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

- Rogue Medic

FDA takes steps to improve reliability of automated external defibrillators

Wed, 28 Jan 2015 12:15:06 -0500 by

 

Why improve the reliability of AEDs (Automated External Defibrillators)?

AEDs are important, much more important than the epinephrine I wrote about yesterday, because AEDs actually work – at least when the AEDs work as they are supposed to.

AEDs fail much more often than they should.
 

From January 2005 through September 2014, the FDA received approximately 72,000 medical device reports associated with the failure of these devices. Since 2005, manufacturers have conducted 111 recalls, affecting more than two million AEDs. The problems associated with many of these recalls and reports included design and manufacturing issues, such as inadequate control of components purchased from other suppliers.[1]

 

72,000 reports over ten years. In the US, there are about 300,00 cardiac arrests a year where treatment is considered and an AED might be applied. Out of those, how many times is an AED applied? 1/3?

If I use that ballpark number guess, then 72,000 out of 1,000,000 is 0.72%. The reporting of problems that are identified during equipment checks and maintenance should also decrease the rate of failure in the treatment of real patients. Maybe I decrease that guess at a failure rate during cardiac arrest treatment/assessment to 0.5% or 0.1%?

A decrease to 0.1% is one out of every 1,000 uses. Is that a tolerable level of failure for a device that has only two tasks, but has to remain ready to perform those tasks at all times? The two tasks are to differentiate between ventricular fibrillation/ventricular tachycardia and any other cardiac rhythm and to deliver a shock to the patient after ventricular fibrillation or ventricular tachycardia has been identified.
 


Image credit.
 

There are only a few moving parts and the designs may vary from what I describe. The wire that is manually attached to the defibrillator pads. The lids that is opened, turns on the AED, and triggers the voice prompts. The buttons that are pressed to turn on the AEDs not turned on by opening the lid, to analyze the rhythm, and to deliver the shock.

Would Do we accept a similar failure rate from an ambulance, which has many more moving parts?

Do we accept similar failure rates from our personal vehicles, which have many more moving parts?

Do we accept similar failure rates from aircraft, which has many more moving parts?

Yes and no.

We deal with the failures in these vehicles by building in redundancies and paying attention to maintenance, but the result is that the failures rarely cause death, or the lack of resuscitation that could have occurred with a properly functioning AED.
 

For example, NASA management claimed that they had an isty-bitsy teeny-weeny failure rate. They were shown to be wrong in a very dramatic, and deadly, fashion. Twice.
 

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

. . . .

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[2]

 

We need to understand what the actual failure rates are. We also need to work on the failure rate that comes from operator error.

The reason people are able to lie to us with statistics (statistics do not lie, but statistics can be used by liars) is that we choose to remain ignorant of the appropriate use of statistics. We ask to be lied to.
 

What is an acceptable failure rate? It isn’t zero, because a zero failure rate is a lie.

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Footnotes:

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[1] FDA takes steps to improve reliability of automated external defibrillators
January 28, 2015
Food and Drug Administration
FDA News Release

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[2] Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
by R. P. Feynman
Conclusions
NASA report

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Filed Under: AED, Critical Judgment, Defibrillation, FDA, Heresy

A Better Way to Locate the Closest AED

Thu, 09 Feb 2012 12:45:08 -0500 by
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In having to come up with games, or other methods of locating AED (Automated External Defibrillators), we are trying to solve a system design problem that might be as simple as an equipment design problem.

Maybe the answer is to put RFID (Radio Frequency IDentification) chips in each of the AEDs. Last night I was discussing this with Brandi Winemiller and she suggested that I write more about this.

RFID is usually short range, but the signal can be picked up at longer distances with the right equipment. Then it becomes a problem of where to place equipment to locate RFIDs or what type of mobile equipment to use and how to use it. RFID is easier to keep up to date than running the occasional contest.

