We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Spinal Immobilization – Untested and Unreasonable


 

Why do we keep trying to justify using a simple flat splint to align the many bones of our curved, articulated spines?

We keep trying to put a square object in a round hole. Small children do not make this mistake.

The spine is curved.

The board is not curved.

Does the board offer any real protection?

It seems that the board is just there for security theater.[1]

We make a big show of dressing people up in a collar, a backboard, blocks, and straps. Do we have any reason to believe that this fad works?

Bleeding patients to get rid of the bad humors lasted for hundreds of years, so this backboards are still new and in the fad category.

-

Footnotes:

-

[1] Security theater
Wikipedia
Article
 

Security theater is the practice of investing in countermeasures intended to provide the feeling of improved security while doing little or nothing to actually achieve it.[1]

 

.

What Does a Moon Landing ECG Look Like?

 

Some interesting ECG from the first people to land on the Moon.

During landing, they were running low on fuel and Buzz Aldrin appears to be showing signs of stress.

 

Click on images to make them larger.
 

The image above is from the following video describing the monitoring of the ECGs of the astronauts.
 


Download | YouTube MP3 Converter
 

The reason this is in the news now is that one of four of the ECGs of Neil Armstrong as he stepped on the Moon was scheduled to be auctioned, but has been pulled due to questions about whether the owners have clear title to these items.[1]

How low on fuel were they? Were they going to crash?

They were just going to have to abort the mission and return to the Command Module, but after years of preparation for a Moon landing, that can be a huge amount of stress.
 


 

“EKG Recordings Taken as Apollo 11 Commander Neil Armstrong Took Man’s First Step on the Moon” and “4:13:24:28 Ground Elapsed Time.” Sheet is signed and inscribed in pencil, “To Paul Jones, The heartbeats that made this accomplishment possible as recorded at MCC on my console. Keep up your heart work. Charles A. Berry M.D.” Presentation also bears a Neil Armstrong autopen signature. Sheet is matted and framed with mission patches from Apollo 7, Apollo 8, Apollo 9, Apollo 10, Apollo 11, Apollo 12, Apollo 13, and two Snoopy patches, to an overall size of 20.75 x 24.75.[2]

 

Look at Buzz Aldrin’s ECG. The rate is about 400 BPM (Beats Per Minute).

Can a human heart beat that fast?

I have seen close to 300 BPM in a febrile infant.

Is the following rate possible for a human?
 


 

The rate is probably not possible.

The reason it looks so fast is most likely because the paper is being fed at a much slower speed than usual.

Conversely, we can get a better idea of what a very fast tachycardia looks like by speeding up the paper feed rate from the standard 25 mm/second to 50 mm/second or by manually pulling the paper through the printer faster than its normal rate.
 

EKG strip, six inches long, taken as Apollo 11 Commander Neil Armstrong took man’s first step on the moon. This is an actual strip of the EKG from Armstrong’s heart monitor at the moment he stepped onto the lunar surface.[2]

 


 

Compare that with a “six second section” of Buzz Aldrin’s ECG during their very low on fuel landing.
 


 

At 12.5 mm/second, this would be a rate of about 200 BPM, faster than the calculated maximum heart rate, but still capable of being a sinus tachycardia that is only associated with minor/moderate symptoms. At 10 mm/second, this would be a rate of about 160 BPM, which I regularly exceed (and recover from without any need for adenosine or cardioversion).
 


Download | YouTube MP3 Converter
 

Several times you hear them checking with the flight surgeon and receiving a “Go,” each time. A heart rate of 400 should have resulted in something other than a “Go.” A few questions to Buzz Aldrin about how he is feeling would have been prudent.

If I have a patient with a heart rate of 400 and I do not ask a few questions about how the patient is doing, it would probably be because the patient is not capable of communicating. How are you feeling, hummingbird?
 

