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

- Rogue Medic

Is placebo better than aggressive medical treatment for patients NOT having a heart attack?

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

Is cardiac catheterization placebo better than aggressive medical treatment for patients not having a heart attack?

No.
 

The answer is not really different from before. This should not be surprising for anyone who pays attention to EBM (Evidence-Based Medicine). We should all pay attention to EBM, because it is the best way to find out what works.

Many routine treatments are not beneficial to patients, but are considered to be standards of care. We continue to give these treatments out of unreasonable optimism, a fear of litigation, or fear of criticism for not following orders. The difference between the banality of evil and the banality of incompetence does not appear to be significant in any way that matters.

PCI (Percutaneous Coronary Intervention) treatment does not add any benefit – unless you are having a heart attack.

The placebo group received sham PCI in addition to optimized medical treatment. this did not provide any benefit over actual PCI in addition to optimized medical treatment. The patients in the placebo group received all of the same medications that the patients in the PCI group received.

Why is this news today?

A recent article in The Lancet is encouraging snake oil salesmen and snake oil saleswomen to claim that it shows the miracle healing power of placebos, but this is not true.

Apparently, Big Placebo (the multi-billion dollar alternative medicine industry) is trying to use this to promote their scams (homeopathy, acupuncture, Reiki, naturopathy, prayer, . . . ).

Big Placebo seems to think that this study shows that placebo is better than medical treatment. A placebo is an inactive intervention that is undetectable when compared with the active treatment. The placebo group received the same aggressive medications that the treatment group received.
 

All patients were pretreated with dual antiplatelet therapy. In both groups, the duration of dual antiplatelet therapy was the same and continued until the fial (unblinding) visit. Coronary angiography was done via a radial or femoral arterial approach with auditory isolation achieved by placing over-the-ear headphones playing music on the patient throughout the procedure.[1]

 

What is new about this?

A much larger study a decade ago showed that aggressive medical therapy was as good as PCI and aggressive medical therapy. The difference is the use of sham PCI to create a placebo group for comparison, rather than using a No PCI group for comparison.
 

CONCLUSIONS:
As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.
[2]

 

Compare that with the conclusion (interpretation) of the new paper.
 

INTERPRETATION:
In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy.
[1]

 

The unfortunate outcome is that we will have fewer hospitals providing PCI, so patients with heart attacks (STEMI – ST segment Elevation Myocardial Infarctions) may have to wait longer for emergency PCI, which really does improve outcomes.
 

What other Standards Of Care are NOT supported by valid evidence?

Amiodarone is effective for cardiac arrest, whether unwitnessed, witnessed, or witnessed by EMS.

Kayexalate (Sodium Polystyrene) is a good treatment for hyperkalemia. Anything that causes diarrhea will lower your potassium level, but that does not make it a good treatment, unless you are in an austere environment (in other words – not in a real hospital).

Amiodarone is effective for VT (Ventricular Tachycardia).

Backboards are effective to protect against spinal injury while transporting patients.

Blood-letting is effective for anything except hemochromatosis (and some rare disorders).

More paramedics are better for the patient.

Prehospital intravenous lines save lives.

IV fluid saves lives in hemorrhagic shock.

Oxygen should be given to everyone having a heart attack.

The Golden Hour is important.

Driving fast saves lives. For only some rare conditions, it probably does – and that depends on traffic.

Flying people to the hospital saves lives. Again, for only some rare conditions, it probably does – and that depends on traffic and distance.

Tourniquets are dangerous. As with anything else, if used inappropriately, they are dangerous, but tourniquets save lives.

Prehospital intubation saves lives.

Ventilation in cardiac arrest improves outcomes (other than for respiratory causes of cardiac arrest, which are easy to identify).

Epinephrine improves outcomes in cardiac arrest. It does produce a pulse more often, but at what cost to the long-term survival of the patient and the patient’s brain? PARAMEDIC2 should help us to identify which patients benefit from epinephrine, since it is clear that many patients are harmed by epinephrine in cardiac arrest. If we limit treatment to patients reasonably expected to benefit from the treatment, we can improve long-term survival.

