There are plenty who … claim to be competent at intubation even though their last intubation was months ago on the third attempt and if the patient had not already been dead – that would have finished the patient off …

- Rogue Medic

The Magical Nonsense of Friday the 13th

ResearchBlogging.org
 

Today we celebrate the fears of those who do not understand that magic does not affect reality. Our fears of magic can affect reality, when we act on those fears. Why should a special day cause more problems than a boring day? Many people believe in magic powers as being more than just the fictional entertainment we see in novels and movies.

Here is another study of the effects of Friday the 13th on emergency medicine/EMS that I have not written about. It is no surprise that they did not find what is not there – an influence of this magic date on the type or volume of patients in the emergency department.
 

CONCLUSIONS:
Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day.
[1]

 

When measuring of a large number of variables, it is expected that one, or more, will appear to be statistically significant. This is why the p value of outcomes should be adjusted when there are multiple outcomes being measured. The p value is just a measure of how likely it is that the result occurred by chance (and thus meaningless), so the more chances, the more likely that the meaningless is considered significant.
 

Fear of Friday the 13th is mistakenly attributing some magical power to a day, to a number, to the calendar, and/or to some other variation of belief in the magic of numbers.

Numbers are important and can provide us with useful information about the risks in our lives. The risks we take confidently, cautiously, or those we don’t take. Often our decisions about risk are based on faulty information, such as the fear of a date. Mathematical literacy is necessary to understand the ways that we can use numbers to obtain valid information. John Allen Paulos created the term innumeracy to describe our lack of literacy in the language of numbers. He explained this in 1988 in his book Innumeracy: Mathematical Illiteracy and its Consequences.[2]
 

Innumeracy cover
 


 

Oh! But what about Lies, damned lies, and statistics?

Doesn’t using math make it easier for people to lie to us?

No. Ignorance of math makes it easier for people to lie to us with math.

People do not often lie with numbers. People lie with words. Maybe they lie with the salesman smile. Maybe they lie with the fear monger frown. Maybe they lie unintentionally, because they don’t know what they are talking about. They lie with words. Our ignorance of logic, not our understanding of math, is what allows us to fall victim to most lies.

Today is another Friday that is no more exciting than any other Friday.

Luck works in our favor when we are prepared for the results of our actions, but that is not the kind of luck many people want to understand.
 

Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

T G I Friday the 13th – Fri, 13 Nov 2009

Happy Equinox! – Thu, 20 Mar 2008

Footnotes:

[1] Answering the myth: use of emergency services on Friday the 13th.
Lo BM, Visintainer CM, Best HA, Beydoun HA.
Am J Emerg Med. 2012 Jul;30(6):886-9. doi: 10.1016/j.ajem.2011.06.008. Epub 2011 Aug 19.
PMID: 21855260

[2] Innumeracy: Mathematical Illiteracy and its Consequences
Wikipedia
Page on Wikipedia

.

Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’

ResearchBlogging.org
 

The results of ALPS (Amiodarone, Lidocaine, Placebo Study) are clear. There is no statistically significant difference in cardiac arrest outcomes with amiodarone or lidocaine, when compared with placebo.
 

Conclusions Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.[1]

 

This study was very well done, but it was not designed to provide valid information about the effects of amiodarone or lidocaine on witnessed arrests or on EMS Witnessed arrests. Maybe the authors were overconfident.

In resuscitation research, we have abundant evidence that overconfidence is much more common than improvements in outcomes. There is no study that has shown an improvement in neurologically intact survival to discharge with any drug. Leaving the hospital with a working brain is the result that matters most to patients. We give drugs because we have too much confidence in the drugs and we are treating our confidence, not because we are doing anything to benefit the patients.
 

I WANT TO BE DECEIVED version of Domenichino, Virgin and Unicorn 1 copy
 

In ALPS there was a subgroup that might have reached statistical significance, but the researchers never determined what would be statistically significant when setting up the study, so these results are merely post hoc data mining (fitting the numbers to allow for a positive spin).

This is the Texas sharpshooter fallacy. The Texas sharpshooter shoots at the side of a barn, then draws targets around the bullet holes so that the the bullet holes are in the bull’s eyes.
 


 

The Texas sharpshooter didn’t shoot at any target, but he went back later and made it look like he hit the center of the target, because he drew the target around the bullet holes. Science requires that we state our hypotheses ahead of time, so that scientists are kept honest. Science requires that we calculate statistical significance ahead of time, especially for secondary outcomes/subgroup analysis, which may mean decreasing the p value to less than 0.03, or to less than 0.01, or even lower to reach statistical significance, so that scientists are kept honest. You are not permitted to bet on the outcome of a horse race that is already in progress for the same reason.

Why do we need to keep scientists honest? Because, as Dr. Peter Kudenchuk unintentionally demonstrates, scientists are just as biased as everyone else. Scientists need to follow the rules of science to minimize the influence of prejudices, such as overconfidence. When scientists do not follow these rules, they are just as easily fooled as everyone else and they may use that self-delusion, and their reputation, to fool others. Dr. Oz makes a fortune telling people what they want to hear about treatments that do not work.

