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

- Rogue Medic

Have a Slow, Quiet Friday the Thirteenth

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

 

Superstitious appears to be common among medical people, so this may be seen as offensive. If you doubt me, comment that it is slow or quiet and see how many respond negatively, while they do not receive any criticism for their superstition-based complaints. Rather, people will make excuses for coddling the superstitions of those who are entrusted with the lives of patients.

The evidence does not support their superstitions.

One study did appear to show that women die in motor vehicle collisions more often on Friday the 13th, but that appears to be due to a lack of understanding of statistics by many who cite the article.
 

An additional factor is anxiolytic medication, used by significantly more women than men in Finland (7), which has been reported to reduce attention span and worsen driving performance (8). . . . Why this phenomenon exists in women but not in men remains unknown, but perhaps the twice-as-high prevalence of neurotic disorders and anxiety symptoms in women (7) makes them more susceptible to superstition and worsening of driving performance.[1]

 

The author suspects that those people with conditions that could be diagnosed as neuroses or anxiety disorders may be disproportionately affected by superstition.

In other words, superstition is not an external force affecting you. You are doing it to yourself.

The sample size was national, but still small, and was not able to adjust for many possible confounding variables, so the study would need to be replicated using a much larger data base to be useful.

In other superstition news – the next apocalypse, in a long line of predicted apocalypses, is going to be this Sunday – the 15 of October, 2017, according to David Meade. Meade twice previously predicted that a magical planet would hit the Earth and kill us all. This time he claims that his calculations are accurate, because that was the problem with his previous calculations – inaccuracy, not that they were a superstition deserving of derision.

If you are superstitious, and feel that your neuroses/anxieties will cause you to harm others, or yourself, you may want to stay home today and Sunday – perhaps even until you are capable of grasping reality.

Of course, we would never base treatment on superstition in medicine.

Amiodarone is the go to antiarrhythmic drug for cardiac arrest and ventricular tachycardia, but there are much safer much more effective drugs available. We have our own prophets misrepresenting research results to make it seem that using amiodarone for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[2],[3]

Ventilation during cardiac arrest has been shown to be a good idea only for patients who arrested for respiratory reasons. We do a great job of identifying these patients. We have our own prophets misrepresenting research results to make it seem that providing ventilations for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[4]

Medicine is full of superstition and superstitious people.

Why?

Too many of us believe the lie that, I’ve seen it work.

I have also written about the superstition of Friday the 13th here –

Acute coronary syndrome on Friday the 13th: a case for re-organising services? – Fri, 13 Jan 2017

The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

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

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

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

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

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

Happy Equinox! – Thu, 20 Mar 2008

Footnotes:

[1] Traffic deaths and superstition on Friday the 13th.
Näyhä S.
Am J Psychiatry. 2002 Dec;159(12):2110-1.
PMID: 12450968

Free Full Text from Am J Psychiatry.

[2] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

There are a dozen links to the research in the footnotes to that article. There are also links to other articles on the failure of amiodarone to live up to its hype.

[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[4] Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
Fri, 09 Dec 2011
Rogue Medic
Article

.

Being Fooled By Appearances

In EMS, we are sometimes quick to draw conclusions about what we are dealing with. This is not entirely our fault. Medical directors have frequently required that we get all of that assessment stuff out of the way quickly, so that we can call on line medical command to go through the Mother May I? routine.

Is this any way to encourage a thorough assessment?

Of course not.

We frequently end up making this call in front of the patient, so we have to balance making statements that may upset the patient with upsetting the doctor by presenting a vague, or incomplete, picture.

A recipe for failure?

Absolutely.

Quick impressions are often wrong, or overly simplistic, but that is what the people behind on line medical command permission requirements insist on.


Image credit.

I find it amusing that a mortgage company is using these commercials that point out the ways that we can leap to completely wrong conclusions.

[youtube]QOixDP-SdKw[/youtube]

And since it is the day when a lot of people defile weak beer with green food dye, an optical illusion of a four-leaf clover is appropriate.


