We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Update on – Is it OK to kill children in the name of God?

 

Back in April, I wrote this about the death of the second of the Schaible’s children at the hands of a pastor –
 

Don’t bother using alternative medicine to make a limb to grow back. Take alternative medicine for things that occasionally resolve without any real medicine.

Then claim “Alternative” medicine did it!

Is it OK to kill children in the name of alternative medicine?[1]

 

I am feeling much more prophetic than Sylvia Browne at the moment, but everyone should always feel more prophetic than that fraud.[2]

The other trait of alternative medicine is to blame the patient (in this case, the family) for a lack of faith, when the scam fails.
 

Clark was the spiritual adviser when the Schaibles’ 2-year-old, Kent, died from bacterial pneumonia in 2009, which led to a manslaughter conviction and probation for the couple. And he ministered to them last week when 8-month-old Brandon died, a case now being investigated by police.

In an interview with The Inquirer, Clark said God did not want the Schaible children to die.

Instead, he said, the children died because of some “spiritual lack” in the Schaibles’ lives – a flaw they need to correct to prevent future deaths.[3]

 

The problem is not with the person selling the scam, but with the people not believing enough.

The Schaibles made the mistake of listening to Pastor Nelson Clark and they killed one of their sons with untreated pneumonia.

The Schaibles then made the even bigger mistake of listening to Pastor Nelson Clark again and they killed a second one of their sons with untreated pneumonia.

Pastor Nelson Clark blames the parents and maybe the dead children.

I blame the parents, but not as much as I blame Pastor Nelson Clark.
 


Image credit. Pastor Nelson Clark of the First Century Gospel Church.
 

This human sacrifice is

not the first time that children have died with the help of Pastor Nelson Clark

not the second time that children have died with the help of Pastor Nelson Clark

not the third time that children have died with the help of Pastor Nelson Clark

not the fourth time that children have died with the help of Pastor Nelson Clark
 

The First Century Gospel Church of Philadelphia’s teachings has clashed with authorities in the past.

In 1991, eight children died in a measles epidemic. All the parents were members of either First Century Gospel Church or the nearby Faith Tabernacle of Nicetown which also preaches faith-healing.[4]

 

Let’s just say that Pastor Nelson Clark doesn’t have a good record of praying the germs away.

Keep the Schaibles from being in any position to care for any children – ever.

More important is to stop Pastor Nelson Clark from using the children of his congregation to demonstrate that seriously ill children will die without medicine – even with the wonders of modern sanitation. His God apparently approves of sanitation, and automobiles, but not seat belts. Made Up Biblical References 4:20.

Pneumonia is regularly treated successfully by real doctors, especially when recognized early –
 

The majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics. High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia. Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives. Combination therapy (ampicillin and either gentamicin or cefotaxime) is typically used in the initial treatment of newborns and young infants.[5]

 

Pastor Nelson Clark wants to gamble with the lives of your children. If you lose, he blames you.

Are you willing to bet the lives of your children?

-

Footnotes:

-

[1] Is it OK to kill children in the name of God?
Sat, 27 Apr 2013
Rogue Medic
Article

-

[2] Why Do We Treat Some Frauds Differently?
Sat, 11 May 2013
Rogue Medic
Article

-

[3] Pastor: ‘Spiritual lack’ killed two boys
By Mike Newall, Inquirer Staff Writer
Posted: April 29, 2013
Philly.com
Article

-

[4] Faith-healing parents charged with MURDER after second child died in their home from pneumonia without getting medical help while they were on probation over death of first son
By Daily Mail Reporter
Published: 17:10 EST, 22 May 2013 | Updated: 17:33 EST, 22 May 2013
Capital Bay
Article

-

[5] Pediatric Pneumonia
Author: Nicholas John Bennett, MB, BCh, PhD; Chief Editor: Russell W Steele, MD
Medscape Reference
Article

.

