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

- Rogue Medic

TOTWTYTR vs. Indoctrination in Iatrogenesis

Too Old To Work, Too Young to Retire has an excellent post about, well his title gives it away.

The One where he Rants about EMS Education

TOTWTYTR is right on target with this latest post. Mandatory reading for everyone involved in EMS.

In paramedic school, which is ALS (Advanced Life Support), the approach to airway management seems to be that medics will intubate the patient, so they do not need to be good at the BLS (Basic Life Support) aspects of airway management. The result is medics who do not understand the most essential part of airway management. There is nothing more important than competence in BLS airway management. Assessment is critical to competent BLS airway management, but there are plenty of medics who do not recognize esophageal tubes. Do they understand airway? Even a little bit? No.

Where is the assessment? Playing peek-a-boo with the life of the patient. Now it’s here! Now it’s not!

There should not be ALS without excellence in BLS. Teaching ALS without confirming and reinforcing excellence in BLS is bad instruction.

The medical directors for these schools should not allow this. The instructors should not, either. Nor should the students allow this.

Of course as you move from sentence to sentence, in the previous paragraph, the order of responsibility is dramatically decreasing. We should not expect the students to take responsibility for the curriculum. A bunch of people think that the medical director, the one who says that idiocy is permitted or that idiocy is not permitted, should not be held accountable for the results of his actions.

We allow medical directors to set up a system that proclaims:

Idiocy, Incompetence, and Iatrogenesis are permitted here.


If you look at what happens when these students have graduated and are developing as medics, the next big influence on the way they treat people is, surprise, surprise, the EMS medical director.

I believe that the difference between the ALS services that have excellent quality and the rest . . . .

What do you mean the rest?

There is no bronze medal in medical care, unless you believe in the government quality indicator rankings.

There are places that uniformly provide excellent care.


After excellent it is just a matter of naming the abuses the patient may suffer.

Statistically, many of these patients will arrive at the hospital unharmed, but there will be plenty who do not escape harm. So, what method of medical misadventure will they come up with this time?

I believe that the difference between the ALS services that have excellent quality and the rest lies in the involvement of the medical director.

An absentee medical director means that on a regular basis these are some of the medical misadventure menagerie that the medics will be inflicting on patients:

  • Unrecognized esophageal tubes,
  • Furosemide (Lasix) for pneumonia,
  • Delayed transport for IVs,
  • Patients treated according to the dispatch information instead of their actual medical condition,
  • Poor pain management,
  • Et cetera.
Absentee = Not being there.

  • Performing chart review is the same thing as not being there, because you aren’t.
  • OLMC (On Line Medical Command) requirements are the same as not being there, because you aren’t.
  • Having monthly/quarterly/yearly continuing education is the same as not being there, because you aren’t.
  • Telemetry (transmitting ECGs to be read by the doctor) is the same thing as not being there, because you aren’t.
  • Et cetera.
Being there to take report from medics at the hospital, showing up on calls, following up (with the patient and with hospital staff) on all unstable patients, . . . . are part of being there.

Do you know your medics?

Investing in some smart technology is a good thing (waveform capnography) when it is part of improving the abilities of the medics. Investing in telemetry is just a waste of money, an admission that you are trying to keep it stupid, and that you don’t know how to run ALS. Spending money on technology instead of a medical director, who WILL be there, is a waste of money.

Idiocy, Incompetence, and Iatrogenesis are permitted here.

Would you want this inscription on your certificate/diploma/degree?

Would you want this inscription on the side of your ambulance?

Would you want this inscription on your EMS patch?

The NR (National Registry of EMTs) should come up with a nice round patch EMT-P-III?

This is not the New York level of EMT-III (intermediate). It is quite a bit different.

Iatrogenesis = inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician.

Being There, the book or movie, is not the same as a medical director being there.


Dispatch would have told us if it were something serious.

The 911 crew walk to the house with just a little “first in” bag.


It’s just a syncope call.

No monitor. No thinking. No understanding of patient care. No anticipation of what might be needed.


Because that is the way things are done in that area.


Certainly Deborah Peel can wait until they go back to the ambulance, get the stretcher, bring the stretcher to Deborah Peel. They were expecting Deborah Peel to walk. He’s not known for being that cooperative. Then they wheel Deborah Peel out to the ambulance, where the heart monitor is waiting, as yet unused.

Now that they are in the ambulance, the assessment and treatment can begin.

This is not much different from the medical command approach of “Just transport.”

Anything that happens outside of the Emergency Department doesn’t count.

Of course EMS has translated that to – Anything that happens outside of the ambulance doesn’t count.

The basic EMT is expecting that the medic will come up with a way to make Deborah Peel appear stable – stable enough to go to the hospital without any ALS (Advanced Life Support) care. In other words, the medic does not have to do anything, except drive.

