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

- Rogue Medic

EMS Garage Rant – Kenneth Stokes


On BYOT: EMS Garage Episode 105 we discussed 2 things that I wanted to rant about – and rant I did.

The first was the foolish suggestion that EMS should not wait for police to declare an active shooting scene under control before EMS enters. I wrote a bit about the background of City Councilman Kenneth Stokes in Mississippi Councilman Kenneth Stokes is Reckless and Irresponsible.

City Councilman Kenneth Stokes claims that it took over 20 minutes for EMS to get on scene because they were waiting for police. If that is the case, then maybe the problem is with the availability of police (hire more unless you are trying for the highest unsolved homicide rate in the country), not with EMS.

The odd thing is that the claim by City Councilman Kenneth Stokes does not agree with the dispatch times. 23 minutes per Stokes vs. less than 7 1/2 minutes from the EMS dispatch data.

Trust the dispatch data recorded at the time or trust a guy being investigated for repeated abuses while in office?

Maybe City Councilman Kenneth Stokes is honestly an idiot, but the articles I found about him suggest that there is nothing honest about him. If you feel that he should be given the benefit of the doubt, here is the way to reach him.

On Dave Statter’s blog, he wrote this in the comments, which is not normally where Fire and EMS go to sing Kumbaya together.

dave statter says

Kenneth Stokes is my hero. He has been successful where I have been a failure. In fact, I plan to nominate Mr. Stokes for the Nobel Peace Prize. Send him to the Middle East, for he has been able to inspire peace and harmony where no one else has, the STATter911.com mailbag. Finally something we can all agree on and not tear each other apart (just check the recent PGFD video comments).
For that Mr. Stokes, you will always have my gratitude.

Statter

on September 22, 2010 @ 3:12 pm.

The office of City Councilman Kenneth Stokes contact information from the Jackson, Mississippi government web page.

http://www.city.jackson.ms.us/government/citycouncil/

http://www.city.jackson.ms.us/government/ward3
Term Expires:
July 6, 2012

Committees:
Planning (Chair)
Rules (Vice-Chair)
Budget
Legislative
Water/Sewer Ad-Hoc

Mailing Address:
Post Office Box 17
219 South President Street
Jackson, Mississippi 39205-0017

Telephone:
(601) 960-1090

FAX:
(601) 960-1032

Email Address:
kstokes@city.jackson.ms.us

Administration:
Ms. Magnum

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The Real Gold Standard Of Airway Management at 510Medic


510Medic has a nice post about The Real Gold Standard Of Airway Management.

The way he started out, I expected a riff on Nixon taking us off the Gold Standard – $35 an ounce due to price control then – now just under $1,300 an ounce. Last week, there was this – Gold Bet: $2500 Over/Under 2012. Even I am not cynical enough to take the over on that.

The Gold Standard 510Medic is writing about should be just as dead as the monetary gold standard.

There are some similarities. Both are inflexible and artificial limitations on change.

The idea that intubation is a gold standard only demonstrates an inability to adapt to what is best for the patient.

The gold standard is supposed to mean what is best for the patient, but does it?

In the emergency department, cardiac arrest patients are only intubated in the old fashioned Bretton Woods style of treatment. I expect the new guidelines to continue to de-emphasize intubation as a method of airway management.

In the operating room, intubation has become much less common.

If the emergency physicians and anesthesiologists are switching to more appropriate airway management methods, why isn’t EMS?

Because we are EMS. It sometimes seems as if you have to kick us in the head to get us to use our heads for anything.

As with helicopter abuse, we are not doing what is best for patients.

As with restrictive protocols, we are not doing what is best for patients.

As with on line medical command permission requirements, we are not doing what is best for patients.

As with cardiac arrest drugs, we are not doing what is best for patients.

As with spinal immobilization, we are not doing what is best for patients.

As with restrictions on prehospital pain management, we are not doing what is best for patients.

Are we surprised that, when it comes to airway management, we are not doing what is best for patients?

Let’s put an end to the Gold Standard terminology.

Airway management is about Ventilation – not Intubation.

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Appropriate Morphine Dosing for Opioid Tolerant Patients

What do we do, when treating a patient already taking opioids? When the patient is already taking a large dose of an opioid and has a valid prescription for the doses of opioid being taken?

Remember that there is no maximum dose for morphine. There is no maximum dose for any opioid – as long as there are no adverse effects, such as depressed respirations, altered mental status, hypotension, or bradycardia.

What do we do when this patient has something like a femur fracture that produces severe pain?

