There are plenty who … claim to be competent at intubation even though their last intubation was months ago on the third attempt and if the patient had not already been dead – that would have finished the patient off …

- Rogue Medic

Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’

ResearchBlogging.org
 

The results of ALPS (Amiodarone, Lidocaine, Placebo Study) are clear. There is no statistically significant difference in cardiac arrest outcomes with amiodarone or lidocaine, when compared with placebo.
 

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.[1]

 

This study was very well done, but it was not designed to provide valid information about the effects of amiodarone or lidocaine on witnessed arrests or on EMS Witnessed arrests. Maybe the authors were overconfident.

In resuscitation research, we have abundant evidence that overconfidence is much more common than improvements in outcomes. There is no study that has shown an improvement in neurologically intact survival to discharge with any drug. Leaving the hospital with a working brain is the result that matters most to patients. We give drugs because we have too much confidence in the drugs and we are treating our confidence, not because we are doing anything to benefit the patients.
 

I WANT TO BE DECEIVED version of Domenichino, Virgin and Unicorn 1 copy
 

In ALPS there was a subgroup that might have reached statistical significance, but the researchers never determined what would be statistically significant when setting up the study, so these results are merely post hoc data mining (fitting the numbers to allow for a positive spin).

This is the Texas sharpshooter fallacy. The Texas sharpshooter shoots at the side of a barn, then draws targets around the bullet holes so that the the bullet holes are in the bull’s eyes.
 


 

The Texas sharpshooter didn’t shoot at any target, but he went back later and made it look like he hit the center of the target, because he drew the target around the bullet holes. Science requires that we state our hypotheses ahead of time, so that scientists are kept honest. Science requires that we calculate statistical significance ahead of time, especially for secondary outcomes/subgroup analysis, which may mean decreasing the p value to less than 0.03, or to less than 0.01, or even lower to reach statistical significance, so that scientists are kept honest. You are not permitted to bet on the outcome of a horse race that is already in progress for the same reason.

Why do we need to keep scientists honest? Because, as Dr. Peter Kudenchuk unintentionally demonstrates, scientists are just as biased as everyone else. Scientists need to follow the rules of science to minimize the influence of prejudices, such as overconfidence. When scientists do not follow these rules, they are just as easily fooled as everyone else and they may use that self-delusion, and their reputation, to fool others. Dr. Oz makes a fortune telling people what they want to hear about treatments that do not work.

I don’t claim that Dr. Kudenchuk, or even Dr. Oz, is deliberately fooling others, only that they have fooled themselves and are trying to convince others that their prejudices are accurate representations of reality. Here is what Dr. Kudenchuk has been telling people –
 

Researchers have confirmed that certain heart rhythm medications, when given by paramedics to patients with out-of-hospital cardiac arrest who had failed electrical shock treatment, improved likelihood of patients surviving transport to the hospital.[2]

 

The researchers have not confirmed any such thing.

If Dr. Kudenchuk wants to study whether amiodarone or lidocaine or both improve outcomes for witnessed cardiac arrest patients, or for EMS witnessed cardiac arrest patients, he needs to set up a study with all of the criteria for a positive result specified before the start of the study, because this study did not. The study explicitly states this, so Dr. Kudenchuk should be able to just read the study and see that he is wrong. Here is another statement that contradicts the information that was published.
 

Two groups of patients were pre-specified by the study as likely to respond differently to treatment: those with a witnessed cardiac arrest and those with an unwitnessed arrest. When it was originally designed, the study predicted that because patients with witnessed cardiac arrest are recognized and treated sooner, they would more likely be responsive to effective treatments than unwitnessed arrests. When first discovered, patients with an unwitnessed arrest are more likely to have already sustained irreversible organ damage resulting from a longer “down time” and less likely to respond to any treatment. This is precisely what was seen in the study – a statistically significant 5% improvement in survival to hospital discharge in witnessed arrests, and no effect from the drugs in unwitnessed arrests.[3]

 

Why does the published version of the paper contradict Dr. Kudenchuk? One of our biases is to remember things differently from the way things really happened. This is why eyewitness testimony is so often wrong. Here is what the published paper states about the witnessed arrest results.
 

We observed an interaction of treatment with the witnessed status of out-of-hospital cardiac arrest, which is often taken as a surrogate for early recognition of cardiac arrest, a short interval between the patient’s collapse from cardiac arrest and the initiation of treatment, and a greater likelihood of therapeutic responsiveness. Though prespecified, this subgroup analysis was performed in the context of an insignificant difference for the overall analysis, and the P value for heterogeneity in this subgroup analysis was not adjusted for the number of subgroup comparisons. Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration.[1]

 

The authors did not adjust the p value, so the authors do not claim that the witnessed cardiac arrest results are statistically significant. They only state that these results merit thoughtful consideration. In other words, if we want to claim this hypothesis is true, we need to set up a study to actually examine this hypothesis.

One earlier study (also by ROC – the Resuscitation Outcomes Consortium) even has similar results.[4],[5] These results are also not statistically significant, but suggest that with larger numbers the results might be significant. So why did the authors set up such a small study? Overconfidence and an apparent lack of familiarity with their own research.
 


 

The Seattle phenomenon (they claim that their resuscitation rate is the highest in America) seems to be due to excellent bystander CPR rates (apparently the highest in America), but that is only good enough for them to be experts on improving bystander CPR rates. The rest is probably due to defibrillation and chest compressions, which are the only prehospital interventions demonstrated to improve neurologically intact survival.

Why does a bystander CPR specialist focus on drugs? Overconfidence and an apparent lack of understanding of the resuscitation research. Dr. Kudenchuk preaches like Timothy Leary about the benefits of drugs and with just as little evidence. We should give appropriate credit for Dr. Kudenchuk’s work on CPR, but we should not mistake that for a thorough understanding of the resuscitation research, even the research with his name attached.
 

A new podcast reviews ALPS. Dominick Walenczak does not notice the mistakes of Dr. Kudenchuk, but he is not one of the researchers, so that is easy to overlook. The rest of the podcast is excellent. Listen to it here.
 

