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

- Rogue Medic

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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Drug Shortages Affect Those Still in the Dark Ages – Furosemide

ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging.

Go check out the excellent material at both sites.

In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.

It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss furosemide.

Furosemide is not appropriate for EMS patients, because there are more appropriate drugs, more appropriate other treatments, and it is too often given to patients who have pneumonia.

MANAGEMENT OF APE
Fluid accumulation in the lungs associated with APE, until recently, was attributed to excess accumulation of total body fluid. Accordingly, treatment of APE was aimed at removing excess fluid from the lungs by promoting massive diuresis. However, this explanation for APE could not reconcile the fact that APE typically occurs during early morning hours when fluid intake is minimal. The current explanation is that APE results from fluid redistribution within the body whereby a part of the intravascular volume is redistributed to the lungs as a consequence of increased intravascular pressure as outlined above.13 Primary objectives for the treatment of acute CHF are to reduce pulmonary capillary pressure, to redistribute pulmonary fluid, and to improve forward flow.12,13 These may be achieved by reducing LV preload and afterload, providing ventilatory and inotropic supports, and identifying and treating the underlying etiology of the syndrome (Table 3). It should be recognized that these treatment measures are intended for APE patients who are normotensive or hypertensive and not those who are hypotensive. The latter comprises cardiogenic shock secondary to severe LV systolic dysfunction; treatment of these critically ill patients is beyond the scope of this review.[1]

That is a big paragraph, but there is a lot of information in there. Enough to convince us that we should not be using furosemide to treat an acute onset/exacerbation of heart failure.

In the chart below, before furosemide in treatment there are plenty of other treatments. Notice that only oxygen comes before NTG (NiTroGlycerine) and the more severe the symptoms, the more NTG is given.
 

Mild symptoms – One 0.4 mg NTG spray/tab – repeated every 4 to 5 minutes.
 

Moderate symptoms – High-dose NTG, which is explained below.
 

Severe symptoms – Two to five 0.4 mg sprays/tabs at a time – repeated every 3 to 5 minutes.
 

But, but, but, but, but, . . . . . we can only give a maximum of 3 NTG – ever.

Then you need to get a better medical director, because your medical director has you killing patients.

Am I being too subtle?

Another treatment that is very effective is CPAP (Continuous Positive Airway Pressure) which is a BLS (Basic Life Support) skill, except where medical directors like to kill patients. When using CPAP (a form of NIPPV – Non-Invasive Positive Pressure Ventilation), NTG paste can be applied. Do not be shy with the paste, because nothing is absorbed well through the skin when the skin is pale. Pale means a lack of circulation. Also, since the appropriate dose is much more than standard NTG dosing, there is not much reason to hold back.

I disagree about the placement of CPAP at the bottom. CPAP should be started right away. This was published in 2003, so it is kind of old and conservative.

You call that NTG use conservative?!?!?

I do. I have given dozens of NTG in a period of 10 to 20 minutes and never had a patient experience any adverse effects while in my care or at the hospital. I have written elsewhere about the superstitious way we approach NTG.

Furosemide is in there, but only if the patient has peripheral edema. If there is no peripheral edema, is fluid overload the problem? That is a fluid redistribution problem. There is fluid in the wrong place, but that does not mean that the whole body is overloaded with fluid or that putting a bunch of fluid in the bladder is going to make things better. Moving fluid to the bladder does not mean that we are removing it from the lungs any more than we are removing fluid from anywhere else.


Click on the chart to make it bigger. I know I can’t read any of it at this size. This is from the same paper as the paragraph above.

Well, that is just one paper. Nobody else would be so irresponsible as to recommend such large doses of NTG.

Then let’s read about what they do in the ED (Emergency Department).

Most patients who experience CPE, however, do not have ECG evidence of an acute dysrhythmia or AMI. Treatment should therefore be aimed at redistributing the excessive pulmonary interstitial fluid into the systemic circulation, which improves alveolar oxygen-carbon dioxide exchange and hypoxia; therefore, pharmacologic agents that provide preload reduction and afterload reduction should be administered. In some cases, inotropic support is required also.[2]

What drugs do we use to provide preload reduction and afterload reduction?

Nitroglycerin
The most effective and rapidly-acting preload-reducing medication is nitroglycerin (NTG) [21–25]. Multiple studies have demonstrated the superiority of NTG over furosemide [21,24,26–28] and morphine sulfate [28–30] for preload reduction, symptomatic improvement, and safety. NTG can be administered in sublingual, IV, or transdermal form, although the transdermal absorption can be erratic in the patient in extremis. NTG also has the benefit of a short half-life; therefore, if the patient develops a precipitous fall in blood pressure (generally uncommon in CPE {Cardiogenic Pulmonary Edema} patients), the blood pressure should return to previous values within 5 to 10 minutes of discontinuation of administration.[2]

But what about the dose?

In one study [26], 3 mg IV boluses of NTG were administered every 5 minutes to patients who had developed CPE, a dose equivalent to a 600 mg/min infusion. This protocol was found to be safe, well-tolerated, and effective for these patients and associated with reduced need for mechanical ventilation and more rapid resolution of symptoms. Standard anti-anginal dosages of sublingual NTG with which most physicians are comfortable (ie, 400 µg every 5 minutes), has the bioequivalence of an IV NTG infusion of 60 to 80 µg/min. Physicians should, therefore, be comfortable with the safety of even higher dosages of NTG for patients who experience CPE and usually present in a hyper-adrenergic state with moderately-to-severely elevated blood pressures.[2]

That is 7 1/2 times to 10 times the standard dose of NTG – with no problems.

Maybe that maximum of 3 NTG is something that should be ignored. The AHA (American Heart Association) seems to be ignoring it. Just try to find a limit on NTG administration in the current ACLS, which is from 2005.

These papers are available in PDF format, so you can print them out and hand them to your medical director and/or to the other doctors in the ED.

These are important papers. Both are review articles. One is written for EMS, while the other is written for the ED.

If you are feeling aggressive, maybe you can write on the bottom, Call me about improving the protocols we use to treat our patients.

There is one problem with this. This will lead to fewer intubations.

The best intubation is the intubation that is prevented by excellent patient care.

Footnotes:

[1] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]

Free Full Text PDF

[2] Modern management of cardiogenic pulmonary edema.
Mattu A, Martinez JP, Kelly BS.
Emerg Med Clin North Am. 2005 Nov;23(4):1105-25. Review.
PMID: 16199340 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Mosesso VN Jr, Dunford J, Blackwell T, & Griswell JK (2003). Prehospital therapy for acute congestive heart failure: state of the art. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 7 (1), 13-23 PMID: 12540139

Mattu A, Martinez JP, & Kelly BS (2005). Modern management of cardiogenic pulmonary edema. Emergency medicine clinics of North America, 23 (4), 1105-25 PMID: 16199340

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Drug Shortages Affect Those Still in the Dark Ages – Lidocaine

ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging.

Go check out the excellent material at both sites.

In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.

It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss lidocaine.

Lidocaine is not appropriate for EMS patients, because there are more appropriate drugs. Lidocaine is still used for cardiac arrest, even though there is absolutely no reason to believe that it does anything positive for the patient.

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.[1]

In other words, amiodarone doesn’t work, but lidocaine is even worse.

Lidocaine is also used for ventricular tachycardia with similar lack of effect.

Lidocaine terminated ventricular tachycardia in four of 31 patients, ajmaline in 19 of 30 patients (P<0.001).[2]

Lidocaine is no better than holding the patients hand or any other placebo. Spontaneous remission of ventricular tachycardia should occur in more than 4 out of 31 patients.