I don’t claim that Dr. Kudenchuk, or even Dr. Oz, is deliberately fooling others, only that they have fooled themselves and are trying to convince others that their prejudices are accurate representations of reality. Here is what Dr. Kudenchuk has been telling people –
 

Researchers have confirmed that certain heart rhythm medications, when given by paramedics to patients with out-of-hospital cardiac arrest who had failed electrical shock treatment, improved likelihood of patients surviving transport to the hospital.[2]

 

The researchers have not confirmed any such thing.

If Dr. Kudenchuk wants to study whether amiodarone or lidocaine or both improve outcomes for witnessed cardiac arrest patients, or for EMS witnessed cardiac arrest patients, he needs to set up a study with all of the criteria for a positive result specified before the start of the study, because this study did not. The study explicitly states this, so Dr. Kudenchuk should be able to just read the study and see that he is wrong. Here is another statement that contradicts the information that was published.
 

Two groups of patients were pre-specified by the study as likely to respond differently to treatment: those with a witnessed cardiac arrest and those with an unwitnessed arrest. When it was originally designed, the study predicted that because patients with witnessed cardiac arrest are recognized and treated sooner, they would more likely be responsive to effective treatments than unwitnessed arrests. When first discovered, patients with an unwitnessed arrest are more likely to have already sustained irreversible organ damage resulting from a longer “down time” and less likely to respond to any treatment. This is precisely what was seen in the study – a statistically significant 5% improvement in survival to hospital discharge in witnessed arrests, and no effect from the drugs in unwitnessed arrests.[3]

 

Why does the published version of the paper contradict Dr. Kudenchuk? One of our biases is to remember things differently from the way things really happened. This is why eyewitness testimony is so often wrong. Here is what the published paper states about the witnessed arrest results.
 

We observed an interaction of treatment with the witnessed status of out-of-hospital cardiac arrest, which is often taken as a surrogate for early recognition of cardiac arrest, a short interval between the patient’s collapse from cardiac arrest and the initiation of treatment, and a greater likelihood of therapeutic responsiveness. Though prespecified, this subgroup analysis was performed in the context of an insignificant difference for the overall analysis, and the P value for heterogeneity in this subgroup analysis was not adjusted for the number of subgroup comparisons. Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration.[1]

 

The authors did not adjust the p value, so the authors do not claim that the witnessed cardiac arrest results are statistically significant. They only state that these results merit thoughtful consideration. In other words, if we want to claim this hypothesis is true, we need to set up a study to actually examine this hypothesis.

One earlier study (also by ROC – the Resuscitation Outcomes Consortium) even has similar results.[4],[5] These results are also not statistically significant, but suggest that with larger numbers the results might be significant. So why did the authors set up such a small study? Overconfidence and an apparent lack of familiarity with their own research.
 


 

The Seattle phenomenon (they claim that their resuscitation rate is the highest in America) seems to be due to excellent bystander CPR rates (apparently the highest in America), but that is only good enough for them to be experts on improving bystander CPR rates. The rest is probably due to defibrillation and chest compressions, which are the only prehospital interventions demonstrated to improve neurologically intact survival.

Why does a bystander CPR specialist focus on drugs? Overconfidence and an apparent lack of understanding of the resuscitation research. Dr. Kudenchuk preaches like Timothy Leary about the benefits of drugs and with just as little evidence. We should give appropriate credit for Dr. Kudenchuk’s work on CPR, but we should not mistake that for a thorough understanding of the resuscitation research, even the research with his name attached.
 

A new podcast reviews ALPS. Dominick Walenczak does not notice the mistakes of Dr. Kudenchuk, but he is not one of the researchers, so that is easy to overlook. The rest of the podcast is excellent. Listen to it here.
 

Episode 8: Conquering the ALPS (Study)
Dominick Walenczak
April 7, 2016
Podcast page
 

Footnotes:

[1] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.
N Engl J Med. 2016 Apr 4. [Epub ahead of print]
PMID: 27043165

Free Full Text from NEJM

[2] Antiarrhythmic drugs found beneficial when used by EMS treating cardiac arrest
Press release
For Immediate Release:April 4, 2016
NHLBI (National Heart Lung and Blood Institute)
Press release

[3] Dr. Kudenchuk: Study reveals exciting news about cardiac arrest treatment
Lindsay Bosslet
18 hours ago
Public Health Insider
Article

[4] Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium.
Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P; Resuscitation Outcomes Consortium Investigators.
Resuscitation. 2012 Nov;83(11):1324-30. doi: 10.1016/j.resuscitation.2012.07.008. Epub 2012 Jul 31.
PMID: 22858552 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium – Part I
Mon, 17 Sep 2012
Rogue Medic
Article

 
Kudenchuk, P., Brown, S., Daya, M., Rea, T., Nichol, G., Morrison, L., Leroux, B., Vaillancourt, C., Wittwer, L., Callaway, C., Christenson, J., Egan, D., Ornato, J., Weisfeldt, M., Stiell, I., Idris, A., Aufderheide, T., Dunford, J., Colella, M., Vilke, G., Brienza, A., Desvigne-Nickens, P., Gray, P., Gray, R., Seals, N., Straight, R., & Dorian, P. (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest New England Journal of Medicine DOI: 10.1056/NEJMoa1514204

 

Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P, & the Resuscitation Outcomes Consortium Investigators (2012). Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium. Resuscitation PMID: 22858552

.

