If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

Fall With Dementia and No Change from Baseline Mental Status


This happens many times every day. A patient falls and may have hit her head, but there is no change from her normal mental status. To complicate matter, she takes an anticoagulant.

There are no clear signs of serious trauma. so should we automatically go to the trauma center?

What can help us decide?

Patients were not excluded because of dementia, aphasia, or any cognitive or neurologic deficit that was determined by the physician caring for the patient to be the patient’s baseline.[1]


The conclusion of the study is useful, but I would reverse the emphasis.

Signs of trauma to the head and face or loss of consciousness is predictive of ICI.[1]


An absence of Signs of trauma to the head and face or loss of consciousness is predictive of an absence of ICI (IntraCranial Injury).

The study is not perfect, for example it is not clear what is included in the signs of trauma to the head, but it does strongly suggest that these patients should not be diverted to a trauma center just for anticoagulants, or for dementia, or for being old.

A patient was determined to have no significant acute head injury (1) if he/she had a negative result on head CT performed, (2) if the patient was admitted to the hospital and had no sequelae at discharge, (3) if review of his/her medical record revealed repeat hospital visits unrelated to falls with no sequelae or concerns related to the index visit,or (4) if the patient had no concerns at 30 days postinjury in telephone follow-up.[1]


These clearly are not the patients who needed to be trauma alerts.


Anticoagulants did not matter. While a trend is probably just statistical noise, the trend for anticoagulants other than aspirin was toward less likelihood of ICI.

While Signs of trauma to the head and face increased the likelihood of ICI, History of hitting head had a trend toward less likelihood of ICI.

The sensitivity and specificity for signs of trauma to the face/head or loss of consciousness were 92.6% (74.2-98.7) and 40.2% (36.8-43.8), respectively. The positive predictive value in this“low-acuity”cohort was 5.2% (3.4-7.6), and the negative predictive value was 99.4% (97.4-99.9).[1]


Should we start to write protocols based on this, or triage patients based on this? We should find out more, but patients with dementia and no change in mental status probably should not be triaged differently from patients with no change in mental status who just happen to not have dementia.

We already knew that, but we did not have evidence to support that bit of common sense.

A recent prospective study concluded that 26% of elderly patients presenting to the ED exhibited evidence of cognitive impairment[13].[1]


If a quarter of elderly patients have cognitive impairment, this can have a big effect on EMS.

The following figure that confused me. The percentages in red on the far right are the percentages of each category. That is what I would want to know, when looking at the data. The totals are not explained. Maybe someone will see what I am missing. How did 799 patients become 783, or did they become 783, and what happened to the other 16 patients if the number is now 783?


Regardless of my confusion with the figure above, this paper is one more reason for me to feel comfortable transporting patients with dementia and no obvious head injury (and no loss of consciousness) to the local hospital.




[1] Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury.
Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, Jeanmonod D.
Am J Emerg Med. 2014 May 12. pii: S0735-6757(14)00318-0. doi: 10.1016/j.ajem.2014.04.051. [Epub ahead of print]
PMID: 24929771 [PubMed - as supplied by publisher]


Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, & Jeanmonod D (2014). Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury. The American journal of emergency medicine PMID: 24929771


Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish

Dr. Edward Tobinick might not be a quack, but his behavior suggest otherwise.

Having a medical degree does not mean not a quack.

Using FDA (Food and Drug Administration) approved drugs does not mean not a quack.

Having a medical web site that does not have the word “quantum” all over the place does not mean not a quack.

Threatening to sue people for writing about the lack of evidence for his treatments does not mean not a quack.

Dr. Edward Tobinick is suing Science-Based Medicine for writing about Dr. Edward Tobinick’s dubious medical practices.

That strongly suggests that Dr. Edward Tobinick is a quack.