Image credit.

Why do national celebration days end up as drinking holidays, rather than demonstrations of the qualities of the nationalities?

though I am native here
And to the manner born, it is a custom
More honor’d in the breach than the observance,

Hamlet Act 1, scene 4,
explanatory notes from eNotes.com

The on line medical command Mother May I? recklessness and the drunken revelry as national pride are both pathetic.

These are traditions that are dishonorable when not broken.

Don’t get in trouble for not calling command when it is required, but feel free to point out the foolishness of this practice. There is no evidence of any benefit from on line medical command Mother May I? requirements. These requirements only encourage medical directors to authorize dangerous medics to work as medics.

A magic phone call does not transform a dangerous medic into a safe medic.

On line medical command permission requirements only provide the appearance of oversight, but without any of the substance of oversight. We need to stop pretending that medical directors are doing anything other than fooling themselves with appearances.

.

Mysterious Tics in Teen Girls – What Is Mass Psychogenic Illness – Part I

How should EMS handle something like this?

Last fall, when a dozen teenage girls in a single upstate New York high school developed a condition that looked like Tourette’s syndrome — complete with sudden verbal outbursts, uncontrollable arm motions and facial tics — it seemed likely that a chemical toxin or infectious agent was to blame. But none could be found.[1]

Lights and sirens?

Activated charcoal?

Ipecac?

Naloxone (Narcan)?

Flumazenil (Romazicon)?

Sodium Bicarbonate?

Coma cocktail?

I have had calls like this. My handling has been a thorough assessment (usually in the presence of parents, because they often seem to be called before 911 is called), perhaps cardiac monitoring (depending on the assessment), and a nice calm transport of all patients to the same hospital (in case there is a connection in the origin of the symptoms – chemical exposure, drug ingestion, food poisoning, whatever).

How did things work out in the case being covered by the media? There is no mention of EMS response or treatment, so I don’t know.

doctors have already diagnosed most of the girls with a disorder: mass psychogenic illness — otherwise known as conversion disorder or, to use an outmoded term, mass hysteria.[1]

We act surprised when our minds do not do what we trust them to do – tell us what is real. When our minds mislead us, we don’t believe it, but this is not uncommon.

Which line is longer?


Image credit.

This is the Müller-lyer Illusion. Measure the lines. Print them out if you need to. There is truth and then there is what our minds tell us.

Magicians use our constant distortion of reality to convince us that they are defying the laws of physics. Magic is just deception. Fortunately, most magicians will tell us that they are deceiving us, although they probably won’t tell us how they are deceiving us.

I saw it with my own eyes, so it must be true.

That is a lie. If a con man wants to find an easy mark, anybody who believes that is extremely gullible. The rest of us can be deceived too, but not as easily as someone who thinks that everything they see is real. The job is already mostly done. All the con man has to do is ask the believer for the money.

The medical version for treatments we believe in is –

I’ve seen it work! [2]

Hysteria is the most retrograde and non-womyn-empowering condition. It’s not supposed to happen anymore (we have Title IX!), but it won’t seem to go away. Both history and myth are filled with stories of girls exhibiting bizarre symptoms around the time of puberty — from Cassandra and her raving, to the girls of the Salem witch trials, to the girls whose households were believed to be the site of poltergeist hauntings, to cheerleaders in New York and North Carolina. Pubescent girls, it seems, are manifestly more likely to exhibit extreme and bizarre psychological symptoms than are teenage boys.[3]

The condition may sound unlikely, but it is real, and it has in the past caused significant problems for emergency services.[1]

To be continued in Part II.

Footnotes:

[1] Mysterious Tics in Teen Girls: What Is Mass Psychogenic Illness?
Time – Healthland
By Maia Szalavitz
January 31, 2012Article

[2] I’ve Seen It Work and Other Lies
Rogue Medic
Tue, 21 Jun 2011
Article

[3] Hysteria and the Teenage Girl
NY Times
Opinion
By Caitlin Flanagan
Published: January 28, 2012
Article

.

