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

- Rogue Medic

The March for Science is a March for Honesty and Accountability


 

There were some great signs at the March for Science because the march was about truth and it is difficult to go wrong defending the search for truth. The only time people seem to oppose the search for truth is when truth is seen as a threat to their ideology and/or income.

It is difficult to get a man to understand something, when his salary depends upon his not understanding it! – Upton Sinclair.

Scientists are accused of being arrogant, apparently because scientists don’t waste their time on ideas that cannot be tested or on ideas that repeatedly fail objective testing. Scientists learn by providing the most honest way of assessing the truth – they do everything they can to eliminate bias and to eliminate the effects of anything that is not being tested.

Is that arrogant?

Arrogance would be refusing to allow everyone to criticize your work, but science requires that scientists be open about their work and invite their harshest critics to poke holes in their work.

This means that nonsense will not survive for long. The better hypotheses will survive. Logical fallacies are eventually exposed and we learn the truth.
 


 

This is why science rejects claims that fail experimentation and claims that cannot be tested. These claims are not science.
 

Flat Earth claims are rejected. There is abundant evidence that the Earth is not flat, but people still claim that the Earth is flat. There is no scientific controversy about whether the Earth is roughly spherical in shape.[1]
 

Creationism claims are rejected. Creationism contradicts almost all of the sciences (geology, astronomy, physics, biology, . . .), so Creationism would need to be supported by some very well tested evidence. Creationism is not supported by scientific evidence, but that does not stop Creationists from claiming to be scientists.

The clearest evidence that evolution is real is provided by DNA (DeoxyriboNucleic Acid). When we want to confirm the relationship among different people, we use DNA, because it works. DNA confirms that we are related to baboons, bananas, and bacteria. DNA is able to show how close those relationships are. There is no scientific controversy about whether humans evolved along with the rest of life on Earth.[2]

 

I did not get a clear picture of the sign, but I have not changed the words.

 

Anti-GMO claims are rejected. GMOs (Genetically Modified Organisms) are recognized to be safe, nutritious, important in the prevention of widespread famine, overall much more beneficial than their critics claim, and dramatically better organic foods. Those opposed to GMOs claim that organic foods would not produce a famine, if everyone were to eat organic foods. Those opposed to GMOs claim that modification is bad, even though humans have been modifying crops for over 10,000 years. We even use chemicals and radiation to cause mutations to crops that are still considered organic.
 

From 1930 to 2014 more than 3200 mutagenic plant varieties have been released[1][2] that have been derived either as direct mutants (70%) or from their progeny (30%).[3] [3]

 

There is no scientific controversy about the benefits of GMOs.
 


 

Climate change denial is rejected. Climate change is real and harmful. Some people (not scientists) claim that natural factors are causing the unnatural warming. Some people (not scientists) claim that the unnatural warming is a good thing. Some people (not scientists) claim that the unnatural warming isn’t happening. There is no scientific controversy about the reality of climate change.
 


This chart[4] does not include 2016.

If you are a climate change denier, you were counting on 2016 being something other than the hottest year on record. Three years in a row would be unprecedented. 2017 was hotter than 2016, which contradicts the denier arguments.[5] If you are a climate change denier, you should realize that denying science is not going your way. You have had some political successes, but you can’t deny reality forever. There is no scientific controversy about the reality of climate change.
 

Anti-vaccine claims are rejected. Anti-vaxers claim that vaccines are dangerous and that vaccines do not work. Do vaccines work? We should have eradicated polio by now, but anti-vaxers have discouraged vaccination. If you don’t like your children getting the polio vaccine, blame the anti-vaxers. We did eradicate smallpox in the 1970s. We stopped vaccinating against smallpox. Smallpox was killing 2 million people a year. If you don’t worry about smallpox, thank a scientist. There is no scientific controversy about the safety and efficacy of vaccines.
 

Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States – Table 1


 

In response to the evidence in Table 1,[6] anti-vaxers claim that improved sanitation and hygiene. The decrease in cases and deaths due to the various vaccine-preventable illnesses should be the same for all of these diseases, but that is not the case. The diseases have also produced epidemics when the vaccination level drops below herd immunity levels.[7] There is no scientific controversy about the safety and efficacy of vaccines.
 

