ABCD: Assess for BS and choose Cookbook or Discretion

“Can you tolerate being bamboozled by your patients from time to time?”

In this discussion, I think there is some context that is a bit lacking that needs to be laid down first. Specifically, what is our starting point?

If you work in a system with conservative pain management, then the concern is you’re not administering enough pain medication to enough patients. Conversely, if you work in a system with liberal pain management, then the concern is which patients you’re giving it to.

While I generally agree with the idea of aggressive pre-hospital pain management, I feel that this seemingly new trend towards very liberal, blanket pain management is just too much. It seems like a classic case of over-correction (of the past practice of very conservative pain management). I’m not referring to the safety issues of the various medications that we could use, although balancing risks (potential adverse events) and benefits (relieving bullshit pain) should always cross a provider’s mind, and I’m not referring to the basic, noble idea of relieving somebody’s pain, but rather, I’m displeased by the inappropriate selection of patients for IV pain medications. It’s almost as if people aren’t even thinking about who they’re administering medications to.

Lost in this rush to medicate everybody are basic techniques that work, such as proper splinting, traction, ice and psychological coaching. People tend to forget to use any of these methods before starting IVs and pushing medications or even after they’ve given the medications. I’m not much into cliches, but “BLS before ALS” isn’t necessarily a bad thing here. Besides, I don’t like seeing crews spend time starting IVs on calls before, say, for instance, properly splinting a fractured leg when even the patient tells them the pain is tolerable; it seems like misplaced priorities.

There are always going to be drug seekers, and there are always going to be people who are truly in pain. Our egos take a hit when they fool us, but it doesn’t really matter because it’s ultimately not really our job to decide who falls into which category. Besides, it’s not our dope.

But, at the same time, in many cases, it’s painfully (unintended pun) clear whether patients are full of shit or not. I do not agree with either extreme – either we act like the candy man and give everyone pain medications or we don’t give anyone anything. If it’s not clear if someone’s seeking or truly in pain, certainly there’s nothing wrong with medicating them.

Coincidentally, ERP had 2 posts not long ago, one after the other, in which he encountered a patient who deserved all the narcotics he could handle and 2 other patients who were so clearly seeking. He also posts about drug seekers quite often, and they’re pretty funny.

Am I, as a transport medic with short contact times, going to give IV pain medications to the lady who calls every day for the same pain? Probably not.

The guy who falls asleep on the gurney after complaining of 20/10 pain? Probably not.

The patient against whom EDs have restraining orders because of drug-seeking behavior? Probably not.

“Where the fuck is my fucking dilaudid?” Probably not.

The patient calling from a ED lobby complaining of whatever pain wanting to go to a different hospital? Probably not.

The patient who doesn’t even want medications, even if a bone is sticking out of their body? Probably not.

The patient with a broken finger or an ankle sprain? Probably not.

Menstrual cramps? Probably not.

Toothache? Probably not.

These are just hasty examples, so don’t anyone get all literal on me.

Besides, in these parts, EDs are often way too busy and many ambulance patients are sent to the lobby. EDs absolutely hate it when you bring them someone they want to put in the lobby appropriately but can’t because you’ve inappropriately medicated them, especially when they are already scrambling to find beds for legitimate patients who have been waiting in the lobby. Right or wrong – I’m all for a smooth transition. If that means helping to maintain the actual-sicker-people-first order at the ED, if that means trying to be more in tune with what the EDs want so I don’t have to wait with the patient for a bed for an hour or two and instead be available again in the system for the greater good, i.e. overall system status, then I will do exactly that. It’s a trade-off. Nothing is perfect. In a perfect world, everyone gets everything they want. But this is an imperfect world, and when there are no units available, you do what you can. It’s almost like a mini-MCI in your daily routine, spread out over a larger area and a longer timeframe.

Fundamentally, it’s no different than the concerns about liability The Happy Medic and EMS 2.0 folks raise:

Imagine I take Erma Fishbiscuit in because her dial a nurse told her to call 911 to arrange her colonoscopy.  Erma demands transport and I am bound by law to oblige her, regardless of her lack of need of an ALS ambulance.  We take her because of a perceived liability, that if we don’t take her and she sues us we will not like it one bit.

5 minutes after getting Erma loaded up a code 3 CPR in progress comes in next door to Erma and a 6 month old child dies before ALS can arrive on scene.  Are we liable for not having more ambulances?  Which liability is greater?  Which liability makes national headlines?

