Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

NYFD EMS Loses $172 Million Suit


What does a $172 million loss mean?

1. Something very bad happened.

2. The jury probably thought that the defense sucked.

3. The amount paid will probably be much lower.

4. We continue to face the opposite of intermittent reinforcement – intermittent negative reinforcement – and we continue to respond unwisely.[1]

5. This will be the excuse for a lot of bad management decisions.

What happened?

Image credit.


A girl who suffered brain damage while waiting for an ambulance won a $172 million judgment against New York City on Wednesday when a Bronx jury determined that Fire Department paramedics could be held liable for giving her mother bad advice.[2]


Bad advice?

Wait for the paramedics during a cardiac arrest, rather than transport to the hospital. The medics took 20 minutes to arrive. The child has brain damage.

Was the advice bad?

This took place in 1998, when transport was considered to be important by a lot of people, because the hospital can do so much more of the things that improve outcomes than EMS can, except that the only two treatments that we know improve outcomes are continuous chest compressions and defibrillation. We knew that back then. The main thing we have learned since then is that interruptions of compressions, such as for transport, worsen outcomes.

Tiffany’s mother, Samantha Applewhite, called 911, and the city sent two Fire Department medics in a basic ambulance, without the advanced life support equipment she needed, the documents said. One medic began cardiopulmonary resuscitation while the other called for an ambulance with the proper equipment. The city paramedics also failed to bring oxygen or a defibrillator, evidence at trial showed.[2]


ALS (Advanced Life Support) equipment has never been shown to improve outcomes, unless the BLS (Basic Life Support) ambulances did not carry defibrillators (AEDs – Automated External Defibrillators). This states that they did not bring their defibrillator, which suggests that they carried and AED, but left it in the ambulance with the oxygen.

Should they have brought the AED to the scene? What did dispatch tell them was going on? NYFD EMS (New York Fire Department EMS) probably had a policy describing what equipment is required for certain calls. Cardiac arrest should require an AED (and oxygen and especially suction [because everyone seems to forget suction]), but was this dispatched as a cardiac arrest? The article does not tell us.

Suppose they do transport. One person is doing compressions, while the other is driving, or did they have more personnel on scene? We do not know.

Was the rhythm shockable? We don’t know. If they had brought the AED, it should have recorded the rhythm and would be able to answer that question, but according to the article, they did not.

Ms. Applewhite begged the city paramedics to take her daughter to Montefiore Hospital, a few minutes away, but they advised her to wait for the private ambulance with advanced life support equipment to arrive, the evidence showed.[1]


Does it really matter how far away the hospital is?


What about immunity from liability?

A trial court at first dismissed the lawsuit, ruling the Applewhites had failed to prove the city had assumed a special affirmative duty to take care of the girl by responding to the call.

But the appellate division disagreed, saying the mother “justifiably relied” on the emergency responders, “who had taken control of the emergency situation and who elected to await” the private ambulance.[2]


Maybe we should be a lot better at sharing information and decisions with patients.

Maybe our protocols should be a lot better at encouraging us to share information and decisions with patients.

Did the crew do a bad job? Did they coerce decisions from the mother?

I don’t know.

A bad outcome is not proof of bad patient care.

How much do law suits improve our care?

Do law suits lead to improved patient care?

Do law suits lead to worse patient care?

Maybe a bit of both. Maybe a lot more harm than benefit? The evidence on law suits is that they are unpredictable




[1] Intermittent reinforcement


[2] Jury Awards $172 Million in Verdict Against New York City
By James C. McKinley Jr.
May 29, 2014
NY Times


Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?


If we are going to give epinephrine (Adrenaline in Commonwealth countries) to patients with rhythms that are not shockable (PEA [Pulseless Electrical Activity] or Asystole), it appears that patients receiving epinephrine earlier have better outcomes than patients who receive epinephrine later in the hospital in the less acute care settings.

Does this mean that patients who receive epinephrine have better outcomes than patients who do not receive epinephrine?

We remain willfully ignorant of the answer to that question.

Apart from cardiopulmonary resuscitation, no intervention has been shown to be efficacious in patients with non-shockable cardiac arrest.[1]


Would a placebo group have had better outcomes than the patients who received epinephrine the earliest? We have no way of knowing, because we discourage asking about what we take for granted.


We excluded patients with cardiac arrest in the emergency department, intensive care unit, or surgical or other specialty care or procedure areas,[1]



This does show an impressive association between giving epinephrine earlier and improved outcomes.

