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

- Rogue Medic

Medical Oversight According to the Handbook for EMS Medical Directors – Part II

The Handbook for EMS Medical Directors was developed by the International Association of Fire Chiefs (IAFC) as part of a Cooperative Agreement with the Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA), U.S. Fire Administration (USFA), and was supported by DHS, Office of Health Affairs (OHA).[1]

The magic phone call suggests that only these magic phone call treatments are the potentially dangerous treatments, while other treatments are safe, or comparatively much safer.

There is no basis for claiming that the treatments that require medical command permission are any more dangerous than treatments that do not require the magic phone call. So, what is the basis for this kind of requirement?

Why do some places require medical command permission for a lot of treatments, while others do not require medical command permission for anything?

Do they treat patients who are that different?

Do they use fewer treatments?

Do they not know the incantation to make the magic phone call work?

Do the medical directors just not like being called Mother on these Mother-May-I? calls?

Or do they just have medical directors who provide valid medical oversight?

If the most progressive medical directors have the least use for medical command permission phone calls, what does that say about the value of the medical command permission phone call?

Back in the good ol’ days, we had to use the magic phone call before we did anything.

For permission to transport to the hospital.

For permission to start an IV.

For permission to defibrillate.

For permission to give any medication.

In some places, the medication orders were given by the color of the box of medication. Different manufacturers use different colors, so a change in manufacturer would change the medication delivered. Is that competent medical oversight?

The requirements for medical command permission have almost always moved in one direction – fewer requirements to make the magic phone call more standing orders.

The result has not been a cover-up of medical mass murder.

What if we called some of the medical command doctors for orders to treat severe pain?

There have been very rare benefits, such as the Maryland requirement to call for medical command permission to call for a helicopter for patients with Mechanism Of Injury. Why fly a patient with a Mechanism Of Injury, rather than assess the patient for an actual injury?

The basis for the Mechanism Of Injury criteria for flight is the expectation that EMS is incompetent.

Or was this just an antidote to the medical directors who wanted every occupant of every car with a dented bumper flown?

The basis for the medical command permission phone call is the expectation that EMS is incompetent.

The result of the medical command permission phone call is the ability to feel that EMS incompetence does not matter, because They have to call to do anything dangerous.

Really?

Sign here. That’s probably just indigestion.

Fever, tachycardia, and crackles all over – some Lasix will make the crackles all better.

In the places that do not have medical command phone call requirements, are they incompetent at medical care, but just very competent at hiding the dead bodies?

See also –

The Permisson Paradox by Bob Sullivan.

Adios, Rampart – Give medical control the boot by Dr. Bryan Bledsoe.

Footnotes:

[1] Handbook for EMS Medical Directors
March 2012
International Association of Fire Chiefs (IAFC) and others.
USFA page with link for download

.

Medical Oversight According to the Handbook for EMS Medical Directors – Part I

Groups of people somewhat affiliated with EMS have decided that they know how EMS medical direction should be run. Their approach would have been progressive a few decades ago, but for EMS in many places this document is a return to the Dark Ages.

The Handbook for EMS Medical Directors was developed by the International Association of Fire Chiefs (IAFC) as part of a Cooperative Agreement with the Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA), U.S. Fire Administration (USFA), and was supported by DHS, Office of Health Affairs (OHA).[1]

There are some things with which I do agree.

Physicians interested in becoming a medical director enter into an aspect of emergency medical care that is distinct from the emergency department.[1]

EMS and emergency medicine are very different.

Medical direction is essential to ensure patient care that is high quality, efficient, effective, and safe for patients as well as for providers[1]

The quality of EMS care has a lot to do with the medical director.

The American College of Emergency Physicians (ACEP) highlighted the medical director as an integral component of the EMS agency, stating that the medical director should have ultimate authority over all clinical and patient care aspects of the EMS agency[1]

That should be obvious. Is anyone else more qualified to make these decisions?

Medical oversight ensures that the care is rendered by competent medical professionals, consistent with accepted standards.[1]

But medical command permission phone call requirements assume incompetence.

As previously mentioned, the medical director needs to make every reasonable effort to know all of their providers.[1]

Absolutely. Not so much as friends, but as someone who is assessing the skills of the medics.

