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

Belly flops with cliches, proves he’s a Satirist (You have a dirty mind if you’re thinking what I think you’re thinking this means)


What happens when EMS becomes so distorted that it is embarrassing?

Things get silly.

Image credit.

By silly, I mean the satire starts off simply, but then becomes a multi-layered satire that deserves its own Wikipedia page. There is no page, yet, or is there?

Kelly Grayson started us off with an article about EMS cliches.

From the blank stares I got from all assembled, I realized that none of them had ever seen Bull Durham. So while I educated them in the Tao of Crash Davis, I started thinking about the clichés we spout in EMS. Every cliché has at its root a central truth; that’s how they get to be clichés in the first place.

But nothing is so good as a well-placed cliché as a substitute for real wisdom and knowledge. Just insert one of these babies into a social media comment thread and watch the “Likes” pile up!

. . .

If you learn to use these simple EMS clichés, I guarantee that you will develop a reputation as a paramedic sage in no time. Especially to people who don’t know better.[1]


You’re going to have to read the full article yourself. Polonius would have been skewered several acts earlier if Kelly had been there, but this gets better.

Then Happy Medic turns up the satire by responding to Kelly.


8. “We cheat death.” We do, daily! I have a T-shirt with the Grim Reaper being slapped in the face by a bad ass medic with sunglasses and everything. You are so narrow minded you can’t see how we bring the dead back everyday. Epi works Kelly![2]


Go read the rest, too.

Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them; – Thomas Jefferson.

Finally, Tor eckman takes it to Eleventy!!11!!! in the comments.

I also teach them to think and look for clues on scene, like just last week I got to see the lights come on in this “newb” Paramedic when he wasn’t going to spinal a patient in a MVC until I had him walk down the bank and look at the car, after seeing the mechanism he came back up, told the patient that he was lucky he wasnt paralyzed for walking up the bank. We did a standing take-down right then and there. By the time we got to the hospital the pt had pretty bad back pain, can you imagine if we hadn’t put him on the backboard? lawsuit. So go ahead and make fun of the noobs, I’ll take them and teach them.[3]


I think that someone should Call the Cops for all of this abuse of the witless, because the giggles just keep on coming.

Maybe this is an example of Poe’s law (a legitimate comment from some person who is so blind to their bias that they do not notice the self-parody)?[4],[5]

Maybe, but Tor eckman[6] is a character from Seinfeld. Tor eckman is a ridiculous alternative medicine practitioner, much like our ridiculous EMS providers who do not understand what it means for a treatment to improve outcomes.

Go spend some time reading the comments on social sites and you will see that this might not be satire, but somebody should take credit for it if it is satire – and somebody should be ridiculed for it if it is not satire.




[1] The stupid EMS cliche usage guide – Using phrases like ‘We cheat death’ is so much easier than actually thinking
September 30, 2013
The Ambulance Driver’s Perspective
by Kelly Grayson


[2] Kelly Grayson belly flops with cliches, proves he’s a Noob
Happy Medic
October 3, 2013


[3] Tor eckman’s comment
Kelly Grayson belly flops with cliches, proves he’s a Noob
Happy Medic
October 3, 2013


[4] Poe’s law

Without a blatant display of humor, it is impossible to create a parody of extremism or fundamentalism that someone won’t mistake for the real thing.



[5] Poe’s law

The site’s description of Poe’s law appears to qualify as a parody of extremism or fundamentalism that someone won’t mistake for the real thing. Or is it the real thing that someone will mistake for parody?

Will Andrew Schlafly wait until his mother is dead before he admits that he was just trying to please his mother, just not as violently as Norman Bates? Or is he the real thing that someone will mistake for parody?


[6] The Heart Attack


Bad Patient Care – Literalists


There are many ways that we harm patients.

One way is by claiming that we need to literally interpret some rule, such as a protocol.

Once we start to try to do this, we come across contradictions.

What is most important in patient care?

Doing what is best for the patient?

What is most important in literal interpretation of anything?

Protecting the literal interpretation.

But it is literally what is written, it is not open to interpretation.