And there are many more.

Footnotes:

[1] Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial.
Al-Lamee R, Thompson D, Dehbi HM, Sen S, Tang K, Davies J, Keeble T, Mielewczik M, Kaprielian R, Malik IS, Nijjer SS, Petraco R, Cook C, Ahmad Y, Howard J, Baker C, Sharp A, Gerber R, Talwar S, Assomull R, Mayet J, Wensel R, Collier D, Shun-Shin M, Thom SA, Davies JE, Francis DP; ORBITA investigators.
Lancet. 2017 Nov 1. pii: S0140-6736(17)32714-9. doi: 10.1016/S0140-6736(17)32714-9. [Epub ahead of print]
PMID: 29103656

[2] Optimal medical therapy with or without PCI for stable coronary disease.
Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group.
N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26.
PMID: 17387127

Free Full Text from N Engl J Med.

.

Is mixing Mountain Dew and racing fuel a new trend?

 

Is Dewshine (mixing Mountain Dew and racing fuel) what all the cool kids are doing?

Will it make me cool?
 
DewAndFuel_1453815893474_30645234_ver1.0_640_480
Image credit.
 

According to one article, one recent case of four teens getting together to drink this bad idea of a cocktail may be just the tip of some sort of epidemic iceberg –
 

And that’s just one state, and the just the cases that have been reported.[1]

 

While that is correct, it is also much more than an exaggeration of the facts.
 

She (Tennessee Poison Center Medical Director Donna Seger) says this is the first time she has seen this type of poisoning. The four cases are the only ones reported in Tennessee, and Seger is not aware of any cases in other states.[2]

 

Nationally, there was only one methanol poisoning fatality reported among teens aged 13-19 by the American Association of Poison Control Centers’ National Poison Data System in 2014, the most recent year data is available.[3]

 

Rudy Eugene was shot while eating the face of another person. This was supposed to be the beginning of a wave of attacks by abusers of bath salts, but . . .
 

Lab tests detected only marijuana in the system of a Florida man shot while chewing another man’s face, the medical examiner said Wednesday, ruling out other street drugs including the components typically found in the stimulants known as bath salts.[4]

 

We are still waiting for the bath salts zombie apocalypse.

What did I write about it at the time?[5]
 

This appears to be the first time that mixing Mountain Dew and racing fuel has been reported, so is it the tip of an iceberg or just an example of click bait?

Why mix racing fuel with anything and drink it? Racing fuel contains methanol, a type of alcohol that is much more poisonous to humans than ethanol (the type of alcohol that is sold for to be drunk by humans).

Why drink methanol, rather than ethanol? The dead were both 16 years old. Suppose that you are 16 and you want alcohol. Ethanol is not legally available. You probably do not know much about chemistry or toxicology. You may know that methanol is a form of alcohol. You skip right by due diligence. You draw the wrong conclusion. Four of you are hospitalized, but only two survive.

Teens tend to choose to experiment with marijuana, rather than methanol. Both are much easier to obtain than ethanol, but the dangers of marijuana are more likely to be legal, while the dangers of methanol are more likely to be medical.[6]

Mixing products containing methanol with Mountain Dew may be new, but the use of methanol for intoxication is not new, accidental ingestion of methanol by smaller children is also not new, and inhalation of products containing methanol (such as huffing carburetor cleaner) appears to be more even more common than ingestion of methanol.

The hospital treatment for methanol toxicity is hemodialysis and fomepizole (Antizol) and/or 10% ethanol. The EMS treatment is supportive care.[7]

Patients with initial blood sugar measurements above 140 mg/dL appear to be much more likely to die, which means that we should be especially vigilant with these patients, not that those with blood sugar measurements below 140 mg/dL will not die.[8]

Breath alcohol analyzers may mistake methanol for ethanol, so do not conclude that a positive breath test means drunk, rather than methanol poisoning.[9],[10],[11]

Don’t drink, or inhale, methanol. Methanol is neither fashionable nor healthy.

