 

Episode One: Excited Delirium
 


 


Image credit.
 

Does anything suggest excited delirium as succinctly as that image?

No. That is not a picture of me.

I am putting all of the links on the Rogue Medic Rants page for each post. You can listen to the podcast and look up the links all from one page.

This podcast has almost ten minutes of introduction because it is the first one. Later podcasts will have much less of an introduction, or maybe no introduction.

After the introduction, the discussion of excited delirium is less than 15 minutes long.

I apologize for not being well prepared for the podcast. I had all of my notes set for a different podcast, but we decided that one will be done at a different time for a variety of reasons. I hope that I provided enough information in the notes to correct any inaccuracies in the podcast. I think the only one was the dose of ketamine – the starting dose should be 5 mg/kg, not 2 mg/kg. 2 mg/kg is great for procedural sedation, but not for taking down a violent patient.

I will try to keep the podcasts short.

I may have some longer podcasts with a guest, or with several guests. I have already invited Peter Canning of Street Watch: Notes of a Paramedic. He is currently doing an excellent series on What BLS Should Be Doing Now.

Matt, Brad, and I will be at Gathering of Eagles, so feel free to talk to anyone with a shirt with the Standing Orders logo on it. I don’t have one, so just look for someone who looks weird. 😳

There will probably be some Standing Orders and/or Rogue Medic Rants podcasts from Gathering of Eagles. Not live, but probably without much of a delay.

One of the topics I really want to talk with the attendees about is the recent spinal immobilization research and research reviews, but that is a topic for some other posts.

Let me know what you think about the podcast. Ways to improve it – I am no Morgan Freeman, but I will try to make it easy to listen to.

Suggestions for topics and guests, further information on a podcast, and criticism – all are welcome.

Likewise, let Matt and Brad know what you think.
 

Rogue Medic Rants
 

.

The Circulation Improving Resuscitation Care Trial (CIRC)


We are still waiting for the publication of CIRC (Circulation Improving Resuscitation Care Trial), but the authors are out talking about it at NAEMSP and Gathering of Eagles.[1]

There are a couple of things that seem curious about the slides for the presentations. I have not seen either presentation.


M CPR = Manual. iA CPR = AutoPulse.
The larger circles are from the presentation. The underline and the smaller circles are mine.

The large variations shows inconsistency. That inconsistency is larger with the AutoPulse. Why? Once it is turned on, it should not need to be stopped for defibrillation.

Epinephrine and ventilations are unknown variables that have not been controlled for.

Then there is the problem of what they considered High Quality CPR –

Embarrassed by all of those extra bodies on scene?

Try the Pit Crew method of CPR. They will be running in so many different directions that people will assume that crew members must be doing something important!

This is just high activity CPR for the people with ADHD (Attention Deficit Hyperactivity Disorder), or a union trying to justify hiring more people.

There is no evidence that this attempt at high quality CPR improves survival over compression-only CPR.

If unnecessary ventilations are interrupting, or interfering with, chest compressions, the ventilations are only detracting from quality.

The fraction of AutoPulse compression time is better in the second 10 minutes, but when compressions are most important is during the first few minutes of compressions.

The lower the chance of survival, the better the AutoPulse performs?

89.2 compressions per minute with manual CPR, but only 66.3 compressions per minute with the compression machine. The AutoPulse only does compressions. What is it doing the rest of the time?

The problem may be that there are delays in hooking up the machine.

Not only is it not needed in the initial resuscitation, it seems to interfere with the initial compressions.

When are chest compressions most important?

During the first few minutes.

When does the AutoPulse seem to interfere with compressions?

During the first few minutes. 😳

Witnessed VF/VT Arrests 
• Survival higher for iA-CPR if CPR fraction <78% 
• No survival difference with higher CPR fractions. 
• Example: CPR fraction 70% OR 3.4, 95% CI: 2–7.4[1]

The Subgroup Analysis does not make sense.

The lower the CPR fraction, the higher the odds of survival to discharge?

This is not impossible, but it does raise questions about the results.

A CPR fraction of 50% appears to be over 20 times more likely to produce survival to discharge than an 85% CPR fraction?

To continue with that line of reasoning, if we were to stop doing CPR completely, we could increase the survival to discharge by a factor of 50.

That would be an interesting marketing strategy.

