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

Search Results for: immobilisation

NAEMSP Position Paper on Spinal Immobilization

 

The current issue of Prehospital Emergency Care, the official journal of the NAEMSP (National Association of EMS Physicians), NASEMSO (National Association of State EMS Officials), NAEMSE (National Association of EMS Educators), and the NAEMT (National Association of EMTs) includes a position statement. A big deal is being made about the improvements, but that is because we have been so far in the Dark Ages with our management of potential spine injuries, that any improvement looks wonderful.

This may be the EMS equivalent of Why are you hitting your head against the wall? Because it feels so good when I stop.

Why are we still abusing our patients with potential spinal injuries? Unfortunately, the answer to this question is not as wise as Because it feels so good when we stop.
 

Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.[1]

 

What benefit?

Where is the evidence that this improves outcomes for patients with unstable spinal injuries?
 

However, the benefit of long backboards is largely unproven[1]

 

Largely?

Entirely?

There are no outcomes studies that show any benefit, but there are studies that show serious harm with back boards.[2],[3],[4]

Therefore, the risk/benefit ratio has either a question mark, or a zero as the benefit.

Real risk/?
 


Picture credit.

 

Plus

 


Picture credit from Voodoo Medicine Man.

 

Equals

 


Picture credit.

 
If there were some valid evidence of some benefit to backboarding patients, this position paper might have something positive, but it is only something that can be copied from a journal to be shown to the people who apparently ignore journals.

There is one positive.
 

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[1]

 

A collar and no board?
 

This is still not supported by good evidence of improved outcomes, but there is evidence that it is much less likely to cause movement to an unstable spine than a back board or a KED (Kendrick Extrication Device).[5],[6]

-

Footnotes:

-

[1] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed - in process]

Free Full Text in PDF Download format from NAEMSP.

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[2] 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.

 

This paper was cited by the ACS (American College of Surgeons) as a justification for spinal immobilization for blunt trauma.

-

[3] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.
 

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

 

-

[4] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]
 

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

 

-

[5] Cervical spine motion during extrication.
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
J Emerg Med. 2013 Jan;44(1):122-7. doi: 10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15.
PMID: 23079144 [PubMed - in process]
 

RESULTS:
The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

CONCLUSION:
In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.

 

There is a detailed evaluation of this paper in the article below by Dr. Brooks Walsh at Mill Hill Ave Command.

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[6] In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
Article

.

Should Merit Badge Organizations Define Standards of Care?

 

The AHA (American Heart Association), NREMT (National Registry of EMTs), ACS (American College of Surgeons – PHTLS – PreHospital Trauma Life Support), and other organizations end up making standard of care decisions based on superstition.

We need to stop acting as if these organizations are creating good patient care.

They are improving, but they are so busy defending their ancient dogmas that they delay improvements in patient care.

Our patients are their guinea pigs, but we refuse to learn from their failures.
 

I want to know the real risks and benefits of this treatment.


 
For example –

AHA guidelines.

Ventilations have never been demonstrated to improve survival to discharge, but we are afraid of removing them because we don’t really understand what we are doing and finding out is even more scary than ignorance.[1]

Drugs have never been demonstrated to improve survival to discharge, but we are afraid of removing them because we don’t really understand what we are doing and finding out is even more scary than ignorance.[2]
 

NREMT guidelines.

Objective examination has never been demonstrated to be better than subjective examination by competent examiners. We are more afraid of people passing their friends and failing their enemies, or getting money to pass people (redundant, since the whole testing process requires a payment), than we are of incompetence.[3]

Objectivity does not mean competence.

Subjectivity does not mean corruption.

We need to be smart enough to assess competence.

Instead we hide behind a test that is focused on memorization and not understanding.
 

ACS – PHTLS guidelines.

We still pretend that EMS spinal immobilization is not harmful.[4]

We have evidence of many kinds of harm from EMS spinal immobilization.[5],[6],[7]

We have only a weak hypothesis of how EMS spinal immobilization might protect the spine of a patient if that patient has an unstable spinal fracture that might get worse during transport.

The evidence shows that this hypothesis is at best misguided.

Manipulating people into EMS spinal immobilization is manipulation of the spine.

We can pretend that it is not, but we can also pretend that we have magical powers. Wishing does not make it so.
 

We need continuing education that is continual, not sitting in a classroom for 4, or 8, or 16 hours every two years.

We need to keep improving our care of patients, not excuses for the bad care that is in the guidelines.

When will we find time?

At the beginning of every shift, we can work on something.

Intubation practice should be done on a mannequin at a minimum every week. High-quality practice – even if it is on Fred The Head.

The same for medical and trauma megacodes.

We need to demand evidence that the recommendations of these organizations include evidence of improved outcomes that matter.
 

Any standard of care that does not have evidence of survival benefit needs to have an expiration date.
 

If nobody can show that it works, then it is just an opinion.

Our patients deserve better than to be treated based on dangerous opinions based on wishful thinking.

-

Footnotes:

-

[1] Nothing

No evidence of improved survival with a thinking brain.

-

[2] Nothing

No evidence of improved survival with a thinking brain.

