The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

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

ResearchBlogging.org
 

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

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

50% dextrose has problems.
 

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

 

Furthermore, extravasation can cause necrosis.
 


Image credit.[2]
 

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

Is 10% dextrose practical?
 

Won’t giving less concentrated dextrose delay treatment?
 

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

 

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

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

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

 

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

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

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

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


 

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

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


 

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

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


 

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

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


 

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

Is this perfect?
 

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

 

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

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

Why are we still resisting switching to 10% dextrose?
 

Other articles on 10% dextrose.

Footnotes:

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

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

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

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

.

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

ResearchBlogging.org
 

This study is interesting for several reasons.

In a system that claims excellence, the most consistent way to identify the study group is by documentation of a protocol violation – but it is not intended as a study of protocol violations.

This may hint at some benefit from epinephrine (Adrenaline in Commonwealth countries), but that would require some study and we just don’t study epinephrine. We only make excuses for not studying epinephrine.

The atropine results suggest that the epinephrine data may be just due to small numbers, or that we may want to consider atropine for drug overdose cardiac arrest patients, or . . . .

The Sodium Bicarbonate (bicarb – NaHCO3) results suggest a flaw in EMS education (probably testing, too). If the patient is acidotic, this is one type of cardiac arrest where hyperventilation may be beneficial. Bicarb is the part of the drug that doesn’t do much, especially if the patient is dead. The sodium is what works, such as when the patient has taken too much of a sodium channel blocker, such as a tricyclic antidepressant or a class I antiarrhythmic. Acidosis is treated by hyperventilation. Use capnography.

Most important – antidotes probably don’t work as expected during cardiac arrest. Not even naloxone (Narcan).
 

Despite clear differences in the etiology of suspected OD [OverDose] and non-OD OHCA [Out of Hospital Cardiac Arrest], the International Liaison Committee on Resuscitation guidelines published in 2010 do not specify different treatments for suspected OD-OHCA patients during resuscitation,and state that there is no evidence promoting the intra-arrest administration of the opioid antagonist naloxone.8 [1]

 

What did they find in the study?

They may have located the highest concentration of heroin overdose in the country. 93% of OD-OHCA patients were treated with naloxone.
 

We relied on either naloxone administration or clear description of circumstantial evidence in the PCR [Patient Care Recod] to identify a suspected OD. Clear descriptions are also rare, and most (93%) of the cases were identified by naloxone administration. Naloxone during cardiac arrest is not part of any regional protocol, and all of these administrations are deviations from recommended practice. There may be other cases in which paramedics suspected OD, but did not deviate from protocol to administer naloxone. Therefore, it is impossible to be certain whether the actual number of OD cases is larger or smaller than the reported number. However, the use of naloxone as a proxy indicator of suspected OD has been supported in the literature.11 [1]

 

The EMS approach to naloxone still appears to be –
 


Image credits – 123
 

These results seem to show better response to the prehospital drugs in the OD-OHCA patients, but that ignores the ROSC (Return Of Spontaneous Circulation) rates.
 


Click on images to make them larger.
 

Why would OD-OHCA patients do better than non-OD-OHCA patients if they get a pulse back?

The average non-OD-OHCA patient is 20+ years older. These older patients may not be as capable of recovery nor as capable of tolerating the toxicity of the drugs they were treated with.

The change after ROSC is dramatic. Is that the important point of this study?

Are they doing anything special for OD patients in the hospital, or is it just a matter of That which does not kill me by anoxic brain damage, may allow me to recover twice as often as a typical cardiac arrest patient.
 

Do drugs (antidotes, antiarrhythmics, . . . ) work the same way in dead people as in living people?
 

Pharmacologic insults are just so massive and normal metabolism and physiology so deranged that no mere mortal can make a meaningful intervention. The seriously poisoned who maintain vital signs in the ED have the best, albeit never guaranteed, chance of rescue from a modicum of antidotes and intensive supportive care.[2]

 

We should understand that normal metabolism is irrelevant to cardiac arrest.

We should understand that we do not need to ventilate adult cardiac arrest patients, when the cause is cardiac. An absence of ventilation would not be appropriate in a living adult, but dead metabolism is not normal. If something as basic as oxygen changes, when the patient is dead, how much less do we understand the behavior of other drugs in dead patients?

