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

- Rogue Medic

Influence of Sex on the Out-of-hospital Management of Chest Pain – Part II

Tue, 15 May 2012 08:00:22 -0400 by
ResearchBlogging.org

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Part I was written in 2010, so I am a bit late in continuing to ridicule this example of bad research.

How do we determine what is good care for our patients?

By having our treatment follow the category that dispatch dispatch assigned the call? I used to work in a county, where this did appear to be the case. The medics would become very upset with dispatch if they did not receive a lot of information about the patient prior to arriving on scene.

Dispatchers would express surprise when I would tell them that I did not care about the information they could obtain over the telephone from some unknown person.

Why?

Apparently, these medics never learned to assess patients themselves.

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We conducted a population-based retrospective cohort study of 800 randomly selected patients over the age of 30 years for whom EMS were dispatched for a complaint of chest pain during a single year.[1]

These are not patients with a medical complaint of chest pain, but patients dispatched as chest pain – for whatever reason.

These are not patients considered to be cardiac by the emergency physician, but patients dispatched as chest pain.
 


 

The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured.[1]

Should we give aspirin (as a cardiac treatment) to patients who do not have, and never did have, chest pain?

Should we give nitroglycerin (as a cardiac treatment) to patients who do not have, and never did have, chest pain?

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The role of dispatch is not to determine the treatment for the paramedics or for the physicians. The role of dispatch is to prioritize getting the right people to the patient in the right amount of time.

What information do I want from dispatch?

How many patients they believe are there.

Trauma vs medical.

Reports of any violence or anything suspicious of violence.

Who else is responding.

Any reports of traffic problems in the area, or other unusual events that might affect what we do.

Unusual (or amusing) things picked up during the phone call.

The location of the patient.

Should there be any more of an exchange of information than the following?

Respond to location X for an adult with chest pain. X is also responding.

10-4.

Dispatch has more important things to do than to do assessments for incompetent medics.

According to the authors of the study, if dispatch mentions chest pain, I am supposed to follow my Suspected ACS (Acute Coronary Syndrome) protocol, even though that protocol does not mention anything about receiving medical direction from dispatch. The protocol begins with the words, Initial patient contact. Why doesn’t the protocol begin with Dispatch Diagnosis?

I work in the same state. The protocols have changed since the study, but dispatch is only mentioned three times in my paramedic protocols. All of these times are only related to cardiac arrest.

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Maybe I will write a Part III. Maybe, if I do write it, it will not take over two years.

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Footnotes:

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[1] Influence of sex on the out-of-hospital management of chest pain.
Meisel ZF, Armstrong K, Mechem CC, Shofer FS, Peacock N, Facenda K, Pollack CV.
Acad Emerg Med. 2010 Jan;17(1):80-7.
PMID: 20078440 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine

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Meisel, Z., Armstrong, K., Crawford Mechem, C., Shofer, F., Peacock, N., Facenda, K., & Pollack, C. (2010). Influence of Sex on the Out-of-hospital Management of Chest Pain Academic Emergency Medicine, 17 (1), 80-87 DOI: 10.1111/j.1553-2712.2009.00618.x

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Filed Under: ACS, Cardiology, Heresy, Irrational Government Oversight, Pharmacology, Research Blogging

Research We Bought, Congress Wants Us to Buy Again From Publishers

Sun, 22 Jan 2012 06:30:56 -0500 by
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As if SOPA and PIPA were not misguided enough, some in Congress want us to have to pay twice to read research. We already pay for the research. The only requirement placed on the publishers is that they make the content available for free after one year. the publishers essentially receive the research for free, have volunteer peer reviewers examine the research, and then are able to charge for the research for a full year.

There is nothing about this that is endangering the business model of the publishers.

The publishers are not being forced to publish this research in their journals.

If the publishers do choose to publish this research, there is a contract that the publishers must honor.

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THROUGH the National Institutes of Health, American taxpayers have long supported research directed at understanding and treating human disease. Since 2009, the results of that research have been available free of charge on the National Library of Medicine’s Web site, allowing the public (patients and physicians, students and teachers) to read about the discoveries their tax dollars paid for.