Does this mean that we should avoid giving epinephrine (a drug not yet adequately tested in humans) after a certain amount of time?

Does this mean that we should prioritize giving epinephrine (a drug not yet adequately tested in humans) before a certain amount of time?

Until we find out how harmful/beneficial epinephrine is compared to placebo, we do not know if we are helping with epinephrine, harming with epinephrine, or which patients we might be helping and which patients we might be harming. We have a half a century of I don’t know and I don’t care.

Despite a strong physiologic rationale and anecdotal reports of efficacy, there are no well controlled trials of epinephrine to assess endpoints such as improved survival and neurologically intact survival. A randomized trial failed to show efficacy for advanced cardiac life support drugs, and extrapolation to the potential lack of efficacy of epinephrine has been suggested; the dose, timing, and even use of epinephrine remains controversial.15-16 [1]


But some of the anecdotes are really good anecdotes!

Anecdote-based treatment is just ignorance-based treatment. We assume that we know what we are doing, but we are only imitating Skinner’s pigeons in our reaction to stimuli.

Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher

We have fancier uniforms than the pigeons, but we are just as unaware of the source of our stimuli.

The data was prospectively obtained using specifically defined variables, but the study was a retrospective analysis of that data.

Because data were used primarily as the local site for quality improvement, sites were granted a waiver of informed consent under the common rule.[1]


Because of the way the data are entered, any errors are likely to be at time of entry and may not be capable of being detected at the time of analysis for research. The numbers are very large – 25,095 patients – so that should correct for idiosyncratic errors, but what about cultural errors?


In the sensitivity analyses with adjustment for delays in initiation of cardiopulmonary resuscitation, time to epinephrine administration remained independently associated with survival to hospital discharge after multivariable adjustments.[1]


In the context of our findings, future investigations should consider timing of epinephrine administration in design and interpretation.[1]


We should also consider that epinephrine, if it is beneficial, is probably only beneficial to some patients. We need to try to identify those patients. Our current method of give epinephrine to everybody and let the emergency department sort them out is not reasonable.

This study ran from 2000 to 2009, so the improvements due to the focus on chest compressions might only affect a tiny portion of patients.[2]

Does epinephrine administration – at any time – produce better outcomes from PEA-asystole?

We still have no idea.




[1] Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, Gautam S, Callaway C; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.
BMJ. 2014 May 20;348:g3028. doi: 10.1136/bmj.g3028.
PMID: 24846323 [PubMed - in process]

Free Full Text from BMJ.


[2] Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care.
Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ; ROC Investigators.
Prehosp Emerg Care. 2010 Jul-Sep;14(3):355-60.
PMID: 20388032 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

On December 13, 2005, the AHA published “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”

ROC EMS agencies required an average of 416 days to implement the 2005 AHA guidelines for OHCA. Small EMS agencies, BLS-only agencies, and nontransport agencies took longer than large agencies, agencies providing ALS care, and transport agencies, respectively, to implement the guidelines.

How relevant is that to implementation in the less acute care settings studied in these hospitalized patients?


Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ, & ROC Investigators (2010). Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14 (3), 355-60 PMID: 20388032


Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014). Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry BMJ, 348 (may20 2) DOI: 10.1136/bmj.g3028


The Silver Lining of Epi – Organ Donation – Part 2


Continuing from Part 1. In writing about why we should not get rid of epinephrine, Scott makes the following statement –

Patients who receive epinephrine in cardiac arrests have worse outcomes.[1]


Go read the full paragraph. I am not taking that out of context.

Scott suggests that this is acceptable, because some of these patients will be brain dead and some of those brain dead patients will end up being organ donors.

While it is true that some of those resuscitated from cardiac arrest following administration of epinephrine will end up being organ donors, should that affect our attempts to resuscitate the patient? Currently, the AHA (American Heart Association) does not encourage using treatments that may produce worse outcomes just for the purposes of increasing the number of organ donors.[2]

Even hearts can be transplanted from cardiac arrest patients can produce good outcomes.[3]


So far, so good.

Maybe it is time to look at them from a different angle. We need to look at dealing with a cardiac arrest in stages. Stage one, of course, is to work as hard as we can to achieve ROSC. ROSC is an absolute: there is a pulse, or there is not a pulse.[1]


How much harm do we do in order to get more ROSC (Return Of Spontaneous Circulation)?

ROSC is binary, but there are many ways to obtain ROSC.

The way we obtain ROSC seems to affect the survival of the patient and the brain function in those who do survive.