Footnotes:

[1] Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest.
Koller AC, Salcido DD, Callaway CW, Menegazzi JJ.
Resuscitation. 2014 Jun 26. pii: S0300-9572(14)00581-4. doi: 10.1016/j.resuscitation.2014.05.036. [Epub ahead of print]
PMID: 24973558 [PubMed – as supplied by publisher]

[2] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/01.EEM.0000406945.05619.ca
InFocus
Roberts, James R. MD
Article

Roberts, J. (2011). InFocus: Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions Emergency Medicine News, 33 (10), 16-18 DOI: 10.1097/01.EEM.0000406945.05619.ca

Koller, A., Salcido, D., Callaway, C., & Menegazzi, J. (2014). Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest Resuscitation DOI: 10.1016/j.resuscitation.2014.05.036

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When is a double dose of defibrillation a good idea?

 
In the comments to Double simultaneous defibrillators for refractory ventricular fibrillation, NCMedic and Ambulance Driver write that they have already begun using variations on double defibrillation.
 

That     is     excellent.

 


 

The changes in when to implement the change, as well as the vector to use, are reasons we need to have people publishing results on what is being done. Please, work with your medical directors and/or others to publish some results.

We have had epinephrine (Adrenaline in Commonwealth countries) in ACLS (Advanced Cardiac Life Support) guidelines, and our protocols, for decades, but we still do not know the best dose or even which patients benefit.

NCMedic writes –
 

Has been in our protocols for sometime now, we are finding it more beneficial sooner than later for obvious reasons, next protocol revision will most likely have it on the 4th shock with the 2nd set of pads placed A/P to cover from a different vector.

 

Epinephrine seems to be harmful when given later, or is epinephrine less beneficial later, or is epinephrine always harmful, just much more harmful later, or something else.[1]

The problem is that we do not know when, or for whom, epinephrine is indicated.

Epinephrine is probably indicated in some patients, but which patients, at what dose, and at what time? If epinephrine should be repeated all of the same questions apply to all further doses. Dr. Scott Weingart points out how little we know about the use of epinephrine, because his approach makes more sense than what ACLS recommends and the evidence is equally lacking.[2]

There are many things in the presentation to discuss, such as Dr. Weingart’s misunderstanding of what nihilism means, but that is for another time.
 

There does not appear to be any harm from double defibrillation. As we use more current more often, we should expect to learn of harms, as we do with almost every intervention. However, as NCMedic states, we may be doing harm by waiting too long to deliver the double dose.

Should it be a double dose?

What about 1 ½ times the maximum?

300 j bi-phasic or 540j mono-phasic or maybe some combination of bi-phasic and mono-phasic, and if a combination, what combination, with drugs or without, which drugs if with drugs, . . . ?

What about 3 times the maximum?

600 joules bi-phasic or 1,080 joules mono-phasic or . . . ?

Should the higher-dose defibrillation be after the fifth shock with a return to VF/pulseless VT (Ventricular Fibrillation/pulseless Ventricular Tachycardia)? After the fourth shock? After the third shock? After the second shock? After the first shock?

Is waiting longer to increase joules making it more likely that epinephrine will be given? Is epinephrine more harmful than a double shock, less harmful than a double shock, or roughly the same?

The amount we do not know is huge.

We should learn what we are doing to our patients and not arrogantly choose to remain ignorant, as we have chosen with epinephrine. That is changing, but some still defend the arrogance of ignorance at the expense of our patients.[3]

Footnotes:

[1] Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?
Sun, 25 May 2014
Rogue Medic
Article

[2] Podcast 125 – The New Intra-Arrest from SMACCgold
EMCrit
Dr. Scott Weingart
Web page with video and show notes.

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

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

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

 

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

 

.

IAFF’s Jack Reall faces discipline for delaying a 911 call in order to protest research he does not like


 

One of the advantages of fire department-based EMS is that there is a clear chain of command and that discipline is not a problem. The exceptions to this may be rare enough that they make headlines. Here is one.
 

A Columbus Fire battalion chief could face discipline for insubordination after an internal investigation found that he disrupted a pilot program intended to more efficiently respond to emergencies.[1]

 

The first oddity is that the Battalion Chief (Jack Reall) is also the president of Local 67 of the International Association of Fire Fighters. A management position and a union position – and not just any union position, but president. Jack Reall apparently cannot keep his priorities in order.