I hope you don’t come here for fashion advice, but I have provided valid evidence for my health advice.

Footnotes:

[1] Kids Are Dying From Drinking Racing Fuel Because For Fuck’s Sake, Don’t Drink Racing Fuel
Jason Torchinsky
Yesterday (01/27/2016?) 10:00pm
Article

[2] 2 teens die after drinking racing fuel, soda – The teens evidently thought they could drink methanol, which is extremely toxic, as a substitute for ethanol
EMS1.com
Yesterday (01/27/2016?) at 12:56 PM
AP
Article

[3] No ‘dewshine’ trend, Tennessee officials say
Anita Wadhwani
11:42 p.m. CST January 27, 2016
The Tennessean
Article

[4] Tests find only marijuana in face-chewer’s system
Boston Globe
Suzette Laboy
June 28, 2012
AP
Article

[5] Police fatally shot a naked man chewing on the face of another naked man
Tue, 29 May 2012
Rogue Medic
Article

 

Will I be surprised if the lab results show drugs in his system? No.

Will I be surprised if the lab results do not show drugs in his system? No.

There are other causes of excited delirium. Drugs are most common, so a wise bet would be to bet on there being drugs in his system, but enough patients experience excited delirium without drugs that we would be behaving inappropriately if we did not consider other causes of altered mental status, such as hypoglycemia, head injury, either a clot or a bleed in the brain, or any of the other possible causes of excited delirium.

We do not know what caused this.

 

[6] Cannabis-related hospitalizations: unexpected serious events identified through hospital databases.
Jouanjus E, Leymarie F, Tubery M, Lapeyre-Mestre M.
Br J Clin Pharmacol. 2011 May;71(5):758-65. doi: 10.1111/j.1365-2125.2010.03897.x.
PMID: 21204913

Free Full Text from PubMed Central
 

We estimated that in 2007 the incidence of cannabis-related AEs in the Midi-Pyrenees region ranged from 1.2 per 1000 regular cannabis users (95% confidence interval (CI) 0.7, 1.6) to 3.2 (95% CI 2.5, 3.9).

 

[7] American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning.
Barceloux DG, Bond GR, Krenzelok EP, Cooper H, Vale JA; American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning.
J Toxicol Clin Toxicol. 2002;40(4):415-46. Review.
PMID: 12216995
 

CONCLUSION:
The management of methanol poisoning includes standard supportive care, the correction of metabolic acidosis, the administration of folinic acid, the provision of an antidote to inhibit the metabolism of methanol to formate, and selective hemodialysis to correct severe metabolic abnormalities and to enhance methanol and formate elimination. Although both ethanol and fomepizole are effective, fomepizole is the preferred antidote for methanol poisoning.

 

[8] Hyperglycemia is a strong prognostic factor of lethality in methanol poisoning.
Sanaei-Zadeh H, Esfeh SK, Zamani N, Jamshidi F, Shadnia S.
J Med Toxicol. 2011 Sep;7(3):189-94. doi: 10.1007/s13181-011-0142-x.
PMID: 21336799

Free Full Text from PubMed Central
 

Considering the cutoff level of 140 mg/dL for blood glucose and using logistic regression analysis, and adjusting according to the admission data with significant statistical difference in the two study groups, the odds ratio for hyperglycemia as a risk factor for death was 6.5 (95% confidence interval = 1.59-26.4). Our study showed that blood glucose levels were high in methanol poisoning and even higher in those who died in comparison with the survivors. Therefore, hyperglycemia might be a new prognostic factor in methanol poisoning, but further studies are needed to determine whether controlling hyperglycemia has therapeutic consequences.

 

Don’t make the mistake of treating the blood sugar in the belief that you are improving outcomes. There is no evidence to support that hypothesis. In the absence of evidence of benefit or safety, we should expect that treating the blood sugar would be more harmful than beneficial.