In general, sinus tachycardia is a response to other factors and, thus, it rarely (if ever) is the cause of instability in and of itself.[3]

 

At EMS 12 Lead, there is an excellent discussion of sinus tachycardia, and the nonsense of assuming that anything faster than 150 BPM is an SVT that needs adenosine or cardiversion.[4] This includes comments from Dr. John Mandrola and Dr. Mark Perrin.
 

Go read it.
 

-

Footnotes:

-

[1] Neil Armstrong’s ‘Heartbeat,’ Apollo Joystick Pulled from Auction
by Robert Z. Pearlman, collectSPACE.com Editor
Date: 20 May 2013 Time: 04:34 PM ET
Article

-

[2] Neil Armstrong’s Heartbeat – EKG Up For Auction
By Patrick Lockerby
May 5th 2013 04:20 PM
Science 2.0
Article

-

[3] Overview
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text from Circulation.

-

[4] The Trouble With sinus Tachycardia
April 30, 2013
David Baumrind
EMS 12 Lead
Article

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Let the drug shortages help us make better patient care decisions


Image credit.[1]
-
 

Maryland made smart changes to their protocols because of the drug shortages.[2]

50% dextrose is not as good as 10% dextrose at treating hypoglycemia.[3],[4],[5]

Switching to 10% dextrose is an obvious solution, but not used by everyone.
 

Sedgwick County EMS workers administer about 80 doses of the stuff (50% dextrose) a month, but the county has only received 30 pre-filled doses so far this year through its normal vendor, Braithwaite said.[6]

 

We have research that shows that 10% dextrose is a better choice for EMS, but we continue to use the inferior treatment.

We have trouble obtaining the inferior treatment, but we refuse to change to the better treatment.

Is there a state law that prevents the use of different concentrations of dextrose?

If so, go to the government, explain the problem, and get the law changed. If that does not work, go to the press and point out that the failure to act by the legislature is endangering patients.
 

“We’re now looking at compounding of those medications,” he said.

But that’s an expensive alternative. A pre-filled dose of dextrose costs $6.99. A vial costs $1.81. Pre-filled doses are preferred, Hadley said, because there is one less step for emergency personnel.

Compound dextrose costs $14 per dose and has a much shorter shelf life, 90 days compared with two years.[6]

 

50 ml of 50% dextrose contains 25 grams of dextrose.

A 250 ml bag of 10% dextrose contains 25 grams of dextrose.

The cost of the bag of 10% dextrose is about $2.50, which is much less than the $7 cost of and amp of 50% dextrose.

Is there a difference in shelf life? If they are giving 80 doses a month, how much does that matter?

The only advantage to the 50% dextrose is familiarity, which is due to our failure to change to a better treatment when it becomes the right thing to do.

The drug shortages do not affect 10% dextrose.

Isn’t it time we cut costs, improved safety, improved care, and eliminated 50% dextrose?

-

Footnotes:

-

[1] Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed - indexed for MEDLINE]

-

[2] Drug shortages leading to better EMS protocols
Fri, 19 Oct 2012
Rogue Medic
Article

-

[3] Dextrose 10% or 50%: EMS Research Episode 10
Tue, 05 Jul 2011
Rogue Medic
Article

-

[4] Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.
Moore C, Woollard M.
Emerg Med J. 2005 Jul;22(7):512-5.
PMID: 15983093 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central

-

[5] A review of the efficacy of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycaemia
Ziad Nehme, Daniel Cudini
2009; Volume 7 : Issue 3; Article Number: 990341
Journal of Emergency Primary Health Care
Free Full Text with link to PDF Download

-

[6] Sedgwick County EMS warns of national drug shortages
By Deb Gruver
The Wichita Eagle
Published Tuesday, May 14, 2013, at 8:41 p.m
Article

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Too Much Oxygen, Too Many Backboards

-
 

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and I discuss a variety of topics – quality in EMS, respect for EMS, the value of research and whether we should teach people to use research in EMS.
 

