We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

In Defense of No Improvement by Medic Madness – Part IV

ResearchBlogging.org
 

Continuing from Part I, Part II, and Part III in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -
 

Another issue I have with this data, is that it doesn’t address the following variables:

  • Down time
  • Whether or not bystander CPR was performed
  • Medications used
  • Whether or not an advanced airway was placed
  • Length of resuscitation

All of these things are important when looking at the effectiveness of the LUCAS. Had all of these cases been witnessed full-arrests with immediate intervention, then I might feel differently. Perhaps they did look at these things, but from the data that’s available to the general public, I can’t determine whether or not the LUCAS doesn’t “do any good”. From what we can see, at the very worst it keeps up with some of the best-trained responders out there. Not bad, if you ask me.[2]

 

Did you look at the paper?

Are you guessing at what the study shows based on intuition?

The information is there. This will be mostly a picture book response.

Down time?

Whether bystander CPR was performed?
 


Click on images to make them larger.[3]
 

Medications used?
 


Study design.[4]
 

In both groups, ventilation and drugs were given according to guidelines.16 [3]

 

There is no breakdown for medications.

Of course, medications have not been demonstrated to improve any outcome that matters.

The best way to determine this would be by –

Length of resuscitation or time to ROSC (Return Of Spontaneous Circulation).?
 


 

Whether an advanced airway was placed?
 


 

This may favor the LUCAS, since airways seem to interfere with survival.

Maybe manual compressions really are not the same during an intubation attempt. Maybe people back off on compressions. Therefore, maybe it is easier to intubate under those circumstances. We do not know. The LUCAS may make intubation more difficult.

Worse CPR may mean better intubation, but since intubation doesn’t improve anything, is that a good compromise?

Which is our no improvement device of choice? :oops:
 

Conclusion

We need to be looking at the whole picture here. If we can design a machine to do textbook-perfect CPR, and it doesn’t produce textbook results, then maybe we need to re-evaluate our textbook. Even if the studies do prove that the device isn’t improving survival rates, we still can’t discard the device as “worthless”. It has its place in situations with limited responders. And yes, the data supports that.[2]

 

Why assume that a textbook is right?

How often do I cite any textbook? The only textbook I regularly (and usually negatively) cite is ACLS.

Textbooks tend to be the last to change, but textbooks do change. The change is because research demonstrates that the textbook is wrong and needs to be revised. Textbooks are expected to be revised as we learn more from research.

When you suggest that the research does not confirm the biases of the textbook writers as evidence of a problem with the research, there is the possibility that you are right. This research may be providing evidence that the assumptions of the textbook writers are wrong. The way we find out is by looking closely at the quality of the research and looking at similar research.

However, LINC is good research.
 

Experimental studies with the mechanical chest compression device used in this study have shown improved organ perfusion pressures, enhanced cerebral blood flow, and higher end-tidal CO2 compared with manual CPR, with the latter also supported by clinical data.9- 11 [3]

 

Why is it that improving these surrogate endpoints does not improve what matters – survival? What do we not understand?

We should be more interested in doing no harm.

We seem to be more interested in throwing the kitchen sink at the patient, because what if the arrest is due to a kitchen sink deficiency?
 

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

Peter Canning describes the failures of judgment in advocating for the LUCAS in Whup Kits and Chihuahuas.

-

Footnotes:

-

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

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

-

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

-

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

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

-

[4] The study protocol for the LINC (LUCAS in cardiac arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation.
Rubertsson S, Silfverstolpe J, Rehn L, Nyman T, Lichtveld R, Boomars R, Bruins W, Ahlstedt B, Puggioli H, Lindgren E, Smekal D, Skoog G, Kastberg R, Lindblad A, Halliwell D, Box M, Arnwald F, Hardig BM, Chamberlain D, Herlitz J, Karlsten R.
Scand J Trauma Resusc Emerg Med. 2013 Jan 25;21:5. doi: 10.1186/1757-7241-21-5.
PMID: 23351178 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

-

Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, & Karlsten R (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311 (1), 53-61 PMID: 24240611

-

Rubertsson S, Silfverstolpe J, Rehn L, Nyman T, Lichtveld R, Boomars R, Bruins W, Ahlstedt B, Puggioli H, Lindgren E, Smekal D, Skoog G, Kastberg R, Lindblad A, Halliwell D, Box M, Arnwald F, Hardig BM, Chamberlain D, Herlitz J, & Karlsten R (2013). The study protocol for the LINC (LUCAS in cardiac arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scandinavian journal of trauma, resuscitation and emergency medicine, 21 PMID: 23351178
.

