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
.

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

.

In Defense of No Improvement by Medic Madness – Part II

 

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

No, there isn’t much data to suggest that using a LUCAS improves outcomes. Likewise, we aren’t discovering that it’s hurting people either. So at the very worst, it’s a luxury item.[2]

 

No.

I am critical of treatments that do not work. Once we start making excuses to use these treatments, we take decades to get rid of them.
 

No difference in survival or neurological outcome was seen for up to 6 months after the cardiac arrest as, by then, the vast majority of survivors had CPC scores of 1 or 2, and most patients with initial CPC scores of 3 or 4 had either improved or died. The numbers of serious adverse events and device-related adverse events were low.[3]

 

The LUCAS failed.

Unless your idea of success is to make no difference in outcomes, because improving resuscitation outcomes is not important.
 

Moving out of the big city and going to work in an area that utilizes volunteers as first-responders means that I often find myself working a resuscitation with just me and my partner. If – and I emphasize the word “if” – we happen to get first-responders to these calls, we still have no idea what kind of training or experience they have.[2]

 

The LUCAS as an excuse to tolerate incompetence.

Over, and over, and over, . . . this has been the main argument for the LUCAS.

We can’t expect EMS to perform high quality CPR.

We are too busy doing other things that do not improve outcomes to make sure that compressions are done well.

There are only two things that a paramedic needs to make sure are done well – compressions and defibrillation.

What do paramedics want to do?

We want to do things that do not improve outcomes, because we do not understand what we are doing and are easily distracted by shiny things. Maybe they can put a flashing light on the LUCAS, or give out badges with each use, and raise the price by $5,000 $10,000.
 


Rather than courage, we can award a LUCAS Save! medal – a shiny one.
 

If I am to take Sean seriously, perhaps it will be because he has taken the same argument against intubation and advocated for protecting patients from incompetent EMS by replacing endotracheal tubes with almost foolproof LMAs (Laryngeal Mask Airways).

More consistent, frees up a set of hands, probably less liability, . . . .

What?

Sean hasn’t applied the same logic to intubation in cardiac arrest?

I am shocked. :shock:
 

I too have been a volunteer and I know the value of the care they provide. Having said that, it’s hard to get strict on training when they are already going out of their way to provide service to their community.[2]

 

I don’t blame the volunteer for the quality of care they provide when working with a paramedic right there.

I blame the paramedic.

It is my job to make sure that what is going on is done well. Compressions and defibrillation are all that matter. If I can’t manage that, intubation is definitely beyond my capabilities.
 

What’s the harm of treatments that do not improve outcomes alternative medicine?

I look at the criticisms of the actual research in Part III and 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.

.

In Defense of No Improvement by Medic Madness – Part I

 

I wrote about treatment with the LUCAS CPR machine and stated that There is no price that justifies no improvement.[1]

There are plenty people who want to justify the use of placebo treatments – treatments that do not improve outcomes. Here is one –
 

Before writing this response, I took some time to examine the equipment I use on a daily basis. Needless to say, I was shocked to discover that we spend a lot of money of items that really don’t improve patient outcomes at all. One example is the Stryker Power Cot.[2]

 

The LUCAS is a treatment that is a potential substitute for manual chest compressions.

The selling point was supposed to be that the LUCAS improves outcomes – survival with a working brain – that is the whole purpose of the research I have been writing about.
 

Thus, in clinical practice, CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.[3]

 

The LUCAS failed.

However, Sean is taking my statement about the outcome of a treatment and applying it to the choice of equipment.

Does a power stretcher improve the survival of patients?
 


 

I do not know of any studies that examine this question, but the stretcher is not used as a treatment. The stretcher is used as a means of moving the patient.

What Sean appears to be asking is – since I am going to use a stretcher (is there any state that does not require a stretcher in an ambulance), shouldn’t I use the cheapest stretcher that meets the requirements? Or am I going to base my decision on something other than outcomes?

Is the choice to pay more for a power stretcher based on the outcomes of patients?
 

Although I tried, I couldn’t find any studies that compared patient outcomes to those transported using a manual cot.[2]

 

It is not based on the outcomes of patients, but the choice is based on outcomes.

In a study comparing the injury rate among FTEs (Full-Time Employees), the rate of injury was cut in half after the introduction of a powered stretcher.[4]

Maybe EMS should not consider the outcomes for employees when making decisions?

What is Sean’s next gotcha?
 