Too Much Oxygen, Too Many Backboards
 

Spinal immobilization can be done in many different ways. Strapping a curved spine to a flat piece of lumber/plastic is not the only way to do it and not even the only way that it is done in the US, nor in the rest of the world.
 


 

Long spine board immobilization is continuing to be replaced by the lateral trauma position in Norway.[1],[2]
 

What about in America?

Going back to 2008 (the earliest protocols available on line, all of Pennsylvania has had spinal clearance.
 

Immobilize the entire spine3,4 in any trauma patient who sustains an injury with a
mechanism having the potential for causing spinal injury and who has at least one of
these clinical criteria:5
a. Altered mental status (including any patient that is not completely alert and oriented)
b. Evidence of intoxication with alcohol or drugs
c. A distracting painful injury (including any suspected extremity fracture)
d. Neurologic deficit (including extremity numbness or weakness- even if resolved)
e. Spinal pain or tenderness (in the neck or back)
[3]

 

Without altered mental status, evidence of intoxication, a distracting painful injury, neurologic deficit, and/or spinal pain or tenderness spinal immobilization is a violation of protocol in Pennsylvania.

Alameda County, California; Xenia, Ohio; and all of Connecticut are doing away with backboards.

Spinal clearance has been in place in many more places in various forms for years, or even for decades.

Don’t let local attitudes fool you. this is not new or limited to isolated areas.
 

Spinal immobilization is witchcraft. There is no evidence of benefit.
 

Oxygen was also discussed.

There is a lot to discuss about the absence of good evidence that supplemental oxygen improves outcomes when there is no known hypoxia.
For heart attack patients, why do we want to give a drug (oxygen) that causes vasoconstriction, when our goal is vasodilation?

If the goal is to improve blood supply, and oxygen decreases blood supply, then why are we giving oxygen in the absence of evidence of hypoxia?

Supplemental oxygen without evidence of hypoxia is also witchcraft.

-

Footnotes:

-

[1] The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services.
Fattah S, Ekås GR, Hyldmo PK, Wisborg T.
Scand J Trauma Resusc Emerg Med. 2011 Aug 4;19:45.
PMID: 21816059 [PubMed - in process]

Free Full Text from PubMed Central with links to PDF Download

-

[2] The Lateral Trauma Position: What do we know about it and how do we use it
Sun, 04 Dec 2011
Rogue Medic
Article

-

[3] Spinal Immobilzation – 261
2008 Pennsylvania Protocols
PEHSC
Page with links to protocols in PDF format.

-

[4] More Oxygen Can’t Hurt…Can It?
by William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Created: MAY 1, 2013
EMS World
Article

.

NYPD Officer Stuck in Tree Trying to Rescue Cat is Rescued by NYFD


Image credit.
 

What were you thinking?

That is the obvious question to ask this police officer.

That is after asking is the story true. It was reported by NBC with no author listed.

Do cats die if not rescued from trees?

I wonder if PETA has a page on this. They do not appear to, but it could have been amusing.

However –
 

When a Tennessee woman’s cat was stuck in a pine tree, firefighters gave her two options: they could blast it out with a hose or shake the tree until the cat fell out. When asked how option B was any different from the cat’s just falling out on its own, one firefighter answered, “Neither is real different, ma’am. Just quicker.”[1]

 

Things could have turned out worse for the officer. they could have used the hose or shaken the tree until the officer fell to the ground. Humans have not evolved the ability land as gracefully as other species do.

Still, this rescue may end up being a fate worse than death for this NYPD officer.
 

The officer had lit a flare and set up cones on the ground underneath the tree before going up but onlookers ignored them as they gathered and gawked from the ground, said Yu.[2]

 

Flares and trees and children are not a good combination. Fortunately, it is Spring and there is no drought.

When going to so much trouble to be a hazard to one’s self, protecting others is probably not one of this officer’s strong points.

