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

- Rogue Medic

Flipping the Patient the Bird

There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.


Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.


Furosemide and Drug Shortages 2

Also posted over at Paramedicine 101, which is now at EMS Blogs. Go check out the excellent material there.

I will keep pointing out the problems with furosemide (Lasix) and the evidence against it. Let’s ignore the problems with giving furosemide to patients who actually have CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Can medics correctly identify CHF/ADHF?

The EHS ePCR database identified paramedic reports in which furosemide was administered. As furosemide only appears in the CHF/pulmonary edema protocol, paramedic differential diagnosis of this was assumed by furosemide administration. Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard. Other data points collected included: demographic information; EHS treatment administered; treatment administered in the ED; adverse events and patient disposition.[1]

They do not describe their method of selecting the charts.

Was it completely random?

Was it sequential?

How did they select their sample?

There were three objectives of this study. The first was to determine agreement between paramedic administration of furosemide with EP diagnosis of CHF. The second was to examine differences in interventions administered by paramedics and in the ED by EP diagnosis of CHF. The third objective was to identify any adverse events that occurred during patient care.[1]

How much agreement on CHF/ADHF diagnoses?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question, as it appears CHF may have been in the differential diagnosis for many patients not ultimately diagnosed with CHF. Secondary diagnoses were not sought out and included. Therefore, paramedic accuracy reported in this study may be falsely low, if CHF was part of the EP secondary diagnoses. It should also be noted that there were two patients with a diagnosis of “shortness of breath not yet diagnosed.” It is possible that these patients did indeed have CHF, but were not diagnosed until a later time during hospital care. This needs to be considered when determining paramedic diagnostic accuracy.[1]

OK. For some reason, the emergency physicians gave furosemide to 21% of the patients they diagnosed with something other than CHF/ADHF. That may be explained by the CHF/ADHF being a secondary diagnosis.

This is something that should have been included in the study. What was being treated and for what reason. From the way they describe their data, they had the actual ED physician chart, not just a diagnosis. This is something they should include in a follow-up study, especially with a larger sample size.

Since two of the patients had the diagnosis shortness of breath not yet diagnosed I will move them to the CHF/ADHF side of the graph. After all, most of the patients were diagnosed with CHF/ADHF.

That looks so much better.

On the other hand, there are problems with the way they conclude that some patients do not have CHF/ADHF. How much higher would things be if secondary diagnoses were included?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question[1]

What does NTG (NiTroGlycerin) have to do with ACS (Acute Coronary Syndrome), when examining CHF/ADHF treatment?

NTG is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be studied.

NTG is not just for chest pain.

Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard.[1]

Maybe. Maybe not. And don’t get me started on Gold Standards.

ED mortality was higher in patients with an alternate diagnosis than those diagnosed with CHF by the EP (2/60 vs. 6/34, p=0.017). As documented on ED charts, eight patients in this sample suffered adverse events other than death. These adverse events were: hypotension (n =3), heart rate problem (n =3), electrolyte imbalance (n =1), and respiratory effort decline (n = 1). All of the patients who suffered adverse events were diagnosed with CHF by the EP. Adverse events were not associated with the amount of nitroglycerin, morphine or furosemide administered.[1]

Adverse events in the ED were documented as occurring as often as death in the ED. Almost all of the deaths were in the group not diagnosed with CHF/ADHF, but all of the adverse events occurred in the group diagnosed with CHF/ADHF.

Of the six patients with an alternate diagnosis who had an outcome of death, three were diagnosed with pneumonia. Eight adverse events other than death were identified in this sample. Interestingly, all these patients were correctly identified as having CHF, which contradicts previous research which has found adverse events were more likely in patients incorrectly treated for CHF by paramedics.11,12 This indicates that furosemide should be administered with caution, even in cases where diagnosis of CHF is correct.[1]

Where is the evidence that furosemide should be administered, even if the diagnosis of CHF/ADHF is correct?

What would we want to know?

