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

- Rogue Medic

Protecting Systemic Incompetence – Part I

We demand the lowest standards, because we are willfully ignorant and we do not want to understand. The surprise is that so many of us survive our devotion to incompetence. The loudest voices tend to dominate the discussions and the loudest voices demand that their excuses for incompetence be accepted. The rest of us don’t oppose incompetence enough.

A nurse was told to give 2 mg Versed (the most common brand of midazolam in the US) for sedation for a scan, intended to give 1 mg Versed, but actually gave an unknown quantity of vecuronium (Norcuron is the most common brand in the US). The patient was observed to be unresponsive and pulseless by the techs in the scan. A code was called. The family learned the details from a newspaper article, not from the hospital.

A Tennessee nurse charged with reckless homicide after a medication error killed a patient pleaded not guilty on Wednesday in a Nashville courtroom packed with other nurses who came in scrubs to show their support.[1]

The nurse intended to give a medication that should be limited to patients who are monitored (ECG and waveform capnography), because different patients will respond in different ways. This is basic drug administration and deviation from that basic competence may even have been common in this Neuro ICU (Neurological Intensive Care Unit). We demand low standards, because we do not want to understand.

We don’t need to monitor for that, because that almost never happens.

Except these easily preventable errors do happen. And we lie about it. We help to cover it up, because we demand low standards, regardless of how many patients have to suffer for the benefit of our incompetence.

This is a common argument used by doctors, nurses, paramedics, . . . . It makes no sense, but we keep demonstrating that we don’t care.

The people in charge should act responsibly, but they delegate responsibility and we reward them.

Back to the hospital, Vanderbilt University Medical Center (VUMC) is a university medical center, so the standards should be high. VUMC was founded in 1874 and is ranked as one of the best hospitals in America.

There is a drug dispensing machine, from which less-than-skilled nurses can obtain almost anything and administer almost anything, without understanding enough to recognize the problem. This is an administrative problem. This was designed by someone with no understanding of risk management.

The over-ride of the selection is not the problem, because emergencies happen and it is sometimes necessary to bypass normal procedures during an emergency. Ambulances are equipped with lights, sirens, and permission to violate certain traffic rules for this reason.

Some of the many blatant problems are:

* The failure of the nurse to have any understanding of the medication supposed to be given

* The failure of the nurse to recognize that the drug being given was not the drug ordered.

* The failure of the nurse to monitor the patient being given a drug for sedation.

* Most of all, the failure of the hospital – the nurses, the doctors, the administrators, to try to make sure that at least these minimum standards are in place.

* How often do nurses in the Neuro ICU give midazolam?

* Why is a nurse, who is clearly not familiar with midazolam, giving midazolam to any patient?

* How is a nurse, working unsupervised in a Neuro ICU not familiar with midazolam?

* What kind of qualifications are required for a nurse to give sedation without supervision?

* Since this nurse was orienting another nurse, what qualifies this nurse to orient anyone?

* Given the side effects of midazolam, why was midazolam ordered without monitoring?

* Given the side effects of midazolam, was it the most appropriate sedative for use in a setting where monitoring is going to be difficult?

* Was it the more rapid onset of sedation, in order to free up the PET scan more quickly and/or avoid having to reschedule the scan, that led to the choice of midazolam?

* How well do any of the doctors understand the pharmacology of midazolam if they are giving orders for a nurse to grab a dose, take it down to the scan, give the drug, and return to the unit, abandoning the monitoring of the patient to the techs in the PET scan?

* This is not a criticism of the techs in PET scan, but are techs authorized to manage sedated patients?

* Even though they will often scan sedated patients, are the techs required to demonstrate any competence at managing sedated patients?
The nurses being oriented apparently thought that it is customary to give sedation:

1. without even looking at the name of the medication

2. without confirming by looking at the name again, it before administration

3. without double checking with a nurse, or tech, that the label matches the name of the drug to be given
How many of the doctors, responsible for the care of ICU patients, would agree to be sedated, without being monitored, and to have their care handed off to PET scan technicians?

Why didn’t the doctors and nurses see this as a problem before it made the news?

If the problems were reported, nothing appears to have been done to address the problems beyond the usual – Nothing to see here. Move along. or That’s above your pay grade.

That is the primary point I am trying to make.

The problem is well above the pay grade of the nurse.
Here is the part that experienced nurses have jumped on immediately:

Why did the nurse think that midazolam needs to be reconstituted?