The fire department is studying whether 911 calls should receive an initial response from one paramedic with a basic EMT or from a pair of paramedics. There is no evidence that sending one paramedic and one EMT causes any kind of harm, or that two paramedics provide better care, so there is no basis to claim that anyone is being in any way endangered by this pilot program.

If there were a legitimate concern, then the time to address that was when the pilot program was being considered. It appears that Jack Reall is not happy with that and his union boss persona delayed a 911 response in violation of fire department rules.
 

The Fire Division launched a pilot program that morning to reduce the number of paramedics who respond to routine calls, allowing the division to disperse medics elsewhere. Instead of two paramedics on a truck, there would be one medic and a basic emergency-medical technician, or EMT.[1]

 

Is it possible that this was a complete surprise to Battalion Chief/Union President Jack Reall?

I don’t know what kind of preparations were made by the fire department, but I suspect that they began well in advance of BC/Pres. Jack Reall’s attempt at sabotage.

It is appropriate to study things when there is a state of equipoise about which is best.

Equipoise is just a fancy word for We do not know which is best.

When we do not know what is best, we should find out, rather than arrogantly assume that we know all that we need to know to force an uninformed opinion on others. That is the alternative – I don’t know, but I am going to force my opinion on everyone else because I am certain my opinion is more important than learning the truth.

Research means we learn more, even if we never learn the whole truth. Opposing research is opposing learning more – especially if the truth disagrees with opinion.

Equipoise means that we cannot be certain, because we do not know enough to be certain.
 

Reall was against the plan from the start and said fewer paramedics meant lower-quality service.[1]

 

The fire department and the union probably have worked out procedures for resolving these differences of opinion. They probably do not include delaying 911 responses to make a point.

If Jack Reall were behaving responsibly, he would have raised these concerns at an appropriate time and place.
 

Reall said the plan was not presented well to firefighters and paramedics and was “not well thought out.”[1]

 

He did raise them at the appropriate time, but he did not get what he wanted.

When I don’t get what I want, as a responsible adult, I should throw a tantrum.

True or False?

A Battalion Chief is supposed to be a person to turn to to resolve confusion, not to create confusion. One part of the job is to make a clear decision (such as to protect the interests of a patient) and to take responsibility for that decision.

It appears that Reall was doing the opposite.

Footnotes:

[1] Firefighters-union chief faces discipline from Fire Division
By Lucas Sullivan
The Columbus Dispatch
Wednesday July 9, 2014 5:51 AM
Article

.

The crisis in evidence-based medicine

 
Are there crises in EBM (Evidence-Based Medicine)?

If so, what are the crises and what can we do to make things better?

John wrote this in the comments to We all rely on evidence. The important difference is __________.[1]
 

I wonder what you think about this:

http://theincidentaleconomist.com/wordpress/the-crisis-in-evidence-based-medicine/

 

The article, The crisis in evidence-based medicine,[2] references a BMJ article[3] that I will try to write about soon, since it provides an excellent description of what EBM (Evidence-Based Medicine) is and how EBM is misused.

What many of the opponents of EBM (I am not including Bill Gardner) seem to ignore is that the problems that affect the application of high quality evidence to patient care are even greater with the application of the lowest quality evidence anecdotal experience to patient care. For example, multimorbidity makes it even more difficult to draw conclusions based on anecdotes, than based on evidence prospectively collected in a way that is designed to minimize the complications produced by the many conditions not being studied, while anecdotalists rely on experience, that is more likely to be irrelevant than the research and they rely on their memories. One thing that objective evidence shows us is that our memories are not accurate.[4]

However, Bill Gardner is looking at the ways we can avoid making mistakes with EBM, rather than making excuses for ignoring EBM. I recommend reading the BMJ article first, then going back and reading his article and the other articles at The Incidental Economist on EBM.

There is a weak point in Bill Gardner’s solution, and he is aware of it. At what point does the quality of the data become so low that the massive quantity is not able to provide useful information?

