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

- Rogue Medic

In Defense of No Improvement by Medic Madness – Part I

 

I wrote about treatment with the LUCAS CPR machine and stated that There is no price that justifies no improvement.[1]

There are plenty people who want to justify the use of placebo treatments – treatments that do not improve outcomes. Here is one –
 

Before writing this response, I took some time to examine the equipment I use on a daily basis. Needless to say, I was shocked to discover that we spend a lot of money of items that really don’t improve patient outcomes at all. One example is the Stryker Power Cot.[2]

 

The LUCAS is a treatment that is a potential substitute for manual chest compressions.

The selling point was supposed to be that the LUCAS improves outcomes – survival with a working brain – that is the whole purpose of the research I have been writing about.
 

Thus, in clinical practice, CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.[3]

 

The LUCAS failed.

However, Sean is taking my statement about the outcome of a treatment and applying it to the choice of equipment.

Does a power stretcher improve the survival of patients?
 


 

I do not know of any studies that examine this question, but the stretcher is not used as a treatment. The stretcher is used as a means of moving the patient.

What Sean appears to be asking is – since I am going to use a stretcher (is there any state that does not require a stretcher in an ambulance), shouldn’t I use the cheapest stretcher that meets the requirements? Or am I going to base my decision on something other than outcomes?

Is the choice to pay more for a power stretcher based on the outcomes of patients?
 

Although I tried, I couldn’t find any studies that compared patient outcomes to those transported using a manual cot.[2]

 

It is not based on the outcomes of patients, but the choice is based on outcomes.

In a study comparing the injury rate among FTEs (Full-Time Employees), the rate of injury was cut in half after the introduction of a powered stretcher.[4]

Maybe EMS should not consider the outcomes for employees when making decisions?

What is Sean’s next gotcha?
 

Another major purchase was the LifePak 15 ECG monitor / defibrillator. Once again, I couldn’t find anything showing improved patient outcomes.[2]

 

Sean couldn’t find any evidence that waveform capnography improves outcomes for patients?[5] 🙁

Sean couldn’t find any evidence that an EMS 12 lead ECG (ElectroCardioGram) improves outcomes for patients?[6] 😳

Sean couldn’t find any evidence that EMS defibrillation improve outcomes for patients?[7] 😯

Perhaps Sean works in a state that does not require a defibrillator, 12 lead capability, and/or waveform capnography as minimum paramedic equipment and thinks these are just fun to have toys.

Sean appears to be suggesting that the choice of brand and options, except as mandated by EMS regulatory organizations, must be limited to the cheapest available item. Otherwise, I am misleading people by stating – There is no price that justifies no improvement.

Should I be worried at Sean’s failure to find the valid evidence, when I only provided a small sample of the valid evidence?

Does this affect Sean’s argument? The argument is really just a bait and switch – a logical fallacy known as a straw man.[8] I wrote about one thing and Sean represented my argument as something else, because he has an argument against the argument I did not make. However, his argument does not address the claim I actually did make.
 

That is not the only argument Sean makes. I address the rest in Part II, Part III, and Part IV.

Dr. Brooks Walsh also explains the failure of the LUCAS in this study in “We had a LUCAS save!” – No, you didn’t.

Footnotes:

[1] The Failure of LUCAS to Improve Outcomes in the LINC Trial
Wed, 05 Mar 2014
Rogue Medic
Article

The LUCAS, Research, and Wishful Thinking
Fri, 07 Mar 2014
Rogue Medic
Article

[2] In Defense of the LUCAS
March 12, 2014
by Sean Eddy
Medic Madness
Article

[3] Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R.
JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538.
PMID: 24240611 [PubMed – indexed for MEDLINE]

Free Full Text in PDF Download format from PEHSC.org.

[4] Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers.
Studnek JR, Mac Crawford J, Fernandez AR.
Appl Ergon. 2012 Jan;43(1):198-202. doi: 10.1016/j.apergo.2011.05.001. Epub 2011 May 31.
PMID: 21632034 [PubMed – indexed for MEDLINE]

[5] The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J.
Ann Emerg Med. 2005 May;45(5):497-503.
PMID: 15855946 [PubMed – indexed for MEDLINE]

[6] Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction.
Sivagangabalan G, Ong AT, Narayan A, Sadick N, Hansen PS, Nelson GC, Flynn M, Ross DL, Boyages SC, Kovoor P.
Am J Cardiol. 2009 Apr 1;103(7):907-12. doi: 10.1016/j.amjcard.2008.12.007. Epub 2009 Feb 7.
PMID: 19327414 [PubMed – indexed for MEDLINE]

[7] Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians.
Eisenberg MS, Copass MK, Hallstrom AP, Blake B, Bergner L, Short FA, Cobb LA.
N Engl J Med. 1980 Jun 19;302(25):1379-83.
PMID: 7374695 [PubMed – indexed for MEDLINE]

[8] Straw man
Wikipedia
Article

.

Comments

  1. My company recently purchased the power-load system for their roughly 20 ambulances. At approx 30k a system that is a lot of money and many asked why? The response, just as you mentioned with the power cots is how much does an employe out for a back injury cost? How much is a law suit worth if the pt is dropped while in the stretcher? Then there is the safety factor of the cot being held securely in the system in case of a crash, versus the standard loading system. All these factors made the system a smart investment for my company not to mention a few other nice features with the system.

    How does your system, Rogue Medic run arrests? As somebody who is very vocal about these topics (rightfully so) I would be interested to know what you do, and what your doctors let you do. Are you following full AHA ACLS guidelines? Do you call for orders for any meds during the arrest? What sort of resources are you getting for an arrest? Do you guys use the Lucus? What are your systems Utstein scores? Maybe you did a post on this and I missed it.

  2. Interested to see the follow on to this post. We use the Lucas, I like the Lucas. We have had 1 save out of our last four arrests. Doesn’t matter. I still like the Lucas. If we choose to continue working the patient, it frees up a person, and allows us to keep another unit in service once we choose to transport. So to me, it doesn’t matter if it does not improve outcomes, it does make us more efficient if we choose to work all of the way to the ER. Sometimes you can’t overcome an entire bottle of Flexeril or any type of Asystole. What I do know is that the Lucas provides good, continuous reliable chest compressions, reducing delays. We practice and utilize a pit crew type method we find very effective and efficient. Unless there is evidence that it harms a patient or worsens outcomes, I have no issues with the device.

    As for power cots, I would like to know the health of many of these folks hurting themselves lifting patients. I work in a Fire/Rescue system, so since we actually PT this isn’t seen too often, and we don’t spend our money on power cots. A more proven solution would be to invest money in barbells and spend time doing squats and deadlifts. Heck of a lot cheaper, but if that is not affordable, maybe the Medics could spend their own time working out utilizing methods that would actually help them on the job. I see to many medics from many systems that look like crap. I am busy like anybody else, but I still find time to make it over to Gold’s to move heavy things about. Kettlebells are a great tool also.

    Love your no nonsense approach to this stuff, always gives me something to think about!

  3. Just to clarify, I am not giving the “glory” for the one recent save to Lucas.

  4. Roguey my friend you know I love you but you are taking things a step too far with your analysis of the monitor statement. If I had to make a guess, I would say that Sean was referring to comparing an LP15 to an LP12, for example, which has many of the same features. Its an upgrade.. Its a little more slick looking.. but its core features that you mentioned (capnography and 12-leads) ARE both features available on the LP12.

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