Or:

“Your honor, we had no ambulances because Mr Johnson’s neighbor made us take her in for a sore throat.”

Let’s say I cater to the patient’s demands for pain medications, even though it’s totally silly (and we can name countless examples), because only the patient’s opinion and perception of pain matter, as some people have suggested. (Since when do we provide patient care based solely on whatever other people tell us?) We wait a long period of time for a bed, unable to respond to other calls for service, when without pain medications, this patient could have easily and safely (and deservedly) gone to the lobby. Multiply this by whatever number you want representing other units in the system, because, let’s face facts, some type of “complaint of pain” is frequently one of the most common category of response. I just don’t see blindly medicating everyone as being responsible.

Spending time transporting the sore throat and as a result being late to the VF code is not really all that different from spending time sitting in triage and being late to the VF code. Since the ED staff routinely asks for our input when deciding who goes to the lobby, I’m unwilling to handicap them by making a lobby patient into a room patient because of IV access and medications.

There are also folks out there who say we can’t be 100% correct in sorting out the bullshit, so we shouldn’t be judging at all, in case we miss a legitimate patient, and we should instead be indiscriminately handing out pain medications like candy. I don’t agree with that at all. Following that logic, we’d be:

  • Giving Albuterol to anxiety/hypervents because we might miss bronchospasm.
  • Putting everyone in C-spine, never mind that it’s probably one of the 2 remaining bastions of old wives’ tales in patient management.
  • Bringing all chest pains to cath labs because we might miss a STEMI, especially given the low sensitivity of most algorithms.
  • Bringing all ALOCs to stroke centers because we might miss a hot stroke. (If you think cath labs and stroke centers don’t mind false activations, think again.)
  • Giving D50 to all ALOCs even without hypoglycemia. (Wait, didn’t we do this 20 years ago… oh, right…)
  • Let’s not even mention trauma centers.

Since missing any of the aforementioned conditions is actually more serious than missing a true candidate for pain medications, I would say that a few patients who didn’t get any pain medications when they could have used some isn’t the end of the world as some folks have suggested. In other words, I’ll readily accept responsibility for not going to the cath lab when I should have, but I’ll be less willing to take the blame for not administering pain medications when I could have. Yes, it’s easy to say when I’m not the one in pain – and I have experienced pain (while sucking it up big time) – but medicine by nature is never 100% and it’s not going to change. I would prefer that I be 100% correct, but that’s not going to happen.

I feel that anyone with half a brain can reliably and consistently figure out who is truly in pain and uncomfortable and who is not. We should emphasize thinking before we do something.

Night and Day by Michael Morse

Providence Fire Department’s Lt. Michael Morse, who wrote the book Rescuing Providence, has a sequel, Night and Day, scheduled for release in the fall of 2011.

Go leave a comment on his post.

New medications

Great news – in his latest EMS directive, Happy Medic has just announced the addition of a new medication, Realitee (Worldnotwhatyouthinkatall HCL), to the list of supplies that we carry.

It will nicely complement the other medication he approved for use several months back – the Maan Pill (Maanitoll).

Happy Medic, can you come be my EMS Supreme Chief Overlord (EMSSCO)?

Pink for October

This website has gone pink for October.

I was going to list some web resources for breast cancer, but decided against it since it’s difficult to sort out what organization has what ulterior motive. So, instead, I’m just turning the website pink (without ribbons) to remind you to think about breast cancer, which, like many other diseases, has been linked to environmental pollution and chemicals used in everyday products.

EMS cliche #1

I recently came across a thread discussing whether a strip was VT or SVT with aberrancy. Never mind that a wide-complex tachycardia is VT unless you can prove otherwise. Just about everyone in that thread was all too happy to call it SVT using a bunch of really questionable criteria that don’t even apply. (Tom – I feel your frustration.)

In this thread, at some point, someone said, “Treat the patient, not the monitor.”

There is no doubt that that is a useful saying in EMS. However, in this particular case, it seems an odd statement to make when the discussion is specifically about the EKG itself. Of course we’re looking at the monitor. (Or, rather, at the tracing on paper.)

Furthermore, what is it exactly that looks different on the patient – other than the monitor – that would determine if it’s VT or SVT? Do patients with VT look different from patients with SVT in a very specific way other than what’s on the monitor? Is there a pathognomonic sign for either one?

Aren’t there VTs – usually the more unstable of the two – that are stable?

