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

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


 

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

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

 

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

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

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

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

 

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

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

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

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

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

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

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

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

 

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

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

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

 

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

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

True or False?

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

It appears that Reall was doing the opposite.

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Footnotes:

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

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We all rely on evidence. The important difference is __________.

 
There are many people who will tell us that we should not demand evidence as the basis for our decisions, but what is the basis for their decisions?

Evidence, not logic.

We all rely on evidence. The important difference is the quality of the evidence we rely on.

We should not listen to those who are devoted to low standards that can support any bias at all.
 

Yes, you may have dozens of impressive anecdotes, but an anecdote is just the retelling of events with most of the variables ignored. The reader is encouraged to come to the conclusion that is being promoted. Anecdotes should be viewed as advertising – promotion of a product that hides reality.

When we see advertising for a big, juicy burger, we are being presented with evidence. When we go to buy that big, juicy burger, we are being presented with reality. The advertising used evidence to get us to buy their product. The actual sale was when we were presented with the evidence that we are easily fooled and manipulated by those who make money off of our low standards for evidence.
 

Medicine/EMS is just as susceptible to advertising biased promotion of a favored treatment.

Is it logical to choose a treatment (which can harm and/or help) based on weak evidence?

If we are going to risk harming our patients, why are so many of us in favor of such low standards?

Why are we so arrogant that we assume that unintended consequences do not affect our patients?

Maybe our treatments really can’t be tested.
 


 
Image credit.

Or we claim that a treatment is too important to study

For example, epinephrine (Adrenaline) in cardiac arrest.
 

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.[1]

 

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.[1]

 

Or spinal immobilization.
 

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.

 

That could be the clap for Tinkerbell speech.[2] It could be Dr. Oz justifying his fraud,[3] but it isn’t. This defense of recklessness is from a surgeon who controls trauma policy in EMS.

This was a serious response to my criticism of the lack of evidence of benefit of spinal immobilization. He has studied the effect of oxygen on trauma patients, so he does not apply this Dark Ages thinking to everything.

We pretend that we are not harming patients, rather than find out how much harm we are doing. Everything we do is harmful, but when the benefits outweigh the harms, only then it is appropriate to use the harmful treatment.

We choose to pretend that we are not causing harm.

We can’t even be honest with ourselves.

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Footnotes:

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

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

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[2] Tinkerbell effect
Wikipedia
Article
 

The Tinkerbell effect is an American English expression describing things that are thought to exist only because people believe in them. The effect is named for Tinker Bell, the fairy in the play Peter Pan who is revived from near death by the belief of the audience.

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[3] Dr. Oz Shows How He Lies with Bad Research
Tue, 17 Jun 2014
Rogue Medic
Article

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Dr. Oz Shows How He Lies with Bad Research


 

These pictures show the same thing – abuse of trust.
 


 

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

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

 

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

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

 

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

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

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

Dr. Oz – That’s the difference.[1]

 

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

Dr. Oz – My show is about hope.[1]

 

Translation – Hope sells.

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

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

 

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

I believe in this stuff.

My ratings depend on my belief.
 

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

 

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

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

 

Translation – Don’t you have any integrity?
 

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

 

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

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

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

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

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Footnotes:

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

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No Apologies, Because America is a Victim Nation


 

Scott (MedicSBK – EMS in the New Decade) posted a few tweets about the infamous news reporting by Andrea Isom and Fox2-Detroit – Responsible Reporting and Credibility.
 

That’s right; an Emmy Award Winning reporter told me to “STFU.” While, with that simple statement, she lost all credibility in my eyes, I engaged in a lengthy 140 character at a time discussion with her that ended with her telling me I should contact the station if I was so upset. I took Ms. Lue’s advice and sent the following e-mail to Kevin Roseburger at Fox 2.

 

Is it cyber bullying to point out that people did something wrong?

Is it cyber bullying to point out that a news organization did something wrong?

Is it cyber bullying to use Twitter to attack someone for pointing out that people did something wrong?

Is it cyber bullying to use Twitter to attack someone for pointing out that a news organization did something wrong?

Is pointing out unethical behavior unethical?

Is it television bullying (I have no idea what the politically correct term would be) to use the media to attack someone without any valid basis – then refuse to apologize for that unethical behavior?
 

Go read Scott’s full letter to the station manager.
 

Follow Scott’s directions to –
 

If you would like to contact Fox 2 in Detroit in a professional manner, head over to Dave Statter’s article where you will find all of the contact information that you need.

 

All over a refusal to apologize for presenting a baseless and defamatory interpretation of what is going on in this picture.

 


 

I also wrote about this in –

Does Ignorance Lead to Faulty Assumptions?

Irresponsible Posing? Absolutely.

Here is some of what others have written –

Don’t rely on Dave Statter

UPDATE: TV station pulls report but fails to apologize & explain why it aired bogus story about smiling EMS crew

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The Ethics of Intervention – 1


Image credit. Is the Give tPA propaganda loud enough?
 

Many of us in medicine want to be more aggressive in treating patients with untested/poorly tested treatments.

We’ve got to do something!

What we ignore is the harm that comes from being aggressive with wishful thinking.

Dr. Ryan Radecki points out that we still have no effective way to manage post-thrombolysis intracranial hemorrhage. This is a real problem that is ignored by many proponents of tPA (tissue Plasminogen Activator – Alteplase).
 

If the widespread proponents of tPA would like to subject ever-increasing numbers of patients to this complication, perhaps they ought to put as much energy into developing new treatments for hemorrhage as they do vilifying tPA skeptics?[1]

 

Why don’t we clamor for a treatment for the problems caused by tPA aggressive intervention with tPA?
 