Episode 8: Conquering the ALPS (Study)
Dominick Walenczak
April 7, 2016
Podcast page
 

Footnotes:

[1] 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 Apr 4. [Epub ahead of print]
PMID: 27043165

Free Full Text from NEJM

[2] Antiarrhythmic drugs found beneficial when used by EMS treating cardiac arrest
Press release
For Immediate Release:April 4, 2016
NHLBI (National Heart Lung and Blood Institute)
Press release

[3] Dr. Kudenchuk: Study reveals exciting news about cardiac arrest treatment
Lindsay Bosslet
18 hours ago
Public Health Insider
Article

[4] Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium.
Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P; Resuscitation Outcomes Consortium Investigators.
Resuscitation. 2012 Nov;83(11):1324-30. doi: 10.1016/j.resuscitation.2012.07.008. Epub 2012 Jul 31.
PMID: 22858552 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

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

 
Kudenchuk, P., Brown, S., Daya, M., Rea, T., Nichol, G., Morrison, L., Leroux, B., Vaillancourt, C., Wittwer, L., Callaway, C., Christenson, J., Egan, D., Ornato, J., Weisfeldt, M., Stiell, I., Idris, A., Aufderheide, T., Dunford, J., Colella, M., Vilke, G., Brienza, A., Desvigne-Nickens, P., Gray, P., Gray, R., Seals, N., Straight, R., & Dorian, P. (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest New England Journal of Medicine DOI: 10.1056/NEJMoa1514204

 

Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P, & the Resuscitation Outcomes Consortium Investigators (2012). Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium. Resuscitation PMID: 22858552

.

Ketamine For Anger Management

 

I have been meaning to write about this ketamine study, but Greg Friese wrote about one of the comments on a review of the paper –
 

Most intriguing is this reader comment “talk to your damn patients calm them down and you can avoid this knee jerk, sedate first ask questions later whilst risking side effects, response ,that seems to be coming the norm” which seems disconnected to the actual syndrome of ExDS and the danger to medics, cops, and the patient when a patient’s behavior is out of control.[1]

 

Intriguing?
 

Tasmanian Devil - from outbackcooking dot blogspot dot com 1
 

The review was by Dr. Ryan Radecki of Emergency Medicine Literature of Note (the best quick and to the point reviews of research I know of on line). Did Dr. Radecki even suggest that we should avoid attempts at talking the patient down?
 

From the land of “we still have droperidol”, this case series details the use of ketamine as “rescue” treatment for “agitated delirium”. In lay terms, the situation they’re describing is the utterly bonkers patient being physically restrained by law enforcement for whom nothing else has worked.[2]

 

No.

Did the authors of the original paper suggest that we should avoid attempts at talking the patient down (verbal de-escalation)?
 

The sedation of agitated and aggressive patients in the emergency department (ED) and other acute care areas is a major problem for health care workers. Patients with acute behavioral disturbance may respond to verbal de-escalation or oral sedation, but a substantial proportion of this group requires parenteral sedation and mechanical restraint.1, 2, 3, 4, 5 [3]

 

No.

What about the studies cited above?

This is from one –
 

Combined pharmacological sedation and physical restraint were required on 66 (46%) occasions, pharmacological sedation alone on 20 (14%), physical restraint alone on 14 (10%) and neither on 43 (30%) occasions.[4]

 

30% of patients did not require physical and/or chemical restraint.

What does require mean?

How many patients can be managed by just talking them down? Should we avoid preparation for chemical and physical restraints, just because we are trying to talk the patient down?
 

There is indirect evidence from pharmacologic studies of agitation that verbal techniques can be successful in a substantial percentage of patients. In a recent study, patients were excluded from a clinical trial of droperidol if they were successfully managed with verbal de-escalation; however, the specific verbal de-escalation techniques were not identified or studied.12 [5]

 

Research on chemical management of excited delirium should not be interpreted as discouraging us from talking patients down.
 

Clinicians who work in acute care settings must be good multitaskers and tolerate rapidly changing patient priorities. In this environment, tolerating and even enjoying dealing with agitated patients takes a certain temperament, and all clinicians are encouraged to assess their temperament for this work.[5]

 

There is a lot of good information in the article, but approaching every patient with the expectation that verbal de-escalation will work is unrealistic. A lack of preparation sets everyone up for a worse outcome in the cases where verbal de-escalation does not work. Injuries and death become more likely, when we are not prepared to switch to sedation and have only physical restraint to respond to rapidly changing patient priorities.

We need to be able to adapt to the agitated patient. Verbal de-escalation and excited delirium do not get enough attention. This paper does not address the use of verbal de-escalation, because the enrolled patients had to fail to respond to other chemical sedation first. The patients who failed chemical sedation are also the ones who failed to respond to whatever attempts at verbal de-escalation were used.
 

Read the full paper on verbal de-escalation.

Footnotes:

[1] Sunday morning reader – coffee, ketamine, and EMS news
Everyday EMS Tips
by Greg Friese
March 6, 2016
Article

[2] Ketamine For Anger Management
Emergency Medicine Literature of Note
Friday, March 4, 2016
Posted by Ryan Radecki
Article

[3] Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department.
Isbister GK, Calver LA, Downes MA, Page CB.
Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01562-0. doi: 10.1016/j.annemergmed.2015.11.028. [Epub ahead of print]
PMID: 26899459

[4] Structured team approach to the agitated patient in the emergency department.
Downes MA, Healy P, Page CB, Bryant JL, Isbister GK.
Emerg Med Australas. 2009 Jun;21(3):196-202. doi: 10.1111/j.1742-6723.2009.01182.x.
PMID: 19527279

[5] Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.
Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT.
West J Emerg Med. 2012 Feb;13(1):17-25. doi: 10.5811/westjem.2011.9.6864.
PMID: 22461917

Free Full Text from PubMed Central.

.

The Second EMS What-if-We’re-Wrong-a-Thon

 

Brandon Oto promoted The First EMS What-if-We’re-Wrong-a-Thon last year, but I was taking a break from blogging at the time, so I did not participate. The idea is to consider a position from the perspective of being wrong.

This is the way science works. An idea (hypothesis) is tested by attempting to prove that it is wrong, rather than attempting to prove that it is true. Unfortunately, not all science is done well. Ideology (politics, religion, nationalism, stereotyping, . . . ) is the opposite of science. The goal of ideologues is to defend the dogma, rather than to find the truth.

Since valid evidence to the contrary is all that I need to change my mind, as I have on ventilation in cardiac arrest, high flow oxygen for just about anything, epinephrine any drug for cardiac arrest, intubation as the gold standard of airway management, et cetera, is to look at something based more on opinion, rather than evidence.
 