Aren’t there SVTs – usually the more stable of the two – that are unstable?

So, how do you look at a patient for the EKG tiebreaker in this case? It doesn’t make much sense.

You say “harassment,” we say “police work”

I don’t come across very many law-abiding citizens who say the cops are harassing them.

Anyway, I just couldn’t resist after seeing this absolutely funny post titled “Why do cops get to harass people?” on Motorcop:

Recently, the Chula Vista Police Department ran an e-mail forum (a question and answer exchange) with the topic being, “Community Policing.”

One of the civilian email participants posed the following question: “I would like to know how it is possible for police officers to continually harass people and get away with it?”

From the “other side” (the law enforcement side) Sgt. Bennett, obviously a cop with a sense of humor replied:

“First of all, let me tell you this…it’s not easy. In Chula Vista , we average one cop for every 600 people. Only about 60% of those cops are on general duty (or what you might refer to as “patrol”) where we do most of our harassing.

The rest are in non-harassing departments that do not allow them contact with the day to day innocents. And at any given moment, only one-fifth of the 60% patrollers are on duty and available for harassing people while the rest are off duty. So roughly, one cop is responsible for harassing about 5,000 residents.

When you toss in the commercial business, and tourist locations that attract people from other areas, sometimes you have a situation where a single cop is responsible for harassing 10,000 or more people a day.

Now, your average ten-hour shift runs 36,000 seconds long. This gives a cop one second to harass a person, and then only three-fourths of a second to eat a donut AND then find a new person to harass. This is not an easy task. To be honest, most cops are not up to this challenge day in and day out. It is just too tiring. What we do is utilize some tools to help us narrow down those people which we can realistically harass.

The tools available to us are as follows:

PHONE: People will call us up and point out things that cause us to focus on a person for special harassment. “My neighbor is beating his wife” is a code phrase used often. This means we’ll come out and give somebody some special harassment.

Another popular one is, “There’s a guy breaking into a house.” The harassment team is then put into action.

CARS: We have special cops assigned to harass people who drive. They like to harass the drivers of fast cars, cars with no insurance or no driver’s licenses and the like. It’s lots of fun when you pick them out of traffic for nothing more obvious than running a red light. Sometimes you get to really heap the harassment on when you find they have drugs in the car, they are drunk, or have an outstanding warrant on file.

RUNNERS: Some people take off running just at the sight of a police officer. Nothing is quite as satisfying as running after them like a beagle on the scent of a bunny. When you catch them you can harass them for hours.

STATUTES: When we don’t have PHONES or CARS and have nothing better to do, there are actually books that give us ideas for reasons to harass folks. They are called “Statutes”; Criminal Codes, Motor Vehicle Codes, etc… They all spell out all sorts of things for which you can really mess with people.

After you read the statute, you can just drive around for awhile until you find someone violating one of these listed offenses and harass them. Just last week I saw a guy trying to steal a car. Well, there’s this book we have that says that’s not allowed. That meant I got permission to harass this guy. It is a really cool system that we have set up, and it works pretty well.

We seem to have a never-ending supply of folks to harass. And we get away with it. Why? Because for the good citizens who pay the tab, we try to keep the streets safe for them, and they pay us to “harass” some people.

Next time you are in my town, give me the old “single finger wave.” That’s another one of those codes. It means, “You can harass me.” It’s one of our favorites.

Happy Medic: I have a question for you

According to Mary Roach’s hilarious book Bonk: The Curious Coupling of Science and Sex, there are apparently quite a few cock-ring emergencies in San Francisco.

She is discussing the theory of constricting venous return and the evolution of erector rings, and then in the footnote, she unexpectedly digresses:

In San Francisco, cock-ring emergencies are so common that they have their own shorthand (“C-Ring”) on the Fire Department teletype. The department’s Heavy Rescue Squad has modified a small circular saw especially for this purpose and occasionally stages practice drills. The latter prove challenging owing to the absence of manipulable genitalia on Resusci-Andy dolls and the refusal of male staff to volunteer as mock victims.

Frankly, I’m quite surprised that Roach, with her book full of hilarious irony, doesn’t point out the seeming incongruity between a cock-ring emergency and a Heavy Rescue Squad.

Anyhow, my dear Happy Medic, what say you? Can you confirm these important details?

By the way, Roach was on The Daily Show recently promoting Packing for Mars: The Curious Science of Life in the Void. It was likely one of the funniest interviews I’ve seen.