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

- Rogue Medic

Medicare Rules That Encourage Fraud

A lack of understanding of EMS by Medicare (Centers for Medicare and Medicaid Services) encourages fraud.

When patient care is determined by the fraud investigators, is it patient care or does it transform into what the investigators focus on?

Citing a “significant potential for fraud, waste, and abuse,” federal Medicare officials put a moratorium on the enrollment of new ambulance operators in Philadelphia and six surrounding counties.[1]


In other words – Ambulance companies have a lot of potential for fraud. Our rules do not prevent fraud. We can’t even keep track of the ambulances companies that defraud us. So, we will stick with the frauds we know, rather than to potential frauds we do not yet know.

In EMS, we have competition on everything except quality.

How does an insurance company (Medicare) assess quality of care? By assessing surrogate endpoints that it can track.

At issue is the medical necessity for nonemergency ambulance transportation. Medicare is supposed to pay for an ambulance only if a cheaper form of transportation would endanger the patient’s health.[1]


How do they determine what would endanger the patient’s health?

Getting a doctor, or the doctor’s representative, to check off some boxes on a standard form, because we cannot expect the insurance computer to understand patient care. We can have the computer search for words that indicate that the patient is too healthy for ambulance transport.

Sitting or lying are a couple of words the computer programmers think indicate robust health.

If my acute CHF (Congestive Heart Failure) patient is sitting upright, which is actually an indication of good patient care, the word sitting is an indicator of being too healthy for ambulance transport.

If I fraudulently transport a completely healthy person by ambulance, but check off the bed-confined box on the form, and get a signature, Medicare does not appear likely to recognize the fraud until after I have gone out of business.

Rather than encouraging people to mindlessly check off boxes to justify what should be clearly and accurately documented, the rules discourage good patient care.

When more attention is paid to jumping through hoops than to actual patient care, the rules are making things worse.

Most recently, in January, an emergency-medical technician who worked for Brotherly Love Ambulance Inc., of Philadelphia, pleaded guilty to signing up patients for relatively expensive ambulance rides when he knew they could walk or use cheaper transportation.

In addition, the EMT gave riders cash to entice them to keep using Brotherly Love, which fraudulently collected more than $2 million from Medicare from July 2010 through October 2011, the U.S. attorney in Philadelphia said.[1]


This was going on for over a year and Medicare was blissfully ignorant, but they will solve the problem by preventing new companies from entering the market.

However, only 10 percent to 20 percent of dialysis patients actually need ambulance transportation, according to government and industry estimates. Medical necessity is determined on the “honor system,” said Herman’s partner, Joseph Zupnik.[1]


When insurance companies extrapolate appropriate care for chronic treatment patients, such as dialysis, to patients with acute medical conditions, they make fools of themselves.

“The ambulance business, I think, because of what happened to my dad, became extremely focused on compliance, because we had to be,” Strine said.[2]


We need to get the ambulance companies to focus on good patient care, not extremely focused on compliance with insurance rules.

With the exclusion of new ambulance companies, is any fraud being prevented?

Frustrated by a large number of small, fraudulent competitors, two of the largest Philadelphia-area ambulance operators recently joined forces.[2]


Large companies are merging because small corruption is being addressed?

Any fraud will be among the already existing ambulance companies, but will it be concentrated in the smaller companies or the larger companies?

Are the larger companies benefiting from the economies of scale that FedEx and UPS benefit from?

Are patients more than just packages to be delivered, with the appropriate boxes checked off?

The focus of the insurance companies appears to be on the package delivery model.

If our model is the package delivery model, your patients would be better off with some else.


[1] Phila. area blocked from new Medicare ambulance enrollment
By Harold Brubaker, Inquirer Staff Writer
Posted: March 03, 2014

[2] Two ambulance companies join forces
Harold Brubaker, Inquirer Staff Writer
Posted: Tuesday, March 4, 2014


FAA Giving in to Science – Without Which the FAA Would Not Exist


The FAA (Federal Aviation Administration) is beginning to embrace science.

By today, many of us should be permitted to use most electronic devices during all parts of an airplane flight.

Airlines have been racing for weeks to be first, gathering paperwork and setting up working groups to study the issue.

JetBlue Airways Corp. and Delta Air Lines Inc. were ahead of the pack on Thursday, applying for approval within hours of the new guidelines. The two carriers said they hoped to begin allowing fliers to use devices from gate to gate by Friday.[1]


The FAA exists because of the ability of science to demonstrate the ability of humans to create a safe means of travel through the air. The FAA originally could have decided that the prospect of putting people in metal (or wood) structures, traveling at hundreds of miles an hour, and landing safely on the ground is not something that humans can be expected to do safely, but they didn’t.