What have I been wrong about that I have not yet corrected in writing? Romazicon (flumazenil) is a benzodiazepine antagonist which has the nasty side effect of producing seizures. I have condemned the suggestion that it should be used by EMS, because it is just an ALS (Advanced Life Support) means of trying to correct a BLS (Basic Life Support) problem with the potential for creating ALS problems that would result in even more ALS solutions.[1]
 

In considering the effects of flumazenil, have I put too much emphasis on the adverse effects and not enough emphasis on the ways that the side effects can be prevented or managed?
 

Putting much more emphasis on the side effects, rather than on the benefits is important in pharmacology, because the benefits are usually less than we expect and the serious side effects should be much less frequent than the benefits. If the serious side effects are not much less frequent than the benefits, why use the drug?

The importance of large studies is less in quantifying the benefits, but in having enough data to identify the side effects. The second most famous example of this is the Cardiac Arrhythmia Suppression Trial,[2] which was intended to show which brand of antiarrhythmic drug saved the most lives. The one that saves the most lives is clearly the best and would be marketed aggressively as the best. The result was to demonstrate that the antiarrhythmic drugs were killing people. About 60,000 people, who would not have died at that time, were killed by these drugs. These drugs were the most frequently prescribed drugs in America at that time. All of the best doctors knew that the drugs improved survival – except the drugs were killing patients.

The most famous example of a small rate of serious side effects not being identified until a lot of people were affected is thalidomide.[3] This produced dramatic deformities in the children of mothers who had taken thalidomide for nausea and vomiting of pregnancy. Since the ideas of pure good and pure evil are ideological, rather than real, there are appropriate uses for thalidomide in the treatment of Hansen’s disease (leprosy) and multiple myeloma. Good medicine requires that we balance the benefits and risks in order to increase the probability of an improvement in outcome.
 

What if, in the case of flumazenil, the side effects are both known and manageable?
 
midazolam plus flumazenil = safer qm 2
 

Flumazenil is not as dangerous as I initially thought. I was giving too much emphasis to the problems. I also think that a reasonable case can be made that we should use benzodiazepines more aggressively, while managing airway compromise and oversedation with flumazenil as an occasional supplement to BLS methods such as proper positioning to maintain the airway and stimuli to promote respiratory drive. An IM (IntraMuscular) dose of 10 mg of midazolam (Versed) may be a good starting dose for a small or medium-sized person.

What about seizures? Seizures do occur, but they are not common. Flumazenil is a competitive antagonist, so more benzodiazepine can be given to stop a seizure, but we should not be getting anywhere near that complication. Seizures are not common and only one of the uses of benzodiazepines is to stop seizure activity. There is no good reason to expect seizure activity if we are giving tiny doses (smaller than the recommend doses of flumazenil) to patients who are being sedated with benzodiazepines (the wrong drugs, but often the only ones available to EMS) for agitated delirium and happen to become so sedated that a bad outcome is likely without intervention.[4]

The current issue of the British Journal of Clinical Pharmacology has the theme of the appropriate use of antidotes.
 

Themed issue Antidotes in Clinical Toxicology

Theophrastus Bombastus Paracelsus von Hohenheim (1493–1541) said it all with Dosis sola facit venenum or in modern language “It is the dose, stupid”. So, for a journal of Clinical Pharmacology that as a matter of principle deals with the relation between dose and effect, covering the high end of de (the?) dose – effect relationship is nothing out of the ordinary. This issue is largely about how to treat unfortunate patients who have reached the dark side of the dose–response curve. This can be done by antidotes.[5]

 

This can be done by antidotes.     Not – This must be done by antidotes.

It is the dose, stupid, is usually translated as The dose makes the poison, or –
 

All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.
 

Only one article in this issue addresses flumazenil, and that is only as part of a general discussion of antidotes (which also mentions the use of benzodiazepines as the antidote for overdose of amphetamines and other stimulants and for drug induced delirium). The article does encourage caution in the use of flumazenil –
 

For other antidotes, a clinical effect is pharmacologically expected, obvious and rapid (e.g. reversal of coma with flumazenil or naloxone, or resolution of delirium with physostigmine). However, this does not necessarily translate into improved clinical outcomes over supportive care [2]. [6]

 

What if the important safety criteria are using small doses, repeated reassessment, and critical judgment?

Can EMS do that? Our failures with airway management (it is still popular to claim that no evidence of benefit or safety is needed, in spite of the many studies showing harm from intubation) suggest that we cannot, but people keep pointing out that I am an optimist. I think that education can reach many of the dogmatic deniers of science and promoters of emotion over reality.

The use of tiny doses of naloxone (Narcan) to increase the respiratory drive, but not the alertness, of patients with opioid overdoses may result in a sudden increase in level of consciousness and aggression, but that is not typical.

Can we produce better outcomes with judicious use of antidotes in addition to supportive care as a way of managing aggressive use of benzodiazepines? Maybe, but it is not something people seem to want to study. We have given the drug to be reversed and know the dose we gave, so we are not dealing with an unknown overdose. The patient may have ingested other drugs that are unknown, but they tend to be stimulants, which is why we are giving a sedative. The patient may even have taken a benzodiazepine at some point, but more benzodiazepine is not a reason to avoid flumazenil.

The better question is can we improve outcomes for violent patients and for the people who deal with violent patients, with more aggressive use of benzodiazepines and judicious use of flumazenil to minimize the side effects of aggressive benzodiazepine use?

Benzodizepines are the wrong drugs to use for agitated delirium, unless combined with more effective medication. Some EMS providers do not have access to the most effective sedatives, or even the second most effective sedatives. I am limited to benzodiazepines and only in doses that are too low. Adding flumazenil to my scope of practice might help the medical directors to provide better EMS education and more aggressive standing orders.

There is more to write about flumazenil, but this is plenty for today.
 

Also writing in The Second EMS What-if-We’re-Wrong-a-Thon are –

Michael Morse (Rescuing Providence) — asks… what if community paramedicine really is the future of EMS?

Dale Loberger (High Performance EMS) — asks… what if emergency response times don’t really matter all that much?

Amy Eisenhauer (The EMS Siren) — wonders… whether the role of social media in EMS is such a good thing after all.

Ginger Locke — asks… what if video laryngoscopy really is the best first-pass technique for routine endotracheal intubation?

Footnotes:

[1] Flumazenil and EMS – A Box Pandora Should Not Open
Fri, 20 Mar 2009
by Rogue Medic
Article

[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 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.