DC shock was used in 16 nonresponders (22.9%) to procainamide and 10 non-responders (50%) to lidocaine.[3]

Only 35% of patients improved after lidocaine. Maybe they improved because of lidocaine – maybe not. More important is that 50% of patients who received lidocaine ended up being cardioverted. Did they require cardioversion because of the lidocaine?

Would you recommend a drug that leads to half of patients being cardioverted?

Footnotes:

[1] Medications for Arrest Rhythms
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Free Full Text

[2] Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia.
Manz M, Mletzko R, Jung W, Lüderitz B.
Eur Heart J. 1992 Aug;13(8):1123-8.
PMID: 1505562 [PubMed – indexed for MEDLINE]

[3] Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia.
Komura S, Chinushi M, Furushima H, Hosaka Y, Izumi D, Iijima K, Watanabe H, Yagihara N, Aizawa Y.
Circ J. 2010;74(5):864-9. Epub 2010 Mar 26.
PMID: 20339190 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Table 3 is from this paper. As you can see, lidocaine is a joke compared to procainamide.

Manz M, Mletzko R, Jung W, & Lüderitz B (1992). Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia. European heart journal, 13 (8), 1123-8 PMID: 1505562

Komura S, Chinushi M, Furushima H, Hosaka Y, Izumi D, Iijima K, Watanabe H, Yagihara N, & Aizawa Y (2010). Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Circulation journal : official journal of the Japanese Circulation Society, 74 (5), 864-9 PMID: 20339190

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Comment on Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In response to Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients, there is a comment by medic.

thank you for your post. i’d like to add a few thoughts, and please feel free to comment on them.

Thank you.

1. i have a suspicion that pts who rate their pain 7-8/10 tend to be more honest about their pain than the ones who rate their pain 10/10 (worst pain ever), which perhaps partially explains the study’s findings when sorted by initial pain rating.

That may be. Pain is subjective. Out of 119 patients, only 5 rated their pain 7 out of 10, so this is a small fraction that may not indicate anything. If we wish to draw conclusions about patients with 7 out of 10 pain, we need to set up a much larger study and propose our hypotheses before the study is begun.

Even if a report of 7 out of 10 pain is more honest than a report of 10 out of 10 pain, does that make it any less appropriate to treat 10 out of 10 pain aggressively?

2. competence is a huge factor is any setting, not just ems. there are plenty of (supposedly better-trained) docs and nurses who are clearly retarded.

Retarded is not the right word. However many doctors, nurses, and medics just do not get it. Maybe pain management has not been explained to them in the right way.

Many doctors do seem to become much more comfortable using opioids to treat pain after experiencing severe pain themselves.

We never seem to hear about doctors becoming less comfortable using opioids after experiencing severe pain.

This suggests that there is something important that is not understood by the doctors until after experiencing severe pain.

I suspect that studying this might require a huge sample of doctors, just to be able to track the change in prescribing/ordering habits vs. personal experience of severe pain, whether their own pain or the pain of someone they care deeply about.

3. i personally have a high threshold for when i break the narcs open, as i too work in a poor area. that’s not to say poor people can’t have pain; that’s just taking into account other factors such as a seemingly higher rate of drug use/abuse.

It isn’t our pain threshold that matters, but the patients’ pain threshold.

Opioids are not the appropriate treatment for all pain, but it is appropriate to treat severe pain aggressively with opioids when nothing else works (such as when nothing else is available). Nitrous oxide is something that can be safely used that might significantly decrease the amount of morphine needed to manage severe pain.

4. once i make the decision to use narcs, i am not stingy with them as experience shows that prehospital morphine doses are clearly inadequate. the more important issue here is a training crews for a heightened awareness of the potential for respiratory depression and allergic reactions (just had one last week).

And what did you need to do for the allergic reaction? Diphenhydramine?

Just because something happened last week, does not mean that it is common. We need to be aware of the potential for allergic reactions with all of our medications.

One of the many advantages of fentanyl, over morphine, is that fentanyl is much less likely to produce an allergic reaction.

Recognizing and dealing with respiratory depression should not require anything more than competently monitoring the patient.

Many, but not all, patients will experience respiratory depression with appropriate pain management, because pain tends to stimulate a sympathetic response. Having respirations decrease to normal is a good thing, even though this is respiratory depression.

If the patient shows signs of inadequate oxygenation/ventillation due to respiratory depression, then all that needs to be done is to get the patient to talk. Find a subject that the patient is interested in, people love to talk about themselves, and get them to keep talking. Or just keep asking questions that are not answered with a nod, or shake, of the head. Ask orientation questions. Even just telling the patient to take a deep breath every so often will work.

A talking patient is a breathing patient.

5. it’s a big training issue to get crews to recognize those pts who are in pain and those who are trying to score narcs. this is where experience counts and it’s difficult to teach. that being said, it’s risky to presume that people are trying to score narcs.

We should not presume that people are trying to manipulate us to give them drugs inappropriately. We should be aggressively looking for indications that the patient has legitimate pain.

If I need to give out morphine and fentanyl to a bunch of junkies in order to avoid missing some patients with legitimate pain, then I will be the candy man.

Let me put this in perspective.

If I need to give out albuterol nebulizer treatments to a bunch of people who do not need nebulizer treatments in order to avoid missing some patients with legitimate asthma/emphysema/bronchitis, then I will be the nebulizer man.

If I need to give out IV dextrose to a bunch of people who do not need to receive dextrose through an IV in order to avoid missing some patients with legitimate hypoglycemia and an inability to take glucose by mouth, then I will be the dextrose infusion man.

If I need to take some people with minor injuries to a trauma center in order to avoid missing some critical trauma patients, then I will be the minor trauma man.

I am not encouraging over-treatment, for the sake of over-treatment. We do need to be much better at assessment, rather than treating mechanism. How much training do we have at recognizing drug seekers, who are not seeking drugs for legitimate pain? If we are trained at this in paramedic school, or on the job, what are the qualifications of the person providing this training? What research has been done to demonstrate the accuracy of the methods of differentiating between legitimate drug seekers and illegitimate drug seekers?

The best way to make someone a drug seeker may be to under-treat their pain.

Our concern needs to be much less on being police and much more on being paramedics.

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Prehospital use of analgesia for suspected extremity fractures


ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

This is an older study that puts the prehospital pain management problem into a bit of perspective. While prehospital pain management has improved a lot in some places, other places may still be handling pain as described in this study. This is only ten years old. Attitudes are not changed so easily.

The authors looked at what is probably the least controversial type of pain management. If you were to ask medical directors what they feel most comfortable having paramedics use opioids to treat, the only other choice is likelty to be pain due to burns. Chest pain became a bit controversial after the CRUSADE study, but I will get to that in another post.

Over the last decade, pain and its management have received considerable attention. Most notably members of the medical profession in general and specifically emergency medical professionals undertreat pain to a considerable extent.3 [1]

While I would love to be able to defend everyone from this charge euphemistically referred to as undertreatment, the reality is that a decade later, the problem has not changed that much.

This was an observational study involving a retrospective review of all emergency medical services (EMS) runs for suspected extremity fractures[1]

During the study period, all EMS run reports were evaluated by the fire department’s quality assurance coordinator. Only reports documenting the paramedic’s impression that the patient had sustained a fracture, or suspected fracture, of any extremity were included in the database.[1]

There is no mention of any requirement to document any kind of measurement of pain. This seems to be the most significant problem with pain management in the system studied. How do we assess the quality of pain management if we do not assess pain?

The whole structure of this study revolves around the apparent inability to assess pain. There are a bunch of conclusions drawn. Here is what may be the most important omission of the study.

If we do not assess something, how do we treat it appropriately?

If a medical director does not make it clear that pain assessment and management are taken seriously, then is there much reason to expect the paramedics to be more aggressive than the medical director?

We need to provoke medical directors, emergency physicians, emergency nurses, EMTs, and paramedics to take pain seriously.