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If people willing to do CPR are encouraged in CPR courses to download an application that helps to locate the closest AED, that would bring the information to the target audience. The information might be from the AED itself, or from the mapping application, or both. Maybe RFID is the wrong technology, but it is certainly worth considering.

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One application is AED4 US.

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CPR only requires compressions (CPR/ACLS guidelines admit this is true for bystander CPR, but fear prevents the admission that the same is true for EMS and hospital personnel), so we could use a lot of the course time to teach AED use. Since teaching continuous compressions and AED use does not require a lot of time, we could shorten the courses significantly.

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[youtube]MqyiwSszTXQ[/youtube]

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If the CPR course is shortened and simplified, then mobile CPR teaching might be a better way to bring the knowledge to the people who might use it. We need to get over our fascination with ventilation in cardiac arrest and the pit crew approach that is justified by the lack of understanding of the lack of benefit of ventilations.[1]

CPR can be nice and simple and be even more effective than when we complicate things, but we continue to keep our resuscitation rates down just to satisfy the people who don’t understand.

CPR is not about the instructors.

CPR is not about the students.

CPR is about the patients.

 

Hands-Only CPR

 

  • 1) Call 911

     

  • 2) Push hard and fast

     
     

  • 3) And use an AED

 

Resuscitation does not need to be more complicated than this.

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Footnotes:

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[1] Vinnie Jones’ hard and fast Hands-only CPR
Rogue Medic
Wed, 11 Jan 2012
Article

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Filed Under: ACLS, AED, Heresy

Would You Know Where to Find an AED If You Need One

Wed, 08 Feb 2012 17:00:49 -0500 by
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There is a contest in Philadelphia to map locations of all of the AEDs (Automated External Defibrillators) in the county –

 

$10,000 prize.

 

Who can map the most AEDs by March 13, 2012?

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The MyHeartMap Challenge, which will run until Mar. 13, aims to draw awareness to automatic external defibrillators in the Philadelphia county. Through a scavenger hunt open to the public, the contest offers monetary prizes to groups that can locate the most defibrillators — machines that release electric shocks to the heart to restore normal heart rhythms after cardiac arrest.[1]

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Ooh! Ooh! I found one!

Image credit.

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“This will be the first AED map in a U.S. city by the public that would be comprehensive for the public,” said Raina Merchant, co-director of MyHeartMap and an Emergency Medicine professor at the Medical School.[1]

The medical school? In Philadelphia? There are Temple, Einstein, Jefferson, Drexel/Hahnemann, PCOM (Philadelphia College of Osteopathic Medicine), and HUP (Hospital of the University of Pennsylvania). As I explain to people, when I am criticizing the almost epidemic lack of understanding of medicine – You can’t swing a Philadelphia lawyer without hitting a medical school, so how do they get away with such ignorance? There is not just one medical school. The people at this medical school may not consider the other medical schools to be real medical schools, but that is nonsense. I searched for Dr. Merchant and found that she is at HUP.

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“I ran up to a 50-year-old gentleman who had collapsed on the street and I assessed him, but he didn’t have a pulse,” he said. “A nurse helped me start CPR while I called for a defibrillator,” he added. But in spite of searching a big restaurant and CVS, they could not find an AED right away.[1]

One clue would be to look in places that have a lot of people working there – large office buildings are some of the best places. Nursing homes should have AEDs, but do not expect them to let you use their AED.

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“Starting at a local level, making the 911 services aware of where AEDs are is a good first step,” Merchant said.[1]

No. In Pennsylvania all ambulances are required to carry an AED or a manual defibrillator. Why would EMS need to know where an AED is? Did I mention that all ambulances must have at least an AED.

Just because EMS shows up does not mean that EMS will be smart enough to actually provide appropriate treatment. With all of the time we spend training on CPR (CardioPulmonary Resuscitation), we should be able to remember to start compressions and to quickly deliver a shock, but my off-duty experiences with cardiac arrest suggest otherwise.

