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

- Rogue Medic

Zero Tolerance and TSA Wannabes

Picture credit[1]

Does looking at that picture make you just want to surrender and hand the controls of an airliner to a terrorist?

3 inches long.


No moving parts.

Not even a trigger.

But it is a replica gun, so it was banned from a flight, not by the American TSA (Transportation Security Agency), but by the British security people at Gatwick Airport.

It is true that a replica can be used to hijack a plane, but is anyone going to surrender a plane to an attempted terrorist brandishing a miniature replica?

Would it even be possible to brandish a miniature replica gun?


[with object]

wave or flourish (something, especially a weapon) as a threat or in anger or excitement[2]

Perhaps the attempted terrorist could threaten people with the miniature replica, but would the greater threat be from violence or laughter?


When we have people mindlessly enforcing rules just because they are too afraid to think, aren’t these mindless rules gnomes more dangerous than the terrorists they are supposed to be protecting us from?

Mrs Lloyd, 59, who regularly visits Britain to see her mother, said: ‘I took it to the airport still in its wrapping, but they discovered the little gun when it was scanned.

‘It is only about three inches long and there are no moving parts. There isn’t even a trigger.

‘But they wouldn’t let me take it with me. I had it in my hand luggage. I just didn’t think it would cause a problem. They said rules were rules. There was no flexibility or common sense.’[1]

We need to insist that this kind of person, who follows rules without thinking, be prohibited from enforcing any rules.

The stupid may be much more dangerous than the malicious.

She had bought the figure on a visit to the Royal Signals Museum, in Blandford, Dorset.

Museum spokesman Adam Forty said: ‘This is a military museum and takes security very seriously, especially around military installations and airports, but this does seem more than a little excessive. The “firearm” is three inches long and cast out of resin.

‘It’s probably just as well we didn’t sell her a toy tank.’[1]

One odd thing is that this happened a while ago, but coverage just started.

The story appears to have been a long-time in the making.

The National Post of Toronto writes “Ms. Lloyd purchased the figuring during an April, 2009, trip, but the story is making news now because the Royal Signals Museum at Blandford Camp …, where she bought the souvenir, went public with the story after learning about it from Ms. Lloyd this past autumn.[3]

They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety. – Benjamin Franklin

What about those who prohibit responsibility and/or prohibit thinking?

What punishment do they deserve?

What punishment do their willing victims deserve?

Just give us the illusion of safety, but don’t make us think!


[1] Airport bans toy soldier’s three-inch rifle from plane… because it’s a safety threat
Daily Mail
Last updated at 8:54 PM on 27th January 2011

[2] brandish
Oxford Dictionaries

[3] Three-inch toy gun sparks security flap at London Gatwick
By Ben Mutzabaugh
USA Today
Posted Jan 28 2011 9:56AM


Zero Tolerance For Bad Behavior

TJC/JCAHO (The Joint Commission/the Joint Commission for Accrediting Healthcare Organizations) decided that it would expand its influence in hospitals. While the problem they address is real, their solutions are as unrealistic as ever.

According to this study, their results may match their logic – negligible. Or were things that much worse before JCAHO/TJC became involved? It is hard to believe that anything improves with them. Maybe they justify their behavior with the myth that in spite of being a mass murderer, at least Hitler Mussolini made the trains run on time.[1]

The survey comes almost one year after the Joint Commission began requiring health care facilities to implement zero-tolerance policies that define intimidating and disruptive behaviors. The commission also required that facilities establish disciplinary procedures for medical staff and other health care professionals who violate the standards.[2]

What does Zero Tolerance mean?

How little is required to get a doctor’s privileges suspended?

How little is required to get a nurse fired?

Imagine if this were applied to EMS. I know of several medics who might not make it through the week without indulging in all of these misbehaviors. Some agencies do not seem to believe that medics should talk to EMTs at less than 80 decibels, unless they make up for it with gratuitous projectile spittle.

Is there to be a specific decibel level that is measured? There are decibel monitors at some nurses’ stations already. If JCAHO/TJC were to run this, they would probably require a deafening alarm that would be activated above a certain decibel level.

The real reason the hospital is so noisy, is to drown out the sound of all of the alarms going off. If anybody were aware the alarms, they might feel the need to do something about the alarms – such as hit the silence for 2 minutes button.

Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%

Just think of the benefit to those trying to get someone unjustly disciplined or unjustly fired. Now they will have more excuses to document as justification for their misbehavior.

The AMA developed a policy model that calls for distinguishing between good-faith criticisms and actions that truly rise to the level of disruptive behavior, and for implementing fair medical staff review processes.

Paul M. Schyve, MD, senior vice president of the Joint Commission, agreed there are appropriate moments for speaking up. But he said the ACPE survey findings highlight types of behaviors that exceed constructive criticism, and if left unchecked, can inhibit others and ultimately can undermine patient care. “We can’t let the little things slip.”

Don’t worry. We do not intend to have anyone punished for constructive criticism. Just remember that we decide what is constructive – and we are intolerant of anything that might be disruptive.

Will it be considered disruptive to criticize this policy? Clearly, if TJC/JCAHO states that this policy will make things better, then criticizing the policy is an example of exactly what they are trying to stop. As Dr. Schyve let slip –

“We can’t let the little things slip.”