Some Excellent New Medical-Research Sites

 

Where are the best new places to get emergency medical research?

First, an older place, which gathers a lot of research together.
 


 

Life in the Fast Lane has its Research Review (the most recent is #104), which provides links to what people are writing about emergency medicine and critical care research as well as great writing by their own authors.
 

-

 
But what about the newer sites?
 


Image credit.
 

The Lit Whisperers
 

The new blog of Brandon Oto to go along with The EMSB Digital Research Library by Brandon with Vince DiGiulio as the Head Librarian and Master of Evidence-Based Codices. .
 

-

 

 

Skeptical Medicine
 

Dr. John Byrne tries to explain about the medical mistakes we make in being too cynical or too gullible, rather than appropriately skeptical of claims made by researchers, or those who do not even care if their treatments work.
 

Where do we fall on this spectrum?

Too many of us seem to be fond of the idea of using what some fan of physiology claims works, even though this approach frequently does not even work as well as placebo. We need less of that textbook gullibility that is regularly disproved by research.
 

** It is logically contradictory – and therefore forbidden – to embrace science and logic when they support an idea, but then to reject them when they do not.

 

-

 

 

Mill Hill Ave Command
 

Dr. Brooks Walsh examines recent research with a lot of visual aids that take what could be dense material and makes it very educational and fun. There is otherwise a shortage of paramedic/medical directors out there writing about research.
 

-

 

 

EMS Patient Perspective

Bob Sullivan writes about the way our treatments affect patients, for good and for bad.
 

-

 
Then some of the older sites –
 


 

Street Watch: Notes of a Paramedic
 

Peter Canning writes about what works in patient care from the street level and from the administrator level in one of the first EMS blogs.
 

-

 


 

A Day in the Life of an Ambulance Driver
 

Perhaps the most hated blog name in EMS, because We’re too good to be called ambulance drivers. Those critics may not even deserve to be called taxi drivers.

Kelly Grayson writes about all aspects of EMS, but he has a series with Gene Gandy that looks at the EMS mythology that just does not seem to go away, such as the recent More Oxygen Can’t Hurt…Can It?
 

-

 

 

EMS 12 Lead
 

Tom Bouthillet, Christopher Watford, and David Baumrind write about all things electrical in the heart.
 

-

 

-

 

 

SMART EM

Dr. David Newman, and sometimes Dr. Ashley Shreves, write and podcast about research and emergency medicine. There is an excellent deconstruction of the ACLS (Advanced Cardiac Life Support) guidelines and the lack of evidence for the drugs recommended in the guidelines.

The NNT is another excellent site that is here, too.
 

-

 

 

EM Crit
 

Dr. Scott Weingart podcasting on bringing ICU medicine to the ED, so why shouldn’t we continue that by taking ED medicine to the street?
&nbsp

-

 

 

Emergency Medicine Literature of Note
 

Dr. Ryan Radecki writes a couple of paragraphs that get to the heart of recent research – the important points, including the flaws. His criticism of the only partially disclosed biases of the cherry-picked research misrepresented as a comprehensive research review by JAMA (Journal of the American Medical Association) was posted on his site, rather than trying to get it published in JAMA. It probably received more attention this way. Go read it.

Are blogs the future of peer review, because the journals do not seem to do an adequate job. If they did, I would not have so many badly written papers to criticize.
 

These sites are not examples of gullibility in medicine.
 

I am sure I am missing some important sites, but I am too tired to focus. Going to bed.
 

What sites do you recommend?
 

.

Spinal Immobilization – Untested and Unreasonable


 

Why do we keep trying to justify using a simple flat splint to align the many bones of our curved, articulated spines?

We keep trying to put a square object in a round hole. Small children do not make this mistake.

The spine is curved.

The board is not curved.

Does the board offer any real protection?

It seems that the board is just there for security theater.[1]

We make a big show of dressing people up in a collar, a backboard, blocks, and straps. Do we have any reason to believe that this fad works?