So, they take a blood pressure, but there are problems obtaining the number. They can only get occasional beats. When you are letting the pressure out of the cuff quickly, there can be a bit of a “inaccuracy,” especially if the beats are not cooperating by being close together.

Well, they know that the number can’t be right because that would be really bad.

Why don’t we hook up the monitor? Oh, yeah, good idea. Then we can find out what his heart rate is. The monitor is the keeper of the heart rate on ALS calls, just as the pulse oximeter is the keeper of the heart rate on BLS (Basic Life Support) calls. For some reason the pulse oximeter malfunctioned on Deborah Peel, even though they spent a lot of time trying to troubleshoot it. The best they could get was a sat in the low 80s and a heart rate in the upper 20s.

Now, you are probably already experiencing more than a little frustration reading this. I was watching this as we were returning from the hospital to our station. We had heard the call dispatched and I asked my partner why the crew was coming out of the house with a syncope patient, but without the monitor. The response – “None of the medics do that. You and Jeff are the only ones who bring monitors in on this kind of call.”

Great Googly Moogly, I done died and went the wrong way.

As we are wandering over to lend a hand, which my partner says is a bad idea (not the first time I’ve heard that), we overhear the blood pressure confusion. They are hooking up the monitor and have a nice wide complex bradycardia* on the monitor. The medic automatically grabs the IV kit and tells his partner to get the atropine out.

Since I am just helping, I put an oxygen mask on Deborah Peel. I even turn the oxygen on. I ask about blood sugar and they actually did that inside. The blood sugar is in the normal range.

I suggest, in my helpfulness, that pacing might be a good idea, since Deborah Peel is clearly unstable. As in unconscious, hypotensive, and bradycardic. That atropine is not helpful for ventricular bradycardias. But, they don’t approach ACLS that way. Pacing is something they do not use. Why? I do not recall the response to that question, maybe I never got a response, maybe I was just doing a better job of keeping my mouth shut at that point – to avoid letting out the screaming that is going on in my mind.

The hospital is two minutes away, otherwise we would not have been driving by this call. Do they start driving? No, the EMT has to help the medic with the IV start, spike the bag, cut the tape, hand the tape to the medic, . . . .

The atropine does not make things worse. Then they drive lights and sirens to the hospital.

Everything is already done, as far as the protocol is concerned. Chart review on this should earn the medic brownie points for being so diligent in care. The medical director can rest easy. This officer is one of the good ones, making sure that the others are kept in line. Passing on the right way to take care of patients.

But the chart and reality do not have anything to do with each other. Do they?

For a different perspective, what if this had been something that fell into the significant trauma category?

Well, we would drive to the hospital and meet the helicopter there at the landing pad.

How far of a drive is it to the trauma center?

15 to 30 minutes.

So, to save a few minutes of drive time, you fly the patient?

We have to. We can’t deprive our service area of our excellent patient care. If we aren’t here, mutual aid from the next town over might have to come in and treat our patients.

This reasoning almost makes sense. These guys have seen the neighboring EMS and don’t trust those guys.

Those guys are dangerous!

Of course, the only difference between them is the uniforms. When not working their full time job as these guys, most of these guys work part time as those guys, many of those guys work part time as these guys, but some of those guys work part time as other those guys. This keeps the overtime down.

These guys and those guys probably even pass the National Registry of EMTs paramedic test without any problems.

If you don’t purchase the program on the way into the ball park, you aren’t going to know who the players are.

* Bradycardia means s l o w. In this case to the point of not circulating enough blood to the brain to remain conscious. Wide complex means that even the electricity in the heart is moving very slowly. The heart is slow and the electricity is not connecting efficiently. This may mean that the lower part of the heart is causing the heart to beat. Normally a group of heart cells in the top of the heart (the sinus node) are in charge of causing the heart to beat, if they fail, then farther down the conduction system, where the upper part and the lower part of the heart meet, there is a back up to the sinus node (the AV junction), but even that is not working for Deborah Peel.

Not really a big problem. He just needs a ________.

Even those of you not big on cardiology can probably figure out the word that goes in there. The word is pacemaker. Deborah Peel will receive one in the hospital.

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Helicopter EMS – The Starbucks Effect.

Safety über alles!


Raising the Standards for Rock Ridge EMS

Vince commented on the post “Rock Ridge Hospital and EMS.“:

“Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.”

Bad medic are only bad medics when they fail to have the integrity to realize “these are other people’s lives I am playing with and I better make sure I get my shit together.” A bad OLMC physician may allow medics to continue to deliver substandard care, an issue that needs redress to be sure, but he certainly did not force anyone to be a bad medic.

Medic X, who cannot imagine what a 52 card deck looks like, is responsible for his misbehavior.