Science is not perfect, but science is better than all other means of learning the truth.

When science produces mistakes, we learn about it from scientists, not from politicians, not from preachers, not from placebo pushers, not from psychics, and not from any other deniers of science.

Maybe the message of science got through.

Maybe we won’t need another March for Science.
 


??Gaby Mérida ??‏ @ThatSpanishLady Twitter
Click on the image to make it larger.

Footnotes:

[1] Flat Earth Rising
by Steven Novella
Neurologica
April 6, 2017
Article

[2] Objections to evolution
Wikipedia
Article

[3] Mutation breeding
Wikipedia
Article

[4] The 10 Hottest Years on Record
January 20th, 2016
By Climate Central
Article

[5] 2016 Was the Hottest Year on Record
Both NASA and NOAA declare that our planet is experiencing record-breaking warming for the third year in a row
By Andrea Thompson
January 18, 2017
Scientific American
Article

[6] Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States.
Roush SW, Murphy TV; Vaccine-Preventable Disease Table Working Group..
JAMA. 2007 Nov 14;298(18):2155-63.
PMID: 18000199

Free Full Text from JAMA.

[7] “Vaccines didn’t save us” (a.k.a. “vaccines don’t work”): Intellectual dishonesty at its most naked
by David Gorski
March 29, 2010
Science-Based Medicine
Article

.

The Boy Who Cried Terrorist

 
This is the latest comment from Frederick Blum in response to what I wrote about his absurd defense of Dr. Tobinick.[1].[2] As you can see, in labeling appropriate respect for patients as terrorism, Frederick Blum completely lacks perspective.
 

I think a more apt description of what you are is ” Rogue Terrorist ” . Forget ” Rogue Medic. ” It’s not really you. Think about it.[3]

 

Think like Frederick Blum?

That might be torture.

If you honestly think that I am a terrorist, turn me in.

Go ahead.

It may be even worse to not turn in a terrorist, than to treat patients with inadequately tested medications.
 

If you see something, say something 1
 

“War is peace. Freedom is slavery. Ignorance is strength.”[4]

 

What do terrorists do?
 

You hide behind a cowardly mask exactly as terrorists do.[3]

 

Cowardly?

I have allowed Frederick Blum a forum to make baseless accusations.

I have responded with evidence.

I have not made threats.

Frederick Blum calls this cowardly?
 

You fabricate lies about people and assault them with ad hominem attacks, also exactly as terrorists do.[3]

 

Frederick Blum, provide some sort of evidence to support your imaginative accusations.

I have stated that Dr. Tobinick has failed to produce valid evidence of safety.

Do you have any evidence to show that this is not completely true?

I have stated that Dr. Tobinick has failed to produce valid evidence of efficacy.

Do you have any evidence to show that this is not completely true?

I have not lied.

I have criticized Dr. Tobinick for a failure to provide evidence of safety and efficacy. Using safe and effective treatments is an important part of what separates ethical medical practice from alternative medicine.

If people conclude that Dr. Tobinick is unethical because of what I have written, that is only reasonable.

Neither of you have provided even an iota to suggest any other conclusion.

By the way, have terrorists switched from killing people to using honest criticism? I wish it were so.
 

Really, you’re just another unremarkable terrorist.[3]

 

Is your unremarkable remark intentionally ironic?
 

You should change your anonymous cowardly handle to ” Rogue Terrorist. ” At least in doing so you would be honest about yourself.[1]

 

Without valid evidence of safety, we must conclude that Dr. Tobinick cannot honestly demonstrate safety.

Without valid evidence of benefit, we must conclude that Dr. Tobinick cannot honestly demonstrate any benefit.

If Dr. Tobinick’s treatment is safe and effective, why hide the evidence?