This patient is opioid tolerant, so the standard doses of opioid are unlikely to produce a satisfactory effect. By standard doses, I mean doses that would be appropriate for a patient who is not currently taking opioids. That would be a starting dose of 0.05 mg/kg morphine to 0.1 mg/kg morphine – repeated as necessary until the pain is managed to the patient’s satisfaction or until side effects interfere with treatment.

The patient will probably receive more relief by releasing some flatulence than he will from 2 mg morphine. The flatulence may even provide more benefit than 10 mg morphine for an opioid tolerant patient.

Standard doses are not going to work, so do we just ignore this patient’s pain?

Do we tell this patient that our medical director does not trust us to give larger doses of morphine/fentanyl/hydromorphone than standard, because the medical director either has not really considered this possibility or doesn’t think that patients, who are legally prescribed high doses of opioids, deserve to have their severe pain treated effectively. Or maybe the medical director is just so irrationally afraid of opioid medications that he is not interested in understanding opioid tolerance.

It isn’t necessarily the medical director who is the obstacle to treatment. I know of plenty of medics who would not even start treatment of this patient’s pain. Maybe out of fear of causing respiratory depression. Maybe out of fear of causing addiction, in which case they really need to work on their response time, because it is a bit late to be considering addiction or tolerance.

What do you think are the chances of causing dangerous respiratory depression for this patient:

With 10 mg morphine?

Low Medium High

With 20 mg morphine?

Low Medium High

With 30 mg morphine?

Low Medium High

With 40 mg morphine?

Low Medium High

With 50 mg morphine?

Low Medium High

With 60 mg morphine?

Low Medium High

With 70 mg morphine?

Low Medium High

With 80 mg morphine?

Low Medium High

With 90 mg morphine?

Low Medium High

With 100 mg morphine?

Low Medium High

Why?

What would be considered dangerous respiratory depression for this patient?

Why?

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A Prehospital Pain Management Discussion at the NAEMSP Site

Also posted over at Paramedicine 101. Go check it out at the new location at EMS Blogs.

I would have also posted this at Research Blogging, but this discussion is not the kind of research blog post that they are looking for.

Well, what needs to be said about prehospital pain management?

Drug Seekers.

Fentanyl vs. Morphine.

Fractures dispatched BLS vs. ALS.

Standing orders vs. Mother-May-I?

Nitrous oxide, etomidate, ketamine, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), relaxation, ice, acupressure, et cetera. If it might be used by EMS for pain, it is fair game for the discussion.

Legal issues – when will the lawyers start going after medical directors/medical command physicians for withholding appropriate treatment/neglect/malpractice?

Pediatric Pain Management by EMS.

And more.

There is a discussion of Prehospital Pain Management on the NAEMSP (National Association of EMS Physicians) discussion site on Google Groups. NAEMSP Dialog. Anyone can read the discussions. They are there to be a kind of reference for people working in EMS. This is what some of the top doctors, administrators, educators, street providers, and even the occasional blogger have to say on a topic.

Here is a summary of the rules on participation:

Trying to facilitate a higher level of discourse on contemporary issues in EMS. Most of the list members are physicians, managers, and educators – along with street level EMTs and paramedics with an interest in academics and policy issues.

Everyone who wants to join the list has to provide their name and affiliation; all posts are reviewed by a moderator before being allowed to circulate; and all posts must be ‘signed’. There is some descriptive language about the Dialog on the home page of the Google Group (http://groups.google.com/group/naemsp-dialog).

Go read. If you want to comment, sign up, but don’t try to push the envelope on what you can get away with. The envelope has already been pushed.

Some familiar bloggers are also participating – Adam Thompson, EMT – P from Paramedicine 101, Tom Bouthillet from Prehospital 12 Lead ECG, Mark Glencorse from Medic999, and a couple of doctors from the EMS Garage – Dr. Bryan Bledsoe and Dr. Keith Wesley. Some of the other top medical directors in the country are participating as well.

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First Few Moments – Mechanism Of Injury or Idiocy


On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.

Mechanism of Injury or Idiocy?

Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.

Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.

One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.

Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently transport the patient.

Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient and manage the airway.

50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.

Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?

The alternative is to limit EMS to effective treatments.

Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

It is important to train/educate EMS well enough to be able to provide this competent assessment.

It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.

Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess and manage the patient’s airway.

Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?

The alternative is to have competent EMS.

The answer seems to be that we need to improve EMS and EMS education – a lot.

Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.

Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.

If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.

If we do not understand what is going on medically with the patient, we should not be making patient care decisions.