This is comparing three different treatments HDE (High-Dose Epinephrine), SDE (Standard-Dose Epinephrine), and NE (NorEpinephrine). The lines for the HDE and NE are so close to each other, that you may not be able to see the gold line.[4]

Compare that chart of HDE, SDE, and NE with this chart comparing Epinephrine and No Epinephrine.[5]


More ROSC, but fewer survivors.[6]

More organs, because of fewer survivors of cardiac arrest?

Is this our goal?

We could take the extreme utilitarian approach of Your organs can benefit far more people – if they are not in you.

Scott wouldn’t advocate for that with any other patient, so why head that way with cardiac arrest?

Patients who receive epinephrine in cardiac arrests have worse outcomes.[1]


Is epinephrine the cause of the harm? We do not know and we are perversely not trying to find out.

If giving epinephrine decreases survival from cardiac arrest, then giving epinephrine increases the pool of available organs at the expense of our original cardiac arrest patients. That is not the goal.

Organ donation is important. Harming patients, in order to obtain more organs, is not the goal of organ donation.




[1] The Silver Lining of Epi
February 3, 2014
EMS in the New Decade


[2] Organ Donation After Cardiac Arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 9: Post–Cardiac Arrest Care
Free Full Text from AHA.


[3] Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation.
Ali AA, Lim E, Thanikachalam M, Sudarshan C, White P, Parameshwar J, Dhital K, Large SR.
Eur J Cardiothorac Surg. 2007 May;31(5):929-33. Epub 2007 Mar 26.
PMID: 17387020 [PubMed - indexed for MEDLINE]

Free Full Text from Eur J Cardiothorac Surg.


[4] A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.
Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J.
JAMA. 1992 Nov 18;268(19):2667-72.
PMID: 1433686 [PubMed - indexed for MEDLINE]


[5] Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
PMID: 22436956 [PubMed - indexed for MEDLINE]

Free Full Text from JAMA.


[6] Are We Killing People With ROSC?
Wed, 05 Jun 2013
Rogue Medic


The Silver Lining of Epi – Organ Donation – Part 1


Is there really a silver lining to giving epinephrine for cardiac arrest? Scott writes about organ donation as one possible silver lining.

The next time you bring one of those cardiac arrest patients in who when you follow up on them, you are told that they have “no brain activity” do not look at it as a complete loss. Ask that follow up question, “Are they going to be able to donate any organs?” You might be pleasantly surprised at what the answer is. Although it’s not exactly what we are looking for, a life might have been saved.[1]


That seems reasonable, except that it assumes that the treatment that will produce the best survival, a return to normal life, is produced with epinephrine.

Epinephrine may produce more organ donors, but that is not what we base our treatment on. We treat patients based on what is expected to produce the best outcome for them, not what is expected to produce the best/most organs for donation. Even looking at organ donation, there are many different considerations.

What produces the best organs?

What produces the most organs?

What produces the mixture of quality and quantity that seems to be best for patients?

If we want to improve organ donation rates, one thing we should consider is addressing organ donation directly – not advocating for things that might produce increased organ donation as a side effect. Changing the law from the current opt in to opt out.

With opt in – if I have not made a choice, or if anyone objects to my choice, it is presumed that I object to organ donation and my organs are discarded.

With opt out – if I have not made a choice, it is presumed that I do not object to organ donation and my organs are available to those on the organ transplant lists.

Currently, the license to drive is the indicator and there would be no reason to change that. We are asked to select this if you want to be an organ donor. We would change the question to select this if you do not want to be an organ donor.

Donations are more complex than opt in vs. opt out, but changing one thing may lead to changes in other things because of increased attention.

Here are changes in various rates of organ donation in Belgium before and after a change from opt in to opt out.












Presumed consent alone is unlikely to explain the variation in organ donation rates between different countries. A combination of legislation, availability of donors, transplantation system organisation and infrastructure, wealth and investment in health care, as well as underlying public attitudes to and awareness of organ donation and transplantation, may all play a role, although the relative importance of each is unclear.[2]


Should we assume that epinephrine really improves the likelihood of organ donation without decreasing survival from cardiac arrest? I will discuss that in Part 2.




[1] The Silver Lining of Epi
February 3, 2014
EMS in the New Decade


[2] A systematic review of presumed consent systems for deceased organ donation.
Rithalia A, McDaid C, Suekarran S, Norman G, Myers L, Sowden A.
Health Technol Assess. 2009 May;13(26):iii, ix-xi, 1-95. doi: 10.3310/hta13260. Review.
PMID: 19422754 [PubMed - indexed for MEDLINE]

Free Full Text from National Institute for Health Research.