I dealt with some basic EMT, who insisted that delivering a shock on moist ground is deadly. He was wrong then. He is still wrong. We moved the patient to a backboard made of plastic, which should have satisfied the fool, but he appears to have been more interested in demonstrating that He was in charge, than in patient care. Then the patient was moved to the ambulance and He came up with some other excuse for not shocking the patient. It might have been – I’m not doing anything until the medic shows up! Any basic EMT who ever uses this excuse to not treat a patient should be fired on the spot. This clown was not fired. He was in charge.[2]

Another off-duty cardiac arrest was almost as bad. The only difference is that the patient survived and had a good outcome, even though police and EMS did almost everything they could to avoid delivering a shock to the patient. I may tell about that another time.

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I hope that my anecdotal experiences are just a couple of unusually bad cases. I hope that most patients receive better care. At about a year ago, Kelly Grayson and Too Old To Work, Too Young To Retire had a similar call, but they had a much more professional response from EMS in New Jersey.[3]

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Footnotes:

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[1] Med School scavenger hunt hopes to spread awareness about cardiac arrest
The Daily Pennsylvanian
By David Britto
January 31, 2012, 11:12 pm
Article

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[2] Off Duty CPR in the Middle of the Road
Rogue Medic
Mon, 24 Mar 2008
Article

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[3] Blogger Save!
A Day in the Life of an Ambulance Driver
Mon, 24 Mar 2008
Article

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Filed Under: ACLS, AED, Heresy, Philadelphia

Charging the Defibrillator While Continuing Chest Compressions – Part II

Tue, 27 Dec 2011 06:30:48 -0500 by

ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

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Continuing, after a 6 month delay, a discussion of an EMS 12 Lead article from Part I. ACLS (Advanced Cardiac Life Support) recommends charging the defibrillator during compressions. This is no less of a recommendation than giving epinephrine. How many people ignore ACLS guidelines for compressions during charging, but claim that it is evil to disobey anything ACLS recommends on epinephrine, amiodarone, or ventilations?

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Analyses of VF waveform characteristics predictive of shock success have documented that the shorter the time interval between the last chest compression and shock delivery, the more likely the shock will be successful.141 A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success.142 [1]

Extra pauses in compressions add to the time without compressions.

If the medic/nurse/doctor using a manual defibrillator recognizes a shockable rhythm, why not provide compressions while charging the defibrillator?

Some people will say that this is dangerous.

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But if someone accidentally delivers a shock during compressions, people will be killed!

In a systematic review, Hoke et al. summarized 29 reports of accidental defibrillator discharges, of which only 15 occurred during resuscitation attempts.21 Symptoms included tingling sensations, discomfort, and minor burns, but no long term effects or major consequences were reported.[2]

Where are the dead bodies we hear so much about?

Where are the medics/nurses/doctors needing to be defibrillated back to life?

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There was only one incident where a shock was delivered while a rescuer was actively performing chest compressions. However, the compression transcript continued without any visible change to CPR administration, suggesting that the rescuer was unaffected by the event. Review of clinical records and audio transcripts revealed no evidence of inadvertent shocks to rescuers. In addition, there was no significant difference in the incidence of inappropriate shocks to patients associated with charging during compressions (20.0% vs 20.1%; p = 0.97). [2]

In this study, there was one case of a shock being delivered during compressions, but nobody seems to have been affected by this shock.

What happened to the automatic death that ACLS instructors spend so much time describing?

Where is the evidence?

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In the current study, charging during compressions decreased median pre-shock pause by over 10 s, which previous studies suggest could have a dramatic effect on clinical outcomes. We previously reported an almost two-fold increase in the chances of successful defibrillation for every 5 s reduction in the pre-shock pause.9 Similarly, Eftestøl et al. found that a 10 s hands-off period prior to defibrillation would roughly halve the probability of obtaining ROSC.6 [2]

The risk to rescuers appears to be minimal, but the possible benefit to patients may be dramatic.

