Education – Page 2

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

- Rogue Medic

One Laceration, Two Helicopters, Third Part

Wed, 25 Sep 2013 08:00:25 -0400 by Rogue Medic

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.

Exactly.

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.

[youtube]sao-uEKgJ6Q[/youtube]

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.

–

Footnotes:

–

^[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
Article

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

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

–

^[2] dys-
The Free Dictionary
Definition

dys-
pref.
       1. Abnormal: dysplasia.
       2.
               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.

Filed Under: Critical Judgment, Education, Ethics, Helicopters, Heresy, Spinal Immobilization

Do We Have a ‘Bigotry of Low Expectations’?

Fri, 06 Sep 2013 11:30:16 -0400 by Rogue Medic

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:

Paramedics gripe because they are underpaid and disrespected, and have difficulty obtaining reciprocity in other states.

ED physicians complain because we bring them patients whose airways are poorly managed.

. . . .^[1]

Where does this lead?

Go read the full article.

–

Footnotes:

–

^[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
EMS1.com
August 13, 2013
Article

–

^[2] Command responsibility
Wikipedia
Article

–

^[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.

Filed Under: Airway Management, Critical Judgment, Education, Ethics, Heresy

The Path to Insanity

Wed, 21 Aug 2013 14:30:53 -0400 by Rogue Medic

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.

–

Footnotes:

–

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

–

^[2] Curiosity
NASA
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
Wikipedia
Article

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.

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^[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.

.

Filed Under: Critical Judgment, Education, Evidence, Heresy

Examples of Ventricular Tachycardia Caused by Amiodarone – Part I

Tue, 28 May 2013 09:30:50 -0400 by Rogue Medic

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

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

Right?

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?

–

Footnotes:

–

^[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

Filed Under: ACLS, Cardiology, Education, Heresy, Pharmacology, Research Blogging

Bad Recipe for EMS Event Laughter

Tue, 07 May 2013 12:00:04 -0400 by Rogue Medic

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.

[youtube]51wVDicIm5s[/youtube]

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.

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Footnotes:

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

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^[2] Fallacy
Wikipedia
Article

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^[3] Nervous laughter
Wikipedia
Article

Filed Under: Education, Ethics, Heresy, Risk Management

The Art of Critical Thinking at The EMS Roundtable

Thu, 25 Apr 2013 20:00:18 -0400 by Rogue Medic

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.

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Footnotes:

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

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^[2] Defining Critical Thinking
Criticalthinking.org
Web page

Filed Under: Critical Judgment, Education, Heresy, NTG

Free Transport Ventilator Class from CentreLearn and Jim Hoffman This Thursday

Tue, 23 Apr 2013 15:30:08 -0400 by Rogue Medic

Is this important if we do not do interfacility transport?

Yes.

Eventually, we will be using ventilators for almost everything where we currently use a BVM (Bag Valve Mask).

Why?

Because we humans are pathetic at bagging patients.

If you have not seen a doctor/nurse/respiratory therapist/paramedic/EMT basic bagging a patient at 60 breaths per minute, you have not been paying attention.

Since we seem to be resistant to education, the protocol writers are starting to make this something that is not corrected by education, but is prevented from happening by putting it in the hands of machines.

Needless to write, but this will have plenty of unintended consequences. The best way to avoid these unintended consequences (assuming that we do not magically develop excellent BVM skills, which would be the subject of other posts) is to be as familiar as possible with the use of transport ventilators and the kinds of problems that we can cause.

Original image credit.

The goal of medical care is to make things better, or to not make things worse.

The three most basic points, that apply just as much to BVM use as to ventilator use.

1. How to assess the patient for the cause of a sudden deterioration of the intubated patient. Everyone should know this. It is a part of every PALS/NRP class. If it is not, it was supposed to be. It should also be a part of every ACLS class, since these are some of the preventable causes of cardiac arrest.

