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

- Rogue Medic

Excited Delirium 2

I expect to be writing a lot about the EMS EduCast – Excited Delirium: Episode 72. It is very important essential for EMS providers.

The first comment in response to my post, Excited Delirium: Episode 72 EMS EduCast, is from Tom Bouthillet of Prehospital 12 Lead ECG.

This was an excellent episode and I applaud Mr. Johnson for sharing his experience so that we can all learn from it. Clearly he has paid a high price and he has my sympathy, but I can’t join you in saying that he “did nothing wrong.”

If my understanding is correct, it sounds like he used a police baton to restrain the patient. While this may not have been the proximal cause of the excited delirium, it was very poor judgment. A paramedic should never use a weapon to restrain a patient unless:

1.) The paramedic’s life or his partner’s life is in danger
2.) There is no opportunity for escape
3.) A weapon (or an improvised weapon) is needed to level the playing field to restore safety

I can hear it now. “Hindsight is 20/20″ and “you’re an arm chair quarterback.” No, I’m simply pointing out that it’s a mistake to say that Mr. Johnson did nothing wrong. Clearly at least one major mistake was made.

Tom,

I agree that using the baton was poor judgment. When faced with an unstable situation, we will make snap judgments. Marty Johnson’s explanation is that he felt it was the only way he could get a grip on the patient. He stated that the patient was sweaty and he had latex gloves on, so the patient kept slipping out of his grasp. I would take the gloves off. Even though the patient is bleeding, you have to assume that the gloves have already lost their much of ability to act as a barrier to transmission of germs, but the gloves are acting as a barrier to being able to manage the situation.

We occasionally have to make important decisions about the appropriate amount of force to use. We should have thought these out, as much as is practical, ahead of time. How many of us have thought these things through?

This is a situation that may initially seem like it is not a big deal. the problem is that things do not get better. They get worse. Not just a little bit worse, but a lot worse. Not necessarily getting a lot worse right away, so that you just step back and re-evaluate or to retreat and call for help, but progressively worse, so that you may not be aware of the way things are spiraling out of control.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
[1]

We expect to be in control.

During EMS education, we are even told the lie that we should be in control.

Because of this, we are frequently able to dismiss the evidence that we are not in control. Having developed this ability to ignore just how out of control things are, we react poorly when things do not go our way. We flail about and panic. Ironically, the patient may be doing exactly the same thing.

Would Marty Johnson do things differently, today. I think that he made that very clear. He is trying to get people to understand how badly things can turn out.

Even more important than the baton is the perception of the baton. Is a baton a weapon, if it is not used to strike?

Is a baton a weapon, if the baton is used to protect the person the baton is being used on?

Is a sedative a weapon?

Is a restraint a weapon?

A physical restraint?

A chemical restraint?

Consider the weaponized fentanyl variant used during the Moscow theater hostage rescue.

How much does the result affect the interpretation of the intent.

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, most if not all deaths were caused by suffocation when hostages collapsed on chairs with heads falling back or were transported and left lying by rescue workers on their backs; in such position, tongue prolapse causes blockage of breathing venues.[53]. Thus, part of casualties can be attributed to accident but at least some to unprofessional rescue efforts.[2]

Even if nobody had died in Moscow, the chemical would have been considered a weapon, but many of the deaths of the hostages would probably have been avoided with basic airway positioning. Some people vomited, aspirated, and asphyxiated. Others were suffocated by a lack of positioning, allowing the tongue to obstruct the airway. Had there been better organization of the evacuation, how many of these people would not have died that day? Had there been better organization of the evacuation, this might not have been a disaster.

How we act helps to show our intent.

When we are prepared, we can act more appropriately, even if the initial impression of onlookers (including medical command) is that we are being inappropriately aggressive.

When we are prepared, we can turn an unstable situation into a non-event, except for dealing with the protocols that discourage/prohibit appropriate care.

We use our hands for many purposes. We can use them to deliver painful stimuli. When done appropriately, there should not be any permanent harm, and the pain should be stopped as soon as there is an adequate response to the stimulus and only repeated if stimulus is again appropriate. The entire point of painful stimulus is to produce a response, and we do this on a regular basis.

Most often, we are using verbal stimuli, but we move to more aggressive stimuli, when the less aggressive stimuli do not elicit a response.

If we omit painful stimuli from our assessment/treatment, then we are neglecting some of our patients.

Was he charged with murder just because he used a baton to attempt to restrain a patient?

I don’t know.

Was Marty Johnson charged with murderous assault, even though he was driving the ambulance at the time the alleged crime occurred?

It does look that way.

If he had showed up and aggressively sedated this patient, would this have been anything other than a routine call?

Probably not.

The doctors may have made a big deal about aggressive sedation, even though it is probably the best thing for the patient.