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Click on image to make it larger.

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The difference in time without compressions is significant.

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Interestingly, we found that the most efficient technique with regard to minimizing pauses was not the AHA recommended method of pausing to analyze, resuming CPR to charge, and then pausing again to defibrillate. Rather, charging at the end of every 2 min CPR cycle in anticipation of a shockable rhythm and then pausing only once, briefly, to both analyze and either shock or disarm was associated with significantly shorter total pause duration in the 30 s preceding defibrillation. [2]

If we see asystole, we do not deliver a shock. We cancel the shock.

If we see PEA (Pulseless Electrical Activity, such as sinus rhythm, sinus tachycardia, sinus bradycardia, or any other non-shockable rhythm), we do not deliver a shock. We cancel the shock.

Cancelling the shock is not going to be the same for each defibrillator, but we do need to know how to cancel the shock for each machine we use. We can read the instructions.

How?

We can turn on the monitor, charge it up to the setting we would use to defibrillate, and try to figure out ways to get the charged defibrillator to turn the shock off. We should already know how to do this.

All that appears to be required is competence. Why is that so difficult?

Why do we keep making excuses for misbehavior?

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Footnotes:

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[1] CPR Before Defibrillation
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Rhythm-Based Management of Cardiac Arrest
Defibrillation Strategies
Free Full Text from Circulation with links to Free Full Text PDF

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[2] Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi-center study.
Edelson DP, Robertson-Dick BJ, Yuen TC, Eilevstjønn J, Walsh D, Bareis CJ, Vanden Hoek TL, Abella BS.
Resuscitation. 2010 Nov;81(11):1521-6.
PMID: 20807672 [PubMed – indexed for MEDLINE]

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Edelson, D., Robertson-Dick, B., Yuen, T., Eilevstjønn, J., Walsh, D., Bareis, C., Vanden Hoek, T., & Abella, B. (2010). Safety and efficacy of defibrillator charging during ongoing chest compressions: A multi-center study Resuscitation, 81 (11), 1521-1526 DOI: 10.1016/j.resuscitation.2010.07.014

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Filed Under: 2010 AHA Guidelines, AED, Defibrillation, EMS 12 Lead, Heresy, Mythology, Paramedicine 101, Research Blogging, Risk Management

Automated external defibrillators and survival after in-hospital cardiac arrest

Fri, 18 Nov 2011 06:30:41 -0500 by

ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

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Yesterday I described the problems with the recent article claiming that corruption was the reason the AHA (American Heart Association) recommended AEDs (Automated External Defibrillators) be placed in non-acute care parts of hospitals.[1] Today I will look at the study that seems to have inspired the article, even though it came out a year ago.

Does the research claim that there is any suspicion of corruption in the recommendation?

No. The corruption claims appear to be entirely due to the ideological bias of this conspiracy theory site.

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Although some studies have shown that AEDs improve survival for out-of-hospital cardiac arrests occurring in certain public locations in which 45% to 71% of cases are treatable with defibrillation,5​,6,7​ these devices may be less effective or potentially harmful when used in hospitals where only 1 in 5 hospitalized patients have initial cardiac arrest rhythms that respond to defibrillation.8 [2]

Is it wrong to look at the research and recommend that the AEDs be used in settings where a manual difibrillator is not available?

No.

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The difference between a manual defibrillator and an AED is that the AED will interpret the heart rhythm itself. The nurses and doctors do not need to be able to do this. This makes AEDs ideal for public places where non-medical people can use them to shock a patient out of a fatal heart rhythm. In those settings, AEDs probably save thousands of lives each year.

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With a manual defibrillator, there is much greater cost for equipment and for training to be able to identify shockable rhythms. In the hands of someone familiar with resuscitation a manual defibrillator can be used to deliver a shock with only a few seconds of interruption in compressions, while the AED requires almost a minute of interruption. The greatest problem with resuscitation may be interruptions in compressions.[3], [4]

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What were the results of the study?