TJC/JCAHO has repeatedly demonstrated that they are all about the little things.

The problem with JCAHO/TJC is that they end up paying more attention to the enforcement, than to the actual problem. They look for rules that will be very sensitive, while ignoring the greater need to be very selective.

Inappropriate joking?

I can’t even mention JCAHO/TJC without the use of inappropriate joking. Of course, I do not see it as inappropriate, but I do not make the rules. Those making inappropriate rules will determine what is appropriate. They might consider this post to be a malicious rumor, as well.

Zero Tolerance should not be tolerated.

If we are going to have any JCAHO/TJC Zero Tolerance policies, the policy should be to ban all of their people from health care facilities. We should not tolerate their counterproductive rules. I really would not want this to be a Zero Tolerance policy, since they are foolish (both the policies and JCAHO/TJC), and because even a blind administrative nut might find something that is not completely squirrelly within all of its plotting.


^ 1 Did Mussolini make the trains run on time?

^ 2 Disruptive behavior by doctors, nurses persists a year after crackdown
A survey of physician and nurse executives raises questions on how to implement zero-tolerance policies required by the Joint Commission.

By Amy Lynn Sorrel, amednews staff.
Posted Nov. 16, 2009.


Zero Tolerance – What Does It Mean?

Zero Tolerance is good. Zero Tolerance keeps people from making mistakes.


Zero Tolerance will keep people from making certain mistakes, because Zero Tolerance will keep people from making decisions.

Maybe we need to prevent the people, who make decisions, from making decisions.


That would suggest that we cannot fill administrative positions with people competent to make decisions.

While there are individual cases of bad decisions, this alternative is much worse.

Foolproof is a fantasy.

I do not believe that it is accurate to conclude that administrators cannot make good decisions. And I am regularly critical of administrators. Rather this is a disturbingly reaction to our fear of bad decisions. Zero Tolerance is an example of a bad decision.

We improve our abilities at important skills by regularly practicing and reviewing the use of those skills.

Can critical judgment be replaced by flow sheets/algorithms/guidelines?

No. Critical judgment can be augmented by flow sheets/algorithms/guidelines, but not replaced – at least not safely.

Read more about a particularly bad example of Zero Tolerance in this post at of mule dung and ash. Zero Tolerance – Unexpected, but welcome ruling.

This administration of this school is as idiotic as the fast food managers who strip search their employees based on prank phone calls from people impersonating police officers. Protecting children from the evils of MotrinTM.

Apparently, 8 of the Supreme Court Justices feel that the Constitution does a better job of protecting children, than a school’s slavish devotion to its Zero Tolerance policy.


Zero Tolerance V – Autopilot Oversight – Sparrowmict comment

sparrowmict left a comment on the post Zero Tolerance I – Basic EMT Oversight of Paramedics. I apologize for taking so long to respond. These are not unimportant points. They get to the heart of what is wrong with a lot of EMS. I just have not felt satisfied with my response:

I am disheartened that my company has also succumbed to the lets record everything rather than take care of the patient. We have fallen onto the capnography bandwagon and unless we have a square waveform in spite of the fact that I just saw the cords as the tube went past them and have chest rise and clear bilateral lung sounds and no epigastric sounds they want me to pull the tube.

First, I think that waveform capnography is the single most important assessment for tube placement. Better than seeing the tube go through the vocal cords, which is probably the single most misleading assessment of tube placement and the most common excuse for an esophageal tube.[1], [2]

Katz and Falk39 evaluated 108 paramedic endotracheal intubation patients arriving at a regional trauma center in Florida. The authors used a systematic physician approach to confirm proper tube placement on ED arrival, including the selected use of direct revisualization. The authors found that more than 25% of the endotracheal tubes were misplaced, two thirds of these in the esophagus. The authors partially attributed the results to noncompliance with out-of-hospital protocols requiring placement confirmation using carbon dioxide detection. Jemmett et al40 conducted a similar study of 109 paramedic endotracheal intubation patients in Maine (an emergency medical services [EMS] system with no carbon dioxide detection protocol) and found a similar tube misplacement rate of 12%. Jones et al41 reported a lower (5.8%) tube misplacement rate for 208 paramedic endotracheal intubation in Indianapolis, but this study occurred in a region serviced primarily by a single EMS agency with close medical oversight.[3]

These are examples of the diversity of medical oversight. I think that the best indicator of medical director oversight may be the intubation success rate. No competent medical director should tolerate low success rate, but many do. Some medical directors do not even know what the success rates of their paramedics is.

Here is a different approach. these medics were excellent at intubation before they used capnography. After capnography, they were even better. After capnography the only esophageal tube was due to the medic ignoring capnography

Prior to 1990, tube placement was confirmed by visualization of the tube passing through the vocal cords and auscultation of the chest, axilla, and abdomen. Confirmation of tube placement after 1990 was assisted with portable mainstream capnography . . . .

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since this addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[4]

Second, I think that waveform capnography may be the most important tool that is available in EMS. 12 lead ECG is the main competition. Since they tend to come together in the same machine – the monitor/defibrillator/cardioverter/pacer/12-lead/waveform capnography/pulse oximetry/non-invasive blood pressure/et cetera – I am very fond of the combination monitor/automated paramedic. I do not believe that it should be used as an autopilot for EMS.

