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

- Rogue Medic

Happy Friday the 13th

One of the Most Holy Days of the Church of Anecdote and Confirmation bias is here.

Will it be quiet? Oops, the utterance of the word Quiet can turns any day into a Friday the 13th for some celebrants of this religion, at least for those who work in EM/EMS (Emergency Medicine/Emergency Medical Services).

Are these superstitions unreasonable? Absolutely, but try explaining that to someone who rejects reason.

How do you reason with people who reject reason? Presenting large quantities of objective evidence is not going to matter to believers, because their self-worth depends, to some extent, on protecting themselves from being reasonable.

A coincidence is a remarkable concurrence of events or circumstances that have no apparent causal connection with one another. The perception of remarkable coincidences may lead to supernatural, occult, or paranormal claims. Or it may lead to belief in fatalism, which is a doctrine that events will happen in the exact manner of a predetermined plan.

From a statistical perspective, coincidences are inevitable and often less remarkable than they may appear intuitively. An example is the birthday problem, which shows that the probability of two persons having the same birthday already exceeds 50% in a group of only 23 persons.[1] [1]

Uncountable numbers of unrelated events happen at apparently the same time. Since time itself is relative, the point of reference of the observer can be a factor in the appearance of coincidence. For example, thunder will be heard by a person at the same time the person sees lightning, while a mile away, a person sees the lightning 5 seconds before hearing the thunder. The thunder and lightning have the same cause, but the lightning and the thunder separate by even more time, from the perspective of even more distant observers.

The lack of perspective about observations has led people to develop more superstitions about coincidences than have been documented.

Casinos depend on superstition.

You have a system? Excellent. Come and apply your system to our games of chance. We will take your bets.

Casinos will not just take just your bets. Casinos will take trillions of dollars of bets, because they have arranged the odds to be, at least, slightly in their favor.

Do you wait for someone to put all of their money into a slot machine, then take their seat, expecting that the machine is overdue to pay out?

Casinos pay millions of dollars for famous people to perform on stage to draw you in to use that kind of system. The Casino will take your bet. Your money will help to pay even more for expensive entertainers.

You count cards?

Brilliant! The dealer, or a manager, is also counting cards and trained to recognize when someone is using a betting system based on card counting. The cameras, which watch everything happening at the tables, are also helping to track your habits. The cameras will also get high quality images of you, which casinos share as part of their countermeasures. Card counting is not illegal, but the casino can do a lot to keep the odds in the favor of the casino.

Roulette games have systems, as well. Likewise, the casinos want you to bet your money on your systems. They have bills to pay and your money is just a drop in the bucket to the casinos.

You don’t believe in coincidences?

Companies make trillions of dollars off of your belief. Your belief is their business and their business is profitable.

However, if you want to get better at recognizing the biases you have, challenge yourself to bets on the outcomes of your beliefs. It doesn’t have to be money. You can bet doing something you don’t want to do against doing something you do want to do, based on whether you are right about something you believe.

Write down what you believe/believe will happen. Write down your criteria for winning/losing. Don’t make excuses for fudging the criteria. Maybe doing something that you should do, but really don’t want to do. Think of how much you will accomplish – if you are honest with yourself and you set your bets up objectively.

Footnotes:

[1] Coincidence
Wikipedia
Web page

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Do Emergency Physicians Intubate Often Enough to Maintain Competency?

 

    There is a study of the frequency of intubation among emergency physicians in the current Annals of Emergency Medicine. This study is accompanied by a discussion, which unfortunately does not question the assumption that intubation improves outcome. There is very little evidence to suggest that intubation improves outcomes. That evidence is only using paramedics with the highest success rates – much higher than your average paramedic.

 
Greater intubation experience in paramedics is associated with improved patient outcomes2; does a similar relationship exist for emergency physicians?[1]
 


Image credit.

The unquestioned assumption is that excellent intubation performance improves outcomes, rather than that excellent intubation performance causes less harm than average intubation performance, or below average performance. We do not have any good evidence to support the wishful thinking that paramedics, or even much more experienced emergency physicians, improve outcomes by intubating patients. We just assume this, because we don’t really want to know. If we decide to be honest and actually find out the effect of intubation, how will we handle it if the results show that we are harming more patients than we are helping?

The Cardiac Arrhythmia Suppression Trial was only started because the proponents of the different antiarrhythmics (encainide, flecainide, and moricizine) wanted to prove that their drug was better than all of the rest. They even agreed to include a placebo arm, although the doctors did not like the idea of depriving patients of such beneficial treatment.

 
CONCLUSIONS: There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide.[2]
 

People who had frequent ectopic heart beats – PVCs (Premature Ventricular Contractions) after a heart attack were more likely to die than people who did not have frequent PVCs. The obvious solution – the equivalent of intubation and blood-letting – was to give drugs that will get rid of the PVCs. The problem is that the PVCs were not the problem. The PVCs were just a sign of the problem. The drugs made the actual problem with the heart worse, while making the heart appear to be better. The same is true of blood-letting and may be true of intubation. Abundant evidence for the obvious benefits of blood-letting are quoted in the footnotes.[3]

If intubation is harmful, do we want to know?