Nothing says come hither like cones, flares, and treeful stupidity.

Perhaps cats in trees should have a time limit before someone responds with a hose to dislodge them from the trees. If the cat doesn’t come down on its own in 48 hours, then someone might respond.
 


 

This image accompanied the article.

Maybe this is a mug shot of the tree that abducted the officer.

-

Footnotes:

-

[1] Do fire departments actually rescue cats from trees?
Straight Dope
January 8, 2010
Article

-

[2]
FDNY Rescues Cop Stuck in Tree Trying to Rescue Cat
NBCNewYork.com
updated 5/13/2013 10:47:22 PM ET
Article

.

Improving EMS By Hiring Deaf EMTs


 

We each have many limitations.

Should we assume that one specific limitation, that we do not understand, is too limiting to work in EMS?

Don Burslem could have used that prejudice as an excuse to not hire Chad Grabousky.
 

But Burslem decided to take a chance on hiring Chad Grabousky, and more than two months later, he’s very glad he did.

“His patients love him, our staff loves him, and he actually does a wonderful job in back of the ambulance, better than some of my hearing staff,” Burslem said.[1]

 

Oh, no! What if . . . ?

We can always make excuses for our prejudices, but it is better to learn what the actual limitations might be, how those limitations might be accommodated, whether those accommodations really work or just provide the appearance of accommodation, and what the benefits are of the limitation.

We do not live in a binary world. things are not all good, not all bad.

If we do not understand that, then we should not be administering medications, since medications have benefits (for some patients), side effects, and toxicity.

Medications are not inherently good or bad. This is not even close to being news.

All things are poison, and nothing is without poison; only the dose permits something not to be poisonous. – Paracelsus (1493-1541)
 

EMTs need to communicate with their patients, with their partners, with hospital officials over the radio.[1]

 

Do we really need to communicate on the radio? We include radio communication in EMS classes, but who really needs to know what frequency we communicate on? I don’t.

A lot of communication with dispatch has been by MDT (Mobile Data Terminal) for the past decade. I cannot hear the information that appears on the MDT (but there are text to speech programs available). I do not need to speak to hit the responding, or on scene, or any of the hospital buttons to communicate.

But what about lung sounds?
 

He will not be able to differentiate from rales to rhonchi. Both are very different treatments. No matter how good his observational skills are . He will not be able to differentiate which bad lung SOUNDS the Patient is experiencing!![1]

 

We have too many ignorant people like this in EMS.

Our method of education seems to produce plenty of basic EMTs, medics, nurses, and doctors who believe this myth.

Wheezes are often a sign of CHF (Congestive Heart Failure).

Lung sounds are only a small part of the assessment of the patient with respiratory distress.

Wheezes albuterol.

Crackles NTG (and specifically furosemide).

Rhonchi antibiotics.

Decreased lung sounds tension pneumothorax.

Decreased lung sounds are irrelevant to pulmonary embolus.

We have too many people applying treatments based solely on lung sounds. I brought a stroke patient to the ED. The nurse listened to lung sounds, hooked up a nebulizer, and left the patient alone for half an hour. The patient had a good oxygen saturation, did not have any respiratory distress, but did have neurological distress. The nurse was treating the lung sounds. While this is not common, it is due to the mistake of limiting assessment to one finding.
 


Click on image to make it larger.
 

Not only is wheezing included in the diagnostic criteria for CHF, but wheezing is given more weight than crackles.[2]

Wheezes often indicate CHF.

For those who do not understand that sound is vibration, it is possible to differentiate among lung sounds by placing the hand on the chest to feel the vibrations, which can be as distinctive as sounds they produce.

What is important is a full assessment, not an incompetent jump to conclusions based on lung sounds an inadequate assessment.