The claims and practice of Dr. Tobinick have many of the red flags of a dubious medical practice, of the sort that we discuss regularly on SBM. It seems that Dr. Tobinick does not appreciate public criticism of his claims and practice,[1]


Essentially, what Dr. Edward Tobinick is saying is, Your valid criticism of the way I apparently take advantage of patients might discourage patients from shelling out money for my untested treatment.

or –

Your valid criticism of the way I apparently take advantage of patients might encourage patients to ask reasonable questions about my untested treatment – questions that I cannot honestly answer.

Etanercept might work, but so might steroids, or ribavarin, or eye of newt, or a kick in the groin.

All of these treatments are equally valid. Oddly, the patients receiving a kick in the groin will probably report the fewest symptoms after treatment. 90% of the kick in the groin patients claimed to be cured and not in need of any further treatment.

Without evidence, and with his opposition to evidence, Dr. Edward Tobinick is just a quack with a brainstorm. Nothing original there.

Dr. Edward Tobinick injects etanercept (Enbrel) around the spine. This is not something he covered in his dermatology residency, so has he injected etanercept into the spine yet?

Why etanercept? Etanercept is an immune suppression/anti-inflammation drug. Inflammation is a problem with everything, so preventing/reversing inflammation is the simplistic cure. If this worked in real people, and not just in the hypotheses of pathophysiologists, steroids would have cured everything decades ago.

Perhaps Dr. Edward Tobinick is imitating Dr. Michael Bracken, who is able to produce improved outcomes with steroids (anti-inflammation drugs) for spinal injury, but only when he is in charge of the data.[2]

At least Dr. Michael Bracken published some research to support his claims. Dr. Edward Tobinick just wants us to believe that his interpretation of pathophysiology is miraculously prescient.

Evidence? We ain’t got no evidence. We don’t need no evidence! I don’t have to show you any stinkin’ evidence!

Maybe Dr. Edward Tobinick does have some valid evidence.

Maybe Dr. Edward Tobinick is just hiding the valid evidence because it is proprietary. ;-)

Here are a couple of comments by Dr. Novella on science and the importance of evidence. They probably were not directed specifically at Dr. Edward Tobinick, but they do apply to him.

What do you think science is? There’s nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?


Science is the way we learn what works.

Dr. Edward Tobinick’s criticism is evidence that he does not understand science.

Is any treatment, that is not based on evidence, likely to provide a benefit to patients?

History is strewn with ideas that were intuitive and made sense at the time, but were also hopelessly wrong.

Alternative medicine, opposition to EBM (Evidence Based Medicine), and opposition to SBM (Science-Based Medicine) are all the same mistake – evidence denialism.

Evidence denialism is devotion to being hopelessly wrong and remaining ignorant of being wrong.

Barbara Streisand?[3]




[1] Another Lawsuit To Suppress Legitimate Criticism – This Time SBM
Posted by Steven Novella
July 23, 2014
Science-Based Medicine


[2] Cochrane and a Significantly Biased Review of Steroids for acute spinal cord injury
Fri, 25 May 2012
Rogue Medic


[3] Streisand effect

Maybe there is no such thing as bad publicity for a quack, but the publicity associated with this law suit means that people will associate the name quack with Dr. Edward Tobinick, or vice versa.

Dr. Edward Tobinick is stating I am not a quack.

Reasonable people are hearing –

I, Dr. Edward Tobinick, am a quack.


Was the In-Custody Death of Eric Garner Due to Police and EMS Abuse? Part I


In NYC Medics Restricted By FDNY Pending Investigation Into NYPD Custody Death, The Social Medic writes about the death of Eric Garner during an arrest. Death may have many different causes. Is there any one thing that would have resulted in Eric Garner still being alive – if it had not been done (or if it had been done)?

We do not know.

We probably never will know.

Did Eric Garner deserve to die? No.

Was there a valid reason for an arrest? There is nothing in this video to answer that question.

Should the police have tried to take Eric Garner down the way they did?

Is that a real choke hold, or a movie of the week choke hold?

How much choking was going on?

How much resisting was going on?

The videos only show some of what was going on, but it seems like this was not well thought out.