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest

ResearchBlogging.org
 

I wrote about the start of the ALPS (Amiodarone, Lidocaine, Placebo Study) in 2012[1] and the results are now in.
 

In this randomized, double-blind, placebo-controlled, prehospital trial, we found that treatment with amiodarone or lidocaine did not result in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome at discharge than the rate with placebo after out-of-hospital cardiac arrest caused by shock-refractory initial ventricular fibrillation or pulseless ventricular tachycardia. There were also no significant differences in these outcomes between amiodarone and lidocaine.[2]

 

The primary endpoint is that amiodarone does not improve survival to discharge and neither does lidocaine. However, the results are a bit more complicated than just throw out the drugs.

Two subgroups did have better outcomes, but as the authors appropriately point out, subgroup analysis requires a higher level of significance, because you are essentially getting extra shots at the goal for every subgroup. The more subgroups we have, the more likely that one of them will reach the p value of <0.05.  

We observed an interaction of treatment with the witnessed status of out-of-hospital cardiac arrest, which is often taken as a surrogate for early recognition of cardiac arrest, a short interval between the patient’s collapse from cardiac arrest and the initiation of treatment, and a greater likelihood of therapeutic responsiveness. Though prespecified, this subgroup analysis was performed in the context of an insignificant difference for the overall analysis, and the P value for heterogeneity in this subgroup analysis was not adjusted for the number of subgroup comparisons. Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration.[2]

 

Another important point is that the possibility of an effect was probably overestimated by the researchers. A much larger study would be needed to show this smaller effect.
 

Finally, the point estimates of the survival rates in the placebo group and the amiodarone group differed less than anticipated when the trial was designed, which suggests that the trial may have been underpowered. If amiodarone has a true treatment effect of 3 percentage points, approximately 9000 patients across the three trial groups would be needed to establish this difference in outcome with 90% power. Though seemingly small, a confirmed overall difference of 3 percentage points in survival with drug therapy would mean that 1800 additional lives could be saved each year in North America alone after out-of-hospital cardiac arrest.[2]

 

How could the top doctors in the field be so far off in their estimate?

We dramatically overestimate the good we do and we dramatically underestimate the harm we do. We are unreasonably optimistic.
 

Monty Hall problem vs medicine 1
Image credit.
 

We still do not have any evidence that anything other than compressions and defibrillation improve outcomes for adult patients with cardiac arrest, but we insist on using these treatments, because we believe in magic pills.

Should we consider giving amiodarone or lidocaine to only witnessed cardiac arrest patients or only EMS-witnessed cardiac arrest? Yes, but that is really just limiting the use of these drugs to those who have some weak evidence of benefit.

We are already giving too many treatments to too many patients, based on too little evidence.

That is assuming that we have any valid evidence at all. Medical ethics appears to be only for other people, because we don’t care enough to find out if our treatments work. We just make excuses for the harm we cause to our patients.

Footnotes:

[1] What Will Be the Next Standard Of Care We Eliminate
Wed, 28 Mar 2012
Rogue Medic
Article

[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.
N Engl J Med. 2016 Apr 4. [Epub ahead of print]
PMID: 27043165

Free Full Text from NEJM

 
Kudenchuk, P., Brown, S., Daya, M., Rea, T., Nichol, G., Morrison, L., Leroux, B., Vaillancourt, C., Wittwer, L., Callaway, C., Christenson, J., Egan, D., Ornato, J., Weisfeldt, M., Stiell, I., Idris, A., Aufderheide, T., Dunford, J., Colella, M., Vilke, G., Brienza, A., Desvigne-Nickens, P., Gray, P., Gray, R., Seals, N., Straight, R., & Dorian, P. (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest New England Journal of Medicine DOI: 10.1056/NEJMoa1514204

.

ABQ to Pay $.3 Million More for Bad Oversight of Bad Medic

 

It appears that bad management tolerated, and promoted, bad patient care – right up until it affected one of their own. Now the residents have to pay a lot of money for this failure of oversight.

How typical is this medic?
 

Throughout the litigation, Tate denied any wrongdoing. He maintained his work behavior was part of the “culture” of the Fire Department.[1]

 

AFD_logo
 

The AFD (Albuquerque Fire Department) disagrees and convinced at least one “hearing officer” that it is only because the rest of the paramedics are better than Tate that his patients did not have worse outcomes.

