Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

If We Pretend that Anecdotes are Not Anecdotes, Do We Change Reality?

 

The following comment was written by Duke Powell in response to Where is the Evidence for Traction Splints?
 

I’ve been an urban paramedic for 34 years and, prior to that, a volunteer EMT for 9 years. For those who can’t add, ….that’s a long time.

How many times have I used a traction splint? …… I dunno, let’s guess 10 times.

 

That works out to an average of over four years between uses of the traction splint. That is plenty of time to have the memory of each use reconstructed many times, so that the memory and the reality may not have much in common. Each time we remember something, we recreate and modify the memory.
 

Several years ago, after several years of not even thinking about traction splinting, I found myself using it 3 times in 2 weeks.

Did it help? Yep, clinically, in my opinion, it helped.

 

Maybe it helped the patients. Maybe it harmed the patients. Maybe it helped some patients and harmed other patients. Maybe it helped the pain, but caused longer term harm. We do not know.

Without valid evidence, especially evidence of something more than the superficial appearance of improvement, we have no idea. We can use our imaginations and generate opinions, but we are merely discussing opinions.
 

Will Rogue Medic call my experience “anecdotal” and not worthy of consideration? Yes, he will.

Don’t care what the Rogue Medic thinks.

I care about what my patients and my Medical Director thinks.

 


Image credit.
 

Does calling an anecdote by a different name make it not an anecdote? It does not matter what you call it. A story is an anecdote. More than one story is just more than one anecdote.

What kind of follow up was there on the patients? What kind of comparison of the other variables was there?

Blood-letting looks like an excellent treatment – if we stick to anecdotes about blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[1]

 

How many patients did we kill with blood-letting? Thousands? Tens of thousands? Hundreds of thousands?

The opinions of medical directors have been in favor of many harmful treatments. Do you remember nifedipine?

Anecdotes do not become evidence of good patient care by telling the stories with style. Reality does not work that way, no matter how much we want to change reality. EMS shows us people who are having reality ignore their opinions about how the world should work. If reality is not going to change for a parent who wants their dead child back, how little is reality going to change for a paramedic who wants to put a positive spin on a treatment that he likes?

Reality does not care about our opinions.

Reality does not even care about the opinions of medical directors.

Science is the way we learn the difference between what is real and what is just a pleasing mirage.
 

What do you think science is? There is nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. So which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic? – Dr. Steven Novella.

Anecdotes are not thorough observations. Anecdotes do not use consistent logic. Anecdotes do not have anything to do with systematic evaluation.

-

Footnotes:

-

[1] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

.

Where is the Evidence for Traction Splints?

 

We eliminated tourniquets from ambulances because of anecdotes and some strong opinions, but not because of valid research. Valid research shows that tourniquets work. Tourniquets are back.

We added traction splints because of anecdotes and some strong opinions, but not because of any valid research. Will research result in the same reversal of opinion-based practice.

With so little evidence, devices that are frequently misused, and no apparent need for these Rube Goldberg devices, should we continue to use traction splints?
 


Image credit.
 

Does a traction splint work?

That depends on what we mean by the word work. If work means that it pulls on the leg, then it does work, but if work means that it improves outcomes, then the traction splint is about as effective as eye of newt. Maybe the eye of newt is more effective.

If your have a lot of patients who have no other major injuries, then you may be able to set up a study of traction splints. A ski resort might be a good place for a study. On the other hand, if you are not an isolated femur fracture magnet, then your patients would probably be much better off if you focused on pain management, rather than pulling on their broken bones.
 

The fact is, there were no definitive studies demonstrating efficacy or decreased morbidity or mortality from prehospital use of traction splints 10 years ago, nor are there any now.3 So our use of traction splints is purely anecdotal.[1]

 

What is an anecdote?

An anecdote is misinformation from a know-it-all who doesn’t know what matters.

Anecdotes are just rumors. We believe some things because we want to believe, not because they are true. If we want to know the truth, we look for unbiased information. Unbiased information is the opposite of anecdotes and rumors.