-

[3] Nothing

No evidence of competence at assessment of competence.

-

[4] Nothing

No evidence of any decrease in disability, although there is evidence of an increase in disability with spinal immobilization. See below.

-

[5] 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.

 

This paper was cited by the ACS as a justification for spinal immobilization for blunt trauma.

-

[6] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.
 

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

 

-

[7] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]
 

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

 

-

[8] Cervical spine motion during extrication.
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
J Emerg Med. 2013 Jan;44(1):122-7. doi: 10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15.
PMID: 23079144 [PubMed - in process]
 

RESULTS:
The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

CONCLUSION:
In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.

 

There is a detailed evaluation of this paper by Dr. Brooks Walsh at Mill Hill Ave Command.

In order to protect the c-spine, should we stop helping?

.

C-Spine Death Knell with Rogue Medic

 


Picture credit from Voodoo Medicine Man.

 

I was on John Broyles’ 1-Union-801 podcast this weekend.

C-Spine Immobilization 19 Jan 12 also posted on the ProMed Network as C-Spine Death Knell with Rogue Medic.

On EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, and David Aber also discuss the problems with “spinal immobilization” in Spinal Clearance or Nonsense | BLS 12 Leads.

Several people have commented that I jinxed myself by mentioning that it was quiet at work. The idea of a jinx has even less credibility than the current form of “spinal immobilization.” PS – Not that it proves anything, but it continued to be quiet for the rest of the night. This jinx idea is just based on a misunderstanding of reversion to the mean.[1] Reversion to the mean is real. Jinxes are just products of overactive imaginations at work.

First, I need to mention a couple of mistakes I made during the show. MAO (MonoAmine Oxidase) Inhibitors are not contraindications for morphine. MAO inhibitors do potentiate morphine but that is not a bad thing, as long as we know what we are doing. Narrow angle glaucoma is also not a contraindication for morphine. Generally, stimulant drugs will be the ones that are a concern with narrow angle glaucoma, because those drugs can raise the pressure in the eye.
 

Here are the major problems with “spinal immobilization.”

Does “spinal immobilization” work?

We don’t know and we don’t want to know.

PHTLS (Prehospital Trauma Life Support) made it clear in their most recent text that patients with penetrating injuries should not be immobilized, unless there was an indication of neurological deficit.

In this PHTLS podcast Dr. Jeffrey Guy makes a huge mistake.

 

Haut and his coauthors are very cautious to point out that spinal immobilization has been shown to be well worth the time and effective at saving lives as well as disability of patients who sustain blunt trauma in the form of car accidents and similar events.[2]

 

Not only is there no evidence of any benefit from “spinal immobilization,” the authors of the study explicitly state that there is no evidence in the first sentence of the article.
 

Spine immobilization is often part of the current prehospital treatment for patients with penetrating injuries to the head, neck, or torso, although there are no definitive studies that demonstrate its benefit.1,2 [3]

 

Is there any evidence of harm?

There is plenty of evidence of harm to patients who do not have spinal injuries, but what is much more important is that there is evidence of worse neurological outcomes in the patients treated with “spinal immobilization.”
 


 

Of 334 immobilized patients with acute blunt traumatic spinal or spinal cord injuries, 21% had significant disability.[4]

Of 120 not immobilized patients with acute blunt traumatic spinal or spinal cord injuries, only 11% had significant disability.

There does not appear to be any possibility of selection bias by paramedics or doctors choosing to use the treatment only on the worst patients. Everyone in the US was immobilized. Nobody in Malaysia was immobilized.

There is a difference in the types of injuries between the samples. More falls in Malaysia. More vehicular collisions in the US. Is the difference in the types of injuries the reason that patients were twice as likely to end up disabled with “spinal immobilization”?

What about Cochrane Reviews? What do they state about evidence for “spinal immobilization”?

There is no evidence of benefit. There is strong possibility of harm.

But wouldn’t it be unethical to study “spinal immobilization”?
 

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.[5]

 

How can we advocate for “spinal immobilization” based only on a weak hypothesis?

How can we advocate for “spinal immobilization” with only evidence of harm?

Why don’t we want to know if there is a better way of protecting patients from disability?

Why don’t we want to know if we are protecting patients from disability?
 

If we assume that we know all that we need to know,
 

do we deserve any credibility?
 

In Thinking, Fast and Slow, Daniel Kahneman spends a lot of time discussing the problems that come from assuming that what you see is all there is.
 


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

We need to stop pretending that we know what we are doing and find out if what we are doing works.

At Street Watch: Notes of a Paramedic, there is a description of the continuing fall from grace of “spinal immobilization” – Another Nail in the Board. Go read it.

At Mill Hill Ave Command, there is a review of a recent study of the methods of extrication from vehicles and the amount of movement of the cervical spine – In order to protect the c-spine, should we stop helping?. Go read it.

All that I am asking for is evidence that “spinal immobilization” works.

If this were something less harmful than “spinal immobilization,” such as homeopathy, would doctors oppose finding out if it works?

If “spinal immobilization” does cause disability, is there a reason we should not know?

