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

- Rogue Medic

A Case of Very Rapid Cath Lab Activation.

Last week Dr. Wes wrote The Race is On! about an article Saving a Life in 14 Minutes in the Boston Globe.

The article is interesting for a few reasons. It includes a time line, one that does not omit the EMS times. That is what I am going to focus on.

There are a few important questions from the time line.

8:31 EMS is dispatched.

8:34 EMS meets him at his front door. It should only take a couple of minutes to get to the ambulance and start transporting while assessing and treating. A 3 minute response time is good.

8:42 He is wheeled into the ambulance. 8 minutes later. It only took 3 minutes to “hop into an ambulance for the half-mile trip to Rosen’s house moments after his 911 call.

8:50 The ambulance is en route and notifying the ED of a STEMI. Why not notify when the first 12 lead was done, if the goal is to reduce delays? Although in this case it does not seem to have mattered, not all hospitals will respond as quickly. Yet, another 8 minutes apparently on scene.

8:57 Arrival at the ED.

9:01 Wheeled through ED doors. It took 4 minutes to get from the ambulance to the ED doors? It took less time to drive to the residence and meet the patient at the front door.

Interesting that the only ED contact mentioned is on the radio. The 12 lead ECGs are handed to a cardiology fellow, who works in the cath lab. They go straight through the ED to the cath lab, without stopping. Is there any improvement to the care of the patient that might be contributed by stopping in the ED? No.

The rest of the time line is in the story, but does not relate to EMS as much.

In the ambulance bay, the paramedics perform a second EKG to hone in on the site of the attack. As Rosen’s pain intensifies, they insert IVs and give him morphine and fluids.

They are referring to the interior of the ambulance as the ambulance bay, not the area at the ED where ambulances park. A 2nd 12 lead is nice, but all of this can be done en route – including IVs and drugs. 12 leads can be done while moving. Shaving the chest, if necessary for application of leads, can be done with an electric razor while moving. Using benzoin makes a big difference in getting leads to stick, which can otherwise cause a lot of delays in obtaining a readable 12 lead.

The description of treatment suggests that this was an RVI (Right Ventricular Infarction), since no NTG (NiTroGlycerin in the US, or GTN – Glyceryl TriNitrate elsewhere) was given, but fluids were given (perhaps I am just reading too much into it). There is not much reason to sit on scene for this stuff. Things that do matter are access to the front door of the residence with the stretcher. Was this a reason for delay? Why morphine, when fentanyl is a safer drug – especially with RVI?

If “Kevin and I recognized his heart attack immediately,” why does it take so long to get going?

A study in The Journal of the American College of Cardiology looked at the best practices for improving door to balloon times.

The ideal process (Fig. 1) represents a synthesis of the best practices found in the sample of 11 hospitals and is not meant to reflect the specific process of any single hospital in the study. The door-to-balloon process for patients transported to the ED with a prehospital ECG performed and read by a paramedic before hospital arrival is depicted by Path #1 in Figure 1.

For patients with a pre-hospital ECG indicating STEMI, the benchmark door-toballoon time is 60 min (Fig. 2).

For patients arriving without a pre-hospital ECG, the benchmark door-toballoon time is 80 min (Fig. 3).

No need for telemetry to further delay patient treatment.

Looking at the times:

8:31 response, 8:34 patient contact at front door, 8:42 in ambulance, 8:50 en route with STEMI notification by radio, 8:57 at ED, 9:01 rolling through ED doors and by-passing the ED.

8 minutes from the patient’s door to the ambulance. He met EMS at the door.

8 minutes from entering the ambulance until en route (not sure if I am reading this correctly).

4 minutes from the ambulance arrival at the ED to the ED doors.

There are 20 minutes that could not be completely eliminated, but should be dramatically reduced.

The time from door to balloon is less than the amount of the apparently avoidable EMS delays.

I realize that this article may not be accurate, that these times can never be completely eliminated, that I am reading a bit into this article, but WTF?

Historically, almost all of the unnecessary delays have been in the hospital. Here, it is the hospital that seems to have its act together. Ideal timing does seem to be one thing working in the favor of this patient. He arrived at 9 AM on a week day. The cath lab may have been preparing to take their first scheduled, non-emergency patient of the day and just had to defer that case for a while.

The cardiology fellow is waiting in the ED for the patient. There is little reason for the ED to be involved in the care of this patient. Look at the amount of time saved by the EMS notification of a cath lab patient and by the cath lab staff coming to the ED to take the patient directly to the cath lab.

Let’s add in the 4 minutes that the ambulance was at the ED, but not yet through the doors – 18 minutes door to balloon.