If intubation by the average paramedic is harmful, do we want to know?

If intubation by the average emergency physician is harmful, do we want to know?

It isn’t as if we take intubation seriously. If we did take intubation seriously, we would practice much, much more than we do. In stead, we make excuses for failing to practice something that we claim is life-saving, because we are too arrogant to admit that practice is important to develop and maintain any skill.

Practicing on even the most basic mannequin should be done before every shift, whether you are a paramedic or an emergency physician. Unless you have a 99%, or better, success rate on hundreds of patients.

Footnotes:

[1] Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364

The article above is commentary on the article below:

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101

Free Full Text from N Engl J Med.

[3] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.
 

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Does Room Air Reduce Mortality Among Term Neonates Requiring Respiratory Support at Birth?

     

The title of this meta-analysis suggests that it is important for us to have evidence in order to withhold treatments that are based on assumptions and anecdotes, rather than based on evidence. We should not even suggest this. Fortunately, the neonatal resuscitation guidelines have recommended not using the assumption-based and anecdote-based treatment since 2010.

 

Before 2000, resuscitation guidelines recommended 100% Fio2 for newborn respiratory support.6 However, hyperoxemia caused by high Fio2 results in the formation of free radicals, which can damage the lungs, brain, eyes, and other organs.7 Hypoxemia may also lead to harm. Literature in the early 2000s suggested no harm with room air resuscitation in term neonates, but also potentially an improvement in short-term mortality.8 In accordance with this literature, in 2010 and 2015 ILCOR recommended using room air for the initial resuscitation of term neonates.9, 10 [1]
 

The authors of this summary of the meta-analysis qualify this meta-analysis with a list of the weaknesses of the research. This is important for every analysis of research, but is it relevant, when there is no good reason to recommend the traditional intervention?  

According to these results with low evidence certainty, room air reduces short-term mortality compared with 100% Fio2 among term neonates requiring respiratory support at birth. Despite the low-quality evidence, these results are consistent across studies with low heterogeneity. The effect of intermediate Fio2 levels is not known and may benefit from further study. [1]
 

These are not reasons to reconsider, or oppose, the withholding of any treatments that are based on assumptions and anecdotes, rather than based on evidence.

The burden of proof is on those promoting any intervention. In the absence of valid evidence, we should limit ourselves to interventions that are supported by high quality evidence.

For epinephrine in cardiac arrest, there is no high quality evidence of benefit. The highest quality evidence is evidence of harm from epinephrine. The same is true for amiodarone, ventilation in cardiac arrest not due to a respiratory problem, furosemide in ADHF/CHF (Acute Decompensated Heart Failure/Congestive Heart Failure), and many other treatments we provide to patients, but definitely not for the benefit of patients.

We need to stop putting patients last in treatment decisions. The neonatal resuscitation guidelines are correct in their rejection of supplemental oxygen for neonatal resuscitation and the guidelines should not be changed.

Footnotes:

[1] Does Room Air Reduce Mortality Among Term Neonates Requiring Respiratory Support at Birth?

Brit Long, MD (EBEM Commentator), Michael D. April, MD, DPhil (EBEM Commentator) Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX

Annals of Emergency Medicine

October 2019, Volume 74, Issue 4, Pages 509–511

DOI:&nbps;https://doi.org/10.1016/j.annemergmed.2019.03.017

Free Full Text from Annals of Emergency Medicine. .

Happy Full Moon Friday the 13th


Technically, the full moon is not until 00:33 – 33 minutes after the end of Friday the 13th, so that may help the superstitious to feel better, since these superstition events are not actually coinciding – pitting twice as many Gods against the superstitious (a double whammy). Or the superstitious may feel worse, because they now have two days in a row of the Gods conspiring against them. The reality is that only their own beliefs conspire against them. it is all in the heads of the believers.

Even when someone does claim to come up with some evidence to support their beliefs, those conclusions are not supported by higher quality research.
 

In conclusion, Friday the 13th appears to be dangerous for some women. Since Friday falls on the 13th day of the month only twice a year on average, prospects for significant public health gains are limited. However, the risk of death for women who venture into traffic on this unlucky day is higher by 63%, and it should be possible to prevent one-third of the deaths occurring on this particular day. Even then, the absolute gain would remain marginal, since only one death per 5 million person-days could be prevented.[1]

 

The total number of deaths is small. Drawing that conclusion, based on a small sample size is a problem. In order to be able to come up with larger numbers, to minimize the effects of the small sample size, other researchers looked at the motor vehicle collisions, rather than just fatal motor vehicle collisions. The assumption that the cause of the fatalities was anxiety, produced by superstition among the drivers is projecting a lot onto the drivers – without any evidence to support this supposed cause.

It should not be a surprise that the results of a much larger sample size contradicts the assumptions based on the much smaller sample.
 