Bleeding patients to get rid of the bad humors lasted for hundreds of years, so this backboards are still new and in the fad category.

-

Footnotes:

-

[1] Security theater
Wikipedia
Article
 

Security theater is the practice of investing in countermeasures intended to provide the feeling of improved security while doing little or nothing to actually achieve it.[1]

 

.

What Does a Moon Landing ECG Look Like?

 

Some interesting ECG from the first people to land on the Moon.

During landing, they were running low on fuel and Buzz Aldrin appears to be showing signs of stress.

 

Click on images to make them larger.
 

The image above is from the following video describing the monitoring of the ECGs of the astronauts.
 


Download | YouTube MP3 Converter
 

The reason this is in the news now is that one of four of the ECGs of Neil Armstrong as he stepped on the Moon was scheduled to be auctioned, but has been pulled due to questions about whether the owners have clear title to these items.[1]

How low on fuel were they? Were they going to crash?

They were just going to have to abort the mission and return to the Command Module, but after years of preparation for a Moon landing, that can be a huge amount of stress.
 


 

“EKG Recordings Taken as Apollo 11 Commander Neil Armstrong Took Man’s First Step on the Moon” and “4:13:24:28 Ground Elapsed Time.” Sheet is signed and inscribed in pencil, “To Paul Jones, The heartbeats that made this accomplishment possible as recorded at MCC on my console. Keep up your heart work. Charles A. Berry M.D.” Presentation also bears a Neil Armstrong autopen signature. Sheet is matted and framed with mission patches from Apollo 7, Apollo 8, Apollo 9, Apollo 10, Apollo 11, Apollo 12, Apollo 13, and two Snoopy patches, to an overall size of 20.75 x 24.75.[2]

 

Look at Buzz Aldrin’s ECG. The rate is about 400 BPM (Beats Per Minute).

Can a human heart beat that fast?

I have seen close to 300 BPM in a febrile infant.

Is the following rate possible for a human?
 


 

The rate is probably not possible.

The reason it looks so fast is most likely because the paper is being fed at a much slower speed than usual.

Conversely, we can get a better idea of what a very fast tachycardia looks like by speeding up the paper feed rate from the standard 25 mm/second to 50 mm/second or by manually pulling the paper through the printer faster than its normal rate.
 

EKG strip, six inches long, taken as Apollo 11 Commander Neil Armstrong took man’s first step on the moon. This is an actual strip of the EKG from Armstrong’s heart monitor at the moment he stepped onto the lunar surface.[2]

 


 

Compare that with a “six second section” of Buzz Aldrin’s ECG during their very low on fuel landing.
 


 

At 12.5 mm/second, this would be a rate of about 200 BPM, faster than the calculated maximum heart rate, but still capable of being a sinus tachycardia that is only associated with minor/moderate symptoms. At 10 mm/second, this would be a rate of about 160 BPM, which I regularly exceed (and recover from without any need for adenosine or cardioversion).
 


Download | YouTube MP3 Converter
 

Several times you hear them checking with the flight surgeon and receiving a “Go,” each time. A heart rate of 400 should have resulted in something other than a “Go.” A few questions to Buzz Aldrin about how he is feeling would have been prudent.

If I have a patient with a heart rate of 400 and I do not ask a few questions about how the patient is doing, it would probably be because the patient is not capable of communicating. How are you feeling, hummingbird?
 

In general, sinus tachycardia is a response to other factors and, thus, it rarely (if ever) is the cause of instability in and of itself.[3]

 

At EMS 12 Lead, there is an excellent discussion of sinus tachycardia, and the nonsense of assuming that anything faster than 150 BPM is an SVT that needs adenosine or cardiversion.[4] This includes comments from Dr. John Mandrola and Dr. Mark Perrin.
 

Go read it.
 