EMS medical direction involves granting authorities to act and accepting responsibility for the delivery of EMS patient care. Medical direction is narrower than oversight in that it defines what treatments EMS providers render when presented with medical conditions[1]

But do medical directors accept responsibility for the care provided by paramedics who should never have been authorized to provide paramedics level treatment?

Do medical directors accept enough responsibility for the care provided by paramedics who should never have been authorized to provide paramedics level treatment?

The Federal Interagency Committee on EMS (FICEMS), as well as the National Association of Emergency Medical Technicians (NAEMT), stressed the importance of medical oversight in every EMS system; equally important in day-to-day EMS operations as during catastrophic events.[1]

Medical oversight is much more important when dealing with everyday events. Catastrophic events are not common and we are not staffed to provide paramedic/ALS (Advanced Life Support) treatment on that scale.

Is this a handbook that encourages better oversight, or does this contain too much nostalgia for something that never worked?

To be continued in Part II.

Footnotes:

[1] Handbook for EMS Medical Directors
March 2012
International Association of Fire Chiefs (IAFC) and others.
USFA page with link for download

.

In Defense of Intubation Incompetence – Part III

A continuation of In Defense of Intubation Incompetence – Part II. PA_Medic responded to Part I with –
 

If the patient woke up to a sternal rub, I do not see any reason to consider that as anything other than eyes open to voice.

Your kidding me right? Your going to discount AVPU now? When was the last time you picked up an ETOH overdose? Maybe yelling in the ear from one inch away = painful stimuli.

 

How is the appropriate classification of a response to a sternal rub as the equivalent of a response to voice in any way discounting AVPU?

I am discounting the pain produced by a sternal rub as insignificant. Not quite a massage, but not effective as a painful stimulus. Only a small percentage of patients will respond to a sternal rub as a painful stimulus.

I arrive on scene.

Sternal Rubber – He is unresponsive to deep painful stimulus!

I apply real painful stimulus.

The patient opens his eyes and responds.

Rogue Medic – What kind of painful stimulus did you use?

Sternal Rubber – A sternal rub, of course.

Rogue Medic – A sternal rub is more useful as a way of producing an abrasion on the chest (lifting up patient’s shirt to show the abrasion) which we now need to explain in documentation. Since the shirt was tucked in, I am guessing that none of you checked for any abrasion, and then tucked the shirt back in.
 


Picture credit.
 

EJs (External Jugular IVs) are rarely used in EMS outside of cardiac arrest and do not appear to offer much benefit over a peripheral IV.

 

Really? Come deal with the diabetics and hypovolemic shootings/stabbings in my local. IV’s are nice if you can get it or they have limbs. IO’s are nice as well

 

Considering the safety and efficacy of IO (IntraOsseous) access, there is not much reason for EJs.

A lack of ability to deliver large fluid boluses to patients with uncontrolled hemorrhage may be better for patients.
 

Why is extra practice an insult?

Did I ever say that? I encourage it!!!

 

You wrote – Guess we have to send you with the IV team in the hospital to make sure you know how start a line because you must be out of practice because you failed.

You present this as if it were an insult to be sent with the IV team to work on IV skills – also known as practice.

This discussion all started with my suggestion of a way to improve intubation practice, so it is easy to see your comments as critical of requirements for practice.
 

Signs of incompetence –

Listening to the lungs before listening to the belly.

 

I don’t know how you were taught to intubate but I confirm lung sounds while using the BVM before intubation. After placing the tube, sometimes blind or with a Bougie, I hook up the end tidal and listen to the L lung and compare it to what I heard while using the BVM. If I hear no sound I listen to the belly quickly. If absent I listen to the R lung comparing it to what I heard before assuming I’m to deep. With all breaths I’m watching the belly for expansion. If I can only hear sounds in the right then I am to deep. Reposition and start back from L lung to R lung to belly. 8-10 seconds max.

 

The first place I want to listen to is the place that can tell me most quickly if I am in the wrong place.

That place is the belly.

Too often I see people listen over one lung, then the other, then go back and listen again to the first lung, then listen again to the second lung, then listen to the belly and realize that the tube is not where they want it to be.

Risk management is more about looking for evidence that we are wrong, than looking for evidence that we are right.