As much as I like waveform capnography, it is still only one part of the assessment of the airway. To have one assessment automatically superior to all others demonstrates a lack of understanding of airway management.

So much of what we do has to do with keeping an electronic record of what we did rather then what we do to help the patient.

There are people who believe that the most important thing that can be done is to remove the human from important decisions. If humans are fallible, and we all are, then no human decision can be perfect.

Since humans are imperfect, we must eliminate that imperfection from important decisions.

What they do not realize is that computers are incapable of recognizing the difference between valid data and data errors. For example, if a person is being ventilated with good chest rise, equal lung sounds, no belly sounds, and improving skin signs – increasingly pink, warm, and dry; moving away from cyanotic, cool, and moist – then that is a good thing. Even if the data from the capnography is telling a different story.

The capnography sensor can malfunction, especially if the patient has vomited and some of that vomit is in the tube. The connector might not be tightened properly. The sensor might not even be between the tube and the bag. The tubing from the sensor to the monitor may be kinked, preventing sampling of the exhaled gasses. There are many possible failures. Some will have a malfunction warning, but some will just indicate no CO2.

While some of these are operator errors, some are only malfunctions that can be corrected by a human operator. Proper application and interpretation of the information requires an intelligent human operator.

How can a human operator be responsible for application of the device (both the endotracheal tube and the waveform capnography sensor), yet not be allowed to override the cases of equipment malfunction. Even if the malfunction is due to misapplication of the equipment, the trained operator should be able to recognize that there is a problem of bad data.

To prevent the human operator from making these decisions, as your QA/QI/CYA department appears to, is the worst decision QA/QI/CYA could have made. It is great that they have chosen to use waveform capnography. That is an important and very smart decision. That is a decision made by a human, or a group of humans. It is not great that they decided to try to prevent, as much as possible, decision making by the humans trained in airway management.

We no longer have OLMC requirements but that was because none of the hospitals wanted to be saddled with it and our own Medical Director you see when you start our academy then never again.

EMS by autopilot does not work.

High quality EMS depends on well trained providers who care about their patients.

You might get so see one of his cronies when they choose to yell at you and suspend your clinical privileges because you didn’t get the capnography on within 60 seconds. Our protocols are 1.5 inches thick and have 126 sections and 26 pages alone just for a destination protocol. And don’t even get me started on the hospital divert system or the Level 2 trauma rotation that the State cooked up.

If George Orwell[5] were to write a book about an EMS dystopia, he might write about this kind of lack of oversight. EMS should never be the occupation for unthinking and uncaring people.

One last thing, our new incoming Medical Director (who I had high hopes for because he started out as a medic) has decided that because we do not carry LP12’s on our bike team that we can no longer intubate because we cannot capture that magic waveform for the reports that QI generates.

One of the most important decisions a medic can make is – should I intubate this patient?

That is a decision that may change during the treatment of the patient. Maybe the patient is not responding to treatment. Maybe the patient responds so well to treatment, that the decision to intubate is changed. The waveform capnography cannot make that decision.

One of the big problems with RSI (Rapid Sequence Induction/Intubation) is that some places seem to be making this decision to intubate far too often, just because they can. RSI, as with helicopter transport, is something that can be abused by overuse. That is not something that waveform capnography will recognize.

We do have a lot of nifty toys, but it seems that we are taking steps further backward. Yes we can import all of the data from the LP12 better remember to event scroll push everything you do. 12 lead ECG, but have to transmit all of them to the hospitals (BOY DID PHYSIO CONTROL MAKE A FORTUNE OFF OF THIS DEAL) I still have yet to figure out how they got our medical director to say that we cannot use any other electrodes then Physio control brand.

We all have our biases. Biases that allow us to believe that what we are doing is not bad. Hanlon’s Razor is possibly a much more powerful force than any evil –

Never attribute to malice that which can be adequately explained by stupidity.[6]

Maybe they offered him a pen.[7], [8]

I have talked to, and written to, many doctors who care very much about EMS. Some just do not get it. They believe that certain things prevent paramedics from being allowed to make decisions. They just do not understand EMS. Some of these doctors are smart enough that eventually they will realize that there are better ways to provide emergency patient care. Some will never learn. Some already do understand and spend a tremendous amount of time trying to get others to understand.

Unfortunately, there will probably always be a place for the medical director, who feels comfortable being told what to do by a CEO, a hospital administrator, or a fire chief. Some of them justify this by saying, If I don’t do it, then they will get somebody worse. That is so dangerous, it deserves a post of its own. Too bad that attitude is not uncommon.

I also agree that the National Registry has not helped advance us in any way, so far it just seems to be a method that the state uses to not have to come up with testing or recertification requirements of their own and we still have to pay both the state and the NR license fees.

The NR is the embodiment of what your medical director is doing.

Eliminate the human from the equation, since humans are fallible.

Here is an example of a medical director, who does understand EMS oversight.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.[9]

Their success rate?

Trauma patients – 1,110 patients – 94.1% successful endotracheal tubes.

Nontrauma patients – 547 – 98.3% successful endotracheal tubes.

Total patients (trauma and nontrauma combined) – 1,657 patients – 95.5% successful endotracheal tubes. The rest managed by alternative airways, except as indicted in the first quote. Footnote [4] and Footnote [9].