Vecuronium (most common brand name is Norcuron) is a non-depolarizing neuromuscular-blocker, which comes as a powder, that needs to be reconstituted.

Image source
1. Read label instructions?

This nurse has repeatedly demonstrated a need to be supervised, but those responsible for that supervision have apparently ignored their responsibilities in a way that far exceeds any failures by this nurse.

Is it possible that this is a one time event and that the nurse has behaved in an exemplary manner at all times while around doctors and other nurses before this day? It is possible, but the number and severity of the failures on the part of the nurse strongly suggest a pattern of not understanding, not caring, or both. I suspect that any lack of caring is due to a lack of understanding, because I have not yet lost all hope in humanity.


[1] Nurse charged in fatal drug-swap error pleads not guilty
By Travis Loller
February 20, 2019
Associated Press


Edited 3/24/2022 at 00:34 to correct spelling from less-than-killed to less-than-skilled and poweder top powder.

Anti-Vax Doctors Lack Competence and Ethics


Effective July 27, 2018, the latest anti-vax doctor to have his license revoked will be Dr. Bob Sears. Yes, he promotes his image as Dr. Bob.

Who are the dangerous doctors Bob Sears will be joining?

Andrew Wakefield‘s fraudulent research, unnecessarily painful research on children, lack of ethical approval for research, and other corruption, convinced the British General Medical Council to revoke his license. Wakefield was also trying to sell a vaccine of his own, to compete with the MMR (polyvalent Measles, Mumps and Rubella) vaccine. Wakefield’s attempts to discredit the MMR vaccine would have helped him to sell his own competing vaccine.

the lawyers responsible for the MMR lawsuit had paid Wakefield personally more than £400,000, which he had not previously disclosed.[67] [1]


Andrew Wakefield claims that he is not a fraud and sues a lot of people.

All of the cases have been thrown out by the courts or have been withdrawn by Wakefield.[2]

Do those who claim to be trying to protect their children, by avoiding vaccines, based on a trust of this fraudulent doctor, know what Wakefield has done?

The kiddie castrators – David Geier and Mark Geier.

David Geier was never a doctor, but has been caught faking it.[3] In the make believe world of anti-vaxers, why let reality get in the way of pretending to have credibility?

Mark Geier was a doctor, but had his license revoked in every state where he had a license (Maryland, Washington, Virginia, California, Missouri, Illinois, and Hawaii). Why do the Geiers castrate children? Chemical castration is an approved treatment for some rare conditions. Mastectomy is an approved treatment for some breast cancers, but that does not mean that it is at all ethical, or competent, to recommend mastectomy as treatment for other medical conditions. The Geiers claim to believe that castration cures autism. There is no valid evidence to support their hunch.

Consider this. You have an autistic child and someone tells you there is a cure. The person says that they know their expensive chemicals work. The person may even say, I’ve seen it work.[4] All you have to do is give permission for this doctor (before his license was revoked), and his son the fake doctor, to use chemicals to castrate your child.

Do you ask for evidence?

Their is no valid evidence. You just have to trust the castrators and their excuses for the absence of evidence.

The “evidence” has been retracted, because the research is junk science. All human research has to be approved by an independent IRB (Institutional Review Board) to make sure that there are not any conflicts of interest or unnecessary risks to the children participating in the research. The members of the independent IRB were the Geiers, the Geier’s employees, and the Geier’s lawyer. That is not independent.

If chemical castration doesn’t work, the Geiers can sell you other expensive and dangerous treatments that do not work, such as chelation. Chelation is the use of chemicals to remove heavy metals from the body, based on the assumption that mercury causes autism. Chelation is harmful, so it is only indicated, when there is a good reason to believe the benefit will be greater than the harm. There is no valid evidence to support this hunch of the Geiers.

The motto of the company run by the Geiers is First do no harm. Are they completely unaware of the harm they cause, or so dishonest that they tell the boldest lies? Does it matter why they harm children?

What did Bob Sears do to get his license revoked? He claimed to assess patients, but did not keep records of what he claimed to do. His incompetence/negligence endangered patients.[5] ,[6]

For example, a mother frequently brought J.G., a 2 year old, to see Dr. Bob. One visit was for a head ache a couple of weeks after the child’s father hit the child on the head with a hammer. The only apparent concern of the mother and Dr. Bob was to prevent the child from receiving vaccines. There is no record of any neurological assessment, or referral to a competent doctor for a neurological assessment.