If I listen to the belly first, hear gurgling and pull the tube with only one breath in, there is less likelihood that the patient will vomit, or have other negative consequences of an esophageal intubation.

If I listen to either lung first, do I have enough information to pull the tube after just one ventilation?

No.

If this is a misplaced tube, I will put more air into the stomach before I will recognize my mistake.

Maybe the patient vomits with just one breath. I have had that happen.

Maybe the patient will vomit with the second breath. I would never know that, if there are gurgling sounds over the belly with the first breath, by using my method. You would be dealing with vomit in the airway.

Maybe the patient will not vomit no matter how many breaths are delivered to the stomach. There are patients with unrecognized esophageal intubations and flat waveform capnography readings, who have their stomachs ventilated, but they do not vomit.

By comparing the sounds of lung sounds during bagging (and I am assuming listening to the lungs without bagging for those patients not being bagged for a lack of ventilation), you do avoid the problem of trying to figure out what unfamiliar sounds are, since you have a baseline for comparison. Why not do the same thing with the belly, too, and listen to the belly first?

How much do we want to gamble on the tube not being misplaced?

When I gamble, I want to compare what I can gain with what I can lose. Listening to a lung first is a gamble with nothing to win.

It used to be that medics would complain that waveform capnography is for wimps. Now we understand that not using waveform capnography if for idiots. These medics may not be wimpy, but they are idiots and their patients are not better for it.
 

Reality is there are bad apples in every profession. My wife has saved more patients as a nurse due to bad MD orders then most hospitals want to know. It’s not placing blame or supporting incompetence. It’s reality. There are medics that suck. Period. Show me any job that doesn’t have 5-10 percent of people getting fired due to incompetence or laziness. Unfortunately our mistakes can kill.

 

You see the problem as only 5% to 10%. I think that it is dramatically higher.
 

I get mad when one subject like intubation gets targeted because it’s an easy target.

 

Intubation is an easy target because it is done so poorly by so many medics and because the consequences can be so serious and because there is so little evidence that there is any benefit.
 

Apathy hurts more patients in our profession then intubation ever will!!!

 

I thought that the problem was that I am not apathetic enough about intubation.
 

Wanna meet at Brothers for a slice and a beer for a real conversation?

 

OK. Bryn Mawr or Philadelphia?
 

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In Defense of Intubation Incompetence – Part II

In response to In Defense of Intubation Incompetence – Part I, there is the following from PA_Medic, which results in this being Part II.
 

1. Ego? Really? Do you really think medics intubate due to ego?

 

I think that medics defend the right to intubate due to ego.

I think that a lot of medics intubate when they should not due to many other reasons – inexperience, ignorance, poor assessment, and the myths that have been passed on by bad instructors.
 

2. Do you think people that read your blog support incompetence in EMS?

 

I think that people with all sorts of opinions will read my blog. Some will read what I write and agree with me. Some will read what I write and rant and rave about how stupid I am. I expect that most will be somewhere in the middle. I have not taken a poll.
 

Intubation is more complex than OK/Not OK. Patient care is more complex than OK/Not OK.

Deciding to intubate is complex due to risks short term and long term. The procedure shouldn’t be.

 

The decision to intubate is often much more complicated[1] than the intubation.

Intubations can become complicated.

Did the medic position the patient well prior to the attempt?

Did the medic assess the patient well prior to the attempt?

Not anticipating a difficult airway.

Not having several back-up plans.

Not being able to deal with problems that inevitably arise when we intubate more than a handful of patients.

Anyone can be taught to intubate, but that does not mean that the person is competent to decide when intubation is appropriate. We do not spend enough time on either ability.
 

Show me the data that suggest that any CHF or respiratory arrest patient benefits from bad intubation.

I believe that’s called death. They should benefit from correct intubation.

 

That is exactly the point.

There is no reason to believe that any patient benefits from incompetent attempts at intubation.

I explained this to Too Old To Work, Too Young To Retire in an earlier discussion.[2] He my idea of medics intubating medics is superlative.[3]
 

Research shows that medics do not do this well.

No, research shows that some medics do not do this well.

 

This is true. That is why I am trying to raise the standards for paramedics, so that these dangerous medics can explore more appropriate career options.