Another major purchase was the LifePak 15 ECG monitor / defibrillator. Once again, I couldn’t find anything showing improved patient outcomes.[2]

 

Sean couldn’t find any evidence that waveform capnography improves outcomes for patients?[5] :sad:

Sean couldn’t find any evidence that an EMS 12 lead ECG (ElectroCardioGram) improves outcomes for patients?[6] :oops:

Sean couldn’t find any evidence that EMS defibrillation improve outcomes for patients?[7] :shock:

Perhaps Sean works in a state that does not require a defibrillator, 12 lead capability, and/or waveform capnography as minimum paramedic equipment and thinks these are just fun to have toys.

Sean appears to be suggesting that the choice of brand and options, except as mandated by EMS regulatory organizations, must be limited to the cheapest available item. Otherwise, I am misleading people by stating – There is no price that justifies no improvement.

Should I be worried at Sean’s failure to find the valid evidence, when I only provided a small sample of the valid evidence?

Does this affect Sean’s argument? The argument is really just a bait and switch – a logical fallacy known as a straw man.[8] I wrote about one thing and Sean represented my argument as something else, because he has an argument against the argument I did not make. However, his argument does not address the claim I actually did make.
 

That is not the only argument Sean makes. I address the rest in Part II, Part III, and 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.

-

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] Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers.
Studnek JR, Mac Crawford J, Fernandez AR.
Appl Ergon. 2012 Jan;43(1):198-202. doi: 10.1016/j.apergo.2011.05.001. Epub 2011 May 31.
PMID: 21632034 [PubMed - indexed for MEDLINE]

-

[5] The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J.
Ann Emerg Med. 2005 May;45(5):497-503.
PMID: 15855946 [PubMed - indexed for MEDLINE]

-

[6] Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction.
Sivagangabalan G, Ong AT, Narayan A, Sadick N, Hansen PS, Nelson GC, Flynn M, Ross DL, Boyages SC, Kovoor P.
Am J Cardiol. 2009 Apr 1;103(7):907-12. doi: 10.1016/j.amjcard.2008.12.007. Epub 2009 Feb 7.
PMID: 19327414 [PubMed - indexed for MEDLINE]

-

[7] Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians.
Eisenberg MS, Copass MK, Hallstrom AP, Blake B, Bergner L, Short FA, Cobb LA.
N Engl J Med. 1980 Jun 19;302(25):1379-83.
PMID: 7374695 [PubMed - indexed for MEDLINE]

-

[8] Straw man
Wikipedia
Article

.

The LUCAS, Research, and Wishful Thinking


 

Does the LUCAS improve outcomes?

No. The authors state that clearly.[1]

Do people think that we should use the LUCAS anyway?

Yes. The excuses are presented by many people.

What are the possible benefits?

1. The LUCAS allows us to free up a pair of hands to do other things that do not benefit the patient, so this adds nothing useful.

2. The LUCAS allows us to transport the patient safely. This is a rehash of #1, since routine transport does not improve outcomes.

3. Treatment will be consistent, regardless of the quality of the EMS. Rather than improve quality, we will have a machine take over something we think is done poorly, so that EMS can harm the patient by doing other things poorly.

4. The LUCAS can take over one of the two treatments that can improve outcomes. An AED can take over the other. We no longer need to have EMS respond to cardiac arrest calls until after ROSC (Return Of Spontaneous Circulation).

If the dramatic success of Seattle is due mostly to the frequency of bystander CPR, that would suggest that the best use of the LUCAS is in the hands of bystanders, not EMS.
 


Download YouTube Video | YouTube to MP3: Vixy
 

If that is too much adult material, we can do the version for kids.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Or we can do the version for toddlers.
 


Download YouTube Video | YouTube to MP3: Vixy
 

If EMS cannot manage that, should we be giving them equipment to free them up to mess up intubation or drugs or other things that do not improve outcomes.

Why are we so eager to add treatments that do not help patients?

Ethical patient care means limiting ourselves to treatments that improve outcomes.
 

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

Also see -

The Failure of LUCAS to Improve Outcomes in the LINC Trial

-

Footnotes:

-

[1] 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]
 

The current sample size has a 95% confidence interval for the 4-hour survival ranging from −3.3% to +3.2%. Translated another way, while the point estimate for treatment effect was near 0.0, our study could not rule out the possibility of a 3.2% benefit or a similarly sized harm from mechanical CPR relative to standard CPR.

 

Not just not helpful, but this could be harmful.

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Issues and Challenges Discussed by Medical Directors at Eagles Conference – Part 2

 

Continuing from Part 1, where A.J. Heightman writes that there are several issues that are important to the medical directors attending the Gathering of Eagles. The conference is over. Here are the rest of the issues –
 

Need for exchange of data between hospital and EMS systems;[1]

 

I can find out what happened to my patients much more easily than most people, because I know the unofficial ways to get the information.