It’s not my pain.

Akron Fire EMS employs a two-tiered transport system whereby nonurgent patients who may be safely transported in a private vehicle are deemed code 1, allowing the med unit to be put back into service. Nonurgent patients who require ambulance transport to the hospital become code 2 and their care and transport to the hospital are transferred to a private ambulance. A patient requiring immediate transport, medication, or procedures rendered by a paramedic is transported directly to the hospital as a code 3.[1]

The two-tiered structure of this EMS system may unwittingly serve to negatively affect the administration of pain medication in several ways. Administering pain medication to a code 2 patient, for whom transport to the emergency department would be transferred to a private ambulance, would automatically change the run to a code 3. Upgrade to a code 3 would necessitate transport directly to the emergency department by the treating paramedic squad, extending the time required to complete the run.[1]

Another question is whether code 3 means a lights and sirens transport to the ED. What extremity fractures, other than those cutting off circulation, require such rapid and rough transport? Even fractures cutting off circulation are unlikely to benefit from the slight difference in transport time that lights and sirens would provide. Slightly faster, but much rougher and much more painful in spite of the pain medicine! Why?

How did this service do at using pain medicine to manage suspected extremity fractures, which are expected to have a high correlation with severe pain?

A total of 18 patients (1.8%) received treatment for pain; nitrous oxide was administered to 16 patients (1.6%), and morphine sulfate to two patients (0.2%).[1]

We know that 16 patients (out of a thousand patients with suspected extremity fractures) received nitrous oxide and 2 patients (out of a thousand patients with suspected extremity fractures) received morphine.

We do not know if they were being treated for pain, since there is no indication of any assessment of pain. We expect that the patients with suspected extremity fractures would have a lot of pain. If you have ever had a painful extremity fracture, you might expect all extremity fractures to be painful. You might also desire that many, most, or even all of these suspected extremity fractures be treated with pain medicine. The authors do not provide anything to support this conclusion.

Let’s look at the injuries documented.

All of them seem as if they would be painful fractures. Still, we do not know anything about the pain of these patients.

What else was done that might have acted as pain management?

Supportive medical treatment provided included air splints (25% of patients); full immobilization (19%); ice packs (17%); bandages/dressings (16%); and intravenous lines (9.4%).[1]

Air splints may help to relieve pain by positioning the extremity in a less painful, assuming there is any pain, position. Splinting may temporarily increase pain during application.

Full immobilization is unlikely to provide any pain relief. Full immobilization on a solid long spine board is expected to increase pain.[2]

Ice packs can increase pain, decrease pain, or both.

Bandages/dressings might provide some stabilization, or pressure, that decreases the sensation of pain.

Intravenous lines are often painful. If I only suspect an extremity fracture, I would not have any other justification to be starting an IV, except to have a route to deliver IV pain medication. 2 patients received IV pain medication. 94 patients received IV lines. 2/94?

Did one medic start a line, while the other medic contacted medical command. Since The care of each patient is discussed with an online medical control emergency physician in a local emergency department, the superfluous medic may use that time to get online medical control emergency physician contact out of the way, so that the medic can do something useful, such as assessing or treating the patient.

Did the online medical control emergency physician give this counter-order to the medics? Do not follow your standing orders for pain management. Do not give any pain medicine.

Were the medics, or was one of the medics, hesitant to provide any pain medicine without first contacting the online medical control emergency physician?

Are the medics routinely yelled at by emergency physicians if they administer pain medicine without requesting permission first, even though protocols allow them to give pain medicine without asking for permission?

Do administrators receive complaints from emergency physicians when medics follow standing orders for pain medicine?

The number of patients receiving morphine is so small, that I want to know what was so bizarre about these patients that these Just say No! paramedics gave morphine.

Was the morphine given on standing orders?

Was the morphine even given intentionally?

Since giving morphine for suspected extremity fractures is such a freak occurrence in this system, is there any evidence to suggest that these were not 2 medication errors?

Is the occurrence of morphine administration any less rare than the system’s occurrence of medication errors?

The use of morphine is so breathtakingly out of the ordinary in this system, that I do not see any reason to conclude that there is any connection between morphine and suspected extremity fracture. Were any other medications, aside from nitrous oxide, given to any of these patients? Were any of those medications given more frequently than morphine? 2/1,000 suspected extremity fractures.

The EMS pain control policy included standing orders for administration of either morphine sulfate (adult dose: 2–5 mg intravenous push [IVP], may repeat x 1; pediatric dose: 0.1 mg/kg) or nitrous oxide (50%), self-administered. The care of each patient is discussed with an online medical control emergency physician in a local emergency department. By protocol, analgesic therapy is contraindicated in patients with the following conditions: altered level of consciousness; alcohol or drug use; allergies to morphine or nitrous oxide; hypotension; head injury; chest injury with suspected pneumothorax; abdominal pain with possible bowel obstruction; symptomatic asthma or chronic obstructive pulmonary disease (COPD); or respiratory distress.[1]

Even with standing orders, patient care must be discussed with a doctor. In that case, are they really standing orders? There are a lot of contraindications. I almost expect to see suspected extremity fracture listed as a contraindication for morphine. How much different would the results be, if that were the case?

2/1,000 vs 0/1,000.

Is this number, 2/1,000, even close to being statistically significant?

We don’t know how many of the 1,000 patients actually had pain that would be appropriate to treat with morphine.

This study examined the use of analgesia in 1,000 prehospital patients with suspected fractures of the extremities who were treated by paramedics. Of the 1,000 patients, only a very few (1.8%) received any pain medication, although morphine sulfate and nitrous oxide were available to the paramedics by both standing order and direct physician order through online medical control.[1]

I think it is misleading to suggest that there was any encouragement by medical command to treat patients with morphine. However, I have no way of knowing if one, or both, of the patients treated with morphine only received morphine because the doctor ordered it.

My experience with online medical command has been one of repeated refusal to give orders for for pain medicine for patients with pain – pain that I would be authorized to treat on standing orders under my current protocols.

What is the difference?

The patients treated with morphine do not suffer as much. The medical command physician does not get to exercise a medical whim to deny pain medicine purely due to the physician’s lack of understanding of pain management.

The mean time spent on the scene for all patients in the study was 23 ±3.4 minutes. Scene times were significantly longer for patients who received pain medication (n = 18) 32.8 ±17.4 minutes, than for those who did not, 22.8 ±10.4 minutes (95% CI 5.22 to 14.58). Transport times to the area hospitals average 7 minutes in this system, with the three main receiving hospitals located in the same geographic area.[1]

Unless a patient is unstable (or at risk of injury if not moved), there is no good reason to transport the patient until after the pain is managed. It does not matter if this means an extra 5 minutes on scene or an extra hour on scene. More aggressive dosing (morphine 0.1 mg/kg followed by 0.05 mg/kg every 5 minutes until significant relief) and more appropriate medication (fentanyl at appropriate doses) will result in less time on scene. We should not be manipulating painful injuries until after the pain is managed, unless there is some good reason. That is rare.

When I call for orders for more pain medicine, because the standing orders have not been appropriate in managing pain, medical command often wants to know how far I am from the hospital. My response is, That depends on how quickly I get orders for appropriate pain management, because the patient is not being moved until the pain is managed. Why isn’t that obvious to everyone?

Why increase the patient’s pain to move the patient to bring the patient to the pain medicine in the hospital, when the patient can be treated just as safely, if not more safely, before being moved?

Second, the administration of nitrous oxide requires that in addition to directly transporting the patient, the paramedics must also exchange the used nitrous tank for a new one. In Akron, the only tank exchange site was located in a remote part of the city, necessitating extended duties and travel time for one of the paramedics. Upon completion of this study, replacement nitrous tanks were placed in each of the 12 fire houses to facilitate more convenient restocking.[1]

It is good to see that they are trying to make things better for patients by eliminating the excuses used by paramedics, when medics rationalize avoiding treating patients appropriately.

