A critical look at dopamine

As I was perusing through the online medical education offerings a couple of months ago, an article in the New England Journal of Medicine caught my eye; a comparison of dopamine and norepinephrine in patients with shock:

http://www.nejm.org/doi/full/10.1056/NEJMoa0907118

Since it was a free download, I saved it to my computer and resolved to look at it once things settled down a little bit.  Now that the school semester is drawing to a close, I decided to take a look at it, and was immediately drawn in.  As it turns out, the authors discovered that there were no randomized, controlled trials comparing dopamine with other vasopressor/inotropes.  So they went ahead and did one; enrolling about 1600 patients with shock of all types, they gave either dopamine or norepinephrine and monitored for adverse events, 28-day mortality, and a few other parameters like days spent in the ICU, days spent on mechanical ventilation, and some other stuff that has great relevance in the ICU, but not in the back of the ambulance.

Overall, what they found was, you might say, interesting:

(Image source is the article linked above)

Overall, the choice of vasopressor didn't seem to matter with regards to adverse events, except for arrhythmias.  There, the dopamine group had a statistically significant incease in nasty arrhythmias like ventricular tachycardia and ventricular fibrillation.  The 28-day mortality findings were similar;

(Source: article linked above)
When they measured for 28-day mortality, the survival rates were about equal, except for patients with cardiogenic shock.  Then things changed; if you had cadiogenic shock and were given dopamine, you were more likely to die than if you were given norepinephrine.  This begs the question:

Why does norepinephrine seem to be equal, or better, than dopamine in treating shock?

Well, to start answering that question, we need to go back to the pharmacology book and review what the drugs do.

(Source: www.medscape.com)

Just referencing the chart above, norepinephrine seems to balance between inotropic and vasopressor actions a little better than dopamine, which strongly favors inotropy over vasopressor duties.

In most types of shock, this is not a big deal; the primary problem is not located in the heart, and the heart may be relatively normal.  In cardiogenic shock, however, the heart is dysfunctional and weakened; increasing the sympathetic stimulation and inotropy to it is probably analagous to running your automobile out of oil, transmission fluid, and radiator fluid and then taking it to the drag strip for a night of racing.  Or, it could be the opposite; norepinephrine increases sympathetic tone in the blood vessels, which would result in an increased diastolic blood pressure.  Diastole happens to be the phase during the cardiac cycle when the coronary arteries are perfused.  This could mean that the weakened heart is given its best chance at close-to-normal function with norepinephrine compared with dopamine.

No definitive answer; but then, that's the way that physiology goes.

Which inotrope/vasopressor should be on our ambulances?

Another good question.

Dopamine was a mainstay on the truck by the time that I first ventured into EMS; why that is, I don't know.  It might have been the prototype drug, but I have no information to support this (feel free to comment if you know the answer!).  When I learned about dopamine in paramedic school, it seemed like a neat idea; it could be an inotrope at lower dosages, or it could magically turn into a vasopressor at higher doses.  Truth is, dopamine's a fairly dirty drug (like amiodarone, but that's a whole other rant), without any evidence to support its' superiority in today's formulary.  It may have been the only drug of its' class when EMS began, but it isn't anymore.  And the only RCT comparing it to other agents shows that norepinephrine is just as good, or better in cardiogenic shock (and be honest....how many times have you hung dopamine in a patient who WASN'T in cardiogenic shock?).

Is it time for dopamine to get replaced by "Leave 'Em Dead"?  I'd really like to get your opinions on it....or even better, contrarian research :)

A heavy foot, and no evidence...

As a followup, I'd like to point out the last paragraph of the article;

Less is more when it comes to prehospital care, Dr. Davidson said. “A heavy foot on the gas pedal and only a few interventions, such as defibrillation, are what lead to better outcomes,” he said

Does a "heavy foot" on the gas pedal (which I interpret to mean rapid, emergent transport) really lead to better outcomes?

Maybe.  The research in certain areas like hemmorhagic shock, STEMI, and ischemic CVA seems to indicate that time to definitive treatment (like surgery and lactate clearance, PCI, or tPA administration) is associated with improved patient outcomes.  However, the flip side to that coin is that if you're going to die or be seriously injured in EMS, the odds are that you'll be in the patient compartment, unrestrained, driving with lights and sirens.  How do we judiciously balance the risks to ourselves and our patients with the benefits to the patient?