Calling for a helicopter because I am too stupid to assess my patient is bad medicine.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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Merit Badge Courses: Who Benefits? 1

At EP Monthly, there is an interesting article – Merit Badge Courses: Who Benefits?

I will address this in several parts. First is the quality of the merit badge courses.

Why do we object?
After years of residency training and days of grueling written and oral boards, many EPs find ACLS and BLS to be kindergarten-level courses. The classes address an aspect of clinical practice that we handle on an almost daily basis. When somebody from The Joint Commission asks for your updated ACLS card, but ignores your board certification, it is at very least out of order in importance and frankly insulting to the effort required to obtain the latter. Certainly, ABEM and AAEM agree on this and both organizations have position statements indicating that ACLS or ATLS certification should not be required of board certified Emergency Physicians.

I disagree about the kindergarten-level. That depends on the instructor. If all you are getting is a memorization of guidelines, then it is kindergarten-level, but that is not the way ACLS should be.

That is not the way I have taught ACLS. I certainly did not fit in at every hospital where I taught, but I fit in very well at others. The administrator of the program has a lot to do with that.

If you read much of my blog, you should realize that you would leave my course with more questions than when you arrived at the ACLS class. That is the way it should be. We are faced with guidelines based on expert opinions of inconclusive research, or even based on expert opinion without research.

Anyone who tells you that there are more than a handful of definite answers to be drawn from the research is lying to you. Or they don’t know what they are talking about.

The guidelines are based on thousands of studies.

A lot are animal studies, which are important, but more often than not do not work out as well when applied to real human patients. One of the obvious reasons is that the human patient has a cardiac arrest due to underlying medical conditions, that are not easily recreated in a mouse, pig, or dog. The surrogate arrests we create in animals are no more relevant than the surrogate endpoints that are promoted as answering questions about survival.

A cardiac arrest due to ligation of an otherwise healthy coronary artery in a pig is not the same as a cardiac arrest due to an occlusion of a diseased coronary artery in a human.

The Return Of Spontaneous Circulation (ROSC) is not any better than the animal studies at indicating that a treatment will improve survival to discharge.

Both are necessary intermediate steps in arriving at a treatment that works.

What we know:

1. Chest compressions are important.

2. Fast compressions and deep compressions.

3. Interruptions to compressions are bad.

4. Defibrillation is important.

5. Therapeutic hypothermia also seems to be good.

If I try to tell you that anything more than that is definite, I am telling a lie.

We may even have to revise some of what I have listed as definite.

Revise, not remove.

We may have to revise something, but I don’t think we will have to remove any of it.

Some people will tell you about information that goes well beyond this. They will present it as certain.

They will be either lying, ignorant, or both.

Does epinephrine improve survival to discharge?

We need much larger placebo controlled studies to answer that question. If can’t tell without these extremely large studies to show an effect, then the effect is not large.

Why are we forcing the use of epinephrine?

If we are doing something, we convince ourselves that we are helping.

It is hard to have a bunch of us stand around and just watch someone doing chest compressions, especially if we are trained to give drugs and to do invasive procedures.

We can’t have doctors, nurses, and medics not using their ALS (Advanced Life Support) skills. There has to be something we can do that is better than what a 70 year old spouse can do. There has to be. Something other than those sweaty compressions – that’s what techs are for.

F*&# the research – I’m doing something! Give me an epi!

Look! A pulse! I did it!

If you feel like you are taking a kindergarten course, you should look at the way instructors are taught, hired, and paid.

Most of the ACLS teaching I have done has been for less per hour than what I would make working as a paramedic. Not only that, but it is for fewer hours. Never mind overtime, this is less than straight time. This is great for a single parent, which is a big part of why I did so much teaching, but it is not a way to get people who are not limited by daycare hours (or school hours). If I am making less per hour as a medic, what incentive is there for someone who makes more than a medic?

How many residents are mandated to teach ACLS as part of their program requirements? How many of them are any good at teaching in a classroom? If you want a kindergarten environment, put a mandated resident, with no interest in teaching, in front of a class with a PowerPoint. Ativan does more for your memory.

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Do Drug Shortages Really Impact EMS? – Answer 1



Here is part 1 of the details from the points I raised in commenting on the discussion of the drug shortages and the way these affect EMS. I already gave the short answers in Do Drug Shortages Really Impact EMS? – EMS Office Hours. These will be a bit longer, so I broke it up by answer. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

1. Do the drugs help patients?

I have recently written about why these drugs are inappropriate here, here, here, and here.

These drugs are based on either, or both, of 2 bad ideas.

First – Expired expert opinion. Opinion that is not supported by good research. When the research has been done, the research has not supported these treatments.