But a bill introduced in the House of Representatives last month threatens to cripple this site. The Research Works Act would forbid the N.I.H. to require, as it now does, that its grantees provide copies of the papers they publish in peer-reviewed journals to the library.[1]

Maybe that is just the attitude of the liberals at the New York Times.

What does Forbes say about this?

The world’s largest scientific journal today is the online, open-access, peer-review publication PLoS One, from a nonprofit organization called the Public Library of Science. It was created by a group of distinguished scientists, led by Nobel laureate and current National Cancer Institute Director Harold Varmus, who say results of research funded by taxpayer dollars should not be hidden behind traditional scientific publishers’ paywalls. As Varmus told me in 2010, “We work on the assumption that the reason we publish is to keep science moving forward. If everybody can see the work that we do, and new work is built on what’s come before, science moves faster.”[2]

It appears that this bi-partisan legislation also has bi-partisan opposition.

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But while the journals manage that process, it is carried out almost entirely by researchers who volunteer their time. Scientists are expected to participate in peer review as part of their employment, and thus the publicly funded salaries most of them draw through universities or research organizations are yet another way in which taxpayers already subsidize the publishing process.[1]

Maybe the publishers should receive huge tax credits, too.

Maybe we should shut down PubMed Central and PLoS ONE.

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Who is getting campaign contributions?

Organizations Supporting H.R.3699

Association of American Publishers
Ecological Society of America[3]

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Organizations Opposing H.R.3699

Scholarly Publishing and Academic Resources Coalition
American Association of Law Libraries
The Alliance for Taxpayer Access
International Society for Computational Biology[3]

OpenCongress.Org also list the amounts of money contributed to everyone by the interested parties.[4]

What is the claimed purpose of this bill?

To ensure the continued publication and integrity of peer-reviewed research works by the private sector.[5]

This discourages publication and has no effect on integrity of research, but the campaign contributions may have an effect on the integrity of the legislators.

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This bill would not only reverse the current law, but would forbid any other Federal agency from instituting any similar rule. As with SOPA and PIPA, corporations that refuse to adapt to the changing business world are trying to protect their Luddite franchises with legislation.

In England, when the automobile (road locomotive) came along, the railroad industry had laws passed to require a speed limit of 2 MPH (Miles Per Hour) – yes TWO – and 4 MPH in the country. In case that was not discouraging enough to automobile owners, they also had to have someone carrying a red flag walk ahead of the car to warn people of the approaching danger.[6] This protectionism did not stop the progress of the automobile, but it probably did delay progress. Luddite legislation will not stop progress, but it may delay progress.

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Image credit.

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We need to stop the Luddites.

Should we have laws passed to protect Pokemon from its loss of popularity?

What about Kodak?

Do we really want the government deciding which businesses, with failed business models, should be saved from their own management?

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Here’s a list of AAP members who have publicly disavowed the AAP position on RWA (chronological by announcement date):

MIT Press. See the January 11, 2012, announcement by Ellen Faran, Director of MIT Press.

ITHAKA. See the January 12, 2012, announcement.

Council on Library and Information Resources (CLIR). See the January 12, 2012, announcement.

Penn State University Press. See the January 12, 2012, announcement by Patrick Alexander, Director of the Penn State University Press.

Rockefeller University Press. See the January 13, 2012, announcement by Mike Rossner, Executive Director of Rockefeller University Press.

University of California Press. See the January 13, 2012, announcement by Alison Mudditt, Director of the University of California Press.

Nature Publishing Group and Digital Science. See the January 18, 2012, joint announcement by Steven Inchcoombe, Managing Director for NPG, and Timo Hannay, Managing Director for Digital Science. (Digital Science is a sister company of NPG.)

Association for the Advancement of Science (AAAS). See the January 18, 2012,announcement by Ginger Pinholster, Director of the AAAS Office of Public Programs, and Alan Leshner, AAAS Chief Executive Officer.[7]

There is not even a lot of agreement among those who are members of the main organization that supports the bill.

Those in opposition are not small or insignificant.