If “spinal immobilization” does cause disability, shouldn’t we stop as soon as possible?
 

Where is the evidence of safety?
 

Where is the evidence of benefit?
 

Without evidence, this is witchcraft.

-

Footnotes:

-

[1] Regression toward the mean
Wikipedia
Article

-

[2] Spine Immobilization Following Penetrating Trauma
PHTLS podcast
PHTLS (Prehospital Trauma Life Support)

http://www.phtls.org

1/18/2010 12:00 PM
Podcast page

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[3] Spine immobilization in penetrating trauma: more harm than good?
Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.
PMID: 20065766 [PubMed - indexed for MEDLINE]

-

[4] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

-

[5] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

.

Another Bogus Attempt to Defend Spinal Immobilization

-

Another comment on How Much Harm Does Spinal Immobilization Cause demonstrates the horribly flawed logic that is applied by defenders of alternative medicine and other forms of bad medicine. This post was describing the doubling of disability among patients with unstable spinal fractures treated with spinal immobilization, when compared with those not treated with spinal immobilization. SCI is Spinal Cord Injury.

Anonymous writes –

Can I suggest that research demonstrating a statistically high incidence of SCI in patients who have been immobilised, simply suggests that spinal patients are appropriately treated with spinal immobilisation.

Anomymous can suggest that, but Anomymous is completely wrong.

If we give epinephrine to living heart attack patients and find that there is a high incidence of cardiac arrest after treatment with epinephrine, does that mean that we are doing something good by giving epinephrine to heart attack patients?

No.

We are making things worse by giving a dangerous treatment.

The patients who are not immobilized have much better outcomes.

-


Image credit from Voodoo Medicine Man.

-

To suggest a causal link is like saying hospitals are dangerous places because lots of people die in them.

Actually, that is the argument Anomymous is making, Anomymous just turned it around.

The patient died after the treatment – he must have really needed the treatment. If only we could have given him the treatment sooner (or given him more), he would still be alive.

Anomymous is making the mistake of assuming that the treatment is beneficial.

Anomymous is not providing any evidence that the treatment is beneficial.

-

The level of neurologic deficit was the only independent predictor of bad outcome (Table 4). We repeated this analysis using only the subset of patients with isolated cervical level deficits. We again failed to show a protective effect of spinal immobilization (OR 1.52; 95% CI 0.64-3.62; p = 0.34).[1]

What does that mean?

It means that even adjusting for differences in injuries, there was no benefit from spinal immobilization. Patients were much more likely to be disabled with spinal immobilization than without spinal immobilization.

This would be the same as adjusting for the differences in medical conditions when comparing patients in the hospital and outside of the hospital – the example given by Anomymous. If the patients in the hospital were still more likely to die after adjusting for illnesses, then the conclusion that hospitals are dangerous would be valid.

-

Similarly, I think ethical approval of a study evaluating the effects of not immobilising spinal patients might be hard to obtain – ‘Hmmm, 139 paralysed patients out of 150… I guess we were right all along…’

Why does Anonymous assume that this dangerous treatment (spinal immobilization) is beneficial in any way?

This is just wishful thinking.

Why should anyone believe Anonymous, who claims – without evidence – that a treatment that dramatically increases the rate of disability (according to the best available evidence) will actually prevent disability?

-

Of 334 immobilized patients with acute blunt traumatic spinal or spinal cord injuries, 21% had significant disability.

Of 120 not immobilized patients with acute blunt traumatic spinal or spinal cord injuries, only 11% had significant disability.

Is the better treatment hard to recognize?

That study that Anonymous claims would not be ethical? That study was already done.

Spinal immobilization failed.

-

Footnotes:

-

[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

.

A Change of the Dogma – If spinal immobilization helps only one . . .

-

How dangerous is spinal immobilization? We discuss that on First Few Moments. On this Spinal Immobilization podcast, Kyle David Bates, Russell Stine, Bob Lutz, Dr. Laurie Romig, Kelly Grayson and I discuss the lack of evidence of any benefit from spinal immobilization and the evidence of harm.

A Change of the Dogma: If it helps only one? Episode 36

What is it going to take to get the medical directors, PHTLS (PreHospital Life Support), BTLS (Basic Trauma Life Support), and ATLS (Advanced Trauma Life Support) to eliminate this dogma?

What is it going to take to get someone to do a large enough study of this dogma to find out just how good/bad spinal immobilization really is?

The Cochrane Reviews looked at spinal immobilization and were not impressed –

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]

There is only one large scale study comparing spinal immobilization with no spinal immobilization –

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.

PMID: 9523928 [PubMed - indexed for MEDLINE]

-

Kyle starts out with a great comment for all of those who say that we should not discuss, or criticize, our current protocols, for whatever reason they give.

**This podcast is not meant to change YOUR current practice, only your medical director can do that! …but nothing says you can’t try to convince them ;-) – KDB**

-

 


Picture credit.

 

Plus

 


Picture credit from Voodoo Medicine Man.

 

Equals

 


Picture credit.

 

Not a formula for success.

 

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What do you think?

Go listen to the podcast.

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