Footnotes:

[1] Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Thu, 24 Jul 2014
Rogue Medic
Article

[2] When Minions Attack
Sun, 26 Feb 2017
Rogue Medic
Article

[3] The comment where Blum cried Terrorist
comment on Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Frederick Blum
Comment

[4] 1984
George Orwell
Free Full Text from The University of Adelaide Library

.

When Minions Attack

Minion vampire 1a
Image credit.
 

In the comments to Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish,[1] Frederick Blum (sometimes Frederick S. Blum) states that he does not like my criticism of Dr. Edward Tobinick for using inadequately tested treatment, on patients.
 

The fact that you’ve censored my comments speaks volumes about the kind of person you are, ” Rogue Medic.”[2]

 

I have not censored Frederick Blum’s comments. All comments are moderated. Not all spam is caught by the spam filter.

Since Frederick Blum’s earlier, similarly absurd, comment was approved and appeared in the comments hours before this comment, what leads Frederick Blum to conclude that this is censorship?
 

What are you afraid of being found out for, that you’re no more than a charlatan ?[2]

 

You chose to use the word charlatan. Since the topic is Dr. Tobinick, is this use of charlatan a Freudian slip?
 

Frederick Blum also obsesses about my use of a pseudonym, although I provide links to valid evidence and Frederick Blum only makes excuses to distract from the absence of valid evidence for Dr. Tobinick’s treatment.

Frederick Blum complains that it is wrong to criticize Dr. Tobinick for his failure to post valid evidence, since Dr. Tobinick uses his real name.

Is valid evidence less valid when I use a pseudonym?

No.

This gullibility is one of the primary reasons scams are so successful.

Bernie Madoff, perhaps the biggest thief of all time, had people, like Frederick Blum, defending his business. A lot of people trusted that con man for the same reason.

What was Bernie Madoff’s motto?
 

Also to his advantage, Madoff was adept at both selfpromotion and client relations. His corporate slogan, “The Owner’s Name Is on the Door,” would reinforce his managerial image, as well as provide his growing list of wealthy clients with a reassuring declaration—a personal acknowledgement of his fiduciary responsibility to them.[3]

 

Is Dr. Tobinick a medical, and much more dangerous, version of Bernie Madoff? Is Dr. Tobinick’s name on the door just a confidence gimmick?
 

You can’t hide the truth about yourself forever. Eventually it is seen for what it really is – the truth.[2]

 

We would be able to determine the truth about Dr. Tobinick, if Dr. Tobinick would adequately test his treatment.

Is the treatment safe, as Dr. Tobinick uses it?

Is the treatment better than a placebo, as Dr. Tobinick uses it?

Is the treatment as good as any adequately tested treatments, as Dr. Tobinick uses it?

The only suppression of the truth is from Dr. Tobinick and his worshipers, such as Frederick Blum.

What is the treatment?
 

The list of conditions for which Tobinick claims or even has patented use of Enbrel include Alzheimer’s, stroke, traumatic brain injury, Parkinson’s disease, carpal tunnel syndrome, brain tumor, spinal cord injury, and back pain. That quite impressive for a doctor who isn’t even a neurologist. Tobinick is an internist who, prior to curing a long list of neurological diseases, specialized in laser hair removal.[4]

 

Why doesn’t everyone go to a laser hair removal specialist for inadequately tested treatments?

I am sure that the FDA and the insurance companies are being unreasonable in wanting evidence of safety and efficacy.
 

And, the truth is that you have devised a falsified and libelous campaign against someone who is not only innocent but a truly great medical scientist with a proven honest intelligence that surpasses almost everybody else in medicine today, Dr. Edward Tobinick, only to further your own loathsome self serving agenda.[2]

A proven honest intelligence? Where did you come up with that nonsense? If an intelligent person uses a dangerous treatment, the treatment is still dangerous.

Go ahead. I dare you, Frederick Blum. Stop making excuses and provide evidence to back up your unsupportable claims.

Footnotes:

[1] Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Thu, 24 Jul 2014
Rogue Medic
Article

[2] Censorship comment by Frederick Blum
comment

[3] Catastrophe: The Story of Bernard L. Madoff, the Man Who Swindled the World
Deborah Strober & Gerald Strober
Kindle Locations 1077-1079
Phoenix Books, Inc.