Does that make any sense?

I discussed the complaints at the time of an earlier article about Tate and AFD.[2]

If you work with a dangerous paramedic, and you do not report any problems, does that make you better than the problem paramedic?

How does such a dangerous paramedic get promoted to lieutenant?

Is it likely that competent management remained unaware of these problems for a decade, or that this was a sudden onset of an unprecedented problem, or that in some other way this is not an example of bad management?
 

Other organizations have had to deal with criticism after their management of the corruption was exposed –
 

The Vatican revealed Tuesday that over the past decade, it has defrocked 848 priests who raped or molested children and sanctioned another 2,572 with lesser penalties, providing the first ever breakdown of how it handled the more than 3,400 cases of abuse reported to the Holy See since 2004.[3]

 

For hundreds of years we have been told that priests don’t rape children, because they are more moral than the rest of us. Evidence has demonstrated otherwise, but the corrupt culture still discourages reporting these crimes to the police.

Is there some reason to believe that Tate is just one rotten apple?

No.

This appears to be another example of a corrupt culture, that will end up costing a lot more money and setting bad standards of care.

Are the patients surviving to the emergency department because of the care provided or just because most people will survive what EMS does to them?
 

Cadigan told the Journal in 2014 that he was confident Tate would be “vindicated when he has a neutral judge to review the city’s unfair and arbitrary action. The taxpayers will likely have to pick up the tab for this absurd witch hunt.”[1]

 

Vindicated for treating the family of a fellow AFD lieutenant the same way he would treat other patients?
 

Tate claimed his conduct was consistent with what he learned at the Fire Department and argued that even if he did commit the alleged acts, he should be given corrective training.[1]

 

Maybe Tate did receive corrective training.

Repeated reminders to fit in with the culture is how corruption works.

If the culture is not the problem, why did an investigation only begin after a complaint about Tate treating one of his own the same way he is reported to treat other patients?

Footnotes:

[1] $300K settlement keeps paramedic from getting job back
By Colleen Heild / Journal Investigative Reporter
Saturday, April 2nd, 2016 at 11:45pm
Albuquerque Journal
Article

[2] How Do We Stop Dangerous Paramedics From Harming Patients?
Sat, 02 Nov 2013
Rogue Medic
Article

[3] Vatican says it’s punished over 3,400 priests since ’04 for raping or molesting children
The Associated Press
Published: 06 May 2014 03:56 PM
Updated: 06 May 2014 04:04 PM
The Dallas Morning News
Article

.

What do you do when a patient wakes up during CPR?

ResearchBlogging.org
 

The return of consciousness without the return of a pulse is still rare, but may be more common with our increased focus on high quality chest compressions. There is still no evidence that interrupting chest compressions, for anything other than defibrillation, improves outcomes.

Is this due to the consistency of the machine? Maybe. Maybe not. We do not have enough evidence to draw that conclusion.

Is this growing population really growing? Maybe. Maybe not. We do not have enough evidence to draw that conclusion, either.

It could be that with the ability to use a cell phone camera to record these instances, there is more credibility to the reports. There is a suggestion that this could be common.
 

Parnia et al. conducted a multi-year, multi-center, prospective study of the frequency of awareness during resuscitation by interviewing cardiac arrest survivors after discharge. They found 55/140 (39%) had perceptions of awareness of being alive and even memories that originated during that time.2 [1]

 

Should we be giving ketamine to these patients?
 

Nebraska EMS CPR Sedation Protocol - ALS
Nebraska CPR Induced Consciousness Sedation Protocol (from the PDF)[1]
 

We should find out how common it is for people to regain consciousness without regaining a pulse. This is clearly an experimental protocol that is not supported by evidence of improved outcomes that matter – just like all of the rest of cardiac arrest treatment that is not compressions or defibrillation.
 

RESULTS: The search yielded 1997 unique records, of which 50 abstracts were reviewed. Nine reports, describing 10 patients, were relevant. Six of the patients had CPR performed by mechanical devices, three of these patients were sedated. Four patients arrested in the out-of-hospital setting and six arrested in hospital. There were four survivors. Varying levels of consciousness were described in all reports, including purposeful arm movements, verbal communication, and resuscitation interference. Management strategies directed at consciousness were offered to six patients and included both physical and chemical restraints.[2]

 

6/1,997 is 0.3% – not anywhere near the 39.3% of 55/140, but it is still a large enough group that we should not ignore them.

Depression and anxiety following resuscitation are significant problems, so this might even be a way to help decrease those resuscitation side effects.
 

CONCLUSION:
One fourth of OHCA-survivors reported symptoms of anxiety and/or depression at 6 months which was similar to STEMI-controls and previous normative data. Subjective cognitive problems were associated with an increased risk for psychological distress. Since psychological distress affects long-term prognosis of cardiac patients in general it should be addressed during follow-up of survivors with OHCA due to a cardiac cause.
[3]

 

The similarity to the outcome of STEMI (ST segment Elevation Myocardial Infarction) patients do not inspire confidence in this approach, but that does not mean that it should not be examined.