Did the patients have peripheral edema when given furosemide by EMS. Even with peripheral edema, furosemide is far from the first line drug, but without peripheral edema, it is not going to do anything good.

These patients need the best treatment possible, not the most persistent hold out from the Dark Ages.

We have known that CHF/ADHF is not primarily a fluid overload problem since the 1980s.

Why is EMS still using furosemide?

Is there any problem with a shortage of furosemide?

Not at all, but this isn’t the study to prove it.

I hope the authors use what they learned from this to design a definitive study of the prehospital use of furosemide.

Updated 02-07-11 to correct the uselessness of the original charts I made for this post.

More details are in Corrections of Misleading Charts.


[1] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF


Chest Pain Refusals

Further thoughts on EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights.

How do we determine what is low risk chest pain?

One of the most common judgment calls in the emergency department (ED) is also one of the thorniest: deciding whether to send home a patient who is complaining of chest pain but is highly unlikely to have heart disease. The person is an adult younger than 40 years and with no family history of cardiac problems, and both the ECG and blood test results for troponin are clear.[1]

Under 40? How old was the patient in the article referenced by Ckemtp?

I didn’t see an age.

The article I quoted above, cites this position statement (below) from the AHA. You know the American Heart Association, the people who write the guidelines we use as the basis for EMS cardiac protocols.

Assuming that this is a low-risk chest pain patient, what does the AHA consider to be the defensible way to approach this patient?

A high degree of suspicion and recognition of atypical presentations is important, because a significant number of patients present with “anginal equivalents” rather than chest pain. These symptoms include jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; and unexplained fatigue. These are seen more frequently in the elderly, women, and diabetic patients. Sharp, stabbing, or reproducible pain reduces but does not exclude the likelihood of ACS. Pleuritic chest pain is consistent with a pulmonary condition, musculoskeletal disease, or pericarditis. However, the Multicenter Chest Pain Study found that 22% of patients presenting with symptoms described as sharp or stabbing pain (13% with pleuritic pain and 7% with pain reproduced on palpation) were eventually diagnosed with ACS. 11 The National Heart Attack Alert Program recommends that patients with any of the aforementioned presenting symptoms should be assessed immediately and referred for rapid evaluation. 25 [2]

Jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; unexplained fatigue, and other symptoms.

These are seen more frequently in the elderly, women, and diabetic patients.

Perhaps this description of chest pain is more accurate –

Not the typical non-diabetic middle-aged man chest pain.

Why do we feel that we should assess every possible cardiac patient as if that patient is a non-diabetic middle-aged man?

When assessing female patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing young men, do we not understand that they are not non-diabetic middle-aged men?

When assessing diabetic patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing old men, do we not understand that they are not non-diabetic middle-aged men?

Physical Examination
The physical examination, although more specific than sensitive, can be useful to identify higher-risk patients. Signs of heart failure reflect left or right ventricular dysfunction. Bruits usually indicate peripheral arterial disease and increase the risk of concomitant CAD. The examination should also target potential noncardiac causes for the patient’s symptoms, such as unequal extremity pulses (aortic dissection), prominent murmurs (endocarditis), friction rub (pericarditis), fever and abnormal lung sounds (pneumonia), or reproduction of chest pain with palpation of the chest wall (musculoskeletal disorders). A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

Why do we lie to ourselves about chest pain?

EMS is not responding to 911 calls to look for reasons that the patient’s symptoms are not cardiac.


[1] The Perils of Low-Risk Chest Pain: Emergency Physicians Struggle to Balance Risk With Overtesting
Jan Greene
Annals of Emergency Medicine
Volume 56, Issue 4 , Pages A25-A28, October 2010
Free Full Text from Annals of Emergency Medicine

[2] Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research.
Circulation. 2010 Jul 26. [Epub ahead of print]
PMID: 20660809 [PubMed – as supplied by publisher]

Free Full Text PDF – Only Available as a PDF


EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights

Ckemtp writes EMS case law? AMA Refusals, Death, and Documentation

It is important to read. This is also a job for Star of life Law – a real lawyer. I am not a lawyer, but looking at the legal paper, it seems that this is just a determination of whether the law suit can proceed. If the original judge ruled that there were no grounds for a suit, then there probably had not been a presentation of a defense. That would happen during discovery (which may have been concurrent) and trial.