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. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.

I have written about this in C A S T and Narrative Fallacy and elsewhere.

[3] Thalidomide: the tragedy of birth defects and the effective treatment of disease.
Kim JH, Scialli AR.
Toxicol Sci. 2011 Jul;122(1):1-6. doi: 10.1093/toxsci/kfr088. Epub 2011 Apr 19. Erratum in: Toxicol Sci. 2012 Feb;125(2):613.
PMID: 21507989

Free Full Text from Toxicol Sci.

[4] Excited Delirium: Episode 72 EMS EduCast
Wed, 29 Sep 2010
by Rogue Medic
Article

[5] Issue highlights
British Journal of Clinical Pharmacology
Special Issue: Antidotes in Clinical Toxicology
Volume 81, Issue 3, pages 398–399, March 2016
DOI: 10.1111/bcp.12909
Article

[6] Who gets antidotes? choosing the chosen few.
Buckley NA, Dawson AH, Juurlink DN, Isbister GK.
Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. Review.
PMID: 26816206

Free Full Text from Br J Clin Pharmacol.

.

Deadpool – maybe it only hurts when you laugh, but you laugh anyway

 

What if you took an extremely sarcastic person and made him a god? You could have a triple R rated success.

Horace Walpole has a great quote, that seems to baffle the sanctimonious –

The world is a comedy to those that think; a tragedy to those that feel.

Jonathan Swift and Lewis Carroll might regret that this movie only skims the surface in its satire, but they had to use satire to avoid prosecution for blasphemy, heresy, and other thought crimes that are trying for a comeback.

Marvel vs. DC. iPhone vs. Android. Fire vs. private vs. hospital. Little-Endian vs. Big-Endian and High Heels vs. Low Heels.[1] Mine is the One True WhateverTM.
 

Deadpool kneel before Zod sign 1a
Best still of Deadpool at Comic Con

 


 

Election season is the perfect time for Deadpool to be in theaters, because the preachers, pundits, and politicians are more absurd and obscene than anything in the movie.
 

Satire is a sort of glass wherein beholders do generally discover everybody’s face but their own; which is the chief reason for that kind reception it meets with in the world, and that so very few are offended with it.[2]

 

Deadpool doesn’t even try to fit the right wing or left wing politically correct model. The preachers, pundits, and politicians claim that the greater obscenities they promote are virtues. Perhaps they are so ridiculous, they no longer need others to ridicule them.

 

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”

“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”[3]

 
 

We should soon see an honest emulation among the married women, which of them could bring the fattest child to the market. Men would become as fond of their wives, during the time of their pregnancy, as they are now of their mares in foal, their cows in calf, or sow when they are ready to farrow; nor offer to beat or kick them (as is too frequent a practice) for fear of a miscarriage.[4]

 

If you work in a medical field, you should have seen enough misery to have an appreciation of a dark sense of humor and an understanding of the fraud of treating others as less deserving because they are in some way different.

A world of collateral damage is a comedy. Some of us keep going for the even bigger laugh of the bigger body count.

A world of starvation is a comedy. Some of us oppose using GMOs (Genetically Modified Organisms) to prevent the even bigger laugh of the bigger body count.

A world of death by preventable illness is a comedy. Some of us oppose using vaccines to prevent the even bigger laugh of the bigger body count.

The truly twisted sense of humor is not the obscenity in this movie, but the sanctimony of those encouraging killing, in the name of whatever, while claiming to be good.

Footnotes:

[1] Part I, Chapter IV
Mildendo, the metropolis of Lilliput, described, together with the emperor’s palace. A conversation between the author and a principal secretary, concerning the affairs of that empire. The author’s offers to serve the emperor in his wars.
Gulliver’s Travels into Several Remote Nations of the World (1726)
Jonathan Swift
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Chapter IV
 

For,” said he, “as flourishing a condition as we may appear to be in to foreigners, we labour under two mighty evils: a violent faction at home, and the danger of an invasion, by a most potent enemy, from abroad.

 

[2] The Preface of the Author
A Full and True Account of the Battle Fought Last Friday Between the Ancient and the Modern Books in Saint James’s Library. (1704)
Jonathan Swift
The Literature Network
Introduction

[3] Chapter 5: Wool and Water
Through the Looking-Glass, and What Alice Found There (1871)
Lewis Carroll (Charles Lutwidge Dodgson)
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Chapter 5

[4] A Modest Proposal for preventing the children of poor people in Ireland, from being a burden on their parents or country, and for making them beneficial to the publick (1729)
Jonathan Swift
eBooks@Adelaide
The University of Adelaide Library
University of Adelaide
South Australia 5005
Full Text

.

Should Universities Avoid Sensitive Topics Because of Guns in the Classroom?

 

There is paranoia over having guns on campus at state schools in Texas, but where is the evidence to support the fear that armed students will suddenly resort to violent disagreement? Professors are being encouraged to avoid sensitive topics if there are armed students in the classroom. Has discussion of sensitive topics previously resulted in attacks on professors with knives, clubs, chairs, or fists?
 

With students potentially carrying weapons after Aug. 1, University of Houston faculty members may want to avoid sensitive subjects or drop certain topics from their curriculum altogether, a forum of professors suggested recently.

A slide shown at a recent discussion of a new state law, which will allow licensed individuals to carry concealed handguns on campus, says faculty may want to “not ‘go there’ ” to avoid creating a tense situation. This echoes concerns voiced by professors across the state that allowing guns into the classroom will limit academic freedoms and inhibit discussion of sometimes touchy subjects.[1]

 

We do need to know more about the causes of shootings, but Congress has prohibited studying this because the research often reflect the biases of the researchers, whether pro-gun or anti-gun. Researchers on the topic have not done a great job, but that is a reason to improve the research, not to prohibit research.

While there have been a lot of school shootings, is there anything to suggest that these shootings have had anything to do with discussions of sensitive topics?

No.

Will this change if students are allowed to carry firearms on campus?

Probably not.

Research would be nice, but Wayne LaPierre (executive vice president of the National Rifle Association) appears to be convinced that guns are the cause of all of the problems in America. He is the main opponent of research, which he seems to expect to uncover his secret. LaPierre is also the person who seems to profit the most from every mass shooting that makes the news.

News coverage of a mass shooting is a fund raiser for Wayne LaPierre and the NRA. While LaPierre fights to keep guns in the hands of criminals, most NRA members are more reasonable.
 

