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

- Rogue Medic

Is Direct Medical Command Pointless?


In some places, OLMC (On Line Medical Command) permission requirements are still used.

Isn’t it dangerous to get rid of this physician oversight?

We can’t have a bunch of cowboy medics doing as they please – OLMC requirements are necessary to stop these dangerous medics.

Or is that the wrong way to look at physician oversight?

Physician oversight does not come from a phone call, a radio call, or any other pathetic substitute for real physician oversight.

Biophone Model 3502 – the Original Biophone from Emergency! – similar to the APCOR (Advanced Portable Coronary Observation Radio) I used to use.

The magic oversight phone call only encourages medical directors to approve dangerous paramedics on the assumption that they will have to call to do anything dangerous.

This is nonsense.

We can strap patients to a backboard and not manage the airway and arrive with a dead patient. How would a magic oversight phone call prevent that? What would prevent that is having higher standards and a medical director who is involved in observing the transfer of care, from medic to nurse, in the ED.

Then “there was a movement from on-line orders to offline protocols,” a slow but steadily increasing reliance on evidence-based procedures for specific situations, Dr. Bledsoe explained. And it made sense. “When you take the on-line component out of this, care is faster,” he said. In fact, he spoke directly with a paramedic in the field only a few times in the past few years, and most often it was regarding termination of resuscitation or a similar high-risk situation. “They are well-versed, and we are crazy-busy,” he explained.[1]


What if OLMC requirements do work in some systems?

Seattle has very high standards for their medics, but the medical directors still micromanage patient care.

This kind of medical control has paid off for a few systems, but very few, according to Michael Callaham, MD[1]


Has it worked, or have other aspects of the system made the problems harder to notice?

No evidence is provided that any OLMC requirements anywhere have made anything any better.


Why take the medic away from assessment and treatment to have him tell the doctor something designed to convince the doctor to give the orders the medic wants?

No good reason.

Why take the medic away from assessment and treatment of patients already in the ED (Emergency Department), to give the orders the medic wants?

No good reason.

Why encourage the medics to keep track of which doctor is working where, so that we can avoid calling the doctors who do not understand EMS and refuse basic treatment orders?

No good reason.

Do OLMC requirements improve patient care?


Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 “command” runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.[2]


The autonomy of paramedics at his center would have been curtailed by now if they had seen adverse outcomes, “but that hasn’t been the case,” he stressed.[1]


The real dangerous people are the doctors who use excuses to not provide competent oversight.

OLMC requirements are incompetent oversight.


Go read the whole article.



[1] Special Report: Is Direct Medical Command Pointless?
Scheck, Anne
Emergency Medicine News:
April 2013 – Volume 35 – Issue 4 – p 8–9
doi: 10.1097/01.EEM.0000428924.57911.25
Special Report

[2] Decrease in medical command errors with use of a “standing orders” protocol system.
Holliman CJ, Wuerz RC, Meador SA.
Am J Emerg Med. 1994 May;12(3):279-83.
PMID: 8179730 [PubMed – indexed for MEDLINE]


Calling Medical Command for Deviation from Standing Orders

I occasionally have conversations with paramedics who have been written up for violating protocol, even though they received permission from a medical command doctor.

Some systems that require medical command contact do not permit deviations from the protocols listed, even with permission from a medical command physician.

What is the point of requiring medical command permission for some treatments, but prohibiting medical command permission on things that have not been included in protocols?

1. The medical command physician could recommend something dangerous.

There is nothing about medical command permission that prevents dangerous orders.

2. Paramedics must be limited to really simple things, because paramedics cannot understand anything complicated.

Reading 12 lead ECGs (ElectroCardioGrams) is something that is expected of paramedics in many places, but 12 lead ECG interpretation is not at all simple. Ask a cardiologist.

3. We mustn’t permit paramedics to think. They must pick a protocol and follow it to the end.

The end of the ride, end of the protocol, end of the patient (but not in a Braselow way), . . . .

4. We mustn’t require that QA/QI/CYA employees understand patient care, only that they look for deviations from protocol.