This ruling seems to be – the plaintiffs can proceed with their suit. The trial may still be a long way off.

What is described in this ruling from the Court of Appeals is superficially scary.

15 minutes on scene, for a patient who died less than a day later. Sounds bad, but we don’t have any of the information to explain why.

Did the medic incompetently blow this off as indigestion?

I don’t know.

Did the patient threaten them and chase them from the home?

Probably not. It doesn’t seem that way, but we do not know.

I spend much more time on refusals than almost any other call, although I have spent over an hour on scenes getting patients’ pain to the level where it was not torture to move the patients.

I have even had a refusal from a patient presenting with what gave every sign of being an MI. I showed him the ST elevation. He was a cardiologist. He absolutely refused. I have no idea of the scene time, but I got everybody there to try to persuade the patient to go to the hospital. I got medical command to talk to him, even though this was in a place where the doctors don’t talk to refusals. I’ll talk to this patient, but we don’t do that here. WTF?

I never heard anything further about this patient. It was an ALS assist outside of our territory. I checked the obituaries a couple of times, but this was when that required buying the local paper, or going to the library. As a library addict, I stoned a couple of birds in one shot. No dead doctor.

The part that does not look good is this.

What emergency physician is arrogant enough to discharge a patient with only a 12 lead ECG?

And we don’t even know if they did a 12 lead ECG.

Can we diagnose an MI/STEMI/NSTEMI with just a 12 lead ECG?


Does that mean that we can rule out an MI/STEMI/NSTEMI with just a 12 lead ECG?

Absolutely not.

A positive finding means something.

A negative finding only means that at the time the 12 lead ECG is performed, the patient is not having a heart attack that can be detected by a 12 lead ECG. A negative finding does not mean that the patient is not having a heart attack.

Consider that you are in the woods. It is cold and you are seeking shelter. You see a cave. It is dark in the cave. If you heard growling coming from the cave, you would have a positive finding that there is an animal in there.

If you cannot hear anything, or see anything, does that mean that there are no animals in the cage – nothing big enough to reach out and bite you?

Unless the test has excellent sensitivity, a negative finding only means that nothing was detected. It does not mean that nothing was there.

If you could see through the walls of the cave, you could be sure if there were any animals inside, what kind of animals, how many animals, and many other things. In EMS, we do not have that kind of diagnostic equipment. Waveform capnography may be the closest we come.

It may be nice to tell someone that everything is OK, but it is just a coin flip on whether we are right.

That is not even close to competent.

Will an emergency physician also check cardiac enzymes and still worry that he may be discharging a patient with a real heart attack?


One other thing.

The cause of death was not a heart attack.

The cause of death was pulmonary embolism.

Maybe we do an excellent job of ruling out a heart attack. Yippee!

That does not mean that the only other cause of chest pain and difficulty breathing is indigestion.

We should never approach a patient assuming that the cause of any complain, even abdominal pain, is indigestion. Even if the patient is mixing 5 alarm chili, donuts, beer, chocolate milk, whiskey, candy corn, a soufflé, and a bunch of other food that gives us indigestion just looking at the combination. Even if this patient has GERD and ulcers.

I do not believe in telling lies to patients.

If you don’t go to the hospital, you’re going to die!

If the patient does go to the hospital, the patient is still going to die. Everybody dies. So?

I explain the reasons the patient may want to go to the hospital.

I explain the limitations of my assessment.

I explain whatever they ask (related to the call).

Sometimes (frequently) my answer is – I don’t know.

Refusals require informed decisions.

Treatment and transport also require informed consent, but we seem to ignore that – a lot.

How many of us obtain informed consent for spinal immobilization, or even an IV start?

How many of us would be able to provide accurate information for a patient to be able to make an informed decision to consent to treatment/transport or to make an informed decision to refuse treatment/transport?