Pew - guns - background checks
Section 2: Opinions of Gun Owners, Non-Gun Owners[2]
 

Gun ownership is a topic that many people approach emotionally, rather than logically. People want guns for protection, even though there is no valid reason for the average person to feel safer with a gun. There are plenty of reasons to feel less safe with a gun.

The best way to protect yourself is to stay away from violent people, such as gangsters, but that is not always possible.

What is a gun supposed to protect you from? Being killed –
 

All homicides
Number of deaths: 16,121
Deaths per 100,000 population: 5.1

Firearm homicides
Number of deaths: 11,208
Deaths per 100,000 population: 3.5
[3]

 

What is the greatest risk of owning a gun?
 

All suicides
Number of deaths: 41,149
Deaths per 100,000 population: 13.0
Cause of death rank: 10

Firearm suicides
Number of deaths: 21,175
Deaths per 100,000 population: 6.7

Suffocation suicides
Number of deaths: 10,062
Deaths per 100,000 population: 3.2

Poisoning suicides
Number of deaths: 6,637
Deaths per 100,000 population: 2.1
[3]

 

People with guns are almost twice as likely to intentionally kill themselves as they are to intentionally kill someone else, so why the fear?

Then there are 505 unintentional firearms deaths, 281 firearms deaths in the undetermined category, and 467 firearms deaths in legal intervention/war category. Even the accidental (unintentional) deaths outnumber the appropriate deaths.

This does not mean that there is no good reason to own a gun. There are many, but just for the feeling of protection in a low crime area, like some who are prepared for a home invasion, is like buying a lottery ticket. Your odds of winning do not change, regardless of how many tickets you buy. Estimating the home invasion rate, since it is not usually a specific part of crime statistics, is a guess at what is just a tiny part of the violent crime rate, which has been decreasing for a quarter of a century.

Perhaps a gun is not just supposed to protect you from being killed, but from being attacked, or just from being anxious about being attacked. The suicide statistics do not suggest that guns provide an effective psychological benefit.

The NNT (Number Needed to Treat to produce a benefit) is almost impossible to measure, because of the prohibition on research and the difficulty in identifying cases where a gun might have prevented something vs. when having a gun may have contributed to a bad outcome, vs. the many other difficult to measure possible outcomes. Outcomes of even positive reports might have been better without a gun, since we generally have no way of knowing what the outcome would be if a person did not have a gun.

The NNH (Number Needed to Harm) is easier to measure. Add the accidental injuries, the accidental deaths, and the suicides and divide by the number of guns. Even this will have some difficult to measure possibilities. The difference is that the majority of this number is unambiguous, while the benefit is almost entirely speculative.

The bad outcomes are only going to be a fraction of one percent. They are like dealing with terrorism, which is like mass shootings – rare, dramatic, and emotional. We are not good at making these decisions rationally.
 

But how dangerous are guns?
 

Actual causes of death in US in 2000 - a
Actual Causes of Death[4]
 

Some of the death rates, such as due to motor vehicles and firearms, have decreased since 2000, while others, such as illicit drug use have increased.
 

Three Selected Causes of Injury†— National Vital Statistics System, United States
The full image shows more dramatic changes since 1979, but I edited it to show only the changes since 1999.[5]
 

Guns are much less dangerous than tobacco, obesity/inactivity, or alcohol, but more dangerous than terrorism. We don’t worry much about tobacco, obesity/inactivity, or alcohol, but we panic about terrorism. Risk management is not something we do well. We evolved a fight, flight, or freeze response to threats. These are reflexive and emotional responses. Universities are supposed to promote reasonable discussion of diverse and sensitive topics, but they have encouraged political groups to shout down the ideas they do not want to hear.

Professors are supposed to think clearly about things, and educate students to think clearly. Avoiding sensitive topics, because students might not be reasonable, is not reasonable.

Footnotes:

[1] UH faculty suggest steering clear of some topics if students armed
By Benjamin Wermund
Updated 8:30 am, Wednesday, February 24, 2016
Houston Chronicle
Article

[2] Section 2: Opinions of Gun Owners, Non-Gun Owners
March 12, 2013
Why Own a Gun? Protection Is Now Top Reason
Perspectives of Gun Owners, Non-Owners
Pew Research Center
Study

[3] Deaths-Final Data for 2013
Jiaquan Xu, M.D.; Sherry L. Murphy, B.S.; Kenneth D. Kochanek, M.A.; and
Brigham A. Bastian, B.S., Division of Vital Statistics
National Vital Statistics Reports
Volume 64, Number 2
February 16, 2016
Free Full Text in PDF format

[4] Actual causes of death in the United States, 2000.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
JAMA. 2004 Mar 10;291(10):1238-45. Review. Erratum in: JAMA. 2005 Jan 19;293(3):298. JAMA. 2005 Jan 19;293(3):293-4.
PMID: 15010446

[5] QuickStats: Death Rates* for Three Selected Causes of Injury†— National Vital Statistics System, United States, 1979–2012
Morbidity and Mortality Weekly Report (MMWR)
November 21, 2014 / 63(46);1095
Edited to show only the changes since 1999
Free Full Image with footnotes from CDC.

.

Who would have thought that a vacancy on the Supreme Court would produce so much unintentional comedy

 

First the facts. On the night/morning of February 12-13, 2016, Justice Antonin Scalia died of apparently natural causes. This is not really off topic, since this points out the ways that rules are made and politics can come into play in the masking of rules, protocols, and guidelines.
 

Antonin_Scalia,_SCOTUS_photo_portrait
 

Average life expectancy for an American male is about 79 years. Justice Scalia died about a month before his 80th birthday. Justice Scalia is reported to have health problems, which may have contributed to his death. Is it unusual for a medical examiner to pronounce death over the phone? No. There may be many variations from state to state, but working as a paramedic, as long as the circumstances are not suspicious, pronouncing death is done over the phone and arrangements are often made for the body to go to a funeral home.

Ruth Bader Ginsburg is 82 and her birthday is also next month. She may die soon or she may live another 20+ years. It will probably be something between the two, but we do not know where it will be on that range. Doctors do not exist to predict when someone will die. Doctors are supposed to provide appropriate treatment with the consent of the patient, or the person with power of attorney for the patient.