One benefit of this is the ability to reassign paramedics who are too dangerous to be treating patients. It is easier to enforce a protocol as an absolute rule, much more important than appropriate patient care, if there is no understanding of appropriate patient care.

5. Laziness.

A computer program can match treatment and protocol and identify deviations. No staff is required. No thought is required.

6. We have to control the information the medical directors receives.

We don’t understand medical treatment well enough to explain protocol deviations to our medical director, so we do all protocol-related discipline in-house. Better to kill some patients with ignorance, than to expect us to actually understand what we are doing.



My protocols do not prevent deviation.

Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS personnel to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances. When the practitioner believes that following a protocol is not in the best interest of the patient, the EMS practitioner must contact a medical command physician if possible. Cases where deviation from a protocol is justified are rare. The reason for any deviation should be documented. All deviations are subject to investigation to determine whether or not they were appropriate. In all cases, EMS personnel are expected to deliver care within the scope of practice for their level of certification.[1]

That is from my protocols.

There is no requirement that paramedics in Pennsylvania kill patients to protect protocols. Why do the people who write protocols in other places think that the protocol is more important than the patient?

How many patients really want to be treated by someone who is prevented from using judgment – even when in contact with an approved medical command doctor?

Essentially, these kinds of protocols prevent the medical command doctors from using judgment just as much as they prevent the paramedic from using judgment.


[1] Pennsylvania Statewide Advanced Life Support Protocols
2008 protocols page 6/121
2011 protocols page 6/128
Page with links to protocols


50 Plus Shades of Grey – Protocols

Continuing from the first two 50 Shades of Grey parts, David adds Part 3.

And that same medical director is usually the ones whose license paramedics work under.[1]

Paramedics do not work under a doctor’s license.

If I authorize you to drive my car, you are not operating the car on my license.

I could do street-side surgery and not endanger the doctor’s license.

However, when a system puts something in black and white, then this is what is to be followed. No Grey.[1]

Anything written in black and white has shades of grey. If not, there would not be much reason for a Supreme Court and all decisions by the court would be unanimous. They are working with black and white.

The question is whether our highest priority is the patient or the protocol.

Patients often do not present as black and white, but as grey.

Image source.

The requirement for a Mother-May-I phone call is based on mythology and has never been shown to protect patients. On the contrary, these magic phone call requirements endanger patients.

Epinephrine is not required in ACLS (Advanced Cardiac Life Support), but generally is required in EMS protocols in the US.

In the next revision of ACLS, don’t be surprised if the AHA (American Heart Association) changes their wording from consider to something that is less likely to produce the reflexive everybody dead gets epi that is in so many EMS protocols.

It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).[2]

Black and white. (OK, it is orange and white.)

ACLS does not provide us with any ALS (Advanced Life Support) treatment that improves outcomes, but we convince ourselves that ALS treatments improve outcomes based on wishful thinking and seeing it in black and white.

It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of out-of-hospital cardiac arrest.[2]

For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.128,–,133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.31,33,134,–,138 [2]

Understanding the importance of diagnosing and treating the underlying cause is fundamental to management of all cardiac arrest rhythms.[2]

It is important to understand that the routine ALS treatments probably harm patients, but our protocols tend to prevent us from following the ACLS guidelines.

We are only required to consider epinephrine. Unfortunately, the people writing the protocols do not seem to understand black and white, so the protocols tend to make epinephrine mandatory.

In the example David cites (the pdf does not open), the medic clearly should have called medical command to ask if he should have brought his gear on a call for a patient with difficulty breathing. He also should have called medical command to ask if he should have checked vital signs on the difficulty breathing patient, who apparently was not having difficult breathing due to death.

Magic phone calls encourage medical directors to keep these medics working, because they have to call to do anything dangerous.

That is the idea. That is not the reality, as this example makes clear.

Walking a patient to the ambulance is also something that should only have been done after a Mother-May-I phone call. The same for the IV medication – giving it or withholding it. We can’t be too careful.

It is not at all clear that either the walking or the lack of however much IV medication (probably just saline solution) contributed to the death of the patient.

It is also not clear that the death would have been prevented or that a lawsuit over the death would have been prevented.