This was not a study by people trying to discredit medics, but by medical directors trying to find out if their medics had a problem with intubation.[4]

When we don’t keep track of what we do, we may find out that it is not as good as we thought.

I can understand why anyone would be reluctant to be intubated by a paramedic – especially someone who works with someone, or more than one someone, who cannot intubate well.

The graph just shows the right place/wrong place rate of 3/1, but the graph does not tell us anything about complications of the intubation attempts.
 

You have not read much of my blog.

I’ve read every post since you started.

 

I thought I was the only one.

If you’ve read every post since I started, how do you come to the conclusion that I discount paramedicine in every post?

My goal is to stop paramedics/medical directors from doing things that are bad for patients and to encourage them to do things that are better for patients.

I strongly encourage more aggressive use of treatments that work – without any medical command permission requirements.

The flip side of this is that we do need to eliminate the treatments that harm patients and/or the people who harm patients.

We cannot be aggressive and be dangerous and still be competent.
 

Even in the hospital, the doctors who understand resuscitation are using extraglottic airways.

Yes, and I have seen those fail to secure an airway pre-hospital and in-hospital.

 

That is one of the reasons we have many options. There is no one airway that is right for everything, not even the endotracheal tube.

When the most common reason for the prehospital use of an extraglottic airway is a failed intubation, is the failure of an extraglottic airway in the same patient any worse than the failure of the endotracheal tube?

When the most common reason for the prehospital use of an extraglottic airway is a failed intubation, is the failure of an extraglottic airway in the hands of the same medic the fault of the extraglottic airway?

To be continued later in Part III.

Footnotes:

[1] complex vs. complicated
Wordwizard.com
dante
Article

The distinction may not be important to most people, but this is one of the things that is important about intubation. The steps that should be taken to properly intubate a patient are complex (it can be broken down into a series of many steps), figuring out what is going wrong with an intubation, when the standard intubation becomes non-standard is complicated. Deciding to intubate, or to use some other means of managing the airway, is complicated. We can try to break it down into steps, flow charts, algorithms, et cetera, but this requires understanding of many different factors.

Why did I use complex, rather than complicated? I don’t know. As Kathry Schulz states in Being Wrong about what it feels like to be wrong – It does feel like something to be wrong; it feels like being right. I don’t know why I made that mistake, but at the time, I appear to have thought that I was right.

[2] Comment on Intubation from TOTWTYTR
Rogue Medic
Article

[3] Grand Prize Dumb Idea
Too Old To Work, Too Young To Retire
Article

[4] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

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You Gave Her 20 Milligrams

There is a great post at StreetWatch on prehospital pain management and one of the obstacles to good patient care.

Peter writes about the way that they finally were able to approve standing orders for pain medicines.

The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.[1]

Peter did not just wait for the doctors to get around to doing what is right for patients. This is pain management. How often do we see doctors going out of their way to do the right thing for the patient? I don’t know what your answer is, but my experience has been that it is not enough.

If I were to use two words to describe the management of pain in EMS, those words would be not enough.

There are some great doctors, who do a lot to improve EMS, but those same doctors are also generally trying to accomplish a dozen different things at once. None of those dozen things may be unimportant, or only a few of them are likely to be unimportant.

We need to do what we can, on our own, to get other doctors to change our protocols to allow us to provide appropriate patient care.

If we continue to rely on whatever the doctors let us do, our patients will continue to be limited to not enough.

Do we want to provide excellent patient care?

Or.

Do we want to keep our heads down and avoid doing anything that might attract attention from an administrator, or from a medical director, or from any doctor at any hospital we might transport to – no matter how much we have to hurt patients do do this?

We can change things, so that we do not have to hurt our patients.

And many prefer not to exercise their imaginations at all. They choose to remain comfortably within the bounds of their own experience, never troubling to wonder how it would feel to have been born other than they are. They can refuse to hear screams or to peer inside cages; they can close their minds and hearts to any suffering that does not touch them personally; they can refuse to know.[2]

There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.

There is no research to support any kind of need for on line medical command permission for any pain medicine.

There is no good reason for us to continually be giving doses that are not enough.

if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?[1]

This is also important.