I know the complaints that most people will come up with. We can’t afford that. That’s too expensive. Our people are that good without all of that practice.

Never attribute to malice that which can be adequately explained by stupidity.

These are examples of stupidity. As TOTWTYTR likes to point out – There is no cure for stupid.

Any discussion of airway management is incomplete without Kelly Grayson’s article on how to think about airway management.[10]

Some other writing on these topics. If you want to read more of my ranting, and Yes ranting is appropriate for the topic:

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

Prehospital Advanced Airway – Should Paramedics Be Intubating?

Waveform Capnography vs. Hubris.

RSI, Risk Management, and Rocket Science


^ 1 Waveform Capnography vs. Hubris
Rogue Medic

^ 2 Prehospital Advanced Airway – Should Paramedics Be Intubating?
Rogue Medic
This is commenting on an EMS Garage segment and has 2 follow-up posts.

^ 3 Out-of-hospital endotracheal intubation: where are we?
Wang HE, Yealy DM.
Ann Emerg Med. 2006 Jun;47(6):532-41. Epub 2006 Feb 28.
PMID: 16713780 [PubMed – indexed for MEDLINE]

^ 4 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

^ 5 George Orwell

^ 6 Hanlon’s Razor

^ 7 Medtronic unwraps gifts. But some say vendor’s role not clearly defined.
Rhea S.
Mod Healthc. 2008 Sep 15;38(37):8-9. No abstract available.
PMID: 18810822 [PubMed – indexed for MEDLINE]

Other industry watchers expressed greater skepticism, saying Medtronic’s disclosure highlights the still deeply entrenched practice of vendors gifting to bolster their sales influence. “Their gifting follows areas of their financial interests,” said David Rothman, president of the Institute on Medicine as a Profession.

^ 8 A great gesture on the part of pharmaceutical companies indeed…
The Pump Handle

^ 9 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]
This is the same as Footnote [4].

^ 10 The Airway Continuum
Kelly Grayson

^ 39 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]

^ 40 Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.
Jemmett ME, Kendal KM, Fourre MW, Burton JH.
Acad Emerg Med. 2003 Sep;10(9):961-5.
PMID: 12957980 [PubMed – indexed for MEDLINE]

^ 41 Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.
Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ.
Acad Emerg Med. 2004 Jun;11(6):707-9.
PMID: 15175215 [PubMed – indexed for MEDLINE]


Zero Tolerance III – Star of Life Law second comment

In the comments to Zero Tolerance II – Star of Life Law comment, there is another comment from Star of Life Law:

I just returned from a weekend fishing trip, so I am only now catching this post.

It is good to get away from everything for a while.

By “strict adherence to the protocols” I was intending that to refer to the strict adherence of the protocols for the administration of controlled drugs. In re-reading my comment, I did not effectively make that clear.

I see differentiating, between controlled substances and the rest of the medications we carry, as only a political difference. I do not see politics as something that should affect patient care. I do realize that politics will always influence patient care, but that does not make it right. We should behave responsibly in the use of all of the medications we carry.

Furosemide is not a safer drug than fentanyl. We need to stop acting as if controlled substances are any more dangerous than any other medications. Controlled substances are actually very safe – unless put in the hands of dangerous medics, but then everything else is safe – unless put in the hands of dangerous medics.

Is the purpose of the protocol to protect the patient or to protect the organization? At some point you have to chose one over the other, because these are incompatible goals.

I respectfully disagree with this statement. I believe that both can be done. Protocols are often being revised to reflect advances in patient care, and/or to provide medics with increasingly advanced tools. This both improves patient care and protects the organization by ensuring that they are adhering to the emerging standards for patient care.

Further, protocols protect the organization by complying with the requirements set forth by the State EMS Regulatory Agency.

And that is just one place where the protection of the patient disappears. The organization that is protecting itself is the State EMS Regulatory Agency. They are the ones causing the incompatibility between protocols and protecting the patient.

Your medical director has no clue about EMS pain management.

I think my system’s medical director does the best job he can considering the available resources and the economic and political realities he faces. I have no doubts about his commitment to our mission and his commitment to patient care.

Additionally, I should have mentioned that even if my medical director wanted to allow the administration of pain meds without OLMC orders, he is prohibited by SC State Law from doing so.

The SC State EMS Formulary lists 5 drugs that REQUIRE OLMC orders: Diazepam, Fentanyl, Midazolam, Morphine Sulfate, and Nalbuphine.[1]

So in my State, this is not a Medical Director problem, it is a requirement of the State EMS Regulatory Agency.

I apologize for the comment about your medical director. Your state medical director has no clue about EMS pain management. This is a state medical director/agency failure.

For example,

Lorazepam MAY BE initiated by Standing Order or Protocol. It is RECOMMENDED – where feasible – that On-Line Medical Control be obtained prior to initiation – but this should not supercede the appropriate care of the patient[2]

Diazepam, lorazepam, and midazolam do not require OLMC for the initial dose. They are schedule IV.

For the opioids, there appears to be no possibility of a standing order.