From the website of Bernie Madoff – http://www.madoff.com on December 15, 2008. In Appendix A (Kindle Locations 2760-2765)
 

The Owner’s Name is on the Door

In an era of faceless organizations owned by other equally faceless organizations, Bernard L. Madoff Investment Securities LLC harks back to an earlier era in the financial world: The owner’s name is on the door. Clients know that Bernard Madoff has a personal interest in maintaining the unblemished record of value, fair-dealing, and high ethical standards that has always been the firm’s hallmark.

 

[4] Enbrel for Stroke and Alzheimer’s
Science-Based Medicine
Steven Novella
May 8, 2013
Article

.

Happy Bill of Rights Day – 225 Years Old

bill-of-rights-hero-lg-1
 

The Bill of Rights was ratified on December 15, 1791, which makes today the 225th anniversary of being signed into law. The Bill of Rights protects the interests of minorities from oppression by tyrannical majorities. This is why we are not really a democracy, but a constitutional republic.

If a majority decides that a minority should not be entitled to the same rights as the majority, or promotes some rationalization of the difference as not being a valid difference, that minority can appeal to the courts for relief. On the other hand, there are no absolute rights, which would invalidate all other rights.

You can be executed for a crime you did not commit, even if you can prove that you are innocent. You have to appeal to the governor or president for intervention. As the Supreme Court decided –
 

Held: Herrera’s claim of actual innocence does not entitle him to federal habeas relief. Pp. 6-28.[1]

 

Due process of law does not require that the innocent be set free. Life, Liberty and the pursuit of Happiness are not to be found in the American Constitution. Life, Liberty and the pursuit of Happiness are not to be found in the Bill of Rights.

Rights also come with responsibilities. We need to respect the rights of others, no matter how much we might think that others cannot be trusted to make those decisions, while we claim to be able to make these same decisions, not just for ourselves, but for others.

If people of different races want to marry, the state governments are not permitted to use their authority to sanction marriages to deprive citizens of their right to marry based on tradition. States rights have limitations, just as individual rights have limitations.

Discriminating against citizens of a politically incorrect group for decades, or even centuries, is not a justification for continuing to deprive them of equal treatment under the law.

Others may use their freedom, which always comes with responsibilities, in ways we do not like, but that is part of the price of freedom.

Even though slavery was legal at the time of ratification of the American Constitution and Bill of Rights, and is still endorsed by the Bible, we have recognized that slavery is bad. Our Constitution caught up with a lot of the rest of the world.

The Bible still endorses slavery and says that I can sell my daughter as a sex slave.

What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books. – Sigmund Freud

The Bill of Rights is much better than the Bible. Go blaspheme in celebration of the Bill of Rights, which protects us from those who would burn us, or our writing, or otherwise punish us for being honest.

Footnotes:

[1] Herrera v. Collins (91-7328), 506 U.S. 390 (1993)
Argued October 7, 1992
Decided January 25, 1993
US Supreme Court
Decision

 

In criminal cases, thetrial is the paramount event for determining the defendant’s guilt or innocence. Where, as here, a defendant has been afforded a fair trial and convicted of the offense for which he was charged, the constitutional presumption of innocence disappears. Federal habeas courts do not sit to correct errors of fact, but to ensure that individuals are not imprisoned in violation of the Constitution. See, e.g., Moore v. Dempsey, 261 U.S. 86, 87-88. Thus, claims of actual innocence based on newly discovered evidence have never been held to state a ground for federal habeas relief absent an independent constitutional violation occurring in the course of the underlying state criminal proceedings.

 

.

Flag burning, patriotism, and reality

flagburningtrump2a

Tweet by President-elect Donald Trump on flag burning
 

Is appearance more important than reality?
 

Why do people burn the American flag?

There may be many reasons, but the essence appears to be an attempt to shock people to recognize what the flag burners see as hypocrisy.

What is the purpose of prohibiting burning of the American flag?