Now, for the second part of that statement, do we have proof that only a few interventions lead to better outcomes?

The wording is tricky, and maybe I'm reading it wrong, but I disagree with that statement as it's printed.  I agree with Dr. Davidson that only a few interventions have good evidence that they improve patient outcomes.  However, I interpret his statement to mean that, conversely, all the other interventions we routinely perform don't improve patient outcomes.  And the simple answer is that we just don't know.

This is dangerous; not only to our patients, but to the profession of EMS as we know it.

EMS has become entrenched in dogma; that may have been acceptable when the profession began, but it's not any longer.  While we look forward at new treatments and therapies, we need to also look back at what we currently do; to validate that it does, in fact, make a difference or at least doesn't compromise other care.

But.

"No evidence" doesn't mean "no benefit".  It just means "no evidence".  It identifies an area that needs validation, not necessarily revision or deletion.  To equate the two means a diminution of potentially significant therapies, procedures, and even entire scopes of practice.  If we have no evidence that 90% of ALS treatments improve patient outcome, does that automatically mean that 90% of the ALS scope of practice should disappear?

I hope not.  "No evidence" in many cases means that no research has been done.  Let's change that!  Whether or not we temporarily suspend a therapy until we can prove its' benefit or lack of harm is a decision left to others besides me (although I have my opinions), but we need to put a halt to the automatic association of "no evidence" with "bad" while we generate evidence.  We need to be open to change, but also not change arbitrarily.  It's a tough balancing act, because most of us naturally fear uncertainty, but it's the way it is.  We have to be constantly asking "why?"; but more importantly, we need to also always be seeking the answer.

How can we call ourselves medical professionals if we don't?

What exactly is "medical direction"?

This last week has been fairly busy; it's the week of PALS, grades are being pulled together and finalized for submission.  I'm prepping to take the NAEMSE instructor course soon (and wondering WHAT I've gotten myself into this time!), and still trying to keep the clinical edge on the ambulance.  Then, I was sent a link by a friend who's been VERY supportive of this blog getting on its' feet (I appreciate it Lungs, but you're killing me here!);

http://journals.lww.com/em-news/Fulltext/2013/04000/Special_Report__Is_Direct_Medical_Command.1.aspx

Lungs knew I couldn't resist.

This story raises addresses so many of the big questions in my mind when it comes to the interaction of medical directors and the EMS personnel they oversee.  I thought I'd put them out there, and then hopefully we can discuss one or more of them in the comments.

Just what exactly is a medical director supposed to do in an EMS service?

My last big purchase of EMS literature was the National Association of EMS Physician's "Emergency Medical Services:  Clinical Practice and Systems Oversight".  It's a four-volume set that discusses all aspects of an EMS system, and here's the interesting part; they talk about the substantial role that the physician should play in influencing or managing those areas.  It's a vast difference from what I've experienced in actual EMS services.  At one of the services I work at part-time, all I have is a name; no one has actually physically been in the same room as the medical director.  At the other one, the medical director comes in about once a year to update the protocols and also historically delivers a lecture at the service's annual conference.  I'm fairly certain that were I to walk up to either of them in street clothes, neither would know who I was.

Why is there such a discrepency?  I think it boils back to the old engineers' saying: "Good, fast, and cheap.  Pick any two."

A medical director is supposed to be the authority in all clinical care by all the employees; that includes education, supervising prehospital care, and quality assurance and improvement.  Since medical care costs money, that medical advocacy rightly spills over into operational, logistical, and fiscal aspects of any EMS service.  EMS is really a unique animal; the physician community seems to realize this, given the recent addition of EMS as a specialty recognized by the American Board of Medical Specialties.  There can now be board-certified EMS physicians, just like EM, ortho, critical care, and surgery.  These are well-educated, experienced docs who recognize that EMS is unique.

Why have we, the EMS providers and managers, failed to realize that?

Many medical directors are paid a pittance compared to what they're tasked with, or worse, asked to volunteer.  The article rightly points out that EMTs and paramedics receive a fraction of the formal education of physicians, yet we're often asked to function autonomously or semi-autonomously in critical situations; that's bound to make somebody's malpractice insurance go up and possibly cause a stress ulcer or two.  And we want our medical directors to undertake this burden for as little as nothing?