The FAA could have adopted unscientific approaches to flight safety . . . . Well, they did with electronic devices. Much of what the FAA has done has been based on good evidence, but as with the use of cell phones in hospitals, the evidence of harm is lacking. Science without evidence is rarely good science. The FAA has not been foolish enough to follow the rest of the world into exclusive use of GPS (Global Positioning System) navigation.

The FAA first restricted the in-flight use of devices out of an abundance of caution, in part based on anecdotal evidence that emissions from devices interfered with pilot instruments.[1]


An abundance of caution is often what is used to justify rules that are actually based on an abundance of ignorance.

The use of backboards for potentially unstable spinal injuries are not based on evidence of benefit, but on an abundance of faith in expert opinion, that’s the way we’ve always done it, and wishful thinking. The same is true the rest of abandoned medical treatments and many that have not yet been abandoned.

Other safety policies have been extremely successful. However, these policies have evidence that they work.

The Federal Aviation Administration’s decision, its first big shift on electronic devices since it restricted their use in flight in 1966, caps years of debate over whether electronic emissions from devices can interfere with cockpit instruments.[1]


Almost half a century of restriction without evidence.

Anecdotal evidence should not be ignored, but should prompt research. If valid research does not support the caution inspired by the anecdotes, then we should ignore the anecdotes. If no research is considered to be necessary to determine the necessity of the restrictions, then we should ignore the restrictions.

Airline travel is extremely safe, but can be made to look less safe by looking at the statistics with the wrong perspective.

Image credit.
By the number of trips, airline travel does not appear to be safe, but we do not take airlines to travel to the grocery store. We take airlines to travel long distances.

Image credit.

Since airline travel is much faster than most other forms of travel, the safety per hour (per billion hours) is also not a good metric.

Image credit.

If I am traveling a few thousand miles, and I am only interested in the safety of that trip, there is no difficulty deciding the safest means of making that trip.

Travel by air is 8 times safer than travel by bus.

Travel by air is 12 times safer than travel by train.

Travel by air is 62 times safer than travel by automobile.

Travel by air is 1,084 times safer than walking. Although there would we health benefits to walking, the benefits would not come close to the much larger fatality rate.

The type of air travel also matters.

Image credit. Click on images to make them larger.

Fly and during the flight do work on an electronic device, or relax with an electronic device, but do not worry that you will crash the plane with a cellular phone. If you could do that, we would not even allow cellular phones in checked luggage.

Also see –

Do FAA restrictions on electronic devices make flying safer? Part II
Thu, 11 Apr 2013
Rogue Medic


[1] FAA Says Fliers Can Use Devices During All Phases of Flight
Wall Street Journal
By Jack Nicas and Andy Pazstor
Updated Oct. 31, 2013 8:00 p.m. ET


Do FAA restrictions on electronic devices make flying safer? Part II

The FAA (Federal Aviation Administration) may be easing restrictions on some electronic devices, but do any of these restrictions make flying any safer?

A boombox playing at 100 decibels[1] could cause safety problems, but there are already rules on being disruptive, so only an idiot would feel there is any need for another rule to address that problem.

Setting up a pirate radio station might also cause problems, but…

One member of the group and an official of the F.A.A., both of whom asked for anonymity because they were not allowed to speak publicly about internal discussions, said the agency was under tremendous pressure to let people use reading devices on planes, or to provide solid scientific evidence why they cannot.[2]

Image credit.

We are pandering to the anxieties of the most easily scared ignorant, when there is no evidence of risk.

Not just no evidence of harm, but not even any evidence of risk.

Why are we so stupid?

If cellular phones were so dangerous, all that would need to be done to take down a plane would be to put a cellular phone in the checked luggage of a person on the flight and call it during take off or landing.

No bombs.

No shoe bombs.

No exploding tooth paste.

None of that James Bond stuff that the terrorized worry about.

As I wrote in 2011, travelers are told to turn off their iPads and Kindles for takeoff and landing, yet there is no proof that these devices affect a plane’s avionics. To add to the confusion, the F.A.A. permits passengers to use electric razors and audio recorders during all phases of flight, even though those give off more electronic emissions than reading tablets.

The F.A.A. declined to comment.[2]

We have met the terrorists and they are the ignorant among us.

We have given them the power to terrorize us.

Why is valid evidence important?

Whether it is medicine, flying, education, . . . , valid evidence is our best defense against ignorance.

Common sense and other old wives’ tales are what we valid evidence demonstrates to be wrong.


[1] Sound: The decibel scale

The scale is exponential, so 100 dB is not 11% higher than 90dB, but exponentially higher.

Click on image to make it larger.

[2] Disruptions: F.A.A. May Loosen Curbs on Fliers’ Use of Electronics
March 24, 2013, 11:00 AM
By Nick Bilton
NY Times Blogs


The Wars on Gays, Guns, Drugs, Speech, and Everything Else Not Politically Correct


If you are easily offended, you are in the wrong place.