Justice Scalia was not in the best of health, but nobody appears to have been predicting that he would die right now. On the other hand, nobody should be surprised that a man of his age, with his health problems, died suddenly in his sleep. If you ask young people if they would like to die in their sleep outside of a hospital, at about 80, after living an active and successful life, would it be surprising if many said, Yes.? Justice Scalia was very fortunate.

President Obama was discouraged from making an appointment to replace Justice Scalia, because it is unusual for a Supreme Court Justice to die in the last year of either term of a presidency (an election year). It is unusual for a Supreme Court Justice to die during any year of a presidential term. Most of the time a Supreme Court Justice will retire and will try to arrange to step down without the political hubbub of an election year.

Many opposed to President Obama have stated that he should not nominate anyone to replace Justice Scalia. It seems they do not considered it important to fill a vacancy on the Supreme Court for over a year.

Some have suggested that it is a tradition to delay nominations in the last year of a presidency, but where is the evidence to support this revolutionary approach to Supreme Court nominations? Has this tradition ever happened? What is an unprecedented tradition?

What about the original intent of the Founding Fathers? The Constitution does not have any wording to support a delay in nominating someone.
 

He (The President) shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur; and he shall nominate, and by and with the Advice and Consent of the Senate, shall appoint Ambassadors, other public Ministers and Consuls, Judges of the supreme Court, and all other Officers of the United States, whose Appointments are not herein otherwise provided for, and which shall be established by Law: but the Congress may by Law vest the Appointment of such inferior Officers, as they think proper, in the President alone, in the Courts of Law, or in the Heads of Departments.

The President shall have Power to fill up all Vacancies that may happen during the Recess of the Senate, by granting Commissions which shall expire at the End of their next Session.[1]

 

George Washington, nominated and appointed two Supreme Court Justices in his last full year in office. President Washington’s second term ended March 4, 1797.
 

President George Washington nominated (Samuel) Chase to the Supreme Court of the United States on January 26, 1796, and the Senate confirmed the appointment the following day.[2]

 

Followed by –
 

On March 3, 1796, Ellsworth was nominated by President George Washington to be Chief Justice of the United States, the seat having been vacated by John Jay. (Jay’s replacement, John Rutledge, had been rejected by the Senate the previous December, and Washington’s next nominee, William Cushing, had declined the office in February.) The following day, Ellsworth was unanimously confirmed by the United States Senate, and received his commission.[3]

 

Should we condemn the actions of President Washington as not reflecting original intent?

President Washington was succeeded by President John Adams, who nominated and appointed John Marshall with less than a month and a half to go in his term. President John Adams was also one of the Founding Fathers and George Washington’s choice for a successor. Should we condemn his nomination and appointment as contrary to original intent?
 

As the incumbent Chief Justice Oliver Ellsworth was in poor health, Adams first offered the seat to ex-Chief Justice John Jay, who declined on the grounds that the Court lacked “energy, weight, and dignity.”[31] Jay’s letter arrived on January 20, 1801, and as there was precious little time left, Adams surprised Marshall, who was with him at the time and able to accept the nomination immediately.[32] The Senate at first delayed, hoping that Adams would make a different choice, such as promoting Justice William Paterson of New Jersey. According to New Jersey Senator Jonathan Dayton, the Senate finally relented “lest another not so qualified, and more disgusting to the Bench, should be substituted, and because it appeared that this gentleman [Marshall] was not privy to his own nomination”.[33] Marshall was confirmed by the Senate on January 27, 1801, and received his commission on January 31, 1801.[4]

 

Those who support President Obama have pointed out that the nomination of Justice Anthony Kennedy was made in the final year of President Reagan’s term, but that was to fill a vacancy due to a retirement over a year and a half before the end of President Reagan’s term. Still, that did not stop President Reagan from continuing to nominate candidates until one was appointed.
 

On November 11, 1987, Kennedy was nominated to the Supreme Court seat vacated by Lewis F. Powell, Jr., who announced his retirement in late June.[11] His nomination came after Reagan’s failed nominations of Robert Bork, who was nominated in July but rejected by the Senate on October 23,[12] and Douglas Ginsburg,[13][14] who withdrew his name from consideration on November 7 after admitting to marijuana use.[15] Kennedy was then subjected to an unprecedentedly thorough investigation of his background, which he easily passed.[5]

 

Those are the facts.
 

Suppose President Reagan had six months left in his second term and a vacancy developed on the Supreme Court. Should President Reagan have left that nomination for the winner of the next election? Nobody yet knew who would win the election. The choice between Vice President George H. W. Bush and Governor Michael Dukakis of Massachusetts would be half a year away and that is plenty of time for some unexpected news to affect the outcome of the election.

What would President Reagan do? What would President Bush (41) do? What would President Clinton do? What would President Bush (43) do?

While we can only speculate about what someone would do, there does not appear to be any reason to suspect that any American president would refuse to nominate someone under the same circumstances.

Please let me know if you are aware of any cases of any refusal to nominate a candidate to fill a vacancy on the Supreme Court.

What I expect to happen is that the process will be dragged out and eventually there will be a vote along party lines to reject the candidate. I would expect the same thing if the parties were reversed (the president Republican and Enough Democrats in the Senate to reject a candidate). The Constitution does not require the Senate to be reasonable. The Constitution and Bill of Rights were written because the Founding Fathers expect politicians to be unreasonable. The debate over this is nothing new.
 

The Supreme Court has become more polarized and the nomination process may have become even more polarized than the Court. Even Justice Scalia has stated that he would not expect to be approved in the current environment

How could the president use that understanding of politics in his favor?

1. Nominate someone who has a history of moderate in views, rather than liberal views.

2. Point out that the Senate is willing trying to keep the seat vacant for a year.

3. Frequently remind the eight justices, through others, that they are the full Court for the next year.

4. Remind the voters that the nomination is moderate, demonstrating that the opposition to the nomination is not moderate.

5. Use the Federalist Papers, and other writings of the Founding Fathers, to show that the original intent was never to support the rights of factions at the expense of individual rights.

6. Appealing to the judgment of the people who are appointed for their judgment is a way around the politics, but only if the nomination is not political.

Our next president will be just another politician, pandering to the polarized views that have been encouraged by the political propaganda of MSNBC, CNN, and Fox News. This is an opportunity to set an example of doing what is better, rather than what is political. Eventually America will move away from our current temporary infatuation with extremes.
 

How does that relate to making laws, protocols, or guidelines in EMS?