Limits on standing orders are not limits on patient care. We can always call medical command for orders to give more.

What’s the worst that can happen?

A doctor tells me that the patient cannot be in pain after that much morphine/fentanyl. Then we transport to the hospital and I get the doctor to come over and assess the patient himself and the doctor learns that a patient can be in a lot of pain after that much morphine/fentanyl. The doctor is then better able to understand what appropriate pain management is.

If the worst that can happen is that the doctors think I care too much about treating pain, is that a bad thing?

It is important to point this out to the doctor. Unless you have some sort of remote medical command system, the doctor is the one who does not believe that the patient is in pain after whatever treatment was given on standing orders.

It is medical command doctor’s job to demonstrate to us that this patient is not still in significant pain.

If this doctor is comfortable denying treatment to this patient, the doctor needs to see what the patient is really like – if we are to change things so that we can provide appropriate pain management.

We should not be disrespectful.

Doctors are generally great about answering questions. When I ask doctors about what is going on with a patient, unless they are extremely busy, they take some time to answer me. By getting doctors to try to explain how patients in severe pain do not actually have severe pain, we should be able to get these doctors to realize that their orders are not enough.

There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.

There is no research to support any kind of need for on line medical command permission for any pain medicine.

There is no good reason for us to continually be giving doses that are not enough.

Footnotes:

[1] You Gave Her 20 Milligrams?!!
StreetWatch
Article

[2] Text of J.K. Rowling’s speech
‘The Fringe Benefits of Failure, and the Importance of Imagination’

Harvard Commencement 2008
Harvard Gazette
Text

.

Up in the Air – Suspending Ethical Medical Practice I

In this week of holiday travel and the stress produced by the security theater of the TSA (Transportation Security Administration), it is reasonable to look at the stress that can be produced by medical theater.

An article in the New England Journal of Medicine describes a complication faced by five doctors in dealing with an in-flight cardiac arrest.

After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The five physicians agreed that it was time to stop the code and declare the patient dead. But the flight attendant explained that if we stopped CPR, the airline’s protocol would require the cabin crew to continue it in our stead. “This is futile,” muttered the surgeon, and without discussion, he returned to his seat, leaving four of us facing a dilemma: If we turned the resuscitative efforts over to the crew, who would look after the passengers? But if we continued CPR, we would be treating a patient who had clearly been “overmastered” by his disease.[1]

There are a lot of comments in response to this. Two of the doctors continued CPR (CardioPulmonary Resuscitation), even though there was no good reason to continue CPR at this point.

The pilot announced that he was diverting the plane to a small airport. The crew calmed the passengers, addressed their other needs, and attended to landing preparations. As we descended steeply, the pilot ordered everyone to be seated. The anesthesiologist and oncologist complied. We were down to two physicians administering CPR. A flight attendant took over the use of the Ambu bag and required coaching on technique. I was instructed to hold onto my wife as she continued chest compressions, both of us half-strapped into stretched safety belts to allow us to continue CPR during the landing.[1]

Being transported in a car, a baby held in the arms of the baby’s mother is not considered restrained. The rapid deceleration from even 30 miles per hour is going to dramatically increase the weight of the baby to the point where the mother cannot hold onto the baby. The baby is no longer a baby. The baby is now a projectile.

Now, if a baby travelling at the speed of 30 MPH is too heavy for a mother to restrain, how much more futile will it be to attempt to restrain an adult travelling at several hundred MPH?

Futile CPR x futile attempts at restraint = Futile2?

I have never attempted to perform CPR during the landing of a plane, but I do not expect that it is any more effective than the ineffective CPR performed in a moving ambulance. The doctor and the flight attendant performing ineffective CPR were only endangering the other passengers and themselves. They are not just not restrained, but they are not even in seats that might act to partially restrain them.

Doesn’t the airline have a protocol requiring everyone, including flight attendants, to wear seat belts during take-off and landing?

Why does the ridiculous protocol trump the sensible protocol?

We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline’s protocol. CPR was going to go forward whatever we decided, and we chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing.[1]

How is endangering everyone in the cabin a practical concern?