Creationism and the Politics of Ignoring Reality – Part 1

 

National Review Online has an odd apologist for Creationism claiming that without the secular left, Creationism would not be a problem.

Of course, he does not appear to think that Creationism is a problem, only that criticism of Creationism is a problem.
 


Image credit. Click on images to make them laerger.
 

No one thinks about creationism more than the secular Left.[1]

 

There is an outbreak of Ebola virus in Guinea.

While Creationists will tell us that since humans and monkeys are not related, they cannot have the same diseases. However, Ebola virus comes to humans from monkeys. Monkey DNA and human DNA are almost identical. We have small genetic differences that make a big difference in genetic expression, but these are terms that have to do with science and Creationism is about rejecting science that makes the Creationists uncomfortable about their beliefs in their Gods.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Ebola will probably not make it to the US, this time, but it is expanding its range. We cannot make Ebola go away with prayer. We need medicine, which is based on valid science. The fewer people we have who understand biology, the longer it will take to find effective treatments.
 

To be sure, a small number of Christians fiercely and zealously defend the young-earth position, but their influence is vastly overstated by secular journalists who need them more than the church does.[1]

 

Journalists are creating a push to teach Creationism religion in science classrooms?

Apparently, it is only a small number, when David French is defending something by trying to get people to ignore it.

Why is a political writer so opposed to keeping non-science out of science education?

Science is not easy to understand and he appears to be upset that this version of Cosmos seems to explain science as well as the last version. For example, the eye is commonly used as an example of irreducible complexity, the Creationist way of saying, I don’t understand, therefore it is impossible.

Neil deGrasse Tyson explains the evolution of the eye pretty well in about 8 minutes below (I apologize for the advertising) –
 


 

At every stage of its development, the evolving eye functioned well enough to provide a selective advantage for survival and among animals alive today, we find eyes at all these stages of development – and all of them function.

The complexity of the human eye poses no challenge to evolution by natural selection. In fact the eye, and all of biology, makes no sense without evolution.[2]

 

There are no gaps in the evolution of the eye. We can see the various degrees of evolution of the eye in different species, including species with much better eyesight than our eyesight. So why do we assume that the claims of evolutionary gaps, from people who do not understand evolution, are true?

Do we ask the person who has trouble with a paper airplane to explain the theory of flight?

Do we ask the person who does not understand gravity to explain relativity?

The failure of Creationism may not even be because scientists do a better job of explaining science, but because of the ethical failures of those trying to discredit science. I will explain in Part 2.

-

Footnotes:

-

[1] The Left’s Strange Obsession With Evangelical Creationism
By David French
April 1, 2014 2:19 PM
National Review Online
Article

-

[2] Some of the Things That Molecules Do
Cosmos: A Spacetime Odyssey
Season 1, Episode 2
Fox
28:48
Video at Hulu.com

.

New Kansas EMS policy limits use of backboards

 


 

No, this is not an April fools prank, just another example of reason and sanity prevailing over EMS dogma.

Another large region in Kansas has stopped using backboards to transport trauma patients. :D
 

The Wichita-Sedgwick County Emergency Medical Services System is no longer keeping patients on long spineboards when transporting them to the hospital, officials say.[1]

 

More people are realizing that manipulating patients onto boards does not protect patients from manipulation.

This is EMS, so dogma dies hard, but now that some EMS systems have pointed out that this EMS dogma is naked, it is just a matter of time until most of the country abandons this witchcraft.

We don’t quite have 150 years of tradition, unimpeded by progress, but we can eliminate tradition earlier than others.
 


Download YouTube Video | YouTube to MP3: Vixy
 

I do have a problem with one statement –
 

The change was prompted by scientific studies that showed most patients do not need the boards during transport, officials said.[1]

 

There is no evidence that any trauma patient needs a board during transport.
 

“The issue of backboards has become more prominent in the last couple of years,” said Sabina Braithwaite, EMS System medical director. “We found that ‘Wow, we don’t have anything that shows this helps people,’ and there’s more and more evidence that it hurts people potentially.”