[9] Breath alcohol analyzer mistakes methanol poisoning for alcohol intoxication.
Caravati EM, Anderson KT.
Ann Emerg Med. 2010 Feb;55(2):198-200. doi: 10.1016/j.annemergmed.2009.07.021. Epub 2009 Oct 14.
PMID: 19833410
 

A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL,

 

[10] Methanol ingestion: prevention of toxic sequelae after massive ingestion.
Lushine KA, Harris CR, Holger JS.
J Emerg Med. 2003 May;24(4):433-6.
PMID: 12745047

[11] Observations on the specificity of breath-alcohol analyzers used for clinical and medicolegal purposes.
Jones AW.
J Forensic Sci. 1989 Jul;34(4):842-7.
PMID: 2760587
 

Three different methods of alcohol analysis are reported: semiconductor sensing (Alcotest 7310), electrochemical fuel cell (Alcolmeter SM-1), and infrared (IR) absorptiometry (IR Intoximeter 3000). Methanol could not be distinguished from ethanol with any of these breath-test instruments. When nonspecific techniques of ethanol analysis are used, the results must be considered with caution when interfering substances expelled in breath cannot be excluded.

 

.

The Most Misleading Medical News of 2014

 

The media are horrible at reporting medical stories, or any other science stories. They regularly report that some recent study shows a cure for cancer, as if cancer is just one illness. What were the media worst at covering this year?

Ebola.
 

They said Ebola was easy to catch, that illegal immigrants may be carrying the virus across the southern border, that it was all part of a government or corporate conspiracy.[1]

 


 
Image credit.
 

The part of that quote that affects EMS is the claim that ebola is easy to catch.

Ebola does require isolation precautions – and we are not good at using, or understanding, isolation precautions. Just watch your coworkers putting everything on. Even worse, watch them take them off. Much worse, watch yourself in a mirror.

We are far from good at using isolation precautions.
 

Ebola spreads through direct contact with bodily fluids such as blood, vomit and diarrhea. Coughing and sneezing are not symptoms.

Airborne viruses, meanwhile, have the ability to travel large distances propelled by a sneeze or cough. In those cases, people breathe in virus particles without even realizing it. Scientists say there is no evidence Ebola works like that.[1]

 

Back in August Dr. Anthony Fauci described how we should expect this outbreak to progress. Looking back, we should have ignored the news media and reread this article.
 

Although the regional threat of Ebola in West Africa looms large, the chance that the virus will establish a foothold in the United States or another high-resource country remains extremely small. Although global air transit could, and most likely will, allow an infected, asymptomatic person to board a plane and unknowingly carry Ebola virus to a higher-income country, containment should be readily achievable.[2]

 

Dr. Fauci predicted that in August (print edition September 18). His prediction was more accurate than the media reported it as it happened a month later (a week later than the print edition).

Perhaps we should pay as much attention to what Dr. Fauci wrote about our optimism in favor of inadequately studied treatments.
 

Among the therapies in development is a “cocktail” of humanized-mouse antibodies (“ZMapp”), which has shown promise in nonhuman primates. ZMapp was administered to two U.S. citizens who were recently evacuated from Liberia to Atlanta, and both patients have had clinical improvement. However, it is not clear whether ZMapp led to the recovery, and with only two cases, conclusions regarding its efficacy should be withheld.[2]

 

Perspective is important and we should apply it more often.
 

For example –
 

1. Restricting travel from Ebola-outbreak countries to the United States is the best way to prevent the spread of Ebola to our shores.

FALSE

There is no evidence that restricting travel will prevent spread of Ebola to the U.S. Exposed and infected persons might reach our country undetected and thereby escape essential public health monitoring, which could worsen transmission risk. The key to controlling this epidemic is to stop Ebola at its source in West Africa.[3]

 

If we won’t take the risk of caring for these patients, we should not interfere with those who do understand appropriate treatment and do treat these patients.

Footnotes:

[1] 2014 Lie of the Year: Exaggerations about Ebola
Politifact
Tampa Bay Times
By Angie Drobnic Holan, Aaron Sharockman
Monday, December 15th, 2014 at 3:08 p.m.
Article
 

PolitiFact editors choose the Lie of the Year, in part, based on how broadly a myth or falsehood infiltrates conventional thinking. In 2013, it was the promise made by President Barack Obama and other Democrats that “If you like your health care plan, you can keep it.”