This Schedule CII Controlled Substance may be administered:

In other words, this OLMC requirement should supercede the appropriate care of the patient, they just dropped that wording. This wording probably does not give the impression they were looking for, but the wording does rephrase what they wrote about schedule IV medications. This approach to pharmacology only seems to reinforce my earlier statement – Is the purpose of the protocol to protect the patient or to protect the organization? At some point you have to chose one over the other, because these are incompatible goals.

RSI (Rapid Sequence Induction/Intubation) is a standing order, but no amount of opioid is permitted without OLMC permission. I couldn’t find any disrupted communication provision. It appears that those patients in areas with bad communications just have to suffer, until a doctor can be reached, assuming the doctor gives permission.

How can medics competent to perform RSI, not be competent to give opioids on standing orders?

How can medics not competent to give opioids on standing orders, be competent to perform RSI?

Nalbuphine (Nubain) is not a good drug for EMS. There are a bunch of mixed agonist/antagonist opioids available. These mixed agonist/antagonist drugs do not appear to be of benefit in the EMS setting. At least not of benefit to the patient.

Nalbuphine hydrochloride may produce the same degree of respiratory depression as equianalgesic doses of morphine. However, nalbuphine hydrochloride exhibits a ceiling effect such that increases in dose greater than 30 mg do not produce further respiratory depression in the absence of other CNS active medications affecting respiration.[4]

an equianalgesic doses of morphine?

Nalbuphine hydrochloride is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis.[4]

And yet, the initial dosing of nalbuphine is 5 to 10 mg, while morphine is 2 to 5 mg[5].

Then there is the whole concept of there being any one dose that leads to respiratory depression. A person with severe pain, but pain that is very responsive to morphine, may have respiratory depression at less than 20 mg of morphine. While another person with severe, but pain not very responsive to morphine, may not have respiratory depression until well over 100 mg of morphine.

When people tell me a dose and the effect that it will have on the patient, I distrust their grasp of pharmacology. Pharmacology requires some kind of context, at least if you believe that the dose makes the poison.[6] Paracelsus was not just referring to numbers.

And you have a protocol for flumazenil. If only I had just written a post on the subject of flumazenil.[7]

It appears that I shouldn’t rush out to the get mail, to see if I will be invited to speak at the next SC EMS convention.

Is this situation ideal? No. Is it “placebo oversight?” Likely. But then again, we haven’t exactly been great stewards of the responsibility we seek. Somewhere along the way we lost the trust that we could independently handle these drugs responsibly or appropriately. Thus, the hoops are set into place.

I don’t think that I would use the word ideal.

Who did what, in South Carolina, to lead to the removal of appropriate protocols for the use of controlled substances? Did this removal of the existing standing orders have to do with bad medical oversight, or was it something out of the control of the medical director? Was the medical director not noticing signs of abuse by one medic? So all EMS patients are punished? Was the medical director not picking up on signs of diversion?

I agree with you that we need more training in EMS. I think that, at a minimum, Paramedic should be an Associate Level Degree, and fully believe that a Bachelor Level Paramedic Degree could be established on par with BS RN’s. Further I would love to see a Paramedic to PA bridge program. But those are topics for another day, over good beer.

You are mistaking time in the classroom for understanding. Our EMS education system is broken. We need to eliminate organizations, such as the National Registry, that encourage teaching to the test. EMS education needs to be overhauled before we start requiring more-of-the-same as the solution. Our biggest problem is not time in the classroom.

I would say that we have 2 equally big problems – the quality of instruction in the classroom and the pressure to churn out graduates. Even good instructors can be significantly handicapped by the teach to the test curriculum. The administrations that focus on numbers destroy quality, too.

We have too many paramedics, but we do not have enough good paramedics

At the BS level in an EMS program, do you lose the ability to use instructors who do not have a BS?

As for your suggestion of having a debate over good beer, I cannot find anything to dispute in that suggestion. 😉


^ 1 SC EMS Formulary
Free PDF

^ 2 SC EMS Formulary
Page 53 in pdf counter (page numbers match the pdf counter).
Free PDF

^ 3 SC EMS Formulary
Page 37 in pdf counter.
Free PDF

^ 4 nalbuphine hydrochloride (Nalbuphine Hydrochloride) injection, solution
[Hospira, Inc.]

FDA label
Free PDF – automatic download . . . html from DailyMed

^ 5 SC EMS Formulary
Pages 58 and 60 in pdf counter.
Free PDF

^ 6 Paracelsus

^ 7 Flumazenil and EMS – A Box Pandora Should Not Open
What I coincidentally wrote about flumazenil a few weeks ago.



Zero Tolerance II – Star of Life Law comment

In the comments to Zero Tolerance I – Basic EMT Oversight of Paramedics, Star of Life Law wrote:

RM: First off, I read all of the OLMC (On Line Medical Command requirements for permission to treat patients) posts you referenced. Looks like I hit a nerve! Ok, so here we go.

This is not the first time I have been told, I’ve got some nerve.

I think we are on the same page that patient care is-or should be-the top organizational priority. (Note that I said organizational here, I think for the majority of street medics this already is the top priority).

I agree.

My first point was directed to my view that management is likely most concerned about the potential liability stemming from protocol violations.

While a protocol violation may produce better care in some situations, that is likely secondary to management’s desire to maintain strict adherence to the protocols.

strict adherence?

No. No. No. No. No.


My blog is not yet 2 years old, but you have me acting like a 2 year old.