The apparent mandatory nature of protocol makes this a protocol violation and therefore grounds for a law suit.

The failure to bring equipment on a difficulty breathing (or cardiac arrest) call and the failure to assess for vital signs are signs of horrible judgment that were not addressed by Mother-May-I phone call requirements. The failure is the dependence on the Mother-May-I phone call, rather than a requirement to assess the competence of the care delivered to patients by the paramedic.

Poorly written, inflexible protocols are not oversight. A magic phone call requirement is not oversight.


[1] 50 Shades of Grey…Protocols (Part 3)
David Aber
The EMS Difference
July 13, 2012

[2] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Free Full Text from Circulation


Protocol Deviation and Mother-May-I Silliness

In response to the conversation David Aber and I had at the end of last week’s episode of EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, David Aber and I discuss the problems with requiring permission to deviate from protocols that cannot possibly cover every patient. I was on a call for the first 45 minutes of the show, but I do get on the show at the end.

EMS Protocol Deviation

When is the right time to talk with a doctor for protocol deviation?

Is the protocol badly written?

Before the new protocol is finalized is the best time, but not all of us can attend protocol development meetings.

Next would be after the protocol is written, contacting the medical director(s) to change the protocol.

The best time to change a bad protocol is before the call, but that is not always possible.


Protocol deviations are NOT a bad thing.

The protocols are guidelines and cannot be intended to cover all patient care situations, except in systems where the medical director is discouraging competence.

Rigid protocols are part of the the same idea that is behind on line medical command permission requirements. Both encourage incompetence and discourage competence.

I know he’s incompetent, but he can’t do anything dangerous without calling, so the patients are safe.

I used to regularly hear variations on this from a county medical director as a justification for ignoring incompetence, but requiring rigid protocols and medical command permission for almost everything.

What kind of education is required to follow rigid protocols?

Very very little.

What kind of education is required to follow on line medical command permission requirements?

Very very little.

Skills training – IV training, minimal intubation training, an ability to ignore the harm we are causing, a ruthless devotion to the protocol, and not much else.



Really. There is no requirement for an understanding of assessment.

There is no need, since that would suggest that a paramedic is capable of understanding what to assess for without calling command or without reading it out of the protocol.

If a medic understands what to assess for, who knows what kind of things the medic might do next. Assessment involves thinking and we cannot have thinking.

Image credit.

This is what our EMS education is geared toward in too many places.

Doctors are encouraging bad EMS care because they do not trust EMS.

They don’t trust EMS for a variety of reasons, but a big one is the low quality of education.

Our education is based on handing down traditional treatments and only discarding treatments reluctantly, and only when told to by someone in a position of unquestioned authority.


We don’t know and we don’t care. It isn’t going to be on the test.

How do we know what works?


What is the quickest way to scare away medics, nurses, and doctors?

Start talking about research.

This is changing as more understanding of research is required in medical school, but even medical schools are ignoring research and adopting alternative medicine.[1]

What are two things NOT supported by research?

Rigid protocols.

Medical command permission requirements.

Where is the evidence to support these dangerous practices?

But that’s the way we’ve always done it.

Put that in a translator and out comes –

But we like being incompetent. You can’t expect us to change now.

What is required to get a medic card? A multiple choice written test and a highly structured practical exam. Does this have anything to do with ability to work independently?

We cannot even take the test without first completing a paramedic course, because if we were to allow untrained people to take the test, too many would pass.

A valid test does not need to limit candidates to only those who have taken a full course. If the candidates do not know what they are doing, they cannot pass a valid test.

Well, they sat through all of paramedic school, so how dangerous can they be?

How bad can we be?

Look at how bad we are at treating tension pneumothorax.[2]

Click on the image to make it larger.

How dangerous is that?

It depends on which side of the needle you are on.

We are sticking needles in the chests of patients who do not have any reason to be harpooned.

What kind of remediation was there? None was mentioned in the study.

How bad can we be?

Look at how bad we are at intubation.[3]

How dangerous is that?

It depends on which side of the endotracheal tube you are on.

Go listen to the podcast.