Eric Garner is a big man and should be approached with a well coordinated plan for the safety of everyone – for the safety of Eric Garner, for the safety of the police, and for the safety of the bystanders. Was ESU (Emergency Services Unit) there? Was a Taser available and is Taser use permitted in that jurisdiction?

A Taser might have saved Eric Garner’s life, but Eric Garner still might have died, even if the police had not arrested him. Sudden death happens hundreds of thousands of times a year in America.

When the police initially take him down, they brush up against/bounce off of a window. If it is glass, what would have happened if it broke? If it is glass, what if they had continued through the glass? If it is not glass, how do they know?

The difference between broken glass and a knife (or a sword) is not in the amount of danger they present, since all can kill you very quickly. This difference is in the perception of that danger.

In this video, Eric Garner repeatedly states that he cannot breathe, but this is probably not the first time that police have heard similar statements while wrestling someone into custody. EMS was not there, so no treatment was immediately available, if any treatment had been indicated. We cannot tell. His death later is not proof that he was having trouble breathing, but it does suggest that he was not breathing adequately.

Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher

The commentary from the person filming the video is useless. It is just as prejudiced and uninformed as that of any other politically motivated commentary.

All he did was break up a fight?

Unlikely, but how would the person filming this know?

Prejudiced cops on Staten Island, this is what they do?

Does that applied to the non-white cops, too? Or is that just a prejudiced comment? Prejudice does exist. Nobody is immune from it, but what is the critic basing his comments on? He appears to be basing his comments on his prejudice.

Eric Garner was beat up?

He was violently subdued/wrestled to the ground, but I did not see anyone strike him.

Eric Garner was not beat up.

The critic seems to be singing along with the music in the background, which does not really give the impression of someone who thinks he is witnessing someone being killed. He makes a lot of accusations, but his actions do not match his words. If you are singing along with Muzak, you appear to be indicating that there is nothing important distracting you from your singing. Maybe it is someone next to the critic, but that still suggests that there was not a lot of concern among those as close to events as the critic.

Did the police choke Eric Garner into submission or did one officer overestimate the effect he would have on a much larger guy by grabbing him around the neck?

Someone has written, None of the officers knew what to do in this situation on the bottom of the video. What would the film critic like the police to do? Should they put Eric Garner in the back of a police car?

What does the film critic suggest that they do?

They have called for an ambulance and they have Eric Garner in the rescue position.

Did the police use an inappropriate method of arresting Eric Garner?

The prohibition on the use of a choke hold for restraint may have more to do with the way things look to bystanders, than the effect it has on the person being restrained. Choke holds are not prohibited in most combat sport because apparently choke holds can be used safely. Did the choke hold cause death?

Image credit – Wikipedia article on choke holds.

At about 4:30 of the video, EMS enters.

I have not commented on what The Social Medic wrote about this incident, yet. I will comment on what can be seen of what EMS did (did not do) and whether excited delirium is a part of this in Part II.


Does a Medic Need Two Eyes to be Safe?


When this story first was reported, there were plenty of social media comments about the lack of safety of having only one eye.

Is there any difference in outcomes for patients treated by two-eyed medics and one-eyed medics? What about medics who wear glasses? Should a three-eyed medic be given preference over two-eyed medics?

Is there any evidence of a difference in job performance?

Is there any evidence of a difference in driving?

Is there any evidence of a difference in anything that is a part of the job?

Provide some valid evidence.

If we are going to make these decisions without evidence, we should admit that we are basing our decisions on prejudice.

A Queens woman with a prosthetic eye is suing the FDNY because it won’t hire her as a paramedic.[1]


The article lacks information. There may be other reasons she has not been hired, but NYFD is not likely to discuss those directly in the media, because that might also lead to a law suit. If this does go to court there should be more information available.

This topic has generated a lot of righteous indignation from those who insist that two eyes are necessary for the safety of patients. I have not yet seen any evidence to support their attitude.

If there is valid evidence that I am wrong, I am willing to learn from that.