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Very late to keep up with this. Added 6/06/2012 @ 12:50 –

On February 29, 2012, the sponsors of the bill have stated that they will not pursue this.[8]

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Footnotes:

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[1] Research Bought, Then Paid For
By Michael B. Eisen
Published: January 10, 2012
Berkeley, Calif.
NY Times
Opinion Pages
Article

Michael B. Eisen, an associate professor of molecular and cell biology at the University of California, Berkeley, is a founder of the Public Library of Science, an organization devoted to making research freely available.

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[2] Democrat Maloney and Republican Issa Ally to Hurt Science and Help Companies
Adrienne Burke, Contributor
Techonomy
1/17/2012 @ 2:19PM
Forbes
Article

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[3] H.R.3699 – Research Works Act
OpenCongress.Org
Web page

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[4] The Money Trail
OpenCongress.Org
H.R.3699 – Research Works Act
Web page

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[5] H.R.3699 – Research Works Act
OpenCongress.Org
Text of the bill
Bill

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[6] Locomotive acts
Wikipedia
Article

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[7] Notes on the Research Works Act
Harvard Open Access Project (HOAP)
Web page

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[8] Anti-Open Access Bill Dies – Legislators have dropped the Research Works Act, which would have nixed policies that require federally funded research findings to be deposited in public databases.
By Bob Grant
February 29, 2012
The Scientist
Article

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Filed Under: Fraud, Heresy, Irrational Government Oversight

SOPA Will Protect Monopolies From US

Tue, 17 Jan 2012 09:30:10 -0500 by
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For American Censorship Day, in response to the proposed SOPA and PIPA legislation, this site will go dark tomorrow from 8 AM to 8 PM (Eastern Time – New York’s time zone).

SOPA and PIPA are about more than just privacy or copyright or due process, but I decided to address copyright.

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Section. 8.

The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;

…

To promote the Progress of Science and useful Arts, by securing for limited Times to Authors and Inventors the exclusive Right to their respective Writings and Discoveries;[1]

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How does that work for current copyrights and patents?

Works created in or after 1978 are extended copyright protection for a term defined in 17 U.S.C. § 302. With the passage of the Sonny Bono Copyright Term Extension Act, these works are granted copyright protection for a term ending 70 years after the death of the author. If the work was a work for hire (e.g., those created by a corporation) then copyright persists for 120 years after creation or 95 years after publication, whichever is shorter.[2]

95 to 120 years for copyright.

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Under current US law, the term of patent is 20 years from the earliest claimed filing date.[3]

20 years for a patent, which includes the time during which approval is being sought from the FDA (Food and Drug Administration to sell the product.

I guess big pharma is not able to manipulate Congress as effectively as Disney.

The purpose of copyrights and patents is to provide exclusive government protection for the people who create things that are important without depriving everyone of the use of these things. Why would an author/artist/composer/et cetera need protection for something for 70 years after death?

How does this encourage creativity?

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nor be deprived of life, liberty, or property, without due process of law;[4]

How does eliminating due process, in this area, protect Americans?

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Footnotes:

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[1]
The Constitution of the United States
Article I, Section 8
Wikipedia
Full transcription

Section. 8.

The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;

To borrow Money on the credit of the United States;

To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes;

To establish an uniform Rule of Naturalization, and uniform Laws on the subject of Bankruptcies throughout the United States;

To coin Money, regulate the Value thereof, and of foreign Coin, and fix the Standard of Weights and Measures;

To provide for the Punishment of counterfeiting the Securities and current Coin of the United States;

To establish Post Offices and post Roads;

To promote the Progress of Science and useful Arts, by securing for limited Times to Authors and Inventors the exclusive Right to their respective Writings and Discoveries;

To constitute Tribunals inferior to the supreme Court;

To define and punish Piracies and Felonies committed on the high Seas, and Offences against the Law of Nations;

To declare War, grant Letters of Marque and Reprisal, and make Rules concerning Captures on Land and Water;

To raise and support Armies, but no Appropriation of Money to that Use shall be for a longer Term than two Years;

To provide and maintain a Navy;

To make Rules for the Government and Regulation of the land and naval Forces;

To provide for calling forth the Militia to execute the Laws of the Union, suppress Insurrections and repel Invasions;

To provide for organizing, arming, and disciplining, the Militia, and for governing such Part of them as may be employed in the Service of the United States, reserving to the States respectively, the Appointment of the Officers, and the Authority of training the Militia according to the discipline prescribed by Congress;

To exercise exclusive Legislation in all Cases whatsoever, over such District (not exceeding ten Miles square) as may, by Cession of particular States, and the Acceptance of Congress, become the Seat of the Government of the United States, and to exercise like Authority over all Places purchased by the Consent of the Legislature of the State in which the Same shall be, for the Erection of Forts, Magazines, Arsenals, dock-Yards, and other needful Buildings;–And

To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof.