That should not be necessary and HIPAA does allow sharing of this information.
 

Active Shooter management, policies and integration issues, particularly in their Police & EMS integration;[1]

 

It isn’t about who is in charge.

It is about having everyone recognize the same person as being in charge and having that person know how to handle the scene. The person should probably be a specialist, rather than cross-trained to do everything with just the appearance of minimum competence.
 


Images credit from Life in the Fast Lane.
 

STEMI transfers – Hospital are demanding valuable ALS resouces to transfer STEMI and stroke patients when, in some cases, BLS units could handle the task;[1]

 

Why were these patients taken to hospitals that need to transfer the STEMI and stroke patients?

If they were transported by paramedics initially, what good is that kind of paramedic during any transport.

I can’t recognize a stroke or a STEMI, but I am here because you think I am someone who understands strokes and STEMIs.

If the problem is that the protocols require transport to the wrong hospitals, change the protocol.
 


 

Intranasal Narcan delivery by police and firefighters (There is a national push for this by responders who arrive on scene before EMS);[1]

 

It is popular?

So was blood-letting.

Being popular does not mean that it is safe, effective, or a good idea.

What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera?

What are the outcomes for these patients in systems that make naloxone a BLS treatment, or even just an advanced first aid treatment?
 

Consistency in approach to patient refusals;[1]

 

The patient has the capacity to make informed decisions.

EMS is able to provide adequate information for a person to make an informed decision.

EMS is not coercing refusals.

EMS is competently assessing patients and communicating with patients.
 

Use of video laryngoscopes and capturing the data from them for QA review and documentation;[1]

 

Maybe we should find out if video laryngoscopy is the right tool before we make it the standard of care.

EMS loves standards of care. We don’t care how dangerous they are.
 

Limited funds to bring people in for continuing education;[1]

 

More than continuing – expanding education.

Keeping up with original paramedic education is not enough.

What we need to know changes. We need to keep up, with the changes, not with the past.
 

Airway management and monitoring (particularly failure by crews to use waveform capnography) continues to be an issue;[1]

 

The medic did not include waveform capnography tracings with the chart?

There is less than 100% QA/QI/CYA of intubations?

The medical director does not understand waveform capnography, airway management, and/or oversight?

Not using waveform capnography is due to a critical failure of management that has been adopted by paramedics who have a ceremonial understanding of EMS – enough to pass a test to get a patch, but not enough to provide competent care.

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Footnotes:

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[1] Issues and Challenges Discussed by Medical Directors at Eagles Conference – Editor-in-Chief A.J. Heightman reports from the 2014 Eagle Creek Retreat in Dallas
A.J. Heightman, MPA, EMT-P
Wednesday, February 26, 2014
JEMS
Article

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Issues and Challenges Discussed by Medical Directors at Eagles Conference – Part 1


 

A.J. Heightman writes that there are several issues that are important to the medical directors attending the Gathering of Eagles. The conference is over, but here are some of the issues –
 

More attention to crew “time on chest” during resuscitations and avoiding interruptions;[1]

 

Other than defibrillation, chest compressions are the only treatment that has been shown to improve the one outcome that matters – survival with a working brain.

Why is this so hard for people to understand?

Don’t stop until the patient is no longer in need of compressions. OK, pause for a couple of seconds to analyze the rhythm and deliver a shock from the defibrillator that was charged before the pause. More than that is bad patient care.
 

Shortage of paramedics and new EMS leaders – Referenced by several systems;[1]

 

Is this a real shortage?

Or are they trying to have all responders be paramedics?
 

The expense of placing the same monitor/defibrillators on ALS engines is now becoming an issue. Some systems are exploring use of AEDs with screens on first response units because the number of times the “full system” is needed is not high;[1]

 

When the paramedic on the engine is there just to stop a clock, the position is purely ceremonial and there is no reason to give the ceremonial paramedic real paramedic equipment. We really do not want these inexperienced ceremonial paramedics treating patients, because almost everything a paramedic carries can kill the patient.

There is a shortage of EMS leaders who lead in a way that is good for our patients.
 

Budget cuts and shortages are limiting what can be done in EMS systems, particularly in training, equipment replacement/updating and quality assurance;[1]

 

We need to spend more on fewer paramedics, so that they are better able to provide appropriately aggressive care to the few patients who will really benefit from paramedic care.

We do not need a bunch of IV technicians to save the nurse from having to start an IV.