Acting appropriately aggressively initially will often prevent a lot of bad outcomes. Our goal should be calls that are not memorable, because the patient was protected by aggressive intervention. Unfortunately, we have patients harmed by some protocols that discourage aggressive intervention, because What if . . . ?

I am not cavalier about the aggressive use of sedatives, opioids, or other drugs. I think that aggressive treatments should be treated as sentinel events. RSI Intubation is an excellent example of a treatment that should not be treated as anything other than a sentinel event.

Everything that we do has the potential for harm.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be competent before allowing them to work on their own.

Aggressive oversight means throwing out the medical command permission requirements, but requiring that medics be accountable for all of their actions.

Medical command permission requirements are purely for the psychological benefit of the people who do not understand medical oversight.

Medical command permission requirements are dangerous.

Footnotes:

[1] The Second Coming
William Butler Yeats
Poem of the Week
Poem

[2] Moscow theater hostage crisis – Chemical attack
Wikipedia
Article

According to court testimony from Prof.A.Vorobiev, Director of Russian Academic Gemology Center, . . . .

Gemology? – the science dealing with natural and artificial gems and gemstones?

Why is a gemologist, academic or otherwise, giving expert testimony on toxicology?

A better question may be – Why does the gemologist make more sense than everyone else quoted?

Or is it a translation error?

.

What is a Nursing Dose?

I was assisting the ED staff with restraining a patient. The emergency physician gave orders for some lorazepam (Ativan). A whopping dose of 1 mg, although I was not aware of the dose at the time. I was busy trying to keep Mr. Agitated from doing anything other than setting off vital signs alarms.

The nurse gives an injection.

RM – What did you give?

Nurse – 1 mg. Nursing dose.

RM – Huh? This line was delivered with my most intelligent befuddled expression. 1 mg isn’t going to do a thing for this guy.

Nurse – Nursing dose, heavy dose, we hit a bump, . . . . You know what I mean.

What she meant was that the entire 2 mg in the syringe was administered, rather than the 1 mg ordered by Dr. Inadequate.

Now, we could criticize the nurse for exceeding her orders by giving a dose that is less inadequate than the ridiculously inadequate dose ordered by the doctor. I have much more of a problem with Dr. Inadequate depriving the patient of appropriate care, just because a doctor can get away with inadequate pain management and inadequate sedation.

What are the risks from the actions of the nurse?

Respiratory depression. Since Mr. Agitated is breathing at an alarmingly high rate, a bit of respiratory depression is actually needed.

Just to amuse the Dr. Inadequate defenders, what if the respiratory depression becomes a problem? Talk to the patient. If this is an iatrogenic respiratory depression due to any remotely reasonable dose of sedative or opioid, talking to the patient should be more than adequate to keep the patient breathing. Such high tech treatment might confuse Dr. Inadequate, but any ED tech is capable of handling this BLS intervention.

A talking patient is a breathing patient.

Why would anyone think otherwise? Because there are too many Dr. Inadequate clones giving orders. They don’t understand, so they give a dose that does not have much of an effect. They only see the risk from too much medication, not the more significant risk from not enough medication.

Drop in blood pressure. sedatives can lower the blood pressure. Treating Mr. Agitated’s blood pressure by sedating Mr. Agitated is probably the least dangerous method of dealing with his alarmingly high blood pressure. As with respiratory depression, lowering the blood pressure is expected and is a good thing

Just to amuse the Dr. Inadequate defenders, what if hypotension does become a problem? Since it is unlikely that there is a significant bleed, it is perfectly appropriate to give some fluids. Low blood pressure secondary to sedation is not something that should encourage anyone to panic. If this does encourage panic, the answer is to sedate the panicking person, too.

Change in mental status. Not really a problem. We are hoping that Mr. Agitated’s behavior will change. Mr. Agitated already has altered mental status. A more cooperative, more sedated, altered mental status would be better.

Does sedation equal a change in mental status?

We hope so.

If Mr. Agitated is now sedated to the point where he only responds to voice, but now answers all questions appropriately, isn’t that the goal of sedation? Isn’t that a dramatic improvement?

I wrote about the problems with bad orders/protocols in EMS Needs to Be a Separate Medical Specialty – Now – Part I. This is a little bit different.

Has the nurse endangered her patient/Dr. Inadequate’s patient?

No.

I think that I have made it clear that Mr. Agitated is at much greater risk from Dr. Inadequate, than from the appropriate dose of lorazepam given by the nurse.

Has the nurse done anything wrong?

She exceeded her orders.

She has not done this for herself, but for Mr. Agitated, who probably cursed at her and hit her, or tried to hit her. She is doing something that could get her in a lot of trouble, but she is doing this for one of the least pleasant patients. Will she get any credit for this? More likely she will get in trouble for this if anyone finds out.

Dr. Inadequate will assume that his ridiculously low doses are adequate.

This is the real problem.

