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

- Rogue Medic

The Medical Command Permission Ruse I

Ruse – ▸ noun: a deceptive maneuver.

When using the term Medical Command Permission Ruse, I am using ruse to describe the role of requirements for medical command permission. The ruse is the suggestion that medical command permission requirements protect patients.

Where is there any evidence to support this? The requirement for medical command permission is only a deceptive maneuver to give the appearance of doing something to protect patients. It allows medical directors to protect their ignorance unfounded fears from exposure. If they required competence from paramedics and encouraged appropriate pain management, they should not feel any need for these restrictions.

Have you ever tried to treat a patient with legitimate severe pain, but you were refused orders for morphine?

How does refusing appropriate pain management help the patient’s severe pain?

Have you ever tried to treat a patient with legitimate severe pain, but you were only given orders for 2 mg of morphine?

How does refusing appropriate pain management help the patient’s severe pain?

Have you ever tried to treat a patient with legitimate severe pain, but you were only given orders for 2 mg of morphine with the possibility of one, and only one, repeat of the same dose?

How does refusing appropriate pain management help the patient’s severe pain?

And yet, doctors continue to use these medical command permission requirements to restrict the amount of morphine a patient may receive.

To be fair, there are plenty of medical command physicians who give appropriately aggressive orders for pain management. I have not had many medical command physicians refuse to give orders for morphine for severe pain, but some is still too many.

More often, I have had medical command physicians hesitant to give more than 2 mg of morphine and maybe a repeat if the initial homeopathic dose does not produce a miracle. Perhaps the simple formula below will explain this.

Severe Pain + 2 mg Morphine = Severe Pain.

When treating severe pain in otherwise healthy adults, the starting dose of morphine should be 5 mg or 10 mg, but that is just the starting dose. For one patient who had a couple of fingers amputated, 20 mg of morphine brought his pain all the way down from 10 out of 10 to the almost indistinguishable 9.8 out of 10. He weighed 70 kg, so this was not a size thing.

The only competent way to tell if the dose is appropriate is to reassess.

For that patient, 20 mg of morphine was not close to enough. Unfortunately, the flight nurse and flight medic were not comfortable giving this awake and alert patient with severe pain any treatment for his severe pain because he had already had so much. They should have been more worried about his severe pain being so much.

The only competent way to tell if the dose is appropriate is to reassess the patient, not to reassess the dose or to reassess the protocol.

Discouraging pain management should be an embarrassing part of EMS history, but it still exists and it is still defended. This needs to stop.


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.


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


To Restrain or Not To Restrain, But That’s Just the Beginning of the Question – comment

In the comments to To Restrain or Not To Restrain, But That’s Just the Beginning of the Question, jeg43 wrote,

I am astonished that restraint is an issue in this day and age.

Restraint should not be an issue, but it still is. Pennsylvania actually has better protocols than many other states/localities.

Wait! I do see the legal components.

There are many legal components of this, but consider the first footnote I showed in the chemical restraint protocol –

2. Do not permit patient to continue to struggle against restraints. This can lead to death due to severe rhabdomyolysis, acidosis, dysrhythmia, or respiratory failure. Medical command should be contacted for possible chemical restraint with sedative medication.[1]

I think the suggestion that medical command be contacted, is one that appeals to a medical director who does not have to physically get involved in restraining patients. Dr. Kupas is the state medical director for Pennsylvania, the one who has his name attached to these protocols. He was (probably still is) a paramedic. He has to convince a committee of regional medical directors of the appropriateness of these protocols. Or, it could be the other way around.

I have only briefly talked with him about pain management protocols, something that could have progressed into a conversation on sedation. It would be a natural progression of such a conversation. In stead the conversation was quickly terminated by Dr. Kupas. He stated that he was trying to change the pain management protocols to get the regions that prohibit standing orders for pain management, to be more aggressive.

He also stated that he wanted to reign in the more aggressive regions. These regions had standing orders that are only dangerous if the medical directors are authorizing incompetent paramedics to treat patients. Of course, any protocol can be dangerous in the hands of an incompetent paramedic, but these medical directors really, really believe in the magical powers of OLMC (On Line Medical Command requirements for permission to treat). He ended the conversation right there. Then went to stand in the back of the conference room.