Intubation Education

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation – JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.

We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.

We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can’t intubate competently.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Perhaps you do not believe that we do a poor job at intubation education.

Results

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

Conclusions

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.[2]

Those numbers may be considered good in many areas – batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.

These failure rates are unacceptably high.

Overall intubation success was low, and consistent with previously published series.

In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.

Can anyone show that this is not true?

The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.

This is the expected result of the way we train paramedics to intubate.

Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

5.2% had a malpositioned tube on arrival to the ED.

5.2% Unrecognized Esophageal Intubations!

Ongoing monitoring Watching is not enough.

We need to dramatically change the way we handle intubation education.

Footnotes:

[1] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article

[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]

.

Experts Debate Paramedic Intubation – JEMS.com

In JEMS, there is an article by almost all of the top people in EMS airway management. There are several omitted, who contribute to the understanding of airway management, such as Richard Levitan, MD[1] and Kelly Grayson, CCEMT-P.[2] This is not that much of a criticism, since the people they included are definitely among the top airway management experts.

The article points out some of the problems we have in teaching paramedics/nurses/doctors to use critical judgment. We do a very poor job of educating people to make good decisions. Then we conclude that our failure means that the alternative is rigid protocols – even for doctors.

That is just another example of bad judgment.

What is wrong with the following paragraphs?

An EMT listens over the chest and abdomen with a stethoscope. He says he hears breath sounds over the chest but doesn’t say anything about the presence or absence of breath sounds over the abdomen. An ECG monitor with capnography is attached to the patient. The EMT operating the monitor is unsure how to set the device to measure waveform capnography.

Approximately a minute later, the EMT states, “There’s something wrong with the monitor.” The paramedic quickly checks the monitor and re-checks placement of the ET tube. He says, “Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.” The patient is then moved to the ambulance and transported to St. Joseph Hospital with mechanical ventilation continued.[3]

When the monitor does not produce a waveform, or confirm what the EMT expected to see, the conclusion is that There’s something wrong with the monitor.

This is bad, because the EMT is already deciding where the problem is. He has made a statement that he will probably feel the need to defend later on. He doesn’t even appear to be considering operator error.

As the patient becomes less stable, the operator error rate increases.

The EMT operating the monitor is unsure how to set the device to measure waveform capnography. Still, he concludes, not that he doesn’t know what he is doing, but that the equipment is wrong.

I’m not the problem! The equipment I don’t understand is the problem!

Not to worry. We still have a paramedic, trained in the use of waveform capnography and drilled in intubation until he talks about it in his sleep. Sorry. Paramedic programs do not seem to drill paramedics on intubation that much, nor do employers, EMS systems, or even medical directors. Intubation is just not taken seriously. Tube placement confirmation and waveform capnography are taken even less seriously

Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.

This is the motto of a serial killer.

It is only a matter of time until someone, who thinks like this, kills and kills again.

Who taught this guy to think like this?

Who hired him to think like this?

What EMS system licensed him to think like this?

What medical director authorized him use this kind of thinking to go out and kill patients?

His paramedic instructor from the local community college is subpoenaed and, during his deposition, reports that it was very difficult for his students to gain access to local hospitals to practice intubation, explaining that students simply learned the procedure on manikins.[3]

So what?

You can learn to intubate competently on mannequins.

You do not need real live dead people to learn to use critical judgment.

The lack of human intubation practice is a pathetic excuse for poor education.

Would this medic have made a better decision about the obvious lack of waveform during his intubation attempt if he had practiced on dozens of live patients?

No.

The education he received does not appear to have included thorough coverage of tube placement confirmation. And that is not even the most important part of intubation.

We spend too much time worrying about intubation, when the real issue is airway management. This medic does not understand airway management – not even a little bit.

This is a systemic problem.

This lack of understanding of airway management begins in EMT/paramedic school, continues with employers, is certified by EMS systems, and is given the Dominus vobiscum of the medical directors.