-

Footnotes:

-

[1] Deaf EMT ‘better than some hearing staff’ with Bethlehem ambulance company
By Lynn Olanoff
The Express-Times
on May 12, 2013 at 6:00 AM, updated May 12, 2013 at 6:06 AM
Article

-

[2] Clinical diagnosis of congestive heart failure in patients with acute dyspnea.
Marantz PR, Kaplan MC, Alderman MH.
Chest. 1990 Apr;97(4):776-81.
PMID: 2182296 [PubMed - indexed for MEDLINE]

Free Full Text in PDF format from Chest.

.

Why Do We Treat Some Frauds Differently?

 

Sylvia Browne is receiving some deservedly bad press for the exposure of her psychic deception.
 

In 2004, the year following the then 16-year-old schoolgirl’s disappearance, Browne appeared on “The Montel Williams” show and told Berry’s distraught mother Louwana Miller – who died from heart failure a year later – that her daughter was “in heaven and on the other side” and that her last words were “goodbye, mom, I love you.”[1]

 

Should anyone be surprised?

But where’s the harm?

Psychics make their living by exploiting our selective memories.

We remember the hits, but forget the misses.

If I throw out as many guesses as I can, some of them are bound to be right.

Should I tell you I have the ability to see the future, or communicate with the dead?

This is not a psychic power.

This is deceit.
 


 

Jeffrey Skilling is trying to get a sentence reduction for his part in the disaster that was Enron. Fraud? Mismanagement? The Secret?

 

He spoke haltingly, stopping in mid-sentence. “In terms of remorse, Your Honor, I can’t imagine more remorse,” he said. He had “friends who have died, good men.” He was innocent—”innocent of every one of these charges.” He spoke for two or three minutes and sat down.[2]

 

Malcolm Gladwell provides a good argument that what Jeffrey Skilling did was not an intentional fraud. It was complicated. It was not hidden. Maybe Skilling was a more of a true believer than a fraud.

He apparently believed that the problem was that the employees were not willing to do what was necessary to make the company grow at an unsustainable pace. He should be able to demand results and it is their fault if they cannot deliver. Why let reality get in the way of a perfectly good plan?

The Enron financial statements were examined two years before the peak using the information that was available at the time.
 

The students’ conclusions were straightforward. Enron was pursuing a far riskier strategy than its competitors. There were clear signs that “Enron may be manipulating its earnings.” The stock was then at forty-eight —at its peak, two years later, it was almost double that—but the students found it over-valued. The report was posted on the Web site of the Cornell University business school, where it has been, ever since, for anyone who cared to read twenty-three pages of analysis. The students’ recommendation was on the first page, in boldfaced type: “Sell.”[2]

 

We don’t want to know the truth. If you had shorted Enron at the time, you probably would have lost a lot of money and had to cover your losses before Enron dropped to its actual value – less than nothing. Enron’s debts were much greater than its assets.

Psychics depend on this gullibility, too.

This is beyond your understanding.

It is arrogant to question what I am doing.

John Edward also scam the bereived and he had the backing of America’s favorite scam promoter – Dr. Mehmet Oz.
 

In a letter to producers of “The Dr. Oz” show Nordal said, “I provided very balanced responses to Dr. Oz’s questions during the show’s taping, however, the editing of my responses did not capture my full comments or give viewers an accurate portrayal of my professional view on John Edward’s methods. Instead, it seems that ‘The Doctor Oz’ show intentionally edited my responses in a way that gave the appearance of my endorsement of Edward’s methods as a legitimate intervention.”[3]

 

Dr. Oz is as bad as John Edward and Sylvia Browne. He is promoting stuff that a child should realize is nonsense.[4]

People trust him, even though he promotes frauds.

How is Sylvia Browne any better than Jeffrey Skilling?

How is John Edward any better than Jeffrey Skilling?

How is Dr. Mehmet Oz any better than Jeffrey Skilling?
 