The NTDB® (National Trauma Data Bank®) is a great idea. We objectively collect as much data on as many trauma patients as possible and mine that data for signals that stand out from the noise. I have pointed out some of the problems with the application of this approach several times.[5],[6],[7]

Eventually, we should become much better at acquiring data, but so far we have demonstrated that even data prospectively collected by the experts can be GIGO (Garbage In = Garbage Out). The same is true for EBM. If we use low quality data, we should expect low quality results. Eventually, we should find better ways to filter out the noise, but we are not there, yet.

The Framingham Heart Study[8] is an example of using massive amounts of data to find evidence that several risk factors lead to significantly shorter lives.

As with anything else, the problems are not a reason to abandon hope, but a reason to use caution. We will learn as we go, while the acolytes of anecdotalism will continue to promote misunderstanding and continue to discourage progress.

We need to learn more about how to use science and how not to be misled by science, rather than to abandon science. Here is just a start to learning how not to get fooled by bad science.
 


Image credit. Click on the image for a much larger version (1754×1280).
 

While the perfect is often the enemy of the good, that does not mean that good is not good, or that we should reject anything that is not perfect in favor of the alternative (not good or bad or much worse). It means that we need to keep improving. Science does keep improving.

Footnotes:

[1] We all rely on evidence. The important difference is __________.
Tue, 24 Jun 2014
Rogue Medic
Article

[2] The crisis in evidence-based medicine
June 23, 2014
Bill Gardner
The Incidental Economist
Article

[3] Evidence based medicine: a movement in crisis?
Greenhalgh T, Howick J, Maskrey N; Evidence Based Medicine Renaissance Group.
BMJ. 2014 Jun 13;348:g3725. doi: 10.1136/bmj.g3725. No abstract available.
PMID: 24927763 [PubMed – in process]

Free Full Text from BMJ.

[4] Who you gonna believe, me or you own eyes?
Dr. Mark Crislip
July 12, 2013
Science-Based Medicine
Article

Or listen to the audio version in MP3 format by Dr. Mark Crislip –
121: Who you gonna believe, me or your lying eyes

[5] Correction to Spine Immobilization in Penetrating Trauma: More Harm Than Good
Tue, 15 Mar 2011
Rogue Medic
Article

[6] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part III
Tue, 01 Mar 2011
Rogue Medic
Article

[7] Flawed Helicopter EMS vs Ground EMS Research – Part II
Thu, 19 Apr 2012
Rogue Medic
Article

[8] Framingham Heart Study
Home page

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Is First Responder Narcan the Same as First Responder AED?


Image credit.
 

Are these the same?

If one works, does the other work?
 


Image credit.
 

The idea that first responders can safely give naloxone (Narcan) is popular, but only based on things that we want to be true. Dr. Oz would love it.

It has been suggested that giving first responders naloxone is the same as giving them AEDs (Automated External Defibrillators).[1] AEDs are defibrillators that can deliver the same shock as a manual defibrillator, but AEDs do not require all of the education needed to become a paramedic, nurse, PA, NP, or doctor.

Unlike naloxone, AEDs are designed to do almost all of the assessment for the first responder. The AED is only supposed to be attached to a pulseless patient, so assessment for responsiveness and the presence of a pulse is expected by the first responder. Is naloxone assessment that simple?

When a patient actually has an opioid overdose, it can be that simple, but –

Not all patients who respond after naloxone, respond because of naloxone.

This is the concept that is difficult to explain to the advocates of first responder naloxone programs.

1. Some advocates deny that this happens, even though it is documented.

2. Some advocates claim that we already know all that we need to know about naloxone.

3. Some advocates also claim that we should not study this because we already know all that we need to know.

Since there is overlap among the groups, the failure to understand the problem of improper assessment, especially among paramedics, nurses, and doctors is a huge problem. If we do not understand naloxone, with all of our education in pharmacology, how can we expect first responders to understand naloxone without any education in pharmacology?

What kind of education can prevent mistakes? How do we know?

If we listen to those who don’t know, but claim that they know all that they need to know, we will be ignoring the possibility of unintended consequences and assuming that we are too smart to make mistakes. Is that reasonable?

Do AEDs save lives?
 

CONCLUSION:

Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.[2]

 

The problem is not that AEDs do not work.

The problem is not that AEDs are not safe.

The problem is thinking that AEDs are a simple solution to a problem that is not as simple as some would like us to believe.
 