There I was, standing on the corner, minding my own business, when all of a sudden . . .

He was dying and we gave the special sauce and he got better and ran a marathon last year.

These are examples of anecdotes. Anecdotes are what sells alternative medicine.

-

Footnotes:

-

[1] Sacred Cow Slaughterhouse: The Traction Splint
By William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Jul 31, 2014
EMS World
Article

.

Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?


 Some in the media have been critical of the upcoming British study of adrenaline (epinephrine) vs. placebo for cardiac arrest.[1] They assume that the guidelines require that we give adrenaline, but that is not true.

The guidelines only state that adrenaline may be considered.

If you are a dog, pig, or rat in a laboratory and you have had an artificially induced cardiac arrest, then adrenaline will help resuscitate you. If you are a human who has a cardiac arrest for any one of a variety of reasons, then there is not a good reason to give this rat resuscitation drug, which has not been adequately studied in humans.

There probably are some human patients who do benefit from adrenaline in cardiac arrest, but we have no idea which patients those are and there probably are humans who are harmed by adrenaline. The most common cause of cardiac arrest is heart attack, but you were having a heart attack while still alive, is there a worse drug we could give you than adrenaline? Does adrenaline suddenly become sugar and spice and everything nice, just because we cannot feel a pulse? Maybe, but should we assume that?

What if you have lost so much blood that your heart is not able to produce a pulse, even though your heart is beating as hard as it can? Adrenaline is indicated according to the same guidelines. Why? Unreasonable optimism.

Which patients benefit from adrenaline? We don’t know.

Which patients are harmed by adrenaline? We don’t know.

How do we find out? Research, such as the upcoming study of adrenaline (epinephrine).

What do the guidelines say about conducting this research?
 

Given the observed benefit in short-term outcomes, the use of epinephrine or vasopressin may be considered in adult cardiac arrest.

Knowledge Gaps

Placebo-controlled trials to evaluate the use of any vasopressor in adult and pediatric cardiac arrest are needed.[2]

 

Vasopressors are adrenaline, vasopressin, norepinephrine, and phenylephrine. We need evidence to find out if any of them work.

When the 2010 guidelines were written there was an inescapable need for placebo studies.

Has anything changed?

No.

There was a placebo study in 2012 that was aborted by pressure from media and politicians before any useful results could be obtained.[3]
 

There is evidence that adrenaline improves the return of a pulse, but that appears to just produce comatose patients who die in the hospital without waking up, so the initial improvement appears to be very misleading.

We could try real medicine, where we find out what the right treatment is and give the right treatment to the right patient, but that seems to be asking too much for some people.

-

Footnotes:

-

[1] The Controversy of Admitting ‘We Do Not Know What Works’
Wed, 13 Aug 2014
Rogue Medic
Article

-

[2] Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TL, Böttiger BW, Drajer S, Lim SH, Nolan JP; Advanced Life Support Chapter Collaborators.
Circulation. 2010 Oct 19;122(16 Suppl 2):S345-421. doi: 10.1161/CIRCULATIONAHA.110.971051. No abstract available.
PMID: 20956256 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

-

[3] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com
 

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

 

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

 

.

Imagine if Ebola Spread in America

 
What if there were an Ebola epidemic in America?

In the aftermath of the spread of Ebola in America, would we have Congressional hearings like this?
 


 

 

Dr. Oz – My show is about hope.[1]

 

Translation – Hope sells.

You can rape people who are desperate, but as long as you give them hope, it is OK.[2]
 

A traditional healer, practicing naturopathy in Sierra Leone, appears to be the main reason for the spread of Ebola from Guinea into Sierra Leone.
 

“She was claiming to have powers to heal Ebola. Cases from Guinea were crossing into Sierra Leone for treatment,” Mohamed Vandi, the top medical official in the hard-hit district of Kenema, told AFP.[3]

 

It is a mistake to state that Ebola never would have spread, but this was just another alternative medicine practitioner selling hope, fortunately with a much smaller audience than Dr. Oz.
 