I apologize to all of those who will claim that Dr. Inadequate has some sort of sacred right to mistreat his patients, just because he has a medical license. He does not.

An interesting article addresses appropriate use of opioids, just not from the point of view of Dr. Inadequate.

Avoiding trouble when using opiates to treat patient pain.
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
Article

.

Flumazenil and EMS – A Box Pandora Should Not Open

Fentanyl is easily titratable, has a more rapid onset than other available opioids, and has a much shorter half life than morphine. The only advantage morphine has is that it is more familiar. As long as people keep advocating this longer lasting, slower onset, more problematic drug, people will be less familiar with the much safer drug – fentanyl. However fentanyl does have a long, safe, predictable history of use with good patient response and good outcome. Should you find it necessary, or just convenient, to use naloxone to reverse iatrogenic respiratory depression, it would be much safer to use an opioid with a similar half life to that of naloxone – again that would be fentanyl. Reversal agents are nice to have. Much more important to remember is that the safest treatment for iatrogenic respiratory depression is supportive care, not a reversal agent. Primum non nocere (First, do no harm). Be able to get out of trouble quickly.

Similarly, midazolam is a safer drug than lorazepam or diazepam. Much shorter acting. Midazolam allows you to treat the patient aggressively for the time the patient is in the care of EMS. Once you are arriving at the hospital, it should be starting to wear off. This is important, because in the ED they do not have the staff to observe the patient as closely as EMS does. In EMS, it is rare that I am more than an arm’s length away from the patient. If I cannot recognize oversedation problems in that setting, I should not be treating patients. In the hospital the nurses will have several patients, and not have the ability to sit next to the patient I bring them. Delivering a patient, who requires continual observation of his breathing, is not helping the ED at all. For violent patients, it becomes a bit of a balancing act. If the patient is still violent, that means there is even more need to pull ED staff away from other patients. Be able to get out of trouble quickly.

Using haloperidol (Haldol), droperidol (Inapsine), ziprasidone (Geodon), or some other non-benzodiazepine sedative also improves the safety of sedating the patient. You won’t find many EDs using just a benzodiazepine to sedate violent patients. That wouldn’t be right. Having EMS use just a benzodiazepine, assuming that EMS is allowed to use any kind of sedative? That is looked at as progressive EMS. Orwell would love it.

Flumazenil is not anywhere near as safe a reversal agent as naloxone. Naloxone that may induce hypertension, flash pulmonary edema, seizures, ventricular tachycardia. If naloxone leads to seizures, in EMS, we have a way to treat the seizures – benzodiazepines. If flumazenil leads to seizures, most EMS providers can only drive faster and hyperventilate (themselves, the patient, or both – but neither is likely to help). Flumazenil has nothing to do with being able to get out of trouble quickly. Flumazenil can create problems that EMS cannot treat.

If EMS carries paralytics, then that is one way to stop the physical seizure activity. I do not oppose well trained medics carrying paralytics. Carrying paralytics to reverse the seizures that may occur because somebody found it necessary, or just convenient, to use flumazenil to reverse iatrogenic respiratory depression? Very bad idea. Paralytics are a last ditch effort to treat seizures. Paralytics do nothing to stop the seizure, they just prevent the physical expression of the activity in the brain.

Maybe nobody would ever decide to use the flumazenil to reverse a possible benzodiazepine overdose, rather than the much safer supportive care. Conversations with those who work in systems that use flumazenil, suggest that if it can be used, it will be used. Should EMS then carry phenytoin, barbiturates, and/or other antiseizure medications to be able to treat iatrogenic seizures?

Flumazenil has a role in procedural sedation/heavy sedation. Does that mean that EMS should be using procedural sedation/heavy sedation? Should EMS be reversing procedural sedation/heavy sedation? When supportive care is the safer treatment, why use flumazenil? If the medics are not good at supportive care, the problem is with the medics, not with the medicine. The problem is in focusing on the signs that can be documented, rather than on what is least risky for the patient. Flumazenil is a box Pandora should hesitate to open, and she was not known for her caution.

Remember, the safest treatment for iatrogenic respiratory depression is supportive care. Primum non nocere. Be able to get out of trouble quickly.

I apologize for not providing any references in this post, but I am having internet connection problems. I will follow up with more on flumazenil.

.

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?
HooBoy!

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.

Footnotes:

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

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

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

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

.

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

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

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

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

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

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

 

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

 

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

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

 

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

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

From the Agitated Behavior/Psychiatric Disorder Protocol –

Contact Medical Command, if possible

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

Monitor continuous ECG and Pulse Oximetry, when feasible

Sedation Options:
(Choose one)

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

OR

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

OR

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

 

Protocol Footnotes:

 

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

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

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

 

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

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

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

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

 

And:
 

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

 

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

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

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

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

Footnotes:

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

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

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

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

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

.