All writing is open to interpretation. We can try to simplify it as much as possible. We can try to make it as clear as possible. Someone will read the writing as meaning something else. Some of those people will have valid points about what the writing means.

For EMS protocols, are all penetrating injury patients the same?

Of course not, so we try to be specific.

Are all penetrating injuries to the neck the same?

Of course not. When I shave, I occasionally penetrate the skin of my neck with the razor, thus lightly slashing my neck.

Should that be treated the same as the slashed neck of someone who is slashed with a knife in an attempt to kill the person?

Of course not.

You may claim that I am being ridiculous.

That is the point. Literal interpretation is ridiculous.

That is why protocols should be written as guidelines that are flexible enough to deal with the real world.

Assessment is the way we determine the difference between a penetrating injury to the neck that needs a trauma center and the minor injury that does not.

Competent assessment does not work with attempts at literal interpretation.

Literal interpretation is an excuse to lower standards so that the least intelligent people can participate.

We need to raise our standards.

If raising our standards mean that some people cannot play with the lives of others, that is a real shame. :oops:

How little do we care about our patients that we are more worried about offending dangerous instructors and dangerous medics, rather than worried about protecting patients from the results of dangerous instructors and protecting patients from dangerous medics?


One Laceration, Two Helicopters, Third Part


There is also a comment from steve mauch on Two Children Abducted by EMS Helicopter for One Laceration that deserves comment.

Rouge, I see what you’re getting at, but the problem is not so much with the medic, its what/how he was taught. If in his area they are taught if you see skull you fly, then he did everything right.



That is what I am criticizing.

We are supposed to be doing what is best for the patient.

We are not supposed to be blindly following protocol, nor blindly following the local culture of fly everyone and let the trauma center discharge them right away.

We need to hold the medical directors and the EMS agencies accountable for this ridiculous approach to patient care.

Where is your outcry against the flight crew that made the decision to fly the second child?? Why not crucify the flight nurse too?!


It was not my intent to crucify the medic.

It is my intent to crucify the system.

I just need some people with hammers and nails and we can nail the system to a Star of Life. ;-)

OK. I will settle for metaphorical crucifixion, but we didn’t have to settle for metaphor in the good old days.

I agree with rick in the fact that we should not be ridiculing each other, we get enough of that.


Sometimes ridicule is an excellent way to expose a problem.

Again, I was not focused on the medic, but on the actions that are commonplace in EMS.

Look at that mechanism!

We can’t be out of service for an hour! What if a call comes in and our dangerous neighboring service has to cover for us? Many of the people in the neighboring service work for both EMS services, because that is the way EMS works. So how dangerous is the neighboring service, if they have the same employees?

This encourages us to take a helicopter out of service for real emergencies, so that we can fly someone for vehicular damage, yet vehicles are designed to deform to protect the occupants of the vehicle – and that kind of design works very well.

My response to the doctors in the trauma center who have questioned me about why I did not fly a patient, why I did not call for a trauma alert, and/or why we took our time driving with traffic, rather than using lights and sirens is this –

Assess the patient and tell me what you find that is unstable, then we will talk.

I also am familiar with the research. There is no valid research that supports flying patients within a 45 minute drive of a trauma center.

There is no valid research supporting the idea that we are not using HEMS enough.

The helicopters are often in the wrong place. Many are close enough to the trauma centers that EMS should be driving patients, but that is not where a helicopter would make a difference in outcomes. Helicopters make a difference in outcomes for unstable patients who are well over an hour drive time from the trauma centers.

We are encouraging the helicopters to flock near the trauma centers, so that they can service the medical directors who write mechanism-only flight protocols that endanger patients.

Maryland changed their protocols so that medical command permission is required for a mechanism-only flight. Helicopter transports were cut by over half. Where are the dead bodies that Dr. Thomas Scalea predicted would be the result of this cut in flights?

But I agree with you that issues DO need to be addressed, but we need to look at the initial educators. As a fairly recent paramedic graduate, I can tell you that medics are being taught to be cookbook medics, we are not taught to think.


I agree.