$16M on EMS Stroke Trial? Dr. Rick Bukata Wants His Money Back!


FAST-MAG[1] actually has good methodology, so why is Dr. Rick Bukata so upset? Is this just USC vs. UCLA off the field/court?

Should the hypothesis being tested have received the Queen for a Decade treatment?

He wants his money back? Roughly 160 million tax payers in the US, so $0.10 per tax payer, but he makes more than the average schlub, so maybe as much as 50 cents for him. He can’t even buy enough caffeine to raise his blood pressure with that.

In a commentary regarding the IMAGES trial by Larry Goldstein of the Duke Center for Cerebrovascular Disease in the same issue of the Lancet in which the study was published, he noted that of more than 40 clinical trials of “neuroprotectants” involving over 11,000 patients, none has shown any evidence of benefit. Ten years later, the same is true.[2]


But look at the animal studies!

But look at the time being saved!

The authors actually like to repeat the term Golden Hour – as if that is new or valid.

So, if you are still a believer in the potential of magnesium, why not try and give magnesium in a pilot clinical study involving stroke patients in the ED? It would have been a relatively simple study to do. It could have been performed in selected EDs throughout the country and the answer would have been established in a fraction of eight years and at a very small fraction of $16 million.

Instead, the Fast-Mag investigators decide that giving magnesium in the field (probably about 10-20 minutes faster than could be given in the ED) would be a reasonable study.[2]


Gosh, when he brings reason into the argument, it just seems that the other side has none.

What could the money have been spent on?

Epinephrine vs. placebo in cardiac arrest? The number of lives affected is large and we are currently treating based on philosophy, not science.

IV (IntraVenous) bolus NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) vs. SL (SubLingual) NTG for acute CHF (Congestive Heart Failure)? This affects even more patients than cardiac arrest and there is good evidence that IV bolus NTG dramatically improves outcomes, while SL NTG is not based on evidence.

Excited delirium treatment with various IM (IntraMuscular) medications to see what is safest and most effective and at what dose. A large trial would be necessary.

With no good reason to be optimistic about outcomes, why take this multimillion dollar long shot?

Maybe it has to do with tPA (tissue Plasminogen Activator) and the failure to get emergency physicians to accept the poor research on tPA – tPA showed harm, or no benefit, in 9 out of 11 studies.[3]

Ironically, if those studies used methodology similar to this study, that could be showed harm, or no benefit, in 11 out of 11 studies.

Dr. Jeffrey L. Saver, one of the authors, has a presentation on FAST-MAG that spends a lot of time on tPA, even prehospital tPA.

What does Dr. Sarver consider to be positive about FAST-MAG? Here are some of his slides.[4]


FAST-MAG means more tPA use.


FAST-MAG means doing a lot of things that have not been done before and expecting the outcome to be good.

This is the kind of person who starts turning all of the dials on a ventilator and then looks at the patient to see what the result is.

A reasonable approach to research is to limit variables, not brag about how much prudence has been abandoned.


FAST-MAG means time will be saved, but . . . .

Walter Koroshetz, MD, neurologist and deputy director of the National Institutes of Health’s (NIH’s) National Institute of Neurological Disorders and Stroke, sponsor of the FAST-MAG study, says that lessons can be learned from the trial.[5]


“The NIH have a new network to do more prehospital trials, but we need phase 2 studies first that demonstrate some biological effect before going into a large costly phase 3 trials.”[5]


This is a $16 million bet that time is the only factor that matters.

I hope these doctors do not drive the way they gamble.

What were the results?

The results were the same as all of the previous studies of magnesium – no improvement.

There is no Magnesium Golden Hour.

And, please, no – don’t even consider the idea of giving tPA in the field.[2]


Well, . . . .

Dr. Saver explained that tPA cannot be given at present in a prehospital setting because hemorrhagic stroke has to be ruled out with computed tomography (CT). The use of ambulances with a CT scanner on board has been studied in Germany and is now starting to be tested in the United States.[5]


Be very afraid.

On the other hand, the authors did not rush this treatment into EMS protocols, as we recently have in EMS in so many places with therapeutic hypothermia, based entirely on research done in the ED (Emergency Department). It works in the ED, but not in the ambulance. :oops:

FAST-MAG was approved in 1999, several years after the EMS nifedipine (Procardia) for hypertensive crisis crisis. There was no study in the EMS setting of a treatment for the EMS setting. This involved treatment of the surrogate endpoint of blood pressure numbers, which makes for an easy win, such as a systolic drop of 250 -> 90 in ten minutes. :oops:

We need a balance between rushing to add the new cool treatment (and the predictable removal of the treatment decades later) and the inappropriate rush to a large scale trial of something that has repeatedly failed smaller studies.