Managing pain in the prehospital setting may require a multifaceted approach. Pain experienced by the patient must be evaluated in an objective manner, and once assessed, managed appropriately. Prehospital care providers should be encouraged to appreciate their patients’ pain and given the tools and affirmation needed to provide the most appropriate care.[1]

Yes.

CONCLUSION
Prehospital care providers and their medical control supervisors have room to improve the quality of pain control in the prehospital setting. In this review of the use of analgesia for patients with suspected fractures of the extremities, pain medication was rarely used. Improvements in both the recognition and assessment of pain and in treating the pain in the prehospital setting are slow to be implemented. Education, pain control evaluation, protocol development, and quality assurance and audit systems are all measures that can be used to improve the quality of pain management in the prehospital setting.
[1]

All good points, but the most important point is not in there.

Pain management is about treating pain, not treating specific medical conditions.

If you look at all of the contraindications to the use of pain management in this study, there appears to be a strong bias against treating many painful conditions that are not medical contraindications. These appear to be just demonstrations of discomfort with pain management and ignorance of appropriate pain management. As critical as I am of this study, at least the authors are working to improve the way their system manages pain. Most systems seem to deny that there is a problem.

We need to educate prehospital providers to be much more aggressive with pain management.

We spend so much time worrying about paramedics being too aggressive with pain management, but nobody seems to be able to come up with any evidence to support this paranoid fantasy.

We need to provoke medical directors, emergency physicians, emergency nurses, EMTs, and paramedics to take pain seriously.

Footnotes:

[1] Prehospital use of analgesia for suspected extremity fractures.
White LJ, Cooper JD, Chambers RM, Gradisek RE.
Prehosp Emerg Care. 2000 Jul-Sep;4(3):205-8.
PMID: 10895913 [PubMed – indexed for MEDLINE]

[2] Unnecessary out-of-hospital use of full spinal immobilization.
McHugh TP, Taylor JP.
Acad Emerg Med. 1998 Mar;5(3):278-80. No abstract available.
PMID: 9523943 [PubMed – indexed for MEDLINE]

Standard backboard immobilization is not harmless and can cause significant pain, especially at the occipital prominence and lumbosacral areas. Within 10 minutes of being placed in FSI, Hamilton and Pons12 showed that volunteers developed moderate to severe pain. After 30 minutes in FSI, Chan et al.13 found 100% of volunteers complained of pain, with 55% of the group grading their pain as moderate to severe in quality. Interestingly, 29% of the subjects developed new symptoms over the course of the next 2 days. Chen et al. concluded that “the standard process of immobilization may complicate the evaluation of the trauma patient by generating additional symptoms . . . leading to unnecessary laboratory tests and radiographic studies, time of immobilization, and ultimately, health care costs.” In addition to pain, FSI can cause changes in pulmonary function. can cause pressure ulcers of the buttocks, scalp, or neck, and can increase the risk of aspiration after vomiting.13,14 Because standard FSI can compromise maternal and fetal circulation, it is relatively contraindicated in gravid women.

12 The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization.
Hamilton RS, Pons PT.
J Emerg Med. 1996 Sep-Oct;14(5):553-9.
PMID: 8933314 [PubMed – indexed for MEDLINE]

13 The effect of spinal immobilization on healthy volunteers.
Chan D, Goldberg R, Tascone A, Harmon S, Chan L.
Ann Emerg Med. 1994 Jan;23(1):48-51.
PMID: 8273958 [PubMed – indexed for MEDLINE]

14 A review of spinal immobilization techniques.
De Lorenzo RA.
J Emerg Med. 1996 Sep-Oct;14(5):603-13. Review.
PMID: 8933323 [PubMed – indexed for MEDLINE]

White, L., Cooper, J., Chambers, R., & Gradisek, R. (2000). P REHOSPITAL U SE OF A NALGESIA FOR S USPECTED E XTREMITY F RACTURES Prehospital Emergency Care, 4 (3), 205-208 DOI: 10.1080/10903120090941209

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Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients


ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

The EMS Garage also covers pain management on the 5/08/10 podcast. Pain Management: EMS Garage Episode 85. Go listen to that, as well. Chris Montera, Dr. Keith Wesley, Will Dunn, Kyle David Bates, Kelly Grayson, and I discussed several aspects of prehospital pain management.

I have been meaning to cover the research on prehospital pain management for a long time. I did write about one excellent study of fentanyl.[2] Currently, the big obstacle is that there is now so much research to cover. Back in the 1990s, when I would try to persuade doctors that prehospital pain management was safe, there was very little to show to support that statement. A common medical command order was for 0 mg morphine, but we could repeat that as often as we liked. Some times we would get orders for 2 mg morphine and sometimes have the possibility of repeating that dose one time.

From the title of this, you can see that the authors take a dim view of that kind of dosing. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. This study was just on adults, so we should consider the size of an adult. I consider ballpark figures for a small adult to be 50 kg (110 pounds), a medium sized adult to be about 80 kg (176 pounds), and a large adult to be about 110 kg (231 pounds), although there does not seem to be any shortage of people significantly larger than that.

Using these very rough estimates, 0.1 mg/kg would be 5 mg morphine for a small adult with severe pain. The title of the article states that this dose would be inadequate for most patients with severe pain. If the common doses of morphine that used to be given were 0 mg, 2 mg, and 4 mg, were we doing anything more than relying on the placebo effect for the majority of pain relief?

If 5 mg is inadequate for a small patient with severe pain, 8 mg is inadequate for a medium patient, 11 mg is inadequate for a large patient, and there are plenty of much larger patients, what good was a typical dose of 2 mg morphine, assuming that the doctor would be generous enough to even give orders for this dose? Another reason for putting off writing about this has been my attempt to avoid making this just a rant about neglect of patients with severe pain.

Let’s assume that you are not a misanthrope. You are not the kind of person to hurt strangers, just because you can get away with it. You might even occasionally apply the Golden Rule of Do to others as you want them to do to you. What would you want done to you?

0 mg morphine? This can be roughly translated to non-medical terminology as, What are you crying about? I am the one who has to listen to your crying!

2 mg morphine? Even for the small adult, this does not come close to the 0.1 mg/kg that the authors state is inadequate.

2 mg morphine with a repeat dose of 2 mg morphine? At least we are moving away from a complete placebo dose in the small patient, but in the medium sized patient, this is not much different from the single dose of 2 mg for the small patient. For the large patient, this is still just a placebo. For the extra-large patient this is just a very bad joke.

After all of that, what does the actual study state?

A standard means of taking into account the heterogeneity of analgesic response in treatment is titration of dosage, with small increases of dose over short periods of time. Some emergency medicine texts recommend a range of doses (eg, 0.05 to 0.15 mg/kg)6; others provide a single dose (eg, 10 mg)7 or a single weight-based dose (0.1 mg/kg)8 with the proviso that the dose should be titrated to desired analgesic effect. There is little evidence about whether these recommendations are routinely followed in ED care.

Although titration is a goal for optimal management of acute pain, a first step is to assess the recommended starting dose. Given the various recommendations for intravenous morphine, ranging from 0.05 mg/kg to 10mg, we chose to assess the analgesic response to the recommended weight-based dose of 0.1 mg/kg. The purpose of this investigation was to quantify the proportion of patients in acute pain who had less than a 50% reduction in pain intensity 30 minutes after intravenous administration of 0.1 mg/kg of morphine.[2]

Arguments can be made that this endpoint is as valid as reduction of pain to less than 3 out of 10. Farther down, I will compare the results if 3 out of 10 had been used.

patients were eligible if they were between 21 and 65 years of age, spoke English or Spanish, or had acute pain with onset within the past 7 days. Exclusion criteria included previous use of methadone, use of other opioids or tramadol within the past 7 days, previous adverse reaction to morphine, chronic pain syndrome, altered mental status, pregnancy, use of monoamine oxidase inhibitors in the past 30 days, systolic blood pressure less than 100 mmHg, or inability to provide informed consent.[2]

Those are all reasonable exclusions.