Click on the images to make them larger.

The big benefit from an AED would be when a shockable rhythm is the cause of a cardiac arrest in a less than acute care setting. The nurses are not likely to be certified in ACLS (Advanced Cardiac Life Support). The doctors probably have not treated a cardiac arrest since their last ACLS class. There are no manual defibrillators in that part of the hospital.

While the use of AEDs would require longer interruptions of CPR for the AED to analyze the rhythm, one expectation would be that there would be a significant increase in successful resuscitations of patients with shockable rhythms. According to the data above, only about 1/5 of patients who had the AED applied actually had shockable rhythms ventricular fibrillation of pulseless ventricular tachycardia.

The patients were very well matched for everything that might predispose toward a survival advantage in either group.

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Even worse is that the anticipated significant increase in resuscitation of patients with shockable rhythms did not happen.

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The good news is that hospitals seem to be doing a great job of defibrillating patients quickly without the AEDs.

The median time to shock is 2 minutes. That is recognizing a pulseless, apneic, unresponsive patient, calling a code, beginning CPR, and getting the defibrillator to the patient, turning it on, and delivering shocks to appropriate patients.

The message from this study appears to be that the hospitals are not experiencing significant delays in delivering shocks without AEDs, so there is not likely to be any benefit from adding AEDs. The possible worsening of outcomes is probably due to complicating the response to resuscitation.

Hospitals are big buildings with a lot of people. Many of these people will experience cardiac arrest. Those are two of the things that suggest that AEDs would improve outcomes.

There is an important difference between hospitals and casinos, airports, and other buildings that showed dramatic increases in survival from cardiac arrest after the addition of AEDs and the training of staff in the use of AEDs.

I started out by asking, Is it wrong to look at the research and recommend that the AEDs be used in settings where a manual difibrillator is not available?

Hospitals already have plenty of manual defibrillators and staff trained to use the defibrillators. While there may be many ways to improve the responses in hospitals, the addition of AEDs does not appear to improve responses to cardiac arrest.

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Should the AHA have made this recommendation? The AHA too often goes from no recommendation to permanent part of the treatment guidelines without any transitional phases for assessment of benefits. Their reasoning is understandable. What if this is a treatment that will save thousands, or tens of thousands, of lives? Do we want to delay such a wonderful treatment. Part of me still expects to see the ACLS guidelines printed by Acme.

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As with second marriages, the AHA seems to continually expect optimism to triumph over experience. The AHA needs to be more cautious.

It is too easy to implement a plan and too difficult to reverse course. How many of the AHA guidelines worked out as planned? Are we really going to miss out on the next multi-thousand patient life saver? If we don’t play the lottery, are we giving up on a shot at millions? We need to put less emphasis on unproven interventions.

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In light of our data, national organizations and hospitals may need to reconsider the use of AEDs in general hospital ward units or develop different strategies for using them.[2]

Maybe hospitals should donate/sell their AEDs to places/organizations that are more likely to benefit from AEDs. Large buildings, EMS agencies, fire departments, police departments, et cetera.

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Footnotes:

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[1] Bad Shock – Automated Devices for Jolting Hearts May Save Fewer Lives in Hospitals
Rogue Medic
Article

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[2] Automated external defibrillators and survival after in-hospital cardiac arrest.
Chan PS, Krumholz HM, Spertus JA, Jones PG, Cram P, Berg RA, Peberdy MA, Nadkarni V, Mancini ME, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Investigators.
JAMA. 2010 Nov 17;304(19):2129-36. Epub 2010 Nov 15.
PMID: 21078809 [PubMed – indexed for MEDLINE]

Free Full Text from JAMA with links to Full Text PDF Download

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[3] 60 Year Old Male CC: Sudden Cardiac Arrest
EMS 12 Lead
Article

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[4] Charging the Defibrillator While Continuing Chest Compressions – Part I
Rogue Medic
Article