Then the medic has his license to kill. The question is, Why is anyone surprised when the medic does kill?

We all seem to believe that this series of failures – school to employer to EMS system to medical director – works.

How many people are killed by this misunderstanding?

How many people are killed by this ignorance?

Am I being too harsh on these failures?

No.

Am I going too easy on the medic?

Calling him a serial killer is not exactly killing him with kindness. This is similar to Murder on the Orient Express. There are plenty of fingerprints on the murder weapon. There is plenty of guilt to go around.

Marc Eckstein, MD, MPH, FACEP, EMT-P: The take-home point here is that we need prehospital research that involves prospective randomized controlled trials (RCTs) with meaningful outcome variables, which are decreased morbidity and mortality.[3]

Essential to the study of intubation and airway management is that the researchers control for the quality of the paramedics.

We need to stop looking at intubation as something that is not affected by the quality of the people attempting intubation.

Dr. Eckstein: These alternative airway devices, particularly the King airway, can be placed quickly, and they provide good oxygenation and ventilation. However, they don’t protect against aspiration, which of course is a major concern with emergency airway management, especially in the field.[3]

I disagree about the major concern of aspiration.

Where is the research to support this?

In the studies comparing intubation with basic BVM use, where is the flood of emesis worsening outcomes?

I think that intubation protecting against aspiration is mostly just another EMS myth.

William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them.[3]

If you have heard Gene (William E. Gandy) talk about airway management, you have heard this over and over.

You may get tired of hearing that airway management is about ventilation, not intubation or oxygenation. If that is the case, then you really do not understand airway management.

If you do not understand airway management, then you do not understand intubation.

Footnotes:

[1] Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
Levitan RM, Kinkle WC, Levin WJ, Everett WW.
Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.
PMID: 16713784 [PubMed – indexed for MEDLINE]

Free Full Text Free PDF

[2] The Airway Continuum
The Ambulance Driver’s Perspective
by Kelly Grayson
ems1.com
Article

[3] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article

.

2009’s Top Threat To Science In Medicine

ResearchBlogging.org













Science-Based Medicine, has a post by Dr. Val Jones – 2009’s Top 5 Threats To Science In Medicine.

I do not disagree with the list except, and what would one of my posts be without an except, the number one threat to science in medicine is much more of a problem. Our science education in grade school is where we fail our children. Before they even become adults, they are exposed to all sorts of magical thinking.

Full moons, speaking about something bad increasing the chances it will occur (a jinx), believing that something natural is safer than something manufactured – just because it is not man made, or just a belief in the stereotypical mad scientist bringing about horrors by using the scientific method of inquiry.

That is what science is. Science is a method of inquiry. Science is a tool we use to find out how the world works.

We see something that makes us think. Most people may form an opinion, but not look at this with a method designed to minimize the effect of our biases. And we all have biases.

It seems that there are more patients during a full moon. With a full moon falling at 19:15 GMT (Greenwich Mean Time) this past New Years Eve, this must have been a horrible night of death and destruction. Or was it?

We formulate a hypothesis.

The full moon causes accidents and/or illnesses, or makes accidents and/or illnesses even worse than they would be if there were no full moon.

We figure out what we need to control for to limit our variable to just the possible influence of the full moon. So, let’s look at a study that investigated the effect of a full moon on something that would be very difficult to misinterpret.
 

We postulated that on full moon days there would be more available moonlight, thus influencing individuals’ activities, and in turn, the propensity for cardiac arrest.[1]

 

Interesting. They are not really assuming that the cause of an increase in cardiac arrests would be due to some mystical property of the moon, but that it would be due to more moonlight. fortunately, it does not matter what the actual cause would be for an increase in cardiac arrests, if they set the experiment up properly.

What do they need to do?
 