Can we really blame them for being absentee medical directors?

Why do we even have online medical control?  Why do we have these ridiculous restrictions on what we can do on standing orders, like performing a cric or sedating before we cardiovert unstable V-tach?  Why do I get permission for 1mg of morphine for a patient with a shattered femur?

I think we just found the answer to that one.

The article correctly, in my opinion, points out that now, most online medical control is being provided by extremely busy physicians who don't have significant out-of-hospital experience; they may or may not know you by the sound of your voice, they probably don't have a lot of time to chitchat with you as they scamper around to see ever-increasing numbers of patients and learn about your knowledge and experience.  Who would they talk to if they wanted to learn more about the EMS system?  The medical director, who may not know you either?

I see a pattern here; the less involved your medical director is with the clinicians, the more on-line medical control in the protocols, and the more conservative on-line direction you get.  This only makes sense to me; if you're a doctor, how much risk to your prestigious, expensively-acquired livelihood are you prepared to take for a volunteer gig?  If you're an ED doc huddled over a radio, how much leeway or power would you want to give to someone who you don't know, whom no one with a medical degree will vouch for, and who cops an attitude anytime you ask why they did or didn't do something to their patient?

How do we fix this?

Let's start at the source.  I think it's time we redefined what "medical direction" and "online medical control" are.

A "medical director", at least according to what I read from the NAEMSP, is more of a "physician mentor".  He or she is heavily vested in the success of an EMS program; works to make sure that medical education is appropriate, acts as a preceptor and resource during prehospital care, and works retrospectively to make sure that an EMS system is providing good quality clinical care (this includes weighing in on things like ambulance deployment and new medical equipment).  Since they provide such an invaluable service to the EMS system, the EMS system compensates them appropriately for the work they put in on behalf of the service.  We need to recognize that "good" is part of the engineer's triad that simply can't be sacrificed.  With a high-quality physician mentor on board, online medical direction changes; the ED docs recognize that a fellow physician is confident enough in EMS clinicians to stake their name, reputation, and livelihood on their actions.  Protocols can become less dependent on taking the ED physician away from their already busy shift.

Online medical direction shifts to a concept of "ED consultation".  With a good physician mentor as an ally, there is far less need to call the ED and ask for permission to do things.  As clinicians, however, we gain an understanding that the actions or inactions we take in the ambulance have consequences to the hospital staff; they, like the patient, have to live with what we do.  Online medical direction starts to move to those cases where we either don't know what to do, or want to make sure that hospital care is consistant with prehospital care.  "Hey doc, I've got this patient.....how do you want me to manage this for you?".

If we want to redefine our profession for the betterment of our patients, we also need to redefine our relationships with those who have the ultimate say in medicine; the physician.  Our link to the medical community is our medical director.  It's time to stop neglecting that relationship and start building a lasting bridge to the medical community.

Following the engineers' triad, of course.

Pain Management, Part 2

Zachary posted a comment in my last post regarding pain management;

"Do you see any problems with an increase in drug seeking?"

The short answer (from my perspective, anyway) is: no.  But this does lead to another facet of why we treat pain the way that we do.

Why do we scrutinize our patients to see if they're "worthy" of our precious narcotics?

Fear.

When I was learning the profession of EMS as a new EMT, then again as a paramedic student, I saw plenty of examples of patients who reported they were in significant pain, but didn't receive adequate analgesia because the treating paramedic didn't feel they were "really in THAT much pain".  Similarly, I saw patients with a history of opioid abuse; some actually told us their addiction, while other times the crew made an assumption based on their medications, allergies, or history of ED visits.  These patients too rarely, if ever, received pain meds.  When I (curious mind that I am) asked these medics "why?", I heard various answers:

"They didn't look like their pain rating was 10 out of 10."

"Their vital signs were normal; if they're really in severe pain they'll be tachycardic or hypertensive."

"There's no way in hell I'm going to support their addiction; they'll just keep calling us and calling us.  If we give them narcotics, they'll just relapse."

These are all excuses based on fear, bad information, or burnout.


They didn't look like they were hurting that bad.