Do your patients exhibit strict adherence to the protocol presentations?

When the patients decide to read the text book protocol before calling 911, then strict adherence might be a goal. Maybe.

But they don’t.

In that case, how should we prepare paramedics to deal with such uncooperative and selfish people. To think that their emergency might be more important than strict adherence to the protocols. We should sue them for malpractice of emergency presentation. Don’t they know that it is their duty to present to us as if they are ideal NR (National Registry of EMTs) stimulus/response scenarios?

Is the purpose of the protocol to protect the patient or to protect the organization? At some point you have to chose one over the other, because these are incompatible goals.

Why should good patient care involve a protocol violation? Ambulance Driver writes a must read article[1] about the way a protocol should be written. I could quote extensively from this article, but I already write too much. Go read the article. He states it better than I could.

the best legal defense is to provide the best care for the patient.

Indeed. It’s hard for a plaintiff to ‘back up the money truck’ when you can demonstrate you were doing everything possible to help them and improve their condition.

I don’t like the term doing everything possible. It suggests that doing something is better than not doing something. Assessment is doing something, but it is not perceived as doing something by too many people. Reassessment is repeating that essential skill, but again it is perceived as inaction.

The most important paramedic skill is assessment.

The same is true for basic EMTs, nurse, doctors, and anyone else who provides patient care. Not obedience. Not strict adherence to the protocols. Assessment.

Without a competent assessment, how do you know what protocol to adhere to?

Without a competent assessment, how do you know what protocol to deviate from?

The requirement that medics seek OLMC approval prior to administering pain meds is a topic worthy of debate. In my system Morphine is all we carry for pain control, and it is OLMC controlled. I must obtain OLMC approval prior to administering Morphine.

Let me phrase this gently. You medical director has no clue about EMS pain management.

How does this provide any protection for patients?

Why do patients need protection from pain relief?

How is delaying treatment good for the patient?

How is having to get permission each and every time anything other than a ritual?

This is not patient care. This is just paying tribute. Any medical director who demands this tribute does not deserve any tribute.

Do we need Catch-22 medicine?

Is this medicine or feudalism?

I haven’t been denied orders for Morphine when I have expressed my patient’s need through a thorough assessment report. But that batting average certainly won’t last given the variables involved.

In other words, you are stating that you expect this requirement for OLMC permission will lead to an inappropriate denial of treatment for some of your future patients?

How is that worth defending?

How is it ethical to defend that, while claiming to be trying to provide good patient care?

And morphine is the wrong drug for prehospital pain management. Just put “fentanyl” in the search box in the upper left hand corner of the page. Search and start reading from the bottom. Or for just a couple of articles of mine, these footnotes are a good start.[2], [3], [4] Fentanyl is much safer than morphine.

In the hands of poorly trained people . . . Well, does it matter what poorly trained people use? Everything is dangerous in the wrong hands.

Would I like the ability to administer pain meds sua sponte? (grabbed the Latin bug from one of your OLMC posts) Sure.

The problem is that OLMC requirements allow the medical directors to feel that it is safe to put incompetent medics on the street. OLMC requirements are dangerous.

Requiring medics to call for permission to give pain medicine is just a way for the medical command physician, whichever one answers the phone, to deny appropriate treatment.

From this and your other OLMC posts, I sense an adversarial vibe towards the OLMC docs, which may indeed be the case in your system. My system has its moments too.

My adversarial vibe is toward medical command doctors who inappropriately deny pain relief to patients. There are all sorts of childish excuses given, but this puerile behavior does nothing to help the patient. Or do you think that there is some benefit to the patient from this grin-and-bear-it approach. You’ve got another hand. Stop crying like a baby.

If the medic OLMC relationship is that adversarial it is sad. The medic and OLMC should be on the same team and working toward the same goal-giving the patient the best available care.

OLMC requirements only encourage an adversarial relationship. OLMC requirements do nothing to help provide the patient with the best available care.

Contacting medical command seems to be more about manipulating the doctor to get the orders that are appropriate for the patient. How is that good for patient care or for cooperation between medics and doctors?

There is a lot to be said for pre-hospital pain control.

I agree. I have written a lot on the subject.

But here is another unintended side effect of requiring OLMC approval for pain meds: It makes medics ‘reluctant’ to administer the meds.

That is something I have not written about. It does happen. It is a big problem in some places.

The extra paperwork is another problem.

Patients that would likely benefit from pre-hospital pain control don’t get it because the medic is scared of the ‘controlled’ drug or is afraid of being denied and/or ridiculed by OLMC for thinking *this* patient needed it. So they don’t even bother calling OLMC for orders.

One of the best things that could be done to improve EMS education might be to rotate people through burn units and other places where very large doses of opioids are given. Allow the students to see aggressive pain management. Aggressive pain management by those who do it regularly. Aggressive pain management by those who do it well. EMS providers need to learn to asses the effects of opioids properly.

Is that best for our patients? Certainly not.

Avoiding care for no good reason is not good for patients.

Between the extremes of total OLMC control and Medic free reign likely lies the happy medium that is best for our patients.

You misunderstand the problem. OLMC requirements are not a valid form of medical oversight. We need more aggressive medical oversight, not Medic free reign. OLMC requirements are just a pathetic sham. OLMC requirements are placebo oversight.