“Realistically, when you break your neck and go into the hospital they don’t keep you on a board there either.”[1]

 

Exactly.
 
 

Agencies/EMS Systems Minimizing LSB use -
 

Let me know if I should add your agency to this list.
 

Alameda County
CA
 

Albuquerque-Bernalillo County Medical Control Board
NM
 

Bernalillo County Fire Department
NM
 

CentraCare Health
Monticello, MN
 

Connecticut, State of
CT
 

Durham County EMS
NC
 

Eagle County Ambulance District
CO
 

HealthEast Medical Transportation
St. Paul, MN
 

Johnson County EMS
KS
 

Kenosha Fire Department
Kenosha, WI
 

Maryland, State of
MD
 

MedicWest Ambulance
NV
 

Milwaukee EMS
WI
 

North Memorial Ambulance & Aircare
Minneapolis, MN
 

Rio Rancho Fire Department
NM
 

SERTAC (Southeast Regional Trauma Advisory Council)
WI
 

Wichita-Sedgwick County EMS System
KS
 

Xenia Fire Department
Xenia, OH
 

Outside of the US –
 

St. John Ambulance
New Zealand
 

Norway
 

QAS
Queensland, Australia
 
 

Here are some articles on the problems with backboards –
 

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

Free Full Text in PDF Download format from NAEMSP.
 

EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed - as supplied by publisher]
 

A re-conceptualisation of acute spinal care.
Hauswald M.
Emerg Med J. 2013 Sep;30(9):720-3. doi: 10.1136/emermed-2012-201847. Epub 2012 Sep 8.
PMID: 22962052 [PubMed - indexed for MEDLINE]

Free Full Text in PDF Download format from emsinternational.org
 

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

Free Full Text from Academic Emergency Medicine.
 

The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World
Article
 

For You Disciples of Spinal Immobilization…
… Bryan Bledsoe debunks your religion in the August issue of EMS World Magazine. And in that same issue, I take a dump on your altar. Our karma ran over your dogma.
August 1, 2013
by Kelly Grayson
A Day in the Life of an Ambulance Driver
Article
 

Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article
 

Board to Death – The state of prehospital spinal injury care in 2013
Rommie L. Duckworth, LP
Created: July 15, 2013
EMS World
Article
 

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

Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning
Article
 

Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World
Article
 

Plastic Snake Oil – EMS Spinal Immobilization
February 24, 2014
Life Under the lights
Article
 

Here is what I have written about other systems that do not require backboards for the transport of trauma patients –
 

More EMS Agencies Eliminating Backboards
 

Another System Eliminates Backboarding for Potential Spinal Injuries
 

The Slow, Agonizing Death of Conventional Spinal Immobilization
 

Stop the Madness! Reducing Unnecessary Spinal Immobilizations in the Field – Part I
 

The Lateral Trauma Position: What do we know about it and how do we use it
 

-

Footnotes:

-

[1] New Kan. EMS policy limits use of backboards – They will use backboards when moving patients to the ambulance, but then roll them onto a cot during transport to the hospital
EmailPrintCommentRSS
March 21, 2014
EMS1.com from The Wichita Eagle
By Kelsey Ryan
Article

.

In Defense of No Improvement by Medic Madness – Part III

ResearchBlogging.org
 

Continuing from Part I and Part II, in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -
 

So do these results reflect on a device that’s over-hyped, or are we missing something in our current CPR guidelines? Keep in mind that this study involved highly trained and prepared responders using the most up-to-date recommendations for CPR delivery. We developed a machine to do exactly what we tell it to. It follows the guidelines exactly as we want, and yet, it can’t produce the results we hoped for. Perhaps the machine isn’t the problem.[2]

 

Maybe the machine was never the answer.
 

In clinical practice, mechanical CPR using the presented algorithm did not result in improved effectiveness compared with manual CPR.[3]

 

This is probably just a reflection of how little we understand of what we are doing.

Everything we do in EMS, and especially in resuscitation, is over-hyped.

If our worry is that we will look like we are not doing enough, then open heart cardiac massage can make it clear that we are doing a lot.[4]   :shock:
 

Image credit.
 

How many survival studies do we have that randomize patients between a placebo and a vasopressor treatment?