The medical director is responsible for allowing this paragon of EMS to work in EMS.

Medic X is irresponsible and incompetent and reckless.


He cannot grant himself the authority to treat patients.

The medical director is supposed to protect the patients from Medic X.

Otherwise, what do we need the medical director for? Not much.

Personal Responsibility.

Exactly. Why excuse the medical director from personal responsibility?

This is why it is outrageous to me, in principle, to focus on ways to make bad medics ‘less dangerous’ by any means other than those discussed above (remediation, counseling et al)

When there is the possibility to improve the care delivered, we should look into that.

You know that I am not a fan of fancy gadgets. Waveform capnography is one gadget that is extremely useful, and improves the care delivered by competent medics. CPAP is a treatment that helps to avoid intubation. CPAP should be used, not because we are afraid of the medic missing the tube, but because CPAP is better for the patient.

I realize your motivation is patient care and, after all, that is what this is all about. I also concede that these are not mutually exclusive ideas.

But as I alluded to earlier, any tool/device etc. that makes it ‘appear’ easier and ‘more foolproof ‘ will likely have the unintended consequence of allowing an already sub-standard paramedic, to rely on them at the exclusion of his underdeveloped assessment skills and judgment.

I am just advocating eliminating the middleman 😉

I am also not a fan of middlemen.

The term foolproof is, at best, an exaggeration. Similar to unsinkable.

Snopes.com has a great page, Sinking the Unsinkable, on the use of the term unsinkable, its relation to the Titanic, and the arrogance of many involved. The current approach to physician oversight is often closer to the arrogance of pretending the Titanic was unsinkable, than it is to any real risk management.

We need to weed out the substandard medics, instead we find ways to accommodate them. That is not what I am trying to do. I am interested in better tools. Tools that will help competent medics provide better care.

Obviously, anything that would improve patient care and eliminate potentially fatal errors are something I think we are all on board with. I am not that arrogant. I just would put more of my ova into the standard raising basket.

Just how arrogant is to be determined. The ale in your most recent post appears to have been drained.

I am in favor of raising standards. We also need to police ourselves and insist that medical directors get rid of those who cannot be remediated.

Instead, we seem to try to defend the bad medics. Until they harm someone. Why shouldn’t we do something before they harm someone?

Just applying standards that relate to patient care would be much better than checking to make sure the prospective medic has a pulse and a license, which seems to be all too common in EMS. We also need to put an end to the distraction of the medics with unrelated tasks, such as janitorial work, landscaping, fire fighting, or whatever else is dreamed up to occupy medics’ time not actually on calls.

If you remember for many many years I have been of the opinion that the paramedic profession take similar steps that nursing did insofar as making itself a profession, i.e. with minimum education requirements. Not only would this serve as a first-line filter to keep out some of the knuckle-draggers with the “Your life is my hobby” attitude, it may make inroads in garnering much deserved respect from other professionals, in particular OLMC physicians, not to say anything about an increase in salary. Perhaps you can post on this idea….

I am not convinced that more school will make a big difference. Appearances may be changed, but look at how overeducated medical directors are. In many cases, these highly educated medical directors still do not get EMS. Otherwise, why would we have OLMC (On Line Medical Command) requirements? We used to have to call for permission to do everything, even to start an IV. As EMS becomes better understood, the need to have medics call for permission has been gradually going away, but there are still places that insist on it.


As long as there are OLMC requirements, the medical director can point to this fraud and claim that there is physician oversight.


There is no real physician oversight – the medical director has no idea what is going on with patient care.

Not many people understand medicine and fewer understand EMS. Few realize that OLMC requirements are just a substitute for real physician oversight. And a very dangerous substitute.

Real physician oversight is not cheap or easy. Many do not want to do all of that work. Many services do not want to pay what it would take.


If you aren’t going to provide real physician oversight, you need to limit care to BLS (Basic Life Support).

How many services will behave responsibly? Pay up for real physician oversight, get a medical director who understands EMS and oversight, or get out of the ALS (Advanced Life Support) business.

It doesn’t matter if you are the volunteers, fire fighters, private ambulance company, third service, National Registry, or anything else.

Do it the right way, or not at all.

How EMS Manages Pain

In my last post Burns and Pain and Little Kids, I wrote about a case of bad pain management.

The comments included a lot of discussion of how EMS handles pain management.

I was talking with another medic and the topic of pain management came up. Not the first time that has happened.

One of the problems in EMS is that medics are trained to believe that morphine is some dangerous, magical drug that will sneak in on little cat paws and steal your patient’s breath away. This is told to us by doctors, nurses, and other medics – even non-medical personnel.

We frequently treat respiratory depression in EMS. And we often overreact when we do.