This has not much to do with EMS, except that there is the contrast between those who try to avoid responsibility for their actions (and try to make sure anyone who acts differently is punished) and those who try to do what is right (because it is about taking care of the patient, regardless of what the rules state). The Supreme Court will soon be deciding if anti-gay marriage laws violate any civil protections from discrimination. Since the Justices are known for decisions based on their ability to find precedents for their ideological political preferences, this is not necessarily just a secular legal decision, but it should be. In that vein –

What is the definition of marriage and when did a bunch of politically correct whiners start caring about the poor defenseless dictionary?

The dictionary is not really of interest to the opponents of gay marriage. A Gallup poll shows what reasons were given by people. Maybe being a dictionary Nazi was not a choice.

Image credit. Click on images to make them larger.

What does the Bible state?

21 And they asked him, saying, Master, we know that thou sayest and teachest rightly, neither acceptest thou the person of any, but teachest the way of God truly:

22 Is it lawful for us to give tribute unto Caesar, or no?

23 But he perceived their craftiness, and said unto them, Why tempt ye me?

24 Shew me a penny. Whose image and superscription hath it? They answered and said, Caesar’s.

25 And he said unto them, Render therefore unto Caesar the things which be Caesar’s, and unto God the things which be God’s.[1]


There is God’s law and there is government law and they are different and should not be confused.

Is Jesus the source of our wall of separation between Church & State?[2]

If gay marriage required priests, ministers, rabbis, imams, or other religious leaders to perform gay marriages, then that would be a problem, according to what Jesus said.

Only people who take exaggeration to sinful levels make that ridiculous claim. Where is there any suggestion that this would be anything other than a legal elimination of discrimination?

As with teaching Creationism in publicly funded schools, this is a religious dispute, not a legal dispute.

If the religious cannot agree, the government should not be adopting one particular religious interpretation.

But how does the Bible define marriage?

Image credit. Click on the image to see all of the forms of marriage that are acceptable to God and should be legalized if we are to be consistent.

But that is the Old Testament. We just use that to make the Book look bigger and the tradition seem older. We ignore everything in it, unless it suits us.

True. The most vocal critics of the behavior of others are the ones who use this excuse, but those include the opponents of gay marriage. Maybe they should have this tattooed on their foreheads to warn others of their hypocrisy. Except that tattoos are forbidden in the Old Testament.[3]

3 And why beholdest thou the mote that is in thy brother’s eye, but considerest not the beam that is in thine own eye?

4 Or how wilt thou say to thy brother, Let me pull out the mote out of thine eye; and, behold, a beam is in thine own eye?

5 Thou hypocrite, first cast out the beam out of thine own eye; and then shalt thou see clearly to cast out the mote out of thy brother’s eye.[4]


What does Jesus say about banning any kind of marriage?

When given the opportunity, Jesus does not criticize an example of Old Testament marriage.

27 Then came to him certain of the Sadducees, which deny that there is any resurrection; and they asked him,

28 Saying, Master, Moses wrote unto us, If any man’s brother die, having a wife, and he die without children, that his brother should take his wife, and raise up seed unto his brother.

29 There were therefore seven brethren: and the first took a wife, and died without children.

30 And the second took her to wife, and he died childless.

31 And the third took her; and in like manner the seven also: and they left no children, and died.

32 Last of all the woman died also.

33 Therefore in the resurrection whose wife of them is she? for seven had her to wife.

34 And Jesus answering said unto them, The children of this world marry, and are given in marriage:

35 But they which shall be accounted worthy to obtain that world, and the resurrection from the dead, neither marry, nor are given in marriage:

36 Neither can they die any more: for they are equal unto the angels; and are the children of God, being the children of the resurrection.

37 Now that the dead are raised, even Moses shewed at the bush, when he calleth the Lord the God of Abraham, and the God of Isaac, and the God of Jacob.

38 For he is not a God of the dead, but of the living: for all live unto him.

39 Then certain of the scribes answering said, Master, thou hast well said.

40 And after that they durst not ask him any question at all.[5]


In other words, for those who want to use the use the words of Jesus to discriminate against others, Jesus appears to be saying, Get off my lawn, Punk.

What about guns, drugs, speech, and everything else not politically correct?

We are fond of demanding freedom for ourselves, but prohibiting our neighbors from having freedom.

Gay marriage prohibitions are just more of the same.

I am safe with a gun, but he is not.

I can consume alcohol safely, but that marijuana is dangerous.

I can speak without restriction, but he should not.

Freedom means tolerating what we perceive as the excesses of others with the freedoms we want for ourselves, or with freedoms we have no interest in.

Freedom is not about only allowing us freedom.

If we cannot trust our neighbors with the same freedom, we should not have that freedom – or should we just grow up and stop trying to control others?

What is the opposite of freedom?

Not slavery, but prohibition.