It is most important that we not make the mistake that has been made with ventilations, endotracheal tubes, extraglottic airways, antiarrhythmic drugs, pressor drugs, anti-acidosis drugs, antidote drugs, anti-hypoglycemic drugs, et cetera. We should insist that there be valid evidence of some sort of benefit before the ACLS (Advanced Cardiac Life Support) Committee of Failed Treatments adds this to the ACLS algorithms because of an abundance of wishful thinking.
 

This time will be different.
 

This use of ketamine is interesting. Ketamine is a sedative that should not depress vital signs, so it may do what we expect. There may be more benefit than harm, but there may be more harm than benefit, or there may be all harm and no benefit. We will not know until we have valid research.

We have added the other treatments without finding out if they improve outcomes. We continue to remove these treatments as we obtain evidence, because they have one thing in common – they don’t improve outcomes.

These treatments have increased the ignorance of those who work in EMS (Emergency Medical Services) and EM (Emergency Medicine). We keep convincing ourselves that we know what we are doing, but evidence keeps showing that we are lying to ourselves.

Maybe ketamine sedation during compressions will be beneficial. It is such a small patient population, that it will be difficult to study. Introducing a treatment without studying it will always be a mistake. Is Nebraska studying this? Probably, but it is not stated in the paper. Has this been approved by an IRB (Institutional Review Board)? I do not know.

Footnotes:

[1] CPR induced consciousness: It’s time for sedation protocols for this growing population
Rice, D., Nudell, N., Habrat, D., Smith, J., & Ernest, E. (2016). Resuscitation DOI: 10.1016/j.resuscitation.2016.02.013
Free Full Text from Resuscitation.

[2] Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review.
Olaussen A, Shepherd M, Nehme Z, Smith K, Bernard S, Mitra B.
Resuscitation. 2015 Jan;86:44-8. doi: 10.1016/j.resuscitation.2014.10.017. Epub 2014 Nov 4. Review.
PMID: 25447435

[3] Anxiety and depression among out-of-hospital cardiac arrest survivors.
Lilja G, Nilsson G, Nielsen N, Friberg H, Hassager C, Koopmans M, Kuiper M, Martini A, Mellinghoff J, Pelosi P, Wanscher M, Wise MP, Östman I, Cronberg T.
Resuscitation. 2015 Dec;97:68-75. doi: 10.1016/j.resuscitation.2015.09.389. Epub 2015 Oct 9.
PMID: 26433116

Rice, D., Nudell, N., Habrat, D., Smith, J., & Ernest, E. (2016). CPR induced consciousness: It’s time for sedation protocols for this growing population Resuscitation DOI: 10.1016/j.resuscitation.2016.02.013

Olaussen A, Shepherd M, Nehme Z, Smith K, Bernard S, & Mitra B (2015). Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review. Resuscitation, 86, 44-8 PMID: 25447435

Lilja G, Nilsson G, Nielsen N, Friberg H, Hassager C, Koopmans M, Kuiper M, Martini A, Mellinghoff J, Pelosi P, Wanscher M, Wise MP, Östman I, & Cronberg T (2015). Anxiety and depression among out-of-hospital cardiac arrest survivors. Resuscitation, 97, 68-75 PMID: 26433116

.

Ketamine For Anger Management

 

I have been meaning to write about this ketamine study, but Greg Friese wrote about one of the comments on a review of the paper –
 

Most intriguing is this reader comment “talk to your damn patients calm them down and you can avoid this knee jerk, sedate first ask questions later whilst risking side effects, response ,that seems to be coming the norm” which seems disconnected to the actual syndrome of ExDS and the danger to medics, cops, and the patient when a patient’s behavior is out of control.[1]

 

Intriguing?
 

Tasmanian Devil - from outbackcooking dot blogspot dot com 1
 

The review was by Dr. Ryan Radecki of Emergency Medicine Literature of Note (the best quick and to the point reviews of research I know of on line). Did Dr. Radecki even suggest that we should avoid attempts at talking the patient down?
 

From the land of “we still have droperidol”, this case series details the use of ketamine as “rescue” treatment for “agitated delirium”. In lay terms, the situation they’re describing is the utterly bonkers patient being physically restrained by law enforcement for whom nothing else has worked.[2]

 

No.

Did the authors of the original paper suggest that we should avoid attempts at talking the patient down (verbal de-escalation)?
 

The sedation of agitated and aggressive patients in the emergency department (ED) and other acute care areas is a major problem for health care workers. Patients with acute behavioral disturbance may respond to verbal de-escalation or oral sedation, but a substantial proportion of this group requires parenteral sedation and mechanical restraint.1, 2, 3, 4, 5 [3]

 

No.