Highlighting of the Copyright Clause is mine.

Wikipedia will not be available on Wednesday in protest of SOPA and PIPA.

More information is available here.

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[2] Copyright law of the United States
Wikipedia
Article

Wikipedia will not be available on Wednesday in protest of SOPA and PIPA.

More information is available here.

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[3] United States patent law
Wikipedia
Article

Wikipedia will not be available on Wednesday in protest of SOPA and PIPA.

More information is available here.

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[4] United States Bill of Rights
Wikipedia
Fifth Amendment
Article

No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any person be subject for the same offence to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation.

Wikipedia will not be available on Wednesday in protest of SOPA and PIPA.

More information is available here.

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Filed Under: Blasphemy, Ethics, Fraud, Heresy, Irrational Government Oversight

How Dangerous Is Droperidol

Wed, 23 Nov 2011 06:30:32 -0500 by

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Continuing from Droperidol – Black Box Warning.

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Well, how dangerous is droperidol?

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These 271 reports occurred between November 1997 and December 2001. After a review of these records, it appeared that some of these cases represented the same patients reported by different sources. Cases that matched by age, gender, and medication list were eliminated as duplicate and triplicate reports. This left us with what appeared to be 93 unique instances of death reported in association with droperidol use.[1]

93 deaths over a 4 year period.

Out of how many doses?

In an audit in five major hospitals in our metropolitan area, more than 38,000 doses of droperidol are dispensed annually, with 1,200 of those being used in our ED.[1]

Millions of doses.

If the hospitals in Portland, OR use 38,000 doses per year, and Portland is only the 29th largest city in the US,[2] just assuming the same number of doses for all of the larger cities in the US, no matter how many times larger than Portland they may be, would put the number over 1,000,000 doses. The reports of deaths are from all over the world, not just in the US, so millions is not some wild, or exaggerated, guess.

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Less than 100 cases of death that might be due to droperidol over a 4 year period.

Millions of doses of droperidol each of those four years. At worst, still much less than 1/100th of 1 percent. A death rate of less than 0.01%.

It could be tens of millions of doses, or even more than 100 million doses. That means that the difference could be a ten times greater safety factor – or it could mean a 100 times greater safety factor than what I conservatively calculated.

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How dangerous is excited delirium?

According to an ACEP (American College of Emergency Physicians) task force, the death rate is over 8%. [3]

Over 8% vs. much less than 0.01%.

Excited delirium is much more than 800 times more dangerous than droperidol.

Can we directly compare these numbers?

The first group includes a lot of patients being treated for nausea, vomiting, and pain in addition to some patients being treated for excited delirium.

The second group (excited delirium patients) is probably not even aware of any nausea, vomiting, or pain, but the excited delirium will kill a large number of these patients.

If the best way to prevent the death of these patients is to sedate them and the most appropriate sedative is droperidol, is there any reason to believe that the low death rate blamed on droperidol is even relevant? Is there any reason to believe that the high death rate attributed to excited delirium is due to anything other than a lack of appropriate sedation?

 

Death due to a lack of droperidol during excited delirium is much more than 800 times more likely than death due to droperidol.

 

Is anyone having trouble understanding that math?

Should anyone even hesitate to use droperidol to treat excited delirium?

The most appropriate sedative may be droperidol. I will discuss this in some more posts.

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Footnotes:

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[1] Droperidol–behind the black box warning.
Horowitz BZ, Bizovi K, Moreno R.
Acad Emerg Med. 2002 Jun;9(6):615-8. No abstract available.
PMID: 12045077 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from Academic Emergency Medicine

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[2] Portland, Oregon
Wikipedia
Article

As of the 2010 Census, it had a population of 583,776,[5] making it the 29th most populous city in the United States.

