I find it just a bit ironic that as I type this article, I have recently been in the ER for my customary Status Asthmaticus that accompanies the high pressure, windy stormfronts, was sent home on PRN and NOC home oxygen, and I am taking a DuoNeb. The ER doc that took my case “got it”. I think I may have even scared him a bit as I am not really a typical asthmatic. Ultimately, because of the Pulmonologist, not the ER doc, I wasn’t admitted on what was nearly the two year anniversary of my anaphylaxis episode and the beginning of a regular occurrence of severe asthma episodes that really don’t respond well to customary treatment. Each time I go in, I wonder, “Will I be in time for them to stop it or will I buy the tube?”
No two ways about it – It’s barbaric:
Today, yet another Facebook discussion is going on with unnamed EMS transport team arriving to an unnamed small ER to take a vent patient to unnamed big ER. This is nothing new. We have this discussion several times a week lately. Frankly, in this day and age, where we are pretty damned enlightened about the effects of the medications we give our patients, what is inappropriate to give, and especially what is inappropriate to not give certain patients, it scares the $h!T out of me to think I will be the next guy getting a laryngoscope shoved down my throat after getting Succs, Etomidate, and…, and…, and nothing else.
How many times does it need to be said?
Paralytics and Pharmacologic Facilitation are NOT Analgesics and Amnestics!
Did you hear it that time? It’s barbaric. It’s cruel and unusual punishment. Even the most hardened criminal and the most amp’ed up dope addict can be reduced to tears and have lost their ability to have any interaction to what you are doing to them. Imagine a fragile respiratory failure patient. Imagine a seizure patient that you paralyzed because you thought you were stopping the seizure (that’s a subject for another article) and now he’s post-ictal and starting to recover his mentation, but unable to move.
If you don’t understand the big colorful letters above, put down your laryngoscope and step away from the patient until you figure out the difference between paralytics and sedatives (any proper combination of benzodiazepines, narcotics, analgesics, and more). You have no business touching a patient’s airway until you get it through your head how utterly and distinctly different these things are. Attempting pharmacologically-assisted intubation without the proper combination of these medications can and will cause irreparable damage to the human psyche and maybe even irreparable physical damage too. Even death row inmates are entitled to humane treatment at their execution. If you aren’t treating your intubation patients with the proper pharmaceutical cocktail for their present condition, you deserve to have your licenses revoked, or at the very least, suspended pending considerable re-education.
Why is this still happening?
This is 2017, at least at the time of the writing of this article, so why, in this golden age of digital information, available at the fingertips on smorgasbord of digital devices in nearly every room and vehicle we occupy, is it that people still seem unaware that the standard of good care for pharmacologically-assisted intubation and ventilatory maintenance? To paralyze, facilitate, intubate, restrain, and walk away is surely as cruel as you can possibly be. Have you not bothered to read the textbooks? Have you not seen any studies? Surely, there are multiple studies justifying the use of sedation in RSI and DSI.
The patch I show you in the pic above is on my jacket. They were pretty popular last year. They get a good chuckle from medics, nurses, and ER docs. It goes along with the ROCKETamine pic below. The thing is, they’re great reminders of what many across the country view as the “hands down” (pun intended) best intubation cocktail out there. Do you understand what the difference is between the two medications? Really? Or do you push them because they’re part of a protocol? Or because the doc told you to? Do you understand what could happen when you have one without the other? And vice versa? Do you understand what the whole pharmacology-ventilatory management standard is if you don’t have these two specific awesome drugs on your ambulance? Why Succs and Etomidate alone aren’t a management plan? If you are being honest, and you don’t understand, you are part of the problem, but you can fix it. If you are being honest and you don’t care, you are the barbarian.
The Band of Brothers:
I propose that it is high time we band our collective professional asses together and put an end to this nonsense. Every professional association and board relevant to airway control, whether EMS, nursing, emergency medicine, critical care, anesthesia, trauma, surgery, pulmonology, psychiatry, and any other relevant group, should co-sign a joint position statement decrying the failure to use proper sedation in the initial and ongoing invasive airway-managed patient. Sign the death note on the barbaric, cruel treatment of ventilatory patients being withheld or underdosed sedation. Look upon those who do not comply with scorn and shame, limiting their licenses to practice in this area until they complete a comprehensive re-education program on the subject, and if they fail to see the light, rebuke them and strip them of their lawful ability to inflict harm upon the innocent and those unable to resist and let justice be served!
Come on all you alphabet soup groups (ACEP, NAEMT, NAEMSP, AOBEM, AAOS, BCCTPC, HEMS, SCT, CCT)! Step up and do something about this. How many times is too much? I keep to a couple smaller EMS groups and I hear my colleagues complain about it regularly! Stop complaining and act!
To my colleagues in the field, don’t just complain anymore. Report it up. I hear people saying they don’t necessarily know the whole story, and that may very well be true, but here’s the thing… let the review board decide. If the caregiver was in the right, then they will and should be exonerated. Don’t decide for the board. Let them investigate. If they find there were problems, then you owe it to the patients to be their advocate and the provider may not even be aware they are not properly caring for their patient. The provider NEEDS to be re-educated, and once that happens, if they continue to mistreat patients, they MUST be removed from that role so they can never harm another patient.