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

- Rogue Medic

EMS Needs to Be a Separate Medical Specialty – Now – Part I

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following the protocol orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic’s place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can’t imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this – from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts – here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8th Law – Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur – 10 Laws I’ve Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 – 1541, so this is not exactly new) wrote –

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population – a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.


When Michael Jackson Is The Patient – A Call That Everyone Will Criticize

While there are probably people going to write about the coverage of this being like Elvis all over again, I am just interested in the EMS aspects of what happened.

The 911 call was simple, but it did raise one question for me. Was CPR being done on a bed?

CPR on a surface that absorbs some of the force of compressions, decreases the effect of the compressions. A hard surface that does not move is an important component of effective CPR.

There is a report that CPR had been in progress for an extended period of time and that lidocaine might have been used. No mention of epinephrine, not that either would have changed anything. These drugs, amiodarone as well, are nothing but plumage. ACLS has us focusing on things that are irrelevant.

Marc Eckstein, MD, MPH, FACEP, Medical Director of the Los Angeles Fire Department, told JEMS.com. “They found Mr. Jackson in full cardiac arrest with CPR in progress.”

“LAFD members immediately took over CPR and intiated both basic and advanced life support interventions,” Eckstein continued. “They aggressively attempted resuscitation on scene for approximately 30 minutes, and after consultation with on-line medical control at the UCLA base station, they continued resuscitative efforts during the short transport to the UCLA emergency department. There was no change in the patient’s status during his prehospital course.”[1]

What about Narcan (naloxone)? Since he is reported to have been receiving Demerol (meperidine) wouldn’t Narcan be a life saver?

I have written here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, and here on what naloxone does. Perhaps more specifically these are about what naloxone does not do and why naloxone is rarely the first choice of intervention for opioid overdose.

What naloxone does not do is make a difference when the patient is already receiving artificial ventilation, as is the case here. This would be one of the cases of cardiac arrest where ventilation is important. The focus on continuous compressions is not appropriate when it appears that the arrest is due to respiratory causes. Naloxone does not charm the heart beat into returning. Naloxone does not persuade the brain to function again.

This patient was dead. EMS wanted to pronounce him on scene, but the patient’s private physician insisted that futile resuscitation efforts be continued.

What do you mean futile?

The patient is reported to have been asystolic (my conclusion based on the description of lack of response and desire to pronounce on scene) and unresponsive to half an hour of full resuscitative attempts. I do not know the specifics, but Los Angeles protocols are likely to be very close to the ACLS guidelines. There is nothing about the circumstances that suggests any of the reversible cause of cardiac arrest.

What about OverDose?

It was already being treated by ventilating the patient.

But opioids also cause vasodilation!

And EMS has probably pushed enough epinephrine to make any patient, with a chance at resuscitation, hypertensive and hyperactive. Vasodilation is not a concern. The reason for the lack of blood pressure is the lack of a heart rate, not histamine induced vasodilation.

Demerol toxicity can also lead to seizures, because of accumulation of a toxic metabolite in the body.

This is true, but seizures would have been an improvement at this point. Cadavers do not have to worry about toxicity.

Then why did they work on him for so long at the hospital?

Famous people with lots of money may pursue ridiculous law suits much longer than other people. When a lawyer, who works on a percentage basis, sees no reason to continue, the lawyer will find a way to drop the case. When the client is paying out of pocket, pockets that contain hundreds of millions of dollars, and the client does not care how much it costs, and the client has unreasonable expectations, things will be done differently. The patient’s personal physician was probably part of the reason. I have never heard of any case of resuscitation being continued even half as long as this, except in the case of intermittent return of pulses or a potentially reversible cause of cardiac arrest (such as hypothermia).

On scene, the patient’s doctor is one person, who generally outranks EMS. The same would be true for a hospitalized patient being transferred. As long as the patient’s doctor is present, the patient’s doctor has final say on medical decisions. That may be different in different states. Generally, a doctor needs to get permission from OLMC (On Line Medical Command) to take over treatment decisions from EMS. Part of that is agreeing to accompany the patient to the hospital. The patient’s private physician is probably not covered by this. In a VIP case, like this, I would expect the physician to want to accompany the patient. I doubt that OLMC would want to tell the private physician to let EMS run things, unless the private physician is causing problems other than demanding that care be continued. That is one thing OLMC is unlikely to fight about with the doctor who is there and is the patient’s doctor.

What about the pictures that were published? How could EMS let that happen? That is a HIPAA violation!

The primary responsibility of EMS is to take care of the patient. Privacy comes second. With a team of private security on scene, I would be delegating all privacy management to the people who are paid around the clock to protect his privacy. They also have a responsibility above privacy – his safety. They have already done all they are going to be able to do to address his safety, so privacy may be their primary remaining job.

It is unfortunate that there is a picture of the resuscitation efforts. As with Jett Travolta, the fame, or money, or both, or something else, caused someone to decide that this was a good time to get a picture to share with the gossip rags. Others have republished the picture, because it is already out there.

The blame should be addressed primarily at the people who took the picture, sold the picture, bought the picture, and first distributed the picture. Much less important is blaming those in security, or EMS, who might have prevented this. This kind of picture gets out because there is a huge market for it. The publisher will make a killing in both sales volume and reputation. The purchasers may not be the majority of the population, but there are enough to make this very profitable. We have met the enemy . . . . My doesn’t that reflection make us look unattractive.

So, blame EMS?

No. I don’t even have real criticism for security. They are probably not used to dealing with a death. Not like that.

Blame EMS for not reversing an opioid overdose?

He was already dead. Not much chance of a good outcome when an opioid overdose leads to cardiac arrest. He had probably been receiving inadequate CPR, so what is there to work with in a situation that deteriorates rapidly over just a few minutes.

What about the Demerol?

I will have to write a follow up on the use of Demerol. There is a lot to write.

Again, STATter 911 is the source that seems most current on EMS aspects of this case.


^ 1 Michael Jackson EMS Response Details Emerge
Posted by Firefighter Nation WebChief on June 26, 2009 at 3:14pm in Fire/Rescue News
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citing JEMS.com