Conclusion:
We conclude that, in the Finnish traffic accident statistics for 1989–2002, females have not incurred more injury (or fatal) road traffic accidents on Fridays the 13th than expected, as a driver, bicyclist or pedestrian. We suggest that Näyhä’s contradicting result on fatalities is due to different sampling, non-optimal setting and chance in a fairly small data. However, this does not imply a nonexistent effect on accident risk as no exposure-to-risk data [18] are available. People who are anxious of “Black Friday” may stay home, or at least avoid driving a car. The only relevant data [4], suggesting a small decrease in highway traffic, is rather limited and should be confirmed with more extensive research.[2]

 

The law of small numbers is an attempt to expose the mistake of extrapolating from small numbers as if the small numbers are representative. Small numbers are misleading. Small numbers are often used to promote ideas that are not supported by adequate numbers – such as the claims that epinephrine improves cardiac arrest outcomes that matter, or that amiodarone improves cardiac arrest outcomes that matter.[3]

Footnotes:

[1] Traffic deaths and superstition on Friday the 13th.
Näyhä S.
Am J Psychiatry. 2002 Dec;159(12):2110-1.
PMID: 12450968

[2] Females do not have more injury road accidents on Friday the 13th.
Radun I, Summala H.
BMC Public Health. 2004 Nov 16;4:54.
PMID: 15546493

Free Full Text from PubMed Central.

[3] Chapter 10
The Law of Small Numbers

Thinking, Fast and Slow
Daniel Kahneman
2011
Wikipedia page

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Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction

 

Is prehospital use of NTG (NiTroGlycerin; GTN GlycerylTriNitrate in Commonwealth countries) safe for treating prehospital suspected STEMI (ST segment Elevation Myocardial Infarction) patients?

The evidence is limited, but does not suggest that prehospital NTG produces enough harm to discourage use in suspected STEMI. These researchers looked at the emergency department assessments of patients following prehospital NTG for suspected STEMI.  

Despite the theoretical risk, the limited retrospective studies of NTG in the prehospital setting for multiple indications suggest that the medication is safe.(10-13) However, with regard to NTG use for STEMI, the AHA International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care concluded that there was not enough evidence to determine the benefit or harm of out-of-hospital use of NTG.(14) Given the high false positive rates for STEMI identified in the field, an additional concern is that many patients treated with NTG for presumed STEMI will ultimately have an alternate etiology for their pain.(15, 16) Therefore, it is not clear that the benefits outweigh the risks of administering NTG to all patients with suspected STEMI in the field.[1]
 

This paper helps to show the safety of prehospital NTG for suspected STEMI, providing evidence that blood pressure changes were similar in suspected STEMI patients with an SBP (Systolic Blood Pressure) of 100, or higher, regardless of whether they were treated with NTG. The study is a retrospective chart review, so we do not know why some of the patients were not treated with NTG.

One reason mentioned, but not discussed, is that only 22% (96 of 440) suspected STEMI patients not treated with NTG are documented to have had pain, but there is no information on the type of pain or other cardiac symptoms of the patients. Were the paramedics avoiding treating atypical chest pain, such as pressure, heaviness, gastric discomfort, difficulty breathing, et cetera? We do not know. Was only chest pain being documented, rather than shoulder, or arm, or jaw, pain? We do not know. Did the pain resolve prior to EMS arrival? We do not know. Were the paramedics correctly recognizing when the machine interpretation of the ECGs (ElectroCardioGrams) were wrong? We do not know.

The median Initial Pain Score is documented as 8, with an IQR (Inter-Quartile Range) of 5-9 for those treated with NTG. For those not treated with NTG the Initial Pain Score is documented as 0, with an IQR of 0-0. We do not know the Initial Pain Score of those who did have pain, but were not treated with NTG. All of these patients were in an IQR that was not documented in the paper. The good news is that the suspected STEMI patients not treated with NTG act as a control group, although possibly with important differences that are not discussed in the paper.

Click on the image of the LA County protocol to make it larger.[2]

What about the 17% of suspected STEMI patients with SPB <100 mmHg who were treated with NTG?

Was medical command (California has certified MICNs [Mobile Intensive Care Nurses] providing medical command on the radio, with physicians available, as well) contacted for authorization to deviate from the protocol? If so, that is something that should be documented in the charts, which were reviewed for this paper. That information is not included in this paper. Those patients are much more interesting to me.

I do not object to using NTG to treat suspected STEMI with an SBP below 100 mmHg, but the authors seem to think that EMS should not even consider it. Do the outcomes of those patients support the approach of the authors? We do not know.

I suspect that the fears of bottoming out the blood pressure are very exaggerated, but it would be nice to have some evidence either way.

An important secondary end point was the differences between those with inferior/right ventricular STEMI, but treated with NTG.  