“It is a disease that spreads very fast, without regard for academic or economic status, political affiliation, age, ethnic grouping, gender or religion.”[3]

 

Ebola also doesn’t care about hope. Hope helped to spread Ebola.
 

The other end of the alternative medicine market is fear. People preach that there are government conspiracies so evil that the conspirators kill anyone who might expose the conspiracy, but can’t manage to keep Mike Adams[4] from spreading paranoia.

Blame the CDC (Centers for Disease Control and Prevention) for everything.
 

Alternative medicine and conspiracy theories are all fun and games, until someone spreads a deadly epidemic.

They assume that we are supposed to be healthy, and sell empowerment to be healthy, but blame the victim when the quackery does not work.
 

Based on what is known to date, I do not worry overmuch about the spread of Ebola in the US. Direct contact is not a very efficient way to transmit infections, especially infections that are rapidly fatal.[5]

 

Ebola requires more than good health to prevent transmission, but the people promising hope and trying to scare us away from real doctors do not seem to understand that.

Is it easy to become infected with Ebola?

Only if we do not know what we are doing and do not have appropriate PPE (Personal Protective Equipment). Quacks believe in magic, because they do not understand science.
 

Thirty year of following infection control procedures and I have yet to catch an infection from a patient. I remember at the start of the AIDS epidemic there were those who refused to care for AIDS patients due to worries of catching the disease. It never worried me since I knew the modes of transmission and I did not partake of those behaviors.[5]

 

We should ignore the quacks and listen to people who understand what they are doing, but it is difficult to resist the temptation to believe in magic – Naturopathy, herbalism, homeopathy, Reiki, acupuncture, . . . .

It is also difficult to resist the temptation of an easy explanation. Conspiracy theories provide simple explanations for complex problems. As with the belief in magic, this is not a new problem.

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H.L. Mencken.

We continue to enrich those who promote hope. We continue to enrich those who spread fear. We continue to ignore those who try to understand, because understanding requires work, and that is asking too much. We need to ask for evidence, examine the evidence critically, and not fall for things because they appeal to our biases.
 

For a more information from Science-Based Medicine read – Ebola outbreaks: Science versus fear mongering and quackery

-

Footnotes:

-

[1] Weight-Loss Product Advertising – Witnesses testified on ways to protect consumers from false and deceptive advertising of weight-loss products.
June 17, 2014
C-SPAN
Page with embedded video.

-

[2] Dr. Oz Shows How He Lies with Bad Research
Tue, 17 Jun 2014
Rogue Medic
Article

-

[3] Sierra Leone’s 365 Ebola deaths traced back to traditional healer
AFP | 20 August, 2014 08:26
Times LIVE
Article

-

[4] Mike Adams is a Dangerous Loon
Steven Novella
July 25, 2014
Neurologica
Article

-

[5] Yet another plague panic
by Mark Crislip
August 8, 2014
Science-Based Medicine
Article

.

Opponents of EBM Now Have More Evidence to Justify Their Rejection of Evidence


 

Those scientists clearly can’t get it right. They are constantly changing the guidelines to correct their mistakes. Why don’t they just do it right the first time.

Finally, somebody is recognizing that a treatment should only be eliminated when there is clear evidence that it harms patients – and only when we have run out of excuses to ignore the irrefutable evidence.
 

The 2015 American Heart Organization (AHO) Cardiovascular Care Guidelines will introduce three new levels of evidence in addition to the current existing levels of evidence
In addition to the current levels of evidence classes the AHO’s 2015 guidelines will include Class IVa (Anecdotal Evidence), Class V (Provider Opinion) and Class XI (Treatments Not Proven to Not Work)
[1]

 

When I was in paramedic school we were told the rules. Intubation is the most important treatment, because the airway is the most important part of patient care, because Airway begins with A, Breathing begins with B, and Circulation begins with C. A comes before B and B comes before C.

Do you think that is a coincidence? No. There’s a reason for that. We are supposed to treat the airway first – no matter what. A paramedic can only have one thought in his head at a time, so it has to be the one best thought. Airway always comes first. Did you ever try to live without an airway? Well, did you? It just doesn’t happen. The Gold Standard of Airway is intubation, so we have to intubate people or they will be dropping like flies. You don’t hear about people surviving in places where medics don’t intubate. Dead! All of ‘em. Dead! It’s a fact.