Some people place more value in this symbol of America (the flag), than they do in what makes America great (the Constitutional protections of the rights of Americans).

Is President-elect Trump an opponent of the American Constitution? Is President-elect Trump just engaging in a politically correct theatrical display for people who do not seem to understand that the American Constitution doesn’t care if their feelings get hurt?
 


 

In 1798, Congress passed, and President John Adams signed, the Alien and Sedition Acts.[1] These restricted eligibility to vote, restricted immigration, allowed for increased deportation of aliens considered dangerous, and made criticism of the federal government illegal. This is one example of Founding Fathers acting in a way that is contrary to what many consider their original intent.

Recently deceased Supreme Court Justice Antonin Scalia voted in the majority to protect flag burning in 1989.[2] Did Justice Scalia hate America, hate the American flag, or is it more complex than an early morning tweet can express?

In 1943, during World War II, the Supreme Court decided on a variation of this concept. Is it Constitutional to force people to demonstrate patriotism?
 

To believe that patriotism will not flourish if patriotic ceremonies are voluntary and spontaneous instead of a compulsory routine is to make an unflattering estimate of the appeal of our institutions to free minds.[3]

 

Real patriotism is not a politically correct compulsory display.
 

But freedom to differ is not limited to things that do not matter much. That would be a mere shadow of freedom. The test of its substance is the right to differ as to things that touch the heart of the existing order.[3]

 

The American Constitution does not authorize thought crimes.
 

If there is any fixed star in our constitutional constellation, it is that no official, high or petty, can prescribe what shall be orthodox in politics, nationalism, religion, or other matters of opinion or force citizens to confess by word or act their faith therein. If there are any circumstances which permit an exception, they do not now occur to us.[3]

 

What about those who claim that Americans have risked their lives, and even died, to protect the sanctity of the American flag? Does service in any branch of the American military contain any oath to protect the American flag?
 

(a) Enlistment Oath .-Each person enlisting in an armed force shall take the following oath:
“I, ____________________, do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; and that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations and the Uniform Code of Military Justice. So help me God.”
[4]

 

The So help me God is optional, since there is no truth to the myth that there are no atheists in foxholes and the American Constitution prohibits all religious requirements for service.

The oath is to protect the American Constitution, which protects flag burning. The oath is not to protect the American flag.

Even Jesus stated opposition to this kind of political theater.
 

5 “When you pray, you are not to be like the hypocrites; for they love to stand and pray in the synagogues and on the street corners [a]so that they may be seen by men. Truly I say to you, they have their reward in full. 6 But you, when you pray, go into your inner room, close your door and pray to your Father who is in secret, and your Father who sees what is done in secret will reward you.[5]

 

What does it say about America that we reward theatrical patriotism, rather than respect for the Constitution which makes America great?

Or is President-elect Trump taking initial steps to try to get Citizens United v. Federal Election Commission[6] overturned by expressing that not everything is protected expression? Who can tell with someone who expresses himself in such a vague manner?

Is appearance more important than reality?

Footnotes:

[1] Alien and Sedition Acts
1798
Primary Documents in American History
Library of Congress page

[2] Texas v. Johnson, (1989)
No. 88-155
Argued: March 21, 1989
Decided: June 21, 1989
United States Supreme Court
case

[3] West Virginia State Board of Education v. Barnette (No. 591)
Argued: March 11, 1943
Decided: June 14, 1943
case

[4] §502. Enlistment oath: who may administer
Text contains those laws in effect on November 28, 2016
US Code page

Amended in 1962 – inserted “So help me God” in the oath, and “or affirmation” in text.

[5] Matthew 6:5-6
New American Standard Bible (NASB)
You can go to the site and look up all of the other versions of the Bible or just pick up a Bible and read this.
Bible Gateway
Bible

[6] Citizens United v. Federal Election Commission
2009
case

.

SWAT Fuel – Suing Me to Defend Their Scam

swat-fuel-stop-exposing-our-scam-or-we-will-sue
 

Earlier, I wrote about SWAT Fuel, explaining why SWAT Fuel’s amphetamine-like products are a scam and providing evidence.
 