Read Ambulance Driver‘s article on EMS1.comThe Airway Continuum. The comparison between airway management and police use of lethal force is a useful one. Why do we automatically leap to the most invasive approach to airway management?

Conversely, why do we leap to the paranoid expectation of respiratory depression and respiratory arrest, when dealing with pain management?

This is an EMS version of an Urban Legend.

A site that is devoted to finding the truth about urban legends is Snopes.com. We have some people who provide the EMS version of urban legend debunking. AD does that, but he does not go far enough in this article. Not that he might think he exhausted airway management in this one article. AD could go on for days with only a pause for something to whet his whistle. And it would be entertaining, even if he does occasionally plagiarize himself.

Airway management is far more complex than “Intubate ‘Em All and Let Respiratory Sort ‘Em Out.” EMS protocols often do not acknowledge this.

Another problem with the use of morphine is the rush to use naloxone when there is any uncertainty about the patient’s respiratory status. This questionable nature of the respiratory drive should encourage a much more conservative approach. AD discusses this in Naloxone: The Most Abused Drug in EMS.

Pain management is also a far more complex treatment than “One Dose Fits All.” It is also something where “One Drug Fits All,” does not apply. Morphine is commonly used to manage pain, but it is far from a good drug for EMS. The big thing morphine has going for it is Tradition!

But the worst tradition associated with morphine is the dosing. If you are good, you may receive orders to treat an adult with 2 mg morphine. If you are really good you may receive orders to repeat that dose One Time. At least from some OLMC doctors.

The Danger.

The Peril.

The Horror.

There are some big problems with this approach. Pain management is not about rewarding paramedics with aggressive doses for good behavior. These doses that aren’t really even close to aggressive.

Pain management is about providing appropriate care for the patient.

Why is it that paramedics have to fight with some OLMC (On Line Medical Command) physicians for permission to appropriately treat patients?

Why are some doctors such vigorous opponents of appropriate pain management?

Why are some doctors such vigorous opponents of appropriate patient care?

Opponents of appropriate patient care? How can I say that about doctors?

A patient in moderate to severe pain.

A patient with no real contraindications to morphine (if hypotensive, no real contraindications to fentanyl).

A patient who will benefit from the treatment.

A patient too often denied appropriate pain management.

A patient too often denied any pain management.

Now, back to my talk with my friend.

He had a patient with a probable hip fracture. His partner insisted on calling OLMC for orders, even though they have standing orders. OLMC gave orders for 4 mg of morphine – much less than is available on standing orders.

Here are the standing orders for isolated extremity trauma:

(Choose one)
Fentanyl 50-100 mcg IV/IO 6,7 (1 mcg/kg)
may repeat ½ dose every 5 minutes until maximum of 3 mcg/kg
Morphine sulfate 2-5 mg IV 6,7
(0.05 mg/kg)
may repeat dose every 5 minutes
until maximum of 0.2 mg/kg
Nitrous Oxide (50:50) by inhalation 8

If we assume that the patient weighs 50 kg (110 pounds), then the standing orders would allow for the patient to receive 10 mg of morphine before having to call command for orders to give any more pain medicine. Not that those orders are likely to take into consideration that the patient is still in pain after 10 mg of morphine – only the “recklessness” of requesting to give more than 10 mg. This is the world of EMS pain management. Pain management isn’t about the patient. Pain management isn’t about appropriate care. Pain management is commonly about treating medical command for discomfort.

If only medical command were familiar with research on EMS pain management, such as I described in Public Perception of Pain Management.

Look at the standing orders again. In the system where he works, the medical director does not allow them to carry nitrous oxide or fentanyl. The medical director does not appear to have any plans for EMS to carry these drugs. The medical director does not encourage the use of the pain management standing orders.

One way that the medics are discouraged is by being labeled “Too Aggressive.”

I once did some ride time with them and was told that they did not want to hire me because some of the medics I rode with said I was too aggressive and others said I was not aggressive enough.

My interpretation of that was that I am Goldilocks’ porridge. Their interpretation was lacking in literary reference. They probably would have labeled me an Upstart.

You can see where the problem is in EMS. When it comes to pain management, it isn’t about patient care. There are several other things that are considered before the well being of the patient is considered. The other things that are considered can all veto the standing orders.

Then there is the problem of pain that is not due to an extremity injury. If the pain is not from an isolated extremity injury, then the pain is categorized as “too risky” to treat.

Not that this is based on research, these are doctors after all, their expert opinion is to “That’s the most foul, cruel, and bad-tempered medicine you ever set eyes on!” and “Look, that morphine’s got a vicious streak a mile wide! It’s a killer!” and “He’s got huge, sharp… er… He can leap about. Look at the breathing!”