See also -

Improving EMS By Hiring Deaf EMTs




[1] FDNY won’t hire woman with fake eye as paramedic: suit
By Kathianne Boniello and Georgett Roberts
July 6, 2014 | 4:37am
NY Post


When is a double dose of defibrillation a good idea?

In the comments to Double simultaneous defibrillators for refractory ventricular fibrillation, NCMedic and Ambulance Driver write that they have already begun using variations on double defibrillation.

That     is     excellent.



The changes in when to implement the change, as well as the vector to use, are reasons we need to have people publishing results on what is being done. Please, work with your medical directors and/or others to publish some results.

We have had epinephrine (Adrenaline in Commonwealth countries) in ACLS (Advanced Cardiac Life Support) guidelines, and our protocols, for decades, but we still do not know the best dose or even which patients benefit.

NCMedic writes –

Has been in our protocols for sometime now, we are finding it more beneficial sooner than later for obvious reasons, next protocol revision will most likely have it on the 4th shock with the 2nd set of pads placed A/P to cover from a different vector.


Epinephrine seems to be harmful when given later, or is epinephrine less beneficial later, or is epinephrine always harmful, just much more harmful later, or something else.[1]

The problem is that we do not know when, or for whom, epinephrine is indicated.

Epinephrine is probably indicated in some patients, but which patients, at what dose, and at what time? If epinephrine should be repeated all of the same questions apply to all further doses. Dr. Scott Weingart points out how little we know about the use of epinephrine, because his approach makes more sense than what ACLS recommends and the evidence is equally lacking.[2]

There are many things in the presentation to discuss, such as Dr. Weingart’s misunderstanding of what nihilism means, but that is for another time.

There does not appear to be any harm from double defibrillation. As we use more current more often, we should expect to learn of harms, as we do with almost every intervention. However, as NCMedic states, we may be doing harm by waiting too long to deliver the double dose.

Should it be a double dose?

What about 1 ½ times the maximum?

300 j bi-phasic or 540j mono-phasic or maybe some combination of bi-phasic and mono-phasic, and if a combination, what combination, with drugs or without, which drugs if with drugs, . . . ?

What about 3 times the maximum?

600 joules bi-phasic or 1,080 joules mono-phasic or . . . ?

Should the higher-dose defibrillation be after the fifth shock with a return to VF/pulseless VT (Ventricular Fibrillation/pulseless Ventricular Tachycardia)? After the fourth shock? After the third shock? After the second shock? After the first shock?

Is waiting longer to increase joules making it more likely that epinephrine will be given? Is epinephrine more harmful than a double shock, less harmful than a double shock, or roughly the same?

The amount we do not know is huge.

We should learn what we are doing to our patients and not arrogantly choose to remain ignorant, as we have chosen with epinephrine. That is changing, but some still defend the arrogance of ignorance at the expense of our patients.[3]




[1] Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?
Sun, 25 May 2014
Rogue Medic


[2] Podcast 125 – The New Intra-Arrest from SMACCgold
Dr. Scott Weingart
Web page with video and show notes.


[3] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.


In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.



Double simultaneous defibrillators for refractory ventricular fibrillation

It looks as if the next generation of defibrillators will go to 11. This patient received a double dose of defib.

Is 720 joules too much?

If your answer is Yes, please explain how 720 joules is worse than death.

What about 400 joules? Some older mono-phasic defibrillators go to 400 joules, but we might see 400 joule bi-phasic defibrillators.

Until then, there is the possibility of using two defibrillators to deliver shocks at the same time, or milliseconds apart. By the time that this is a relevant treatment, the patient has been down for several shocks and is still in a shockable rhythm, but a supervisor or second medic unit should have arrived with a second defibrillator.


It is important to not put the pads from the same defibrillator next to each other.

The paper describes a patient with a BMI (Body Mass Index) of 40, a STEMI, and an onset of VF (Ventricular Fibrillation) in the presence of EMS.

CPR (being performed by the son when EMS arrived at the ED?), 200J x 3, epi x a bunch, amio x 1 by EMS.