Go read Dr. Bukata’s full article.




[1] Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 2 – prehospital study methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):220-5. doi: 10.1111/ijs.12242.
PMID: 24444117 [PubMed - in process]

Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 1 – rationale and general methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):215-9. doi: 10.1111/ijs.12243. Epub 2014 Jan 13.
PMID: 24444116 [PubMed - in process]


[2] $16M on EMS Stroke Trial? I Want My Money Back!
by Rick Bukata, MD
March 24, 2014
Emergency Physicians monthly


[3] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM


[4] Treat Stroke in the Field:
Lessons from the NIH FAST-MAG Trial

Jeffrey L. Saver, MD, Professor of Neurology
UCLA Stroke Center
Presentation Slides in PDF Downoad format.


[5] FAST-MAG: No Benefit of Prehospital Magnesium in Stroke
Sue Hughes
February 14, 2014


Top Ten Resuscitation Headlines from Rescue Digest – Read ‘Em and Learn


This should catch your attention -

RescueDigest’s Top Picks of essential resources for critical topics in emergency services.

What should we be paying attention to?

Headline #1: EMS Saves Everyone / EMS Saves No One[1]


If you read the main stream media, you get one version, or the other, or even both in the same week/month/year.


If we get our science reporting from the news media, we are not getting valid science reporting.

We are probably getting a poor translation of a secondhand account of what the researcher denied was the result of the study.

Trust the media. We would never misrepresent anything!

Image credit.

This article provides evidence to explain what the truth is.

Does EMS save everyone?

We haven’t put the funeral homes out of business, yet – and we never will.

Does EMS save no one?

Systems that focus on excellent uninterrupted compressions and rapid defibrillation save 40% – 60% of the patients who are in a shockable rhythm when EMS arrives.

You were dead.

No pulse.

No brain function.




But – after EMS treatment – you are alive.

This is a true improved outcome, not getting a pulse back only to die in the ICU, or to die in a few weeks/months in a nursing home without ever waking up.

Your brain is working again.

You can play with your children/grandchildren, again.

You are alive.

Only 40% to 60% of patients in shockable rhythms when EMS arrives!

Not perfect, but nothing is perfect. Less than perfect is imperfect, but everything is imperfect. Less than perfect, but better than nothing is still better than nothing. 40% to 60% are better than they would be with nothing.

The NNT (Number Needed to Treat) is a little more than two.

That makes this one of the most effective medical treatments available. Prevention of cardiac arrest is still better, but when prevention does not work, this frequently does.

Less than perfect is the best that is available from real medicine. Charlatans will promise to do better, but they will end up making excuses for failure – and they cannot resuscitate.

The basic trouble, you see, is that people think that “right” and “wrong” are absolute; that everything that isn’t perfectly and completely right is totally and equally wrong.[2]


What about the rest of the headlines?

Don’t end up like this –

Image credit.

Go read what Rommie Duckworth is writing.

Go through the slides from his presentation. If you get a chance, go to a conference where he is presenting, such as EMS Today in Washington, D.C., a little over a week from today.

2:15PM- 3:15PM
Don’t Lose Your Cool: Dealing With Problem Students

Room: 207B
The Know-it-all. The Worrier. The Heckler. The Rambler. The Cheater. Is one rotten apple going to spoil your whole program? This program provides educators of all levels with insight into the sources of student issues as well as the mistakes that instructors commonly make that contribute to classroom unrest. Using read more…

Rommie Duckworth
N.E. Ctr. for Rescue & Emerg. Med.
Sherman, CT, United States





[1] RescueDigest Resources: Top Ten Resuscitation Headlines
Rescue Digest
Posted on Jan 29, 2014
Rom Duckworth


[2] The Relativity of Wrong
The Skeptical Inquirer
Fall 1989, Vol. 14, No. 1, Pp. 35-44
By Isaac Asimov

Read the whole article. It is not long, but it is an excellent introduction to how science works.


[3] EMS Today
February 5-8, 2014
Walter E. Washington Convention Center
Washington D.C.

Results of search for Rommie Duckworth in EMS Today’s schedule search.