It is true, the bunny in Monty Python and the Holy Grail was a killer. At times morphine can produce respiratory depression that can be a killer, too. Just not when well trained medics use it to appropriately treat their patients’ pain. Titrating the dose to the patient’s pain. The well trained medic is the Holy Hand Grenade of Antioch that counters the respiratory depression from a larger than appropriate dose of morphine, or any opioid.

If only the medical director would insist that the medics be competent in the use of the medications that the medics carry, instead of discouraging the use of the unpopular ones.


Failure to communicate

Gertrude at Ridin’ The Bus has some interesting comments about OLMC (On Line Medical Command), one of my favorites, in Failure to communicate.

I like it.

Well, Gertrude seems to have similar sentiments about OLMC and Medic X and throws in a reference to Cool Hand Luke. What’s not to like?

I do need to gather some research on this and find a way to present it properly, but the problems she discusses have been documented in some of the research on OLMC.

There is even a suggestion of medics using critical judgment. She must be a Witch! 🙂

Somehow, I managed to come up with a few words of my own on OLMC here:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.


National Registry Exam

There I am testing people for the NR (National Registry of EMTs) medic exam, saying to the examinee –

RM – It rubs the lotion on its skin. It does this whenever it is told.

Examinee – Lotion? We ain’t got no lotion. We don’t need no lotion. I don’t have to show you any stinking lotion.

RM – It rubs the lotion on its skin or else it gets the hose again.

Examinee – I see the tube going through the vocal cords.

I guess I was drifting off a bit. All this mindless repetition of the same thing, again and again and again.

The examinee removes the stylet from the tube, inflates the cuff on the tube, and attaches the bag.

When he squeezes the bag, his lie becomes apparent. The stomach/whoopee cushion inflates instead of the lungs. It is immediately obvious with this mannequin because there is no covering to the chest and abdomen. There is no real reason for confirmation of tube placement, because the mannequin makes it irrefutably clear where the tube is.

NR is not about reality. They are more interested in the equality of testing experience for the examinees than anything else. The only thing I am allowed to ask the examinee is “Is there anything else you would like to add?” And I must ask everyone that unless they obviously have passed. Maybe, even then. It has been a while and some of the NR silliness is less memorable than other NR silliness.

Since we are discussing reality, I never really recited the lines from The Silence of the Lambs. The examinee never really responded with any parody of the “badges” lines from The Treasure of the Sierra Madre.

NR insists that there not be any possibility of discrimination in its tests. Unfortunately discrimination is exactly what is needed. We need to discriminate between those who understand what they are doing and those who only memorize a routine and coincidentally place the tube in the correct hole.

We need to discriminate between those who are competent to begin work as medics and those who are not.

NR is all about the memorization of an entirely predictable testing station so that any idiot who can mouth the words and get the tube into the imitation trachea in the time allotted – well they pass.

If, as examiner, you have a question about the examinee’s technique, or knowledge, or why the examinee is doing something a certain way – you may not ask anything to clarify if the examinee has a clue. Even though that is supposed to be the whole reason you are there.

Catch-22 has nothing on NR testing.

The medic, because there is no reason to focus on those who do not pass. Well, the medic has learned to always say that he saw the tube go through the vocal cords.

What if the medic does not say this parrot phrase, but skillfully places the tube?

Automatic failure.

What if the medic cannot place the tube at all?

Automatic failure.

What if the medic says “I see the tube going through the vocal cords,” but the tube is in the wrong place?

You can’t get any extra points taken off for not telling the truth.

You need to learn to say I see the tube going through the vocal cords.”

No matter what!

You are taught that you have nothing to lose by telling a lie to please those who can punish you.

This could lead to serious problems.

You remember the article High-risk EMS procedure gets a low level of oversight[1] about esophageal intubations that were not recognized?


This is the way to train people to do that. Don’t think – jump to optimistic conclusions.

People were killed.

That is to be expected from this kind of thinking.

Surely, doctors know better than to go along with this.

Actually, doctors do the same thing when placed in a similar testing environment. ACLS (Advanced Cardiac Life Support) used to require that everyone intubate as part of the class.

Not everyone has intubation in their scope of practice.

True. Eventually that requirement was taken out of ACLS, but it is still there for physicians and medics. I used to have an easier time getting nurses, who had never before intubated anything, to intubate the mannequin than a lot of the doctors, but the one thing the doctors would consistently say is I see the tube going through the vocal cords.”


It is what they have been trained to say. It has become something they convince themselves that they really do see.

And they never went through the NR test.

No, but this is one of the big problems in intubation and airway education.

But, when the tube is in the trachea, that means that they saw it go through the vocal cords.

Maybe. All we know is that they say they saw the tube go through the vocal cords. They say the same thing when it doesn’t go through the cords, so why should we pay any attention to this statement at any time?