But, each paramedic program is different.

We need to encourage those medic programs that do a great job. There are many out there.

We need to discourage those medic programs that teach people to be protocol technicians, IV technicians, monitor technicians, alarm technicians – Oh, look! The asystole alarm is going off. I need to start CPR. There are many out there.

Download YouTube Video | YouTube to MP3: Vixy

How much have we changed from the days of calling for orders and being told to give one amp of the yellow box?

If we do not understand pharmacology, we do not understand the most important part of pharmacology – when not to give a drug.

The same is true for procedures. We need to understand when not to use a procedure. Defibrillation, as in the video, or cricothyrotomy, or intubation, or synchronized cardioversion, . . . .

When needle decompression is used, the use almost always appears to be inappropriate.

Needle decompression does save lives when used appropriately.

Click on the image to make it larger.[1]

The chart is for all patients stuck in the chest at least once with a needle in an attempt to decompress a suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

Maybe. Maybe not. We do not know.

It seems that many in EMS need a lot of work in learning when not to attempt needle decompression.

One of the biggest things I recall is SVT. I was “taught” greater than 150=SVT. I went on thinking this was fact. I was not taught svt is a class of rhythms, not a rhythm by itself.


SVT – SupraVentricular Tachycardia.

The sinus node is supraventricular.

Sinus rhythms do not benefit from adenosine or synchronized cardioversion.

Do not blame the medic for not knowing what someone else never took the time to pass along.


Yes and No.

We need to take responsibility for our own education.

Education does not stop once we put on a patch or get authorized to work on our own.

I was supposed to be writing about the presentations at EMS Expo this week, but it is looking as if that will be next week. If we attend EMS conferences, we can learn about the things our instructors misinformed us about.

Backboards probably do more harm than good, especially for the patients with unstable spinal injuries.

Helicopters do save lives, but probably only for unstable trauma patients over an hour from the trauma center.

How to interpret 12 lead (and 15 lead and 18 lead, . . .) ECGs and how to identify unusual rhythms.

Now I am off to once again demonstrate that a heart rate faster than my calculated maximum heart rate is possible and can still be sinus tachycardia. When I wake up, my heart rate will be a respiratory arrhythmia sinus bradycardia. All of these are arrhythmias/dysrhythmias, but they are not bad rhythms and they are not the absence of rhythm.[2]

These arrhythmias/dysrhythmias are better than normal sinus rhythm.

Arrhythmias/dysrhythmias are treatable, but most do not benefit from treatment.

Should anyone ever use the term normal sinus rhythm?

What do we base normal on?

Does that mean that the patient’s heart is healthy?

How much beat-to-beat irregularity is permitted while still calling the rhythm normal?

What is the difference between normal and healthy?

If a patient is having a normal episode of angina, is that a good thing?

If a patient is having a normal seizure, is that a good thing?

If a patient is having a normal case of hypoglycemia, is that a good thing?

Based on what?

We often use terms we do not think about. Does that mean that it is not normal for us to think?

Is normal good?

In all of that I forgot to mention, I agree that they should not have been flown, ESPECIALLY since mom was against it, but I wasn’t there and it wasn’t my call. I do think way too many people are flow, and even more people are backboarded that don’t require it. We need to improve critical thinking and assessments BEFORE applying devices and treatments, but that’s a whole new blog!


Again, this is about highlighting the problem, not the person.

We have a big problem. Making a scapegoat out of one individual does not change the problem.




[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]

Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010


[2] dys-
The Free Dictionary

       1. Abnormal: dysplasia.
               a. Impaired: dysgraphia.
               b. Difficult: dysphonia.
       3. Bad: dyslogistic.
[Latin dys-, bad, from Greek dus-; see dus- in Indo-European roots.]
The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.



Do We Have a ‘Bigotry of Low Expectations’?

Kelly Grayson writes that -

The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves[1]


Image credit.

Is this an unreasonable assessment?

No, it may be too subtle for most to understand, because Kelly does not appear to have received the usual hate mail that comes with the exposure of EMS problems.

What lies do we tell ourselves?