 

[2] Ebola–underscoring the global disparities in health care resources.
Fauci AS.
N Engl J Med. 2014 Sep 18;371(12):1084-6. doi: 10.1056/NEJMp1409494. Epub 2014 Aug 13. No abstract available.
PMID: 25119491 [PubMed – indexed for MEDLINE]

Free Full Text from New England Journal of Medicine.

[3] Ten Key “Facts” About Ebola: True or False?
Kristi L. Koenig, MD, FACEP, FIFEM
November 7, 2014
JournalWatch Emergency Medicine from NEJM
Article

.

Would a Taser Have Made a Difference in the Outcome?


Investigators on the scene of a deadly shooting by San Mateo County Sheriff’s deputies. (CBS)
 

What kind of response should EMS have when a person is reported to be acting violently and carrying a knife? We stage around the corner, or a few blocks away.

What about the police? They need to try to disarm the person and control things without anyone getting hurt, but that is not always possible.

According to the various articles in the news, two deputies arrived and confronted Yanira Serrano-Garcia, an 18 year old woman who had not been taking her medication.
 

Two deputies responded to the Moonridge Housing Complex at Miramontes Point Road, east of Highway 1, where the woman lived, Rosenblatt said. The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[1]

 

However, another article states that the police were provided with different information.
 

The information received by emergency personnel who responded to the incident was that the woman was acting erratically and violently and had a knife. The woman’s family asked her to put the knife down, and when she didn’t comply, family members called the fire department for medical assistance, Rosenblatt said.[2]

 

Another states –
 

The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[3]

 

No recordings of 911 tapes are quoted, but the information that was provided to the responding deputies might change how they approached her.

Should the family have tried to get unarmed EMS to respond to care for a violent armed patient? No.

Were they just trying to protect her? Probably.

What happened?

The two deputies confronted Yanira Serrano-Garcia and shot her at least once. She was pronounced dead on scene.
 

“I don’t know why they couldn’t have done better things instead of getting a bullet through her and trying to shoot her,” said Saul Miramontes, Serrano-Garcia’s cousin. “She was kind of sick — you know, at least they could have Tasered her or at least tackled her.”[1]

 

Tackling someone who has a knife is a very bad idea for everyone. It had Darwin award written all over it.

A Taser may be appropriate, but it should involve at least two armed people, one with the Taser and one backup with a firearm that is drawn and aimed at the person to be taken down. It is not considered appropriate to just drive up and use the Taser without making some attempt to get the person to put down the knife voluntarily.

One problem with the use of the Taser is that if you are close enough to use the Taser, and the person with the knife lunges toward you, you may be stabbed without being able to hit the person with the Taser.
 

[youtube]9igSoJHEdUo[/youtube]
 

Did either deputy have a Taser out? We do not know from any of the articles.

Why did only one deputy shoot? It may be that they were not positioned well and when the deputy who did shoot moved, he moved into the line of fire of the other deputy. Maybe the other deputy froze. Maybe the other deputy did not think that a shot was the appropriate response for the circumstances. There can be many other reasons. We do not know.

Was there some other reason that the deputy felt the need to shoot quickly (the shot is reported to have taken place within a minute of arriving on scene)?

There is another bit of information that has not been included in the more recent news reports. This is from a cached copy of one article.
 

Dyanna Ruiz, 12, said she had been walking to a friend’s house when she saw the deputy running away from a woman who had her arm raised and was chasing him with what appeared to be a knife.

“I saw the girl running at him with something in her hands,” Dyanna said. “I didn’t know what was happening. I was really scared about what to do.”

The deputy saw Dyanna, stopped and yelled at Serrano-Garcia, the girl said. When Serrano-Garcia kept coming at him, the deputy fired, Dyanna said.[4]

 

The deputies may have had a plan for controlling the situation that may have seemed reasonable with just the two of them and the person with the knife at risk. With a child/adolescent also at risk, the plan may fall apart. That is pure speculation on my part, but I have a lot of experience with plans falling apart, as does anyone who deals with emergencies.