Guns are dangerous.

If we pass a law banning guns, we will create safety.

Drugs are dangerous.

If we pass a law banning drugs, we will create safety.

Speech is dangerous.

If we pass a law banning speech, we will create safety.

Many have attempted to ban speech. They have been unsuccessful.

Is flag burning wrong?


Flag burning is a way of getting attention for the speech that is protected by the Constitution that Americans have fought, and some have died, to uphold.

The flag is just a symbol. The flag is a symbol of our republic that protects the minority from the abuses of powerful anti-American majorities, even when all of those trying to harm the US Constitution are American citizens.

If you think that you know someone who died to oppose the US Constitution and defend a symbol against being burned, then you deserve ridicule.

We have attempted to ban drugs. We have been unsuccessful.

Is consuming intoxicants wrong?


There are many ways that we might harm ourselves, but drugs are not always harmful.

Claiming that drugs are always harmful is absurd.

What if we legalize drugs? Then everyone will take drugs!

Half of American adults already have tried marijuana, including Presidents Clinton, Bush, and Obama.

Portugal decriminalized everything, including heroin.

Their crime rate decreased. Obviously, the drug crime rate would decrease if it is eliminated. Other crimes decreased – the ones that we claim the drug laws are supposed to protect us from.[6]

We have a history of abandoning prohibition. The only Amendment to the US Constitution to be repealed was the 18th.

The police, courts and prisons were overwhelmed with new cases; organized crime increased in power, and corruption extended among law enforcement officials. The amendment was repealed in 1933[7]


Why do we keep trying to stop others from doing things we do not like?

Why don’t we recognize that we are harming ourselves and we are harming them?

Are we really that illogical?

The number one killer is tobacco.

In the United States, smoking is responsible for about one in five deaths annually (i.e., about 443,000 deaths per year, and an estimated 49,000 of these smoking-related deaths are the result of secondhand smoke exposure).1 [8]


We do not ban them, although we seem to be trying. If we did ban cigarettes, would we do anything other than encourage a lot of otherwise law abiding Americans to break the law?

The next biggest killer is alcohol.

Number of alcohol-induced deaths, excluding accidents and homicides: 25,692[9]


If we include accidents, the number might double, but it is still a tiny fraction of tobacco-related deaths. Should we ban tobacco and alcohol?

Only is we want to encourage criminal behavior among people who would not otherwise engage in criminal behavior.

Someone will whine that there will be drug-related driving fatalities.

This is not about legalizing driving while impaired/intoxicated. That would remain illegal.

We have attempted to ban guns. We have been unsuccessful.

Is owning a gun wrong?


There are many ways that we might harm ourselves, but guns are not always harmful.

If we are interested in limiting the traffic in illegal guns, we should make the gun laws national. Wherever you go, the rules on gun ownership should be the same. Why should Virginia be the source of illegal guns used by gangsters in neighboring states?

These different laws only make it easy for criminals to buy guns, but they do nothing to protect the rights of legal gun owners.

Banning guns is no different from banning drugs. Many otherwise law abiding Americans will break the law, diverting a significant portion of the US GDP (Gross Domestic Product – the measure of financial income of a country) to criminal organizations.

What will a ban on large capacity magazines (more than 10 rounds per clip) do to the millions of large capacity magazines already owned by Americans?

It will make an insignificant dent in the supply. The large capacity magazines turned over to law enforcement will be from the people least dangerous with them – least dangerous to law abiding Americans.

The law will not do anything to discourage criminals from obtaining large capacity magazines. A prohibition will do just the opposite.

A prohibition will create a lucrative criminal market in these magazines, but it will not save any lives.

This is not a spoof video. The full CSPAN link is in the footnotes.[10]

Sen. Dianne Feinstein is just as ridiculous as the people who claim that the marriage of someone else will destroy the sanctity of their marriage.

And the designated hitter rule in the American League destroyed the sanctity of baseball in the National League. Riiiight.

Is it really legal to hunt humans with any capacity magazine?


There are plenty of laws that would be available to police to charge someone who is hunting humans. If you doubt me, go try to hunt Sen. Feinstein and explain to the police that Sen. Feinstein says hunting humans is legal.

What about assault weapons?

Shouldn’t we use rules about cosmetic accessories, that do not affect function, to be paramount?

Ask any fashion maven and they will tell you that accessories make the wardrobe, but are we trying to prevent people from being scared to death by guns, or are we trying to prevent people from being shot with guns?

We do need to have some limitations on weapons. Even the President cannot arbitrarily decide to launch nuclear missiles.

We need to have those laws made by people who understand more about guns than That looks scary!

Are guns dangerous in the hands of well trained, law abiding citizens?


Are guns dangerous in the hands of criminals?


why don’t we focus on the dangerous people, rather than the people who are not shooting up schools, and not shooting out of car windows to protect the illegal drug business we created for them?