On solid ground, I believe that medical policy and protocols should preclude such dilemmas. The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient.[1]

What if focusing solely on the good of the patient, in this case a clearly dead patient, endangers others who are not yet patients? The others may end up being patients due to the actions of the physician, or the others may end up so dead that no resuscitation is even attempted on them.

Terminating Resuscitative Efforts in Adult OHCA
Terminating Resuscitative Efforts in a BLS Out-of-Hospital System
Rescuers who start BLS should continue resuscitation until one of the following occurs:

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met.
  • One set of reliable and valid criteria for termination of resuscitation is termed the “BLS termination of resuscitation rule” (see Figure 1).23 All 3 of the following criteria must be present before moving to the ambulance for transport, to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest: (1) arrest was not witnessed by EMS provider or first responder; (2) no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and (3) no AED shocks were delivered.[2]

    During landing, continuation of the resuscitative efforts places others in jeopardy.

    Termination of Resuscitative Efforts and Transport Implications
    Field termination reduces unnecessary transport to the hospital by 60% with the BLS rule and 40% with the ALS rule,25 reducing associated road hazards34,35 that put the provider, patient, and public at risk. In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement.36-38 More importantly the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.39-41
    [2]

    In the absence of an effective restraint system that permits CPR in an airplane during landing, those who do not regain pulses should be pronounced dead.

    The airline should have a protocol that specifically states this. Encouraging passengers or flight crew to endanger others, when CPR has not been effective, is endangering the passengers and the flight crew.

    This is irresponsible behavior by the airline.

    There are a lot of comments. Some provide good approaches to this. Others demonstrate that being a doctor and being sensible do not necessarily go together. I will address the comments in Up in the Air – Suspending Ethical Medical Practice II and later in Up in the Air – Suspending Ethical Medical Practice III

    Footnotes:

    [1] Up in the Air – Suspending Ethical Medical Practice.
    Shaner DM.
    N Engl J Med. 2010 Nov 18;363(21):1988-1989.
    PMID: 21083383 [PubMed – as supplied by publisher]

    Free Full Text Article from N Engl J Med with comments and links to Free Full Text PDF download

    [2] Terminating Resuscitative Efforts in Adult OHCA
    Part 3: Ethics
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Witholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital Cardiac Arrest (OHCA)
    Terminating Resuscitative Efforts in OHCA
    Free Full Text Article with links to Free Full Text PDF download

    .

    Confessions of An EMS Newbie podcast interview with Dr. Bryan Bledsoe

    – 

    For those who disagree with what I wrote in I am not the only one saying EMS education is Broken, go listen to the Confessions of An EMS Newbie podcast interview with Dr. Bryan Bledsoe.

    Dr. Bledsoe is explaining the feedback he received from his publisher on why some people do not want to use his paramedic textbook –

    Bledsoe’s book’s too sophisticated – the reading level’s too high – we don’t need to know that much stuff –

    In other words, we are not trying to use the best textbook. We are dumbing down the curriculum and avoiding the textbooks that require thinking students and thinking educators.

    He is going to paramedic school. I asked him what book he’s using. He said, Not yours . . . The instructor said that your book’s just too hard. I can’t understand that. There’s more detail, but it’s written at an 11th grade reading level.

    Dr. Bledsoe’s book is written at a level so that it can be understood by people who cannot yet graduate from high school. That is considered just too hard?

    How is reading and understanding at the high school student level too hard?

    We should not be asking, How low should our standards be?

    We should be asking, What do our students need to understand to be able to take care of emergency patients safely?

    We are worried about staffing and graduation rates and other nonsense.

    Yes, these are nonsense, when compared with the only thing that matters.

    What is best for the patient?

    This is the future of EMS.

    Dr. Bledsoe points out that one of the problems with textbooks is that they are at least 5 years behind the current research, because of the amount of time involved in textbook writing, review, editing, publishing, and distribution to schools in time for the next semester class. This is EMS education training, we do not use fancy words, like semester. That thinking stuff is for those evil intellectuals.

    If the textbook is expected to take at least 5 years from concept to classroom, then we need to have paramedic schools start demanding better textbooks now – that is if we want to have better textbooks in 5 years.

    The current dismal state of EMS education training is the fault of the paramedic schools.

    The paramedic schools are catering to the lowest common denominator.

    We need to throw these incompetent administrators out of the paramedic schools.