If we do not do a good job with informed consent, are we surprised that a lot of refusals are not well informed?


Excited Delirium 2

I expect to be writing a lot about the EMS EduCast – Excited Delirium: Episode 72. It is very important essential for EMS providers.

The first comment in response to my post, Excited Delirium: Episode 72 EMS EduCast, is from Tom Bouthillet of Prehospital 12 Lead ECG.

This was an excellent episode and I applaud Mr. Johnson for sharing his experience so that we can all learn from it. Clearly he has paid a high price and he has my sympathy, but I can’t join you in saying that he “did nothing wrong.”

If my understanding is correct, it sounds like he used a police baton to restrain the patient. While this may not have been the proximal cause of the excited delirium, it was very poor judgment. A paramedic should never use a weapon to restrain a patient unless:

1.) The paramedic’s life or his partner’s life is in danger
2.) There is no opportunity for escape
3.) A weapon (or an improvised weapon) is needed to level the playing field to restore safety

I can hear it now. “Hindsight is 20/20″ and “you’re an arm chair quarterback.” No, I’m simply pointing out that it’s a mistake to say that Mr. Johnson did nothing wrong. Clearly at least one major mistake was made.


I agree that using the baton was poor judgment. When faced with an unstable situation, we will make snap judgments. Marty Johnson’s explanation is that he felt it was the only way he could get a grip on the patient. He stated that the patient was sweaty and he had latex gloves on, so the patient kept slipping out of his grasp. I would take the gloves off. Even though the patient is bleeding, you have to assume that the gloves have already lost their much of ability to act as a barrier to transmission of germs, but the gloves are acting as a barrier to being able to manage the situation.

We occasionally have to make important decisions about the appropriate amount of force to use. We should have thought these out, as much as is practical, ahead of time. How many of us have thought these things through?

This is a situation that may initially seem like it is not a big deal. the problem is that things do not get better. They get worse. Not just a little bit worse, but a lot worse. Not necessarily getting a lot worse right away, so that you just step back and re-evaluate or to retreat and call for help, but progressively worse, so that you may not be aware of the way things are spiraling out of control.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;

We expect to be in control.

During EMS education, we are even told the lie that we should be in control.

Because of this, we are frequently able to dismiss the evidence that we are not in control. Having developed this ability to ignore just how out of control things are, we react poorly when things do not go our way. We flail about and panic. Ironically, the patient may be doing exactly the same thing.

Would Marty Johnson do things differently, today. I think that he made that very clear. He is trying to get people to understand how badly things can turn out.

Even more important than the baton is the perception of the baton. Is a baton a weapon, if it is not used to strike?

Is a baton a weapon, if the baton is used to protect the person the baton is being used on?

Is a sedative a weapon?

Is a restraint a weapon?

A physical restraint?

A chemical restraint?

Consider the weaponized fentanyl variant used during the Moscow theater hostage rescue.

How much does the result affect the interpretation of the intent.

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, most if not all deaths were caused by suffocation when hostages collapsed on chairs with heads falling back or were transported and left lying by rescue workers on their backs; in such position, tongue prolapse causes blockage of breathing venues.[53]. Thus, part of casualties can be attributed to accident but at least some to unprofessional rescue efforts.[2]

Even if nobody had died in Moscow, the chemical would have been considered a weapon, but many of the deaths of the hostages would probably have been avoided with basic airway positioning. Some people vomited, aspirated, and asphyxiated. Others were suffocated by a lack of positioning, allowing the tongue to obstruct the airway. Had there been better organization of the evacuation, how many of these people would not have died that day? Had there been better organization of the evacuation, this might not have been a disaster.

How we act helps to show our intent.

When we are prepared, we can act more appropriately, even if the initial impression of onlookers (including medical command) is that we are being inappropriately aggressive.

When we are prepared, we can turn an unstable situation into a non-event, except for dealing with the protocols that discourage/prohibit appropriate care.