1-Union-801 Podcast Discussing Epi for V Tach, Cardioversion, Procainamide, Paralytics During Hypothermia, Quality of CPR, and DNA Transfer


On 1-Union-801 John Broyles and I discussed some things that I had written. I was supposed to be on the podcast two weeks earlier, but I am on duty at the time of the podcast, and I had a call a few minutes before the show. This podcast was not interrupted by any calls.[1]

Go listen to the podcast.

Epinephrine for V Tach – Instant Death or Effective Treatment?

What might happen if epinephrine is given for this V Tach (Ventricular Tachycardia)?

Click on images to make them larger. Image credit and article about epinephrine for V Tach.[2]

We also discuss sychronized cardioversion and procainamide.
Other things we discussed (in order) were –

Do Paralytics Improve Outcomes Following Resuscitation?

We want to minimize movement after starting therapeutic hypothermia. Is the use of paralytics the right way to do this?

Un-extraordinary measures: Stats show CPR often falls flat

The author appears to take the comments of Dr. David Newman completely out of context in order to make a point that I do not think Dr. Newman would ever make.

Who is Dr. Newman?



Dr. David Newman, and sometimes Dr. Ashley Shreves, write and podcast about research and emergency medicine. There is an excellent deconstruction of the ACLS (Advanced Cardiac Life Support) guidelines and the lack of evidence for the drugs recommended in the guidelines.

The NNT is another excellent site that is here, too.

At Annals of Emergency Medicine, Dr. Newman and Dr. Ashley Shreves present excellent summaries of the articles in each issue. Annals of Emergency Medicine Podcast

I also mentioned Dr. Richard Levitan’s No Desat approach of using high flow oxygen by nasal cannula, which works wonders. Read about No Desat!

Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment

Do we use gloves properly?

Is DNA transfer between patients an indication of a lack of use of gloves?

Go listen to the podcast.




[1] Rogue Medic Saved Our Bacon 20 Jul 13
John Broyles
Podcast page.


[2] Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia.
Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, Fontaine G.
World J Cardiol. 2012 Oct 26;4(10):296-301. doi: 10.4330/wjc.v4.i10.296.
PMID: 23110246 [PubMed]

Free Full Text from PubMed Central.


Comment on Are We Killing People With ROSC?


In the comments to Are We Killing People With ROSC? Adam Thompson, EMT-P of Paramedicine 101 writes –

Go figure, right? I suppose that’s where the old H’s & T’s come in…


The Hs and Ts do not really affect the dose of epinephrine.

I have never liked the Hs and Ts mnemonic. I know what you’re thinking: ‘Did he recall six Hs, or only five?’ Well, to tell you the truth, in all this excitement I kind of lost track myself. But, being as this is epinephrine, the most powerful cardiotoxin in the world, and would blow your head clean off, you’ve got to ask yourself one question: ‘Do I feel lucky?’ Well, do ya, PUNK?

Since PUNK is the patient, PUNK is not likely to respond. PUNK is dead.

There are arguments that other drugs are more powerful cardiotoxins, but they are not routinely used for resuscitation.


I have always thought it was crazy that if someone has a ‘heart attack’ we fill their static vasculature with epinephrine, so when they get a pulse back, they now have a chemical pumping through their blood that is known to be lethal in people with acute coronary syndrome.


The blood should not be static if there are effective chest compressions. Nobody should be considering any drugs in the absence of chest compressions for a cardiac arrest patient.

Also, if it constricts the blood vessels of the entire body, wouldn’t that include the cerebral arteries…making cerebral anoxia worse…? “But hey, if we get pulses back, who cares?”, says the cretin medic.


Epinephrine has both alpha and beta effects, so there is probably a combination of constriction and dilation of the arteries.

It does not appear that epinephrine produces the beneficial effects that the physiologists claim that epinephrine produces, based on their knowledge of physiology. At least, no beneficial effects other than the supposed beneficial effect of ROSC (Return Of Spontaneous Circulation), which seems to be harmful for those who receive epinephrine. For physiologists, maybe understanding of the word beneficial is inconceivable.

Any physiologic claim that cannot be backed up by improved outcomes is just an example of the arrogance of ignorance.

Half a century of hundreds of thousands of patients treated each year, but still no evidence of benefit.

What? Increased ROSC is a benefit?

It allows the family to say good-bye to their comatose family member for a price that is profligate.

It allows the EMS crew to claim they had a save!

It allows us to pretend that a pulse and a life are the same thing.

Image credit.

If we do not understand the difference between ROSC and a living, thinking person, then ROSC is a reasonable goal.

ROSC is not a reasonable goal.