This is serious business people. Every second counts, but there are a lot of seconds, so we don’t count seconds. We count minutes. So every minute counts, but only with an Airway. Without an Airway, you are dead, but you are only dead after we race your cadaver to the hospital and a doctor pronounces you dead and mutters something under his breath about us being straight out of the Dark Ages. We do respect the classics. We have to honor our roots. We can’t be eliminating traditional treatments just because they seem to harm patients.
 

AHO includes the following in the new guidelines, section IVa (Anecdotal Evidence): “Many people have seem something work or they know of someone who has seen something work, or perhaps have heard of someone who knows someone that has seem something work. If a treatment has been said to work in the past then it stands to reason that it will work again. The AHA now accepts anecdotal evidence as equivalent to and just as valid as a Class I intervention provided that the evidence is no more than 4 degrees of separation from the person.”[1]

 

They shouldn’t have left out treatments based on animal research. We have to include everything. It doesn’t matter that people do not do as well with these treatments as animals do. Don’t you love dogs and cats, or are you some kind of monster? If a treatment can bring a dog back to life then that is good enough for grandpa. If cancer can be cured in animals, but we don’t give the treatments to people we are killing people. It is a Big Pharma conspiracy to find cures and then hide them from everyone, because that is why these scientists do all of this research – so they can have the cures for themselves and watch us die. If it works in animals, there is no reason to not use it in people.

All of this research is just too expensive.

We need to just use what we know works.
 

Go read the full article.

-

Footnotes:

-

[1] Heart Organization Endorses New Level of Evidence Guildlines
Call The Cops
Posted by: RJ Beam
8/20/2014
Article

.

Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

ResearchBlogging.org
 

Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?

If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?

50% dextrose has problems.
 

Animal models have demonstrated the toxic effect of glucose infusions in the settings of cardiac arrest and stroke.2 Experimental data suggests that hyperglycemia is neurotoxic to patients in the setting of acute illness.1,3 [1]

 

Furthermore, extravasation can cause necrosis.
 


Image credit.[2]
 

I expect juries to look at this kind of image and say, Somebody has to take one for the 50% dextrose team. We can’t expect EMS to change.

Is 10% dextrose practical?
 

Won’t giving less concentrated dextrose delay treatment?
 

The median initial field blood glucose was 38 mg/dL (IQR = 28 mg/dL – 47 mg/dL), with subsequent blood glucose median of 98 mg/dL (IQR = 70 mg/dL – 135 mg/dL). Elapsed time after D10 administration before recheck was not uniform, with a median time to recheck of eight minutes (IQR = 5 minutes – 12 minutes).[1]

 

If that is going to slow your system down, is it because you are transporting patients before they wake up?

Did anyone require more than 10 grams of 10% dextrose, as opposed to 25 grams of 50% dextrose?
 

Of 164 patients, 29 (18%) received an additional dose of intravenous D10 solution in the field due to persistent or recurrent hypoglycemia, and one patient required a third dose.[1]

 

18% received a second dose, which is 20 grams of dextrose and still less than the total dose of 25 grams of dextrose given according to EMS protocols that still use 50% dextrose.

Only one patient, out of 164 patients, required a third dose. That is 30 grams of dextrose.

Only one patient, out of 164 patients, received as much as we would give according to the typical EMS protocol, which should be a thing of the past. If we are routinely giving too much to our patients, is that a good thing? Why?
 

Maybe the blood sugars were not that low to begin with.
 


 

The average was 38 mg/dL, which is not high.
 

Maybe the change in blood sugar was small after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) change was 67 mg/dL, which is enough to get a patient with a blood sugar of 3 up to 70.
 

Maybe the blood sugar was not high enough after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) repeat blood sugar was 106 mg/dL, which is more than enough.
 

Maybe it took a long time to treat patients this way.
 