I never had the opportunity to ask him the relevant questions.

Why do EMS patients not deserve appropriate pain management in Pennsylvania?

Why do EMS patients not deserve appropriate sedation in Pennsylvania?

Why is this at the whim of the doctor answering the phone?

It all does depend on the mood of the doctor answering the medical command phone, their approach to pain management, the culture at that particular hospital, . . . . Some doctors are great and give appropriate orders for the patient. Some act as if the patient is unimportant and they are doing me a favor by giving me orders to treat the patient appropriately.

My patient vs the doctor’s patient. Is there a real distinction, when I am following the doctor’s orders? Of course, my patient is also their patient. So by doing me this wonderful favor, they are allowing me to prevent them from mistreating their patients. Try getting some of the doctors to understand that.

Eventually, some lawyers will recognize that inadequate prehospital pain management and inadequate prehospital sedation are areas of medical direction malpractice that will probably be gold mines in the courtroom.

The doctor has an obligation to the patient.

The doctor ignores that obligation, perhaps out of some infantile attitude that the patient’s pain does not matter until the doctor sees the patient. Maybe the doctor is overworked. Maybe the doctor just has no competence in pain management. Maybe the doctor just authorizes a lot of incompetent paramedics, and thinks this provides some safety for the patients. It does not.

After reading most of your linked posts I have another reaction: Self, never, never let anyone put you in an ambulance. Wait! Bad idea. I may not be able to make that decision and may need help urgently. Another thought: This is information I really did not want to have. And: Damn. The EMS have issues of clusterf**kedness just like the rest of reality.

Yes, there are many problems, but things are improving. As more physicians have more experience with EMS, and with pain management and sedation, the competence level improves. There are still hospitals that do not allow emergency physicians to use fentanyl or propofol in the management of patients. These are considered anesthesia-only drugs in some hospitals. The research on the use of fentanyl and propofol by emergency physicians is extensive. This research demonstrates the safety of administration by emergency physicians without an anesthesiologist holding their hand.

As there is research to show that emergency physicians can safely administer these medications. Anesthesiologists are becoming much more comfortable with emergency physicians using these drugs.[2] There is less extensive, but similar research showing the safety of aggressive pain management and sedation by EMS. Some emergency physicians are becoming more comfortable with EMS treating these patients without the, OLMC holding their hand, Mother-May-I call.[3]

Both examples are in the interest of improving patient care. Some physicians will use the irrelevant distinction that medics are not doctors. Of course medics are not doctors. If we are treating patients according to EBM (Evidence-Based Medicine, or as some prefer – SBM or Science-Based Medicine), then the critical part is, What is best for the patient?

The question is not, What is best for maintaining the customary hierarchy? The question is not about the status or authority of the emergency physician. Appropriately aggressive oversight requires an involved competent medical director. It does not require polling the local OLMC to see what mood the doctor is in, or to see if Dr. Just Transport is working, or any other random factor, factors that are irrelevant to what is going on with the patient. Factors that are irrelevant to patient care.

The evidence is clear. EMS can aggressively manage sedation and pain without ED doctors holding their hand. This hand holding only serves to delay appropriate care, not to improve it. For these patients, delayed care is worse care. For these patients, delayed care is bad care.

Then: You mean to tell me that there are incompetent medics actually treating emergency patients? And OLMC is in place because no one will fire the incompetent medics thus adding to the problems of timely emergency care/treatment?

Maybe I should phrase it – OLMC is in place, because of a poor understanding of risk management, a poor understanding of EMS, and a lot of other responsibilities. I have spent a lot of time trying to convince medical directors of the safety of standing orders and of the importance of aggressive oversight. They deny that there is a problem. They deny that there is a better solution. They see the problem as other medical directors approving dangerous medics and they have to protect patients from those medics. this only perpetuates the problem. As the state changes to more liberal standing orders – appropriately liberal – medical directors will need to adapt.

Yes, there is a problem of inappropriately liberal standing orders. The medical director, who says, Do whatever you want, yet does not provide aggressive oversight. This does nothing to manage the quality of care, either.