There are powerful people in EMS. Some understand and pay attention to evidence, while others put aside reason and are suckers for anecdotes. Some can be persuaded with evidence. Some will find excuses to reject evidence. By addressing those who are respected and can convince those driven by emotion, more can be accomplished.

Ask permission to forward a PDF, or a link to the full text, of a paper that supports your position. Mention that you are interested in their opinion of the paper. Maybe some of them will read the papers. Maybe some of those who do not read the papers (we don’t have enough time to read everything we should) will feel guilty about not reading it and go along out of guilt. Follow up by asking what they thought of the paper.

While it is disappointing to encounter a broad lack of familiarity with the relevant research, this is an opportunity to provide objective information, which should persuade most reasonable people. Repeat as often as necessary. Most unreasonable people find it difficult to remain unreasonable when presented with valid objective evidence.

Footnotes:

[1] Article II Section 2
U.S. Constitution
Transcript

[2] Samuel Chase
FindLaw
Supreme Court Center
Supreme Court Justices
Article

[3] The Ellsworth Court and later life
Oliver Ellsworth
Wikipedia
Article

[4] Nomination
John Marshall
Chief Justice (1801 to 1835)
Wikipedia
Article

[5] Appointment to Supreme Court
Anthony Kennedy
Wikipedia
Article

.

Happy Darwin Day 2016

 

Today is the 207th birthday of both Charles Darwin and Abraham Lincoln, two people who were condemned for their great works. One changed the way we treat other members of our species, while the other changed our entire understanding of species.

Lincoln held America together in spite of attempts to divide America into those who used the law to support equal treatment of Americans and those who would start their own country to be able to expand what may be the worst economic system ever seen in America – slavery. We don’t like communism, but when we condemn communism, we use slavery as a metaphor for how bad communism really is. We used to be worse than the communists. Some of us were willing to kill Americans to avoid having to deal with the possibility of giving up the horror that is slavery.

Darwin explained how life evolved into the many different species that exist and into those that no longer exist. The connection among those seemingly unconnected species of animals, plants, fungi, bacteria, . . . is DNA (DeoxyriboNucleic Acid). We can use DNA in a court room to demonstrate that one person is the parent of another person, or that one person had direct (or occasionally indirect) contact with another person and thus may have had the opportunity to commit a crime. Criminal DNA evidence is just a tool and its appropriate use does require judgment, just as with any other evidence. If used without judgment, DNA evidence can be just as unreliable as eyewitness testimony.[1]

DNA is able to tell us how people and species are related. DNA is able to tell us that we are very closely related to other apes. When we trace our ancestry back far enough, we have the same ancestors. If we trace our ancestry back even farther, we have the same ancestors as snails. We have all evolved, over billions of years, to exist in our current temporary state of evolution. Will we humans split into several species or remain just one species until we become extinct?

DNA had not even been identified at the time that Darwin explained evolution in On the Origin of Species, so he did not have the ability to explain how these changes were taking place, but he could show that the changes were taking place and that the changes favored adaptations that increased the probability of survival of the species. He wasn’t right about everything, but science is not perfection. Science is a method of increasing our understanding and Darwin is one of a handful of scientists who dramatically changed the way we understand biology.

Medicine is a branch of biology. We can go practice monkey see, monkey do medicine, but we will cause a lot of harm with our lack of understanding. We can try to understand as much as possible or we can make excuses for rejecting science.

As we learn, science changes. The same is true for everything else. As we learn, we change. Change is unstoppable.

Could over 99% of biologists be wrong about evolution?
 

How Gavin Smythe Broke Science

How Gavin Smythe Broke Science


 
Go see the rest of How Gavin Smythe Broke Science here.
 

If you understand science, Tell Congress to Support Darwin Day 2016.

In addition, House Resolution 548 and Senate Resolution 337:
 

Footnotes:

[1] Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment
Fri, 05 Jul 2013
Rogue Medic
Article

.

The RAD-57 – Still Unsafe?

ResearchBlogging.org
 

Brandon Oto of EMS Basics and Degrees of Clarity organized The First EMS What-if-We’re-Wrong-a-Thon. I did not participate, because I was taking a break from blogging at the time. Brandon is doing it again, so I decided to look for something I wrote that I have been wrong about to contribute. I thought about Masimo. I had been very critical of Dr. Michael O’Reilly (then Executive Vice President of Masimo Corporation) for being an advocate of bad science. He has since been hired away by Apple.[1] He should be less dangerous with a telephone than he was with the RAD-57. At the time, he wrote –
 

Masimo stands by its products’ performance and knows that when SpCO-enabled devices are used according to their directions for use, they provide accurate SpCO measurements that provide significant clinical utility, helping clinicians detect carbon monoxide poisoning in patients otherwise not suspected of having it and rule out carbon monoxide poisoning in patients with suspected carbon monoxide poisoning.[2]

 

The problem is that there is no evidence that the RAD-57 is safe or effective at ruling out carbon monoxide poisoning in anyone.

There is evidence that the RAD-57 will fail, if used to try to rule out carbon monoxide poisoning. One study showed that the RAD-57 will miss half of the people with elevated carbon monoxide levels.
 

The RAD device correctly identified 11 of 23 patients with laboratory values greater than or equal to 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%).[3]

 

What if I was wrong?

Is there any evidence that the RAD-57 is able to rule out covert, but life threatening carbon monoxide poisoning?[4]
 


 
 

Was I wrong?

While there have been several studies of the RAD-57, I could not find any evidence that the RAD-57 is safe or effective at ruling out carbon monoxide poisoning.

There does not appear to be any research on the use of the RAD-57 to screen firefighters to rule out carbon monoxide poisoning, even though advertising shows using the RAD-57 to screen firefighters.

Was I wrong? No. That is why this is not a part of The First EMS What-if-We’re-Wrong-a-Thon.

However, I did find some interesting carbon monoxide poisoning papers –

One shows that we may be causing harm by aggressively providing oxygen. This is not enough of a reason to stop providing oxygen, but if this hypothesis is supported by further research, we will need to change treatment.
 

While CO’s affinity for hemoglobin remains undisputed, new research suggests that its role in nitric oxide release, reactive oxygen species formation, and its direct action on ion channels is much more significant. In the course of understanding the multifaceted character of this simple molecule it becomes apparent that current oxygen based therapies meant to displace CO from hemoglobin may be insufficient and possibly harmful.[5]

 

Another shows that the addition of catalytic converters seems to have dramatically decreased the car exhaust suicide rate and the level of carbon monoxide in survivors of these suicide attempts.
 

