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

- Rogue Medic

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.