“We don’t diagnose.”[1]


We have no idea of what we are doing, but we give deadly drugs and perform deadly procedures based on this no idea.

“We work under the physician’s license.”[1]


Using similar logic, when I drive a car, truck, ambulance, . . . I am driving on the Governor’s driver’s license. If I drive dangerously, the Governor will share liability, since I am driving on his license.

It may state in the health code that medics in some states do practice on the license of the medical director, but please provide some evidence of action against that license because of a paramedic’s actions.

Where is the command responsibility?[2]

“The protocol says…”[1]


This is usually followed by misinterpretation.

This is not because protocols are so well written that they do not encourage bad treatment, but the approach is to find absolute rules to prevent the person from thinking. The person is afraid of his own thinking. This does not suggest that he does a good job of thinking. Therefore, whatever interpretation he makes can be expected to be a misinterpretation.

“Right or wrong, he’s the doctor. We have to follow orders.”[1]


That excuse has failed before.

despite the fact that the medication was ordered by a physician, each of these individuals knew from the Advanced Cardiac Life Support guidelines that the medication could have “lethal,” “disastrous” consequences when administered to someone like the plaintiff, and they recognized that the standards of care applicable to them required that they exercise independent judgment and not just “blindly follow a doctor’s order that they knew posed an extreme degree of risk to the patient”

Columbia Medical Center of Las Colinas v. Bush, 122 S.W.3d 835 (Tex. App.—Fort Worth 2003, pet. denied).[3]


We are responsible for our actions.

If you are looking to avoid responsibility, you should not be in any position of trust.

Where does all of this lowering of standards lead?

Never mind all that. We can’t meet our goal. Let’s lower the standard.

Allow me paint for you a little self-fulfilling prophecy:

  1. Paramedics gripe because they are underpaid and disrespected, and have difficulty obtaining reciprocity in other states.
  2. ED physicians complain because we bring them patients whose airways are poorly managed.
  3. . . . .[1]


Where does this lead?

Go read the full article.




[1] The bigotry of low expectations – The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves
By Kelly Grayson
August 13, 2013


[2] Command responsibility


[3] Malice/gross negligence.
Thornton RG.
Proc (Bayl Univ Med Cent). 2006 Oct;19(4):417-8. No abstract available.
PMID: 17106507 [PubMed]

Free Full Text from PubMed Central.


The Path to Insanity


With this podcast,[1] Dr. Weingart is preaching to the choir in many ways.

Insanity is looking at the world and seeing something different from what normal people see.

Normal people don’t want to know about that, but curious people do.

Curiosity is the basis of science and learning.[2]

Curiosity is the antithesis of dogma.

Curiosity will lead us to think about what others call insane.

Go listen to the podcast.



I do have a couple of points to criticize, but these are slips of the tongue by Dr. Weingart. They are not errors of judgment, nor are they errors of fact.

He refers to Malcolm Gladwell as Gladstone. His brain is probably well ahead of what he is saying and he did not realize that what came out of his mouth was not what he intended.

The other is more likely to be confusing.

This homophony has the possibility of confusing the listener, because it is difficult to tell if he is using the word confidence or competence. Just a few sentences before, he was discussing competence, but now he is discussing confidence, specifically unjustified confidence. For the Australian listener, it may have been more difficult to understand with Dr. Weingart’s American accent. Written, it should be clear which word Dr. Weingart intends.

At 19:30 –

“To become competent you must feel bad”Hubert Dreyfus[1]


Unless we push ourselves beyond our current comfort zone abilities, we are only treading water, or we are sinking. This is the way we learn.

If we do not understand how our students feel, maybe it is because we have stopped learning. Maybe we have stopped putting ourselves in positions where we are novices.

If we are comfortable at everything we do, we are not trying anything truly new to us. If we do not try anything new to us, how do we understand the experiences of our students, who are often overwhelmed by the amount of new information they are expected to learn?