J.G. had visited Dr. Bob the previous month for constipation. Assessment and treatment plans were documented. Constipation can be very serious, but so can hitting a child on the head with a hammer. The reason for the difference in approaches was determined to be gross negligence. Another visit, following apparent resolution of otitis media following treatment with Omnicef (cefdinir), there was a diagnosis of a sudden onset of flu, with a prescription for Tamiflu (oseltamivir), so there is no apparent hesitation to use ineffective, or minimally effective, treatments. Is J.G.’s last name Munchausen, or is he just unlucky in his choice of parents?

Bob Sears does not appear to be hesitant to prescribe drugs based on hunches, but he does appear to recognize that being anti-vax can be very profitable. Sears has written 4 books, but still fails to document assessments.

Bob Sears will have to be monitored by another physician for 35 months, following this revocation, to be able to get his license reinstated. He must follow all laws, not be negligent, and not deviate from the standard of medical care. He cannot just take the 3 years off and write books, because he has to be monitored while working to get his license back.

It looks like Bob Sears will be vaccinating children, just as real doctors do.

Vaccines save millions of lives every year.

Vaccines are probably the safest and most effective medical intervention we have, and anti-vaxers hate that.

If some of us do not see the need for vaccines, it is because of the success of vaccines. Vaccines are an important part of the reason that the average life expectancy has doubled in a little over 100 years.

For a great review of the effect of vaccines on vaccine-preventable illnesses, there is a study in JAMA (Journal of the American Medical Association), which shows how the rate of each illness, and deaths from each illness, declined after the introduction of each vaccine. There are anti-vaxers who claim that it wasn’t the vaccines, but sanitation that stopped these illnesses. Don’t fall for that.[7]

Sanitation is important at preventing the spread of illnesses, but sanitation does not wait for each different vaccine to be introduced for each different vaccine-preventable illness to change the illness and fatality rates.

Look at the evidence.

Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States.
Roush SW, Murphy TV; Vaccine-Preventable Disease Table Working Group.
JAMA. 2007 Nov 14;298(18):2155-63.
PMID: 18000199

Free Full Text Article from JAMA.


[1] Aftermath of initial controversy
Andrew Wakefield

The referenced article by Brian Deer is:

Huge sums paid to Andrew Wakefield
The Sunday Times
December 31 2006
Brian Deer

Andrew Wakefield has repeatedly sued Brian Deer and lost or run away every time.

[2] Deer counter-response
Andrew Wakefield

[3] Medical licenses revoked
Mark Geier

In 2011, his son David Geier was charged by the Maryland State Board of Physicians with practicing as if a licensed physician when he only has a Bachelor of Arts degree in biology,[42] and was fined $10,000 in July 2012.[40]


Charges by the Maryland Medical Board
In the Matter of David A. Geier before the Maryland State Board of Physicians
Practicing without a license
PDF document of charges

The Respondent is not and never has been licensed to practice medicine or any other health profession in the State of Maryland or any other State.


[4] I’ve Seen It Work and Other Lies
Tue, 21 Jun 2011
Rogue Medic

[5] Antivaccine pediatrician Dr. Bob Sears finally faces discipline from the Medical Board of California
Respectful Insolence
June 29, 2018

[6] Stipulated Settlement and Disciplinary Order
Decision of the Medical Board of California
Department of Consumer Affairs
State of California
Case No. 800-2015-012268
OAH No. 2017100889
PDF of Decision

[7] “Vaccines didn’t save us” (a.k.a. “vaccines don’t work”): Intellectual dishonesty at its most naked
Science-Based Medicine
David Gorski
March 29, 2010


Irresponsibility and Intubation – The EMS Standard Of Care


There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.

Image source
Details here and here.

The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.

We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.


Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]


Most effective?

There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

Most effective?


This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.

Please sign this petition so that these patients have a chance to live[1]


Prove that requiring higher standards for intubation would take away a patient’s chance to live.

Prove that intubation improves outcomes.

This is a petition to keep standards low for paramedics.

This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

This is the Protect Incompetent Paramedics from Responsibility Petition.

Responsibility is for professionals. In EMS, we reject responsibility.

We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

Most effective? Maybe intubation is the most effective theater.

The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

How much vomiting, and aspiration, do we cause?