We use our hands for many purposes. We can use them to deliver painful stimuli. When done appropriately, there should not be any permanent harm, and the pain should be stopped as soon as there is an adequate response to the stimulus and only repeated if stimulus is again appropriate. The entire point of painful stimulus is to produce a response, and we do this on a regular basis.

Most often, we are using verbal stimuli, but we move to more aggressive stimuli, when the less aggressive stimuli do not elicit a response.

If we omit painful stimuli from our assessment/treatment, then we are neglecting some of our patients.

Was he charged with murder just because he used a baton to attempt to restrain a patient?

I don’t know.

Was Marty Johnson charged with murderous assault, even though he was driving the ambulance at the time the alleged crime occurred?

It does look that way.

If he had showed up and aggressively sedated this patient, would this have been anything other than a routine call?

Probably not.

The doctors may have made a big deal about aggressive sedation, even though it is probably the best thing for the patient.

Acting appropriately aggressively initially will often prevent a lot of bad outcomes. Our goal should be calls that are not memorable, because the patient was protected by aggressive intervention. Unfortunately, we have patients harmed by some protocols that discourage aggressive intervention, because What if . . . ?

I am not cavalier about the aggressive use of sedatives, opioids, or other drugs. I think that aggressive treatments should be treated as sentinel events. RSI Intubation is an excellent example of a treatment that should not be treated as anything other than a sentinel event.

Everything that we do has the potential for harm.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be competent before allowing them to work on their own.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be accountable for all of their actions.

Medical command permission requirements are purely for the psychological benefit of the people who do not understand medical oversight.

Medical command permission requirements are dangerous.


[1] The Second Coming
William Butler Yeats
Poem of the Week

[2] Moscow theater hostage crisis – Chemical attack

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, . . . .

Gemology? – the science dealing with natural and artificial gems and gemstones?

Why is a gemologist, academic or otherwise, giving expert testimony on toxicology?

A better question may be – Why does the gemologist make more sense than everyone else quoted?

Or is it a translation error?


EMS Garage Rant – Prehospital Pain Management

On BYOT: EMS Garage Episode 105 we discussed 2 things that I wanted to rant about – here is some of the second rant.

The second topic was prehospital pain management. I think that Chris Montera saw my post A Prehospital Pain Management Discussion at the NAEMSP Site and wanted to discuss it. There is a lot of excellent material at the NAEMSP discussion site.

There are a lot of ideas discussed on the podcast.

Listen to it.

Why are there so many doctors discouraging appropriate patient care?

What can we do to convince them that prehospital pain management is safe, effective, and necessary?

This is not directed at Chris, since he is aggressive with pain management. He was only repeating one of the arguments against aggressive prehospital pain management – actually, it is an argument against all prehospital pain management.

I scared Chris a little bit with my response, when he repeated what some people claim about pain – Pain never killed anyone!

If anyone wishes to provide some evidence, please do so.

If there is no evidence to support this claim, then prove it. Let me deliver some extreme pain to you, just for a while. I won’t break anything or burn anything, but I will see if I can cause enough pain to kill you.

If Pain never killed anyone!, it won’t kill you either.

What have you got to lose?

You will have experienced some memorable pain. You may have nightmares and other PTSD (Post Traumatic Stress Disorder) symptoms, but since you have already made it clear that you don’t take pain seriously, why should you mind?

We’ll strap you to a chair, so that you don’t injure yourself by thrashing around. Safety first. We’ll hook you up to a monitor to see just how much stress your body is experiencing. We’ll even get a medical director, who believes in Mother-May-I protocols, to supervise. What could be safer – if you are right?

Pain is not dangerous, this is completely safe – Right?

If pain does not need to be treated, then there is no medical problem created by just causing a bit of pain – OK – a lot of pain. Or is pain dangerous?

Pain never killed anyone!

I dare you to prove to me.

Put up or shut up.

I can be reached at the email below or in the comments.



A Conversation on Mechanism of Injury

I was talking with one of the long time, weekend, night shift nurses. The people I count on to do what is right for the patient, because the administrators are not around.