By vasodilating all blood vessels, and the venous system in particular, it causes a drop in blood pressure and preload. Thus, there is concern for precipitating hypotension in ACS involving the right ventricle.(1-3) Contraindications to the use of NTG, as outlined by the American Heart Association (AHA) Guidelines on the treatment of ACS, include right ventricular infarction.(4) This raises concern for use in inferior ST-segment elevation myocardial infarction (STEMI) in the prehospital setting, since many inferior STEMI result from proximal right coronary artery (RCA) occlusion and 50% involve the right ventricle.(3) Traditional 12-lead ECG is focused mainly on the left side of the heart and typically EMS protocols do not include acquisition of right-sided ECG leads. Further, in many systems, Basic Life Support (BLS) protocols allow for administration of NTG without differentiating the location of STEMI. There is also risk of other adverse events including bradycardia and cardiac arrest.(5-9)[1]
 

I have aggressively promoted the use of NTG for even hypotensive CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Many physicians are not comfortable with that, even though the available evidence shows that aggressive IV NTG doubled the survival rate for these hypotensive patients. More research is needed on the use of NTG, especially in hypotensive patients.  

Further, we did not find an increased risk of hypotension among patients with proximal or mid RCA occlusions confirmed on coronary angiography. There are several possible reasons for our findings. First, while right ventricular involvement in inferior STEMI is common, hemodynamic instability is actually rare due to the right ventricle’s more favorable oxygen supply-demand ratio compared to the left heart and more extensive collateral flow.(3, 22) In addition, left heart occlusions may also involve the right ventricle and result in a preload dependent condition.(23-25) While limited by sample size, our results suggests that specifically avoiding NTG use in inferior STEMI, which is common in EMS systems, may be misguided. One quarter of the local EMS agencies in the state of California, for example, currently prohibit the use of NTG in inferior STEMI.(26) This analysis would benefit from additional study with a larger sample size and specific information about the infarct territory. Further studies are needed to determine which patients, in particular, are at increased risk for hypotension when treated with NTG.[1]
 

Perhaps NTG is also safe for treating patients with inferior ischemia and even right ventricular ischemia.

Footnotes:

[1] Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction.

Bosson N, Isakson B, Morgan JA, Kaji AH, Uner A, Hurley K, Henry TD, Niemann JT.

Prehosp Emerg Care. 2018 Dec 17:1-9. doi: 10.1080/10903127.2018.1558318. [Epub ahead of print]

PMID: 30556765

[2] Treatment Protocol: Chest Pain */ Acute MI

Reference No. 1244

LA County Paramedic Protocols

Los Angeles County Department of Health Services – Emergency Medical Services

Protocol

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How Effective Is Epinephrine for Improving Survival Among Patients in Cardiac Arrest?

   

There have been two studies comparing epinephrine with placebo to treat out of hospital cardiac arrest. The Jacobs study was stopped early, because of interference by those who do not want to know if their medicine actually works.[1] The purpose of research is to determine, as objectively as possible, if a treatment is better than placebo nothing.  

Click on the image to make it larger.  

Even the small sample size shows a impressive p values of <0.001 for both ROSC (Return Of Spontaneous Circulation) and being admitted to the hospital. Unfortunately, that does not lead to outcomes that are better than placebo.

The Perkins study (PARAMEDIC2) did not find a significant difference between adrenaline (epinephrine in non-Commonwealth countries) and placebo.[2] The Jacobs study also did not find a difference, but the numbers were small, due to the interference by the less than knowledgeable. Following the Jacobs study, some intervention proponents have suggested that the problem is not a lack of evidence of benefit, but need to look at the evidence from the right perspective. The inadequate evidence is not “inadequate”, but really just misunderstood. All we need to do is use a method of analysis that compensates for the tiny sample size. A Bayesian approach will produce the positive outcome that is not justified by so few patients.[3]

What happens when the numbers are combined, so that the sample size is large enough to eliminate the need for statistical chicanery to come up with something positive?

The outcomes do not improve.  

Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome.[4]
 

If the Bayesian approach were appropriate, then the much larger sample size would have provided more than enough patients to confirm the optimism of the epinephrine advocates. The result is still not statistically significant. Maybe a much, much larger study will show a statistically significant, but tiny, improvement in outcomes with epinephrine, but don’t hold your breath for that. It took half a century to produce the first study, then seven more years for the second. With the cost of research and the problems coordinating such a large study, it is more likely that the guidelines will continue to recommend spending a lot of time and money giving a drug that diverts attention from the interventions that do improve outcomes.

There is still no evidence that adrenaline provides better outcomes than placebo in human cardiac arrest patients.

  –  

Footnotes:

  –  

[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. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2. PMID: 21745533

Free Full Text PDF Download from semanticscholar.org  

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.

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.

  –  

[2] A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18. PMID: 30021076

Free Full Text from N Engl J Med.

  –  

[3] Regarding “Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial”. Youngquist ST, Niemann JT. Resuscitation. 2012 Apr;83(4):e105; author reply e107. doi: 10.1016/j.resuscitation.2011.09.035. Epub 2012 Jan 18. No abstract available. PMID: 22266068

Free Full Text from Resuscitation.