How much airway swelling do we cause?

How many airway infections do we cause?

How much harm do we cause?

We don’t know. We don’t care. We oppose attempts to find out.

We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.

Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?


[1] Allow paramedics to continue to save lives with endotracheal intubation!
Anthony Gantenbein United States
Petition site


ABQ to Pay $.3 Million More for Bad Oversight of Bad Medic


It appears that bad management tolerated, and promoted, bad patient care – right up until it affected one of their own. Now the residents have to pay a lot of money for this failure of oversight.

How typical is this medic?

Throughout the litigation, Tate denied any wrongdoing. He maintained his work behavior was part of the “culture” of the Fire Department.[1]



The AFD (Albuquerque Fire Department) disagrees and convinced at least one “hearing officer” that it is only because the rest of the paramedics are better than Tate that his patients did not have worse outcomes.

Does that make any sense?

I discussed the complaints at the time of an earlier article about Tate and AFD.[2]

If you work with a dangerous paramedic, and you do not report any problems, does that make you better than the problem paramedic?

How does such a dangerous paramedic get promoted to lieutenant?

Is it likely that competent management remained unaware of these problems for a decade, or that this was a sudden onset of an unprecedented problem, or that in some other way this is not an example of bad management?

Other organizations have had to deal with criticism after their management of the corruption was exposed –

The Vatican revealed Tuesday that over the past decade, it has defrocked 848 priests who raped or molested children and sanctioned another 2,572 with lesser penalties, providing the first ever breakdown of how it handled the more than 3,400 cases of abuse reported to the Holy See since 2004.[3]


For hundreds of years we have been told that priests don’t rape children, because they are more moral than the rest of us. Evidence has demonstrated otherwise, but the corrupt culture still discourages reporting these crimes to the police.

Is there some reason to believe that Tate is just one rotten apple?


This appears to be another example of a corrupt culture, that will end up costing a lot more money and setting bad standards of care.

Are the patients surviving to the emergency department because of the care provided or just because most people will survive what EMS does to them?

Cadigan told the Journal in 2014 that he was confident Tate would be “vindicated when he has a neutral judge to review the city’s unfair and arbitrary action. The taxpayers will likely have to pick up the tab for this absurd witch hunt.”[1]


Vindicated for treating the family of a fellow AFD lieutenant the same way he would treat other patients?

Tate claimed his conduct was consistent with what he learned at the Fire Department and argued that even if he did commit the alleged acts, he should be given corrective training.[1]


Maybe Tate did receive corrective training.

Repeated reminders to fit in with the culture is how corruption works.

If the culture is not the problem, why did an investigation only begin after a complaint about Tate treating one of his own the same way he is reported to treat other patients?


[1] $300K settlement keeps paramedic from getting job back
By Colleen Heild / Journal Investigative Reporter
Saturday, April 2nd, 2016 at 11:45pm
Albuquerque Journal

[2] How Do We Stop Dangerous Paramedics From Harming Patients?
Sat, 02 Nov 2013
Rogue Medic

[3] Vatican says it’s punished over 3,400 priests since ’04 for raping or molesting children
The Associated Press
Published: 06 May 2014 03:56 PM
Updated: 06 May 2014 04:04 PM
The Dallas Morning News


Giving New Meaning to Carpe Diem


On facebook, Jon Kuppinger describes the following situation –

So what made you decide to call now given your patient has been in full tonic-clonic seizures for over three hours now?


Maybe their washing machine was broken.

Image credit.

The response by the nurse?

The nurse was out and we don’t have access to any meds and it just seemed worse than it was earlier and we weren’t sure what to do about it so we decided to wait until she got back to call.


Paging Nurse Gilligan! Paging Nurse Gilligan!

The nurse was out for over three hours and . . . .

Just sit right back and you’ll hear a tale,
A tale of an endless fit
That started at a nursing home
Then went straight to $#!†.

The patient was a flailing man,
The aide had not a clue.
The patient’s brain was fried that day
In a three hour spaz, a three hour spaz.

The seizure started getting rough,
The patient quaked and tossed,
If not for the callousness of the staff,
The seizure would be stopped.
The seizure would be stopped.


Maybe they were engaging in a modern Tuskegee experiment.

Maybe they were using homeopathy or some other form of alternative medicine and were waiting for for the scam treatment to work.