What you are stating is that when a medic or nurse or doctor says I saw the tube going through the vocal cords,” there is absolutely no reason to believe that person?

I couldn’t have said it better myself.

Then why focus on this?

Tradition – the enemy of progress and the antidote to thinking.

Why does NR try so hard to avoid discrimination?

They do not understand that patients’ lives are at stake. They think avoiding a law suit for “improper” examiner behavior is more important than keeping dangerous people from becoming medics.

You’re telling me that we are more concerned about the examinees than about endangering patients.

Exactly. There is money to be made convincing states to abandon their pathetic exams and try to slough off their responsibility to their citizens. NR is happy to make money on that and they will preach about how their ivory tower gurus can make this irresponsibility look good.

But this is nowhere near good.

That is correct.

When the medic has a real patient and is not protected from reality by the NR artificial test, the patient is in trouble?


Who protects the patient?

The medical director is supposed to by aggressively discriminating against those medics who do not know what they are doing, by continuing to look for signs of problems, by remediation, by continuing education, . . . . , and by termination when all else fails.

Many medical directors just look at the NR card and sign the medic’s license to kill.

I’m guessing that the NR will not be added to the list of organizations on your sidebar.

Not likely.

Pure evil, huh?

No, they do some good things, but the bad definitely outweighs the good.

This is one way to create your own Medic X.

My other posts on Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.

Other posts about medical oversight:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science


^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at EMS1.com


More RSI Oversight

RSI (Rapid Sequence Induction, sometimes referred to as Rapid Sequence Intubation) is sedating and paralyzing a patient to assist with intubation. The intubation doesn’t change. The patient who was moving, biting down, agitated, or . . . is no longer able to move – or breathe. Unless EMS breathes for the patient.

In RSI Problems – What Oversight?, I briefly wrote about medical oversight problems. In the article, High-risk EMS procedure gets a low level of oversight,[1] there was a description of one of the unrecognized esophageal tubes and the response to this. I am reprinting the comments of the paramedic “training coordinator” for AMR (American Medical Response).

The paramedic, Jeffrey Dektor, stated in a deposition that he made two attempts to intubate Cannon, the second time with the ambulance stopped at a parking lot.

He testified that he believed his first attempt was successful but tried again with a larger tube when he noticed that Cannon’s oxygen saturation levels continued to decline. During that attempt, he said, the tube became dislodged.(article)

He did not think the tube was in the wrong place, but was going to put in a bigger tube apparently to bring up the patient’s oxygen saturation, or to keep it from dropping.

Hmmm. If the patient’s sat is dropping, why do you think it is because of tube size?

If you put a 6.0 mm tube in a 300 pound patient you can still move enough 100% oxygen (because that is what we use) to keep the patient’s sat up. You might have to work a little bit more and keep the respiratory rate up to make up for the extra resistance of the tube.

Of course, the real problem with putting an itty-bitty 6.0 mm tube in somebody that large is that you won’t get any kind of cuff seal in the trachea. So, maybe the problem was that he used a tube that was so small that he could not get the cuff to act as a seal in the trachea.

Why would he be using a tube that is so inappropriately small? Was he using a formula to calculate the size of the tube?

If he feels that During that attempt, he said, the tube became dislodged, perhaps he doesn’t understand that the original tube needs to come out for the new tube to go in.

He thinks changing tube size is going to improve oxygen saturation, but doesn’t think that the tube might be in the wrong place. He knows when the tube became dislodged, but never did anything to correct it?

Is he so good that his patients will survive without oxygen?

Since this patient did not survive, I guess we know the answer to that.

Asked why he didn’t use any form of carbon dioxide monitoring, even though it would have been available on the ambulance, he replied: “I cannot state why I did not.”

Twenty minutes passed from the time of Dektor’s first attempt until Cannon was successfully intubated at Presbyterian Hospital, records show.(article)

He cannot say why he did not check tube placement.

He should have been checking, not once, not twice, but continually on every intubated patient.

This didn’t just happen.

How did the medical director – Dr. Robert Kowalski not know about this?

He stated repeatedly during the deposition that the matter did not cause him any concern.(article)

Clearly, Dr. Robert Kowalski doesn’t know anything about oversight of airway management.

Is there a more dangerous airway incompetence than not continuously confirming tube placement?

These are things that should be done on every intubated patient, RSI or not.

This is probably not the first time that this has happened.

How does the medical director remain oblivious to this?

Chart review is not a real form of quality control/quality assessment/quality improvement. It is just CYA.

Chart review is just a way of enjoying creative fiction. Do all medics honestly document their care, or lack of care?

If the medical director is only looking for certain things on charts, he is going to see those things on the chart, because medics are capable of learning.

If he were to train them to actually do what they document, that would be something good.