The problem is not the gays, or the drugs, or the guns, or the language, but the ways we act like tyrants to protect our egos.

In the immortal words of Sgt. Hulka, Lighten up, Francis.


We need to stop listening to those who claim that they are better than everyone else and that all we have to do is keep other people from having rights, then everything will be perfect.

We are responsible for our actions.


[1] Luke 20:21-25
King James Version

[2] Jefferson’s Wall of Separation Letter

To messers Nehemiah Dodge, Ephraim Robbins, & Stephen S. Nelson, a committee of the Danbury Baptist association in the state of Connecticut.


The affectionate sentiments of esteem & approbation which you are so good as to express towards me, on behalf of the Danbury Baptist association, give me the highest satisfaction. my duties dictate a faithful & zealous pursuit of the interests of my constituents, and in proportion as they are persuaded of my fidelity to those duties, the discharge of them becomes more & more pleasing.

Believing with you that religion is a matter which lies solely between man & his god, that he owes account to none other for his faith or his worship, that the legitimate powers of government reach actions only, and not opinions, I contemplate with sovereign reverence that act of the whole American people which declared that their legislature should make no law respecting an establishment of religion, or prohibiting the free exercise thereof, thus building a wall of separation between church and state. [Congress thus inhibited from acts respecting religion, and the Executive authorised only to execute their acts, I have refrained from presenting even occasional performances of devotion presented indeed legally where an Executive is the legal head of a national church, but subject here, as religious exercises only to the voluntary regulations and discipline of each respective sect.] Adhering to this expression of the supreme will of the nation in behalf of the rights of conscience, I shall see with sincere satisfaction the progress of those sentiments which tend to restore to man all his natural rights, convinced he has no natural right in opposition to his social duties.

I reciprocate your kind prayers for the protection and blessing of the common Father and creator of man, and tender you for yourselves and your religious association, assurances of my high respect & esteem.

Th Jefferson


[3] Leviticus 19:28
King James Version

28 Ye shall not make any cuttings in your flesh for the dead, nor print any marks upon you: I am the Lord.


[4] Matthew 7:3-5
King James Version

[5] Luke 20:27-40
King James Version

[6] 5 Years After: Portugal’s Drug Decriminalization Policy Shows Positive Results – Street drug–related deaths from overdoses drop and the rate of HIV cases crashes
By Brian Vastag
Scientific American

“Drug decriminalization did reach its primary goal in Portugal,” of reducing the health consequences of drug use, he says, “and did not lead to Lisbon becoming a drug tourist destination.”


[7] Eighteenth Amendment to the United States Constitution

[8] Smoking & Tobacco Use
CDC (US Centers for Disease Control and Prevention)
Fact Sheet

[9] Alcohol Use
CDC (US Centers for Disease Control and Prevention)
Fact Sheet

[10] Gun Control legislation Markup
Senate Committee Judiciary
March 7, 2013
Forward to 50:30 of the video.


Not Carrying Essential Drugs on an Ambulance


A paramedic responded to dispatch that he did not have any seizure medicines and that no other medics have seizure medicines.


How does this happen?

Is it a result of the drug shortage?[1]

Paramedic: “We don’t have any seizure medication?”
Dispatcher: “You don’t have any seizure medication?”
Paramedic: “That’s affirmative. No paramedic unit does.”


This was in January. A similar conversation occurred in December.

The article makes it seem as if the medics only carry lorazepam (Ativan) for seizures – when they carry seizure medication.

Why not any IM (IntraMuscular) seizure medication?[3],[4],[5],[6]

Unreasonable optimism?

Inability to keep up with research?

Inability to understand research?

There is a lot of that in EMS.

Do they carry a dose that will be effective?

4 mg IV lorazepam for an adult and 2 mg IV for a small child – if the goal is to actually stop the seizure, rather than just document the administration of sub-therapeutic doses of something.[7],[8]

If the dose is inadequate or if the dose cannot be given because of a failure to obtain an IV – then the drug is not a life saving drug.

Does Rural Metro/Clark County have these under-dosing problems with their seizure medications? I don’t know.

As it turns out, the reason the medics do not have lorazepam is that the DEA (Drug Enforcement Administration) is investigating.

It’s because of a DEA investigation into Rural Metro Ambulance when they worked out of Louisville. There was morphine and Valium missing from ambulances and the DEA was trying to figure out who took the drugs. Because of that investigation their paramedics were banned from carrying certain medications, medications used to stop seizures.[9]


Diazepam (Valium) is also a seizure medication. Diazepam can be given IM, but EMS usually gives it rectally.


Because giving a drug in a socially inappropriate way that is also less effective than other ways of giving the drug is what EMS does. Does Rural Metro/Clark County give rectal seizure medications? I don’t know.