DOPE – DOPE (or POET for the more politically correct) stands for Dislodged, Obstructed, Pneumothorax, Equipment failure. I have discussed these elsewhere.^[1]

2. Hypotension – Even in a trauma patient, hypotension is often resolved by correcting the ventilation, rather than by adding fluid to the blood vessels.

3. Waveform Capnography – Continuous waveform capnography should be mandatory for the movement of all intubated patients anywhere. The same is true for extraglottic devices (LMAs, CombiTubes, King Airways, et cetera).

This is from CentreLearn and Jim Hoffman.

CentreLearn Webinar: Automatic Transport Ventilators in EMS
Thursday, April 25, 2013 8:30 PM – 9:30 PM EDT

Registrater here.

You will be connected to audio using your computer’s microphone and speakers (VoIP). A headset is recommended.

Or, you may select Use Telephone after joining the Webinar.
Toll: +1 (914) 339-0030
Access Code: 677-535-345
Audio PIN: Shown after joining the Webinar
Webinar ID: 799-127-985

System Requirements
PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees
Required: Mac OS® X 10.6 or newer

Mobile attendees
Required: iPhone®, iPad®, Android™ phone or Android tablet

Read our Audio Checklist for tips on using your computer’s microphone and speakers with GoToWebinar.

Registrater here.

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Footnotes:

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^[1] Origins of the Dope Mnemonic
Wed, 26 Jan 2011
Rogue Medic
Article

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^[2] Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
Aufderheide TP, Lurie KG.
Crit Care Med. 2004 Sep;32(9 Suppl):S345-51.
PMID: 15508657 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from burndoc.net.

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^[3] Capnography Use Saves Lives AND Money
Rogue Medic

Part I
Fri, 10 Dec 2010

Part II
Mon, 13 Dec 2010

Part III
Thu, 16 Dec 2010

Part IV
Thu, 16 Dec 2010

Part V
Tue, 04 Jan 2011

Filed Under: Airway Management, Education, Heresy, Waveform Capnography

Paramedic School Accreditation – Advanced Airways vs. BVM

Sun, 17 Feb 2013 08:00:42 -0500 by Rogue Medic

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This week on EMS Office Hours, Jim Hoffman, Josh Knapp, John Broyles, and I discuss a few topics. National Registry of EMTs accreditation of paramedic schools.

Paramedic School Accreditation | Advanced Airways vs. BVM

If we are going to have standards, they should be based on some evidence that they work.

Is something better than nothing?

Something is only better than nothing if the something is something good.

Is a grade better than 80% good for bragging rights?

What does the grade mean? Does the exam demonstrate that the person understands good patient care? I do not see evidence that this initial exam does that.

The NR exam is just an initial exam, but some benighted people think that there should be higher pay for people who have passed this particular brand of entrance exam. Are they supposed to remain beginners forever?

Is a structured way of doing things a good way to evaluate people for the unstructured, or minimally structured, job of paramedic.

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We also discuss what I wrote in Advanced Airway vs. BVM During CPR – Which is Worse?

There is no evidence that ventilations improve outcomes.

I was at Dr. Banerjee’s presentation on cardiac arrest and how their treatment protocol produces better outcomes than the rest of the country. One person in the audience kept complaining that he is wrong to not follow the ACLS guidelines because he will be sued. Dr. Banerjee’s response should be obvious – You need to show evidence of harm to win a law suit. I produce better outcomes than the rest of the country.

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John Broyles brought up the way we educate badly with our focus on verbalizing Gloves on – Scene safe! and not thinking about what we are doing as far as using gloves and continually assessing scene safety.

Gloves are often inadequate BSI (Body Substance Isolation), but we act as if wearing gloves will protect against everything; as if wearing gloves somehow produces a force field around the body that protects parts of the body not covered by the gloves; as if gloves do not tear or break down and need to be replaced on the job; as if gloves make up for not cleaning our hands; as if touching clipboards and other equipment with gloves on is doing anything other than spreading germs all over the equipment that we will later pick up without gloves on; as if gloves need to be worn for every patient.

Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings
CDC (Centers for Disease Control and Prevention)