Image credit.
 

We recite the usual platitudes –

If it helps just one patient . . . .

Yet, if it harms more than it helps – it is bad.

Why is that math so difficult?

An intervention that cannot be shown to be beneficial should be assumed to be harmful until after there is evidence to the contrary. If that evidence never exists, it will be just one more dangerous treatment avoided.

Why?

Because almost every treatment that has been tried has been more harmful than beneficial.

There is no reason to assume that this does not also apply to the treatments based on a modern understanding of pathophysiology.

Why does expert opinion seem only to favor the experts who are hopelessly optimistic pro-interventionists?

Why doesn’t critical judgment support pro-interventionist expert opinion?

Why doesn’t history support pro-interventionist expert opinion?

Why doesn’t reality support pro-interventionist expert opinion?

Is reality biased against endangering our patients in the absence of valid evidence that our treatments are safe and effective?

Yes.

Reality doesn’t care what we want.

If reality cared, the patient would not have the medical condition to begin with.

Reality is neutral, but we are biased in favor of thinking that we know what is best for others.

We consistently provide evidence that we are wrong, then we ignore that evidence and make lame excuses that it wasn’t our fault.

We need to grow up and admit that it is our fault when we harm patients with expert opinion.

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Footnotes:

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[1] tPA ‘Em & Let ‘Em Bleed
Monday, April 28, 2014
Posted by Ryan Radecki
Emergency Medicine Literature of Note
Article

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Is a 48 Hour Paramedic Class Possible?


 

Maybe the Is this going to be on the test? people are in charge.

Is this a case of bad reporting, is Brownsville, TX trying to find a way to force people out of the fire department, is Brownsville, TX trying to suggest that a 48 hour paramedic refresher course is an acceptable initial paramedic course?

Well over 20 years ago, my paramedic class was around a thousand hours long. A few years earlier, my EMT class was over a hundred fifty hours long.
 

Oakerson claims he is being retaliated against because of an expert opinion he offered that stated firefighters needed more than a two-week refresher course to take and pass the National Registry Exam to become paramedics.[1]

 

If someone does not know the difference between a refresher course, which assumes the successful completion of initial paramedic education and experience as a paramedic, and an initial course, should we trust them to make any important decisions?
 

BFFA president Carlos Elizondo said the union sued Brownsville over allegations that Fire Chief Lenny Perez was forcing 13 firefighters to take a 48-hour refresher course over two weeks before taking the National Registry Exam to become paramedics, which is a condition of employment set out in the collective bargaining agreement.

That lawsuit was settled and dismissed March 13.[1]

 

If you know nothing about EMS, a 48 hour course might sound reasonable to become a paramedic, but this is not a feel good movie, or The Secret,[2] or something that Deepak Chopra is selling as quantum[3] education.

These charlatans take advantage of misunderstanding.

Maybe we need to develop more understanding of what medicine/EMS is, if only to protect the public from those who would harm them.

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Footnotes:

-

[1] Lawsuit alleges retaliation – EMS service takes action against city
Monday, April 21, 2014 10:21 pm.
The Brownsville Herald
Mark Reagan
Article

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[2] The Secret is wishful thinking nonsense that claims positive thinking causes positive results and the cause of our misfortunes are negative thoughts.

In other words, children born with birth defects, or cancer, are the victims of their own negative thoughts, but they could be cured by positive thinking.

This works in movies – actually started out as a movie and was later adapted to a book. Unfortunately, many of us think this way. We ignore the bad things that happen and claim that the good things that happen are proof. This is self-deception.

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[3] Deepak Chopra is just as ridiculous, only he throws in the word quantum to explain everything. People do not understand quantum, so they will be afraid to challenge him. I do not understand quantum, but I do recognize a scam and this is as much of a scam as when electricity was new and the frauds described their scams as electric. The words change, but the dishonesty remains.

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Why is it a Less Serious Crime to Assault EMS, than Other Emergency Responders?

 

If EMS is not allowed to be armed, the laws should be fair.

Is an assault on any emergency responder less significant than an assault on any other emergency responder?
 


Image credit for original image.
 

Isn’t this the message that the Colorado Legislature has been sending?

Some assaults on emergency responders are more equal than others.
 

A house bill granting emergency medical technicians and paramedics the same protections against assailants as police officers and firefighters was referred to the Judicial Committee for further review Wednesday.[1]

 


 

I disagree with some of what is presented in the video.

While we may be assaulted by diabetics with low blood sugar, or other patients with medical causes of disorientation, this should not be the reason for the change in the law.

These are conditions which we treat medically, not with criminal charges. A patient who becomes disoriented is not legally responsible for behavior while truly disoriented, so this law should not change anything about the way that the law is applied.

We do not imprison people for medical conditions. We treat the medical conditions.
 

Currently, 38 states have passed similar legislation protecting EMTs and paramedics.[1]

 

What other 11 states that see a need for some difference in assault laws?

How did a majority of legislators (in Colorado and 11 other states) vote to treat assault on EMS personnel as less serious than assault on other emergency responders?
 

The bill must make it to the senate floor before the end of the current session May 7, or it will have to be reintroduced next year.[1]

 

Are there other emergency responders treated differently, if so, the law should be changed for them, too.

I do not think that EMS should be armed, because I do not see a benefit, while I see a lot of potential problems. If we are not armed as well as the police, why does the law make us even more of a target to those who are violent?

Does anyone oppose treating people equally under the law for the same offense?

Why?

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Footnotes:

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[1] Bill would make assault against paramedics a felony
Kelly Sommariva
KUSA
11:09 p.m. MDT April 23, 2014
Article

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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.

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Footnotes:

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

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[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.

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