If he is using chart review and they are honestly documenting their lack of airway management, how does he justify that?

This medic had so many blatant errors on this call. This can’t be his first Charlie Foxtrot. He obviously has practiced to arrive at this level of destruction.

In each of the cases examined by the Star-Telegram, records show that EMS personnel failed to use the rudimentary tools that are standard for checking whether breathing tubes are in the proper place.(article)

This is the part of the article that few people seem to have noticed.

It does not matter if RSI was used for the cases in the article. The problems that killed two patients and severely damaged the brain of another patient were problems that are problems even without RSI.

Any time an endotracheal tube is placed the location of the tube must be confirmed by multiple methods and reconfirmed continually. Only an idiot doesn’t do this.

A medical director who has medics who regularly do not do this is just letting the medics kill people.

How many patients were intubated without RSI and did not have tube placement confirmed.

It is possible to put the tube in the wrong place. As long as you check placement and keep checking, this should not be a serious problem. If you never manage to get the tube in the right place, there are several alternatives that even non-medical people should be able to place correctly. They just are not as effective at manging the airway, but are adequate if the tube cannot be correctly placed quickly.

If you do not check placement and the tube is in the wrong place you are a killer.

If you are the medical director and you should know that your medics do not check placement of tubes you too are a killer. As a medical director, you just kill more people.

Other posts about this:

RSI Problems – What Oversight?

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science


^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at JEMS.com

Now apparently only available at Free Republic.


Misleading Research

In my last post, RSI Problems – What Oversight? I quoted from an article by Danny Robbins High-risk EMS procedure gets a low level of oversight. [1] In the article is one quote that really required a post of its own.

One physician willing to speak out on the evils of RSI, not bad medical oversight, is Dr. Henry Wang.

“My gut feeling is that, for every one of these cases, there’s probably a handful of others you never hear about,” said Henry Wang, an assistant professor of emergency medicine at the University of Pittsburgh who has closely examined intubation by EMS personnel.(article)

Unfortunately, Dr. Wang does not evaluate quality – only quantity. He and his accomplice, Dr. Donald Yealy, have studied the average number of intubations performed by medics in Pennsylvania. He found that the number was 1 per year, on average.[2]

A reasonable researcher might look at how different medical directors dealt with the low average number. How do you maintain a skill that is used so infrequently? It apparently has not occurred to Dr. Wang that one might train successfully for low frequency procedures. Maybe he did not have the right hunch?

Another study from Dr. Wang and Dr. Yealy was How many attempts are required to accomplish out-of-hospital endotracheal intubation?[3]

Remember the study that looked at epinephrine use in cardiac arrest and used the government’s death index to assess their patients?[4] Dr. Wang, again. This time without Dr. Yealy.

Dr. Wang and Dr. Yealy sent a letter to the journal Academic Emergency Medicine. Human patients or simulators for teaching endotracheal intubation: whom are we fooling?[5] In it they criticize a study of the use of simulators for intubation training, instead of OR (Operating Room) practice. What were their complaints? The real world of EMS presents a variety of intubation settings and the simulator is not real. Well, the experience of intubating in the OR is also not like the real world of EMS. Another criticism of the use of the simulator is that OR training is the traditional “proven” method of intubation training. Of course they did not provide any evidence that it has been proven superior to any other method of training. Science? Hardly.

If you are looking for a study of the effect of lax medical supervision, which is common in their home state of Pennsylvania, you will not find them evaluating that. They study things that can be counted, so that the numbers can be put in a computer, and out pops an answer. It must be right. Anything that cannot be counted doesn’t matter. Quality cannot be counted.

It is as if Lord Kelvin[6] were working in EMS, today.

Almost 30 years ago, Alvin Feinstein coined the phrase, ‘‘the curse of Kelvin,’’ to refer to the unthinking and inappropriate worship of quantifiable information in medicine.1 Lord Kelvin (who was addressing physicists, not physicians), had been quoted as saying in effect, that if your knowledge could not be expressed in numbers, then it was of a meager and unsatisfactory kind. Health care, because of its desire to be ‘‘scientific,’’ has not only been stricken by the curse of Kelvin, but has positively embraced it; this despite the fact that many prominent scientists (including some of Kelvin’s contemporaries, eg, Darwin or Virchow) succeeded while completely ignoring his advice. Thus, we see a proliferation of scales and measurement instruments aimed at quantifying the hitherto unquantifiabled for example, patient satisfaction.[7]

Perhaps, I am being a bit unfair to Dr. Wang and to Dr. Yealy. They are the dominant EMS researchers in Pennsylvania. Their research is revered in Pennsylvania. There must be some value in these quantitative studies. Some value in nasty letters criticizing important EMS research for not being traditional enough.

