Archives for 2013

Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Can EMS Expect From 2014? #2 Prehospital Therapeutic Hypothermia


 

It was the sexy new EMS treatment.

The use of fluids for prehospital therapeutic hypothermia was rushed into protocols.

Now that we have evidence, was a mistake?

Some of us are now trying to defend the rush to treat before evidence.
 

CONCLUSIONS:
In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.
[1]

 

Cooler was not better in this study.

Patients were cooler, but outcomes were slightly worse for the cooler patients.

The difference was not statistically significant.
 

Conclusion and Relevance Although use of prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, it did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF.[2]

 

Patients were cooler, but outcomes were again slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.
 

There was one study that did trend toward improved outcomes for asystole/PEA (Pulseless Electrical Activity) patients, but the results were not statistically significant.
 

In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146).[3]

 

Maybe there will be some benefit shown for asystole/PEA patients with a larger study, but this is the most positive evidence and it is not statistically significant –

In other words, there is no evidence of benefit and no reason to use this treatment outside of a controlled trial.
 


 

CONCLUSIONS:
In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.
[4]

 

Patients were cooler, but once again outcomes were slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.

There is a free editorial that is important to read accompanying this paper. There are possible explanations for the consistent failure to improve outcomes.
 

Swine studies show that ice-cold saline delivered during cardiac arrest reduces coronary perfusion pressure (CPP).4,5 Yannopolous et al4 found that iced saline reduced CPP during CPR from 24 mm Hg to only 4 mm Hg, an alarmingly low value that makes survival unlikely.[5]

 

We rushed to implement protocols to give fluids for prehospital therapeutic hypothermia.

Because of our failure to wait for evidence, we need to get rid of these protocols.

When will we learn to wait for evidence?

When will we put our patients’ health above our need to use the new and untested?

Footnotes:

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

[2] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed – as supplied by publisher]

[3] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed – indexed for MEDLINE]

[4] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

[5] Cooling heads and hearts versus cooling our heels.
Becker LB.
Circulation. 2010 Aug 17;122(7):679-81. doi: 10.1161/CIRCULATIONAHA.110.968222. Epub 2010 Aug 2. No abstract available.
PMID: 20679546 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

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What Can EMS Expect From 2014? #1 Ketamine Again


 

What changes need to be made in 2014, if they have not already been made?

Ketamine – for those of you who already have ketamine, great work. Continue to improve patient care. Do not let the rest of us slow you down.

Excited delirium – ketamine is the fastest way to sedate a violent patient.

Pain management – ketamine dissociates without respiratory depression.

RSI (Rapid Sequence Induction/Intubation) – ketamine dissociates without respiratory depression.

Asthma – ketamine opens the airway.

Awake intubation – ketamine dissociates without respiratory depression.

Sedation for extrication – ketamine dissociates without respiratory depression.

Seizures– ketamine stops seizures.
 

Safety – ketamine is safe.
 

Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.[1]

 

Is any other sedative that safe?
 

Here are some podcasts to explain in more detail.

Dr. Mel Herbert on ketamine.
Ketamine Update.
Free mp3 Download From Free Emergency Medicine Talks

Dr. Baruch Krauss on ketamine.
Ketamine in the Emergency Department.
Free mp3 Download From Free Emergency Medicine Talks

Dr. Sergey Motov on ketamine.
Ketamine for Everything.
Free mp3 Download From Free Emergency Medicine Talks

Dr. Scott Weingart on ketamine.
Podcast 104 – Laryngoscope as a Murder Weapon Series – Hemodynamic Kills
Page with a link to the free mp3 download, but watch the video first – it is excellent.

More from Dr. Weingart.
EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)
Free mp3 DownloadFrom EMCrit.

Dr. Jim DuCanto on ketamine.
Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD
Page with a link to the free mp3 download, but watch the video first – it is excellent.

Dr. Minh LeCong on ketamine myths –

PHARM Podcast 75 Ketamine MythBusters
Part 1 – Blowing your mind

PHARM Podcast 76 Ketamine MythBusters
Part 2 – Take the pressure down

PHARM Podcast 77 Ketamine MythBusters
Part 3 – Are you mad enough?

PHARM Podcast 78 Ketamine MythBusters
Part 4 – A fitting end?

 

Would you prefer to have something to read about ketamine?
 

 

Dr. Reuben Strayer on ketamine.

The Ketamine Brain Continuum
December 25th, 2013
by reuben in PSA & analgesia
Article

Awake Intubation: A Very Brief Guide
July 7th, 2013
by reuben in airway
Article

Ketamine as a suicidality reversal agent
June 4th, 2011
by reuben in psychiatry
Article

Taming the Ketamine Tiger
January 27th, 2011
by reuben in PSA & analgesia
Article

Ketamine for RSI in Head Injury
April 3rd, 2010
by reuben in .trauma-general, .trauma-head & face, airway
Article

Another reason to use ketamine for RSI in sepsis
November 24th, 2009
by reuben in airway
Article
 

Is there any good reason to not be using ketamine in EMS?