 

The average (mean) time was 9 minutes, which is not a lot of time.
 

Is this perfect?
 

Three patients had a drop in blood glucose after D10 administration: one patient had a drop of 1 mg/dL; one patient had a drop of 10 mg/dL; and one patient had a drop of 19 mg/dL.[1]

 

All patients, even the three with initial drops in blood sugar (one had an insulin pump still pumping while being treated) had normal blood sugars at the end of EMS contact.

10% dextrose is cheaper, just as fast, probably less likely to cause hyperglycemia, probably less likely to cause rebound hypoglycemia, probably less likely to cause problems with extravasation, less of a problem with drug shortages, . . . .

Why are we still resisting switching to 10% dextrose?
 

Other articles on 10% dextrose.

-

Footnotes:

-

[1] Dextrose 10% in the treatment of out-of-hospital hypoglycemia.
Kiefer MV, Gene Hern H, Alter HJ, Barger JB.
Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15.
PMID: 24735872 [PubMed - indexed for MEDLINE]

-

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

-

Kiefer MV, Gene Hern H, Alter HJ, & Barger JB (2014). Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29 (2), 190-4 PMID: 24735872

-

Levy SB, & Rosh AJ (2006). Images in emergency medicine. Dextrose extravasation causing skin necrosis. Annals of emergency medicine, 48 (3) PMID: 16934641

.

The Controversy of Admitting ‘We Do Not Know What Works’

ResearchBlogging.org

 

There are several news articles today criticizing a study because the patients might be deprived of a drug that has not been adequately studied in humans. This criticism is coming from journalists – the people who publicized the fraudulent vaccines research by Andrew Wakefield, who was trying to sell his competing vaccine and was being paid to produce negative research by lawyers suing the vaccine companies.[1]

The real controversy is that this untested drug became the standard of care with no evidence that it improves outcomes that matter.

Is it controversial to give a placebo, rather than a drug not yet adequately tested in humans?

No.

We are not informing patients that there is no evidence that the standard treatment is effective. We are not obtaining consent to give the unproven drug – epinephrine (Adrenaline in Commonwealth countries). How are the ethics different when we substitute a placebo for a mystery medicine?

What is less ethical than continuing the tradition of giving an inadequately studied drug to people who cannot consent to treatment?

Are we depriving patients of effective medicine or are we depriving them of witchcraft?

If you think that epinephrine is effective medicine at improving survival to discharge, provide the evidence and stop this study. The reason the study is being done is that evidence of benefit does not exist.
 

Click on image to make it larger.[2] The studies are in the footnotes.[3],[4],[5],[6],[7],[8],[9],[10]
 

Is Adrenaline beneficial in cardiac arrest?

Probably, but only for some patients and we do not know which patients benefit.

Is Adrenaline harmful in cardiac arrest?

Probably, but only for some patients and we do not know which patients are harmed.

What is the right dose of Adrenaline in cardiac arrest?

Pick a number – any number. We do not know the right dose.
 

 

Even the patients who only received the minimum dose – 1 mg – had worse outcomes.[11]

Wrong timing? Wrong dose? Wrong drug?

We do not know.
 

We have used this untested treatment for half a century and not bothered to find out if it works. A recent study shows that epinephrine produces worse outcomes when given by EMS later,[12] but that does not mean that the outcomes are good when epinephrine is given early. The study had no placebo group, so like a study comparing different doses of cyanide, just because one dose is not as bad as another dose, the results do not suggest that cyanide is beneficial.
 


 

This is comparing three different treatments HDE (High-Dose Epinephrine), SDE (Standard-Dose Epinephrine), and NE (NorEpinephrine). The lines for the HDE and NE are so close to each other, that you may not be able to see the gold line.[13] Other studies produce similar results.[3],[14],[15],[16],[17] Only one study showed better ROSC with standard dose epinephrine.[18]
 

Epinephrine does produce more ROSC (Return Of Spontaneous Circulation – at least a temporary pulse) than placebo, but high dose epinephrine produces even more ROSC than standard dose epinephrine, so why do we give the standard dose that only produces middling ROSC?