  –  

[4] Adrenaline and vasopressin for cardiac arrest. Finn J, Jacobs I, Williams TA, Gates S, Perkins GD. Cochrane Database Syst Rev. 2019 Jan 17;1:CD003179. doi: 10.1002/14651858.CD003179.pub2. PMID: 30653257    

.

ACLS Excuses for Causing Harm with Epinephrine

 

The next ACLS guidelines are available for review and comment, before they are finalized. The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR) are available for two guidelines:

Vasopressors in Adult Cardiac Arrest

Advanced Airway Management During Adult Cardiac Arrest

We have been using these interventions for so long, that there should be great evidence to show that benefits and harms of both interventions, but there is no good evidence to support either intervention.

For epinephrine (adrenaline in Commonwealth countries), the most commonly used vasopressor and the only one rally being considered, there is no evidence of actual benefit – increased survival without severe brain damage.

Nothing else matters.

There is no valid evidence that increasing any surrogate endpoint improves survival without severe brain damage. The evidence cited by ILCOR shows that epinephrine increases the rate of severe brain damage.
 

Intervention: Vasopressor or a combination of vasopressors provided intravenously or intraosseously during cardiopulmonary resuscitation.[1]

 

Here are the outcomes that are supposed to indicate that the patient is better.
 

Outcomes: Short-term survival (return of spontaneous circulation (ROSC) and survival to hospital admission), mid-term survival (survival to hospital discharge, 28 days, 30 days, or 1 month), mid-term favorable neurological outcomes (Cerebral Performance Category score of 1-2 or modified Rankin Scale 0-3 at hospital discharge, 28 days, 30 days, or 1 month) and long-term favorable and poor (modified Rankin Score 4-5) neurological outcomes (after 1 month).[1]

 

Is ROSC an improvement?

We aren’t supposed to ask that question. These are faulty assumption that the guidelines are based on.

1. Doing something more is better than only doing things supported by valid evidence of improved survival without severe brain damage.

No.

How much harm is being caused in this rush to get a pulse back?

We are supposed to ignore our understanding of research, look at a statistically insignificant “trend”, and extrapolate that statistically insignificant “trend” to support the prejudice that our intervention has not been harmful.

That is not good science.

That is not good medicine.
 

Why aren’t there any studies large enough to show improved survival without severe brain damage for anything other than rapid defibrillation (when indicated VF/pulseless VT) and chest compressions?

The research has only produced excuses and surrogate endpoint. Surrogate endpoints are for hypothesis generation and sales pitches to the least knowledgeable, but not for treatment guidelines.

ILCOR has told us this before, but that was because the choice was between large doses of epinephrine and small doses of epinephrine, not between epinephrine and no epinephrine.

The choice is the same.

Is the more aggressive intervention helping?

The answer is the same. No. That is not the conclusion of the evidence.
 

CONCLUSIONS
In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.[2]

 

If the goal is a pulse with more severe brain damage, then epinephrine is the way to go.

If the goal is increased survival without severe brain damage, we have to keep looking.

We should limit the use of epinephrine to well controlled research until there is evidence of improvement in outcomes that matter.

If this evidence is never found, our patients will not have been harmed by epinephrine.

If this evidence is eventually found, it is something that should have been insisted on decades ago. We should not use wishful thinking and surrogate endpoints to justify interventions that harm patients.

We used to stop compressions to let the medic/nurse/doctor intubate, or start an IV (IntraVenous) line.

We knew that the tube was more important.

We knew that the drugs given through the IV line were more important.

The 2005 guidelines told us to continue compressions during intubation and during IV attempts and to improve the quality of the compressions.

That focus on high quality compressions is the only time we have improved outcomes that matter.
 

CONCLUSIONS: Compared with controls, patients with out-of-hospital cardiac arrest treated with a renewed emphasis on improved circulation during CPR had significantly higher neurologically intact hospital discharge rates.[3]

 

33 1/3% vs 60% increased survival without severe brain damage.
 

In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR.[4]

 

18% vs 34% increased survival only – not increased survival without severe brain damage.
 

In the analysis of MICR [Minimally Interrupted Cardiac Resuscitation] protocol compliance involving 2460 patients with cardiac arrest, survival was significantly better among patients who received MICR than those who did not (9.1% [60/661] vs 3.8% [69/1799]; OR, 2.7; 95% CI, 1.9-4.1), as well as patients with witnessed ventricular fibrillation (28.4% [40/141] vs 11.9% [46/387]; OR, 3.4; 95% CI, 2.0-5.8).[5]

 

9% vs 4% increased survival only – not increased survival without severe brain damage.
 

Neurologic outcomes were also better in the patients who received CCR (OR=6.64, 95% CI=1.31 to 32.8).[6]

 

6 2/3 more likely to have increased survival without severe brain damage. The range is 1 1/3 to almost 33 times, because of the small numbers, but unlike epinephrine, this is statistically significant and supported by other research.