Buy our machine, but don’t even turn it on for the best results. Just use it as a lucky charm.

Once this is published, we should be able to see more of the data and maybe see where these numbers come from. Maybe.

Footnotes:

[1] CIRCular Arguments: Was It Win, Lose or Draw in the CIRC Auto-Pulse Trial?
David E. Persse, MD (Houston)
Gathering of Eagles 2012
Presentation in PDF format

.

Preventing Medication Errors from Gathering of Eagles

There are some interesting case studies in this presentation.[1]

1. Rule out seizures, patient is waking up, then becomes combative, medication given IM (IntraMuscularly), combativeness continues, combativeness resolves, everything seems OK.

Later, the empty medication is found to be morphine, not midazolam (Versed).

There is a problem in giving the wrong medication. We need to be more careful about what we give.

Just because the packaging looks the same does not mean the contents are even remotely similar.

2. Rule out hypoglycemia, medication given IV (IntraVenously), but it was sodium bicarbonate, rather than D50W (50% dextrose), then D50W was given.

Similar appearance does not mean the drug is the same.

3. Rule out extrapyramidal reaction to psychiatric medications, medication given IV, the medication was 10 mg morphine, medical command was contacted, the appropriate 50 mg of diphenhydramine (Benadryl) was given.

Appearances can be deceiving.

We trust what we think we see, but our brains jump to conclusions on insufficient evidence. We need to find ways to prevent us from misleading ourselves.

It is interesting that morphine is the drug accidentally given in two of the three cases. It is expected that the morphine and midazolam would be stored together. The diphenhydramine might be stored with the controlled substances to make it easier to treat histamine release from morphine administration. There is plenty of time to get diphenhydramine after noticing a reaction to morphine. I do not know of any cases of anaphylactic reactions to morphine. Keeping the diphenhydramine with the morphine does not improve patient safety. If the controlled substances need to be opened each time that diphenhydramine is given, that is probably not going to please the DEA (Drug Enforcement Administration, the controlled substances oversight organization in the US).

The good news is that the sodium bicarbonate is probably only going to result in some hyperventilation to blow off the CO2 (Carbon diOxide) produced by the breakdown of sodium bicarbonate.

The boxes do not look the same, but . . .

. . . the syringes do look alike (except for the identifying labels).

All the fear of giving too much morphine , but when 10 mg IV morphine is given to somebody who has no medical indication for morphine, there are no complications at all.

None.

10 mg morphine was harmless, but some doctors still worry about giving 2 mg without orders.

The medical education provided by some medical schools has some blatant gaps in the area of pain management and pharmacology.

Some medics still worry about giving 2 mg without orders.

The medical education provided by some paramedic schools also has some blatant gaps in the area of pain management and pharmacology.

Footnotes:

[1] Preventing Medication Errors
Gathering of Eagles 2012
Page with links to presentations

.

Most Common Cause of Death in Anaphylaxis is Failure to Give Epinephrine

ResearchBlogging.org

The most common cause of death in anaphylaxis is failure to give epinephrine.

That is according to Dr. Corey Slovis, presenting at the 2012 Gathering of Eagles Conference.[1]

This is shocking news. Where do we have any evidence of that?

Although five of the six children and adolescents had experienced definite allergic reactions to the incriminated food on previous occasions, none had had a near-fatal reaction.[2]

No problem. There is no reason to expect that they will have a severe reaction this time, either.

Well, we can always use epinephrine to resuscitate them. 😳

Near-fatal reactions were not that much better.

Three of the six children and adolescents appeared to be improving before the occurrence of terminal cardiorespiratory arrest.[2]

With anaphylaxis, symptoms can mislead. Do not underestimate the condition of patients who have a history of anaphylaxis.

What did they have in common?

All the patients received epinephrine and appropriate medical care once they reached a hospital emergency room, but by then all were unresponsive and had had extended hypoxia and hypotension.[2]

All the patients had asthma and were taking bronchodilator medications.[2]

The asthma in all but one of the patients with nonfatal reactions appeared to be well controlled by medication, whereas two patients with fatal reactions and one with a nonfatal reaction had serious wheezing in the two weeks before the anaphylactic reaction.[2]

All the patients had a history of serious anaphylactic reactions to food, and all but two had had such reactions to the food responsible for the fatal or near-fatal reaction.[2]

A history of anaphylaxis is a good reason to give epinephrine to someone with minor, or moderate, symptoms. I will assume that nobody is withholding epinephrine from patients with severe symptoms.