Patients were asked by the research associates to rate their pain intensity at baseline and 30 minutes post baseline. Peak analgesia from intravenous morphine is achieved within 5 minutes of administration in most patients.9,10 Clinically, 30 minutes seemed to be a reasonable time within which adequate analgesia should be achieved in patients with severe pain. Further, it is unlikely that an analgesic effect would be missed with this interval because the elimination half-life of morphine is 2 to 4 hours.9,10 [2]

I confess. I only checked the abstracts for footnote 9[3] and footnote 10[4] cited for morphine reaching peak effect within 5 minutes. I do not feel that 5 minutes is accurate for peak effect. For peak serum levels, 5 minutes may be correct. When acute pain patients start discussing their serum morphine levels with me, then I will wonder about this, but not before then. I will address the onset of effect of morphine and the peak effect in covering other acute pain research that more directly addresses this.

I feel that an assessment of pain at 30 minutes will not miss a significant amount of the pain relief that morphine will provide.

On the side, I have provided parts of the chart from the study that shows the change in pain levels at 30 minutes. this is the caption – Figure.

Distribution of 30-minute pain score by baseline pain score.*

*Shaded area indicates number and percentage of patients whose pain scores decreased <50%.[2]

In other words, if a patient’s rating of their pain started at 10 out of 10, the shaded area extends down to the top of 5 out of 10. If a patient’s rating of their pain started at 8 out of 10, the shaded area extends down to the top of 4 out of 10. You can see how many patients remained in the less than 50% relief by the shading.

Pain is generally rated on an 11 point scale from 0 being no pain. Some people like to start at one, feeling it is more important to have the scale only have ten points, but end at ten. So 1 is nothing for them. I feel much more comfortable explaining to patients that nothing means nothing. Actually, I find that I do not have to explain the concept of zero. For somebody experiencing severe pain, I expect that zero is their desired level of pain.

10 out of 10 is the worst pain imaginable. Dr. Wesley had a very imaginative way of expressing this on the podcast.

For the patients starting with the pain level of 10 out of 10, 68.1% did not have relief of at least 50%. That number really does not tell us a lot, but it is less than one third, so that means a lot of patients with very little relief. We are not describing complete relief of pain, but only a reduction of 50%. Less than 1/3 having a 50% reduction in pain level is pathetic.
 

15.9% had no relief at all.
 

None.

15.8% had a decrease in pain to 3 out of 10 or less. The difference is just due to rounding. Both percentages represent 13 out of 82 patients. I added up the fractions, so that the numbers on the chart match my numbers. For patients with an initial pain level of 10 out of 10, a decrease of 50% is expected to be much more likely, because the target also includes patients with a decrease in pain to 4 out of 10 and patients with a decrease in pain to 5 out of 10.

For these patients, it would not have mattered if we had started at 0 mg morphine, 2 mg morphine, 4 mg morphine, or the larger dose of 0.1 mg/kg. There was no improvement. I know what you’re thinking.

At least the pain did not get worse.

How would we know? Maybe their pain did get worse, but they didn’t have any higher number to use to tell us. Maybe they just initially rated their pain higher than they should have. It happens. This is one of the problems of the pain rating scale – subjectivity.
We also have too many people who feel quite comfortable under-treating the pain of other people. I do not think they should be making pain management decisions. Well, maybe they would be more appropriate making pain management decisions if they were intentionally torturing people.

If a lack of compassion/lack of empathy is a problem for healthcare providers, perhaps this is one criterion that we can use to identify those who might be better off being seamlessly integrated into the exciting field of fast food service. These paramedics, viewing patient care with a Quantity is Job One approach, will not be missed by patients. A lot of people have been saying that we should find a way to eliminate those without empathy from the classrooms.

They feel that it is easier to teach people to be paramedics, than it is to teach empathy. I am not convinced, but this is certainly worth considering.

Now, let’s look at the patients who were slightly better off. They only rated their pain as a 9 out of 10, initially. How did they do?

74.9% had less than a 50% relief of pain. One problem here is that half of 9 is 4 1/2. There is no 4 1/2 out of 10 on the list. Patients who started with a pain level of 9 out of 10 needed to lower it to 4 out of 10for the purposes of it being considered a 50% decrease in pain for this study.

How would things have been different, if we split the 3 patients in half? Don’t worry, when we get to the overall numbers, we end up with an even number. No procrustean methodology is intended. These 3 patients make up 25% of the patients who initially rated their pain 9 out of 10. If we split that in half, we would have 62.4% with a 50% reduction in pain. If we considered all of the 4 out of 10 patients to have had a 50% reduction in pain, then the split is 50% of the 9 out of 10 patients with a 50% reduction in pain.

The 8 out of 10 patients had 16.7% with no change in pain. A 50% reduction in pain was reported by half of the 8 out of 10 patients.

The 7 out of 10 patients had the most interesting changes. None of the patients had the same pain level as initially. 40% of the 5 patients with7 out of 10 pain (2 patients) had an increase in level of pain. This is the kind of thing that is supposed to be impossible. Apparently, impossible is a bit over-rated.

How could a patient receive such a large dose, at least compared with what has been considered the normal dosing, and not only not improve, but have an increase in pain? Not just one patient, but 2 patients.

There is always the possibility of drug diversion, but during a study, with more people paying attention to what is going on, that is even less likely than under normal circumstances.

The 7 out of 10 patients had the worst improvement of all. Some had their pain increase, but none of them had a more than 50% improvement in their pain. Zero.

If you were to use the same approach as with the 9 out of 10 patients and count a change to 4 out of 10 as a 50% improvement, since there is no 3 1/2 out of 10, you would still have 80% with less than 50% improvement.

Finally, there are the 6 out of 10 patients. Both improved to 4 out of 10, which means none of them had more than 50% improvement in their pain.

Overall, more than 2/3 of severe pain patients had a less than 50% improvement in pain. Even if you added in the patients who improved to 5 out of 10 from 9 out of 10 and the patient who improved to 4 out of 10 from 7 out of 10, you only end up with 63.9% improving by less than 50%. Just under 2/3.

The primary measure of adequate analgesic response to morphine is percentage of reduction in pain intensity dichotomized into less than 50% versus greater than 50%. Although there are other measures, we chose a 50% or greater reduction in pain because this threshold has been used frequently in pain meta-analyses and has the appeal of quantitative simplicity and easy clinical interpretation. Patients’ age, sex, and pain location were obtained from the medical record or the patient. Ethnicity was self-reported. Additional administration of analgesics was ascertained from the records and consultation with the ED staff. Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff and thus were under constant supervision. The research associates monitored the patients carefully as well. Vital signs were routinely measured by the nursing staff at 0, 15, and 30 minutes. For the purposes of the study, the research associates monitored the oxygen saturation, blood pressure, pulse rate, and respiratory rate at 0 and 30 minutes. Patients were reassessed by the clinical staff if systolic blood pressure was less than 100 mm Hg, pulse rate was less than 60 beats/min, or respiratory rate was less than 12 breaths/min to determine whether an opioid antagonist was needed. If oxygen saturation dropped by more than 5%, the patient was reassessed, and oxygen was administered at a fraction of inspired oxygen that returned the oxygen saturation to its baseline level. Patients whose presenting oxygen saturation was 95% or less were given oxygen on presentation.[2]

How many patients ran into problems from this larger than normal dose of morphine?