Footnotes:

[1] Ketamine Hydrochloride (ketamine hydrochloride) Injection, Solution, Concentrate
[Bedford Laboratories]

FDA Label
DailyMed
Label

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EMS EduCast – Dr. Ben Abella on Coursera and Therapeutic Hypothermia

 

On the EMS EduCast, Dr. Ben Abella was on the EMS EduCast discussing the Coursera resuscitation course he taught and the way recent research on therapeutic hypothermia [1]should affect prehospital resuscitation.

Go listen to the podcast.

During the podcast Dr. Abella states –
 

I fear, many of the patients that I deal with are much more injured from iscemia reperfusion than the patients in that study. I wonder if the patients in that study just didn’t need that much cooling. You know, if you’re not that sick, you don’t need that much of a dose of medicine, maybe, and if you’re dealing with sicker patients you need more. Now, what I have just said is an unsubstantiated hypothessis. OK. That’s important for people to know. I am not basing that on fact, rather on my experience and opinion.[2]

 

That is only relevant in some cases.

Sometimes sicker patients require more.

Sometimes sicker patients require less.
 

Shock Values - 2004 Anes
 

Even with adequate fluid resuscitation, propofol remains substantially more potent in patients with hemorrhage. In marked contrast, the potency of etomidate is nearly unchanged in shock.[3]

 

According to this, we should only give 10% to 20% of the normal dose of propofol (Diprivan) to the sickest trauma patients, but we should give more than 100% of the normal dose of etomidate (Amidate) to the same patients.

Do the sickest patients require more medicine?

Sometimes yes. Sometimes no.

Pathophysiologists can provide good arguments either way, but pathophysiologists are the philosophers of medicine trying to explain the limited evidence that is available – until more evidence becomes available.

Dr. Abella may be right about starting therapeutic hypothermia prior to transport, but the best available evidence does not support his hypothesis.

Dr. Abella is clear that this is just his hypothesis and he is encouraging more research, because that is the way we find out whether the hypothesis is correct.

Go listen to the podcast.

The EMS EduCast is ending. This is the second to last podcast, from Bill Toon, Greg Friese, and Rob Theriault, but they have nearly 200 podcasts archived to listen to.

Footnotes:

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

[2] Dr. Ben Abella and the Coursera Cardiac Arrest MOOC: Episode 194
EMS EduCast
December 16, 2013
Podcast page.

[3] Shock values.
Shafer SL.
Anesthesiology. 2004 Sep;101(3):567-8. No abstract available.
PMID:15329579[PubMed – indexed for MEDLINE]

Free Full Text from Anesthesiology.

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Should Basic EMTs Give Naloxone (Narcan)?

 
Should basic EMTs be giving naloxone (Narcan) when paramedics do not really understand the drug?

If a patient wakes up after naloxone, does that mean the patient had a drug overdose?

No – but most paramedics do not understand that.[1]

As of January 1, 2014, there will be even more people giving Narcan with little understanding of what they are doing.
 


Peter Thomson.
 

La Crosse firefighters soon could start carrying a life-saving drug for heroin users. The department is applying to be one of the state’s first groups of emergency medical technicians to administer Narcan, the antidote to an opiate overdose.[2]

 

Does naloxone save lives or just make it less work for first responders?

If the basic EMTs are not good at basic ventilation, will they be any better at drug administration?

Are drugs the cure for ventilation problems?
 

The department has witnessed a 53 percent jump in the number of potential drug overdoses since 2009, Chief Gregg Cleveland said.

In 2012, firefighters responded to 98 potential overdoses and 86 so far this year.[1]

 

A 53% increase?

98 last year.

86 so far this year (as of October).

10 months in, so an average of 8.6 per month = 103.2 for the whole year.

Going from 98 to 103 is not a 53% increase.

It isn’t even a 5.3% increase, but only 5.1%
 

Only 5% – not 53%.
 

Bad math.

Correction (13:00 12/28/2013) – the math is not based on the numbers in the article and I did not read the article correctly. The bad math is mine, not Chief Gregg Cleveland’s. Thank you to Christopher Jennison, Jordan L, and Parastocles for pointing out my error.

I apologize to Chief Gregg Cleveland for misrepresenting his statement as bad math, when it was my mistake.
 

Bad decisions.

What kind of time would be saved by having the fire department give naloxone?

What kind of bad outcomes would be prevented?

What kind of better outcomes would be expected?

What is the added cost of implementing this program?