Ever get fooled by a patient presentation?  Happened once to me....actually, it happened lots of times to me.  When we view our patients through our own prisms of belief or subjectivity, we stop being objective and exploring all the possibilities.  And we make mistakes.  Consider the initial pushback that came when 12-lead ECGs starting finding their way onto ambulances.  Many seasoned, experienced medics said "I don't need some fancy machine to tell me when my patient's having a heart attack!  I KNOW what a heart attack looks like."

And they got suprised when normotensive patients without crushing chest pain had a 12-lead ECG that showed a STEMI.  Oops.

A large portion of our assessment relies on subjective information relayed by the patient; the best example of this is pain.  Some patients might communicate their pain level in a nonverbal way pretty well; but what about the mom who's trying hard to not cry from the pain and freak out her kids?  Or the guy trying to be tough in front of his buddies?  We can't objectively measure pain; we have to trust what the patient is telling us.  Trying to objectively measure the subjective is tricky at best, and unethical at worst.  I miss "Scrubs"; this clip summarizes the idea pretty well.

http://www.youtube.com/watch?v=-VR4onx2riQ

"Their vital signs were normal."

For most of us, this is pretty true; pain is accompanied by anxiety, which causes a sympathetic response and a catecholamine rush.  Hence the tachycardia and hypertension.  However, if patients have a condition that causes chronic pain, their body often adapts.  Rather than having an almost constant rush of catecholamines, their body simply stops releasing them every single time the brain registers pain.  It's called "sympathetic modulation".  Again, you can't objectively measure pain.

"They're drug-seeking."

So what?  People with opioid dependence hurt, too.  As a matter of fact, people who abuse opioids can have an exaggerated response to a painful stimulus; that is, something that would merely annoy you or I can be excruciating to a heroin or oxycontin addict.  I can identify with not wanting to prolong or complicate an illness with your treatment; I think many paramedics who withhold opioids from patients with opioid dependence are trying to do the best for the patient in the long run.  But there are two fundamental problems with this approach;

1)  Acute pain management doesn't seem to make dependence worse.  In fact, undertreating acute pain can make long-term management MORE difficult.  Here's a nice article that summarizes some common misconceptions and myths about giving opioids to patients with opioid dependence;  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816/

2)  As EMS providers, we're not long-term care providers.  That's not our role.  Nor are we addiction specialists.  That's not our role either.  When an ER doc identifies a medical condition in one of their patients that needs to be managed outside of their domain, they do one of two things; they refer the patient to their primary care doc for long-term management, or they refer them to a specialty service that has the training and clinical experience to give the best care to the patient.  In the meantime, the ED doc does what he/she can to treat the symptoms and make the patient feel better.  Why should we do any different?  Drug seekers don't call 911 and complain of abdominal or back pain for the fun of it; their body is demanding that drug.  Their body needs that drug to function.  Who are we to tell our patients "no"?

I do think we get hamstrung by the meds we carry; EMS is the only medical specialty I know that only has one option to control pain.  There's a lot to be said for ibuprofen and Tylenol (that's just about all I used after my hernia surgery).  Why aren't we using those as alternatives to use the right med for the right problem?

This has been a little long-winded...sorry.  But a little hisotrical perspective is in order.  Medicine all started because one guy (probably a guy, anyway) saw that people felt bad, and started looking for ways to make them feel better.  We've grown much, MUCH more sophisticated in how we do that, but the "why" should still be the same; someone doesn't feel good, and we want to make them feel better.  It goes right along with one of my favorite quotes from Hippocrates:  "Cure sometimes, treat often, comfort always."

Why do we treat pain the way we do?

Here recently, I found myself reviewing the pain management protocol for one of the services I work for.  I was reviewing it because I had received a QA flag for one of my runs; it seems I gave morphine (4mg, to be precise) to a patient with abdominal pain.  Now, I was clearly in violation of the service's protocols.  In my defense, I instinctively followed a protocol for another service I had worked for, which specifically indicated analgesia for abdominal pain on standing orders.  But in any case, as I reviewed the protocol like I promised to, I found statements that got my brain in motion:

"Abdominal pain is a contraindication for pain management under this protocol."

"Traumatic chest injury or multisystem trauma is a contraindication for pain management under this protocol."