How to scam the police – SWAT Fuel
 

Now, I am being threatened with a law suit, unless I remove what I wrote, all of the comments (even the fawning SWAT Fuel fanboy comments), and cease writing about SWAT Fuel.

Is SWAT Fuel a scam?

SWAT Fuel, Inc. has not provided any evidence of safety.

SWAT Fuel, Inc. has not provided any evidence of efficacy.

I asked for evidence.

I was threatened with a lawsuit.
 

Will I remove what I wrote? Will I stop criticizing the amphetamine-like products of the SWAT Fuel scam?
 

molon_labe-1a
 

Should I pretend that SWAT Fuel’s amphetamine-like concoctions are safe, when even SWAT Fuel cannot provide valid evidence of safety?

I do not approve of poisoning the police, the military, or anyone else. SWAT Fuel, Inc. needs to provide valid evidence that their amphetamine-like products are safe.

Should I pretend that SWAT Fuel’s amphetamine-like concoctions are effective, when even they cannot provide valid evidence of efficacy?

Amphetamine-like? If we are to believe their advertising, SWAT Fuel is even stronger than amphetamines – SWAT Fuel was described as being like strapping a JATO rocket to your back! SWAT Fuel does not seem to use that terminology any more. I ridiculed that language and they changed. Coincidence? I don’t know, but maybe I can persuade them to develop some ethics and produce some valid evidence.
 

How to scam the police – SWAT Fuel
 

.

The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

ResearchBlogging.org
 

This is a very interesting trial that may surprise the many outspoken amiodarone advocates, but it should not surprise anyone who pays attention to research.

ALPS showed that we should stop giving amiodarone for unwitnessed shockable cardiac arrest. The lead researcher is still trying to spin amiodarone for witnessed shockable cardiac arrest, even though the results do not show improvement in the one outcome that matters – leaving the hospital with a brain that still works.[1],[2],[3]

There is an excellent discussion of the study on the podcast by Dr. Salim Rezaie and Dr. Anand Swaminathan REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia.

One problem with the study that they do not address on the podcast is that the patients in the study appear to have had time to watch Casablanca before treatment started. Here’s looking at you, while we’re waiting, kid. This is apparently unintentional one way of doing a placebo washout. If we wait long enough . . . .
 

Time from arrival to start of infusion was 87 ± 21 min for procainamide and 115 ± 36 min for amiodarone patients (P = 0.58).[4]

 

If nothing else, this demonstrates how little we need to worry about immediately pushing drugs for stable monomorphic VT (V Tach or Ventricular Tachycardia). Should we expect much from antiarrhythmic treatment?

Research shows that for stable monomorphic VT (V Tach or Ventricular Tachycardia) amiodarone is not very likely to be followed by an improvement. Only 29%[5] or only 25%[6] or only 15% within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29%.[7] For those of you who are not good at math, that means amiodarone is about the same as doing nothing, only it comes in a syringe. Even though these poor outcomes ignore the side effects, they are the best evidence in favor of amiodarone, so what Kool-Aid are the advocates drinking?

Adenosine, yes adenosine the SVT (SupraVentricular Tachycardia) drug, appears to be more effective at treating ventricular tachycardia than amiodarone – and adenosine is faster and safer than amiodarone.[8]

What if the patient becomes unstable? First start an IV (IntraVenous) line. Then sedate the patient. Then apply defibrillator pads. After the patient is adequately sedated, then cardiovert. We do not need the pads on the patient first. If it takes a while to put the pads on, that is a problem with the ability of the doctors and nurses, not a medical problem.

It does not appear as if any patient received amiodarone or procainamide until after waiting in the ED (Emergency Department) for over an hour. Were some patients cardioverted in well under an hour? Probably. The important consideration is that the doctors and nurses be able to apply the defibrillator pads properly and quickly and deliver a synchronized cardioversion in less than a minute. If the patient has not yet been sedated, the cardioversion should be delayed until after the patient is adequately sedated, so the intervention that depends most on time is the sedation of the patient.
 