Maybe three hours of seizure was getting boring and they thought that a few more hours of this might be life-threatening. If the patient dies, what will they do for entertainment tomorrow?

Unlike Robin Williams’ character in Dead Poets’ Society, I guess that we can be glad that they did not decide to let the patient seize the whole day. This is not what carpe diem means.

We’ve schedule you for a three hour high colonic tonic/clonic today. Ordering activities using drop down menus can cause some real problems.

Out of 205 patients, only 19 died in a study comparing using diazepam (Valium), lorazepam (Ativan), or placebo by EMS to treat seizures.[1]

Most of those who died were in the placebo group, even though the placebo group was only one third of the patients. Over 15% of the placebo group died during their hospitalization.

NNK = 6.4 (for untreated seizures)

NNK = Number Needed to Kill. NNH (Number Needed to Harm) is the actual term. These seizures were only untreated for about 15 minutes – not for three hours.

NNH = 3 1/3 (for untreated seizures).

Even an inadequate dose of benzodiazepine would lower the death rate. None of those received IM (IntraMuscular) medication. All received IV (IntraVenous) medication.

Half of the lorazepam group received only one 2 mg dose of lorazepam. The other half of the lorazepam group was given a second dose of 2 mg of lorazepam.

With such low doses, over 40% of the lorazepam patients were still seizing when they arrived at the ED (Emergency Department).

The FDA (Food and Drug Administration) recommends 4 mg lorazepam as the initial dose for seizures.

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.[2]


A slightly smaller percentage of the diazepam patients were given a second 5 mg dose of diazepam, so it is not surprising that well over half were still seizing when they arrived at the ED.

A low dose means continuing seizures. My brand new protocols ignored the evidence from the recent IM midazolam (Versed) vs IV lorazepam study and have us continuing to use inadequate doses.[3]


Only 1 mg – 2 mg lorazepam?

Only 1 mg – 5 mg midazolam?

Holy Continuing Seizures, Batman!

Even the FDA recommends 4 mg.

4 mg was the initial dose in recent study that was safe, but not as effective as 10 mg IM midazolam

Does anyone take the adverse effects of seizures seriously?

After three hours of seizing, the patient might end up as brain damaged as the staff who decided not to treat him, but maybe not.

Brooks Walsh asks Although I’ve read the study before, I am only wondering now how the IRB for Alldredge 2001 thought there was “equipoise” between placebo and benzos.

Equipoise and Ethics and IRBs, Oh My! is my answer.


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

Free Full Text from N Engl J Med.

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

FDA label

[3] Seizure
7007– ALS – Adult/Peds
Statewide ALS Protocol
Page with link to Full Text Download of Full Protocols in PDF format.

[4] 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


Excited Delirium, Sedation, and Comments – Part III

There are some more responses to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

Why do I write so much about excited delirium?

Few of our patients will have any kind of life-or-death intervention from EMS. These are some of the patients. We can make the difference between life and death.

These are also some of the least likable patients we will deal with – they are often attacking us. How do we protect ourselves and protect our patients?

Some people continue to tell us that sedation is evil.

This is from kindofafireguy

Granted, I’m no lawyer, but it seems to me the greatest potential for liability is when the standard of care is NOT met, as opposed to when it is.

So if you have protocols for chemical restraint (as my region does), to me that would imply greater liability for not restraining a patient in need of it and said patient wreaking mayhem and injuring people.

But that’s just me applying common sense. So it’s probably wrong.

I am not a lawyer, either. I think that we have too many people telling us what a jury will do, when we do not know what a jury will do. The jury determines what is the standard of care and whether that standard was met. Trying to predict what 12 people (or six) will agree on – after listening to very biased, but antagonistic descriptions of the same events and expert testimony that is similarly antagonistic – is not something intelligent people should do.

The only legal advice that makes sense to me is –

Do what is best for the patient.

The problem is that we do not always know what is best for the patient, but –

If the patient is excited, with all other patients, we would be trying to calm the patient down. With excited delirium, we seem to be going out of our way to make them even more sedated. Here are some nice soothing leather restraints.

If we follow the physical restrain promptly with chemical restraint, that is patient care.

If we do not follow the physical restraint with chemical restraint, how is that patient care?

This is from Kelly Grayson of A Day in the Life of an Ambulance Driver

“By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.”

How… quaint.

Don’t know what hospitals Shane is dealing with, but virtually every hospital I take patients to has virtually done away with leather restraints, partly because of Joint Commission requirements, but also because they’d much prefer to sedate.