One patient was reassessed by the medical staff because the respiratory rate was 12 breaths/min, 1 patient’s oxygen saturation dropped more than 5%, 2 patients had a systolic blood pressure less than 100 mg Hg, and 8 patients had a pulse rate less than 60 beats/min (range 52 to 60 beats/min). None of the patients required administration of an opioid antagonist at any time during the 30-minute study period or for 2 hours thereafter.[2]

Not any problems that required any kind of intervention that could not be handled by a basic EMT, never mind a medic with all sorts of advanced implements of destruction. Essentially, with 10 minutes of training and authorization to add oxygen, people from registration and housekeeping could have manged these patients safely.

The protocol specified a dose of 0.1 mg/kg morphine to be given intravenously during 1 to 2 minutes. Because of rounding up or down, some patients received weight-based doses that varied slightly from the specified dose. Before data analysis, we decided to accept weight-based doses ranging from 0.09 to 0.11 mg/kg as meeting the protocol criterion for a 0.1 mg/kg standardized dose.[2]

Earlier, I mentioned that a decrease in pain to a level of 3 out of 10 is commonly used. In this study of severe acute pain, there was a less than 50% decrease in the pain level for 67% of patients.

What if the goal had been a reduction of pain to 3 out of 10, rather than the easier to reach reduction of 50%?

82% of patients did not reach the 3 out of 10 pain level.

An 82% failure rate when the goal is a pain level of 3 out of 10, or better.

A 67% failure rate when the goal is a 50% decrease in pain, or better.

People continue to tell me that this is not a problem. However, these people are not the patients with severe pain. These people are the administrators, the medical directors, the nurses, and other paramedics. In other words, the people denying the problem are the ones supposed to be making sure that this problem does not happen.

Things are improving, but it would be difficult for things not to improve. A lot of this improvement is due to research. This dismal starting point I attribute to the paranoia of the What if . . . ? crowd. They would rather restrict something they do not understand, than learn how to use it properly. They are very dangerous. Fortunately, abundant research is pointing out the ridiculous nature of their restrictions on pain management.

LIMITATIONS
Our sample is almost entirely composed of poor, inner-city Hispanic and black patients. Given the many cultural influences perception and expression of pain, it is quite possible that prevalence of poor response to morphine in other settings and other populations may differ from what we have reported. Because a convenience sample was recruited when trained research associates were present, the findings might have differed if consecutive patients had been enrolled. The patients in this study had heterogeneous locations of pain, having in common only high pain intensity and need for opioid analgesics. However, this reflects the true variety of clinical emergency practice. Some of the pain, though severe, was episodic and fluctuating. Thus, assessment of it at 30 minutes using a single numeric rating scale reading may not provide an accurate overall reflection of the degree of pain relief experienced during the preceding half hour. There is no a priori reason, however, to postulate that this methodology of sampling produces bias because pain that is changing over time seems about as likely to worsen as it does to improve throughout a constant interval.
[2]

Pain of 3 out of 10 is often used, because this is a decrease to mild pain, rather than severe or moderate pain. There is much more that can be said about the ways of measuring pain, but I am not going to do that, today.

This study assessed an initial dose of morphine that is consistent with starting doses recommended in standard texts.6-8 [2]

This dose clearly provides inadequate analgesia, and it may well be higher than what is routinely administered in many EDs.[2]

To summarize. 0.1 mg/kg should only be viewed as a starting dose.

Some of you may be wondering why I am using a study of morphine administered by doctors in an ED as a surrogate for morphine/fentanyl administered by paramedics before arriving at the hospital. The paramedic is as close to the patient as you are to the computer screen. How does a competent paramedic miss significant changes in patient presentation under those circumstances? There are incompetent paramedics. They should be remediated, but if they are not capable of providing competent care, they need to explore areas of employment where their lack of competence is less dangerous. There is no obligation by any employer to endanger patients by protecting the jobs of less than competent paramedics.

In the hospital, the doctors and nurses are assessing and treating other patients, documenting patient care, restocking, dealing with other patients, et cetera. If anyone believes that there is closer observation in the ED, than in a competently staffed ambulance, please provide some evidence to support this extraordinary claim.

Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff and thus were under constant supervision.[2]

That may seem reasonable to someone who has never set foot in the Montefiore Medical Center’s ED. This is not meant as a sleight to anyone working there. There are times when all sorts of craziness is going on and the claim that, without some staff member directly assigned to their care, any patients thus were under constant supervision, is not believable. In EMS, we almost always have more providers than patients. In the ED, the reverse is true. This is unavoidable.

The quote actually states, Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff. That leads up to a conclusion that is inappropriately drawn from the first part of the sentence. The conclusion should be that because patients were directly in the line of sight of the staff, if the staff actually did look up and did focus their eyes on the patients directly in their line of sight and did decide to assess the appearance of those patients, then the patients could be said to be thus under occasional intermittent supervision at a distance. To claim that these patients thus were under constant supervision, is an unreasonably optimistic exaggeration.

Footnotes:

[1] Public Perception of Pain Management
Rogue Medic
Article

[2] Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients.
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
PMID: 16187470 [PubMed – indexed for MEDLINE]

[3] The diposition of morphine in surgical patients.
Berkowitz BA, Ngai SH, Yang JC, Hempstead J, Spector S.
Clin Pharmacol Ther. 1975 Jun;17(6):629-35.
PMID: 1139854 [PubMed – indexed for MEDLINE]

The disposition of serum morphine following administration of 10 mg/70 kg was determined by a sensitive and specific radioimmunoassay in 31 anethetized surgical patients ranging in age from 23 to 75 yr. Following iv injection, 93 per cent of the morphine disappeared from the serum within 5 min. The early serum levels of the drug (2 min) correlated directly with the patients’ ages (r equal to 0.63, p smaller than 0.01). Patient 23 to 50 yr of age averaged 0.29 mug/ml, whereas patients 51 to 75 ur of age averaged 70 percent higher, 0.49 mug/ml. The serum half-life between 10 and 240 min was independent of age and averaged about 2 hr after either iv or im administration. Following im admininstration, morphine was rapidly absorbed, with peak levels occurring within 10 to 20 min. The decline in morphine serum levels paralleled the decline in morphine analgesia and was coincident with the apperance of morphine glucuronide in the serum. These studies demonstrate the applicability and specificity of the radioimmunoassay for morphine and suggest that serum levels of morphine may be a useful and objective indicator of its pharmacologic activity.

[4] Kinetics of intravenous and intramuscular morphine.
Stanski DR, Greenblatt DJ, Lowenstein E.
Clin Pharmacol Ther. 1978 Jul;24(1):52-9.
PMID: 657720 [PubMed – indexed for MEDLINE]

The disposition of parenteral morphine was assessed in two pharmacokinetic studies. In Study 1, 10 mg of morphine sulfate was administered by intravenous (IV) infusion, intramuscular (IM) injection, or both, to 8 healthy young adult male volunteers. Plasma morphine concentrations were determined by radioimmunoassay in multiple blood samples drawn after each dose. Mean (+/-SE) kinetic parameters following IV morphine were: volume of distribution (Vd), 3.2 (+/- 0.3) L/kg; elimination half-life (t1/2beta), 2.9 (+/- 0.5) hr; clearance, 14.7 (+/- 0.9) ml/min/kg; extraction ratio, 0.70 (+/- 0.04). After IM morphine, peak plasma levels ranged from 51 to 62 ng/ml and were reached within 20 min of injection. The absorption half-life averaged 7.7 (+/- 1.6) min. Systemic availability was 100% complete. In study 2, 4 elderly male patients (61 to 80 yr of age) received 45 to 80 mg of morphine sulfate IV prior to operative repair of an abdominal aortic aneurysm. Morphine pharmacokinetics were determined as described above. Kinetic variables were Vd, 4.7 (+/- 0.2) L/kg; t1/2beta, 4.5 (+/- 0.3) hr; clearance, 12.4 (+/- 1.2) ml/min/kg; extraction ratio, 0.59 (+/- 0.05). Both studies demonstrate that morphine distribution is rapid and extensive and its t1/2beta relatively short. IM morphine is rapidly and completely absorbed.