-

Footnotes:

-

[1] Neil Armstrong’s ‘Heartbeat,’ Apollo Joystick Pulled from Auction
by Robert Z. Pearlman, collectSPACE.com Editor
Date: 20 May 2013 Time: 04:34 PM ET
Article

-

[2] Neil Armstrong’s Heartbeat – EKG Up For Auction
By Patrick Lockerby
May 5th 2013 04:20 PM
Science 2.0
Article

-

[3] Overview
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text from Circulation.

-

[4] The Trouble With sinus Tachycardia
April 30, 2013
David Baumrind
EMS 12 Lead
Article

.

Let the drug shortages help us make better patient care decisions


Image credit.[1]
-
 

Maryland made smart changes to their protocols because of the drug shortages.[2]

50% dextrose is not as good as 10% dextrose at treating hypoglycemia.[3],[4],[5]

Switching to 10% dextrose is an obvious solution, but not used by everyone.
 

Sedgwick County EMS workers administer about 80 doses of the stuff (50% dextrose) a month, but the county has only received 30 pre-filled doses so far this year through its normal vendor, Braithwaite said.[6]

 

We have research that shows that 10% dextrose is a better choice for EMS, but we continue to use the inferior treatment.

We have trouble obtaining the inferior treatment, but we refuse to change to the better treatment.

Is there a state law that prevents the use of different concentrations of dextrose?

If so, go to the government, explain the problem, and get the law changed. If that does not work, go to the press and point out that the failure to act by the legislature is endangering patients.
 

“We’re now looking at compounding of those medications,” he said.

But that’s an expensive alternative. A pre-filled dose of dextrose costs $6.99. A vial costs $1.81. Pre-filled doses are preferred, Hadley said, because there is one less step for emergency personnel.

Compound dextrose costs $14 per dose and has a much shorter shelf life, 90 days compared with two years.[6]

 

50 ml of 50% dextrose contains 25 grams of dextrose.

A 250 ml bag of 10% dextrose contains 25 grams of dextrose.

The cost of the bag of 10% dextrose is about $2.50, which is much less than the $7 cost of and amp of 50% dextrose.

Is there a difference in shelf life? If they are giving 80 doses a month, how much does that matter?

The only advantage to the 50% dextrose is familiarity, which is due to our failure to change to a better treatment when it becomes the right thing to do.

The drug shortages do not affect 10% dextrose.

Isn’t it time we cut costs, improved safety, improved care, and eliminated 50% dextrose?

-

Footnotes:

-

[1] Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed - indexed for MEDLINE]

-

[2] Drug shortages leading to better EMS protocols
Fri, 19 Oct 2012
Rogue Medic
Article

-

[3] Dextrose 10% or 50%: EMS Research Episode 10
Tue, 05 Jul 2011
Rogue Medic
Article

-

[4] Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.
Moore C, Woollard M.
Emerg Med J. 2005 Jul;22(7):512-5.
PMID: 15983093 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central

-

[5] A review of the efficacy of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycaemia
Ziad Nehme, Daniel Cudini
2009; Volume 7 : Issue 3; Article Number: 990341
Journal of Emergency Primary Health Care
Free Full Text with link to PDF Download

-

[6] Sedgwick County EMS warns of national drug shortages
By Deb Gruver
The Wichita Eagle
Published Tuesday, May 14, 2013, at 8:41 p.m
Article

.

Too Much Oxygen, Too Many Backboards

-
 

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and I discuss a variety of topics – quality in EMS, respect for EMS, the value of research and whether we should teach people to use research in EMS.
 

Too Much Oxygen, Too Many Backboards
 

Spinal immobilization can be done in many different ways. Strapping a curved spine to a flat piece of lumber/plastic is not the only way to do it and not even the only way that it is done in the US, nor in the rest of the world.
 


 

Long spine board immobilization is continuing to be replaced by the lateral trauma position in Norway.[1],[2]
 

What about in America?