Why was the statement of this witness removed from more recent versions of the article? I do not know.

Will a Taser always work? No. Sometimes, in spite of reasonable attempts to do everything right and protect lives, bad outcomes still happen.

Footnotes:

[1] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie eivie@mercurynews.com
Posted: 06/04/2014 05:56:45 AM PD Updated: 6 Days ago
Contra Costa Times News
Article

[2] Officer Who Killed Woman Felt His Life Was in Danger
Joan Dentler (BCN)
Friday June 06, 2014 – 09:51:00 AM
Page One
The Berkely Daily Planet
Article

[3] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie
eivie@mercurynews.com
Posted: 06/04/2014 05:56:22 AM PDT Updated: 6 Days ago
San Jose Mercury News
Article

[4] Woman, 18, shot dead by San Mateo sheriff’s deputy
Henry K. Lee and Kurtis Alexander
Updated 5:07 pm, Wednesday, June 4, 2014
SFGate.com
Cached version of the article. It is a snapshot of the page as it appeared on Jun 5, 2014 00:40:18 GMT.

Woman, 18, wielding knife shot dead by San Mateo deputy
Henry K. Lee and Kurtis Alexander
Updated 8:46 pm, Friday, June 6, 2014
Article at the same link, but when I last checked at 18:00 6/10/2014, the part I quoted was not in the article.

.

EMS Needs to Grow a Pair – EMS Garage Video Podcast


 

Like procainamide, the EMS Garage is back.

Do we need to grow a pair, or do we just need to grow up and think critically?
 

Go listen to the podcast or watch the videocast.
 

Response times only seem to matter for patients in cardiac arrest, but that does not stop people from making a big deal out of response times – even criticizing excellent response times. This was discussed (at 29:50 of the podcast) –
 

Holyoke city leaders are sounding the alarm about delayed ambulance response times in the Paper City. This comes after an ABC40 investigation last February showed troubling ambulance response times in Springfield.[1]

 

What about those EMS response times in Springfield, Massachusetts? The response times were well within the specifications of their contract, but people were complaining. How did we in EMS handle that?

Suppose that I buy a car, then have a few more kids, and then complain that the car does not do what I want it to do – grow to meet my desires. People would call my complaint ridiculous, because that complaint is ridiculous.

Brendan Monahan of WGGB News Channel 40 began an investigation into the response times of the ambulance company in Springfield. The response times are actually very good, but why let that get in the way of a story? There is dihydrogen monoxide in the water! Don’t drink it!

I wouldn’t expect Brendan Monahan and WGGB News Channel 40 to make a big deal about a car that doesn’t expand to meet the desires of its owner.

Why not?

There are many people who understand enough about cars to realize that expecting a car to expand to meet my desires is ridiculous.

EMS is much less understood. EMS contracts can be very complicated..

The contract for Springfield does not require Springfield to pay the ambulance company to staff extra ambulances, so that imaginary response times can be met.

If Springfield wanted better response times, they could have specified those requirements in their RFP (Request For Proposals). Maybe they did and nobody was willing to supply an RFP that would meet more stringent response times. That is a problem with unrealistic expectations. People will tell you that the expectations are unreasonable, they will try to fulfill the expectations and fail, or they will lie.

The contract requires 95% of life threatening dispatches have a response time of less than 10 minutes. That is what Springfield and the ambulance company agreed to.

The investigation should be – What are the motives of the people investigating an ambulance company just before contract negotiations?

What is the ambulance company being investigated for?

For providing much better service than required by their contract.

This is one place where EMS needs to be very aggressive in correcting the misinformation being presented

Now there is criticism of the same ambulance company for the same thing – much better response times than required.
 

“We do realize that they do have a bottom line and their vested interest is a lot different than what the Holyoke Fire Department is set to do,” Menwer said.[1]

 

Menwer? Fire Commissioner Yasser Menwer.