This study was a retrospective analysis of a computerized billing database of ED visits.[1]

 

The study population consisted of CPR (CardioPulmonary Resuscitation) occurring daily at a cohort of seven hospital ED in northern New Jersey, USA, during the period of 1 January 1988 to 31 December 1998, comprising 4018 days over 11 years. Consecutive patients seen by an emergency physician were included. Emergency physicians see 80–95% of all ED patient visits and the vast majority of cardiac arrest patients. Private physicians see the remainder of the patients.[1]

 

Their theory was that the increased moonlight would lead to more activity; more activity would lead to more cardiac arrests; thus there would be more cardiac arrests during a full moon.

Did the investigators prove their hypothesis?

According to their table, which does not reproduce well, there is no increase in cardiac arrest incidence during a full moon. They actually recorded a decrease, but the difference is not statistically significant. The reported statistically significant difference in incidence of cardiac arrest is this. During the new moon, there is less likely to be a cardiac arrest treated by an emergency physician.
 

There were 2370233 patient visits in the database during the 4018-day (11year) period of study, with 6827 having the primary ICD-9 diagnosis of cardiac arrest.[2] Table 2 contains the time series regression results. Full moon days were not significantly different from other days (P=0.97). We had an 80% power to identify a difference of 4.5%. However, on average 0.12 fewer CPR occurred on new moon days than on other days (P=0.02). This translates into an average of 6.5% fewer CPR (95% confidence interval 1.3–11.7%) on new moon days than other days. In addition, the results for the potentially confounding variables are presented in Table 2.[1]

 

I left part of their original hypothesis off of the initial quote. The stated objective of the study is –
 

Objective
To determine the effect of the phase of the full and new moon on the variation in the number of daily cardiopulmonary resuscitations.
[1]

 

In the discussion, they elaborate on their purpose –
 

Our results show a small but statistically significant decrease in the incidence of CPR with new moon days. We speculate that this may be secondary to a decrease in activity because of less available light on these days, as it has been shown that increased activity is a risk factor for sudden death[39]. Our initial rationale sought to identify and determine the size of any effect on the occurrence of cardiac arrest and its attempted resuscitation (‘CPR’) by lunar influence as a potential insight into an aspect of the occurrence of cardiac arrest. In addition, we sought to identify patient volume variation by lunar cycle potentially to allow for staffing modifications; however, the effect identified did not warrant this.[1]

 

This –
 

We postulated that on full moon days there would be more available moonlight, thus influencing individuals’ activities, and in turn, the propensity for cardiac arrest.[1]

 

Becomes –
 

We speculate that this may be secondary to a decrease in activity because of less available light on these days, as it has been shown that increased activity is a risk factor for sudden death[39] [1]

 

They have found a way to stick with their initial hypothesis by reversing it.

More moonlight does not appear to lead to more cardiac arrests. Why this lack of correlation does not need to be explained is not in the paper. However, the correlation between fewer deaths during a new moon is something that they feel needs to be explained. Haven’t they just misappropriated a Willy Wonka quote? Strike that. Reverse it. Willy Wonka was reversing the meaning of what he was saying. That was the reason he needed to reverse the order.

The authors have not really changed the meaning, only the way they express it. More light/less light leads to more activity/less activity. This leads to more/fewer cardiac arrests.

While I do not dispute the results of this study, I do have a problem with the way they get from Point A to Point C. They seem to travel there by way of a study that shows that more activity leads to more cardiac arrest. Actually the study is of vigorous exertion, not just more activity, but the authors seem to have interpreted the study as couch potatoes live longer. The vigorous exertion study did show –
 

As expected, the base-line level of habitual exercise significantly attenuated the increase in the risk of sudden death that was associated with an episode of vigorous exertion in both the primary analysis and the three sensitivity analyses. Habitually active men had a much lower risk of sudden death in association with an episode of vigorous exertion than men who exercised less than once a week; however, the most active men’s risk remained significantly elevated during and after vigorous exertion in all analyses.[3]

 

There is no suggestion that these episodes of vigorous exertion occurred less frequently during the time of the new moon. According to the hypothesis of the full new moon study, the effect of the new moon should only be at night, when it would make a difference in the amount of available light. This might make more difference in rural areas, than in the suburbs, and more of a difference in suburbs, than in cities, due to the wonders of electrical lighting.