VT + Amiodarone Cardioversion
 

Is there a better treatment than amiodarone? Sedate the patient before the patient becomes unstable, then cardiovert. How do the MACEs (Major Adverse Cardiac Events) compare with sedation and cardioversion vs. antiarrhythmic treatment.
 

5.4 Proarrhythmia
Amiodarone may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. Proarrhythmia, primarily torsade de pointes (TdP), has been associated with prolongation, by intravenous amiodarone, of the QTc interval to 500 ms or greater. Although QTc prolongation occurred frequently in patients receiving intravenous amiodarone, TdP or new-onset VF occurred infrequently (less than 2%). Monitor patients for QTc prolongation during infusion with amiodarone. Reserve the combination of amiodarone with other antiarrhythmic therapies that prolong the QTc to patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent.
[9]

 

All antiarrhythmic drugs can cause arrhythmias. In the absence of information about a specific problem that is best addressed by a specific drug (amiodarone is the opposite of specific), we should avoid treatments that have such a high potential for harm.

Amiodarone doesn’t even do a good job of preventing arrhythmias.
 

Intravenous amiodarone did not prevent induction of sustained ventricular tachycardia in any of five patients inducible at baseline. Of six patients with non-sustained ventricular tachycardia, five had sustained ventricular tachycardia or fibrillation induced after amiodarone infusion.[10]

 

Is anything worse than amiodarone? Even epinephrine, yes epinephrine the inadequately tested cardiac arrest drug, has been followed by improved outcomes from V Tach after amiodarone failed.[11]
 

What is best for the patient?

Sedation, search for reversible causes, apply defibrillator pads, and be prepared to cardiovert.

Maybe sedation isn’t that important? This is by Dr. Peter Kowey, one of the top cardiologists in the world.
 

The man’s very first utterance was, “If it happens again, just let me die.”

As I discovered, the reason for this patient’s terror was that he had been cardioverted in an awake state. Ventricular tachycardia had been relatively slow, he had not lost consciousness, and the physicians, in the heat of the moment, had not administered adequate anesthesia. Although the 5 mg of intravenous diazepam had made him a bit drowsy, he felt the electric current on his chest and remembered the event clearly.

The patient’s mental state complicated the case considerably.[12]

 

How unimportant is sedation? How unimportant is consent?

For sedation, I would recommend ketamine, but etomidate was recommended in the podcast. Both work quickly and the most important obstacle to immediate treatment of a patient who suddenly deteriorates is the time to effect of sedation. Neither drug is expected to interfere with perfusion, which is the main excuse given for avoiding sedation for cardioversion.

This study is very small (not the fault of the authors), but it adds to the evidence that amiodarone is not a good first treatment for the patient.
 

Go listen to the podcast by Dr. Salim Rezaie and Dr. Anand Swaminathan REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

 

Over the years, I have written a bit about cardioversion and the importance of sedation –

Cardioversion – I’m not doing that, you do it! – Mon, 24 Mar 2008

Cardioversion – 2010 ACLS – Part I – Mon, 25 Oct 2010

Cardioversion – 2010 ACLS – Part II – Sun, 31 Oct 2010

Cardioversion – 2010 ACLS – Part III – Thu, 11 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part I – Thu, 11 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part II – Fri, 12 Nov 2010

Synchronized Cardioversion Without Sedation – Part II Scallywag’s Response – Sun, 14 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part III – Tue, 16 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part IV – Wed, 24 Nov 2010

Comments on Cardioversion – 2010 ACLS – Part II – Mon, 16 Apr 2012
 

I have also written a bit about amiodarone –

Merit Badge Courses, Amiodarone, and tPA – Fri, 17 Sep 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part I – Wed, 01 Dec 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part II – Fri, 03 Dec 2010

Is Nexterone the Next Amiodarone? – Sat, 04 Dec 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part III – Mon, 06 Dec 2010

Where are the Black Box Warnings on These Drugs – I – Mon, 05 Dec 2011

Where are the Black Box Warnings on These Drugs – II – Sun, 11 Dec 2011

Is Amiodarone the Best Drug for Stable Ventricular Tachycardia – Wed, 14 Dec 2011