It seems that the fire department wants the ambulance company’s jobs, but they can’t find anything wrong with the ambulance company, so they are making things up.

What was the result of the WGGB News Channel 40 investigation in Springfield?

The city council unanimously renewed the contract of the ambulance company.

In other words, everybody on the city council realized that the WGGB News Channel 40 investigation was nonsense.

What will happen this time?
 

Currently, 911 calls go to police, then an AMR dispatch center and if the dispatcher thinks a fire engine could help the call, they ask for one. Holyoke Mayor Alex Morse and the fire commission say before a new contract is signed, they want firefighters dispatching AMR ambulances.[1]

 

The fire department will be competing for the contract, but they should be the ones who dispatch the ambulances, so that they can affect the already excellent response times? Would it be a surprise if response times became worse with a competitor influencing response times?
 

“We will then be able to properly track using GPS that’s already installed in their ambulances to know where they are at at all times,” Menwer said.[1]

 

Of course, Fire Commissioner Yasser Menwer will also make sure that the ambulance company has the ability to track fire trucks at all times, because he is interested in being fair and not hiding anything. Right?
 

“They shouldn’t refuse it because if they are where they are supposed to be it should be a ‘no brainer’ and that is why I’m challenging them,” Menwer said.[1]

 

The article does not mention response times, but Scott Kier did. The ambulance company’s response times are excellent.

We can expect that ABC40 will continue to hide that information, because it does not support their story.

Much more important than response times is the care provided by EMS.

Who care how quick the response is, if the people responding are not great at providing emergency medical care?
 


Image credit.
 

Fast – Cheap – Good.

There is no criticism of the cost or quality of patient care.

Does Fire Commissioner Yasser Menwer only care about fast?
 

Go listen to the podcast or watch the videocast.
 

Go read what Scott Kier wrote about the WGGB News Channel 40 investigation of the ambulance company for much better than required response times in Springfield.

Emergency Response
February 28, 2013
EMS in the New Decade
Article

A Chat with Brendan Monahan
March 1, 2013
EMS in the New Decade
Article

An Open Letter to the City of Springfield
March 24, 2013
EMS in the New Decade
Article

5 More Years for Springfield!
May 17, 2013
EMS in the New Decade
Article

Footnotes:

[1] Ambulance Delays Lead To Proposed Changes In Holyoke
August 22nd, 2013
by Brendan Monahan?
WGGB News Channel 40
Cached article

The link is to the cached article because the article is no longer available on the WGGB web site.

Why was it removed from public view?

Has it just been moved to another link? This does not appear to be the case.

Here is the original WGGB News Channel 40 link – http://www.wggb.com/2013/08/22/ambulance-delays-lead-to-proposed-changes-in-holyoke/

.

Paramedic refused to carry dying girl over safety fears

There is a horrible story in the Telegraph on the inquest of a 14 year old girl. Here is the sub-title of the story –

Shannon Powell, a paramedic, refused to carry a dying 14-year-old girl from a cross-country race course because of health and safety fears for herself, a coroner heard.[1]

The biggest problem with the story might be that a paramedic refused to carry a patient, or refused to treat a patient.

The problem is that the story is so badly written that there is no way to tell what really happened. For example –

Shannon Powell is probably not the name of the paramedic. Other parts of the story claim that Shannon Powell is the name of the dead little girl. Which is it? We don’t know. Maybe they are both named Shannon Powell, but that kind of coincidence ought to have been mentioned by the reporter.

The life-saver declined to take part in the “chaotic” rescue mission to save Shannon Powell, saying she was worried about her own back, a witness told the inquest.[1]

That seems bad, but the names have changed. What was “chaotic” about the rescue mission? What kind of back problems does the life-saver have? What is it about this patient – apparently a 14 year old runner, probably not a big patient – that is a danger to the life-saver, that is not a danger on every other call. Won’t most of those calls be for much bigger patients?