Let me repeat that: MUCH prefer to sedate.

There are EMS agencies near me that do not aggressively sedate agitated patients.

As our medical protocols become more and more aggressive, that is changing, but we still have to wait for some of the old medics (and old medical directors) to die off. Being treated according to their own protocols may be the best way to do that. If it does not kill them, being treated by their own protocols may convince them that their approach to patient care is not good patient care.

They’d much rather use a B52, or Geodon, or Zyprexa, or increasingly, ketamine, and they’re tickled pink if we get a head start on that before we even arrive.

B52 refers to a mixture of B (Benadryl – diphenhydramine) 50 mg, haloperidol (Haldol) 5 – 10 mg, and lorazepam (Ativan) 2 mg. These doses are not limits, but starting points for sedation. We can always give more, even if we have to make a phone call while in the middle of wrestling with the patient.

The Haldol does not get the recognition it deserves, but that is what is doing the most to knock the patient down – not knock the patient out. Knocking the patient down has little to do with gravity. Knocking the patient down means getting rid of the patient’s combative behavior.

The diphenhydramine is there both as a sedative and as prophylaxis against extrapyramidal symptoms.[1]

This is from an article in Emergency Medicine News on treating excited delirium –

Regardless of one’s choice of medication, the key to success is to use enough drug. Internist- and pediatrician-type doses usually don’t cut it. The PDR is clueless about effective doses for our purposes, and safety caveats in that publication are merely fodder for lawyers, not information for clinicians. The best guideline is to give enough to achieve the intended result.[2]


Regardless of one’s choice of medication, the key to success is to use enough drug.


Why do so many of us attempt to justify giving an inadequate dose?

Image source.

See also –

‘Hog-tying’ death report faults Fla. medics.

Excited Delirium, Sedation, and Comments – Part I

Excited Delirium, Sedation, and Comments – Part II


[1] Extrapyramidal symptoms

[2] Rapid Tranquilization of Violently Agitated Patients
Roberts, James R. MD
Emergency Medicine News:
November 2007 – Volume 29 – Issue 11 – p 15-18
doi: 10.1097/01.EEM.0000298833.70829.ad
Free Full Text from Emergency Medicine News


Excited Delirium, Sedation, and Comments – Part II

Others responded to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

CombatDoc wrote –

Why are medics so scared of sedation?

This is the main problem.

Ignorance leads to fear.

But this does not lead to Yoda quotes.

We should not be arrogant, assuming that we know everything about the drugs we use. That can be just as dangerous as ignorance, but we need to learn more about the medications we use.

Too many people tell us that sedatives and opioids are dangerous. These are probably the safest drugs we use. They have well known side effects, but the side effects are not remotely as common as the Just say No people would have us believe.

We need to base our treatments on understanding, not fear.

If we understand what we are doing, we will continually reassess our patients, but we should do this with every treatment, not just the treatments portrayed as evil.

My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient.


The purpose of sedation is to sedate.

That is a description of a sedated patient. We are not supposed to be producing awake and alert and cooperative patients. That is asking the impossible.

We are supposed to be sedating the patient to the point of both no longer being a danger to himself and no longer being a danger to others. Awake and alert have nothing to do with that.

I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

I would prefer to use IV (IntraVenous) midazolam over IM (IntraMuscular), because it wears off pretty quickly when given IV, especially with the exaggerated metabolism of excited delirium patients. The reality of excited delirium is that an IV is usually not practical, so I have to settle for longer duration and less predictable absorption.

I like the idea of the sedative wearing off quickly, because some patients just need to have their excited delirium interrupted. After a period of sedation, some are able to be reasoned with. Some will ask for more sedation, because they realize they cannot control they way their body is acting. This can be like a panic attack. The patient would like to control it, but does not do well without sedation. It should not be a surprise that benzodiazepines are commonly used for panic attack.

How have your results been with IN (IntraNasal) midazolam for excited delirium?

I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that.

If a medic cannot handle respiratory depression, or apnea, by BLS (Basic Life Support) methods, should that person be allowed to use any ALS (Advanced Life Support) treatments?

We can’t handle simple cases of respiratory depression, but we should still be allowed to play paramedic?


Absolutely not.