High-quality CPR, a bunch more epi, 200 J x 2, lido x 1, bicarb x 1 (bicarb might have been indicated by the patient’s astrological sign), then the shock at 400 joules.

The patient then regained a palpable pulse and blood pressure. He had another brief episode of ventricular tachycardia that responded to a second defibrillation with 400 J. The patient had a wide QRS rhythm that quickly narrowed into normal sinus.[1]


Maybe the patient was not told about the concerns of some people that too much is too much. If he had been told, he would have remained dead, like a good scenario patient.

Next time he can follow the approved scenario.

Five studies have demonstrated safety in patients receiving 720 J of monophasic energy for cardioversion of atrial fibrillation (17,22–25).[1]


Five papers demonstrate the safety of 720 joules in living patients with atrial fibrillation, but many in EMS will tell us that it is too dangerous to use on dead people after the failure of standard doses of energy.

Lake Sumter EMS has been providing compression-only CPR, even adding 720 joule defibrillation, and they may have the best resuscitation rates in America. The rest of us should consider catching up. I wonder how things have gone for LEMS, since I wrote about them a couple of years ago.[2]


While ROSC (Return Of Spontaneous Circulation) is not the right outcome to use to evaluate a treatment, 70% suggests that we should pay attention to what they are doing in Lake Sumter. 46% ROSC in those who could not get ROSC any other way by EMS.

You can’t be too safe is still a lie.


Also read –

When is a double dose of defibrillation a good idea?




[1] Double simultaneous defibrillators for refractory ventricular fibrillation.
Leacock BW.
J Emerg Med. 2014 Apr;46(4):472-4. doi: 10.1016/j.jemermed.2013.09.022. Epub 2014 Jan 21.
PMID: 24462025 [PubMed - in process]


[2] Optimizing Outcomes in Cardiac Arrest
Mon, 10 Dec 2012
Rogue Medic


IAFF’s Jack Reall faces discipline for delaying a 911 call in order to protest research he does not like


One of the advantages of fire department-based EMS is that there is a clear chain of command and that discipline is not a problem. The exceptions to this may be rare enough that they make headlines. Here is one.

A Columbus Fire battalion chief could face discipline for insubordination after an internal investigation found that he disrupted a pilot program intended to more efficiently respond to emergencies.[1]


The first oddity is that the Battalion Chief (Jack Reall) is also the president of Local 67 of the International Association of Fire Fighters. A management position and a union position – and not just any union position, but president. Jack Reall apparently cannot keep his priorities in order.

The fire department is studying whether 911 calls should receive an initial response from one paramedic with a basic EMT or from a pair of paramedics. There is no evidence that sending one paramedic and one EMT causes any kind of harm, or that two paramedics provide better care, so there is no basis to claim that anyone is being in any way endangered by this pilot program.

If there were a legitimate concern, then the time to address that was when the pilot program was being considered. It appears that Jack Reall is not happy with that and his union boss persona delayed a 911 response in violation of fire department rules.

The Fire Division launched a pilot program that morning to reduce the number of paramedics who respond to routine calls, allowing the division to disperse medics elsewhere. Instead of two paramedics on a truck, there would be one medic and a basic emergency-medical technician, or EMT.[1]


Is it possible that this was a complete surprise to Battalion Chief/Union President Jack Reall?

I don’t know what kind of preparations were made by the fire department, but I suspect that they began well in advance of BC/Pres. Jack Reall’s attempt at sabotage.

It is appropriate to study things when there is a state of equipoise about which is best.

Equipoise is just a fancy word for We do not know which is best.

When we do not know what is best, we should find out, rather than arrogantly assume that we know all that we need to know to force an uninformed opinion on others. That is the alternative – I don’t know, but I am going to force my opinion on everyone else because I am certain my opinion is more important than learning the truth.

Research means we learn more, even if we never learn the whole truth. Opposing research is opposing learning more – especially if the truth disagrees with opinion.