By expired, I do not mean that the expert has expired, but that the opinion has been kept in use long past any possible justification. If this were canned food in your cupboard, the can would be bulging at both ends from the disgusting growth on this very dead opinion.

Second – Not just expired expert opinion, but opinion that is not based on any research. There is the possibility that research will someday demonstrate that these treatments are effective, if anyone ever appropriately studies these ideas. It is also possible that the parts of the moon that have not been examined actually are made out of cheese. This is the morass of Class IIb level of evidence.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa. Weight of evidence/opinion is in favor of usefulness/efficacy

IIb. Usefulness/efficacy is less well established by evidence/opinion.[1]

There is no requirement for any evidence.

The highlighting is mine, but the wording is 100% ACC/AHA (American College of Cardiology/American Heart Association). The people who thought antiarrhythmics were the answer to everything, until research showed an antiarrhythmic fatality rate several times higher than placebo.[2]

Oopsy.

Perhaps I am putting too positive a spin on the Class II levels of evidence. Some of what is classified as IIa is not much different from IIb, because there is still the allowance for expert opinion. Any reading of this research should be preceded by the words, Wouldn’t it be nice if . . .

However, that is not the way to decide what chemicals to test on a patient.

Let’s be honest. That is all we are doing. We are testing chemicals and/or procedures on patients. We are not treating patients, because treatment implies some sort of concern for the patient. This is just a bunch of large scale never-to-be-published, uncontrolled, unregistered, unreasonable experiments on patients who are not informed of their guinea pig status.

I want to know the real risks and benefits of this treatment.

Wouldn’t it be nice if . . .

How far do we need to go to demonstrate that bad ideas really are bad ideas?

We need to demand that medical directors base their EMS protocols on research.

Why are medical directors ignoring what is best for their patients?

Why are medical directors ignoring what is best for our patients?

Why should we tolerate this ignorance?

I’m a doctor.

Wouldn’t it be nice if . . .

Continued in –
Do Drug Shortages Really Impact EMS? – Answer 2
Do Drug Shortages Really Impact EMS? – Answer 3
Do Drug Shortages Really Impact EMS? – Answer 4

Footnotes –

[1] Manual for ACC/AHA Guideline Writing Committees
Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines
Section II: Tools and Methods for Creating Guidelines
Step Six: Assign Classification of Recommendations and Level of Evidence
Free Full Text Article

[2] C A S T and Narrative Fallacy
Rogue Medic
Article

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Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract


ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging.

Go check out the rest of the excellent material at both sites.

Over at 510 Medic, there is an interesting abstract of a new article on treatment of tension pneumothorax. Frequency of Inadequate Needle Decompression in the Prehospital Setting.

CONCLUSIONS: In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.[1]

I have not read the full text. I do not have access to this journal. If anyone can send me the full text, I would like to address some of the details, rather than just speculate about them. Late entry – I have received the article. Thank you to Jeff Williams and Jeremy Blanchard. I will write more about the full text later on.

510 Medic makes some important points and asks some good questions. Then 510 Medic asks –

So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients?[2]

I think that there is a more important question.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

A pneumothorax is not the same as a tension pneumothorax. Even the definition of a tension pneumothorax is not easy to agree on. I tend to treat with opioids what many others would treat with needle decompression. I have not had any of these patients deteriorate, while in my care. They received chest tubes in the trauma center.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

57 patients with a prehospital diagnosis of tension pneumothorax. Yes, EMS does diagnose, but that is a discussion for elsewhere. Yes, these patients were diagnosed by EMS with tension pneumothorax, unless we are suspecting acupuncture, because what other prehospital indication is there for sticking a needle into a patient’s chest?

Out of 57 patients diagnosed with tension pneumothorax, only 42 patients had a pneumothorax.

How many patients had a tension pneumothorax at the time the needle was stuck into the chest wall?

How many of those patients would have been better off if treated with something other than a needle?

How many complications were there from the needle decompression?

Am I wrong to use italics to highlight the word decompression, since so many of the patients did not have anything to decompress?

We rush to perform procedures that we have little experience with. Isn’t this a situation likely to lead to misdiagnosis?

Isn’t the infrequent use of needle decompression for suspected tension pneumothorax likely to lead to operator error?

The actual occurrence of tension pneumothorax appears to be much less frequent than the prehospital diagnosis of tension pneumothorax. Isn’t that an indication of a failure to properly educate medics?

Footnotes:

[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

[2] Frequency of Inadequate Needle Decompression in the Prehospital Setting
510 Medic
Article

Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183

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