BIJUR, P., KENNY, M., & GALLAGHER, E. (2005). Intravenous Morphine at 0.1 mg/kg Is Not Effective for Controlling Severe Acute Pain In the Majority of Patients Annals of Emergency Medicine, 46 (4), 362-367 DOI: 10.1016/j.annemergmed.2005.03.010

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The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival


ResearchBlogging.org
Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

A recent study looks at The association between emergency medical services staffing patterns (the number of paramedics dispatched on an ambulance) and out-of-hospital cardiac arrest survival. They make some interesting observations.

We tested the hypothesis that two or more paramedics at the scene of OHCA would be correlated with a higher rate of survival to hospital discharge.[1]

Since there were at least 2 paramedics on scene, they really compared the presence of 2 medics with the presence of 3 medics and with the presence of more than 3 medics. OHCA is Out-of-Hospital Cardiac Arrest.

Paramedic treatment of cardiac arrest is provided by protocol and direct medical oversight.[1]

An interesting interpretation of the word direct. A medical command physician is available by phone or radio for consultation/orders. This is historically the way direct medical oversight has been interpreted, but it requires some flexibility in the interpretation of the meaning of direct. The word oversight requires similar flexibility, since the physician depends entirely on what the medic says, except for the medical command physicians who perversely just say no to everything.

Cardiac arrests resulting from a drug overdose, suicide, drowning, hypoxia, exsanguination, stroke, or trauma were excluded from the study. Also excluded were cases in which no crew configuration or responding unit information was available, cases in which no resuscitation effort was attempted, and cases in which no time data were available.[1]

It is reasonable to exclude some of these causes, since they are not standard medical cardiac arrests and do not contribute significantly to resuscitation statistics. The intent of the study seems to be the effect of the number of medics on standard cardiac arrest. Trauma is reasonable to exclude, since resuscitation from traumatic arrest is, for all practical purposes, zero percent. Movies and TV suggest otherwise, but there is nothing about chest compressions that reverses blood loss, TBI (Traumatic Brain Injury), pneumothorax, cardiac tamponade, or other traumatic causes of sudden death. On the other hand, there are some causes of cardiac arrest that do respond to chest compressions, such as commotio cordis[2], [3] or lightning strike,[4] that might appear to fall into the trauma category. Cardiac arrest due to stroke may have resuscitation outcomes as dismal as trauma.

Why exclude cardiac arrest due to hypoxia? Are they looking only at airway obstruction as a cause of hypoxia? Does this include anaphylaxis or asthma? What about CHF (Congestive Heart Failure), which could be categorized as hypoxic or as cardiac? These are questions that were not addressed.

There is no explanation for any of these exclusions anywhere in the paper. Are these excluded because the authors consider resuscitation to be so unlikely that they would only contribute a more zeros to the data?

If a paramedic responded as part of the first response unit’s crew, the paramedic was not counted as being part of the crew configuration. The independent variable was categorized solely on the number of paramedics present in the responding ALS unit crew. Milwaukee County EMS operates with a minimum of two paramedics on ALS ambulances. During the study period, there were no cases treated by one paramedic.[1]

In other words, although we are looking at whether more medics lead to better outcomes, we will set aside cases where the medics are first responders, unless those first responders are responding on an ambulance. Interesting, but it is difficult to tell if this would have any influence, since no numbers are reported. If medic first responders are rare, it probably will not have any effect on outcomes. Not having data, we do not know if it is rare. If medic first responders are common, this should not be ignored as a variable.

It might be nice to evaluate the effect of paramedic first responders. Even though there does not appear to be any benefit from having paramedics treating cardiac arrests, as first responders or otherwise, some systems are adopting the practice of having every responder be a paramedic. These systems seem to encourage the belief that, even though paramedic treatments do not improve outcomes, the sight a lot of paramedics on scene is more important than anything that might actually improve outcomes. There is no need to address things that matter, when we can put on an impressive show, unless survival is important.

Neurologic status at discharge was not available.[1]

Too bad. That could be useful information to have.

There were sufficient data to analyze 10,057 (98%)cases.[1]

That is very good.

FIGURE 2. Frequencies of cardiac arrest outcome by year in Milwaukee County.
ROSC = Return Of Spontaneous Circulation.
I added the red circles and green squares to make it easier to identify the lines. Nothing else was changed about this chart.

The most interesting thing that I notice is that increases in one of the surrogate end points (ROSC) seems to indicate drops in the end point that matters – survival to discharge. While they did not have access to the neurological status at discharge, this information seems to contradict what everyone claims is important about resuscitation – If we don’t have ROSC, we cannot improve survival to discharge.

In the above chart, as ROSC increases, survival to discharge decreases. Is this statistically significant? I don’t know, but it appears to be pretty consistent. The numbers are not provided by years, but the trend can be determined from the chart. Below, I list the the changes from year to year in ROSC (Return Of Spontaneous Circulation) and in Survival (survival to discharge from the hospital).
= year to year decrease. = increase. = no change. More arrows = more change.

1993 to 1994         ROSC               Survival

1994 to 1995         ROSC               Survival          

1995 to 1996         ROSC ⇑⇑⇑⇑     Survival              

1996 to 1997         ROSC ⇑⇑            Survival            

1997 to 1998         ROSC ⇑⇑            Survival          

1998 to 1999         ROSC ⇓⇓⇓        Survival

1999 to 2000         ROSC ⇑⇑            Survival

2000 to 2001         ROSC ⇓⇓⇓        Survival            

2001 to 2002         ROSC ⇑⇑            Survival ⇓⇓        

2002 to 2003         ROSC ⇑⇑            Survival ⇑⇑

2003 to 2004         ROSC               Survival

2004 to 2005         ROSC               Survival ⇑⇑        

I need to point out that this study was not designed to examine any connection between ROSC and survival to discharge. The yearly data are not included, so I am only looking at the direction of change of the bars connecting one year to the next. Out of 12 years, the change in percentage of ROSC is the same as the change in percentage of survival only 5 times. Sometimes these divergences are dramatic. Almost every big change in ROSC had an opposite change in survival.

As percentage of ROSC improves, percentage of survival seems to decrease. Maybe we need to stop obsessing about improving ROSC and just work on the more complicated problem of improving long term survival, which is all that really matters.

it appears that even though there was a medication change in the treatment protocol, changes to the American Heart Association guidelines, advances in abilities, training, equipment, CPR performance, and variation in hospital care, survival to hospital discharge remained stable during the study period. This may indicate that we have not yet identified the factors that are crucial to improving survival and that more research is needed to find the ideal treatment for cardiac arrest.[1]

Contrariwise, it may indicate that we have already found the most effective paramedic/ALS (Advanced Life Support) treatment. We are just unwilling to accept it, because we cannot believe it is that simple. Excellent continuous compression CPR interrupted only by rapid defibrillation.

We do not need paramedics for this. Therefore the number of paramedics on scene may only lead to interference with effective treatment.

It is important to note that, as is shown in Table 1, crews with two paramedics treated fewer cardiac arrest cases with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia than crews with three or more paramedics. Yet the unadjusted and adjusted odds ratios demonstrated that two paramedics conferred a survival advantage. This seems counterintuitive and may indicate an even stronger association between crew size and survival.[1]

If there is a bias in the data, it is likely one that hides the magnitude of the harm to patients from more paramedics.