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[3] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.

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Filed Under: Excited Delirium, Heresy, Irrational Government Oversight, Pharmacology, Sedation

Droperidol – Black Box Warning

Tue, 22 Nov 2011 06:30:03 -0500 by
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Back in 2001, Akorn Pharmaceuticals sent out this warning letter.

Dear Health Care Professional,

Reports of deaths associated with QT prolongation and torsades de pointes in patients treated with doses of INAPSINE (droperidol) above, within and even below the approved range have prompted Akorn to revise sections of the prescribing information[1]

Oh, no! Droperidol is dangerous!

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The FDA (Food and Drug Administration) label now includes a Black Box Warning – the most serious warning short of being withdrawn from the market.

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WARNING

Cases of QT prolongation and/or torsades de pointes have been reported in patients receiving INAPSINE at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.[2]

 

Wait a second . . .

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

Droperidol is so dangerous that the dose doesn’t matter, or even what other drugs are given to patients, the only thing that matters is that there is a documented presence of droperidol.

I think Paracelsus would have a bit of a problem with that overly simplistic conclusion.

Clearly, droperidol is a witch!

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I am only interested in the use of droperidol for agitated delirium/excited delirium. There are many doctors who claim that droperidol is the most appropriate drug for this life threatening condition. I will discuss that in later posts, but when is it acceptable, according to the black box, to give droperidol for excited delirium?

Cases of QT prolongation and serious arrhythmias (e.g., torsades de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE to determine if a prolonged QT interval (i.e., QTc greater than 440 msec for males or 450 msec for females) is present. If there is a prolonged QT interval, INAPSINE should NOT be administered. For patients in whom the potential benefit of INAPSINE treatment is felt to outweigh the risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias.[2]

A 12 lead on a violent patient?

Even on a restrained violent patient, a 12 lead ECG is a waste of time. If Lewis Carroll were alive today, he would probably be hesitant to include such nonsense in one of books of nonsense, because who would believe something so preposterous?

The 12 lead ECG is appropriate for patients receiving droperidol for pain, or nausea, or vomiting, or some combination of these, but it is not appropriate for excited delirium.

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INDICATIONS AND USAGE
Droperidol injection is indicated to reduce the incidence of nausea and vomiting associated with surgical and diagnostic procedures.[2]

According to the label, droperidol is not indicated for excited delirium. How much does that change the black box warning?

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I will discuss droperidol some more in later posts.

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Footnotes:

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[1] Inapsine (droperidol) Dear Healthcare Professional Letter Dec 2001
FDA
Safety Information
Dear Healthcare Professional Letter

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[1] Inapsine (droperidol) Injection
[Taylor Pharmaceuticals]
DailyMed
FDA Label

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Filed Under: Excited Delirium, Heresy, Irrational Government Oversight, Pharmacology, Sedation

Making Things Worse With Spinal Immobilization – 1

Tue, 25 Oct 2011 12:59:04 -0400 by
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This video of spinal immobilization for leg pain was sent to me by Dan Crawford.

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[youtube]JpXerAwOapM[/youtube]

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This apparently begins 2 minutes after the motorcycle crash. Nice response time, but from there things only get worse. This guy looks as if he would rather go by taxi than by ambulance.

He has leg pain, so that does qualify as distracting pain for those who believe that spinal clearance criteria matter. So immobilizing him is following protocol.

That does not mean that there is any benefit to the patient.

Is there even any potential benefit to the patient?

That only depends on how imaginative you are in your What if the sky really is falling? scenarios. In the real world, there is no reason to believe that there is any benefit to this patient from being strapped to a board.

There is obvious harm.

Spinal clearance criteria assume that there is some benefit to immobilizing patients who actually have spinal injuries.

There is no good evidence to support this belief.

There is good evidence that the opposite is true.

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The OR for disability was higher for patients in the United States (all with spinal immobilization) after adjustment for the effect of all other independent variables (2.03; 95% CI 1.03-3.99; p = 0.04).[1]

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04).[1]

For a person with a spinal injury, being immobilized doubles the likelihood of being disabled.