We are still making excuses for using a drug that causes harm and does not appear to provide a benefit that is greater than the harm. If there is more benefit, it is too small to be measured, even in a study with over 9,000 patients. We do not know which patients benefit and which patients are harmed, so we do not know how to minimize the harm that we cause.

Our patients deserve better.

Footnotes:

[1] Vasopressors in Adult Cardiac Arrest
Time left for commenting: 11 days 15:49:49
ILCOR staff
Created: March 21, 2019 · Updated: March 21, 2019
Draft for public comment
Consensus on Science with Treatment Recommendations (CoSTR)
Vasopressors in Adult Cardiac Arrest page for comments until April 04, 2019 at 06:00 Eastern Time

[2] A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators.
N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.
PMID: 30021076

Free Full Text from N Engl J Med.

[3] Implementing the 2005 American Heart Association Guidelines improves outcomes after out-of-hospital cardiac arrest.
Aufderheide TP, Yannopoulos D, Lick CJ, Myers B, Romig LA, Stothert JC, Barnard J, Vartanian L, Pilgrim AJ, Benditt DG.
Heart Rhythm. 2010 Oct;7(10):1357-62. doi: 10.1016/j.hrthm.2010.04.022. Epub 2010 Apr 24.
PMID: 20420938

Free Full Text from Heart Rhythm.

[4] The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest.
Ewy GA.
Scand J Trauma Resusc Emerg Med. 2012 Sep 15;20:65. doi: 10.1186/1757-7241-20-65. Review.
PMID: 22980487

Free Full Text from PubMed Central.

[5] Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65. doi: 10.1001/jama.299.10.1158.
PMID: 18334691

Free Full Text from JAMA.

[6] Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, Bobrow B.
Acad Emerg Med. 2010 Mar;17(3):269-75. doi: 10.1111/j.1553-2712.2010.00689.x.
PMID: 20370759

Free Full Text from Acad Emerg Med.

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Happy Darwin and Lincoln Day 2019

 

Today we celebrate two 210th birthdays. Both stood up to right wing religious fanatics and were attacked for it. One was assassinated.

The first birthday boy is Abraham Lincoln, who might have been the most famous aggressively pro-civil rights, do gooder, Social Justice Warrior president – except that secession began before Lincoln even took office. The slave states were so afraid of what Lincoln might do that they didn’t even wait to find out. They didn’t use any valid legal means to try to win their case, but essentially stated, We’re leaving and we’re taking these parts of America, because we believe they belong to us and secession is 9/10ths of the law. We double dog dare you to enforce the law – and just to comply with the wording of the Constitution of the United States, we are going to open fire on the United States Army. The hurt themselves and the rest of America by promoting secessionists’ devotion to enslaving those not white and the secessionists’ adamant opposition to states’ rights. Yes, the secessionists’ claimed to be fighting for states’ rights, but liars lie.
 

Treason against the United States, shall consist only in levying war against them, or in adhering to their enemies, giving them aid and comfort. No person shall be convicted of treason unless on the testimony of two witnesses to the same overt act, or on confession in open court.

The Congress shall have power to declare the punishment of treason, but no attainder of treason shall work corruption of blood, or forfeiture except during the life of the person attainted.[1]

 

Ironically, those who seceded were Democrats, but the parties have flipped and the Republicans are now the anti-civil rights party.

The following statement is from Sen. Barry Goldwater, who was the 1964 Republican and Conservative candidate for president, but now would be rejected by the Conservatives and the Republicans.
 

Mark my word, if and when these preachers get control of the [Republican] party, and they’re sure trying to do so, it’s going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can’t and won’t compromise. I know, I’ve tried to deal with them.[2]

 

Modern America has moved so far to the right, that Goldwater would probably be accused of being a socialist and a communist by various members of the right wing media. Sen. Goldwater also opposed government intrusion into the personal lives of LGBT people, because he was opposed to the big government that much of the right wing wants to use to force their lifestyle on everyone.

At that time, the right wing media being condemned by Sen. Goldwater was just beginning a resurgence. The ironically named Moral Majority was preaching its Christian sharia law to gather a lot of followers. Jerry Falwell, Sr. was their leader and Barry Goldwater condemned that earlier, less powerful, Falwell. His son, Jerry Falwell, Jr. seems to be able to tell our current president what to do, but a lot of people manipulate the president.
 

I think every good Christian ought to kick Falwell right in the ass.[3]

 

Since the Civil War, the propaganda machine of the secessionists has been more successful. They have been able to place statues of the traitors throughout the states they led in treason to show everyone that the secessionists still maintain power in spite of being defeated on the battlefield. Why don’t we have statues of Benedict Arnold?

We could celebrate Robert E. Lee for his opposition to secessionists after the war and for Lee’s unintentional(?) destruction of his cavalry at Gettysburg. Pickett’s Charge may have been the final straw for the Army Promoting Expansion of Slavery.