At 19:50 –

Charles Darwin put it even better – ignorance more frequently begets confidence than does knowledge.[1]


At 20:15 –

Unconscious incompetence – You don’t know and you don’t know that you know.[1]


It should be obvious that Dr. Weingart did not misunderstand the Dunning-Kruger effect.[3] He makes it clear through the rest of this excellent presentation that he understands what Dunning and Kruger demonstrated. However, he does appear to have had a slip of the tongue.

The Dunning-Kruger effect can be summed up by adding back the dropped don’t.

Unconscious incompetence – You don’t know and you don’t know that you don’t know.[1]


The title of the paper by Dunning and Kruger is -

Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments.[4]

Later, Dr. Weingart states –

Never assume your own excellence.[1]


We should always consider that we may be wrong. This is the way to not fall victim to dogma.

How much less likely will we be to automatically give a medication, because it is the customary thing to do, if we consider that we may be wrong?

How much less likely will we be to automatically perform a procedure, because it is the customary thing to do, if we consider that we may be wrong?

How much less likely will we be to automatically follow custom, if we consider that we may be wrong?

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

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


Go listen to the podcast.


Also look at the excellent references provided by Dr. Weingart in the show notes.




[1] Podcast 105 – The Path to Insanity
Dr. Scott Weingart
Podcast/Videocast page.


[2] Curiosity
Name the Rover Contest
Winning entry by Clara Ma.

Curiosity is an everlasting flame that burns in everyone’s mind. It makes me get out of bed in the morning and wonder what surprises life will throw at me that day. Curiosity is such a powerful force. Without it, we wouldn’t be who we are today. When I was younger, I wondered, ‘Why is the sky blue?’, ‘Why do the stars twinkle?’, ‘Why am I me?’, and I still do. I had so many questions, and America is the place where I want to find my answers. Curiosity is the passion that drives us through our everyday lives. We have become explorers and scientists with our need to ask questions and to wonder. Sure, there are many risks and dangers, but despite that, we still continue to wonder and dream and create and hope. We have discovered so much about the world, but still so little. We will never know everything there is to know, but with our burning curiosity, we have learned so much.


If we do not question everything, we must be satisfied with ignorance.


[3] Dunning-Kruger effect

Science denialism is excellently described by the Dunning-Kruger effect. A comedian claims to know more about vaccines than scientists – and people believe the misinformation. Some politicians claim to know more about climate than scientists – and people believe the misinformation. Some preachers claim to know more about biology, geology, paleontology, . . . than scientists – and people believe the misinformation.


[4] Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments.
Kruger J, Dunning D.
J Pers Soc Psychol. 1999 Dec;77(6):1121-34.
PMID: 10626367 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from Emory.edu.


Examples of Ventricular Tachycardia Caused by Amiodarone – Part I


How much worse could the patient get if we give amiodarone?

But amiodarone doesn’t cause V Tach (Ventricular Tachycardia). Amiodarone stops V Tach.


If amiodarone can cause V Tach, shouldn’t someone have told us?

Click on image to make it larger.

This is a wide complex tachycardia, which should be presumed to be V Tach. The diagnosis of the rhythm as V Tach is supported by the P-wave dissociation and by the history of a heart attack a couple of weeks before. 19 QRS complexes in 5 seconds (multiply by 12 to get the rate for 60 seconds) = 228.

According to ACLS (Advanced Cardiac Life Support) what drug would be indicated for the above rhythm?

For the old timers, let’s throw in a bit of information that is supposed to be important in deciding among the various antiarrhythmics –

Transthoracic echocardiography was performed, and the ejection fraction was 34% based on the modified Simpson method.[1]


Does the ejection fraction matter in treating wide-complex tachycardia?

Note that amiodarone becomes the antiarrhythmic of choice (after failure of adenosine) if the patient’s cardiac function is impaired and the ejection fraction is <40% or there are signs of congestive heart failure.[2]


That was only mentioned in the 2000 ACLS guidelines. The 2005 ACLS guidelines and the 2010 ACLS guidelines do not mention ejection fraction in the treatment of V Tach.

Do we have good evidence that amiodarone is effective for stable V Tach?