Equipoise means that we cannot be certain, because we do not know enough to be certain.

Reall was against the plan from the start and said fewer paramedics meant lower-quality service.[1]


The fire department and the union probably have worked out procedures for resolving these differences of opinion. They probably do not include delaying 911 responses to make a point.

If Jack Reall were behaving responsibly, he would have raised these concerns at an appropriate time and place.

Reall said the plan was not presented well to firefighters and paramedics and was “not well thought out.”[1]


He did raise them at the appropriate time, but he did not get what he wanted.

When I don’t get what I want, as a responsible adult, I should throw a tantrum.

True or False?

A Battalion Chief is supposed to be a person to turn to to resolve confusion, not to create confusion. One part of the job is to make a clear decision (such as to protect the interests of a patient) and to take responsibility for that decision.

It appears that Reall was doing the opposite.




[1] Firefighters-union chief faces discipline from Fire Division
By Lucas Sullivan
The Columbus Dispatch
Wednesday July 9, 2014 5:51 AM


Ambulance Crash ‘Caused by’ Overtime?


Was this crash caused by paramedics working an extra shift, or two, or three, or . . . ?

Does management’s math work (as reported)? Does management’s math (as reported) suggest that management does not understand math (or that a mistake was made reporting the story)?

HONOLULU (HawaiiNewsNow) – An ambulance crash at Ala Moana Center involved overworked paramedics on overtime.[1]


A paramedic on overtime? Oh, no! In many places, it seems that paramedics (who get paid more than basic EMTs) have to work more than one job to just be able to live paycheck to paycheck. Part of the problem is that we humans spend money unwisely (as a species, we are horrible at money management). Part of the problem is that EMS often does not pay well. If pay is low, people will work other jobs – or they will not be able to continue to pay their bills and complications ensue.

Here is the math problem.

The city wants to reduce chronic vacancies which lead to back-to-back shifts by changing the length of the shift from eight to 12 hours. The move would mean the city’s 22 ambulances could be run with one-third less staff each day, allowing other medics to have much-needed time off, but sources said the United Public Workers union is holding up the negotiations.[1]


If shifts are changed from 8 hours to 12 hours, there will be one third fewer shift changes, but that should not affect the number of calls the ambulances run. If the ambulances are not currently busy, changing the schedules might reduce the amount of time crews are not on calls, but so would cutting shifts. That does not seem to be an option, so this appears to be a bit of bad math that nobody in management has corrected.

If I work six 8 hour shifts a week, I am working 48 hours a week.

If I work four 12 hour shifts a week, I am still working 48 hours. I am only cutting the number of shifts in a week, not cutting the hours worked in a week.

If I work nine 8 hour shifts a week, I am working 72 hours a week. If I work six 12 hour shifts a week, I am still working 72 hours.

Should I expect to be any less tired if my shifts are divisible by 12, rather than by 8?

Will the proposed schedule result in fewer ambulances on the street at peak times. Someone will still have to pick up the patients. If ambulances are not currently busy, this could result in treating and transporting the same number of patients with fewer paramedics, but that can also be achieved with 8 hour shifts. Ambulance contracts often mandate that a certain percentage of response times be under X minutes. If management is able to get that to change, that could result in fewer crews on the street, but working much harder, and might be seen as a success by shortsighted management.

Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher

We can speed up what we do, but at some point we will increase the rate of errors. This is to be expected and should not be blamed on the employees. Management deserves the blame. The role of management is to help the income producing employees to do their jobs, not to blame the employees for bad management.

I have worked for people who manage this way – and not just in EMS, but we do seem eager to make excuses for bad management.

If management is not capable of competence with simple math (as was reported here), what are their other weaknesses?

If management isn’t able to manage with 8 hour shifts, will Goldilocks come to the rescue when the shifts are 12 hours long?




[1] First responders hurt in ambulance accident at Ala Moana
Posted: Jul 12, 2014 11:40 PM EDT
Updated: Jul 13, 2014 4:45 AM EDT
Hawaii News Now