Who should be notifying Clark County when required drugs are pulled from the ambulance?

The DEA apparently gave the order, so they should be notifying Clark County of the DEA’s change to the medications carried by medics.

Rural Metro appears to be required to carry the medications, so they should notify Clark County that they are not satisfying the drug requirements. The contract should be specific about what minimum standards any company must meet and what notification must be made when the minimum standards are not met. If the contract does not require notification, then Clark County is being willfully ignorant. Especially with the drug shortages, Clark County (and any EMS agency) should be keeping aware of any supply problems ambulance companies are having.

Maryland changed their protocols because of the drug shortages, so this is affecting EMS in other places.[10]

It looks as if all three (Clark County, Rural Metro, and the DEA) failed to act responsibly toward the citizens of Indiana.


[1] Drug Shortages
Drug Safety and Availability
Current Drug Shortages Index

[2] Paramedics say area Ambulance service not carrying needed medicine
Posted on February 5, 2013 at 6:22 PM
Updated Tuesday, Feb 5 at 6:41 PM

[3] Midazolam in treatment of epileptic seizures.
Lahat E, Aladjem M, Eshel G, Bistritzer T, Katz Y.
Pediatr Neurol. 1992 May-Jun;8(3):215-6.
PMID: 1622519 [PubMed – indexed for MEDLINE]

Midazolam (Versed), the first water-soluble benzodiazepine, has had widespread acceptance as a parenteral anxiolitic agent. Its antiepileptic properties were studied in adult patients with good results. Midazolam was administered intramuscularly to 48 children, ages 4 months to 14 years, with 69 epileptic episodes of various types. In all but 5 epileptic episodes, seizures stopped 1-10 min after injection. These results suggest that midazolam administered intramuscularly may be useful in a variety of epileptic seizures during childhood, specifically when attempts to introduce an intravenous line in convulsing children are unsuccessful.

That is from 1992 – over two decades ago.

[4] Midazolam in treatment of various types of seizures in children.
Yakinci C, Müngen B, Sahin S, Karabiber H, Durmaz Y.
Brain Dev. 1997 Dec;19(8):571-2.
PMID: 9440805 [PubMed – indexed for MEDLINE]

No side effects were observed. These results suggest that i.m. administration of midazolam may be useful in a variety of seizures during childhood, especially in case of intravenous (i.v.) line problem.

That is from 1997 over a decade and a half ago.

[5] A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children.
Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y.
Pediatr Emerg Care. 1997 Apr;13(2):92-4.
PMID: 9127414 [PubMed – indexed for MEDLINE]

IM midazolam is an effective anticonvulsant for children with motor seizures. Compared to IV diazepam, IM midazolam results in more rapid cessation of seizures because of more rapid administration. The IM route of administration may be particularly useful in physicians’ offices, in the prehospital setting, and for children with difficult IV access.

That is also from 1997 over a decade and a half ago.

[6] Use of intramuscular midazolam for status epilepticus.
Towne AR, DeLorenzo RJ.
J Emerg Med. 1999 Mar-Apr;17(2):323-8. Review.
PMID: 10195494 [PubMed – indexed for MEDLINE]

The pharmacodynamic effects of midazolam can be seen within seconds of its administration, and seizure arrest is usually attained within 5 to 10 min. Case reports and a recent randomized trial that demonstrate the successful use of i.m. midazolam in the termination of epileptic seizures are reviewed.

That is from 1999 – still over a decade ago. There have been more studies of IM midazolam (Versed) in this century.

[7] Lorazepam (lorazepam) Injection, Solution
[Baxter Healthcare Corporation]

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.

[8] 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.

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.


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

[9] Rural Metro Ambulance responds about carrying meds on their vehicles
by Renee Murphy
Posted on February 6, 2013 at 7:02 PM
Updated Wednesday, Feb 6 at 8:49 PM

[10] Drug shortages leading to better EMS protocols
Fri, 19 Oct 2012
Rogue Medic


Experts, Forecasting, Causality, and Complexity


A huge problem in medicine is the failure to see where problems will come from, even when those problems appear to be obvious in hindsight.

The field of economics shares this problem. A perfect example is the recent release of the transcript from the August 2007 Federal Reserve Board meeting. This is 136 pages of stuff that even I am not interested enough to do more than skim through.[1] There is too much good medical research, and some good books, already on my to do list. However the New York Times paid someone to look through this and these are some of the insi

However, there is a lot to think about in just the press release. This was about a year and a half after Alan Greenspan had stepped down as the inscrutable, indecipherable (but not inconceivable), philosopher king of government financial oversight. The Maestro.

President George W. Bush presents the Presidential Medal of Freedom to Alan Greenspan, on November 9, 2005 in the East Room of the White House.[2]


The markets did well. Few understood what Chairman Greenspan was saying and it appeared that opacity was the goal. People looking for cause and effect assumed that the cause of the success of the markets was Alan Greenspan.