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Chan PS, Krumholz HM, Spertus JA, Jones PG, Cram P, Berg RA, Peberdy MA, Nadkarni V, Mancini ME, Nallamothu BK, & American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Investigators (2010). Automated external defibrillators and survival after in-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 304 (19), 2129-36 PMID: 21078809

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Filed Under: ACLS, AED, Heresy, Paramedicine 101, Research Blogging

Gravity and CPR

Wed, 02 Nov 2011 06:30:54 -0400 by
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This is meant purely as constructive criticism. I’ve worked a lot of codes. I’ve made a lot of mistakes. You may want to turn the volume down, or off. There does not appear to be anything but a hysterical family member to listen to.

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When CPR (CardioPulmonary Resuscitation) is in progress, we should try to make sure that the patient is as level as practical.

In this video, you can see how easy it is to get tunnel vision and ignore the much simpler ways of moving the patient. One person commenting suggested having the driver pull forward. This may work, but may also lead to communication problems with the driver and safety issues with the car sticking out into the street. The first police car does not appear to be blocking traffic, but with an unknown situation this may be department policy. Going back to move the police car would probably confuse the people on scene and lead to conflict.

The best place to move the patient is probably behind the car. The ground is level and firm and the area should be well protected from traffic, unless someone rear ends the first police car or someone steps out into traffic.

Dragging dead weight (this is what is meant by dead weight) up a hill, even a small one, is much more difficult than dragging them along level ground. If you don’t believe me, try it.

With the body in Reverse Trendelenburg position, the blood will pool in the lower extremities. The blood vessels have probably dilated due to lack of neurological control. Death will do that. The result is that chest compressions may not be any more effective than on a trauma arrest patient. We do CPR on trauma arrest patients just for appearances, not for any benefit to the patient.

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Reverse Trendelenburg position image credit.

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On level ground, there is also less of a problem with equipment rolling/sliding away.

Apparently, this was a successful resuscitation, but that does not mean that there is no room to improve. We harm our patients when we do not learn and improve from patient to patient. Too many people will try to imitate what they think worked the first time, even though they probably do not understand what worked. We tend to have good luck rituals, or good luck charms, because we do not understand what we are doing. The good luck here was that the police arrived quickly and began treatment.

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Filed Under: ACLS, AED, Heresy

The Myth of Response Times

Tue, 09 Aug 2011 06:30:47 -0400 by

In response to my post A Comment on Myths and the 2015 ACLS Cardiac Arrest Algorithm, which contains a quote from 2015 ACLS Cardiac Arrest Algorithm is an objection from Tom Bouthillet of EMS 12 Lead.

The response suggests that I got Tom’s ST segment a bit elevated, but that was not my intention. Goozfraba, Tom.

First, I should repeat my objectionable statement, since that is what Mr. M objected to as well. Mr. M’s objection was by reference to The Myth of the Golden Hour.

SSM (System Status Management) continues to burn out crews and vehicles, but some administrators continue to believe. Since they administrate in back offices, we do not know where their hands are. Improved response times? The difference in response times is insignificant and response times have never been shown to be important outside of cardiac arrest.

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Tom avoids incantations of The Myth of the Golden Hour, but his more eloquent wording amounts to essentially the same thing.

The Myth of Response Times.

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Image information at Wikipedia.

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No, Tim, the bizarre claim that response times are insignificant comes from non-fire based EMS and their desperate attempt to show that their inability to respond to emergencies in a timely manner is irrelevant.

Gosh, Tom, do you have anything to support that claim?

When did you become a spokesperson for the IAFF (International Association of Fire Fighters)?

Show me the fire based EMS research that provides support for The Myth of Response Times. Please.

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Craig D. Newgard, MD, MPH wrote –

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.18,19 Despite the paucity of outcome evidence supporting rapid out-of-hospital times for the broader population of patients activating the 911 system, EMS agencies in North America are generally held to strict standards about intervals, particularly the response interval.[1]

Tom, are you claiming that Dr. Newgard is a part of some sort of non-fire based EMS Illuminati?