[1] Evil Spirits, Shock Trauma, Anecdotes, and Gullibility
Rogue Medic
Sun, 26 Sep 2010

[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011

[3] In Defense of Intubation Incompetence – Part II
Rogue Medic
Sun, 21 Aug 2011


50 Shades of Grey…Protocols

David Aber has some nice words to say about me in a recent post, so it is a bit of a disappointment to disagree with his main point. He writes –

I am one who believes that if protocols are well written, there should be no grey areas. I also consider myself far from a “cookbook” provider. However, I do realize that should something occur as a result of deviation from the protocols without proper authorization, that is where providers run into trouble.[1]

Well written protocols would encourage paramedic discretion. If there is a deviation from protocol that is not bizarre, why not address it at the hospital after the call?

Is there some reason that doctors cannot evaluate the appropriateness of treatment after seeing the patient?

Are medical directors really putting such dangerous medics on the street that the medics will harm patients without the magic phone call?

In the last few decades, one thing we have learned is that medical command permission requirements will be discarded as we realize admit that these requirements are not good for patients.

It is ingrained in EMS providers that should they ever have a question about deviation from a protocol, they should contact medical control.[1]

Protocols should be written for thinking paramedics, not for multiple choice from textbook patient presentations.

A thinking paramedic understands the harm of providing too much treatment, such as the 2 mg naloxone or the 25 gm 50% dextrose that David mentions.

Given the must get permission first approach, if medical command does not give permission, should the medic give an unnecessary treatment to a patient just to satisfy the protocol?

What if the medic calls command and is told to just follow the protocol?

Does the medic waste the supratherapeutic medication?

Does the medic harm the patient by giving a drug that has no possibility of providing benefit?

Is it worse to violate a protocol or to intentionally harm a patient just to protect the protocol?

I realize that David was referring to well written protocols, but well written protocols make allowances for protocol deviations and the review of these protocol deviations after the call. Are protocol violations that are expected and allowed still grey areas?

Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS providers to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances.[2]

Medicine is not black and white, but grey and probabilistic.

Protocols should be written so that if a provider follows them, there should never be a question about the care they provided.[1]



Choosing the protocol is not much different from a multiple choice exam.

If I choose the wrong protocol, is that good?

Does it matter how perfectly I follow the protocol I chose?

If I disable, or kill, a patient by perfectly following a protocol that should not have been followed, should I be immune from criticism, or from recourse?

Hell No!

But that is exactly what a lot of students say they are looking for –

What do I have to do to make sure that I will not get in trouble?

Well, you have to avoid any kind medical job.

If we want to know how to screen the bad people out of EMS, this kind of question is a clue.


How can I occasionally kill patients and not be responsible for my actions?

Why do we encourage these people in EMS? Why do we cater to them?

I am not the only one who thinks protocols should be written to encourage discretion. Kelly Grayson writes –

We are doing unnecessary things just because they’re in the protocol.[3]

We are poisoning our patients, just to avoid getting in trouble.

Yay! Aren’t we cool.


[1] 50 Shades of Grey…Protocols
Posted by David Aber
The EMS Difference
June 30, 2012

[2] The Two Most Important Words in an EMS Protocol
The Ambulance Driver’s Perspective
by Kelly Grayson
March 26, 2008


Increased Standing Orders

Peter Canning has been writing about the 16 biggest treatment changes over his 20 years as a paramedic. He starts his list by emphasizing the positive –

Increased Standing Orders.[1]

I would probably emphasize the negative –

Decreased Mother-May-I Restrictions.

I am not criticizing Peter’s style. He has made a living as a writer before becoming a paramedic and has added to that by writing a couple of books after becoming a paramedic. I am just easing my way toward why I emphasize the negative of these requirements.

As with many other things I write about, there has never been any evidence that Mother-May-I restrictions OLMC (On-Line Medical Command) permission requirements provide any benefit. There is plenty of evidence of harm to patients from these obstacles to patient care.[2],[3]

We would be much better off with more aggressive oversight of EMS by medical directors. This magic phone call is not oversight, but only smoke and mirrors.

Then there is the bigger problem – the ridiculous idea of They have to call to do anything dangerous.