The Milwaukee County EMS system operates with a minimum of two paramedics on ALS ambulances. During the study period, no cases were treated by one paramedic. A single paramedic’s influence on outcome was not able to be evaluated.[1]

The data do appear to be stating that the more paramedics on scene, the less likelihood that the cardiac arrest patient will leave the hospital alive.

When adjusted for variables previously correlated with cardiac arrest survival and referenced against crews with two paramedics, patients treated by crews with three paramedics (0.83, 95% confidence interval [CI] 0.70 to 0.97, p = 0.02) and crews with four or more paramedics (0.66, 95% CI0.52 to 0.83, p < 0.01) were associated with reduced survival to hospital discharge.[1]

The number of paramedics does not appear to interfere with ROSC, only with long term meaningful outcome.

The studies of ALS interventions keep pointing out the increased ROSC with ALS interventions. Unfortunately, the surrogate endpoint of ROSC does not appear to lead to improved survival to discharge.

Standard cardiac arrest treatment has led to more of an emphasis on continuous compressions and defibrillation. Standard cardiac arrest treatment still includes epinephrine, amiodarone, atropine, intubation, and intravenous access – treatments that have repeatedly failed to show improved survival to discharge.

During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.[5]

By supported by strong evidence, they mean that there is not any evidence of improved survival to discharge with drugs, IVs, endotracheal tubes – anything other than good continuous compressions and defibrillation.

Maybe this study means that the more people capable of performing less-than-helpful treatments, the more likely that less-than-helpful treatments will be given.

Perhaps, with the next revision of the cardiac arrest guidelines, we will make the ethical decision to limit treatments to those that have been shown to improve survival, rather than subjecting everyone to these treatments that have not been shown to improve survival.

Footnotes:

[1] The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival.
Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB.
Prehosp Emerg Care. 2010 Jan-Mar;14(1):71-7.
PMID: 19947870 [PubMed – indexed for MEDLINE]

[2] An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis)
Link MS, Wang PJ, Pandian NG, Bharati S, Udelson JE, Lee MY, Vecchiotti MA, VanderBrink BA, Mirra G, Maron BJ, Estes NA 3rd.
N Engl J Med. 1998 Jun 18;338(25):1805-11.
PMID: 9632447 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM         Free PDF from NEJM

[3] Protecting our children from the consequences of chest blows on the playing field: a time for science over marketing.
Link MS, Bir C, Dau N, Madias C, Estes NA 3rd, Maron BJ.
Pediatrics. 2008 Aug;122(2):437-9. No abstract available.
PMID: 18676560 [PubMed – indexed for MEDLINE]

Free Full Text from Pediatrics         Free PDF from Pediatrics

[4] Electric Shock and Lightning Strikes
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 10.9: Electric Shock and Lightning Strikes
Free Full Text         Free PDF

[5] Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Access for Medications: Correct Priorities
Free Full Text         Free PDF

Eschmann, N., Pirrallo, R., Aufderheide, T., & Lerner, E. (2010). The Association between Emergency Medical Services Staffing Patterns and Out-of-Hospital Cardiac Arrest Survival Prehospital Emergency Care, 14 (1), 71-77 DOI: 10.3109/10903120903349820

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Journal Club 3: Episode 53


ResearchBlogging.org
Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

Of the two podcasts I had the opportunity to be on this week, this one is more to my liking, due to my desire to increase the use of research-based treatments. Having the lead author of one of the studies on the show was another positive. Greg Friese hosts Journal Club 3: Episode 53.

There is a much more thorough discussion of these papers on the podcast.

The papers covered are:

Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama.
Harris D, Willoughby H.
Resuscitation. 2009 Nov;80(11):1275-9. Epub 2009 Aug 20.
PMID: 19699021 [PubMed – indexed for MEDLINE].
Presented by Rob Theriault.

This study raises a lot of interesting questions about the way that people learn about making end of life decisions, what they anticipate the outcome of resuscitation will be, and even how medical professionals may respond to skills presented in TV medical dramas.[1]

Dismissing TV dramas as trivial ignores the effect that they may have on members of the audience, up to and including doctors.

The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care.
Jensen JL, Petrie DA, Travers AH; PEP Project Team.
Acad Emerg Med. 2009 Jul;16(7):668-73.
PMID: 19691810 [PubMed – indexed for MEDLINE].
Presented by Joe Clark.

This is a study that deserves several posts to cover, so I will not even start here. As with the other studies, this paper is discussed on the podcast.

My impression is that this resource is wonderful. If you know of a relevant paper that they do not cover on the site, send them a link to it. As with all of science, this will always be a work in progress, but that is certainly not a bad thing.

Canadian Prehospital Evidence Based Protocols.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.
Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, Snooks H, Perrin J, Nicholl J.
BMJ. 2007 Nov 3;335(7626):919. Epub 2007 Oct 4.
PMID: 17916813 [PubMed – indexed for MEDLINE].
Presented by Bill Toon.

In the US, we have studies that show an inability of the medics (at least the medics in US studies) to be able to safely direct patients to alternative destinations, such as an appointment with a general practitioner. Is the basic EMS education difference, between the US and the UK, the reason?

This study does show that specially trained experienced paramedics can identify stable patients and safely direct these patients to more appropriate resources than the Emergency Department (Accident & Emergency in the UK).

This is an education program that appears to focus on critical judgment, rather than protocol adherence. If done the right way, this should be good for patients, and therefore good for EMS and hospitals.

The full text PDFs of the three papers discussed on the podcast are available for free (until the next EMS EduCast Journal Club) at the Journal Club page of the EMS Educast.

Special guests on the show are Joseph F. Clark, PhD of JosephFClark.com and Jan Jensen of the Canadian Prehospital Evidence Based Protocols.

Footnotes:

^ 1 Positioning prior to endotracheal intubation on a television medical drama: perhaps life mimics art.
Brindley PG, Needham C.
Resuscitation. 2009 May;80(5):604. Epub 2009 Mar 18. No abstract available.
PMID: 19297069 [PubMed – indexed for MEDLINE]

Inadequate positioning of the head and neck was especially prevalent prior to intubation attempts, and improving this was seen as a simple but important first step.

As part of ongoing nationwide efforts to ensure basic resuscitation skills5 we explored all potential causes for the inadequate positioning, and this included trainees’ prior experiences. Many trainees reported limited supervision or hands-on training. Remarkably, however, when asked how they had therefore learned, after “trial and error”, a surprising number answered that television medical dramas had been an important influence.

Of the remaining 22, none (0/22) achieved more than one, let alone all three, components of optimal airway positioning. In terms of individual components, the lower cervical-spine was flexed in 0/22, the atlanto-occipital joint extended in 1/22, and the ears level with the sternum in only 3/22 cases.

While few would suggest that medical dramas can be held responsible for physician performance, it has been previously suggested that they can significantly influence beliefs.6, 7

This does show that ignoring the effect of medical dramas has the potential to be harmful to patients.

Harris, D., & Willoughby, H. (2009). Resuscitation on television: Realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama☆ Resuscitation, 80 (11), 1275-1279 DOI: 10.1016/j.resuscitation.2009.07.008

Jensen, J., Petrie, D., Travers, A., & , . (2009). The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care Academic Emergency Medicine, 16 (7), 668-673 DOI: 10.1111/j.1553-2712.2009.00440.x

Mason, S., Knowles, E., Colwell, B., Dixon, S., Wardrope, J., Gorringe, R., Snooks, H., Perrin, J., & Nicholl, J. (2007). Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial BMJ, 335 (7626), 919-919 DOI: 10.1136/bmj.39343.649097.55

Brindley, P., & Needham, C. (2009). Positioning prior to endotracheal intubation on a television medical drama: Perhaps life mimics art Resuscitation, 80 (5), 604-604 DOI: 10.1016/j.resuscitation.2009.02.007

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