Or is that non-fire based EMS, but desperate Illuminati?

Are strict standards good, if they are irrelevant and lead to promotion of myths?

Fire based EMS may be held to many strict standards, but that does not mean that these are in any way relevant to patient care just because they are strict standards. Standards Of Care are just the popular adoption of a temporarily appealing mythology.

We are discussing fashion, not function. Just like having your nail polish match your panties. I admit that I do not know how strict fire based EMS is on a standard for polish/pantie pairing. What if one if fire red, but the other is fire engine red? How strict is the standard? Lives are at stake. Think of the children. Tom, if you do not wear nail polish, does that mean that you go commando? Think of the children. Think of the strict standards based on our old friend wishful thinking.

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The problem is that third-service EMS can’t function without fire department first response but it’s become the monster that’s slipped its leash.

Really?

Systems that do not have fire department first response can’t function?

Based on what?

Why not have the police provide first response?

I have worked in places where the police do provide first response, so I know it can be done – and done well.

A police officer meets me on scene and provides a brief report on the patient’s condition, a list of medications, allergies, and history. The patient would already have oxygen, immobilization, or other BLS treatments initiated by the same police officer prior to my arrival. One officer in one police car.

Is this a continuation of that charming rivalry between fire and police that led to excessive deaths on 9/11/2001? When The Finest and The Bravest compete to be The Dumbest, we all lose.

When we let our dislike for the personality, or job category, or skin color, or gender, or politics, or sexual orientation, or religion, or native country, or anything else that is irrelevant to patient care affect how we work together, we need to abandon all claims at responsibility. We abandon credibility if we let the irrelevant dictate patient care.

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Why not have the post office provide first response?

Or we could train the public to provide Hands-Only Compressions. Without bystander chest compressions, most cardiac arrest response times are too long. And cardiac arrest is the only condition with evidence of benefit from quick response times.

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It really doesn’t matter anyway because it’s the taxpayers through their elected representatives who decide what kind of response times they’re willing to pay for,

You start out by claiming that fire based EMS is doing what is best for patient, but end up stating that this is just politics. We know that the public has no understanding of good patient care, so why pretend that the opinions of the public have anything to do with whether response times make a difference?

Yes, the public has been sold The Myth of Response Times.

The public used to believe that the world was flat. That did not make the world flat.

Why can’t you come up with some evidence that response times are relevant to outcomes?

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and if that doesn’t having milk shooting out your nose,

It’s a little early for milk.

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you know how I feel about the fun and games associated with response time reporting. It’s time for everyone to grow up and work together because it doesn’t matter what response times are reported.

And you know how I feel about the fun and games associated with promoting myths.

It’s time for everyone to grow up and work together, because myth-based EMS harms patients.

Myth-based EMS delays efficacious treatments.

Myth-based EMS encourages/sets strict standards for treatments that have no potential for benefit, but plenty of potential for harm.

Myth-based EMS encourages lowering our lowest common denominators even more than we already have in our delusional quest for faster response times.

What is your quest?

I seek the Holy Grail of universal fire based EMS.

What is your strict standard for response times?

7 minutes and 59 seconds in 90% of responses.

What is this based on?

Purely psychological manipulation of those who do not know any better.

Right. Off you go.

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What matters is whether or not patients live or die.

Other than for cardiac arrest, what does that have to do with response times?

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You can have excellent response times on paper and abysmal survival from sudden cardiac arrest. Clearly there’s more to EMS quality than how fast the meat wagon shows up. But insignificant? You need to ventilate your office my friend.

Then provide some evidence that, other than for cardiac arrest, response time is in any way significant.

As long as people keep claiming that response times are important, I will keep pointing out that this is just The Myth of Response Times.

We used to bleed patients to get rid of their bad humors.

Now, everybody knows how dangerous that is.