For epinephrine (Adrenaline), vasopressin, norepinephrine (Levophed), or phenylephrine (Neo-Synephrine)?[5]

Here is the evidence of of what happens to survival with epinephrine.[6] I added the two most recent studies.[7],[8] There are no positive epinephrine studies.
 

 

Epinephrine may turn out to be beneficial for some subset of patients, but it is unlikely that epinephrine is beneficial just because the patient remains dead long enough to be given a drug.

A mnemonic for teaching ACLS is – Everybody dead gets epi, because current ACLS (Advanced Cardiac Life Support) guidelines tell us to give epinephrine (or norepinephrine, or vasopressin, or phenylephrine) to all patients who remain dead long enough to be given a drug.

Got a dead patient and can’t think of what to do next? Give epi.

What are we going to do, poison them? Our first dose was so far above the therapeutic range, that it would be considered poisonous if the patient were not already dead.

Vasopressors produce just as much no improvement as a LUCAS.
 

How many survival studies do we have that randomize patients between a placebo and an antiarrhythmic active treatment in cardiac arrest?

Foe amiodarone (Cordarone), lidocaine (Xylocaine), procainamide (Procaine), and magnesium?[9]

In two studies of magnesium, there was no improvement in survival vs. placebo.[10],[11]

In one study of amiodarone, there was improvement in everything except survival to discharge – more patients were resuscitated, but they died in the hospital.[12]

Antiarrhythmics produce just as much no improvement as a LUCAS.
 

There have been other studies of vasopressors and of antiarrhythmics against other unknowns, but does a positive outcome against a different unknown mean more beneficial than the other unknown or just less harmful than the other unknown?

We are aren’t even using Schrödinger’s treatments, because we don’t know if a good outcome means that the patient is surviving because of what we are doing or surviving in spite of what we are doing. We appear to be just happy to be doing something.

Still, we insist on giving these treatments, because we are afraid of doing too little.

We don’t know enough to know what too little is, but it is our fear of doing too little that keeps us from learning what works.

While this is not Sean’s fault, he is aggressively advocating for more of the status quo – the dramatic lack of improvement that we expect from EMS treatments.
 

The LUCAS failed – unless our idea of success is to make no difference in outcomes, because improving resuscitation outcomes is not really our goal.

EMS – we improve nothing more expensively, more dramatically, and more consistently than anyone else!
 

I look at the flawed claims of flaws in the paper in Part IV.

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

Peter Canning describes the failures of judgment in advocating for the LUCAS in Whup Kits and Chihuahuas.

-

Footnotes:

-

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

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

-

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

-

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

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

-

[4] A Resuscitation Question So Obvious That . . . .
Sun, 19 Jan 2014
Rogue Medic
Article

-

[5] Vasopressors
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Free Full Text from Circulation with link to PDF Download

-

[6] 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.

-

[7] 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.

-

[8] 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.

-

[9] Antiarrhythmics
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Free Full Text from Circulation with link to PDF Download

-

[10] Randomised trial of magnesium in in-hospital cardiac arrest. Duke Internal Medicine Housestaff.
Thel MC, Armstrong AL, McNulty SE, Califf RM, O’Connor CM.
Lancet. 1997 Nov 1;350(9087):1272-6.
PMID: 9357406 [PubMed - indexed for MEDLINE]

-

[11] Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting.
Allegra J, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, Yablonski M.
Resuscitation. 2001 Jun;49(3):245-9.
PMID: 11719117 [PubMed - indexed for MEDLINE]

-

[12] Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation.
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T.
N Engl J Med. 1999 Sep 16;341(12):871-8.
PMID: 10486418 [PubMed - indexed for MEDLINE]

Free Full Text from New England Journal of Medicine.

-

Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, & Karlsten R (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311 (1), 53-61 PMID: 24240611

-

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

-

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

-

Thel MC, Armstrong AL, McNulty SE, Califf RM, & O’Connor CM (1997). Randomised trial of magnesium in in-hospital cardiac arrest. Duke Internal Medicine Housestaff. Lancet, 350 (9087), 1272-6 PMID: 9357406

-

Allegra J, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, & Yablonski M (2001). Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting. Resuscitation, 49 (3), 245-9 PMID: 11719117

-

Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, & Walsh T (1999). Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. The New England journal of medicine, 341 (12), 871-8 PMID: 10486418

.

$16M on EMS Stroke Trial? Dr. Rick Bukata Wants His Money Back!