Amiodarone has not been studied specifically for the pharmacological termination of hemodynamically stable VT, but it is effective in treating hemodynamically unstable VT and VF.78 81 82 83 84 85 86 87 88 89 90 91 [2]


That was written in 2000 and the answer was NO.

Now we have evidence that amiodarone may be effective in about one out of four patients – if we are prepared to wait a half hour, or more. In other words, it is rare for amiodarone to work and rarer still for amiodarone to work before we can get the patient to the hospital.[3],[4],[5]

We do have evidence that amiodarone may be a part of the long-term treatment of unstable V Tach. On the other hand, maybe not.

I do mean long-term treatment, even though these are unstable patients.

Twenty-seven (58.5%) of the 46 patients responded to intravenous amiodarone, and an additional 6 patients (13%) showed a late response to amiodarone (Fig. I). Fifteen of the 27 responders (33% of all patients) responded immediately (0 to 2 h), and 26 responded within 72 h . The other patient responded within 84 h (Fig. 2).[6]

Up to 84 hours to take effect.

Not exactly an emergency drug.

I have worked some very long shifts. I have never worked an 84 hour shift.

If amiodarone can take 84 hours to work, and the patient is receiving a variety of other treatments during those 84 hours, is it really the amiodarone that is working?

Compared with 84 hours, a less than two hour time to response seems almost instantaneous, but it is not fast for EMS.

This patient was treated with oral amiodarone for sustained V Tach during his previous hospital admission for an acute anterior MI (Myocardial Infarction) treated with a stent in the LAD (Left Anterior Descending) coronary artery.

This time he was treated with IV (IntraVenous) amiodarone. The problems began on the first day of IV amiodarone treatment.

On the first day of hospitalization, the patients had 10 attacks of pulseless VT treated with successful DC shocks. Occasionally, VT attacks degenerated to ventricular fibrillation.[1]


And continued –

On the second day of hospitalization, the patient had 14 pulseless VT attacks with successful DC shocks.[1]


But the V Tach stopped after the amiodarone was stopped and antithyroid therapy was begun.

Thyroid gland toxicity is one of the most important adverse effects of amiodarone and is called amiodarone-induced thyrotoxicosis. Thyrotoxicosis may alter arrhythmia and lead to frequent ventricular tachycardia attacks.[1]


All things are poison, and nothing is without poison; only the dose permits something not to be poisonous. – Paracelsus (1493-1541)

We do not seem to explain that well in EMS, or even in emergency medicine.

All antiarrhythmic agents have some degree of proarrhythmic effects.[7]


Amiodarone is one of the most dangerous drugs we carry in EMS.

How much thought do we give to the problems we can cause for our patients with this drug?

How much do we understand about the problems we could be causing when we push medications, such as amiodarone?




[1] Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm.
Erdogan HI, Gul EE, Gok H, Nikus KC.
Am J Emerg Med. 2012 Nov;30(9):2092.e5-7. doi: 10.1016/j.ajem.2011.12.035. Epub 2012 Mar 3.
PMID: 22386340 [PubMed - indexed for MEDLINE]


[2] Amiodarone
2000 ECC Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 5: Pharmacology I: Agents for Arrhythmias
Arrhythmias and the Drugs Used to Treat Them
Hemodynamically Stable Wide-/Broad-Complex Tachycardias
Treatment of Wide-Complex Tachycardias
Free Full Text from Circulation.


[3] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed - indexed for MEDLINE]


[4] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306. doi: 10.1111/j.1553-2712.2010.00680.x.
PMID: 20370763 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.


[5] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed - indexed for MEDLINE]


[6] Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias.
Helmy I, Herre JM, Gee G, Sharkey H, Malone P, Sauve MJ, Griffin JC, Scheinman MM.
J Am Coll Cardiol. 1988 Oct;12(4):1015-22.
PMID: 3417974 [PubMed - indexed for MEDLINE]

Page with link to Free Full Text Download in PDF format from J Am Coll Cardiol.

This is footnote 84 from the second 2000 ACLS quote.