Well, I mentioned in passing – I thought it was going to be just in passing – about the recent comment kerfuffle about MOI (Mechanism Of Injury criteria for trauma triage, or just mechanism). This is the assessment skill substitute for assessment that people use as a justification for flying uninjured patients in helicopters.

As if that is safe.

All of a sudden, the nurse started a little tirade about a medic who brought in a patient to this non-trauma center ED (Emergency Department) because he did not bother to report on the MOI when calling for medical command destination decision.

I do not remember what the mechanism was, but it was something vehicular and must have sounded bad, because that’s what MOI means –

The 911 call sounds bad!


That dent looks like it is going to cost a lot to repair!.

That has nothing to do with the patient, except that the mechanism suggests things to be more careful in assessing for.

This is all that mechanism means.

You might want to pay extra attention to these things suggested by mechanism.

Mechanism is not assessment.

Mechanism is the equivalent of stereotype, or prejudice, or bias, or racism.

Mechanism is not about understanding.

Mechanism is a shortcut that encourages ignorance.

Mechanism is just a superficial substitute for a patient assessment.

Mechanism is for those who cannot assess real patients.

Anyway, being the blunt person that I am, I interrupted the nurse’s rant, because my shift is only 12 hours long and her rant was looking like a filibuster. I didn’t even have to ask the obvious question about what a simple assessment showed, because the nurse mentioned over a dozen rib fractures and a flail chest.

Clearly, this is not a patient who should have been transported to the local ED with several trauma centers less than 20 minutes away by ground. This is a case, if reported accurately, of an incompetent medic. And not just a little bit incompetent.

Back to mechanism.

What does mechanism add to the assessment of a patient with a flail chest?

A flail chest is a portion of the ribs acting like a trap door. The ribs are broken in so many places that there is no resistance to pressure, except when the patient exhales.

Breathing is not very complicated. The diaphragm creates negative pressure. On inhalation, the diaphragm pulls away from the chest and the accessory muscles also cause the chest to expand. This sucks air in.

On exhalation, the diaphragm and accessory muscles relax and create pressure. This forces air out.

With a flail chest segment, breathing mechanics are mostly normal for everything except the flail segment. The rest of the chest is creating a pressure difference that moves the air. As long as the ribs are intact, they will all move together. When there is a flail segment (2, or more, ribs broken in 2, or more, places is the textbook definition) that broken part of the ribs will move the opposite direction from the rest of the ribs. The flail segment will move in the opposite direction from the intact part of the ribs.

When the ribs are expanding out to create negative pressure, the negative pressure is pulling air into the chest, but the negative pressure is also pulling the broken ribs inward.

When the ribs are relaxing and creating positive pressure, the positive pressure is  forcing the air out of the chest, but the positive pressure is also forcing the broken ribs outward.

This is one of those assessment findings that is hard to miss. The patient may be trying to keep you from assessing that part of the chest, because . . . well . . . it hurts. It doesn’t hurt a little bit. This isn’t just a hairline fracture that hurts a lot. This is a bunch of broken bones that are moving around – a lot – with every bit of breathing.

Not – It only hurts when I laugh.

Not – It only hurts when I move.

But – It only hurts when I breathe.

The normal response to the first two is pretty easy. If it hurts, when you do that, don’t do that.

That doesn’t work very well for breathing. Go ahead. See how long you can hold your breath. Now take a hammer and break a bunch of your ribs. Now, how long can you hold your breath? Not the same thing, at all.

The only time that a flail chest should be missed is when the ribs are not completely broken, in which case, it is not really a flail chest, except for the textbook definition of 2, or more, ribs broken in 2, or more, places. That is the textbook definition. The textbook definition should include the paradoxical movement. Paradoxical movement is what everyone is supposed to be looking for.

Paradoxical means the opposite of what we would ordinarily expect. We would ordinarily expect the ribs to all move together. With a flail chest, the flail segment is moving in the opposite direction from the rest of the ribs.