What about the studies cited above?

This is from one –
 

Combined pharmacological sedation and physical restraint were required on 66 (46%) occasions, pharmacological sedation alone on 20 (14%), physical restraint alone on 14 (10%) and neither on 43 (30%) occasions.[4]

 

30% of patients did not require physical and/or chemical restraint.

What does require mean?

How many patients can be managed by just talking them down? Should we avoid preparation for chemical and physical restraints, just because we are trying to talk the patient down?
 

There is indirect evidence from pharmacologic studies of agitation that verbal techniques can be successful in a substantial percentage of patients. In a recent study, patients were excluded from a clinical trial of droperidol if they were successfully managed with verbal de-escalation; however, the specific verbal de-escalation techniques were not identified or studied.12 [5]

 

Research on chemical management of excited delirium should not be interpreted as discouraging us from talking patients down.
 

Clinicians who work in acute care settings must be good multitaskers and tolerate rapidly changing patient priorities. In this environment, tolerating and even enjoying dealing with agitated patients takes a certain temperament, and all clinicians are encouraged to assess their temperament for this work.[5]

 

There is a lot of good information in the article, but approaching every patient with the expectation that verbal de-escalation will work is unrealistic. A lack of preparation sets everyone up for a worse outcome in the cases where verbal de-escalation does not work. Injuries and death become more likely, when we are not prepared to switch to sedation and have only physical restraint to respond to rapidly changing patient priorities.

We need to be able to adapt to the agitated patient. Verbal de-escalation and excited delirium do not get enough attention. This paper does not address the use of verbal de-escalation, because the enrolled patients had to fail to respond to other chemical sedation first. The patients who failed chemical sedation are also the ones who failed to respond to whatever attempts at verbal de-escalation were used.
 

Read the full paper on verbal de-escalation.

Footnotes:

[1] Sunday morning reader – coffee, ketamine, and EMS news
Everyday EMS Tips
by Greg Friese
March 6, 2016
Article

[2] Ketamine For Anger Management
Emergency Medicine Literature of Note
Friday, March 4, 2016
Posted by Ryan Radecki
Article

[3] Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department.
Isbister GK, Calver LA, Downes MA, Page CB.
Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01562-0. doi: 10.1016/j.annemergmed.2015.11.028. [Epub ahead of print]
PMID: 26899459

[4] Structured team approach to the agitated patient in the emergency department.
Downes MA, Healy P, Page CB, Bryant JL, Isbister GK.
Emerg Med Australas. 2009 Jun;21(3):196-202. doi: 10.1111/j.1742-6723.2009.01182.x.
PMID: 19527279

[5] Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.
Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT.
West J Emerg Med. 2012 Feb;13(1):17-25. doi: 10.5811/westjem.2011.9.6864.
PMID: 22461917

Free Full Text from PubMed Central.

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The Second EMS What-if-We’re-Wrong-a-Thon

 

Brandon Oto promoted The First EMS What-if-We’re-Wrong-a-Thon last year, but I was taking a break from blogging at the time, so I did not participate. The idea is to consider a position from the perspective of being wrong.

This is the way science works. An idea (hypothesis) is tested by attempting to prove that it is wrong, rather than attempting to prove that it is true. Unfortunately, not all science is done well. Ideology (politics, religion, nationalism, stereotyping, . . . ) is the opposite of science. The goal of ideologues is to defend the dogma, rather than to find the truth.

Since valid evidence to the contrary is all that I need to change my mind, as I have on ventilation in cardiac arrest, high flow oxygen for just about anything, epinephrine any drug for cardiac arrest, intubation as the gold standard of airway management, et cetera, is to look at something based more on opinion, rather than evidence.
 

What have I been wrong about that I have not yet corrected in writing? Romazicon (flumazenil) is a benzodiazepine antagonist which has the nasty side effect of producing seizures. I have condemned the suggestion that it should be used by EMS, because it is just an ALS (Advanced Life Support) means of trying to correct a BLS (Basic Life Support) problem with the potential for creating ALS problems that would result in even more ALS solutions.[1]
 

In considering the effects of flumazenil, have I put too much emphasis on the adverse effects and not enough emphasis on the ways that the side effects can be prevented or managed?
 

Putting much more emphasis on the side effects, rather than on the benefits is important in pharmacology, because the benefits are usually less than we expect and the serious side effects should be much less frequent than the benefits. If the serious side effects are not much less frequent than the benefits, why use the drug?

The importance of large studies is less in quantifying the benefits, but in having enough data to identify the side effects. The second most famous example of this is the Cardiac Arrhythmia Suppression Trial,[2] which was intended to show which brand of antiarrhythmic drug saved the most lives. The one that saves the most lives is clearly the best and would be marketed aggressively as the best. The result was to demonstrate that the antiarrhythmic drugs were killing people. About 60,000 people, who would not have died at that time, were killed by these drugs. These drugs were the most frequently prescribed drugs in America at that time. All of the best doctors knew that the drugs improved survival – except the drugs were killing patients.