Is there any evidence to support this string of conclusions? I don’t think so.

That does not mean that this hypothesis is incorrect, just that their way of getting there is not supported by the information provided.

One very nice part of this study is the brief review of previous studies and whether they seemed to support, or refute, a connection between various activities and the full moon, but this post is already too long. I will write about other full moon research elsewhere.

Another problem is the way they define a full moon –
 

We identified full and new moon days that occurred during the study period from the United States National Oceanographic and Aeronautic Administration website. Using this information we created variables for full and new moon days to be used in a regression model of daily CPR, described below.[1]

 

So. What is their definition of a new moon, or a full moon? They have not made that clear, but it appears to be limited to one specific day during each lunar cycle.

Using NOAA’s (United States National Oceanographic and Aeronautic Administration’s) website, I found a page that identifies new moons, full moons, and other phases by entering the time period I want to look at. The problem I see is that there is not much detail about how they used this information, or if they were using the same part of NOAA’s website.

Why no discussion of this?

Why no discussion of their definition of new moon and full moon?

If their hypothesis is one that depends on the available light, why does the day before a new moon not count, or the day after, or two days before (or after)?

However, if they are looking for a mystical connection between the full moon and bad events, a case can be made that the full power of the full moon would be on one specific date.

If they are claiming that they are examining the effects of the amount of moonlight, how much difference is there in the amount of moonlight from one day to the next? Where is your cut-off? Why?

I think that their conclusion should be that they find no apparent mystical connection between the full moon and cardiac arrests treated by emergency physicians. Their attempts at explaining their results wander into narrative fallacy, which I have written about here, here, here, here, here, here, here, here, here, and here.

As I have stated before about the way we should look at explanations for scientific results –

Bet that the explanation is wrong.

This is one of the failures of our basic education of students. We do not make this clear to them. Yes, this was where the post started, with the failure of science education in the grade schools.

The media report that a certain study means X, even though the authors of the study may not have suggested that this is true. It is later found that the conclusion popularized by the media is wrong. The blame goes, not to the reporters misrepresenting the science, but to the science. We need to avoid creating explanations that are unsupportable and likely to be found to be in error. We need to stop telling fairy tales. We need to stop talking to media members, who spin research results with misleading explanations.

We have people graduating from high school, but unable to recognize the difference between good science and bad science. Unable to look at a study and determine if there is something there that is meaningful. This continues through college, and even medical school. Number 3 on the list was – Academic Medical Centers, so I am not the only one critical of these ivory towers. The top threat to science in medicine is the lack of understanding of what science is. We fail before the students ever get started. This lack of understanding is due to a lack of education in grade school.

We need to change how we teach science. Some do it well, but the debates on scientific topics in the media suggest that few have been well taught. The ignorant mobs are trying to keep themselves in scientific debates for which they are not even remotely qualified. We need to make it so that more are qualified.

We need to improve our basic science education, because we cannot rely on people from other countries coming here to do the science that we have become too ignorant to handle. Eventually, the destination of smart foreign-born scientists will not be the United States. We do not develop enough of our talent. We remain a scientific power because import talent. We do the same thing with grape pickers and day laborers. These seem to be the jobs that we will no longer do for ourselves. Scientist and day laborer are both looked at as undesirable. We need to change this.

It is in the earlier grades that the problems of bad science education are established. After that point it is a much more difficult task to correct this creeping indoctrination in magical thinking.

I think that this is the number one threat to science in medicine. All of the others only contribute to this.

Magical thinking is a form of corruption. As with other types of corruption, it usually does not start with a cannonball into the deep end, but a gradual acclimatization to more and more corruption. At some point, critical judgment is only a fond memory.

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.Tom Stoppard.