If the patient is conscious and not disoriented, the pain should be a clear clue to examine the part of the chest being protected. The patient’s arm may act as an excellent splint. Expect to use a lot of morphine/fentanyl/Dialudid. Pain will interfere with breathing more than the opioids will. Fentanyl is less likely to affect cardiac output (blood pressure), so that is my preference.

If people are missing flail chest, we need to ask Why?

We don’t need to complain that the person is ignoring mechanism.

Focusing on mechanism just ignores everything we understand about assessment.

Or do we just not understand assessment?

Mechanism Of Injury criteria for trauma triage encourage incompetence.


“I’m Only An EMT Basic”

I stole the title of this from Steve Whitehead. He wrote “I’m Only An EMT Basic” at The EMT Spot. I agree with all of what he wrote, and I do mean all, but here is the part that got my attention.

I had one EMT tell me that lung sounds were not in her scope of practice. I’m serious. She was worried someone might charge her with malpractice if she placed a stethoscope on someone’s chest and asked them to breath deep. I’m not making that up…lung sounds.

In Pennsylvania, we have our scope of practice specifically spelled our every year, or two, in state commonwealth law. Most people in EMS in Pennsylvania are probably aware of this, but I would be surprised if more than a tiny minority have actually looked at the web page. Most have probably seen a printout at some time in their career. Scope of practice changes every couple of years. What good is maybe having occasionally seen an old printout of the scope of practice on the back of a door? Not even the toilet door, where you might spend the time to read through it.

Depending on the way the law is interpreted, this may be very restrictive, or it might involve the use of common sense. From what I have seen of the way EMS education is handled in Pennsylvania, the law is presented as being interpreted in a very restrictive sense. There certainly are people who will write up others for violating their scope of practice.

I have been accused of violations of scope of practice several times. None of these write ups ever went beyond the level of the medical director, because I had not violated the scope of practice. What I had done was to use my head and not accept some silliness repeated by semi-literate EMS instructors worried about, What if . . . ? When questioned about these imagined violations, I always express disappointment at not having actually violated anything except someone’s delusions. I also mention my eagerness to do some violating in the future. 😉

One of the problems is that there are so many know it alls out there, full of misinformation. They are more than willing to tell everyone exactly what they don’t know. Unfortunately, there are not enough people willing to stand up to the know it alls. People are intimidated by the absolute certainty with which the know it alls present their misinformation.

Always ask for evidence to support any claim that anyone makes.

An honest person has nothing to fear from being questioned.

The dishonest person will change the subject, or accuse you of something, or just plain refuse to answer.

It becomes tricky when the know it all is a supervisor, instructor, or someone else with some authority to hurt you. You may need to find other ways to get the information you want, or you may decide that the potential consequences are not worth it. There may also be valid reasons for changing the subject or not answering, but these should be volunteered in private by the person who was not answering the question.

If you are in Pennsylvania, I have a link to the relevant information.[1] The EMS section of Pennsylvania’s web site[2] is not the easiest to get to without a link, nor is it easy to navigate once you do get there. Many of the links are .DOCs (Microsoft Word) or .PDFs, so clicking on one that is large can tie up your computer if you multitask, as I do. Have the cursor hover over the link before you click on it to see what it is, but that is a good idea with any link anywhere.

After all of that, what does that Scope of Practice document say about assessing breath sounds?

Assessment of Glasgow Coma Scale (GCS)
Assessment of Level of consciousness (LOC)
Assessment of Patient assessment skills identified in the NSC5
Assessment of Vital sign–body temperature
Assessment of Vital sign–pulse
Assessment of Vital sign–pupils
Assessment of Vital sign–respirations
Assessment of Vital sign–skin color/temperature & condition (CTC)

That is everything listed as assessment.