Do we need to give an auto-injector, or an intramuscular injection?

No. We can approach this more gradually with a slow epinephrine drip –

1 mg in 1 liter starting at 1 ml per minute.

Corrected at 12:15 4/13/2012 from 1 mg in 1 ml starting at 1 ml per minute. It is 1 mg in 1,000 ml (1 liter) starting at 1 ml per minute. Thank you to Jeffrey R. Vaughn and Tony Heibel for pointing this out.

The starting dose epinephrine by IV infusion is 1-2 micrograms/minute.[1]

If there is no protocol for this, calling medical command is always an option. Even though there may be systems that foolishly forbid medics from deviating from protocol with orders from medical command.

None of the patients were aware that the implicated allergen was in the food they ate, indicating that attempts at strict avoidance are often unsuccessful.[2]

Even if the patient does not know of an exposure, there can still be a deadly exposure.

Too simple? Not simple enough? Just right?

Another explanation of how to treat anaphylaxis.[3]

Read the PDF[1] and listen to the recording from Free Emergency Medicine Talks and you should become comfortable with it.

Footnotes:

[1] Using IV Epinephrine Expertly
Dr. Corey Slovis
2012 Gathering of Eagles
Presentation in PDF format

Care of the Wheezing Patient – Slovis, from Free Emergency Medicine Talks

[2] Fatal and near-fatal anaphylactic reactions to food in children and adolescents.
Sampson HA, Mendelson L, Rosen JP.
N Engl J Med. 1992 Aug 6;327(6):380-4.
PMID: 1294076 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM

[3] Anaphylactic reactions – 5 things.
Sunday, September 4, 2011
Doc Cottle’s Desk
Article

Sampson, H., Mendelson, L., & Rosen, J. (1992). Fatal and Near-Fatal Anaphylactic Reactions to Food in Children and Adolescents New England Journal of Medicine, 327 (6), 380-384 DOI: 10.1056/NEJM199208063270603

.

What should an epinephrine in cardiac arrest study look like?

Since the Hagihara[1] study was published, there is a lot more support for a study of epinephrine. One of the problems with studying epinephrine is the religious devotion that some have to maintaining the status quo.

How do we prevent paramedics from violating the study protocol?

I have been told of paramedics testing the study drug to see if it produces the cocaine-type of numbness to the tongue, since epinephrine produces effects similar to cocaine without the euphoria. If the study drug is not epinephrine, the syringe is broken, or replaced, or . . . .

How much epinephrine is needed on an ALS (Advanced Life Support) ambulance?

We generally carry a bunch of 1:10,000 epinephrine (1 mg in 10 ml) for cardiac arrest. Maybe 5 – 10 with a multi-dose 30 ml vial of 1:1,000 (1 mg in 1 ml) epinephrine for those prolonged arrests, so that 1 mg at a time can be drawn up and given to the patient.

We also carry some ampules of 1:1,000 epinephrine for IM (IntraMuscular), SC (SubCutaneous), or IV (IntraVenous) administration for anaphylaxis or asthma.

We can easily replace the 1:10,000 epinephrine and the multi-dose vial with just one study drug packet. After each code, a new packet would be placed in the ambulance’s drug bag/box. This would discourage the tendency to switch kits if the study drug is not epinephrine – not that there is any good reason for the medic to know what is being given.

For anaphylaxis/asthma, participating ambulances would be assigned only autoinjectors. This would decrease the availability of epinephrine available to violate protocol.

Supervisors would only carry study kits and autoinjectors.

Is it still possible to intentionally violate protocol? Yes, but anyone thinking that far ahead should be smart enough to realize that they are only harming patients by possibly requiring that the study be repeated. The maturity of the medics should be the best protection against protocol violation, but true believers can be immune to maturity.

What would the study kits include?

The RAMPART[2], [3] study gives an excellent example of how to

Patients are not entered into the study unless they have reached the point in the algorithm where epinephrine would be given. When the kit is opened, the recording beginsand the first syringe of the study drug is given.

Monitors capable of recording the quality of CPR would also be used. The ROC (Resuscitation Outcomes Consortium) should already be using these, so it would not be an added expense.