The concept of equipping as many emergency responders as possible with AEDs has been widely adopted,2 and 31 but it should not be blindly adopted without improving the EMS system at all levels. This decision should be individualized to each EMS system based on all of the variables in EMS response. As an isolated enhancement, it is doubtful that addition of AEDs will provide a measurable survival benefit.[2]

 

If first responder naloxone were limited to people found with needles in their arms, less thought would be required. As the presentation of overdose changes to prescription opioids, there is less clear evidence of overdose and more of a need for a good assessment and understanding of pharmacology.

First responder naloxone may save lives, when it is administered appropriately. We should study this before implementation. Discouraging us from studying the safety and efficacy of this type of use of naloxone is bad medicine.
 

Also see –

Is ‘Narcan by Everyone’ a Good Idea?

Should Basic EMTs Give Naloxone (Narcan)?

The Myth that Narcan Reverses Cardiac Arrest

To Narcan or not Narcan

What About Nebulized Naloxone (Narcan) – Part I

Footnotes:

[1] I’ve heard that PA is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone. . . .
Facebook
Narcan post

[2] EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.
Sweeney TA, Runge JW, Gibbs MA, Raymond JM, Schafermeyer RW, Norton HJ, Boyle-Whitesel MJ.
Ann Emerg Med. 1998 Feb;31(2):234-40.
PMID: 9472187 [PubMed – indexed for MEDLINE]

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Dr. Oz Shows How He Lies with Bad Research


 

These pictures show the same thing – abuse of trust.
 


 

Today, Dr. Oz was questioned by Sen. Claire McCaskill of the Senate Commerce subcommittee on Consumer Protection, Product Safety and Insurance. Watch how Dr. Oz spins nonsense to defend his promotion of treatments that do not work. Fortunately, Sen. McCaskill does not fall for his propaganda. The video is embedded at the end.
 

Dr. Oz – These are the five papers. These are clinical papers. We can argue about the quality of them, very justifiably. I could pick apart the papers that show no benefit, as well.[1]

 

Translation – People do not understand science, so I, Dr. Oz, can easily fool them.
 

Dr. Oz – It is remarkably complex to figure out what works for most people in a dietary program.[1]

 

Translation – I almost don’t have to lie, but I just can’t help myself.
 

Dr. Oz – I don’t think this ought to be a referendum on the use of alternative medical therapies, because if that’s the case, I’ve been criticized for having people come on my show talk about the power of prayer. Now, as a practitioner, I can’t prove that prayer helps people survive an illness.

Sen. McCaskill – It’s hard to buy prayer.

Dr. Oz – That’s the difference.[1]

 

Translation – I would sell prayer if I could, but the real point of my comment was to try to change the subject and make it seem like I am defending prayer. I am defending fraud.
 

Dr. Oz – My show is about hope.[1]

 

Translation – Hope sells.

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

Dr. Oz – I actually do personally believe in the items that I talk about on the show. I passionately study them. I recognize that, often times, they do not have the scientific muster to present as fact,[1]

 

Translation – There is no good reason to believe in this stuff.

I believe in this stuff.

My ratings depend on my belief.
 

Sen. McCaskill – The scientific community is almost monolithic against you in terms of the efficacy of the three products you described as miracles.[1]

 

Translation – You are a taking advantage of your position to deceive your audience.
 

Sen. McCaskill – When you call a product a miracle, and it’s something you can buy, and it’s something that gives people false hope, I just don’t understand why you needed to go there.[1]

 

Translation – Don’t you have any integrity?
 

Dr. Oz – My job on the show is to be a cheerleader for the audience.[1]

 

My job on the show is to be a cheerleader for the audience Big Placebo – the companies that make billions of dollars off of the audience.

Translation – No. I don’t have any integrity.
 

We need to stop making excuses for those who endanger patients with treatments that do not work and have not been demonstrated to be safe.

We need to be consistent in applying this to alternative medicine and conventional medicine.
 

Footnotes:

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

.

Would a Taser Have Made a Difference in the Outcome?


Investigators on the scene of a deadly shooting by San Mateo County Sheriff’s deputies. (CBS)
 

What kind of response should EMS have when a person is reported to be acting violently and carrying a knife? We stage around the corner, or a few blocks away.

What about the police? They need to try to disarm the person and control things without anyone getting hurt, but that is not always possible.

According to the various articles in the news, two deputies arrived and confronted Yanira Serrano-Garcia, an 18 year old woman who had not been taking her medication.
 