We need medical directors who know what they are doing. Medical directors who like to play mother-may-I have no idea if their medics know what they are doing, so OLMC requirements seem reasonable to them.

The first step might be removing OLMC requirements.

This would require a well compensated medical director with appropriate support staff.

The medical director needs to have the authority to have the final say on all patient care issues. Not a fire chief. Not a CEO. No other non-medical person should have a say on patient care issues.

There needs to be enough ride time prior to being allowed to work without direct supervision. EMS is working without direct supervision.

EMS should not just be a sub-specialty of the medical specialty Emergency Medicine. There are tremendous differences between the two. EMS should be a separate specialty for doctors. There is probably more similarity between Internal Medicine and Emergency Medicine, than there is between Emergency Medicine and EMS. We have more and more paramedics becoming doctors, so I expect that this will happen eventually. In the mean time, making EMS a sub-specialty of Emergency Medicine is the least we should demand.

We need a better understanding of EBM (Evidence Based Medicine). This is improving, but there is always that obstructionist who makes ridiculous claims, such as parachutes had no placebo controls, so EBM cannot be applied to medicine. This is bad logic, but a topic for another post. Protocols are the ideal place to apply EBM. Just not in restrictive protocols.

Restrictive protocols and OLMC requirements are just substitutes for medical oversight.

There is no substitute for medical oversight.


^ 1 The Two Most Important Words in an EMS Protocol
The Ambulance Driver’s Perspective
by Kelly Grayson

^ 2 Pain Management – What is too much?

^ 3 Public Perception of Pain Management

^ 4 How EMS “Manages” Pain


Zero Tolerance I – Basic EMT Oversight of Paramedics

Imagine a world where an organization that is not really interested in providing EMS has been put in charge of EMS. How would patient care concerns be handled in an organization that having engaged in a hostile takeover of the local ambulance drivers, finds it is now responsible for supervising patient care. Not that this would ever happen, because the public is too sensible to fall for this.

This would be like Walmart taking over hospitals in the area, because they already have much of what a hospital uses and they have an excellent supply network to get everything else (and at a lower price). But this is EMS, so if your branch of government is faced with downsizing, you might as well take over the unimportant but staffing friendly job that is EMS. What could go wrong?

Well, how would we arrange supervision, so that the best care is delivered to the patient? It is a patient care business, so the existing medical personnel, in the organization taking over, would handle that. That is if there were any medical personnel in the corporate raider’s non-medical supervisory structure. Here is a story from just such a corporate raider situation. Of course, this is not a real story, because no corporate raider would ever have the hubris to do this.

Imagine 2 different protocol violations. The protocol is below.[1] How would you handle the discipline on these two instances of protocol violation?

One violation is by a medic giving morphine for back pain without medical command permission. The protocol has no provision for treating back pain without at least attempting medical command contact. MVC (Motor Vehicle Collision) with a chronic pain patient already receiving pain medication. Medic does not call for orders. Medic gives everyone at the ED a bunch of attitude. Medic is suspended.

The second violation is by a different medic. A patient with an obvious humerus fracture. Pain is 10/10. If you look at the protocol, they do not allow treatment if the GCS (Glasgow Coma Score) is less than 15. I do not believe that you can have true 10/10 pain and be fully oriented, but that is a different post. The medic initiates treatment with 5 mg morphine slow IVP (IntraVenous Push). The protocol states that dosing is to be 2 mg to 4 mg at a time. The pain is still 10/10. The medic repeats the dose of 5 mg morphine slow IVP. Pain is now 7/10. Atta boy!

This is what EMS is about. We are supposed to make a difference. This is good treatment. This treatment did slightly exceed the dosing guidelines in the protocol. I have started out with 10 mg morphine on several patients – slow IVP initial dose. I have repeated the dose of 10 mg morphine later in the same patients. This is not bad care. We are supposed to adjust treatment to the patient.

The second medic arrives at the ED (Emergency Department) with the much improved patient, realizes that the protocol called for 4 mg, 4 mg, and 2 mg as the acceptable way of treating the patient. Perhaps 3 1/3 mg, 3 1/3 mg, and 3 1/3 mg. The medic notifies the doctor. The doctor, recognizes that the protocol violation is not a significant one and begins treating the patient’s 7/10 pain with dilaudid, which is much stronger than morphine.

In the first case, the medic gave the doctor a hard time about the medic’s violation of protocol.

In the second case, the medic started out by pointing out the protocol violation. Not a willful violation, just a mistake of dosing when dealing with a patient in severe pain. Not even close to an unreasonable dose of morphine, so there is no significant danger to the patient.

The second medic notified all of the appropriate people in the NEMSO (short for – NEMSOTCPEMSBOAAA, which is short for – Non-EMS Organization That Coincidentally Provides EMS, But Only As An Afterthought) and writes an incident report. The brass feel that informal counseling is all that is needed. The Executive Grand Supervising IHMITTDTDWABOM (I Have More Important Things To Do Than Deal With A Bunch Of Medics) looks at the paperwork and decides that there is no difference between these protocol violations. The Executive Grand Supervising IHMITTDTDWABOM decides that the punishment should be the same as for the completely outside of protocol treatment.

