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

- Rogue Medic

Evidence Based Medicine and Law – Star of Life Law

This is a follow-up to the discussion of MOI (Mechanism Of Injury) begun on Ambulance Driver’s column for EMS1.com – The Cult of Mechanism, which was given a brief introduction at Ambulance Driver’s blog, then hijacked over to here for some commentary, but mainly remaining at AD’s place. Then out of nowhere it is re-hijacked by Star of Life Law. Has he no ethics about this secondary hijacking? Well, he is a lawyer.

What does this lawyer do with his post?

He writes about legal stuff. So predictable. However, a lot of the discussion was about what may land EMS in court, or our patient in the ICU/cemetery. The court room can be scary. Pete Reid writes Star of Life Law and promises to address the legal aspects of EMS on his blog. Of course he starts by picking on the guy with the big yellow head.

From the way we are quoted, it almost seems as if AD and I do not agree on the value of MOI. We do not agree on everything. For example, AD does get a bit carried away when it comes to bacon.

Neither of us seem to have much respect for the abused tool that is MOI. A tool that is held out to the EMS community as a stay out of court free card.

Will you get in trouble for basing your treatment on MOI?

If your medical director knows what the value of MOI is, then Yes. You will probably be questioned on the reason for treatments that are not based on a patient assessment.

Is there a reason to be treating a person based on what does not appear to have injured the patient?

Not really. MOI is a clue. I thought about wording this differently, so that I could write that those basing treatment on MOI don’t have a clue. That would be misrepresenting MOI. MOI is a clue about the patient’s condition, but it is a very weak clue.

What are the MOI criteria?

First let’s look at all of the ACS (American College of Surgeons) trauma triage criteria.

Physiologic criteria:
Systolic blood pressure 29 breaths/min

Anatomic criteria:
Flail chest
≥2 proximal long bone fractures
Penetrating injury (nonextremity)

“Other” criteria:
Age 55 years
Known cardiac or respiratory disease

Mechanism criteria:
Crash speed >20 mph
≥30-inch vehicle deformity
Rearward displacement of front axle
Death of a same-vehicle occupant
Ejection of patient from the vehicle
Opposite-side intrusion >24 inches
Same-side vehicle intrusion >18 inches
Vehicle rollover[1]

The funny thing about these criteria is that you cannot find them on the ACS web site. At least I cannot. I have spent hours searching the site on different occasions. Apparently these are some sort of secret.

This is all I am going to write today. There is a lot about the trauma triage criteria, their application/misapplication, and other stuff to discuss. read what others have written. Welcome Star of Life Law to the EMS blogging community.

Footnotes:

^ 1 Evidence for and impact of selective reporting of trauma triage mechanism criteria.
Burstein JL, Henry MC, Alicandro JM, McFadden K, Thode HC Jr, Hollander JE.
Acad Emerg Med. 1996 Nov;3(11):1011-5.
PMID: 8922006 [PubMed – indexed for MEDLINE]

These criteria are from a 1996 study, so they are probably not the most recent, but they do provide a lot to write about.

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Endotracheal Drug Administration in Cardiac Arrest

ET (EndotTracheal) drug administration in cardiac arrest is one resuscitation topic that refuses to die. People keep trying to bring ET drugs back to prominence in ACLS (Advanced Cardiac Life Support). In the absence of evidence of benefit of a treatment, the intervention should be studied in settings that are as controlled as possible. When the evidence suggests harm from the treatment, unless that apparent harm is outweighed by apparent benefit, the treatment probably should not even be used in controlled studies.

How does this apply to ET drug administration in cardiac arrest?

Before looking at the research, let’s look at the theory behind this.

ALS (Advanced Life Support – drugs, IVs, intubation, . . .) improves outcome from cardiac arrest.

In one recent and very large study of this, Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest[1], the claim that ALS saves lives in cardiac arrest is shown to be not supported, at least not with the ALS that was used at the time of the study. That ALS has not changed much, but the BLS (Basic Life Support – CPR, defibrillation, . . . generally non-invasive treatments) has changed significantly.[2] There is one ALS treatment that is promising, therapeutic hypothermia,[3] but that was not being used at the time and is not the reason for this post.