5 Is the footnote for the list of abbreviations used. Is there a link for any of these? Not that I could tell.

This only encourages the problem that Steve Whitehead pointed out. When confronted with a choice, doing less seems to be the safest route for a lot of people. Maybe not for the patient, but why deal with the important things? It’s all about the regulations. We work in EMS to give meaning to EMS regulations, not to provide appropriate care to patients. If you doubt me, try getting some patient information (that you are entitled to under HIPAA) from a bunch of hospitals. Some of them will just say, No. They don’t know what they are doing, but they have been told they will not get in trouble for doing less of their job than they are supposed to do. For some people, that is their dream job.

NSC = U. S. Department of Transportation National Standard Curriculum

So, wondering what the scope of practice of an EMT-Basic is, I have made my way to this document for answers. The listing for assessment of respirations only mentions Vital sign. Hmmmm. When I document vital signs, I am only documenting numbers – heart rate, respiratory rate, et cetera. Looking at this official site, the one that some will refer you to, does not answer the question of whether listening to lung sounds is in the EMT-Basic scope of practice. I need to track down the U. S. Department of Transportation National Standard Curriculum. Looking around the rest of the PA EMS web site, I did not find any link to the U. S. Department of Transportation National Standard Curriculum. That does not mean that the link is not there, just that I did not find any link anywhere I looked.

I tried a few search engines using ems and “national standard curriculum” as search terms. They all made it pretty easy to find what I wanted. The top link for each search engine was the EMT-B National Standard Curriculum, just with different links depending on search engine. I did not look for the path not taken.

Here is what I found cunningly hidden under the heading Curriculum in the last place anyone would think to look – Page 1.

Establish a Physician Board to review and approve all medical curriculum content.

Emphasize an assessment-based format rather than a diagnostic-based format for all levels and all ages.

Ensure that there is adequate focus on primary skills of assessment and ABCs in all provider levels (with emphasis on airway).[3]

I am only on page 1, but they make it quite clear that they consider airway assessment to be a big deal.

Are lung sounds part of airway assessment?

According to my scanning of the document, Yes and No.

It seems to state that listening to lung sounds is limited to determining the presence and equality of respirations in adults. Then, in some fit of irony, they appear to conclude that by avoiding training in auscultating for wheezes, rhonchi, crackles, et cetera in adults, students will be well prepared to auscultate for them in young children.

Anyway, I may have missed it in the National Standard Curriculum, but I don’t think so. It does appear that, while they do not specifically forbid auscultation for adventitious lung sounds, they do not seem to encourage it.

Steve, my interpretation is this. While auscultation of lung sounds does not appear to be forbidden, I wouldn’t be surprised if this was told to her by an instructor. Maybe with a stern warning about practicing medicine without a license.

Please, if you can point out where I am missing the inclusion of assessment of adult lung sounds for more than presence and equality, let me know.

In the mean time, about all I can add is, Augh!!!

Does that mean that an EMT-Basic may not auscultate lung sounds?


Does that mean that an EMT-Basic documenting adventitious lung sounds on an adult will get in trouble in Pennsylvania?

I sure hope that is not what is intended either by PA or the NSC.

I remember discussions over the removal of education in lung sounds from the EMT-Basic curriculum years ago, even though the use of albuterol was being added to the EMT-Basic curriculum. Nobody had a good explanation except that it helped to keep the number of hours down. If we want to minimize the course hours, and I do not, why eliminate time from assessment.

The two most important skills in EMS are assessment and critical judgment. This appears to be detrimental to both.


^ 1 Prehospital Practitioner Scope of Practice
[38 Pa.B. 6565]
[Saturday, November 29, 2008]
This appears to be the most recent publication of scope of practice.
Free Full Text of PA Bulletin 11/29/2008

Free PDF from PEHSC.org

^ 2 Pennsylvania Emergency Health Services Council (PEHSC.org) Home page
“The core mission of the Pennsylvania Emergency Health Services Council is to serve as an independent advisory body to the PA Department of Health and all other appropriate agencies on matters pertaining to Emergency Medical Services.”
The most useful parts all seem to be found in the tabs at the top. Resources, links, and legislative info are the ones I find most useful.
Web Page

^ 3 National Standard Curricula
EMS.gov links to the various National Standard Curricula in different formats.
Web Page