RESULTS:
Since 1985, the CDR for suicidal motor vehicle-related CO poisoning has decreased in parallel with CO emissions (R2 = 0.985). Non-fatal motor vehicle-related intentional CO poisoning cases decreased 63% over 33 years (p = 0.0017). COHb levels decreased 35% in these patients (p < 0.0001).
[6]

 

CO is Carbon monOxide.
CDR is Crude Death Rate.
COHb is CarbOxyHemoglobin.

There are still some papers that show that we do not understand what the RAD-57 can’t do –
 

The fact that all the Paramedic Rescue Squads were equipped with medical triage sets and were able to conduct non-invasive measurements of carboxyhemoglobin made it possible to introduce effective procedures in the cases of suspected carbon monoxide poisoning and abandon costly and complicated organisational procedures when they proved to be unnecessary.[1]

 

No. The Magic 8 Ball did not indicate a problem, but that does not mean that it is safe to rule out carbon monoxide poisoning with a Magic 8 Ball. The Magic 8 Ball RAD-57 is not accurate enough to rule out carbon monoxide poisoning.

The RAD-57 is only appropriate for sending more people to the hospital. While the extra cost of these false positives is a problem and will cause people to mock Masimo, this may save some lives or just prevent more serious consequences of carbon monoxide poisoning.

If you use the RAD-57 to determine that someone does not need to go to the hospital, get a lot of very good insurance, because eventually one of those patients will have a heart attack, or a stroke, or die and carbon monoxide will be part of the reason for the bad outcome. Your advice will have contributed.

If you send a firefighter back into a fire because you think you have ruled out carbon monoxide poisoning, eventually you will be the cause of death or disability of firefighters. Don’t do it.
 

CONCLUSIONS:
While the Rad-57 pulse oximeter functioned within the manufacturer’s specifications, clinicians using the Rad-57 should expect some SpCO readings to be significantly higher or lower than COHb measurements, and should not use SpCO to direct triage or patient management. An elevated S(pCO) could broaden the diagnosis of CO poisoning in patients with non-specific symptoms. However, a negative SpCO level in patients suspected of having CO poisoning should never rule out CO poisoning, and should always be confirmed by COHb.
[7]

 

Highlighting in bold is mine.

SpCO is Masimo’s registered trademark for their noninvasive indirect measurement of carbon monoxide using the RAD-57.

Was I wrong? I will find something else to write about, because there is even more evidence that the RAD-57 should not be used to try to rule out carbon monoxide poisoning now than when I originally criticized Masimo.
 

Also read the article by Dr. Brooks Walsh on the RAD-57 and screening for carbon monoxide poisoning in fire fighters – Checking firefighters for carbon monoxide – recent studies, persistent concerns.
 

Here is the rest of what I have written about the Dr. O’Reilly, Masimo, and the RAD-57

The RAD-57 Pulse Co-Oximeter – Does It Work – Part I
Fri, 12 Nov 2010

The RAD-57 Pulse Co-Oximeter – Does It Work – Part II
Wed, 17 Nov 2010

How Not to Respond to Negative Research
Fri, 26 Nov 2010

How Not to Respond to Negative Research – Addendum
Fri, 26 Nov 2010

How TO Respond to Negative Research
Sun, 05 Dec 2010

Bad Advice on Masimo’s RAD-57 – Part I
Fri, 18 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part II
Mon, 21 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part III
Thu, 24 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part IV
Mon, 28 Feb 2011

Performance of the RAD-57 With a Lower Limit – Better?
Wed, 18 May 2011

Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients
Tue, 21 Feb 2012

Mass sociogenic illness initially reported as carbon monoxide poisoning
Wed, 22 Feb 2012

Psychic vs. RAD-57
Thu, 23 Feb 2012

Footnotes:

[1] Apple makes yet another medical field hire for unknown project
By AppleInsider Staff
Thursday, January 30, 2014, 04:04 pm PT (07:04 pm ET)
AppleInsider
Article

[2] Performance of the Rad-57 pulse co-oximeter compared with standard laboratory carboxyhemoglobin measurement.
O’Reilly M.
Ann Emerg Med. 2010 Oct;56(4):442-4; author reply 444-5. No abstract available.
PMID: 20868919 [PubMed – indexed for MEDLINE]

Free Full Text of letter and author reply from Ann Emerg Med.

[3] Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement.
Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P.
Ann Emerg Med. 2010 Oct;56(4):382-8. Epub 2010 Jun 3.
PMID: 20605259 [PubMed – indexed for MEDLINE]

Free Full Text Article from Ann Emerg Med.

[4] Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients
Rogue Medic
Tue, 21 Feb 2012
Article

[5] A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement.
Roderique JD, Josef CS, Feldman MJ, Spiess BD.
Toxicology. 2015 Aug 6;334:45-58. doi: 10.1016/j.tox.2015.05.004. Epub 2015 May 18. Review.
PMID: 25997893

[6] Suicidal carbon monoxide poisoning has decreased with controls on automobile emissions.
Hampson NB, Holm JR.
Undersea Hyperb Med. 2015 Mar-Apr;42(2):159-64.
PMID: 26094291

[7] False positive rate of carbon monoxide saturation by pulse oximetry of emergency department patients.
Weaver LK, Churchill SK, Deru K, Cooney D.
Respir Care. 2013 Feb;58(2):232-40. doi: 10.4187/respcare.01744.
PMID: 22782305

Free Full Text from Respir Care.

Weaver, L., Churchill, S., Deru, K., & Cooney, D. (2012). False Positive Rate of Carbon Monoxide Saturation by Pulse Oximetry of Emergency Department Patients Respiratory Care DOI: 10.4187/respcare.01744

Hampson NB, & Holm JR (2015). Suicidal carbon monoxide poisoning has decreased with controls on automobile emissions. Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 42 (2), 159-64 PMID: 26094291

Roderique, J., Josef, C., Feldman, M., & Spiess, B. (2015). A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement. Toxicology, 334, 45-58 DOI: 10.1016/j.tox.2015.05.004

Touger, M., Birnbaum, A., Wang, J., Chou, K., Pearson, D., & Bijur, P. (2010). Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 382-388 DOI: 10.1016/j.annemergmed.2010.03.041

O’Reilly, M. (2010). Performance of the Rad-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 442-444 DOI: 10.1016/j.annemergmed.2010.08.016

.