The second 210th birthday boy is Charles Darwin, who is remembered for explaining the diversity of life on Earth. Evolution explains the evidence showing the progression from the simplest life form to the current diversity of life – a diversity which appears to be decreasing due to our failure to value our children above our politics. Extinction is a part of that explanation. Extinction was once thought to be an argument against evolution, because it would violate God’s perfect plan, but eventually, extinction became undeniable, too. Oddly, people still deny biology. Evolution is so essential to biology, that Theodosius Dobzhansky wrote a paper titled, Nothing in Biology Makes Sense Except in the Light of Evolution.[4]

It is interesting that the science denial that affects biology, Creationism, is promoted most aggressively in the same slave states Bible Belt that fought against the United States of America in favor of treating diversity as a justification for violence.

It was science that helped the liberal Christians to convince the rest of America that slavery is wrong – something that much of the often less Christian rest of world already understood.
 

Book that Changed America - cover 1
 

As I wrote in 2017:

Darwin provided scientific evidence for a common origin, which gave a scientific argument to those criticizing slavery. How is it moral to enslave other humans? Well, the Bible repeatedly endorses slavery and Jesus never criticized slavery. Jesus actually used slavery as an analogy for belief in God, with believers as slaves and the slave owners as God.

Contrariwise, those who focused on the good parts of the Bible and avoided the bad parts, used Darwin’s book as the basis for advocating for a more moral approach to our fellow humans. Those who read the Bible differently from the advocates of slavery saw that they were not along. Science also opposed the moral abyss of slavery.

Not to spoil the ending, but the abolitionists were not successful at reasoning with those in the Bible Belt to end slavery in America. We ended up with over 600,000 Americans dead over different interpretations of the Bible on how to treat humans.[5]

The anti-science of Young Earth Creationism, the most basic form of Creationism, is the belief that the particular version of the God of that sect of believers literally just poofed itself into existence, then created life in its current diversity and that mutation can never produce a beneficial outcome.

For some bizarre reason, this God has organs of evolution. A true only one of its kind creature would not be male, nor would it be female, but the plot holes are numerous and demonstrate the impossibility of the story, when promoted as accurate. What other creature(s) God need sexual organs for? How did this God evolve them? Most Christians seem to view the two contradictory Creation stories in Genesis (Genesis 1 vs. Genesis 2) as metaphorical. How else do you defend something that dramatically changes when you turn to the next page? Hallucinogens? Hypoxia? Dementia? Metaphor – it is poetic, rather than literal. At least, that is the only reasonable approach.

Some Creationists take a shot at creating a middle approach. These not-so-literalists claim that microevolution is real, but macroevolution is impossible. These are real terms, but not the way the not-so-literalist Creationists use them.

These Creationists see that microevolution is undeniable, so they try to move the goalposts to try to protect their belief in Separate Creation.

Here is a further irony. These not-so-literalist Creationists claim that while they cannot deny that evolution happens on a small scale, they absolutely refuse to accept that it continues. Evolution is required to stop. Although they cannot provide any kind of evidence to support their claim and scientists provide plenty of evidence that evolution is not stopped, they continue to make this claim.

The irony gets even greater, because when you are dealing with apologists, the excuses will differ, thus the increasing disagreements among the dozens/hundreds/thousands of flavors of Creationism. Some of these micro yes, macro no Creationists claim that the restriction on evolution prevents the development of any new species, because they just can’t seem to understand that a lot of change can produce a dramatic difference. Other micro yes, macro no Creationists claim that this restriction prevents the evolution of any new genus. They claim that the story of the Ark saving 8 people from the murderous God of the Bible is the reason. This story is borrowed from the Babylonians, who taught the Israelites to write during the Babylonian captivity.[6]

Anyway, the story of the Ark mentions 19 Every beast, every creeping thing, and every fowl, and whatsoever creepeth upon the earth, after their kinds, went forth out of the ark.[7] This is a justification for being able to put billions of creatures on one supposedly seaworthy vessel. Not everything had evolved at the time, some evolved after their kinds after they disembarked. Two contradictions attacked with one excuse. Brilliant!

Some of the not-so-literalist Creationists accept that evolution is possible, as long as it does not produce a new species, because that would be too much. They insist that there must be an artificial limit on evolution.

Other not-so-literalist Creationists accept that evolution is possible, as long as it does not produce a new genus, because that would be too much. They insist that there must be an artificial limit on evolution.

Still other not-so-literalist Creationists accept that evolution is possible, as long as it does not produce a new family, because that would be too much. They insist that there must be an artificial limit on evolution.
 


Taxonomic Rank, from Wikipedia page
 

No matter what they have to invoke, all flavors of Creationist insist that there is some sort of artificial limit on evolution. Some Creationists insist that all evolution is prevented, while others accept varying amounts of evolution, rather than try to reject the overwhelming evidence.

We flawed humans must be explained, but their ambiguous creator must just be believed in all of its million different interpretations, and with all of its impossible contradictions – and all of the other Gods are just made up by people.

Footnotes:

[1] Constitution
Article III, Section 3
The Legal Information Institute
Article III

[2] Barry Goldwater
Wikiquote
 

Said in November 1994, as quoted in John Dean, Conservatives Without Conscience (2006).