Is ROSC the goal? No.

For the guidelines (ACLS and ILCOR), ROSC is the basis for giving standard dose epinephrine, but it would make more sense to give high dose epinephrine if the goal is ROSC. More ROSC, but no more survivors leaving the hospital. If all we want is put the patient in a coma long enough to run up a big hospital bill, then the drugs are great.

If we want people to leave the hospital alive, then We Do Not Know What Works.
 

The guidelines are based on wishful thinking and rationalization. They are not based on improved survival. A lot of research is cited (hundreds of papers), but the research does not show improved survival with any drug(s).

Will the guidelines be revised to remove epinephrine? Maybe.
 

The exciting development is that these data create equipoise about the current standard of resuscitation care. The best available observational evidence indicates that epinephrine may be harmful to patients during cardiac arrest, and there are plausible biological reasons to support this observation. However, observational studies cannot establish causal relationships in the way that randomized trials can.[19]

 

Some cocktails have produced better results than epinephrine in tiny studies. It is too probably too early to tell if these are just statistical aberrations. I will write about them later.

Continued in Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?

-

Footnotes:

-

[1] “Piltdown medicine” and Andrew Wakefield’s MMR vaccine fraud
Science-Based Medicine
Posted by David Gorski
January 6, 2011
Article
 

In a mere decade and a half, several decades of progress in controlling this scourge had been unravelled like a thread hanging off a cheap dress, all thanks to Andrew Wakefield and scandal mongers in the British press.

-

[2] Vasopressors in cardiac arrest: a systematic review.
Larabee TM, Liu KY, Campbell JA, Little CM.
Resuscitation. 2012 Aug;83(8):932-9. Epub 2012 Mar 15.
PMID: 22425731 [PubMed - in process]
 

CONCLUSION: There are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.

-

[3] High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest.
Woodhouse SP, Cox S, Boyd P, Case C, Weber M.
Resuscitation. 1995 Dec;30(3):243-9.
PMID: 8867714 [PubMed - indexed for MEDLINE]

-

[4] Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?
Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, Holmberg S.
Resuscitation. 1995 Jun;29(3):195-201.
PMID: 7667549 [PubMed - indexed for MEDLINE]

-

[5] Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.
Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A; Cardiac Arrest and Resuscitation Epidemiology Study Group.
Ann Emerg Med. 2007 Dec;50(6):635-42. Epub 2007 May 23.
PMID: 17509730 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from prdupl02.ynet.co.il

-

[6] Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed - indexed for MEDLINE]

Free Full Text from JAMA

-

[7] Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial.
Olasveengen TM, Wik L, Sunde K, Steen PA.
Resuscitation. 2011 Nov 22. [Epub ahead of print]
PMID: 22115931 [PubMed - as supplied by publisher]

-

[8] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com
 

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

 

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

 

-

[9] Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
PMID: 22436956 [PubMed - indexed for MEDLINE]

Free Full Text from JAMA.

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[10] Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest.
Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, Kai T.
Circ J. 2012;76(7):1639-45. Epub 2012 Apr 5.
PMID: 22481099 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation Japan.

-

[11] 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.

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[12] Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, Gautam S, Callaway C; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.
BMJ. 2014 May 20;348:g3028. doi: 10.1136/bmj.g3028.
PMID: 24846323 [PubMed - in process]

Free Full Text from BMJ.

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[13] A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.
Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J.
JAMA. 1992 Nov 18;268(19):2667-72.
PMID: 1433686 [PubMed - indexed for MEDLINE]

-

[14] A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group.
Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, Jastremski M.
N Engl J Med. 1992 Oct 8;327(15):1051-5.
PMID: 1522841 [PubMed - indexed for MEDLINE]

Free Full Text from NEJM.

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[15] Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital.
Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, Petit P.
Resuscitation. 1995 Feb;29(1):3-9.
PMID: 7784720 [PubMed - indexed for MEDLINE]

-

[16] A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group.
Gueugniaud PY, Mols P, Goldstein P, Pham E, Dubien PY, Deweerdt C, Vergnion M, Petit P, Carli P.
N Engl J Med. 1998 Nov 26;339(22):1595-601.
PMID: 9828247 [PubMed - indexed for MEDLINE]

Free Full Text from NEJM.