The most famous example of a small rate of serious side effects not being identified until a lot of people were affected is thalidomide.[3] This produced dramatic deformities in the children of mothers who had taken thalidomide for nausea and vomiting of pregnancy. Since the ideas of pure good and pure evil are ideological, rather than real, there are appropriate uses for thalidomide in the treatment of Hansen’s disease (leprosy) and multiple myeloma. Good medicine requires that we balance the benefits and risks in order to increase the probability of an improvement in outcome.
 

What if, in the case of flumazenil, the side effects are both known and manageable?
 
midazolam plus flumazenil = safer qm 2
 

Flumazenil is not as dangerous as I initially thought. I was giving too much emphasis to the problems. I also think that a reasonable case can be made that we should use benzodiazepines more aggressively, while managing airway compromise and oversedation with flumazenil as an occasional supplement to BLS methods such as proper positioning to maintain the airway and stimuli to promote respiratory drive. An IM (IntraMuscular) dose of 10 mg of midazolam (Versed) may be a good starting dose for a small or medium-sized person.

What about seizures? Seizures do occur, but they are not common. Flumazenil is a competitive antagonist, so more benzodiazepine can be given to stop a seizure, but we should not be getting anywhere near that complication. Seizures are not common and only one of the uses of benzodiazepines is to stop seizure activity. There is no good reason to expect seizure activity if we are giving tiny doses (smaller than the recommend doses of flumazenil) to patients who are being sedated with benzodiazepines (the wrong drugs, but often the only ones available to EMS) for agitated delirium and happen to become so sedated that a bad outcome is likely without intervention.[4]

The current issue of the British Journal of Clinical Pharmacology has the theme of the appropriate use of antidotes.
 

Themed issue Antidotes in Clinical Toxicology

Theophrastus Bombastus Paracelsus von Hohenheim (1493–1541) said it all with Dosis sola facit venenum or in modern language “It is the dose, stupid”. So, for a journal of Clinical Pharmacology that as a matter of principle deals with the relation between dose and effect, covering the high end of de (the?) dose – effect relationship is nothing out of the ordinary. This issue is largely about how to treat unfortunate patients who have reached the dark side of the dose–response curve. This can be done by antidotes.[5]

 

This can be done by antidotes.     Not – This must be done by antidotes.

It is the dose, stupid, is usually translated as The dose makes the poison, or –
 

All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.
 

Only one article in this issue addresses flumazenil, and that is only as part of a general discussion of antidotes (which also mentions the use of benzodiazepines as the antidote for overdose of amphetamines and other stimulants and for drug induced delirium). The article does encourage caution in the use of flumazenil –
 

For other antidotes, a clinical effect is pharmacologically expected, obvious and rapid (e.g. reversal of coma with flumazenil or naloxone, or resolution of delirium with physostigmine). However, this does not necessarily translate into improved clinical outcomes over supportive care [2]. [6]

 

What if the important safety criteria are using small doses, repeated reassessment, and critical judgment?

Can EMS do that? Our failures with airway management (it is still popular to claim that no evidence of benefit or safety is needed, in spite of the many studies showing harm from intubation) suggest that we cannot, but people keep pointing out that I am an optimist. I think that education can reach many of the dogmatic deniers of science and promoters of emotion over reality.

The use of tiny doses of naloxone (Narcan) to increase the respiratory drive, but not the alertness, of patients with opioid overdoses may result in a sudden increase in level of consciousness and aggression, but that is not typical.

Can we produce better outcomes with judicious use of antidotes in addition to supportive care as a way of managing aggressive use of benzodiazepines? Maybe, but it is not something people seem to want to study. We have given the drug to be reversed and know the dose we gave, so we are not dealing with an unknown overdose. The patient may have ingested other drugs that are unknown, but they tend to be stimulants, which is why we are giving a sedative. The patient may even have taken a benzodiazepine at some point, but more benzodiazepine is not a reason to avoid flumazenil.

The better question is can we improve outcomes for violent patients and for the people who deal with violent patients, with more aggressive use of benzodiazepines and judicious use of flumazenil to minimize the side effects of aggressive benzodiazepine use?

Benzodizepines are the wrong drugs to use for agitated delirium, unless combined with more effective medication. Some EMS providers do not have access to the most effective sedatives, or even the second most effective sedatives. I am limited to benzodiazepines and only in doses that are too low. Adding flumazenil to my scope of practice might help the medical directors to provide better EMS education and more aggressive standing orders.

There is more to write about flumazenil, but this is plenty for today.
 

Also writing in The Second EMS What-if-We’re-Wrong-a-Thon are –

Michael Morse (Rescuing Providence) — asks… what if community paramedicine really is the future of EMS?

Dale Loberger (High Performance EMS) — asks… what if emergency response times don’t really matter all that much?