    These incompetent administrators are killing patients by churning out dangerous medics.

    At the end of the podcast, Dr. Bledsoe has some nice things to say about me.

    Thank you, Dr. Bledsoe. I learned a lot of what I know from you, not from people saying that knowing just a little bit is good enough.

    .

    Technology In EMS Part I – TOTWTYTR

    Technology In EMS Part I is a post by TOTWTYTR that is critical of an article on technology. This is not an article that is about technology improving things, but about technology making it so that doctors and administrators experience a delusion of control.

    TOTWTYTR writes –

    Do we routinely need the telepresence of an ED physician in the back of an ambulance? Frankly I doubt it. I’ve been doing this long enough that I remember when paramedics were so new that we had to call in for permission to start an IV. We could intubate (cardiac arrest patients only) on a standing order, but that was about it. Back then we spent a lot of time on scene at many medical calls and spent a lot of time talking to doctors on the radio.

    The irony is that we now realize that the intubation is often not good for patient care, particularly in non-respiratory cardiac arrest. The one thing originally permitted by the doctors on standing orders (intubation) is now a rarity, because it is not what the patient needs. While decreasing intubation of corpses, the addition of high-dose NTG (NiTroGlycerin) and CPAP (Continuous Positive Airway Pressure) to hypertensive CHF standing orders and elimination of furosemide (Lasix) from CHF standing orders means that there is much less need for intubation.

    Rather than just intubating patients, we need to be better assessing them, avoiding harmful treatments (Lasix), and treating them expeditiously, rather than dragging them in front of the camera in the back of the ambulance. One thing an unstable patient does not need is to be hustled into a TV studio.

    Wait, how is my makeup? Dr. Hottie is working and this is my big chance. Do these BDUs make my butt look big?

    This is just technology that will allow absentee medical directors to come up with more creative excuses for neglecting their patients with Mother-May-I protocols.

    Now, if I were an independent duty medic in a remote location, the technology outlined in this article would help a lot.

    Of course, if I am an independent duty medic in a remote location, my patient will not be in the emergency department in front of an emergency physician in less than half an hour, or even in less than an hour. The circumstances are tremendously different.

    We need to teach medical directors to provide competent oversight, not how to find the Horizontal control knob on the TV.

    What happens when the equipment is not working properly?

    How will the patients ever survive?

    White’s idea isn’t new. About five years ago I had a long running email discussion with a man who had developed this type of system and had convinced the Tucson FD to give it a trial. I asked him the same questions I’m posing here, but he had no answers.

    Both TOTWTYTR and I know a medic who moved to Tucson. One of the smartest medics around. Gene moved from Texas, where he only had to contact medical command for permission rarely. Tucson requires that the medics call medical command for permission to urinate between calls. OK. I exaggerate, but not by much.

    We learn what we do.

    When we teach people to call up and paint a picture, we get a variety of responses. Some will paint a picture created to push the medical command physicians buttons, so that the medical command physician will say that the medic can give the orders the medic sees as appropriate for the patient.

    The information presented to the medical command physician is at the discretion of the medic. Just because the medical command physician may have a sheet he needs to fill out with gender, age, vital signs and other occasionally pertinent stuff doesn’t mean that we will give it to him the way he wants it. This is a negotiation. We are negotiating for the patient. He is negotiating for Kindergarten Memorial Hospital.

    Knowing which doctor is providing medical command in which hospitals is also important. Dr. No Narcs is on at KMH, but Dr. Candyman is on at Laissez-Faire Medical Center. If I have a patient with significant pain, I would have to be a sadist to knowingly call Dr. No Narcs. The same would be true, even if I have a reality TV studio in the back of the ambulance.

    And if a medical command physician has not had a good night’s sleep, or is fighting with the spouse (or kids), why should those who call 911 be the ones to suffer?

    One of the things that many places have realized. EMS has a long history of treating patients appropriately on standing orders.

    Medical command permission requirements allows incompetent medics to remain employed longer and harm more patients.

    Medical command permission requirements allows incompetent medics to avoid responsibility for their incompetence.

    How is this a good thing?

    Imagine improving the assessment and critical judgment of EMS providers, rather than substituting technology for quality.

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