 

FAST-MAG[1] actually has good methodology, so why is Dr. Rick Bukata so upset? Is this just USC vs. UCLA off the field/court?

Should the hypothesis being tested have received the Queen for a Decade treatment?

He wants his money back? Roughly 160 million tax payers in the US, so $0.10 per tax payer, but he makes more than the average schlub, so maybe as much as 50 cents for him. He can’t even buy enough caffeine to raise his blood pressure with that.
 

In a commentary regarding the IMAGES trial by Larry Goldstein of the Duke Center for Cerebrovascular Disease in the same issue of the Lancet in which the study was published, he noted that of more than 40 clinical trials of “neuroprotectants” involving over 11,000 patients, none has shown any evidence of benefit. Ten years later, the same is true.[2]

 

But look at the animal studies!

But look at the time being saved!

The authors actually like to repeat the term Golden Hour – as if that is new or valid.
 

So, if you are still a believer in the potential of magnesium, why not try and give magnesium in a pilot clinical study involving stroke patients in the ED? It would have been a relatively simple study to do. It could have been performed in selected EDs throughout the country and the answer would have been established in a fraction of eight years and at a very small fraction of $16 million.

Instead, the Fast-Mag investigators decide that giving magnesium in the field (probably about 10-20 minutes faster than could be given in the ED) would be a reasonable study.[2]

 

Gosh, when he brings reason into the argument, it just seems that the other side has none.

What could the money have been spent on?

Epinephrine vs. placebo in cardiac arrest? The number of lives affected is large and we are currently treating based on philosophy, not science.

IV (IntraVenous) bolus NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) vs. SL (SubLingual) NTG for acute CHF (Congestive Heart Failure)? This affects even more patients than cardiac arrest and there is good evidence that IV bolus NTG dramatically improves outcomes, while SL NTG is not based on evidence.

Excited delirium treatment with various IM (IntraMuscular) medications to see what is safest and most effective and at what dose. A large trial would be necessary.

With no good reason to be optimistic about outcomes, why take this multimillion dollar long shot?

Maybe it has to do with tPA (tissue Plasminogen Activator) and the failure to get emergency physicians to accept the poor research on tPA – tPA showed harm, or no benefit, in 9 out of 11 studies.[3]

Ironically, if those studies used methodology similar to this study, that could be showed harm, or no benefit, in 11 out of 11 studies.

Dr. Jeffrey L. Saver, one of the authors, has a presentation on FAST-MAG that spends a lot of time on tPA, even prehospital tPA.

What does Dr. Sarver consider to be positive about FAST-MAG? Here are some of his slides.[4]
 


 

FAST-MAG means more tPA use.
 


 

FAST-MAG means doing a lot of things that have not been done before and expecting the outcome to be good.

This is the kind of person who starts turning all of the dials on a ventilator and then looks at the patient to see what the result is.

A reasonable approach to research is to limit variables, not brag about how much prudence has been abandoned.
 


 

FAST-MAG means time will be saved, but . . . .
 

Walter Koroshetz, MD, neurologist and deputy director of the National Institutes of Health’s (NIH’s) National Institute of Neurological Disorders and Stroke, sponsor of the FAST-MAG study, says that lessons can be learned from the trial.[5]

 

“The NIH have a new network to do more prehospital trials, but we need phase 2 studies first that demonstrate some biological effect before going into a large costly phase 3 trials.”[5]

 

This is a $16 million bet that time is the only factor that matters.

I hope these doctors do not drive the way they gamble.

What were the results?

The results were the same as all of the previous studies of magnesium – no improvement.

There is no Magnesium Golden Hour.
 

And, please, no – don’t even consider the idea of giving tPA in the field.[2]

 

Well, . . . .
 

Dr. Saver explained that tPA cannot be given at present in a prehospital setting because hemorrhagic stroke has to be ruled out with computed tomography (CT). The use of ambulances with a CT scanner on board has been studied in Germany and is now starting to be tested in the United States.[5]

 

Be very afraid.