What about patients who remain in a shockable rhythm after the syringes of study drug are all used? Transport them to the hospital. Let the hospital do whatever they want with these rare patients.

What if there is a problem with the study kit? Then the patient should not be receiving any medication and should be unblinded participants in the group not receiving epinephrine.

What about amiodarone/lidocaine? There is no good reason to give these derivative magic treatments until there is evidence that they work. This is to try to find out if the primary magic treatment epinephrine works, not to support the whole Chain of Magic.

Maybe the last part of that chain should not be there.

See also –

How to Study Epinephrine in Cardiac Arrest

Images from Gathering of Eagles Presentation on RAMPART

Footnotes:

[1] Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
PMID: 22436956 [PubMed – indexed for MEDLINE]

Free Full Text from JAMA.

[2] Epileptic Fix: Hot-Off-the-Press Results from the RAMPART Trial
Jason T. McMullan, MD (Cincinnati)
Gathering of Eagles
Friday, February 24, 2012
Presentation

[3] 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.

.

What About IV Epinephrine for Patients Who Are Not Dead

Is IV (IntraVenous) epinephrine acceptable for anaphylaxis?

Is IV epinephrine acceptable for asthma?

Is IV epinephrine acceptable for bradycardia?

Is IV epinephrine acceptable for heart block?

Is IV epinephrine acceptable for shock?

5 items? Could it be something from Dr. Slovis?

At the Gathering of Eagles (the conference of the medical directors of the largest cities in the US), Dr. Corey Slovis (Nashville, TN) gave a presentation on using IV epinephrine expertly.

We may be accustomed to giving SC (SubCutaneous) or IM (IntraMuscular) epinephrine for asthma or for anaphylaxis, but maybe IV is a route that allows for better titration. When is the last time any of us gave a medication by the subcutaneous route? I don’t use the SC route for anything. IM is much simpler and faster and does not appear to have a higher rate of complications than SC.

Dr. Slovis suggests that we should be using the IV route, if possible.

First, he wants us to avoid using the concentration terms that we have had drilled into us.

Not 1:1,000, but 1 mg in 1 ml (mg = MilliGram and ml = MilliLiter).

How many of us think in the terms of 1:1,000?

Similarly, 1:10,000 would be the much more obvious 1 mg in 10 ml, but he doesn’t really want us to use that either. Dr. Slovis even uses an image that I like to discourage the use of these more concentrated forms of epinephrine.

Physicians and paramedics make dosing mistakes in using IM and IV epinephrine, especially when dealing with severe anaphylaxis and asthma.[1]

Dr. Slovis points out that the biggest problem may not even be the dosing mistakes, but the failure to give epinephrine at all. Patients die in the presence of EMS, or even in the ED (Emergency Department) because doctors, nurses, and medics are too uncomfortable, or too afraid, or too inexperienced, or too whatever to give epinephrine.

Maybe by simplifying the dosing, and by allowing for titration, this will not happen too often.

The starting dose epinephrine by IV infusion is 1-2 micrograms/minute.[1]

1-2 mcg/minute to start. (mcg = MiCroGram or μg)

Start at 1 mcg/minute and turn it up (or down) every minute, if the dose does not appear to be working.

When it appears to be working, start turning it down, and eventually off.

Is this too complicated?

We can put 1 mg of 1:10,000 epinephrine 1 mg in 10 ml epi into a 1 liter (1,000 ml) bag of NSS (Normal Saline Solution).

We can put 1 mg of 1:1,000 epinephrine 1 mg in 1 ml epi into a 1 liter (1,000 ml) bag of NSS.

The result is the same. There is no significant difference between 1,001 ml from adding 1 mg in 1 ml epi to 1 liter and 1,010 ml from adding 1 mg in 10 ml epi to 1 liter.

The concentration is 1 mg in 1 liter or 1 mcg in 1 ml.

Where does it say that the liter is NSS? It doesn’t but I do not carry liters of D5W (5% Dextrose in Water) and I am not going to use Ringer’s Lactate.

The liter with epinephrine is the Slow Drip.

Even though you have 1 liter of fluid, do not use the epinephrine mix for a fluid bolus.

Too simple? Not simple enough? Just right?

Read the PDF and you should become comfortable with it.

Footnotes:

[1] Using IV Epinephrine Expertly
Dr. Corey Slovis
2012 Gathering of Eagles
Presentation in PDF format

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