Two things more:
1) Each time I read one of your posts, my respect and appreciation for who you are and what you do increases. Thank you, sincerely, for your effort.
2) Is there anything a civilian, not in any way connected to the field of medicine, can do to help you other than shoot identified incompetents?

Thank you. EMS is a job that appeals to several different types of people. Many of us in EMS would not fit in in a M-F 9-5 world. I am glad there are people, other than me, to do those jobs. I could write a lot of posts on EMS personalities and finding the right niche to fit into.

Unfortunately, as a civilian, there is not much you can do. If there are hearings on any changes in EMS, where you live, go find out what you can. Ask questions. Get involved in the discussions. Unfortunately, even those in EMS have a poor understanding of how to best provide EMS. People in EMS do want to help patients, but we often disagree about what is best.


[1] Pennsylvania EMS Statewide ALS Protocols
Effective November 2008
Pages 100/121 to 102/121 in the pdf page counter
Page with link to the full text PDF of the protocols.

[2] “Poachers and Dabblers?”: ASA President’s Incautious Comment Riles Emergency Physicians
George Flynn
Special Contributor to Annals News & Perspective
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed – indexed for MEDLINE]

[3] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

This is just one example of the appropriately aggressive and safe use of fentanyl in EMS. This is much larger than the rest of the research on the topic combined. I wrote about the study, in more detail, in Public Perception of Pain Management.


To Restrain or Not To Restrain, But That’s Just the Beginning of the Question

In a JEMS article,[1] Dr. Keith Wesley reviews a study of an education program on the use of restraints in EMS.[2] This is a one hour teaching module inserted into their paramedic curriculum. The lecture part of it is taught by a physician, even though there is no chemical restraint portion to the class. This is just one hour, but appears to include a pre-test, a lecture, 5 video scenarios, a 14 point module that covers all of this, and a post-test. To me, this seems like a lot to cover in an hour. It seems a bit too ambitious.

If you really want people to understand patient restraint, there is no substitute for a real violent patient. Not a teacher, or another student, pretending to be violent. How much time would it take at a psychiatric facility before a student would have exposure to a violent patient?

Oh, my! You would endanger a student by intentionally putting the student in a violent situation?

Of course. What do you think they will be doing once they are working with real patients?

In a psychiatric facility, there should be plenty of people around to assist with restraining patients. The goal is to have some experience with this before being let loose on real patients without adequate backup.


Emergency medical services (EMS) providers may encounter agitated and violent patients,1-7 and these encounters can result in significant injury to the patient and to EMS personnel.2,3,7,8 In one retrospective descriptive study by Mechem et al., EMS workers in a large urban EMS system submitted 1,100 injury reports during a two-year period. Of these, 44 (4.0%) injury reports were the result of an assault. Paramedics were assaulted in 35 (79.5%) of these incidents and firefighters in nine (20.5%). Forty-one assaults (93.2%) occurred during patient care activities.9 In our own Metro EMS system, which responds to approximately 65,000 calls per year, EMS personnel also frequently face violence from agitated patients.10 EMS providers restrain agitated patients to ensure the protection of providers, to protect the patient from injury, or to facilitate delivery of medical care.1-3,6,7 [3]


The study by Dr. Mechem is from Philadelphia. The study looking at the teaching module is from Pittsburgh. Opposite sides of the same state. For the past few years, they have supposedly been working off of the same protocols. Local medical directors can make their protocols more restrictive. Dr. Mechem is likely to do that. From what I have heard of Pittsburgh, that is less likely, but I do not know how either has handled these protocols. Why do I mention the protocols, since we are looking at a teaching module that does not address chemical restraint?

This study is to be part of a multiphase prehospital restraint use study determined to evaluate the effectiveness of various interventions in reducing patient agitation and resulting assaults on EMS personnel. In the future, we are adding chemical restraints to the system protocols and will add this to the educational module. It was a limitation of the study that chemical restraint information was not included in the module.[3]


As they mention in the study, this is just the beginning of what they are doing. chemical restraints were added to the Pennsylvania ALS (Advanced Life Support) Protocols in November 2008.

The addition of the ability to chemically restrain a patient without calling command for orders is also a start. Pennsylvania seems to be trying to take an evidence based approach to EMS treatment. Unfortunately, it is mostly by slow baby steps.