His successor was Ben Bernanke, who did try to make policy less obscure, but otherwise tried to carry on the Greenspan traditions.

Economic growth was moderate during the first half of the year. Financial markets have been volatile in recent weeks, credit conditions have become tighter for some households and businesses, and the housing correction is ongoing. Nevertheless, the economy seems likely to continue to expand at a moderate pace over coming quarters, supported by solid growth in employment and incomes and a robust global economy.[3]


The market was looking good at the time. The Standard & Poor’s 500 index is one of the best indicators of the state of the market. Here is where the market was at the time of the meeting.

Image credit. Click on images to make them larger.

There were already serious problems with the economy – mortgage defaults (especially sub-prime), falling housing prices (which the government subsidies helped raise), and recent multi-trillion dollar losses in various markets.

Chairman Bernanke had some odd things to say for someone who is supposed to understand the economy.

On the positive side, the repricing of risk and the reevaluation of underwriting standards seem appropriate.[1]


The price of risk was completely out of line, so a move in the direction of something rational would be appropriate, if it were more than a token move.

It is an interesting question why what looks like $100 billion or so of credit losses in the subprime market has been reflected in multiple trillions of dollars of losses in paper wealth. So it’s an interesting question about what is going on there.[1]


When s huge section of the investing community has invested heavily in one area, eventually they will have nobody left to sell to – or even worse, they start believing that what they have been selling is really worth what they have been telling people it is worth. The only bank to not lose a lot of money was Goldman Sachs, but that appears to be because some of their people copied the trades that John Paulson[4] was buying from them.

Obviously, the markets right now are not functioning normally.[1]


And the chart below shows what happened after the meeting (big red dot) up until January 13, 2013.

Was the experts’ unanimous endorsement of steady economic expansion over the coming year, or two, at all close to what happened?

Did the experts understand the economy or the many factors affecting the markets?

How could the experts forecast steady economic expansion as we were entering an economic collapse?

From around 1,500 at the time of the meeting, down to under 700 a year and a half later, then taking almost four years to slowly return to where the market was at the beginning of this continuing gradual expansion.

The market was cut in half. Then it lost some more.

We like to deceive ourselves.

Nassim Taleb wrote about this in a book that did a much better job of anticipating the collapse, and he published that book months before this meeting, while things were looking much better –

We attribute our successes to our skills, and our failures to external events outside our control.[5]


True of many in medicine.

It has been more profitable for us to bind together in the wrong direction than to be alone in the right one.[5]


That is also a problem in medicine.

You cannot ignore self-delusion. Lack of knowledge and delusion about the quality of your knowledge come together-the same process that makes you know less also makes you satisfied with your knowledge.[5]


Again, true in medicine.

Well, a gentleman called Alan Greenspan, the former chairman of the U.S. Federal Reserve Bank, went to Congress to explain that the banking crisis, which he and his successor Bernanke helped cause, could not have been foreseen because it “had never happened before.” Not a single member of congress was intelligent enough to shout, “Alan Greenspan, you have never died before, not in eighty years, not even once; does that make you immortal?”[5]


We only seem to consider what we have already seen – as if that is somehow a limit beyond which no bad things can happen. So we are surprised when this imaginary limit, that only exists in our heads as an anchoring effect,[6] is exceeded.

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation … 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.


This is echoed by Nassim Taleb –

The problem with experts is that they do not know what they do not know.[5]


When experts discourage us from questioning them, and do not provide good evidence to support their positions, those experts deserve criticism.


[1] Meeting of the Federal Open Market Committee on August 7, 2007
Released Jan. 18, 2013
Free Full Text Download in PDF format from the Federal Reserve Board.

[2] Alan Greenspan

[3] Federal Open Market Committee Statement
Release Date: August 7, 2007
Press Release

[4] John Paulson

[5] The Black Swan
Nassim Nicholas Taleb
April 17, 2007
Wikipedia entry about the book

[6] anchoring effect
Skeptic’s Dictionary


Cell phone prohibitions – Winnipeg, Canada; Baltimore, Maryland; and other reactionaries


No company policies were violated in the production and distribution of these images.

That’s my story – and I’m possibly even sticking to it.

The latest fad among fashionable emergency managers appears to be banning cell phones.

Can we misuse technology?

Of course.

Should we ban technology?

Only if we are incapable of responsible behavior.

What does that tell us about the places that are banning the use of cell phones on duty?

These managers are not to be trusted with responsibility.

It is refreshing to have management come right out and tell us that they are too irresponsible to be trusted.

Now we just need to get rid of those admitting to incompetence by banning cell phones or other technology.

You are a fire chief. You send a bunch of fire fighters to respond quickly to fires in a large truck that is capable of driving over most vehicles the public will be using on the same streets.