What other programs would be deprived of this money?

Those are just some of the questions that should be asked.

The main question is –

If your fire department is doing such a bad job of managing BLS skills (BVM, positioning, painful stimulus, . . . ), why should we allow you to harm patients with ALS skills?

If your department is not harming patients, then where is the need?

Naloxone does not appear to be the answer to either problem.

Will naloxone cure the math problems of these drug pushing managers?

Footnotes:

[1] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.

[2] Firefighters could be getting medication to save drug users
October 31, 2013 12:00 am
By Anne Jungen
ajungen@lacrossetribune.com
LaCrosse Tribune
Article

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What is the Role of the Renal System in Acute CHF

 

I was asked this question –

What is the role of the renal system in CHF?

Since the question came from a paramedic, the use of diuretics for chronic CHF (Congestive Heart Failure) is not relevant, except that the Acute CHF/ADHF (Acute Decompensated Heart Failure) may be brought on by poor management of chronic CHF.
 

volume changes during acute pulmonary edema differ from those which were observed during chronic congestive heart failure.[1]

 

I rewrote the question by just adding the word acute

What is the role of the renal system in Acute CHF?

That is the right place to start.
 


Original image source.

This Golden Hour of acute CHF/ADHF is just as much a myth as the Golden Hour of trauma.
 

In

    Acute

        CHF

            There

                Is

                    NO

                        Significant

                            Role

                                For

                                    The

                                        Renal

                                            System.

Acute CHF =

Stress -> Increased work for a weak heart -> Fluid backup in the lungs -> Shunting fluid away from the organs not essential in an emergency – the liver, spleen, intestines, stomach, kidneys . . . .
 

Recovery from acute CHF =

Improvement -> Decreased work for a weak heart -> Fluid removal from the lungs -> Resuming fluid flow to the organs not essential in an emergency – the liver, spleen, intestines, stomach, kidneys . . . .
 

In ADHF/acute CHF, the body shuts down circulation to the renal system.

After the patient improves, the renal system begins to work again.

In acute CHF, there is no significant role for the renal system.

Since the renal system has no significant role in acute CHF/ADHF, diuretics should not have any significant role in the treatment of acute CHF/ADHF.

Footnotes:

[1] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed – indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format.

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1 + 1 = 3 Sometimes – Pharmacology Fun

 

Does 1 + 1 always equal 3?

No.

If you do not give all of the medication in a syringe, vial, ampule, you are rounding off. This is where significant figures matter.[1]

1+1 does equal 3 for sufficiently high values of 1.

For those who do not understand this –

Consider a morphine syringe with a volume of 1 ml that contains a total dose of 10 mg.

We intend to give 1 mg.

Can we give exactly 1 mg?

I cannot.

We give an approximation of 1 mg.

What is considered to be 1 mg?
 


 

0.50001 mg should be rounded to 1 mg if we are not using decimal places. We probably do not have the precision to measure that accurately. If we did, we should use all of the significant digits in our documentation.

I am using this as an example to point out that with no decimal places 0.50001 mg is 1 mg.

We round off to the nearest significant digit.

If we are not using decimals, then 1.49999 mg is also 1 mg.

We will not be measuring that as carefully, either.

What we will be doing is trying to get close to 1 mg, but that could be 1.4 mg, or 1.3 mg, or 1.2 mg, or 1.1 mg, 0.9 mg, or 0.8 mg, or 0.7 mg, or 0.6 mg, or 0.5 mg.

How precisely can we measure the amount?

If we tend to underestimate the doses we are giving, we could be giving a couple of doses of 1.3 mg.

1.3 + 1.3 = 2.6, which is rounded to 3.

1 + 1 = 3.

If I gave 1.3 mg and 1.3 mg to the same patient, I gave 1 mg + 1 mg and the

1.4 can be rounded off to 1.

If there are no significant digits beyond the 1, then the value of 1 is anywhere from 0.6 to 1.4.

Add a couple of 1s that add up to 2.5, or greater, and you have 3.

1.2 + 1.3 = 2.5, which is rounded to 3.

When rounded to one significant digit, 1.2 = 1, 1.3 = 1, 1.4 = 1, and 2.5 = 3.

That is not what we generally think of when we think of 1 + 1 = 3.

We assume a precision that may not be there.
 


 

Error bars do not always result in excess.

We can end up with a small number due to wide error bars.

1+1 can equal 1 for sufficiently low values of 1.
 


 

So,

      how

            accurate

                  are

                        we?

Footnotes:

[1] Significant figures
Wikipedia
Article

.

The Main Stream Media and Superstition


Tomb of Lazarus image credit.
 

This sad story is resulting in a lot of promotion of superstition.

A girl went in for a routine operation and died.

My condolences go out to the family.
 