Going back to 2008 (the earliest protocols available on line, all of Pennsylvania has had spinal clearance.
 

Immobilize the entire spine3,4 in any trauma patient who sustains an injury with a
mechanism having the potential for causing spinal injury and who has at least one of
these clinical criteria:5
a. Altered mental status (including any patient that is not completely alert and oriented)
b. Evidence of intoxication with alcohol or drugs
c. A distracting painful injury (including any suspected extremity fracture)
d. Neurologic deficit (including extremity numbness or weakness- even if resolved)
e. Spinal pain or tenderness (in the neck or back)
[3]

 

Without altered mental status, evidence of intoxication, a distracting painful injury, neurologic deficit, and/or spinal pain or tenderness spinal immobilization is a violation of protocol in Pennsylvania.

Alameda County, California; Xenia, Ohio; and all of Connecticut are doing away with backboards.

Spinal clearance has been in place in many more places in various forms for years, or even for decades.

Don’t let local attitudes fool you. this is not new or limited to isolated areas.
 

Spinal immobilization is witchcraft. There is no evidence of benefit.
 

Oxygen was also discussed.

There is a lot to discuss about the absence of good evidence that supplemental oxygen improves outcomes when there is no known hypoxia.
For heart attack patients, why do we want to give a drug (oxygen) that causes vasoconstriction, when our goal is vasodilation?

If the goal is to improve blood supply, and oxygen decreases blood supply, then why are we giving oxygen in the absence of evidence of hypoxia?

Supplemental oxygen without evidence of hypoxia is also witchcraft.

-

Footnotes:

-

[1] The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services.
Fattah S, Ekås GR, Hyldmo PK, Wisborg T.
Scand J Trauma Resusc Emerg Med. 2011 Aug 4;19:45.
PMID: 21816059 [PubMed - in process]

Free Full Text from PubMed Central with links to PDF Download

-

[2] The Lateral Trauma Position: What do we know about it and how do we use it
Sun, 04 Dec 2011
Rogue Medic
Article

-

[3] Spinal Immobilzation – 261
2008 Pennsylvania Protocols
PEHSC
Page with links to protocols in PDF format.

-

[4] More Oxygen Can’t Hurt…Can It?
by William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Created: MAY 1, 2013
EMS World
Article

.

NYPD Officer Stuck in Tree Trying to Rescue Cat is Rescued by NYFD


Image credit.
 

What were you thinking?

That is the obvious question to ask this police officer.

That is after asking is the story true. It was reported by NBC with no author listed.

Do cats die if not rescued from trees?

I wonder if PETA has a page on this. They do not appear to, but it could have been amusing.

However –
 

When a Tennessee woman’s cat was stuck in a pine tree, firefighters gave her two options: they could blast it out with a hose or shake the tree until the cat fell out. When asked how option B was any different from the cat’s just falling out on its own, one firefighter answered, “Neither is real different, ma’am. Just quicker.”[1]

 

Things could have turned out worse for the officer. they could have used the hose or shaken the tree until the officer fell to the ground. Humans have not evolved the ability land as gracefully as other species do.

Still, this rescue may end up being a fate worse than death for this NYPD officer.
 

The officer had lit a flare and set up cones on the ground underneath the tree before going up but onlookers ignored them as they gathered and gawked from the ground, said Yu.[2]

 

Flares and trees and children are not a good combination. Fortunately, it is Spring and there is no drought.

When going to so much trouble to be a hazard to one’s self, protecting others is probably not one of this officer’s strong points.

Nothing says come hither like cones, flares, and treeful stupidity.

Perhaps cats in trees should have a time limit before someone responds with a hose to dislodge them from the trees. If the cat doesn’t come down on its own in 48 hours, then someone might respond.
 


 

This image accompanied the article.

Maybe this is a mug shot of the tree that abducted the officer.