The Supervising IHMITTDTDWABOM, Grand Supervising IHMITTDTDWABOM and Medical Director all disagree with the Executive Grand Supervising IHMITTDTDWABOM. They make it clear that they disagree. They are overruled. Now this Executive Grand Supervising IHMITTDTDWABOM is not a Paramedic, not a Nurse, not a Physician Assistant, and not a Doctor. There are so many things that this Executive Grand Supervising IHMITTDTDWABOM is not, that I could go on for days. That does not stop him from overruling the medical director on patient care issues.

What describes dangerous better? Some novice completely untrained person telling experts that he knows better. Does he offer proof to support his contrary to medical advice decision? No.

He knows better than everyone trained in the field, because that is the way the chain of command works. If that know-it-all Medical Director doesn’t keep his nose out of corporate raider business, the Medical Director can find work elsewhere. After all, Medical Directors are a dime a dozen.

Are these protocol violations the same?

Both are cases of medical treatment of pain with morphine.

Let us assume that the Executive Grand Supervising IHMITTDTDWABOM responds to a magnesium fire. You know those retina burning, hard to recognize fires. If the Executive Grand Supervising IHMITTDTDWABOM decides it is a fire and should be treated just like any other fire, that would be bad. If the Executive Grand Supervising IHMITTDTDWABOM does not see the difference between these fires, he is applying the same lack of understanding that he is applying in making medical decisions. Not that this has anything to do with Fire Departments as corporate raiders. That would be silly.

The discipline that seems most needed here is suspension, at the least. Not suspension for the medic, but suspension for the Executive Grand Supervising IHMITTDTDWABOM making ALS (Advanced Life Support) medical decisions without any training or understanding of his complete inability to be competent in this are.

Performance Indicators:

Pain Scale Before and After Treatment?

Great Job!

Vital Signs Before and After Treatment?

Great Job!

Patient Mental Status?

Great Job!

Response to Treatment?

Great Job!

Patient Disposition?

Great Job!

This is performance that should be punished?

Anyway, here is the protocol. Please let me know what you think in the comments.

^ 1 Pain Management:

Examples Include:
Suspected kidney stones
Sickle cell crisis
Isolated extremity trauma

Initial treatment is according to relevant protocol

Pain >5 on a 0 to 10 scale?

Blood pressure > 100 mmHg systolic with no evidence of inadequate perfusion?

Glasgow Coma Score = 15?

Isolated extremity trauma?

2-4 mg Morphine IV/IM every 5 minutes (Do not give more than 10 mg without medical command permission)

Contact Medical Command

Pediatric Patients (<5 years old):
Morphine 0.1 mg/kg IV/IM (May repeat one time only)
(Do not give more than the adult dose without medical command permission)

Performance Indicators:

Pain Scale Before and After Treatment
Vital Signs Before and After Treatment
Patient Mental Status
Response to Treatment
Patient Disposition


Zero Tolerance I

Of Mule Dung and Ash writes a couple of posts about zero tolerance laws. Zero Tolerance as a Product of the War on Drugs and Zero Tolerance Gone Wild. He makes some excellent points about the problems with these laws. Even if you agree with the drug laws, these zero tolerance policies only encourage incompetence.

Nice and simple is what they promise.

Mean and stupid is what they deliver.

How do we differentiate among degrees of guilt, if we prohibit discrimination among degrees of guilt? We have made it impossible.

We have degree of guilt with murder, so why not possession of medication – a legal drug. In his first example, the evil drug is ibuprofen. That is sold under the brand names Advil and Motrin. The student involved is a 13 year old girl. What idiot would deprive a female, old enough to menstruate, of effective medication? Is this an old Superman plot of the evil archvillain, Lex Luthor? Is this an attempt to get lazy men to work, by driving them out of the home? Is this a kinder gentler form of genital mutilation?

No, this appears to be some adult virgin male demonstrating why he is still a virgin. If he is not a virgin, it is only because he has raped someone.

While I will probably never write The Rogue Medic Guide to Being a Lady’s Man, I do know enough to never get between a woman and her ibuprofen, her chocolate, and her muscle relaxant. If you did not know about the muscle relaxant, consider the meaning of the ominous word that follows menstrual. It is CRAMPS.

You do not have to be a rocket scientist, brain surgeon, gynecologist to see the connection.

This idiot has tried to break up the Holy Trinity of inter-gender relations. And for you lesbians out there, he hasn’t been doing you any favors, either.

Men and lesbians. To your battle stations. The future of the world is at stake. Hold on. Let’s not leave out the straight women, they benefit from these wonder drugs almost as much as lesbians do. Everybody, that is everybody except this obscene twerp. To your battle stations.

OK, perhaps a bit over the top. BTW, massage can be used to make it a Holy Quartet (which does not make it a string quartet).

One quote, Sullum further says that “Sometimes it’s hard to tell the difference between drug warriors and child molesters.”

I’m a bit more liberal than most in drug policy. I do not see a reason to differentiate between drug warriors and child molesters, but for those of you who might, this is somebody way out of control. Why is the person out of control?

I was just following orders.

Isn’t that what zero tolerance boils down to?

I don’t think. I just follow orders.

Oh boy. I forgot the most important parts. Not only did she not have any of this dangerous drug (ibuprofen) on her, they strip searched this 13 year old to prove it. If I were her father, I would probably be in prison right now.