The Pigasus Award for Refusal to Face Reality goes to Dr. Mehmet Oz, the Harvard-trained cardiologist who hosts The Dr. Oz Show on broadcast television, one of the most popular syndicated television shows in America. The only person to have won a Pigasus Award two years in a row, he wins a third time this year for his continued promotion of quack medical practices, paranormal belief and pseudoscience, including pseudoscientific Reparative Therapy to “cure” gay people, the “energy-healing practice” of Reiki as a way to cure disease, various TV psychics and mediums such as Theresa Caputo and John Edward, faith healers such as “John of God,” GMO conspiracy theories, and any number of new quack diets, herbal remedies, anti-aging cures, and untested “wonder drugs,” among many other pseudoscientific and paranormal claims.[5]

 

Harry Houdini is reported to have stated –

It is not for us to prove the mediums are dishonest, it is for them to prove that they are honest.

Houdini spent years exposing the fraudulent methods of the psychics of his day.

We still believe in magic.

The reason we seem to treat this fraud as something other than fraud is that we act like we know what is best for the people we know who are gullible.

We assist in the fraud.

We lie to people to make us feel that we are helping their grief.

-

Footnotes:

-

[1] Celebrity psychic Sylvia Browne hit for telling mom of Amanda Berry she was dead
By Hollie McKay
Published May 09, 2013
FoxNews.com
Article

-

[2] Open Secrets Enron, intelligence, and the perils of too much information.
The New Yorker
January 8, 2007
Malcolm Gladwell
Article

-

[3] TV Skeptic: The medium and Oz
March 18, 2011 | 2:05 pm
LA Times
Article

-

[4] The trouble with Dr. Oz
David Gorski
Science-Based Medicine
April 26, 2011
Article

-

[5] JREF’s Pigasus Awards “Honors” Dubious Peddlers of “Woo” (VIDEO)
Latest JREF News
James Randi Educational Foundation
Article with video

.

Airway Instruction – Episode 171 of the EMS EduCast

 

We want to be permitted to intubate.

True.

We don’t want to have to practice.

Sadly, that also appears to be true.

Fortunately for those of us who hate to practice, it is difficult to get paramedics time in the OR to practice on live people.

Not true.

Listen to Bill Toon, PhD/Paramedic explain how he was able to set up a system for all of the paramedics to rotate through the OR (Operating Room) to obtain practice and continuing education on real people.
 

Go listen to the podcast.
 


Image credit.
 

Bill Toon, Greg Friese, Rob Theriault, and David Blevins discuss ways of improving airway skills.
 

What if we do not work in a system that is set up like Johnson County Med-Act? Are we out of luck?

No, but we just have to work a bit harder to be good. Bill Toon did not accomplish this overnight, so do not despair that you do not have something already. Get to work on setting one up. It will take time, initiative, and the ability to ignore the people who say it cannot be done.

I would be surprised if Bill did not know some people who know some of the anesthesiologists where you would be trying to set this up. Talking to people who have done this and not been visited by plagues of blood, frogs, locusts, others, and the deaths of their firstborn might help to get them to at least consider trying this.

Do not expect things to happen immediately. That is one of the important lessons bill discusses in airway management.

Slow down!

Work on the skill and ignore the speed. After we have developed skill, then we can work on speed.

Speed without skill is dangerous, but that is the way many of us have been taught.

Panic about the amount of time it might take.

Hold your breath, and when you need to take a breath you may be too hypoxic to remember what you were doing.

Talk to a martial artist. They work on the skill first, then the speed.

Talk to someone who races motorcycles. They work on riding smoothly, then add the speed.
 

Even if you cannot set up a similar OR program, we can practice on mannequins, but most of us seem to lack the imagination and the understanding to put in the thousands of mannequin intubations that we should.

There are some excellent references provided as well.
 

Airway World The only virtual knowledge and collaboration center dedicated to airway management.

Airway Cam: Practical Solutions for Emergency Airways

Johnson County Med-Act

The Power of Video Recording from JAMA

 

Go listen to the podcast.
 

.