Except.

Back then, everybody knew that it was significant.

And it was significant, because if you bleed everyone, you will kill some people, but we didn’t know any better.

How is this myth any different from that myth.

Why are we still encouraging a belief in mythology?

 

More frantic ≠ better.

 

More rushed ≠ better.

 

More attention to the wrong details ≠ better.

 

Tom, you know better than to believe in magic response times.

–

Footnotes:

–

[1] Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort.
Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G; Resuscitation Outcomes Consortium Investigators.
Ann Emerg Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23.
PMID: 19783323 [PubMed – indexed for MEDLINE]

Free Full Text with link to Free Full Text PDF Download from PubMed Central

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Filed Under: ACLS, AED, Heresy, Mythology, Research

AEDs and Water

Mon, 31 Mar 2008 03:42:00 -0400 by
In an earlier post, Off Duty CPR in the Middle of the Road, I wrote about the perceived problem of moisture on the ground when shocking a patient. I do not recall what led me to post that now, but I have found some research on the topic. None of these studies found any problems with defibrillating wet patients. They found that the current delivered to the patient was adequate for defibrillation and that it was safe for rescuers to defibrillate the wet patient. Some of these were addressing the conditions that would affect defibrillation of a patient during therapeutic hypothermia with ice water and with saline. The one bit of advice was to dry the chest before applying pads, but that should be obvious. 🙂

Click on each study for it’s abstract. The one without an abstract is an editorial about the study below it.

Klock-Frézot JC, Ohley WJ, Schock RB, Cote M, Schofield L.
Successful defibrillation in water: a preliminary study.
Conf Proc IEEE Eng Med Biol Soc. 2006;1:4028-30.
PMID: 17945819 [PubMed – indexed for MEDLINE]

Only a small difference was measured in the overall defibrillation voltage and current as applied to the electrodes for the different cases. Thus, underwater defibrillation is safe and can be performed effectively.

de Vries W, Bierens JJ, Maas MW.
Moderate sea states do not influence the application of an AED in rigid inflatable boats.
Resuscitation. 2006 Aug;70(2):247-53. Epub 2006 Jun 27.
PMID: 16806638 [PubMed – indexed for MEDLINE]

Our study demonstrated that all the AEDs involved are robust enough to be used on RIBs (Rigid Inflatable Boats); none of them gave problems with monitoring or defibrillation,

Lyster T, Jorgenson D, Morgan C.
The safe use of automated external defibrillators in a wet environment.
Prehosp Emerg Care. 2003 Jul-Sep;7(3):307-11.
PMID: 12879378 [PubMed – indexed for MEDLINE]

CONCLUSIONS: Thirty volts may result in some minor sensation by the operator or bystander, but is considered unlikely to be hazardous under these circumstances. The maximum currents were lower than allowed by safety standards. Although defibrillation in a wet environment is not recommended practice, our simulation of a patient and a rescuer/bystander in a wet environment did not show significant risk should circumstances demand it.

Varon J.
Therapeutic hypothermia and the need for defibrillation: wet or dry?
Am J Emerg Med. 2007 May;25(4):479-80. No abstract available.
PMID: 17499671 [PubMed – indexed for MEDLINE]

Comments positively on the study below, from the same publication.

Schratter A, Weihs W, Holzer M, Janata A, Behringer W, Losert UM, Ohley WJ, Schock RB, Sterz F.
External cardiac defibrillation during wet-surface cooling in pigs.
Am J Emerg Med. 2007 May;25(4):420-4.
PMID: 17499660 [PubMed – indexed for MEDLINE]

Transthoracic defibrillation via AED pads is safe and effective in a wet condition after cooling with ice-cold water in a pig VF cardiac arrest model because ROSC could be achieved in all animals. Thus, this new cooling device needs further exploration in cases of cardiac arrest
in humans.

By Rogue Medic
Filed Under: AED, Common Sense, Defibrillation, Heresy, Research
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