The mother of a 13-year-old Northern California girl declared brain dead after a routine tonsillectomy says her daughter had expressed fears she wouldn’t wake up after the surgery.[1]

 

This is the kind of comment that people will use to promote the superstition of precognition and other psychic powers.

Did she know what was going to happen?

No.

Did she worry about what was going to happen?

Yes, it is what people do. We worry.

Is there any connection between that worry and the outcome?

There is no reason to believe that there is any connection.
 

The family claim to need time for a miracle.
 

“The medicine has not worked. It’s time to let God work,” said Omari Sealy, McMath’s uncle. “We are calling on God and calling on our faith.”[2]

 

How much time does it take for a miracle?

Since miracles defy the laws of nature, no time would be needed.

Why is life support needed for a miracle?

Since miracles defy the laws of nature, no life support would be needed.

No time or equipment is needed for a miracle.

Only a suspension of the laws of nature is needed for a miracle, so depriving other children of the care that could be provided by the staff and equipment devoted to this brain dead child is not necessary.

What is the history of miraculous recovery from death?

Lazarus and Jesus.

What kind of life support did they have?

None.

Take a look at the picture. A morgue is more high tech than that tomb.

What kind of legal injunction did they require?

None.

Both were buried in tombs.

The family could make an arrangement with a mortuary to wait for a miracle, but they should not interfere with the care of other patients who are not dead.
 

Is that cold?

Does the belief in miracles depend on the use of medicine?

Medicine cannot do anything for brain death, so requiring the use of medicine is of no benefit to the child.

Being cold allows other children to receive the care that could be provided by the staff and equipment devoted to this brain dead child.

This family is going through something no family should go through, but they are increasing the likelihood of another family having a bad outcome by depriving other patients of care.

Miracles are not a part of medicine.

Footnotes:

[1] California girl had fears before tonsil surgery
By Associated Press,
Updated: Friday, December 20, 12:01 PM
Washington Post
Health & Science
Article

[2] Family of Comatose Teen Battles Hospital for ‘Time to Let God Work’
Dec. 18, 2013
By Colleen Curry
Good Morning America
Article

.

Happy Friday the 13th

 
This is a day for superstitious people to pretend that there is some sense to their superstition.

The number 13 will somehow cause bad things to happen.

This is from the elevator of the local Best Hospital in the World. While it is an administrative decision, what about administrative decisions that affect patient care.
 


 

When we make decisions based on superstition, how much harm do we do to our patients?

We will probably never know, because we use superstition to justify ignoring evidence or to justify preventing research to obtain evidence.

A black cat crossing your path will somehow cause bad things to happen.

A backboard and collar forced on a patient will somehow protect the spine from forceful worsening of an injury.[1]

A broken mirror will somehow cause bad things to happen.

Giving fentanyl to someone in pain will prevent them from giving consent to treatment.[2]

Speak of the devil and he will appear.

Response times matter for patients who are not dead.

This is based on superstition, because the only response times that have been shown to matter are for cardiac arrest.[3]

How much less superstitious are people in medicine than anyone else?

Probably even more superstitious.
 


Identifying information obscured to protect the superstitious.
 

People will wave their hands around to manipulate your imaginary energy fields.

People fall for this at many hospitals that claim to be the Best Hospital in the World.[4]

They are just demonstrating their lack of understanding of the placebo effect, random variation, reversion to the mean, and other things that lead us to believe that nothing is something.

Nothing Superstition is harm.

Footnotes:

[1] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]
 

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.

 

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.

[2] Refusal of base station physicians to authorize narcotic analgesia.
Gabbay DS, Dickinson ET.
Prehosp Emerg Care. 2001 Jul-Sep;5(3):293-5. No abstract available.
PMID: 11446548 [PubMed – indexed for MEDLINE]
 

Nevertheless, the notion that a patient’s decision-making capacity may be compromised by “excessive” analgesia seemingly permeates medical practice, but is not evidently supported by the medical literature.11

 

Even a more disturbing possible coercion is the possibility that when pain medication is withheld prior to consent, the patient is either directly or indirectly made to understand that once he or she provides consent, that pain medication will be given as a “reward” for agreeing to the procedure.

[3] Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort.
Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G; Resuscitation Outcomes Consortium Investigators.
Ann Emerg Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23.
PMID: 19783323 [PubMed – indexed for MEDLINE]

Free Full Text with link to Free Full Text PDF Download from PubMed Central
 

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.18,19 Despite the paucity of outcome evidence supporting rapid out-of-hospital times for the broader population of patients activating the 911 system, EMS agencies in North America are generally held to strict standards about intervals, particularly the response interval.

[4] Shock Trauma Infested With Evil Spirits
Wed, 10 Jun 2009
Rogue Medic
Article

.