[7] New Concerns From the International Guidelines 2000 Conference: Impaired Hearts and “Proarrhythmic Antiarrhythmics”
2000 ECC Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 5: Pharmacology I: Agents for Arrhythmias
Arrhythmias and the Drugs Used to Treat Them
Hemodynamically Stable Wide-/Broad-Complex Tachycardias
Free Full Text from Circulation.


Erdogan, H., Gul, E., Gok, H., & Nikus, K. (2012). Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm The American Journal of Emergency Medicine, 30 (9), 209200000-2147483647 DOI: 10.1016/j.ajem.2011.12.035


Marill, K., deSouza, I., Nishijima, D., Stair, T., Setnik, G., & Ruskin, J. (2006). Amiodarone Is Poorly Effective for the Acute Termination of Ventricular Tachycardia Annals of Emergency Medicine, 47 (3), 217-224 DOI: 10.1016/j.annemergmed.2005.08.022


Marill, K., deSouza, I., Nishijima, D., Senecal, E., Setnik, G., Stair, T., Ruskin, J., & Ellinor, P. (2010). Amiodarone or Procainamide for the Termination of Sustained Stable Ventricular Tachycardia: An Historical Multicenter Comparison Academic Emergency Medicine, 17 (3), 297-306 DOI: 10.1111/j.1553-2712.2010.00680.x


Tomlinson, D., Cherian, P., Betts, T., & Bashir, Y. (2008). Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment? Emergency Medicine Journal, 25 (1), 15-18 DOI: 10.1136/emj.2007.051086


Helmy, I., Herre, J., Gee, G., Sharkey, H., Malone, P., Sauve, M., Griffin, J., & Scheinman, M. (1988). Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias Journal of the American College of Cardiology, 12 (4), 1015-1022 DOI: 10.1016/0735-1097(88)90470-6


Bad Recipe for EMS Event Laughter


EduMedic has a post about making public relations more entertaining, but he seems to be entertaining his crews and only scaring the children.

He creates a game of Russian Roulette with each child holding a wire connected to the defibrillator and the appearance of the defibrillator delivering a shock through only one of the wires.

No shock will be delivered to anyone, but the children do not know this. The children are told the opposite.

The defibrillator is charged. Capacitor whining until it stops. Dramatic tension for the children.

The defibrillator is discharged. Since everyone is only ECG leads, nobody is shocked, but the presenter is supposed to give the appearance of having been shocked.

9. Immediately scream in agony, drop your limb lead, and run/jump/cry as you feel is appropriate to convey that you were “shocked.”

10. After catching your breath, thank them for being brave and invite them to bring their friends back for additional demonstrations on the half-hour for the duration of the event. With their full attention at your disposal, it is also the ideal time to discuss relevant public safety messages for your organization.

11. Repeat procedure for the rest of the day, or as long as you can keep a straight face.[1]


Look at the picture that accompanies this. The medics are laughing, but the children are not.

This could be a set up for explaining to children the dangers of playing with a defibrillator/AED (Automated External Defibrillator), or any other electrical device.

This could be justified as a way of teaching children about the dangers of electric current, or the benefits of electricity when used appropriately. This could be used for explaining that everything has risks, no matter how beneficial it might be.

I do not see any reason for not explaining that nobody was shocked, but nowhere is that suggested. Nowhere in the responses to my comments is that suggested.

What is provided is a series of logical fallacies.


Ahh, mounting opposition for anything in EMS that isn’t evidenced-based. True to form for you, Rogue![1]


Nowhere did I criticize this for not being evidence-based.

Logical fallacies have to do with confusion, misdirection, deceit, . . . , but not with anything good.[2] This is just one of many logical fallacies that will be used by EduMedic in his responses to my comments.

“You do not appear to have provided them with any education to justify this.”

1. Re-read the title post. It’s a recipe for laughter. The kids laugh, parents laugh, we laugh. Laughter needs no justification.

2. After this demonstration, I have their undivided attention because they had fun. This is when we talk about what EMS personnel do for the sick & injured and when to call 911.[1]

The bold type is EduMedic’s.

Download YouTube Video | YouTube to MP3: Vixy

We have laughter.