From the Agitated Behavior/Psychiatric Disorder Protocol –

Contact Medical Command, if possible

If continued struggling,2 Administer Sedation
(See box below)

Monitor continuous ECG and Pulse Oximetry, when feasible

Sedation Options:
(Choose one)

Lorazepam 1-2 mg IM/IV/IO 3 (0.1 mg/kg, max 2 mg/dose)
may repeat every 5 minutes until maximum of 4 mg


Diazepam 5-10 mg IM/IV/IO 3 (0.1 mg/kg)
may repeat every 5 minutes until maximum 0.3 mg/kg


Midazolam 1-5 mg IM/IV/IO 3,4 (0.05 mg/kg)
may repeat every 5 minutes until maximum of 0.1 mg/kg


Protocol Footnotes:


2. Do not permit patient to continue to struggle against restraints. This can lead to death due to severe rhabdomyolysis, acidosis, dysrhythmia, or respiratory failure. Medical command should be contacted for possible chemical restraint with sedative medication.

3. If age > 65, reduce doses of sedative benzodiazepines in half.

4. Regional or service policy may permit intranasal midazolam, but this may not be as effective as parenteral medications.[4]


The maximum doses for restraint are not adequate. I have doubled the dose and not caused any decrease in room air oxygen saturation. This is just a start by the state. Perhaps they will improve the protocol as they see it in use. As they see it fail to control patients. As they see EMS and patients hurt, due to confidence that the maximum dose would be enough. If the goal is to protect EMS, police, family, and patients, the dose needs to be capable of actually causing sedation of the agitated patient. These doses may be effective on the sleepy patient, or if the patient has been thoughtful enough to pre-treat himself with alcohol.

According to the medical directors I have asked about restraint, Pennsylvania will never approve of the use of haloperidol (Haldol) or droperidol (Inapsine) for chemical restraint. but these are topics for another post.

Back to the topic at hand. Dr. Wesley states:

Violent patients represent a major risk to you and are a potential of great liability to EMS and law enforcement. This study is, I hope, just the first in what should be a multiphase, multi-center trial. The authors readily recognize its limitations.[5]



The worst thing that can happen is for educators and curriculum writers to read the conclusion and dismiss the value of including such a module into both initial and refresher education merely because it showed no change in behavior in this one small group of students. With the mantra of “Is the scene safe, BSI” forever emblazoned in our minds, I believe it’s the violent patient for whom we are unprepared that is more likely to harm us than any germ, virus or downed power line.[5]


Dr. Wesley has made some great points. In Pennsylvania, I think they are still unprepared, but they are improving. Years ago, when I was on a protocol committee, I was told that we would never have standing orders for opioids. There are now standing orders for morphine and fentanyl, except where the local medical director refuses to allow standing orders, so that the medical director can keep incompetent medics working.

I was told that we would never have a protocol for chemical sedation. There is now a statewide protocol for chemical sedation, except where the local medical director refuses to allow use of this protocol, again so that the medical director can keep incompetent medics working.

We need to put more emphasis on the safety of the patients and the safety of those treating the patients. We need to decrease the emphasis on the ability of the medical director to allow a dangerous paramedic to treat patients. Inappropriately limiting the treatments available to patients, to what the medical director thinks the least common denominator paramedic can use without killing patients, is bad medicine.

I have written about these dangerous medical directors here, here, here, here, and here.


[1] To Restrain or Not To Restrain
Keith Wesley, MD, FACEP
Street Science
2008 Dec 15

[2] Impact of a restraint training module on paramedic students’ likelihood to use restraint techniques.
Campbell M, Weiss S, Froman P, Cheney P, Gadomski D, Alexander-Shook M, Ernst A.
Prehosp Emerg Care.
2008 Jul-Sep;12(3):388-92.
PMID: 18584509 [PubMed – indexed for MEDLINE]

[3] Impact of a restraint training module on paramedic students’ likelihood to use restraint techniques.
Same as footnote 2.

[4] Pennsylvania EMS Statewide ALS Protocols
Effective November 2008
Pages 100/121 to 102/121 in the pdf page counter
Page with link to the full text PDF of the protocols.

[5] To Restrain or Not To Restrain
Same as footnote 1.