We need medics capable of appropriately assessing patients. We have more than enough protocol monkeys.
 

The ability to do effective QA with limited staff, funding and data resources was pointed out as a key need. The need for the seemless and timely integration of data was referenced by multiple medical directors;[1]

 

Do the metrics matter, or are they just making sure that the protocol monkeys are doing the Macarena the way the medical director wants it done.
 

Need for better education and treatment of pediatric patients;[1]

 

Even pediatric hospitals have trouble with this, so there is no easy solution and it is a real problem.
 

Instilling pride back in EMS providers, particularly in systems that do not fully appreciate EMS;[1]

 

Imagine a system that does just EMS and does EMS very well.

We have too many all hazard systems that try to do everything just well enough to avoid getting in the way with whatever they consider their primary job.

Incompetence is common – just don’t point it out. the patients don’t need to know.
 

Use of technology and negative news to help EMS systems solve system woes. Bad publicity can force politicians to correct (and fund) system issue;[1]

 

Rather than punish those pointing out problems, we should be asking them to help fix the problems before they become embarrassing stories on the news.

Embarrassing generally means somebody died and it was our fault and we have to find a way to make people forget that it was our fault.
 

Need to return to basics and not just rely on devices and technology to “assess” the patient;[1]

 

And not rely on a bunch of impressive patches on inexperienced people doing ceremonial paramedic work.

To be continued in Part 2.

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Footnotes:

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[1] Issues and Challenges Discussed by Medical Directors at Eagles Conference – Editor-in-Chief A.J. Heightman reports from the 2014 Eagle Creek Retreat in Dallas
A.J. Heightman, MPA, EMT-P
Wednesday, February 26, 2014
JEMS
Article

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DeMYTHifying Diagnosis – Part II

 

Continuing from Part I of my comments on what Kelly Grayson writes in Demystifying Diagnosis.

But diagnosis refers to definitive care!

We diagnose some patients as well enough to be left safely at home, even if we tell some people with abrasions that we think abrasions are deadly.[1] :oops:
 
Anaphylaxis

We treat anaphylaxis with epinephrine (and/or diphenhydramine, methylprednisolone, . . . ) and some patients refuse transport, while most are just observed in the ED before discharge.[2] Should we be leaving patients on scene with anaphylactic-like presentations, but without a diagnosis of anaphylaxis?

Bradykinin-mediated angioedema may look like anaphylaxis, but it does not respond well to epinephrine. Angioedema can be bradykinin-mediated (non-allergic) or histamine-mediated (allergic).[3],[4]
 
Hypoglycemia

We treat hypoglycemic emergencies and routinely leave patients on scene following a refusal of transport. This is only possible because the unresponsive/minimally responsive patient is now awake, alert, and has the capacity to make informed decisions to accept/refuse further treatment, assessment, and/or transport.[5],[6]
 
Opioid overdose

With some unresponsive opioid overdose patients, we can reverse their conditions. most of these patients may refuse further treatment, refuse further assessment, and/or refuse transport.[7],[8],[9]
 
Seizure

Seizure patients can awaken and be alert enough to refuse treatment and transport.[10]
 


Image credit.[11]
 

We do diagnose and leave patients on scene.

We do not seem to have major problems with patient-initiated refusals.

With increasing use of community paramedics, this will only become more common.

Those are examples of four conditions where we provide assessment, treatment, and a recommendation to follow up with the patient’s primary care provider (not necessarily a physician).
 
Death

We also leave dead patients on scene. No doctor will ever see some of these patients, because we are transferring care to the family/funeral home/police.

The patient’s physician will sign the death certificate, but with no requirement that the doctor has seen the patient after the cardiac arrest. Do we misdiagnose death? Yes, but so do doctors.

Dead is about as definitive as a diagnosis will get.
 

Once we start using words like diagnosis, accountability, and research, it is just a slippery slope to better patient care. :idea:

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Footnotes:

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[1] The Power of the ‘Death’ Chant will protect Us
Wed, 29 Jan 2014
Rogue Medic
Article

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[2] Clinical predictors for biphasic reactions in children presenting with anaphylaxis.
Mehr S, Liew WK, Tey D, Tang ML.
Clin Exp Allergy. 2009 Sep;39(9):1390-6. doi: 10.1111/j.1365-2222.2009.03276.x. Epub 2009 May 26.
PMID: 19486033 [PubMed - indexed for MEDLINE]
 

RESULTS:
There were 95 uniphasic (87%), 12 (11%) biphasic and two protracted reactions (2%). One child with a protracted reaction died. For the management of the primary anaphylactic reaction, children developing biphasic reactions were more likely to have received >1 dose of adrenaline (58% vs. 22%, P=0.01) and/or a fluid bolus (42% vs. 8%, P=0.01) than those experiencing uniphasic reactions. The absence of either factor was strongly predictive of the absence of a biphasic reaction (negative predictive value 99%), but the presence of either factor was poorly predictive of a biphasic reaction (positive predictive value of 32%). All biphasic reactors, in which the second phase was anaphylactic, received either >1 dose of adrenaline and/or a fluid bolus.