 

[3] Barry Goldwater
Wikiquote
 

Said in July 1981 in response to Moral Majority founder Jerry Falwell’s opposition to the nomination of Sandra Day O’Connor to the Supreme Court, of which Falwell had said, “Every good Christian should be concerned.” as quoted in Ed Magnuson, “The Brethren’s First Sister,” Time Magazine, (July 20, 1981).
According to John Dean, Goldwater actually suggested that good Christians ought to kick Falwell in the “nuts”, but the news media “changed the anatomical reference.”
Dean, John (2008). Broken Government: How Republican Rule Destroyed the Legislative, Executive, and Judicial Branches. Penguin Group. “I know because I was there when he said it.”(2006).

 

A further irony is that there is nothing in the Bible that is even slightly critical of abortion, but the Bible thumpers lie about this. If you claim that Thou shalt not kill applies to abortion, you have to find someplace – any place where the Bible refers to abortion as killing. The Bible does not make that claim. The Christian sharia promoters make far more judgmental claims (judge not, lest ye be judged), because irony knows no bounds among fundamentalists.

The Bible states that life begins with the first breath. Genesis 2:7 and Job 33:4 and that a fetus is not a person Exodus 21:22. The Biblical literalists need to reinterpret the words to massage the meaning to be able to come up with something that allows them to claim their interpretation of their God agrees with them.

There is condemnation of divorce, by Jesus, but the religious right has chosen to vote for divorced leaders in order to get the political power that they want. Almost everything Jesus says in the Sermon on the Mount (Matthew 5-7) is a condemnation of the goals of the religious right in America today, but that is not the only place where Jesus condemns the religious right in America today.

Why do so many right wing Christians hate Jesus so much that they blaspheme Jesus?

If you want more information than provided above, read these:

The ‘biblical view’ that’s younger than the Happy Meal
February 18, 2012
Fred Clark
Article
 

In 1979, McDonald’s introduced the Happy Meal.

Sometime after that, it was decided that the Bible teaches that human life begins at conception.

 

and

The Not-So-Lofty Origins of the Evangelical Pro-Life Movement
February 5, 2013
Jonathan Dudley
Religion Dispatches
Article
 

Although evangelicals were mostly silent on abortion after Roe v. Wade, they were not silent on other political issues. Paul Weyrich, one of the evangelical right’s most influential founders, recalls that the movement initially emerged to defend racially segregated Christian schools from government intrusion:

 

Abortion was chosen as the rallying cry, because the religious right were losing ground defending segregation. Now abortion is the headline, while the religious right still work for segregation by more politically correct means.

[4] Nothing in Biology Makes Sense Except in the Light of Evolution
Theodosius Dobzhansky
The American Biology Teacher, Vol. 35, No. 3 (Mar., 1973)
Article in PDF format
 

I am a creationist and an evolutionist. Evolution is God’s, or Nature’s method of creation. Creation is not an event that happened in 4004 BC; it is a process that began some 10 billion years ago and is still under way.

 

Does the evolutionary doctrine clash with religious faith? It does not. It is a blunder to mistake the Holy Scriptures for elementary textbooks of astronomy, geology, biology, and anthropology. Only if symbols are construed to mean what they are not intended to mean can there arise imaginary, insoluble conflicts. As pointed out above, the blunder leads to blasphemy: the Creator is accused of systematic deceitfulness.

 

[5] The Book That Changed America: How Darwin’s Theory of Evolution Ignited a Nation
Randall Fuller

Read ‘The Book That Changed America’ for Darwin Day 2017
Sun, 12 Feb 2017
Rogue Medic
Article

and

Kirkus Review

and

January 24, 2017
Randy Dotinga
Christian Science Monitor
Review

[6] The Ark Before Noah: Decoding the Story of the Flood
Irving Finkel

Kirkus Review

and

How the ark changed shape
13 February, 2014
Will Gore
Catholic Herald
Article/Interview

Here is part of that interview with Irving Finkel from Catholic Herald:
 

We also discuss the negative reaction that his theories might provoke in some Christian quarters. He admits that those who tend towards a literalist reading of the Bible will never be persuaded of its links to the Babylonian era.

He hopes, though, that he is handling the topic sensitively. He is at pains to point out, for example, that, despite what some headlines have suggested, he is not claiming the Bible story to be wrong and that Noah’s Ark should be round. He has, he says, simply traced the origins of the story found in Genesis.

Finkel has resolved to make sure he maintains a sense of humour when dealing with critics. He’s obviously very content with the conclusions he has drawn. Behind that big beard it’s not hard to detect a smile as he says: “I can’t imagine somebody will find something that proves my ideas wrong, so if people reject them it doesn’t matter. People often reject things they don’t like and not necessarily on logical grounds. If I give a lecture and people throw vegetables, then so be it.”

 

Here is a video of a presentation by Irving Finkel.
 


 

[7] Genesis 8:19
King James Version
Verse at BibleHub in all versions

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