I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

I was wrong about bath salts. I did not think this would become a big deal. Maybe I am just getting old and do not understand how stupid people will be to get a high. Maybe I need to chase some kids off of somebody’s lawn, somewhere. 😳

I guess the doctors just don’t have enough faith in the power of leather restraints./

Maybe someday my medical director will give us Ketamine….

That would be great.

Sedation has so many uses, that we our patients are really missing out on an excellent treatment for a variety of conditions.

Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

The people who deny excited delirium exists are not the people who work in EMS, emergency medicine, or the police.

The people who deny excited delirium exists are the people who deal with patients who have already been sedated by EMS and the ED (Emergency Department).

If we do not sedate these patients, we may miss the last opportunity to save their lives.

All for a lack of understanding of sedation.


Excited Delirium, Sedation, and Comments – Part I

It isn’t my birthday. Still, Shane decided to provide me with plenty of giggles in his response to ‘Hog-tying’ death report faults Fla. medics.

Shane wrote –

I think you might want to review your comments and think before making some statements.

I already made the statements, so I cannot review the statements again before making those statement, unless I repeat the same statements. Based on what you wrote, I will have to repeat some comments. I should probably strengthen, and add to, other comments, because you do not appear to understand.

At first, I thought this comment was a joke. After thinking about it for a while, I suspect that you work for the QA/QI/CYA department of an EMS agency (or maybe you are an absentee medical director). Those are positions that seem to be filled with the most blatant promoters of misinformation. You comment is full of misinformation.

99% of the time, Chemical Sedation is NOT a good practice or recommended to control your patient.

According to whom?

Based on what?

You make bold statements, but you do not provide anything, not even a note from your kindergarten teacher, to support your uninformed assertion.

There are many underlying factors to consider, as you should know, and there are a reason hospitals, medical units and such carry leather restraints and other such devices including police handcuffs with an officer accompanying you in the truck.

There is no requirement for leather restraints on my ambulance, but my state medical director has written protocols with a variety of options for sedation for excited delirium.

By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.

By protecting my patient, I am protecting everyone else, too.

Please explain the justification for the legal advice that you are giving. Did you stay at a Holiday Inn Express last night?

You should be a patient advocate,

I am being a patient advocate.

You are advocating putting the employer and the medic first, because of some imaginary legal risk.

this does not mean “knocking them out” to better control them. Unknown medical history, allergies, head trauma… all these contribute and should be considered. By doing so could result in a medic induced code due to your actions to use drugs to control a patient.

We do not need to knock the patient out, but we do need to knock them down – we need to sedate excited delirium patients.

I provided a link to the ACEP White Paper. You should have used that opportunity to learn about excited delirium syndrome. Rather than learn, you decided to be an evangelist of ignorance. You wag your finger at me based on what?

You mention Unknown medical history, allergies, head trauma…. How would we make any of these better by increasing metabolic stress?

Fighting against restraints will only make the metabolic stress worse.

What do the experts state in that White Paper?

The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]

ExDS is Excited Delirium Syndrome.

Acidosis is not going to get better with continued struggling, but sedation can stop the struggling. Leather restraints do not stop the struggling. Leather restraints do protect others, when secured correctly, but leather restraints also increase the danger to the patient.

ExDS subjects are known to be irrational, often violent and relatively impervious to pain.[1]

An irrational struggling acidotic patient is going to become less acidotic because . . . ?

An irrational struggling tachycardic patient is going to become less tachycardic because . . . ?

An irrational struggling hypertensive patient is going to become less hypertensive because . . . ?

An irrational struggling hyperthermic patient is going to become less hyperthermic because . . . ?

An irrational struggling hypoxic patient is going to become less hypoxic because . . . ?

Sedation decreases the struggling and decreases the cycle of worsening metabolism that the patient exacerbates by fighting against restraints.

Most authorities, including this Task Force, posit the beneficial use of aggressive chemical sedation as first line intervention. As with any critically ill patient, treatment should proceed concurrently with evaluation for precipitating causes or additional pathology.[1]

The experts do not agree with Shane’s fear of over-sedation.

The experts do not agree that the rest of the patient’s history is more important than sedation.

The experts appear to want to protect the patients with head injuries by sedating the patient.

The experts have thoroughly investigated the condition of excited delirium (something police, EMS, and emergency department staff are familiar with) and decided that use of aggressive chemical sedation as first line intervention is the right thing to do.

I think a little more thought should go into your blogs.



[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.