High flow oxygen has been a standing order requirement in many of these Mother-May-I systems. High flow oxygen is almost always harmful to our patients.

Dangerous paramedics need to be remediated, and if they cannot be remediated they should be terminated, not given a magic safety phone to use in cases where a competent medic is needed.

Go read the rest of the not-yet-completed list of 16 biggest changes in EMS over the past 20 years.


[1] Increased Standing Orders
Street Watch: Notes of a Paramedic
March 31, 2012

[2] Refusal of base station physicians to authorize narcotic analgesia.
Gabbay DS, Dickinson ET.
Prehosp Emerg Care. 2001 Jul-Sep;5(3):293-5. No abstract available.
PMID: 11446548 [PubMed – indexed for MEDLINE]

We report two cases where paramedics’ requests for intravenous (IV) morphine to treat isolated extremity injuries were refused by base station physicians providing online medical oversight because those physicians felt that the use of morphine would alter the patient’s ability to be consented for potential surgery after arrival at the hospital.

[3] Effects of on-line medical control in the prehospital treatment of atraumatic illness.
Klein KR, Spillane LL, Chiumento S, Schneider SM.
Prehosp Emerg Care. 1997 Apr-Jun;1(2):80-4.
PMID: 9709343 [PubMed – indexed for MEDLINE]

OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.


Skills Monkey or Skilled Medic?

What is a skills monkey?

A skills monkey is someone who has been trained to perform skills well enough to pass a simple choreographed test of that skill.

Medical skills monkeys are not limited to paramedics or EMT basics. Doctors, nurses, PAs (Physician Assistants), NPs (Nurse Practitioners), et cetera can all be skills monkeys.

What is most important in the use of medical skills is not the ability to do what we practiced on a mannequin, but the understanding to know when to treat the patient with that skill and when not to treat the patient.

Because it is the Standard Of Care! is not a competent reason to harm a patient with a skill. Every skill can harm patients.

Why are we using a particular treatment?

What are the possible benefits?

What are the possible adverse effects?

If we do not know of many more possible adverse effects of a treatment (than possible benefits), we probably do not know enough about the treatment to use the treatment safely.

How will we possibly know what to expect?

How will we know what to watch out for?

How will we know when to stop, when to increase, when to repeat, or when we have good evidence that what we were treating the patient for is not what is making the patient sick?

A skills monkey does not understand anything more than –

Α. Select a protocol.

Ω. Follow the protocol to the letter.

Skills monkeys tend to be literalists. Literalists generally cannot comprehend abstract thought and should probably not be allowed to make decisions. Skills monkeys tend to be only aping what they have seen others do. Their reasoning is – That’s what the protocol says to do.

Here are some examples from the skills monkey playbook –

Crackles = Lasix, even if the crackles are from pneumonia.

Fall = backboard, collar, and straps, even if the patient has contraindications to this treatment.

Pain management = transport to the hospital so that someone who has a clue can take care of this scary treatment.

It is better to do nothing than to do something that might be wrong.

If that is what we believe, we should not be making any decisions that affect patients. We can teach that kind of thinking in grade school.

You were expecting a monkey? This kind of thinking does not require the higher thinking skills of a primate.

Everything has the possibility of causing harm.

If we cannot handle that, we should not be permitted to hide behind protocols, or medical command permission requirements, or Standards Of Care.


Safety of prehospital intravenous fentanyl for adult trauma patients


What prevents us from treating pain appropriately?

Actual adverse effects of pain medicine or unwarranted anxiety, due to exaggerated fears of potential adverse effects of pain medicine?

In 1999, the Emergency Medical Services Outcomes Project identified prehospital pain relief as a priority outcome and noted that it is one of the most high-impact prehospital interventions that can be performed on the majority of patients.3 [1]

Pain management is important. Unfortunately, EMS and emergency medicine have been better at coming up with excuses for not treating pain, than we have been at coming up with good protocols that encourage treating pain.

Our hypothesis was that a single dose of intravenous fentanyl administered in the prehospital setting would have no detrimental effect on the shock index of initially normotensive adult trauma patients.[1]

If we appropriately assess our patients, give reasonable doses of fentanyl (or any other pain medicine), is there any good reason to expect that there will be any harm to patients?