On the other hand, the authors did not rush this treatment into EMS protocols, as we recently have in EMS in so many places with therapeutic hypothermia, based entirely on research done in the ED (Emergency Department). It works in the ED, but not in the ambulance. :oops:

FAST-MAG was approved in 1999, several years after the EMS nifedipine (Procardia) for hypertensive crisis crisis. There was no study in the EMS setting of a treatment for the EMS setting. This involved treatment of the surrogate endpoint of blood pressure numbers, which makes for an easy win, such as a systolic drop of 250 -> 90 in ten minutes. :oops:

We need a balance between rushing to add the new cool treatment (and the predictable removal of the treatment decades later) and the inappropriate rush to a large scale trial of something that has repeatedly failed smaller studies.
 

Go read Dr. Bukata’s full article.

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Footnotes:

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[1] Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 2 – prehospital study methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):220-5. doi: 10.1111/ijs.12242.
PMID: 24444117 [PubMed - in process]

Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 1 – rationale and general methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):215-9. doi: 10.1111/ijs.12243. Epub 2014 Jan 13.
PMID: 24444116 [PubMed - in process]

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[2] $16M on EMS Stroke Trial? I Want My Money Back!
by Rick Bukata, MD
March 24, 2014
Emergency Physicians monthly
Article

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[3] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

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[4] Treat Stroke in the Field:
Lessons from the NIH FAST-MAG Trial

Jeffrey L. Saver, MD, Professor of Neurology
UCLA Stroke Center
2012
Presentation Slides in PDF Downoad format.

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[5] FAST-MAG: No Benefit of Prehospital Magnesium in Stroke
Sue Hughes
February 14, 2014
Medscape
Article

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Valsalva the SVT or Shock the Monkey?


 

The Skeptics’ Guide to Emergency Medicine should be on your podcast list. The podcasts are short, so there is not much reason to avoid them. This one is 13 minutes.

Valsalva for SVT (SupraVentricular Tachycardia) is supposed to come before medication. At least that is the order of treatments of every EMS SVT protocol I have seen. Since medicine is expected to have more, and more serious, side effects, this is reasonable.

What medicines?

Adenosine has the side effects of -
 

Cardiovascular

Prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes

Respiratory

Bronchospasm

Central Nervous System

Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness.[1]

 

It appears to be reasonable to try to avoid those side effects.

Too much of this could become more of a problem than an SVT.
 


Click on images to make them larger. Image credit.[2] This is not the actual strip, but a strip of an adenosine pause edited to produce more asystole, which I have seen.
 

The side effect becomes much more of a problem when someone decides to treat the side effect, rather than wait for it to wear off.

We SLAM adenosine in because it wears off quickly. A minute, or two, of asystole is not a problem.

Giving a dose of epinephrine to a patient who had an SVT a minute ago and now has adenosine quickly wearing off – that may be a fatal problem.

But how effective is the Valsalva maneuver (VM)?
 

The VM is a non-invasive way to convert patients from SVT to sinus.It increases myocardial refractory period by increasing intrathoracic pressure thus stimulating baroreceptors in the aortic arch and carotid bodies Increases vagal tone (parasympathetic).[3]

 

Here is a big problem with the use of the Valsalva maneuver. It is just one method of attempting to stimulate the vagus nerve.

There are many other methods and they may be more successful. Carotid sinus massage (after auscultation for bruits), facial immersion in ice water (assuring that the airway does not become a problem), bearing down, blowing through a straw (even better may be a swizzle stick), digital circumferential sweep of the anus, coughing, . . . .

There are many ways of activating the vagal nerve, but my favorite is to act as if I have not started an IV before, go very s l o w l y with the insertion of the largest IV catheter I think I can get in the vein, and this has almost always broken the rhythm.

Yes, that is anecdotal, but I have only rarely needed to follow that with medication.

Yes, pain is not a nice thing, but it is much nicer than the side effects listed above.
 

Bottom Line: There is no standardized methods to perform a VM to terminate uncomplicated SVT that are evidence based.

Clinical Application: VM is a viable technique that is poorly researched for the conversion of SVT and should not be considered essential to attempt prior to chemical cardioversion.[2]

 

We need better vagal maneuvers.

We need good evidence on what works.
 

Go read the article and listen to the podcast.
 

-

Footnotes:

-

[1] ADENOCARD (adenosine) solution
[Astellas Pharma US, Inc.]