Just to complicate things we can put some butter on the fingers of Dr. Shah, who took just 6 minutes from initiating femoral access to inflating the balloon. How about adding 30 minutes – adding 5 times as long as it actually took. This would still give a door to balloon time of 48 minutes. The AHA and JCAHO goal is less than 90 minutes. This is just a smidge more than half of that goal.

If we can by-pass the ED, difficult if the cath lab team is not in the hospital, the amount of time saved is tremendous. This is not a criticism of the ED – we do the same thing with trauma. The cath lab team needs to be prepared to take the patient right away.

Bradley EH, Roumanis SA, Radford MJ, Webster TR, McNamara RL, Mattera JA, Barton BA, Berg DN, Portnay EL, Moscovitz H, Parkosewich J, Holmboe ES, Blaney M, Krumholz HM.
Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?
J Am Coll Cardiol. 2005 Oct 4;46(7):1236-41.
PMID: 16198837 [PubMed – indexed for MEDLINE]

OLMC For Good Medics

You claim that
requiring OLMC (On Line Medical Command) permission to treat patients does not work and actually lowers the quality of medic in a system. You state that Medic X, the example of the dangerous medic, is made worse by OLMC requirements. But, at least, OLMC requirements help the good medics. Let’s call this one Medic A.

Even better, let’s call this example of a good medic – Medic AD – everybody should be able to trust that Medic AD provides excellent care.

OK. Then why wouldn’t OLMC requirements help Medic AD?

You’re asking the wrong question.

The question should be How would OLMC requirements help Medic AD?

Consider it asked.

First – the goal of Quality Control, Quality Improvement, and all other CYA stuff is to improve the quality of the care the patients receive, or to create the appearance of controlling, or improving, or assessing the quality of the care the patients receive.

Focusing QC/QI/CYA on the medic is missing the point – it is about the patient.

How the medic does the job is not the important thing compared to the effect on the patient.

So, how does the need to get permission from OLMC to treat the patient benefit the patient?

The medic, even Medic AD, is not a doctor. He doesn’t know as much as a doctor.

Yes and No.

There are plenty of physicians who just do not understand all areas of emergency medicine.

What ? ! ?

The most obvious example is pain management, such as aggressive fentanyl administration on standing orders.

But these are powerful drugs!

Are there any drugs that a medic carries that are not powerful?

Maybe, but I think I see your point – if all, or almost all, of the drugs a medic uses are powerful, why treat these differently?

That is a good question.

So, what is the answer?

Gosh, I would have to be a psychiatrist – like Dr. Deborah Peel – to be able to diagnose a bunch of physicians without ever having met most of them.

So, you think the problem is psychological?

Not entirely, but there is more than a bit of paranoia about pain medication.

I believe that a lot of this is paranoia and due to a lack of understanding of the medications.

Let me give an example that is typical of what I hear from physicians defending OLMC requirements. The following comments are not at all unusual for conversations I have with medical directors. This written communication just did a wonderful job of bringing so many of them together.

It seems you DO have an opinion, and a sarcastic one at that. But that is beside the point.

Yes, I have an opinion.

Yes, I express it with more than a hint of sarcasm.

You see, you feel comfortable bashing the med control doctors out there because its not YOUR license on the line, and the med control MD hasn’t even seen the patient yet.

So, if I make a mistake the doctor’s license is on the line?

Please, somebody comment about any case where a doctor lost their license because of bad care by a medic. Anyone.

You see what I mean about paranoia?

So, if I make a mistake my license is not on the line?

Why does the doctor need a phone call for permission when it is pain management, but not arrhythmia, or cardiac arrest, or anaphylaxis, or respiratory distress, . . . ?


Its not YOUR so-called “deep pocket” that the lawyer for the patient who, in so much pain that EMS felt the need to give repeated boluses and later respiratory arrested, are going to go after. While I’m sure in your jurisdiction this doesn’t happen, even in the best of EMS systems there are those few EMS personnel that are either new, inexperienced, or just plain too ignorant to know the dangers of too much analgesia.

Sounds as if I found one of those physicians who is comfortable authorizing medics to treat patients, while knowing that these medics are not safe to treat patients.

OLMC to the rescue!

That will fix everything.

After all, just because they are too stupid to deal with pain management without a magical phone call doesn’t mean they can’t handle life threatening emergencies safely.

If they can’t handle something as simple as pain management – relatively simple if you are well trained – how will they handle a difficult airway?

But, maybe he isn’t the medical director for all of the medics in the system and he just doesn’t trust medics from other organizations.

How many of you out there can truthfully say that you haven’t had at least one case in which a big tough guy had apnea after only a minimum of versed or MSO4?