We can still fix that problem in education for those in grade school.

Footnotes:

[1] Effect of lunar cycle on temporal variation in cardiopulmonary arrest in seven emergency departments during 11 years.
Alves DW, Allegra JR, Cochrane DG, Cable G.
Eur J Emerg Med. 2003 Sep;10(3):225-8.
PMID: 12972900 [PubMed – indexed for MEDLINE]

[2] ICD-9 code definition from the study above

The physicians’ billing department assigns codes according to the International Classification of Diseases, Ninth Revision, and Clinical Modification [International Classification of Disease (ICD)-9 codes]. Patients were included as CPR if they contained any of the ICD-9 codes listed in Table 1 as one of their three primary diagnoses.

Table 1
International Classification of Disease 9 codes
427.4       Ventricular fibrillation
427.41     Ventricular fibrillation
427.5       Cardiac arrest
798.1        Death instantaneous
798.2      Death occurring less than 24h from onset of symptoms
798.9       Death unattended

[3] Triggering of sudden death from cardiac causes by vigorous exertion.
Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE.
N Engl J Med. 2000 Nov 9;343(19):1355-61.
PMID: 11070099 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.

Alves, D., Allegra, J., Cochrane, D., & Cable, G. (2003). Effect of lunar cycle on temporal variation in cardiopulmonary arrest in seven emergency departments during 11 years European Journal of Emergency Medicine, 10 (3), 225-228 DOI: 10.1097/00063110-200309000-00013

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Going Against The Conventional Ignorance – I

This is about an example of decision making in sports. No, I am not going to start commenting on sports regularly, besides the EMS relevance is in here, just farther down. I have not followed football since the 70’s. However, there is a lot of criticism of Sunday’s decision by Bill Belichick, coach of the New England Patriots, to go against what everybody knows and attempt to advance 2 yards and keep his team on offense.

One point about this is that punting the ball, in an attempt to give the opposing team worse field position, is really a defensive move. It is playing to avoid being beaten, rather than playing to win. A lot of people like this strategy of hoping to gain an advantage, then just trying to hold onto that advantage for the rest of the game. There is a word for that kind of attitude. That word is Loser.

The Freakonomics blog has several posts that address this way that peer pressure works in the NFL.[1], [2], [3]

One dim witted collumnist wrote, Mere mortals punt downfield and try to put as much real estate between their end zone and Manning’s right arm. Geniuses commit hubris instead.[4] As I mentioned, I haven’t watched football in a while, but I do know this. In the last 2 minutes of the game real estate doesn’t mean much. I remember watching the Raiders play the Jets. Somebody decided to cut to the movie, Heidi with just over a minute on the clock.[5] At the time, it seemed to be evidence that Senator McCarthy might not have been just another paranoid schizophrenic with too much power. It was only a case for the application of Hanlon’s Razor – Never attribute to malice that which can be adequately explained by stupidity. The last 2 minutes of a football game are not the same as the rest of the game. Perhaps the person cutting off the end of the game was the person who taught our myopic moron Borges all about football. Borges makes reference to the Twinkie Defense.[6] It seems more likely that he is smoking too much of his own product.

Remember, as long as you go along to get along, you will always have a place in the herd. Borges will have no shortage of muzzles prodding his anus in the conventional ignorance herd.

There are some sports commentators making positive comments about this deviation from the conventional ignorance.[7] I’m not claiming that the coach did not make mistakes. His punt team mindlessly headed out onto the field, although they were not directed to by the coach. The resulting confusion led to the use of the last timeout that the team had, a timeout that might have made a difference in the outcome of the game. That is a leadership issue. However, criticizing a leader, because the leader does not see things the same as an armchair quarterback – someone who would never be considered qualified to coach a team – that is not meaningful criticism of the leader. Leaders are paid to make decisions that do not even occur to armchair quarterbacks.