If we cannot appropriately assess our patients, what kind of incompetence justifies authorizing us to work as paramedics?

The protocol change allowed paramedics to administer a single 100 µg dose of fentanyl to adult trauma patients being transported “Code 10” (e.g., lights and sirens) to the hospital without a call to the medical command center. No other opioid was allowed for pain management in this population. Before the protocol change, medical command approval was required before administration of fentanyl.[1]

I see this as even more evidence that medical command permission requirements have nothing to do with protecting patients.

When medical command permission was required, pain management was rare.

After the protocol change patients were almost 6 times more likely to receive fentanyl.


The harm of medical command permission requirements is not controlled for, nor is it a hypothesis of the study. If this does reflect the way that medical command permission requirements discourage, or prevent, appropriate patient care, that raises a question –


How can we justify continuing to allow our patients to be harmed by medical command permission requirements?


Image credit.

Inclusion criteria were (1) age ≥ 18 years; (2) systolic blood pressure (SBP) >90 mm Hg; (3) Glasgow Coma Scale (GCS) score ≥13; and (4) emergent trauma transport to Denver Health Medical Center. Emergent trauma was defined as any “Code 10” (e.g., lights and sirens) transport to the hospital. Exclusion criteria were pregnancy and imprisonment.[1]

Pain is not listed as an inclusion criterion.

Severe pain? Moderate pain and severe pain? Abdominal pain? What is permitted on standing orders?

The outcome was the initial ED shock index (defined as the heart rate divided by SBP). As pain relief from fentanyl would typically result in a decrease in both heart rate and blood pressure, the shock index was chosen as a composite outcome for its ability to reflect, as a single dependent variable in a multivariable model, abnormal changes in heart
rate and blood pressure.

This may be a better way to assess vital sign changes than just looking at blood pressure, but is this part of what is used during anesthesia or procedural sedation to assess vital signs?

What if the patient is hypotensive before fentanyl, then receives fentanyl? What if some pain relief produces the expected decrease in heart rate, but the same pain relief also produces an increase in blood pressure?

This study’s protocol would not permit giving fentanyl to hypotensive patients, but that study has already been done –

Click on images to make them larger.[2] [3]

In 47% of cases of administration of fentanyl to already hypotensive trauma patients, the hypotension went away after fentanyl.

Why aren’t we doing larger studies of giving fentanyl to hypotensive patients?

Why are we withholding fentanyl from hypotensive patients?

What if . . . ?

What if we behave intelligently and actually find out?

Perpetuating myths and traditions is bad for patients.

We need to stop the defenders of tradition and mythology from harming our patients.

There is a 97% chance that, after administration of fentanyl to a critical trauma patient who is not hypotensive, the patient will still be not hypotensive.

There is a 47% chance that, after administration of fentanyl to a critical trauma patient who is hypotensive, the patient will be not hypotensive.

If we did not have so much anxiety about fentanyl, we might consider making it the standard of care for hypotension following trauma.

A total of 1,669 patients met criteria for inclusion during the study period.[1]

This is one of the problems with not fully describing the criteria. Did all of these patients have pain that met the criteria for administration of fentanyl? If so, then giving fentanyl to only 217 patients (13% of 1,699) is horrible.

Seven patients had an initial ED SBP <90 mm Hg, and all were included in the control group.[1]

Would fentanyl have prevented those cases of hypotension?


[1] Safety of prehospital intravenous fentanyl for adult trauma patients.
Soriya GC, McVaney KE, Liao MM, Haukoos JS, Byyny RL, Gravitz C, Colwell CB.
J Trauma Acute Care Surg. 2012 Mar;72(3):755-759.
PMID: 22491566 [PubMed – as supplied by publisher]

[2] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast page

[3] Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Sun, 05 Jun 2011
Rogue Medic

Soriya GC, McVaney KE, Liao MM, Haukoos JS, Byyny RL, Gravitz C, & Colwell CB (2012). Safety of prehospital intravenous fentanyl for adult trauma patients. The journal of trauma and acute care surgery, 72 (3), 755-759 PMID: 22491566