Two deputies responded to the Moonridge Housing Complex at Miramontes Point Road, east of Highway 1, where the woman lived, Rosenblatt said. The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[1]

 

However, another article states that the police were provided with different information.
 

The information received by emergency personnel who responded to the incident was that the woman was acting erratically and violently and had a knife. The woman’s family asked her to put the knife down, and when she didn’t comply, family members called the fire department for medical assistance, Rosenblatt said.[2]

 

Another states –
 

The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[3]

 

No recordings of 911 tapes are quoted, but the information that was provided to the responding deputies might change how they approached her.

Should the family have tried to get unarmed EMS to respond to care for a violent armed patient? No.

Were they just trying to protect her? Probably.

What happened?

The two deputies confronted Yanira Serrano-Garcia and shot her at least once. She was pronounced dead on scene.
 

“I don’t know why they couldn’t have done better things instead of getting a bullet through her and trying to shoot her,” said Saul Miramontes, Serrano-Garcia’s cousin. “She was kind of sick — you know, at least they could have Tasered her or at least tackled her.”[1]

 

Tackling someone who has a knife is a very bad idea for everyone. It had Darwin award written all over it.

A Taser may be appropriate, but it should involve at least two armed people, one with the Taser and one backup with a firearm that is drawn and aimed at the person to be taken down. It is not considered appropriate to just drive up and use the Taser without making some attempt to get the person to put down the knife voluntarily.

One problem with the use of the Taser is that if you are close enough to use the Taser, and the person with the knife lunges toward you, you may be stabbed without being able to hit the person with the Taser.
 


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Did either deputy have a Taser out? We do not know from any of the articles.

Why did only one deputy shoot? It may be that they were not positioned well and when the deputy who did shoot moved, he moved into the line of fire of the other deputy. Maybe the other deputy froze. Maybe the other deputy did not think that a shot was the appropriate response for the circumstances. There can be many other reasons. We do not know.

Was there some other reason that the deputy felt the need to shoot quickly (the shot is reported to have taken place within a minute of arriving on scene)?

There is another bit of information that has not been included in the more recent news reports. This is from a cached copy of one article.
 

Dyanna Ruiz, 12, said she had been walking to a friend’s house when she saw the deputy running away from a woman who had her arm raised and was chasing him with what appeared to be a knife.

“I saw the girl running at him with something in her hands,” Dyanna said. “I didn’t know what was happening. I was really scared about what to do.”

The deputy saw Dyanna, stopped and yelled at Serrano-Garcia, the girl said. When Serrano-Garcia kept coming at him, the deputy fired, Dyanna said.[4]

 

The deputies may have had a plan for controlling the situation that may have seemed reasonable with just the two of them and the person with the knife at risk. With a child/adolescent also at risk, the plan may fall apart. That is pure speculation on my part, but I have a lot of experience with plans falling apart, as does anyone who deals with emergencies.

Why was the statement of this witness removed from more recent versions of the article? I do not know.

Will a Taser always work? No. Sometimes, in spite of reasonable attempts to do everything right and protect lives, bad outcomes still happen.

Footnotes:

[1] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie eivie@mercurynews.com
Posted: 06/04/2014 05:56:45 AM PD Updated: 6 Days ago
Contra Costa Times News
Article

[2] Officer Who Killed Woman Felt His Life Was in Danger
Joan Dentler (BCN)
Friday June 06, 2014 – 09:51:00 AM
Page One
The Berkely Daily Planet
Article

[3] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie
eivie@mercurynews.com
Posted: 06/04/2014 05:56:22 AM PDT Updated: 6 Days ago
San Jose Mercury News
Article

[4] Woman, 18, shot dead by San Mateo sheriff’s deputy
Henry K. Lee and Kurtis Alexander
Updated 5:07 pm, Wednesday, June 4, 2014
SFGate.com
Cached version of the article. It is a snapshot of the page as it appeared on Jun 5, 2014 00:40:18 GMT.

Woman, 18, wielding knife shot dead by San Mateo deputy
Henry K. Lee and Kurtis Alexander
Updated 8:46 pm, Friday, June 6, 2014
Article at the same link, but when I last checked at 18:00 6/10/2014, the part I quoted was not in the article.

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