There is research on fourth down actions in the first quarter. This was in the fourth quarter, so the research is only passingly relevant to the current situation. The research shows that the odds are against punting. So why do so many coaches punt? Because –

If his team had gotten the first down and the Patriots won, he would have gotten far less credit than he got blame for failing. This introduces what economists call a “principal-agent problem.” Even though going for it increases his team’s chance of winning, a coach who cares about his reputation will want to do the wrong thing. He will punt, just because he doesn’t want to be the goat.[8]

It really isn’t any different from EMS. Just tell me what the protocol says. Thinking will only get me in trouble.

We have too many people in EMS more concerned about protecting their images than they are about protecting their patients.

We have too many people listening to the EMS conventional ignorance. If we are going to progress, we need to point out the flaws in their thinking. We have too many armchair quarterbacks and not enough leaders.

One writer explains the problem by imagining what it would be like if we did not have the burden of history encouraging this conventional ignorance.

Here’s a thought exercise for you. Imagine that for decades no one ever thought of the punt. Teams knew nothing else than to run or pass on 4th down. And then one day it’s invented. Some guy comes up to a coach and says, “Kick the ball on every 4th down and the other team gets possession 37 yards further down the field.” The coach would think he was crazy: “Wait, you want me to give up one quarter of my opportunities for a first down on every series…just for 35 yards of field position? Do you realize how much that’s going to kill our chances of scoring?”[9]

Maybe that is what we need to do with EMS. We need to imagine what would be our approach if we did not have this overwhelming history of conventional ignorance. If we did not have this pile of excrement for people to point to and say, Well, you can’t throw the baby out with the bath water. As if that had any meaning other than, I like it this way and I will throw a tantrum if anyone tries to change things. Tradition First – Patients Last!

Imagine if we approached trauma patients with the goal of decreasing their injuries, rather than increasing them by nailing them to a cross in a religious ritual that must be obeyed, or else conventional spinal immobilization. Imagine if we were to find a way to minimize the stress placed on a patients neck, rather than by creating an isometric exercise that encourages patients to use their neck muscles to strain against the Rube Goldberg immobilization contraption.

Imagine if we attempted to actually do what is best for the patient, rather than what is best for the protocol. This is the difference between playing to win (what is good for the patients) and playing not to lose (what is good for the lawyers, at the expense of the patients).

Imagine if we had protocols that put patients ahead of excuses.

Footnotes:

^ 1 When Economists Talk, Pulaski Academy Listens
By Steven D. Levitt
November 19, 2007, 11:10 am
Article

^ 2 Why Don’t Sports Teams Use Randomization? A Guest Post
By Ian Ayres
December 11, 2007, 11:34 am
Article

^ 3 Bill Belichick Is Great
By Steven D. Levitt
Freakonomics
November 16, 2009, 3:02 pm
Article

^ 4 Bill Belichick heads off victory – Bad bobble all around
By Ron Borges
BostonHerald.com
Monday, November 16, 2009
Article

^ 5 Heidi Bowl
Wikipedia
Article

^ 6 Twinkie Defense
Wikipedia
Article

^ 7 No problem with Belichick’s decision here
November, 16, 2009; 11:00 AM ET
By Mike Sando
ESPN.com
Article

I wondered which team was more nervous before that play. The Colts’ Peyton Manning had to be hoping the Patriots would punt in that situation because Manning had to like his chances with the ball in his hands.

and

In Belichick’s mind, then, the decision not to punt gave the Patriots a very good chance at winning the game. He played to win.

Punting with 2:08 remaining would have armed Manning with the football and one timeout remaining, plus the 2-minute warning. Going that route would have been playing not to lose. Good luck with that approach against Manning.

I won’t skewer Belichick for making a 2-yard bet on Brady just because he failed to collect.

^ 8 Bill Belichick Is Great
By Steven D. Levitt
Freakonomics
November 16, 2009, 3:02 pm
Article

^ 9 A New Study on Fourth Downs: Go for It
By Brian Burke
September 17, 2009, 7:00 am
The Fifth Down
The New York Times N.F.L. Blog
Article

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