The video shows a way to produce laughter. Nobody really had their fingers cut off. Should we be teaching children to laugh at the misfortune of others?

Laughter needs no justification, because nervous laughter is the same as amusement?


Nervous laughter is a physical reaction to stress, tension, confusion, or anxiety. Neuroscientist Vilayanur S. Ramachandran states “We have nervous laughter because we want to make ourselves think what horrible thing we encountered isn’t really as horrible as it appears, something we want to believe.”[3]


Having the opportunity to talk to the children afterward is important.

Explaining the difference between a real danger and this fake electrocution is more important. Where does he explain, or even suggest explaining that the electrocution was not real?

“You do appear to have taught them that EMS encourages taking unreasonable risks.”

1. At no time is there any risk to anyone involved, only the suggestion of it for the sake of teaching. The same thing is done routinely in HazMat Technician classes with adult students when jars of colored water are presented to the students as something highly toxic. Suddenly the presenter has their full attention.

2. The teachable moment occurs when they quickly realize that there really was no shock. I have yet to see a group of children fail to realize it was purely theatrical. It is at THAT moment when they smile, they laugh, and their minds are open to a new idea… that ambulances and the paramedics on them are not scary after all.[1]


Nowhere did I suggest that there was a real risk of shock. My objection has been to the lack of explanation to the children.

Even in adult education, we should tell the students that there was no actual dangerous chemical in the container. Otherwise, we are suggesting that the chemicals are safe enough to keep in a classroom.

Where is there any suggestion that it should be made clear to the children that there was no real risk at any time?

I’m really trying to understand your preoccupation with the disclosure of an imaginary risk. Remember the context of most any public safety PR event. Law enforcement typically comes with a buckle-up “convincer” or a talking DARE car. However, there are no multi-page waivers to sign prior to riding the convincer, nor are there counselors on hand to debrief children who may have been frightened by an unoccupied vehicle that suddenly comes to life.[1]


Even more logical fallacies, but they don’t end there.

EduMedic provides clear statement that he does not understand that children do not look at the world the same way adults do.

Should we teach children to take risks, but not teach them the difference between real risk and pretend risk?

By the way, the D.A.R.E. program is an example of a myth. D.A.R.E. has been shown to have the opposite effect of what is intended. I would provide evidence, but EduMedic might claim that by citing research I was justifying some of his use of logical fallacies.

A large part of education is about perception.

We are trying to change the way students perceive the world.

Being vague, or omitting information, is not good education. These may be good reasons there are so many myths for me to debunk.




[1] Photo Phriday: Recipe for PR Event Laughter
May 3, 2013 9:00 am
Brian Lilley
Article and comments


[2] Fallacy


[3] Nervous laughter


The Art of Critical Thinking at The EMS Roundtable


Last night I called in to the EMS Roundtable because the topic was one of the most important in EMS – critical thinking.[1]

Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.[2]


More simply, in EMS critical thinking is how we make good decisions based on the limited information available in the emergency setting.

In EMS we definitely can be too safe.

Not applying a tourniquet, because What if the tourniquet causes a problem?

That is being too safe.

Not giving large doses of NTG to a hypertensive CHF patient, because What if the NTG causes the pressure to bottom?

That is being too safe.

Strapping someone to a backboard with straps and a collar, Just to be safe.

How is that not being too safe?

Where is there any evidence that spinal immobilization is safe?

Not sedating (or not adequately sedating) an excited delirium patient, because What if he stops hyperventilating?

That is being too safe.

These are some of the things that need to be considered when we engage in critical thinking.

Go listen to the podcast.

Show Notes:

Guest Dan Limmer: http://limmercreative.com

Live Call-in Tim Noonan: http://roguemedic.com

Chat Room:

Jim Hoffman: http://emsofficehours.com

Tom Bouthillet: http://EMS12Lead.com


Go listen to the podcast.




[1] The Art of Critical Thinking
The EMS Roundtable
Wed, April 24, 2013 07:00 pm
Podcast page.


[2] Defining Critical Thinking
Web page