Amy Eisenhauer (The EMS Siren) — wonders… whether the role of social media in EMS is such a good thing after all.

Ginger Locke — asks… what if video laryngoscopy really is the best first-pass technique for routine endotracheal intubation?

Footnotes:

[1] Flumazenil and EMS – A Box Pandora Should Not Open
Fri, 20 Mar 2009
by Rogue Medic
Article

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.

N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.

CONCLUSIONS. There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.

I have written about this in C A S T and Narrative Fallacy and elsewhere.

[3] Thalidomide: the tragedy of birth defects and the effective treatment of disease.
Kim JH, Scialli AR.
Toxicol Sci. 2011 Jul;122(1):1-6. doi: 10.1093/toxsci/kfr088. Epub 2011 Apr 19. Erratum in: Toxicol Sci. 2012 Feb;125(2):613.
PMID: 21507989

Free Full Text from Toxicol Sci.

[4] Excited Delirium: Episode 72 EMS EduCast
Wed, 29 Sep 2010
by Rogue Medic
Article

[5] Issue highlights
British Journal of Clinical Pharmacology
Special Issue: Antidotes in Clinical Toxicology
Volume 81, Issue 3, pages 398–399, March 2016
DOI: 10.1111/bcp.12909
Article

[6] Who gets antidotes? choosing the chosen few.
Buckley NA, Dawson AH, Juurlink DN, Isbister GK.
Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. Review.
PMID: 26816206

Free Full Text from Br J Clin Pharmacol.

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Deadpool – maybe it only hurts when you laugh, but you laugh anyway

 

What if you took an extremely sarcastic person and made him a god? You could have a triple R rated success.

Horace Walpole has a great quote, that seems to baffle the sanctimonious –

The world is a comedy to those that think; a tragedy to those that feel.

Jonathan Swift and Lewis Carroll might regret that this movie only skims the surface in its satire, but they had to use satire to avoid prosecution for blasphemy, heresy, and other thought crimes that are trying for a comeback.

Marvel vs. DC. iPhone vs. Android. Fire vs. private vs. hospital. Little-Endian vs. Big-Endian and High Heels vs. Low Heels.[1] Mine is the One True WhateverTM.
 

Deadpool kneel before Zod sign 1a
Best still of Deadpool at Comic Con

 


 

Election season is the perfect time for Deadpool to be in theaters, because the preachers, pundits, and politicians are more absurd and obscene than anything in the movie.
 

Satire is a sort of glass wherein beholders do generally discover everybody’s face but their own; which is the chief reason for that kind reception it meets with in the world, and that so very few are offended with it.[2]

 

Deadpool doesn’t even try to fit the right wing or left wing politically correct model. The preachers, pundits, and politicians claim that the greater obscenities they promote are virtues. Perhaps they are so ridiculous, they no longer need others to ridicule them.

 

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”

“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”[3]

 
 

We should soon see an honest emulation among the married women, which of them could bring the fattest child to the market. Men would become as fond of their wives, during the time of their pregnancy, as they are now of their mares in foal, their cows in calf, or sow when they are ready to farrow; nor offer to beat or kick them (as is too frequent a practice) for fear of a miscarriage.[4]

 

If you work in a medical field, you should have seen enough misery to have an appreciation of a dark sense of humor and an understanding of the fraud of treating others as less deserving because they are in some way different.

A world of collateral damage is a comedy. Some of us keep going for the even bigger laugh of the bigger body count.

A world of starvation is a comedy. Some of us oppose using GMOs (Genetically Modified Organisms) to prevent the even bigger laugh of the bigger body count.

A world of death by preventable illness is a comedy. Some of us oppose using vaccines to prevent the even bigger laugh of the bigger body count.

The truly twisted sense of humor is not the obscenity in this movie, but the sanctimony of those encouraging killing, in the name of whatever, while claiming to be good.

Footnotes:

[1] Part I, Chapter IV
Mildendo, the metropolis of Lilliput, described, together with the emperor’s palace. A conversation between the author and a principal secretary, concerning the affairs of that empire. The author’s offers to serve the emperor in his wars.
Gulliver’s Travels into Several Remote Nations of the World (1726)
Jonathan Swift
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Chapter IV
 

For,” said he, “as flourishing a condition as we may appear to be in to foreigners, we labour under two mighty evils: a violent faction at home, and the danger of an invasion, by a most potent enemy, from abroad.

 

[2] The Preface of the Author
A Full and True Account of the Battle Fought Last Friday Between the Ancient and the Modern Books in Saint James’s Library. (1704)
Jonathan Swift
The Literature Network
Introduction

[3] Chapter 5: Wool and Water
Through the Looking-Glass, and What Alice Found There (1871)
Lewis Carroll (Charles Lutwidge Dodgson)
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Chapter 5

[4] A Modest Proposal for preventing the children of poor people in Ireland, from being a burden on their parents or country, and for making them beneficial to the publick (1729)
Jonathan Swift
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Full Text

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