CONCLUSIONS:
Children who received >1 dose of adrenaline and/or a fluid bolus for treatment of their primary anaphylactic reaction were at increased risk of developing a biphasic reaction.

 

It appears to be safe to leave children at home as long as they have received only one epinephrine injection and have not received any IV (IntraVenous) fluids. Most of my 911 anaphylaxis calls have been refusals.

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[3] Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema.
Bernstein JA, Moellman J.
Int J Emerg Med. 2012 Nov 6;5(1):39. doi: 10.1186/1865-1380-5-39.
PMID: 23131076 [PubMed]

Free Full Text from PubMed Central.

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[4] Delayed takotsubo cardiomyopathy caused by excessive exogenous epinephrine administration after the treatment of angioedema.
Patankar GR, Donsky MS, Schussler JM.
Proc (Bayl Univ Med Cent). 2012 Jul;25(3):229-30. No abstract available.
PMID: 22754120 [PubMed]

Free Full Text from PubMed Central.

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[5] Prehospital hypoglycemia: the safety of not transporting treated patients.
Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D.
Prehosp Emerg Care. 2003 Oct-Dec;7(4):458-65.
PMID: 14582099 [PubMed - indexed for MEDLINE]
 

CONCLUSIONS:
Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

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[6] Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature.
Roberts K, Smith A.
Emerg Med J. 2003 May;20(3):274-6. Review.
PMID: 12748153 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

Read the whole paper (both pages) – especially the recommendations for limitations on refusals.

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[7] Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport.
Vilke GM, Sloane C, Smith AM, Chan TC.
Acad Emerg Med. 2003 Aug;10(8):893-6.
PMID: 12896894 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from Academic Emergency Medicine.
 

RESULTS:
There were 998 out-of-hospital patients who received naloxone and refused further treatment and 601 ME cases of opioid overdose deaths. When compared by age, time, date, sex, location, and ethnicity, there were no cases in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opioid overdose.

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[8] No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose.
Wampler DA, Molina DK, McManus J, Laws P, Manifold CA.
Prehosp Emerg Care. 2011 Jul-Sep;15(3):320-4. doi: 10.3109/10903127.2011.569854.
PMID: 21612385 [PubMed - indexed for MEDLINE]
 

CONCLUSION:
The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

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[9] The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting.
Cantwell K, Dietze P, Flander L.
Resuscitation. 2005 Jun;65(3):315-9.
PMID: 15919568 [PubMed - indexed for MEDLINE]
 

CONCLUSIONS:
The concurrent use of alcohol with heroin resulted in the use of greater than standard doses of naloxone by paramedics in resuscitating overdose patients. It is possible that the higher dose of naloxone is required to reverse the combined effects of alcohol and heroin. There was also a link between initial patient presentation and the dose of naloxone required for resuscitation. In light of these findings, it would appear that initial patient presentation and evidence of alcohol use might be useful guides as to providing the most effective dose of naloxone in the prehospital setting.

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[10] The diagnosis and management of seizures and status epilepticus in the prehospital setting.
Michael GE, O’Connor RE.
Emerg Med Clin North Am. 2011 Feb;29(1):29-39. doi: 10.1016/j.emc.2010.08.003. Epub 2010 Oct 15. Review.
PMID: 21109100 [PubMed - indexed for MEDLINE]
 

Such patients must demonstrate to providers the mental capacity to make an informed medical decision to refuse care. In patients who have just had a seizure, it is unlikely that they will demonstrate intact mental status and capacity for medical decision making.12,13 Because the risk of seizure recurrence is approximately 6%, prehospital care providers and medical command physicians should ensure that patients understand the risks of refusal.14

 

Pediatric patients present unique challenges in prehospital seizure management. Galustyan and colleagues15 studied the care of 1516 pediatric EMS calls with a chief complaint of seizure. Of those calls, 189 (17%) refused transport.

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[11] Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation.
Mechem CC, Barger J, Shofer FS, Dickinson ET.
Acad Emerg Med. 2001 Mar;8(3):231-6.
PMID: 11229944 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from Academic Emergency Medicine.
 

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