Again, comments please! Has anyone ever had this happen?

I adjust the dose to match the patient’s weight, underlying health, age, and current condition – then I reassess and determine if more is needed. I keep doing this until side effects discourage further treatment, or I run out of medication (or orders), or the patient is tolerating the pain well. I am always limiting the rate of administration, since most side effects are rate related.

I have never seen this miracle apnea, the doctor describes.

Or one of my most “treasured” memories, the call from EMS who had an unconscious victim and after administering the impaired protocol, called med control for morphine orders because the patient had just “come around and he was screaming in pain”.

Hmm. Unconscious “victim?”

I have addressed appropriate use of naloxone elsewhere.

Maybe a cancer patient treated inappropriately with naloxone?

Point is we are only a voice on the other end of the line sometimes. We cannot see what you see, only hear what you have to tell us.

For a moment, just for a moment, there is reality.

Sometimes we know exactly who you are and what you are all about and we can trust your judgement.

Right here, the doctor states that he does not have a problem with Medic AD using his judgment.

He doesn’t go as far as to say that Medic AD would not benefit from OLMC requirements, but he does suggest that he would automatically give Medic AD the orders being requested.

So, what would be the point of having Medic AD call OLMC before allowing the patient to receive treatment?

OLMC can then hear a familiar, trusted voice and relax.

It is all about the paranoia.

But other times you are simply “that voice over the radio”, the volunteer EMS system from “BFE”, the requested order from an RN who runs into the trauma room asking for morphine for EMS while you are trying to intubate someone,

Doesn’t that sound like a system that works well?

Would you like to be a patient there?

and sometimes, albeit rarely, you are simply another EMS provider who likes to give morphine to everyone, regardless of chief complaint.

This isn’t even using the lowest common denominator to justify OLMC requirements.

This is a medic who makes Medic X look good.

So, why is this medic still working?

OLMC requirements allow medical directors to justify keeping this worse-than-Medic X on the street and pushing drugs.

OLMC requirements endanger patients.

Requiring Medic AD to call OLMC to ask for permission to do what he knows how to do is only interrupting assessment and treatment, delaying patient care, and creating the possibility that an OLMC physician does not give orders that are appropriate for the patient.

The objections from most doctors, who are supportive of OLMC requirements, seem to be most focused on the physician’s ability to control things.

The problem with OLMC requirements is that they are barriers to patient care.

This is about patient care, not physicians’ need for control.

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

Fun with explosives – NTG.

Public Perception of Pain Management

From the movie Juno comes this interesting line about pain management:

Doctors are sadists who like to play God and watch lesser people scream.

This received one of the biggest laughs of the movie. One thing about comedy is that there needs to be some truth for it to be funny – stretched to the extreme, maybe, but some truth to it.

Why do so many people believe this about doctors?

Is there any evidence to support this apparently widespread belief?

There are medical command physicians who seem to approach prehospital pain management from the Nancy Reagan perspective – Just say No!


Is there any evidence that opioids or sedatives are dangerous in the hands of trained medics?

A study in Prehospital Emergency Care (the journal of the National Association of EMS Physicians, National Association of State EMS Officials, National Association of EMS Educators, and National Association of EMTs) strongly suggested that opioids, at least, are safely used by appropriately trained medics.

Pridemark paramedics have administered IV fentanyl under standing order protocols since November 2001. The Pridemark pain management program is very aggressive and field crews receive regular continuing education related to pain management and procedural sedation. The pain management protocol states that an initial dose of 1-2 µg/kg fentanyl can be administered for pain with repeat doses at 1 µg/kg, titrated as needed. The protocol does not limit dosing intervals or maximum total dosing and the contraindications for administration include known hypersensitivity, hypotension, respiratory depression, and myasthenia gravis. The only standing order limitation during the study period was that fentanyl administration for abdominal pain required base contact.[1]

Absolutely no requirement to contact OLMC (On Line Medical Command), except for permission to treat abdominal pain.

That seems very risky!

How can medics possibly make reasonable decisions about the proper amount of medication to use?

Fentanyl is a very powerful drug. In some emergency departments the emergency physicians are not permitted to use fentanyl, since the anesthesia department has convinced the directors of the hospital that it is only safe in the hands of anesthesiologists. Certainly, there is no bias possible in that determination.

If fentanyl is not safe when used by attending emergency physicians, how can it possibly be safe in the hands of lowly paramedics?

How can simple paramedics safely administer this powerful drug on almost unlimited standing orders?

I wish that I worked as a lawyer in that crazy system – or as a mortician!

Well, let’s skip down to the results and find out the death toll.