The research on ALS in cardiac arrest does not show an improvement in resuscitation. Resuscitation is the ability for the patient to leave the hospital with brain function similar to the brain function they had prior to the cardiac arrest. Resuscitation is not arriving at the hospital with a pulse.

While arriving at the hospital with a pulse is important for resuscitation, focus on this is bad patient care. If we were only interested in arriving at the hospital with a pulse, we could just shock the patient into asystole, use a pacemaker and drive fast. we might have to upgrade the pacemakers from milliAmps to Amps and use thicker rubber gloves, but this could improve the number of patients arriving at the hospital with pulses. That does not mean it would improve the number of patients leaving with good brain function. A focus on pulses is not good for patient care. Even Dr. Frankenstein would feel silly yelling, It’s Alive, for a monster with just a pulse. Even the fictional doctor, in a book almost 200 years old, knew that the brain was essential to resuscitation.

If you think that arriving at the hospital with a pulse is a big deal, you probably would have done well as a banker up until this year, thinking that making reckless loans is conservative, because you wear a suit and tie. Either way, other people pay for your mistakes. With all of the increase in resuscitation rates following the improved focus on continuous good compressions, how many thousands of deaths have the get a pulse back crowd been responsible for by distracting paramedics, nurses, and doctors with ineffective and harmful drugs?

So, what research is there on ET drug administration in cardiac arrest?

One study does compare IV (Intravenous) medication administration with ET medication administration in cardiac arrest. Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?[4] There are some differences between the groups. The endotracheal drug group was 5 times larger, 5 years older, much more likely to be female, twice as likely to be in a nursing home, much less likely to have VF and much more likely to have asystole as the initial rhythm. The results still should not be ignored.

Why not?

Although this is a retrospective study with a lot of variables that have not been controlled for, it is the largest only study to look at survival to discharge.

Why does that matter?

There is no other study on ET administration worth looking at. Unless you are interested in something that looks at the change in blood level of epinephrine in a pig in a laboratory. Since I do not treat pigs in a laboratory, this is not really relevant to what I do. Even if I do find a pig in cardiac arrest under a spider web that reads, Humble, I will not be regretting that I am not more familiar with these studies. Besides the IO (IntraOsseous) needle has become standard in cardiac arrest treatment.

What were the results of the study?

Of the IV drug group, 5% survived to discharge.

That sounds typical for the resuscitation rates back then. What about the ET drug group?

Nobody survived.

If you have good circulation, you may absorb medication from the lungs without complication.

If you have circulation by way of chest compressions, that may not be the case.

If you have to stop the compressions in order to deliver the medication, you are doing more harm than any possible good that could come from providing these drugs that are not research based. Since none of the drugs are research based, apparently not even oxygen, that means all of the drugs are a problem.

There is not even evidence that providing oxygen down the ET tube is good for the patient, but we still have people who think that making Mr. Bubble in the lungs is good patient care.

Footnotes:

^ 1 N Engl J Med. 2004 Aug 12;351(7):647-56.
Comment in:N Engl J Med. 2004 Dec 9;351(24):2553-4; author reply 2553-4.
Advanced cardiac life support in out-of-hospital cardiac arrest.
Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.
Free Full Text

One interesting aspect of the OPALS criteria is an attempt to evaluate the quality of the paramedics participating in the study. Listed among the criteria is “and paramedics had to successfully perform an endotracheal intubation in 90 percent of patients. These criteria were monitored regularly, and the three communities that failed to meet the standards were excluded.”

^ 2 Just one example of the improved resuscitation rates is provided in this post from Ambulance Driver and the comments.
Does This Mean I’m Fully Assimilated?

^ 3 Therapeutic Hypothermia
Wikipedia article

^ 4 Niemann JT, Stratton SJ, Cruz B, Lewis RJ.
Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?
Resuscitation. 2002 May;53(2):153-7.
PMID: 12009218 [PubMed – indexed for MEDLINE]

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