-

[17] High dose versus standard dose epinephrine in cardiac arrest – a meta-analysis.
Vandycke C, Martens P.
Resuscitation. 2000 Aug 1;45(3):161-6.
PMID: 10959014 [PubMed - indexed for MEDLINE]

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[18] High-dose epinephrine in adult cardiac arrest.
Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, Dickinson GE.
N Engl J Med. 1992 Oct 8;327(15):1045-50.
PMID: 1522840 [PubMed - indexed for MEDLINE]

Free Full Text from NEJM.

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[19] Questioning the use of epinephrine to treat cardiac arrest.
Callaway CW.
JAMA. 2012 Mar 21;307(11):1198-200. doi: 10.1001/jama.2012.313. No abstract available.
PMID: 22436961 [PubMed - indexed for MEDLINE]

Link to a free 6 1/2 minute recording of an interview with Dr. Callaway about this paper.

On the right side of the page, to the right of the First Page Preview, is a section with the title Multimedia Related by Topic. Below that is Author Interview. Below that is some information about the edition, . . . , and below that is an embedded recording of the interview. Press on the arrow to play. That has the recording of the interview with Dr. Callaway.

The interview with Dr. Callaway is definitely worth listening to.

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Larabee TM, Liu KY, Campbell JA, & Little CM (2012). Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83 (8), 932-9 PMID: 22425731

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Woodhouse SP, Cox S, Boyd P, Case C, & Weber M (1995). High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest. Resuscitation, 30 (3), 243-9 PMID: 8867714

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Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, & Holmberg S (1995). Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference? Resuscitation, 29 (3), 195-201 PMID: 7667549

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Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A, & Cardiac Arrest and Resuscitation Epidemiology Study Group (2007). Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Annals of emergency medicine, 50 (6), 635-42 PMID: 17509730

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Olasveengen, T., Sunde, K., Brunborg, C., Thowsen, J., Steen, P., & Wik, L. (2009). Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial JAMA: The Journal of the American Medical Association, 302 (20), 2222-2229 DOI: 10.1001/jama.2009.1729

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Olasveengen TM, Wik L, Sunde K, & Steen PA (2011). Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial. Resuscitation PMID: 22115931

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Jacobs IG, Finn JC, Jelinek GA, Oxer HF, & Thompson PL (2011). Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation, 82 (9), 1138-43 PMID: 21745533

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Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S (2012). Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307 (11), 1161-8 PMID: 22436956

-

Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T (2012). Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76 (7), 1639-45 PMID: 22481099

-

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

-

Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014). Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry BMJ, 348 (may20 2) DOI: 10.1136/bmj.g3028

-

Callaham M, Madsen CD, Barton CW, Saunders CE, & Pointer J (1992). A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA : the journal of the American Medical Association, 268 (19), 2667-72 PMID: 1433686

-

Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, & Jastremski M (1992). A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. The New England journal of medicine, 327 (15), 1051-5 PMID: 1522841

-

Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, & Petit P (1995). Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital. Resuscitation, 29 (1), 3-9 PMID: 7784720

-

Gueugniaud PY, Mols P, Goldstein P, Pham E, Dubien PY, Deweerdt C, Vergnion M, Petit P, & Carli P (1998). A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. The New England journal of medicine, 339 (22), 1595-601 PMID: 9828247

-

Vandycke C, & Martens P (2000). High dose versus standard dose epinephrine in cardiac arrest – a meta-analysis. Resuscitation, 45 (3), 161-6 PMID: 10959014

-

Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, & Dickinson GE (1992). High-dose epinephrine in adult cardiac arrest. The New England journal of medicine, 327 (15), 1045-50 PMID: 1522840

-

Callaway, C. (2012). Questioning the Use of Epinephrine to Treat Cardiac Arrest JAMA: The Journal of the American Medical Association, 307 (11) DOI: 10.1001/jama.2012.313

.