Well, how do you determine the value of research?

The important thing in research is the predictive value of the results.

Predictive value?

Unfortunately, for Dr. Wang and Dr. Yealy, the research that they have spent the most time on, that is viewed as sacrosanct, hasn’t any predictive value. If you know that a medic averages only one tube per year (mean average) in Pennsylvania, that tells you nothing about an individual medic’s ability to safely and successfully manage an airway.

Explain predictive value.

You study something for a reason.

Yeah, you want to learn about it.

What is worth knowing about something more than how it will behave in specific circumstances?

OK, but how does that work with intubation?

If you want to be able to tell if a medic will do a good job managing an airway –

Any medical director should want to know that.

Well, you want some research that helps you to figure this out.

So this helps medical directors?

Not just medical directors, but anyone looking at research.

Give me an example.

If you count up the number of chest tubes inserted by emergency physicians in a state and divide by the number of emergency physicians in the state, what does that tell you to help you predict the skill of the physician on the next chest tube placement?

Not much.

You will find places where medics have very low intubation success rates (maybe even some unrecognized esophageal intubations) and other areas where it is rare for a tube to be missed and unrecognized esophageal intubation is something they only read about when it happens elsewhere.

Well, that is covered by the average. That’s why they call it an average.

Yes, but how will that help you identify the places where the care is good?

But this research did provide some useful information.

Nothing that a high school student couldn’t have done with access to the same records.

So why do people pay attention to this?

One of my medical directors said that they are very persuasive in person.

Isn’t the same thing true for all salesmen?

Yes, and doctors are not immune to this kind of influence.

What can we do to avoid being misled?

Look at the way the research was done, did the methods bias the results toward some preconceived notion? Did the study ask any important questions that would help to improve patient care, to recognize any problems that are correctable, to identify better treatments, . . . ?

Well, doesn’t this show that paramedics do not get enough tubes?

Maybe, but what does the average tell us about the intubation skill of medics at any one service?

Not much.

So, what was the point?

Scare a lot of people with a number that is presented as unacceptable.

Why is it unacceptable?

If you don’t intubate enough, you won’t be good at intubation?

Yes, this is probably true, but did they look at what the medics do to maintain skill levels where intubation is infrequent?

No. I guess they just assumed that nothing is done.

And that is one of the big problems with medical oversight. It is often done by someone who does nothing to make sure the medics are skilled to begin with and followed with nothing to maintain any skill the medics might have.

Don’t these medical directors care about their patients?

Do these medical directors even view the patients harmed by their medics as their patients?

I guess not.

How is it that there are services where medics intubate better than the ED physicians and other services where the medics seem to be blindfolded and playing pin the tube on the trachea?

Maybe they should have been evaluating different methods of assuring quality, instead of just counting tubes like Count von Count from the Muppets.

Exactly. They criticize researchers who do important work in looking at alternative methods of obtaining airway practice.

But that is important.

They waste their time averaging every medic in the state, when any good medical director will already know which medics need practice and which do not.

Good point. I suppose this does not really answer any questions on intubation.

No it does not, but we will cover predictive value in more depth so that you can see how far out in left field they really are.

In another post?

At least one post.

Other posts about this:

RSI Problems – What Oversight?

More RSI Oversight

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science


^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at JEMS.com

Now apparently only available at Free Republic.

^ 2 Wang HE, Kupas DF, Hostler D, Cooney R, Yealy DM, Lave JR.
Procedural experience with out-of-hospital endotracheal intubation.
Crit Care Med. 2005 Aug;33(8):1718-21.
PMID: 16096447 [PubMed – indexed for MEDLINE]

^ 3 Wang HE, Yealy DM.
How many attempts are required to accomplish out-of-hospital endotracheal intubation?
Acad Emerg Med. 2006 Apr;13(4):372-7. Epub 2006 Mar 10.
PMID: 16531595 [PubMed – indexed for MEDLINE]

^ 4 Wang HE, Min A, Hostler D, Chang CC, Callaway CW.
Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest.
Resuscitation. 2005 Oct;67(1):69-74.
PMID: 16146669 [PubMed – indexed for MEDLINE]

^ 5 Wang HE, Yealy DM.
Human patients or simulators for teaching endotracheal intubation: whom are we fooling?
Acad Emerg Med. 2006 Feb;13(2):232; author reply 232-3. No abstract available.
PMID: 16461753 [PubMed – indexed for MEDLINE]

^ 6 William Thomson, 1st Baron Kelvin (Lord Kelvin)
Wikipedia article

^ 7 Wears RL.
Patient satisfaction and the curse of Kelvin.
Ann Emerg Med. 2005 Jul;46(1):11-2. No abstract available.
PMID: 15988418 [PubMed – indexed for MEDLINE]