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Back to the video. The injured guy is complaining of leg pain. We should address any life threatening injury first, but there do not appear to be any life threatening injuries to address.

What about the possibility of disability if he moves his neck?

I’ve seen bobble-head dolls that move their necks less than this immobilized collared patient.

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Image credit.

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The cervical collar does nothing to decrease movement of his neck. If anything, the irritation from the collar probably causes the patient to move his neck more than he would otherwise. Cervical collar = more neck movement. EMS in action.

When strapping the patient to the board, what benefit is there from putting a strap over the injured leg? This only causes more pain and therefore more movement.

At 4:12 of the video is this exchange –

Patient – It hurts!

EMT – I know it hurts. It’s going to hurt more if you keep moving.

Ouch!

What he means is –

Stop complaining about me hurting you. I am only hurting you out of a misguided attempt to protect myself from you and the theoretical lawyers who will sue me for NOT harming you.

Our only defense is ignorance.

Maybe it should be IMS in action. Ignorant Medical Services.

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When medicine is a bureaucracy, we are better off on our own.

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Footnotes:

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[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

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Filed Under: Heresy, Irrational Government Oversight, Spinal Immobilization

Should EMS Use Nasotracheal Intubation

Tue, 27 Sep 2011 06:30:16 -0400 by
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At EMT-Medical Student, Joe Paczkowski writes about nasotracheal intubation and independent judgement.

In case you haven’t heard yet, California is working towards officially introducing (pdf) (underlined is new legislation. . . . the following line from the proposed Critical Care Paramedic scope of practice struck me as odd.

“1. perform digital and nasotracheal intubation;” -pg 11

Wait, shouldn’t the scope of practice (albeit the basic scope of practice for all paramedics) be “intubation?”[1]

Welcome to California, where reality isn’t. Of course you could state the same thing about most other states.

Some of you are saying, Of course, nasotracheal intubation is dangerous, so restriction is appropriate. What if someone put the tube in the brain of a trauma patient?

What if the patient is not a trauma patient? Should the majority of our medical patients have their airway management choices limited because of the possibility of trauma, specifically a basilar skull fracture?

That would be silly.

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But, is a basilar skull fracture really an appropriate contraindication for nasotracheal intubation?

At the end of the day, we seek an answer to the question: “Is nasotracheal intubation contraindicated in the presence of severe facial or skull trauma?” and the answer is an unequivocal “No.” As with all procedures performed on patients in our emergency care systems, adherence to proper technique is essential. The progressive and systematic shift from BNTI to rapid sequence intubation will eventually render the question moot in all but a very small number of cases.[2]

Is this too vague?

the answer is an unequivocal “No.”

Unequivocal?

▸ adjective: admitting of no doubt or misunderstanding; having only one meaning or interpretation and leading to only one conclusion (“Unequivocal evidence”)
▸ adjective: clearly defined or formulated (“The plain and unequivocal language of the laws- R.B.Taney”)[3]

leading to only one conclusion

And that conclusion is that nasotracheal intubation is safe in the presence of severe facial or skull trauma as long as proper technique is used.

Of course, Dr. Ron Walls is only describing BNTI as performed by doctors.

Although properly conducted rapid sequence intubation is undoubtedly a superior technique for airway management in the acutely traumatized patient, BNTI continues to be used in many prehospital and hospital systems.[2]

At no point does Dr. Walls suggest that he is excluding EMS from his conclusion that BNTI is safe in the presence of severe facial or skull trauma.

Maybe this Dr. Walls just doesn’t understand airway management.

Amazon has several of his books, including the Manual of Emergency Airway Management, the manual for the National Emergency Airway Course. Go read the reviews (the only negative review is that the one reviewer did not think the images were clear enough).[4] What about research? Dr. Walls has dozens of airway research articles listed at PubMed.[5]

Why do I spend any time on who Dr. Walls is? Because this conclusion is not easy to demonstrate through research. There are not large numbers of BNTIs to study to demonstrate a clear complication level. He does mention that the only 2 papers documenting intracranial placement of a nasotracheal tube (BNTI in the brain) both indicated very poor technique.

it remains a mystery as to how the endotracheal tube could have been inserted with such a severely cephalad orientation when the technique of nasotracheal intubation requires insertion of the tube virtually perpendicular to the coronal plane of the patient.[2]

Cephalad means toward the top of the patient. ⇑
Perpendicular to the coronal plane means straight back. ⇒
You have to turn 90 degrees from one to the other. Up is wrong. Straight back is correct.