DailyMed
FDA Label

-

[2] Atrioventricular Re-entrant Tachycardia
Thumbnail Guide to Congenital Heart Disease
edited version of their adenosine ECG strip
Article

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[3] SGEM#67: Shock the Monkey Tonight (Valsalva Maneuver for SVT)
Podcast Link: SGEM67
Date: March 23, 2014
Skeptics’ Guide to Emergency Medicine
Article and link to podcast

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Drunk? or Auto vs. Pedestrian With Major Injuries?

 

Sometimes we miss things that we are expected to miss, such as an atypical presentation of an uncommon condition.

Other times we miss something that even a rookie should not miss.
 

A paramedic has been suspended for a year after he mistook as drunk a man who had in fact been victim of a hit-and-run, suffering a broken back and 12 broken ribs.[1]

 

Suspended for a year is a serious punishment, right?

Maybe not if the medic is retiring anyway – after 30 years on the job.

How does someone with 30 years of experience miss those injuries?
 

A passerby found Mr Wonnacott at 4am on November 20, 2011, and the paramedic failed to establish any of his injuries and made him walk into the ambulance.

While en route to hospital, Mr Gaiger called Mr Wonnacott’s parents and said he was “absolutely plastered” and it was only on arrival to the hospital that his injuries were discovered.[1]

 


Image credit.
 

4 AM on a Sunday morning is a time when we expect to see a higher percentage of drunks.

I have missed things on scene, only to identify them during transport, and I have continued to miss things during transport, but, . . .

Maybe if there were only 11 rib fractures, it would be understandable.

Maybe if it were only 2 vertebrae.

Maybe if both the liver and the spleen hadn’t been lacerated.

Maybe if there hadn’t been a pneumothorax.

Maybe these injuries were actually quite subtle.
 

David Rosenbaum was just another drunk in Washington, DC.[2]

Except that he wasn’t drunk. He had a head injury and died before anyone realized that he was not drunk.
 

“This is not a witch hunt. I just don’t want another family or patient to go through what we have been made to go through as a result of Mr Gaiger’s actions.”[1]

 

The Rosenbaum family said the same thing.

We don’t want money. We want to fix the system so that this does not happen again.

Did anything really change at DC Fire and EMS?

Will anything really change at South East Coast Ambulance Service?

This is a medic they have employed for 30 years. Was this the first time something like this happened? Was this the first time that the news media became aware of the problem? Was he burned out after 30 years? Was he having a horrible day – although a day infinitely better than his patient was having? Out of sight, due to retirement, out of mind? The articles have not been very helpful.

Maybe Mr Wonnacott was gently run over, by someone who really was drunk, and suffered a brain injury that made him appear to be drunk, and only the hospital people could identify the multiple fractures and brain injury.

Maybe, but maybe we should discourage people from concluding a patient is just a drunk, or that the epigastic pressure is just indigestion, or that the hyperventilation of the young female is just hysteria, or . . . .

Hmmmm. Those are things I learned in my original paramedic class that have not changed.

-

Footnotes:

-

[1] Chessington paramedic suspended for a year after treating seriously Esher injured man as though he were drunk
By Laura Proto
6:10am Thursday 20th March 2014
Elmbridge Guardian
Article

-

[2] The Death of David Rosenbaum
By Colbert I. King
Saturday, February 25, 2006
Washington Post
Article

.

Mounting Evidence Against the Long Spine Board in EMS – A Must Watch Video

 

Dr. Ryan Jacobsen explains that I have been using the wrong terminology for this piece of equipment. This is a picture of my padded spine board.

In this excellent video, he describes why and explains the problems with the use of backboards and the absence of any valid evidence to justify the use of backboards for transport.
 


 

The video is one hour and twenty-two minutes, so get comfortable, get some caffeine, and get ready to smile and learn.

And share this video.

There are currently only 188 views of the video. There need to be hundreds of thousands.

If you teach EMS, play this for your students, or just give them the link.
 


Download YouTube Video | YouTube to MP3: Vixy
 

What is the basis for the backboard?

Let’s blame the people who touched the patient first, because EMS will go along with that.
 

Mounting Evidence Against the Long Spine Board in EMS
Ryan C. Jacobsen, MD, EMT-P
Johnson County EMS System Medical Director
Assistant Professor of Emergency Medicine
Truman Medical Center/Children’s Mercy Hospital and Clinics
YouTube page
 

Thank you to Bill Toon, PhD for the link, for obtaining permission from Dr. Jacobsen to share this, and thank you to Dr. Jacobsen for making the video.

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