V Tach Storm – Part I – Wed, 28 Dec 2011

V Tach Storm – Part II – Thu, 29 Dec 2011

Nifekalant versus lidocaine for in-hospital shock-resistant ventricular fibrillation or tachycardia – Wed, 04 Jan 2012

NIH launches trials to evaluate CPR and drugs after sudden cardiac arrest – Sun, 29 Jan 2012

What Will Be the Next Standard Of Care We Eliminate – Wed, 28 Mar 2012

Happy Adenosine Day – Tue, 12 Jun 2012

Too Much Medicine and Evidence-Based Guidelines – Part I – Tue, 26 Jun 2012

Too Much Medicine and Evidence-Based Guidelines – Part II – Tue, 03 Jul 2012

Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part I – Mon, 02 Jul 2012

Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part II – Thu, 05 Jul 2012

Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium – Part I – Mon, 17 Sep 2012

Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium – Part II – Tue, 18 Sep 2012

How do we measure the QT segment when there are prominent U waves? – Thu, 13 Dec 2012

Woman with Risks for Torsades de Pointes Dying within Hours of Leaving the Emergency Department – Wed, 02 Jan 2013

Examples of Ventricular Tachycardia Caused by Amiodarone – Part I – Tue, 28 May 2013

Publication Bias – The Lit Whisperers – Tue, 11 Jun 2013

Standards Of Care – Ventricular Tachycardia – Wed, 31 Jul 2013

Footnotes:

[1] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

[3] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.
N Engl J Med. 2016 May 5;374(18):1711-22. doi: 10.1056/NEJMoa1514204. Epub 2016 Apr 4.
PMID: 27043165

CONCLUSIONS
Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

[4] Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.
Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators.
Eur Heart J. 2016 Jun 28. pii: ehw230. [Epub ahead of print]
PMID: 27354046

Free Full Text from European Heart Journal.

[5] 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.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

[6] 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]

[7] 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]

[8] Adenosine for wide-complex tachycardia – diagnostic?
Thu, 23 Aug 2012
Rogue Medic
Article

[9] AMIODARONE HYDROCHLORIDE- amiodarone hydrochloride injection, solution
DailyMed
5 WARNINGS AND PRECAUTIONS
FDA Label

[10] Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction.
Kułakowski P, Karczmarewicz S, Karpiński G, Soszyńska M, Ceremuzyński L.
Europace. 2000 Jul;2(3):207-15.
PMID: 11227590 [PubMed – indexed for MEDLINE]

Free Full Text PDF + HTML from Europace

[11] 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.

[12] The calamity of cardioversion of conscious patients.
Kowey PR.
Am J Cardiol. 1988 May 1;61(13):1106-7. No abstract available.
PMID: 3364364

Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P, & Resuscitation Outcomes Consortium Investigators (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. The New England journal of medicine, 374 (18), 1711-22 PMID: 27043165

Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J, & PROCAMIO Study Investigators (2016). Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal PMID: 27354046

Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, & Ellinor PT (2010). Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17 (3), 297-306 PMID: 20370763

Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, & Ruskin JN (2006). Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Annals of emergency medicine, 47 (3), 217-24 PMID: 16492484

Tomlinson DR, Cherian P, Betts TR, & 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 : EMJ, 25 (1), 15-8 PMID: 18156531

Kułakowski P, Karczmarewicz S, Karpiński G, Soszyńska M, & Ceremuzyński L (2000). Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2 (3), 207-15 PMID: 11227590

Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, & Fontaine G (2012). Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia. World journal of cardiology, 4 (10), 296-301 PMID: 23110246

Kowey PR (1988). The calamity of cardioversion of conscious patients. The American journal of cardiology, 61 (13), 1106-7 PMID: 3364364

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Is EMS a Trade or a Profession?

 

In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.
 

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.[1]

 
trade vs profession 1

 
In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.
 

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.[1]

 

Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.
 

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.[1]

 

The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?

Footnotes:

[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)
Article

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