-

Footnotes:

-

[1] Do fire departments actually rescue cats from trees?
Straight Dope
January 8, 2010
Article

-

[2]
FDNY Rescues Cop Stuck in Tree Trying to Rescue Cat
NBCNewYork.com
updated 5/13/2013 10:47:22 PM ET
Article

.

Improving EMS By Hiring Deaf EMTs


 

We each have many limitations.

Should we assume that one specific limitation, that we do not understand, is too limiting to work in EMS?

Don Burslem could have used that prejudice as an excuse to not hire Chad Grabousky.
 

But Burslem decided to take a chance on hiring Chad Grabousky, and more than two months later, he’s very glad he did.

“His patients love him, our staff loves him, and he actually does a wonderful job in back of the ambulance, better than some of my hearing staff,” Burslem said.[1]

 

Oh, no! What if . . . ?

We can always make excuses for our prejudices, but it is better to learn what the actual limitations might be, how those limitations might be accommodated, whether those accommodations really work or just provide the appearance of accommodation, and what the benefits are of the limitation.

We do not live in a binary world. things are not all good, not all bad.

If we do not understand that, then we should not be administering medications, since medications have benefits (for some patients), side effects, and toxicity.

Medications are not inherently good or bad. This is not even close to being news.

All things are poison, and nothing is without poison; only the dose permits something not to be poisonous. – Paracelsus (1493-1541)
 

EMTs need to communicate with their patients, with their partners, with hospital officials over the radio.[1]

 

Do we really need to communicate on the radio? We include radio communication in EMS classes, but who really needs to know what frequency we communicate on? I don’t.

A lot of communication with dispatch has been by MDT (Mobile Data Terminal) for the past decade. I cannot hear the information that appears on the MDT (but there are text to speech programs available). I do not need to speak to hit the responding, or on scene, or any of the hospital buttons to communicate.

But what about lung sounds?
 

He will not be able to differentiate from rales to rhonchi. Both are very different treatments. No matter how good his observational skills are . He will not be able to differentiate which bad lung SOUNDS the Patient is experiencing!![1]

 

We have too many ignorant people like this in EMS.

Our method of education seems to produce plenty of basic EMTs, medics, nurses, and doctors who believe this myth.

Wheezes are often a sign of CHF (Congestive Heart Failure).

Lung sounds are only a small part of the assessment of the patient with respiratory distress.

Wheezes albuterol.

Crackles NTG (and specifically furosemide).

Rhonchi antibiotics.

Decreased lung sounds tension pneumothorax.

Decreased lung sounds are irrelevant to pulmonary embolus.

We have too many people applying treatments based solely on lung sounds. I brought a stroke patient to the ED. The nurse listened to lung sounds, hooked up a nebulizer, and left the patient alone for half an hour. The patient had a good oxygen saturation, did not have any respiratory distress, but did have neurological distress. The nurse was treating the lung sounds. While this is not common, it is due to the mistake of limiting assessment to one finding.
 


Click on image to make it larger.
 

Not only is wheezing included in the diagnostic criteria for CHF, but wheezing is given more weight than crackles.[2]

Wheezes often indicate CHF.

For those who do not understand that sound is vibration, it is possible to differentiate among lung sounds by placing the hand on the chest to feel the vibrations, which can be as distinctive as sounds they produce.

What is important is a full assessment, not an incompetent jump to conclusions based on lung sounds an inadequate assessment.

-

Footnotes:

-

[1] Deaf EMT ‘better than some hearing staff’ with Bethlehem ambulance company
By Lynn Olanoff
The Express-Times
on May 12, 2013 at 6:00 AM, updated May 12, 2013 at 6:06 AM
Article

-

[2] Clinical diagnosis of congestive heart failure in patients with acute dyspnea.
Marantz PR, Kaplan MC, Alderman MH.
Chest. 1990 Apr;97(4):776-81.
PMID: 2182296 [PubMed - indexed for MEDLINE]

Free Full Text in PDF format from Chest.

.