This is a much greater danger to the public than the possibility of release of personal information.

If these chiefs cannot manage the use of cell phones, how can they manage the use of fire trucks?

These chiefs should be fired.

You are an EMS chief. You send a bunch of paramedics out to treat patients with a variety of drugs, that are deadly when used inappropriately.

This is a much greater danger to the public than the possibility of release of personal information.

If these chiefs cannot manage the use of cell phones, how can they manage the use of medications?

These chiefs should be fired.

The danger of the people afraid of technology is greater than the danger of the technology.

Technology can be managed.

Stupidity is a much bigger problem.

Firegeezer sums it up in the beautifully titled –

“Just shut the %#*~& up!!”[1]

Several others have written about this.[2],[3],[4],[5],[6]

Then there are the people who would ban cell phones from classrooms, but Greg Friese tells us how to be smarter than the prohibitionists. We can use smart phones to help us teach.[7]

I would rather read what Greg Friese writes at Everyday EMS Tips and learn about how to use technology to help patients, rather than read some anti-technology drivel by someone who does not understand technology.

Obviously, nobody will ever be able to use a hidden camera to record what happens on scene if cell phones are prohibited.


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Ignorance is its own punishment, but ignorance also punishes others.

We need to stop lowering the lowest common denominator of employees and of managers.


[1] “Just shut the %#*~& up!!”
November 2, 2012

[2] Mourning The Loss of Free Speech, Ham-Handed Chiefs, and How We Got Here
November 16, 2012
Firehouse Zen

[3] Firehouse websites banned under new Baltimore social media policy. Critics also concerned about free speech issues.
November 2, 2012

[4] City Fire Department implements new social media policy. Union leaders, experts say provisions infringe on First Amendment rights
By Kevin Rector
The Baltimore Sun
8:10 p.m. EDT, November 2, 2012

[5] A New Danger in EMS?
Posted by daleloberger on November 1, 2012
High Performance EMS

[6] Cellphones off limits for firefighters, paramedics
CBC News
Posted: Oct 31, 2012 5:38 PM ET
Last Updated: Oct 31, 2012 6:51 PM ET

[7] Integrating Smartphones and Tablet Devices into EMS Education
Nov 1 2012 8:00AM
Room: 219
Category: Educator
Greg Friese, MS, NREMT-P
Thursday schedule – EMS Expo 2012

Most EMT and paramedic students arrive at class with a smartphone or tablet device they use to stay in touch with friends, family, and social networks. They use these devices to consume popular media, find and research references, and upload their own multimedia content about their work, academic, and personal experiences. Instead of banning these devices from the classroom or workplace, this session will focus on opportunities to integrate mobile devices into classroom, lab, and clinical experiences. The presenter will share and demonstrate top resources, software programs, apps, and best practices. The audience will have opportunities to share techniques that are working in their programs and discuss the risks and benefits of integrating mobile technology into EMS education.


What if confidential information, provided to protect patients, were no longer confidential?

The Patient Safety and Quality Improvement Act, enacted in 2005, encourages pharmacies, hospitals and physicians to report medical error information to patient safety organizations, the details of which are shielded from public disclosure.[1]

The purpose of this law is to encourage people to report problems without fear that the information will be used against them.

If people contribute information about errors, for the purpose of improving patient safety, but the information can be used to accuse them of wrongdoing, what will happen to the amount of information collected to improve patient safety?

The Illinois Department of Financial and Professional Regulation was investigating three pharmacists from Walgreen Company. The regulators apparently felt that the law does not apply to them. They seem to have the attitude that laws are for other people, but not for them. In 2010, the state regulators filed subpoenas for the confidential documents. Walgreens refused to comply, citing the law protecting the information. The court decided in favor of Walgreens. The state appealed. On May 29, 2012 the appeal was turned down. There is still the possibility of an appeal to the Illinois Supreme Court.

If the state regulators are supposed to be acting to protect patients, should we trust any of their other decisions – decisions that are supposed to be to protect patients.

If a further appeal leads to the release of this information, will anyone report any error that might remotely have a negative effect on them?

“The Patient Safety Act provides that ‘patient safety work product shall be privileged and shall not be subject to discovery in connection with a federal, state or local civil, criminal or administrative proceeding,’ ” the court said. Walgreens “established that the only documents responsive to petitioner’s subpoenas’ narrow scope of incident reports were [such] reports.[1]

Probably not all errors are due to simple individual carelessness or negligence. These regulators seem to be trying to make sure that they have a lot of errors to deal with.

If these regulators were trying to prevent infestation with rats, would they first go after the rat catchers?

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[1] Lawsuit challenging protected medical error data dismissed by state appeals court – Judges said an administrative investigation is not grounds for releasing health information created under a patient safety law.
By Alicia Gallegos, Posted June 15, 2012.

Download of Court Ruling in PDF format