"Administer morphine 2mg IV/IM, to a maximum of 10mg total."

(For the record, I am paraphrasing because I don't have the actual protocol book in front of me.  But hopefully you get the idea.)

Image:  http://www.sindh.gov.pk/dpt/Transport/rule.html

Why do we have so many rules for administering pain medications?  Why do we have such tight restrictions on how much to give?

Now, I'm sure that there's a wide range of pain management protocols, some less restrictive than others.  However, many medics that I interact with seem to have similar restrictions, so the answer is not just "Because your service sucks!".

EMSWorld recently published a nice column that looks at the origins of WHEN this idea of withholding analgesia in abdominal pain came about :  http://www.emsworld.com/article/10862823/its-ok-to-relieve-abdominal-pain

What I get out of this article are two things:

1)  This idea of letting people with certain types of pain suffer came along shortly after trepanning went out of style.

2)  If the ED doc can reverse the medication I gave with naloxone should they so desire, AND if they're not going to make a diagnosis without a CT scan to back up the physical exam, what the hell are we arguing about?

Now as far as withholding for traumatic chest pain goes, it strikes me as odd that prehospital treatment does a 180 from ED management of cracked or broken ribs (as any of you who have suffered such an injury can attest):

"Yep, the X-ray shows that you broke/cracked some ribs.  Here's some pain medicine.  Good luck sleeping."

(my good friend, co-instructor, and former climbing partner Dave Ramsey gets all the credit for that one.)

But for me, my biggest question is why we treat a subjective symptom with objective doses.

Pain is a subjective thing; no one except the patient can experience it (although we may feel sympathy pains from time to time!).  We rely TOTALLY on the patient to relay their level of pain to us, either verbally with a 0-10 scale, or non-verbally with something like the VAS or Wong-Baker.  Then, we dictate a one-size-fits-all solution to the pain.

That doesn't make sense to me!  We recognize that many medications aren't that way; hence all the weight-based calculations we have to do (I'm especially sensitive to this fact because it's PALS month at the medic program.  Good grief, I hate PALS.).  Why are pain medications, which treat a condition that everyone feels just a little bit uniquely, so static in their doses and max doses?  You can't tell me that 2mg of morphine or 50mcg of fentanyl will affect a ballerina and a sumo wrestler the same way.

Hospitals seem to recognize this fact; they may specify a max dose that you can give at a time, but they base their endpoints off the patient.  If your pain level is still above a 3 out of 10, you get more meds.

What if we just changed our protocols to read "Administer morphine in 2mg doses every 5-10 minutes until the patient's pain level is 50% less than their initial pain score"?  What harm would that do?  Would it be more effective?

What do you all think?

ANOTHER EMS blog?!?!?!?!?!?!?!

I've been intimidated by the idea of blogging for a while; as you probably know, there are a LOT of medical, and EMS, related blogs out there.  People much smarter, more opiniated, and probably more passionate than me.  However, a few weeks ago one of the paramedic students in the program I help with told me during open lab "Know what I'm going to start calling you?  Socrates.".

His point was well-taken.

Since I started in EMS an even decade ago, my favorite question has always been "Why?".  It pissed off my partners, got ED docs and nurses to do an abrupt about-face when they saw me walking down the hallway, and sent me down a path of madness; lots of time spent in the library and money spent on medical textbooks.  I still do that, although I've gotten better at balancing medicine with my other interests.  And in getting more and more involved with EMS education over the past few years, it seems I've been directing the same question, albeit with a different purpose, at my students.  You see, I don't think it's enough to know "what" to do; you should also know "why".  It's the mark of a professional.  And the more in-depth you understand the "why", the better.

So here we are.

My plan (at least right now) is to post on topics in EMS and emergency medicine that make me ask "Why?".  And I want to hear back from you....in a professional, mutually respectful way of course :)  I want to dig deeper into what we do in EMS, where all these ideas about how to provide out-of-hospital care came from, see what evidence there is (or isn't) to support our practices, and maybe provide a springboard to start making some change, or at least better understand WHY we do WHAT we do.  Because I think everyone in healthcare, from the bottom up, can benefit from a politely asked

"Why?"

Image:  http://www.geekscape.net/the-top-10-most-annoying-cartoon-characters