Wait – we need to find out more about the patients first.

There were 2,315 patients who received IV fentanyl in the field; 186 patients were excluded because they received other medications such as other narcotics, sedatives, or nitrates (see Methods), thus leaving 2,129 patients who received IV fentanyl alone.

The average total fentanyl administration was 118 µg (standard deviation [SD] = 67), with a range of 5400 µg. Similarly, for the subgroup of patients who had their ED charts reviewed, the average total fentanyl administration was 118 µg (SD = 67),
The average dose was 118 micrograms?[1]

Are they trying to tell us that paramedics are starting with small doses, reassessing patients, and giving further doses only when necessary?

That just reeks of responsibility.

I don’t believe it.

Bring on the dead bodies, the malpractice, the horror!

Of the 2,315 patients who received fentanyl in the field, 66 patients had a vital sign abnormality. Of those 66 patients, three were excluded because they received a sedative in addition to the fentanyl. There were 46 patients who were excluded because their vital sign abnormalities occurred before the administration of fentanyl.[1]

66 vital sign abnormalities! Almost 3%. That sounds like something to worry about.

Of the 46 patients who had a vital sign abnormality before the administration of fentanyl, 38 patients’ vital signs improved after the administration of fentanyl, eight patients’ vital signs remained the same, and none worsened.[1]

I guess we can’t really blame the fentanyl for the problems if they happened before the fentanyl, but almost all of them improved after the fentanyl – and none of them got worse.

The medicine helped the patient, that is an interesting concept.

Bring on the less than 1% of problems left.

There have to be some serious problems and a few cadavers in there!

The retrospective chart review of 2,129 patients who were administered fentanyl citrate in the field for pain management revealed that only six patients (0.3%) had a field vital sign abnormality possibly attributed to the narcotic administration. No patients required a reversal or recovery intervention during transport.[1]

No problems outside of the hospital?

Just wait, in the hospital they will have problems!

Of the subgroup of 611 patients who had their ED charts reviewed,[1]

They only reviewed 611 ED charts out of 2,129 field administrations that were reviewed.

They must have been trying to cover something up!

Review of all 2,129 ED charts, instead of only the charts of those patients transported to a single facility, might have revealed more patients with complications. However, the sample subgroup was necessary because 2,129 patients were transported to 19 different hospitals and would have required IRB and HIPAA clearance from 19 individual facilities.[1]

Gosh, that makes sense, out of 19 hospitals they chose one that received 29% of the patients.

A nice busy hospital. They won’t put up with any of this EMS mayhem.

Let’s go back and see the carnage that must have overwhelmed the hospital!

Of the subgroup of 611 patients who had their ED charts reviewed, only seven patients (1.1%) had a vital sign abnormality that could be attributed to the field narcotic administration. The higher rate of vital sign abnormalities in the ED (1.1%) compared with the field rate (0.3%) was anticipated given the short transport times compared with the drug’s duration of action. Only one patient (0.2%) required a reversal intervention in the ED.[1]

Now we are getting some place! A victim!

That patient was an 81-year-old woman with a possible hip fracture who received two doses of 100 µg of fentanyl and developed respiratory depression, which prompted the administration of 0.4 mg of naloxone with an immediate reversal of the adverse effect.[1]

Well, maybe somebody died later – or had other serious complications!

No patient required admission for any complications of pain management, and there were no deaths. These findings demonstrate that fentanyl administration in the field is a safe method for pain management.[1]

But what about the scare tactics that are regularly employed to discourage us from using pain medicines?

Hah! I know what they missed.

They used so little that it didn’t cause any problems, but it also didn’t provide any benefit to the patients.

Where’s the benefit?

The pre-and post-pain-management verbal rating scale scores for all patients who received fentanyl were also evaluated. These data showed evidence of a statistically significant change in verbal rating scale scores after pain management. Clinically, this illustrates an improvement in pain from a categorization of severe to mild and thus supports the effectiveness of fentanyl administration.[1]

From severe pain to mild pain.

What more could you ask for?

Now that we have looked at the results it looks as if they behaved responsibly.

I would even say that they make a good case that it could be copied elsewhere.

Perhaps everywhere.

Why pretend that this study is too small to provide meaningful data; or that the methods were so limited that the results are irrelevant; or that this means it is OK, but only with tight OLMC requirements?

What this really tells us is that not only is there no good reason to limit standing orders (maybe for abdominal pain, which required OLMC in this study), but that there is a significant difference that can be made in patient care.

Why do we have medics treating patients with unsupportable limitations on what they can do without OLMC permission?

If the medics are not capable of providing this level of care, why does the medical director allow such dangerous medics to treat patients?