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For those who put a lot of faith in credentials, does it help that Dr. Walls is Chief of Emergency Medicine at Harvard?

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Furthermore, provided standard concerns are met like maintaining oxygenation, isn’t the goal of putting an appropriately sized tube into the slightly larger (and correct) tube, and the ensuing confirmation, more important than how that is achieved?[1]

Absolutely, but this is based on ignorance and fear, not on doing what is best for the patient.

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Why is the skill of direct laryngoscopy more important and sacred than the intervention of intubation when other skills can achieve the same goal? Furthermore, if paramedics cannot be trusted to pick the correct mechanical skill when providing the intervention of intubation, what does that say about paramedics, and why are paramedics not fighting back?[1]

There are plenty of paramedics who should not be allowed to intubate, but as long as we have EMS organizations that do not have competent and aggressive oversight from their medical director(s), this will continue.

Maybe we need to publicize bad airway management to ridicule the medical directors and the organizations that allow dangerous medics to attempt intubation.

For some, concern for their patients does not appear to be motivation enough.

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Footnotes:

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[1] Independent Judgement
EMT-Medical Student
Article.

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[2] Blind nasotracheal intubation in the presence of facial trauma–is it safe?
Walls RM.
J Emerg Med. 1997 Mar-Apr;15(2):243-4. No abstract available.
PMID: 9144068 [PubMed – indexed for MEDLINE]

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[3] Unequivocal
OneLook Dictionary Search
Definition

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[4] Manual of Emergency Airway Management
Amazon
Reviews

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[5] “Walls RM”[Author]
PubMed
Author Search – 79 results as of 9/27/2011

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Filed Under: Airway Management, Heresy, Intubation, Irrational Government Oversight

What Allows EMS to Strip a Patient of Civil Rights

Mon, 16 May 2011 06:37:33 -0400 by
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Happy Medic has a post about the guy in Florida who claims to have been kidnapped. Man Forced into Ambulance Ride, but Was He Kidnapped? I am more interested in the comments.

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An unfortunately common statement is made supporting one of the mindless approaches to informed consent.

presence of any intoxicants renders a patient unable to make transport decisions, that is, they can’t make their own choices.

Joe Paczkowski makes some good points about the silliness of this approach.

I take this a bit farther. I do take this to absurd extremes, but this is an example of an absurd extreme in depriving patients of informed consent.

If we are going to throw out a patient’s civil rights any time that any intoxicant is present, where does that end?

We certainly do not want anyone in EMS using their judgment to determine if the patient is impaired. We just want a rule that can be satisfied by a check box.

A. Intoxicant present.

B. No intoxicant present.

It does not matter if the person is the designated driver and has not consumed any of the intoxicant. An intoxicant is present, therefore the guilt by proximity rule is in effect and we can do whatever we want to the poor sucker.

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Then there is the problem of what is an intoxicant?

Cough medicines often contain alcohol.

Other medicines may contain alcohol as a preservative, but an alcohol is an alcohol, no matter how small.

Should we abduct everyone who has taken a medicine containing alcohol.

What about all of the other medicines that could be intoxicants?

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The better question is What is not an intoxicant?

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

Is there any poison that cannot be described as an intoxicant?

If everything (all things) is a poison, then the presence of anything renders a patient unable to make transport decisions, that is, they can’t make their own choices.

In other words, nobody has any right to make any independent decision once EMS shows up.

Power hungry?

Maybe.

Delusional?

Probably.

Dangerous?

Definitely.

Better able to make decisions for patients than the patients?

Absolutely not.

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All this to prevent EMS from making decisions based on an actual assessment of the patient.

This is very dangerous.

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Filed Under: Critical Judgment, Ethics, Heresy, Irrational Government Oversight
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