Since the World is Ending Today, What Should We Do?


 

Oh no! It is the end of the world, again. What should we do?

If the end of the world causes you anxiety, you are probably already prescribed some anti-anxiety medicine. I recommend that you follow the directions on the label and stop annoying less anxious people. Avoid combining your sedatives with other sedatives (alcohol, heroin, propofol, . . . ) and find a way to distract yourself from what you do not understand.
 

Lunar activity is said to mark the END OF TIME, with some religious groups believing it to be a sign of the JUDGEMENT DAY.[1]

 

The end of times has probably been predicted since before writing was first used to record anything. There is one consistent thing about these predictions. They have been completely wrong. Eventually, one will be right, but that will probably be something we learn about from scientists, who will be the first to observe evidence of any problems.

What do scientists predict about the super moon? It will appear a little bit bigger and brighter than most normal full moons. That will be the only noticeable difference from a normal full moon.
 

Lunar activity is said to mark the END OF TIME, with some religious groups believing it to be a sign of the JUDGEMENT DAY.[1]

 

We are still waiting and none of the predictions have come true. None of the predictions are any more likely than any other predictions.
 

But what about he tsunami caused by a super moon?
 

Supermoons have been proven to cause sea levels to rise as the gravitational pull of the Earth’s closest neighbour increases as it gets closer.[1]

 

That is not true.
 

The relative amount of influence is proportional to the object’s mass and distance from the earth.[2]

 

The difference in distance will be tiny.

Here is what the distance will be from our planet to the super moon.
 

Aug 10 5:46 PM         356,922 km         221,796 mi         Closest for this year [3]

 

And here is what the distance was for the full moon on January 1, 2014.
 

Jan 1 9:01 PM         356,945 km         221,811 mi [3]

 

Only 15 miles different.

There is one important thing to understand about a 15 mile difference in the distance between the moon and us. It is not something that humans can notice without machinery to measure the distance.
 

Jul 28 3:39 AM         406,547 km 252,634 mi         Farthest away this year [3]

 

That is a difference of 30,838 miles between the farthest and closest distances. That is a 12% difference. The difference between the 2nd closest full moon and the super moon is 15 miles.

15/221,811

Or 1 our of 14,787. If this is seen by some as prophetic, important, or ominous, it is because those describing the problem lack all sense of perspective.

Some people are claiming that this is important, because they have no idea what they are commenting on, or they are trying to profit from the gullibility of others, or . . . .

But the moon being this close is unprecedented!
 

Jan 30 8:59 AM         356,606 km         221,600 mi         Closest for this year[4]

 

That was the closest distance between the moon and the earth in 2010. 221,600 miles. Today’s end of the world distance – because it is so incredibly close – is 221,796 miles or 196 miles farther than it was in 2010. So much for unprecedented. So much for scary.

If you think that the minuscule difference in distance was enough to cause a disaster, you seem to have the same problem with perspective as the prophets of doom.
 

If this were indeed the case, we would expect to see a correlation between rate at which earthquakes occur and the perturbations to the gravitational field. The dominant perturbation in the earth’s gravitational field generates the semi-diurnal (12 hour) ocean and solid earth tides which are primarily caused by the moon (due to its proximity) and the sun (due to its large mass). No significant correlations have been identified between the rate of earthquake occurrence and the semi-diurnal tides when using large earthquake catalogs.[2]

 

No valid mechanism, no perspective, and no evidence?

The only thing useful out of this is as another example of frauds taking advantage of the vulnerable, but we have no shortage of examples of that. We don’t even have a shortage of people defending the frauds.

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Footnotes:

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[1] SUPERMOON LIVE: Beautiful lunar event could trigger ‘END OF DAYS’
By: Nathan Rao
Published: Sun, August 10, 2014
Sunday Express
Article

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[2] Can the position of the moon or planets affect seismicity?
Earthquake FAQ
Berkeley Seismological Laboratory Outreach Program
Article

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[3] Moon distances for UTC
timeanddate.com
Information page

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[4] Moon distances for UTC
timeanddate.com
Information page

.