Why are we denying appropriate care to patients?

Why are we providing less-than-adequate care to patients?

There is no good reason.


[1] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

I also write about pain maqnagement here:

Pain Management – What is too much?


Pain Management – What is too much?

I was looking at some protocols from another area and saw that, although their protocols are basically more restrictive than my too restrictive protocols, the notes about management had some clear and sane advice on the management of narcosis – the oversedation from an opioid.

The notes included more than I clipped, including continuing the presumption that opioids will cause nausea and vomiting. N/V from opioids is almost always due to the rate of administration, not the dose, not the drug, not anything else. At least, that has been my experience.

There are far too many misguided rituals that surround the administration of this supposed Damoclean chemical. It was nice to see a segment of common sense mixed in

Respiratory depression should be treated with oxygen and ventilatory support if necessary.
• Attempt verbal and tactile stimulation to reverse respiratory depression prior to considering
naloxone (Narcan®).
• Administer the smallest possible reversal dose of naloxone to maintain adequate respirations.
Dilute 0.4 mg naloxone in 10cc 0.9% NS syringe and slowly titrate to effect.
The most important part was probably too simple to be written into the protocols.

If the patient is talking the patient is breathing.

This concept seems to be overly simplistic for some doctors, but where is it wrong?

What if the patient is not talking?

Well, if I gave them enough opioid to manage their pain to the point where they are too comfortable and just want to be let alone to nod off AND there is respiratory depression – they are going to stay awake and talk to me for the rest of their time with me. At the hospital they will be encouraged to continue talking while the management of a bunch of morphine is considered by the doctors and nurses. If fentanyl had been the drug used, then the problem should not have been a problem after transferring the patient at the ED. Fentanyl is metabolized quickly and that is why it is the most appropriate EMS pain management drug.

If they are just not interested in talking, are breathing well, and are indicating that my conversation is now their greatest pain, then they can rest; if respiratory depression develops, then they do not have the option of avoiding conversation. If they wish to yell at me to leave them alone, that keeps air moving, too.

If you think that I give enough opioid to prehospital patients to achieve this effect, I do not. I have assisted/observed plenty of procedural sedation in the ED. Not as a replacement for a nurse, just lending an extra hand to do grunt work. Not a lot of anti-nausea medication used in these procedural sedations, either. Just nice slow administration, reassessment, and repeat as necessary.

It is amazing how much you can learn from someone who knows what they are doing. I think medic schools would benefit tremendously from requiring medics to assist with procedural sedation, or in the burn unit, to develop an understanding of what happens with large doses of opioids. The lesson is not to use the same doses, but to see how to manage the patient if the dose is unintentionally too large.

We let numbers scare us to the point where we ignore the patient. This is bad.

Less-than-cheerful nurse: “You gave 26 mg of morphine to that 45 kg little old lady? Are you insane?”

RM: “Which part do you want me to answer first?”

Less-than-cheerful nurse with a sense of humor: “I guess that answers the second question. Why so much morphine?”

RM: “She has 2 Duragesic patches on; had severe pain; and, even with that much morphine, her pain level is still 4/10, increasing to 7/10 with movement. She felt the pain was tolerable when we moved her, we had already spent a lot of time on scene, and we did not want to switch protocols to compartment syndrome. :-)”

The nurse, although Less-than-cheerful, yet in possession of both a sense of humor and the ability to assess the patient and determine the appropriateness of the dose proceeded to do just that. The patient is awake, alert, oriented, and rates her pain as 4/10. Now the nurse is the Less-than-cheerful nurse with an anecdote to share with the rest of the staff. All of this required on line medical command (OLMC) orders, which were fortunately provided by an aggressive ED physician. With the OLMC roulette that we play, you never know how much appropriate care you may be able to provide to the patient.

Well, I didn’t get the patient to the point of being pain-free, but that is not my goal. A tolerable level of pain is all that should be hoped for with morphine. Fentanyl allows for more aggressive dosing due to its much more rapid metabolism. Metabolism is the medic’s friend.

As clarification for the non-medical people Duragesic is a brand name of fentanyl patch that gives fentanyl slowly over a long time; it is absorbed through the skin; even though the fentanyl that is given by EMS is metabolized (used up quickly in the body) quickly, the slow absorption through the patch of the same drug lasts a long time. Fentanyl can be given IV, IM, and by an atomizer spray in the nose, so that an IV is not always needed (little kids, poor veins, …).

Appropriate use of benzodiazepines is not much different from appropriate use of opioids.

Does anybody have any interesting pain management ideas, anecdotes, questions, … ?

I also wrote about this here:

Public Perception of Pain Management