Shannon had collapsed in the mud and was foaming at the mouth in a violent fit during a cross-country run but, due to a series of gaffes, life-savers only reached her almost an hour later, the coroner heard.[1]

Was the death of the little girl due to one person, out of many people on scene, not carrying the patient, but not due to a delay in care of almost an hour?

What was the cause of death?

We don’t know, but this is an inquest. One of the purposes of an inquest is to determine the cause of death.

Catherine Sheppard, a marshal, told the hearing that the response was so infuriating she almost attacked the rescue worker.[1]

This is someone who has her priorities so mixed up that she is considering attacking EMS. That would be a felony where I work. A lot of people become infuriated for a lot of reasons. Did Catherine Sheppard (assuming the reporter got the name right) not offer to help? Is it beneath her to help? Was there something unsafe about the scene that prevented the marshal from helping?

“I believe that I walked away at that point. I really was very close to being either verbally or physically abusive to the LAS attendant.[1]

The marshal has responsibility for the children participating in the race, but becomes so upset that she runs away from her responsibilities? Again, this depends on the accuracy of the reporting.

The helper, who is also a history teacher, told how she saw the teenage girl fall wide-eyed and rigid, to the floor.

However, rather than call 999 the assistant said she followed athletics’ club policy and told an organiser who sent a first-aider to the scene.[1]

A child having a possible seizure (a life threatening condition – she did die) and club policy is more important than the health life of the patient?

It was only on their arrival, five minutes later, that she said she called ambulance personnel trained to keep Shannon alive.

However, paramedics only arrived at 12.50pm, almost an hour after Shannon collapsed, she believed.

The inquest in Barnet heard how gates at the park were locked and organisers assumed paramedics would have the keys.[1]

They lock the gates, but assume that the paramedics have the keys.

Is there any good reason not to send someone to the gate to make sure that EMS gets to the right place?

Any reason at all?

Did they send GPS coordinates to the ambulance?

Why think that everyone else knows where you are, just because you know where you are?

There was also confusion about where the park was, which entrance they should use and where the teenager was lying freezing on the muddy track with Mrs Sheppard’s fleece over her, coroner Andrew Walker said.[1]

Mrs. Sheppard would not move the little girl off of the reportedly freezing ground, although she did put her fleece over her. An hour of freezing? Were they trying for therapeutic hypothermia?

Maps of the Middlesex Cross Country Championships’ course contained errors delaying medical help as it was rushed to the scene where the talented youngster collapsed in a fit in Trent Parl, Enfield, north London.[1]

Yet, the headline is about the paramedic refusing to carry the little girl.

Mrs Sheppard told how even as the two paramedics, one male one female, were led up to Shannon by another marshal they walked slowly behind the race assistant.[1]

EMS should never run, unless we are running away from something. Maybe Mrs. Sheppard should have called 999 earlier, if she thought time was important, and should have sent someone to guide EMS to their location, and should have moved the little girl off of the freezing ground. That is assuming that the information has been reported with any accuracy.

“The paramedic at the time was saying ‘we can’t carry her because its health and safety and we might fall over’.

“They didn’t come up with any solution at all. Because of the time we had been there I think I can say this for all of us – we all looked at each other as if to say ‘**** health and safety’.”[1]

That according to first-aider Robbie Proctor. Also –

He said: “One of the stewards made a comment and said ‘how come it took you so long?’

“The comment that came out was ‘this is a low priority call’ or ‘a green call’. That was the male paramedic.”[1]

If the call was dispatched as low priority, maybe that is because the information given to the 999 dispatcher downplayed the seriousness of the little dead girl’s medical condition.

The first-aider described how Shannon was being carried by six people from the course on a trolley bed when she sat bolt upright screaming.[1]

Carrying her required 6 people, but they expected the 2 paramedics to carry her by themselves. Was there more to the condition of the grounds than is being mentioned?

He said: “The last time I put the trolley bed down – and I’m being very honest with the parents here because it haunts me – Shannon sat up and screamed ‘let me go’.”[1]

How many times did these 6 people have to put the trolley bed down and rest? Yet, they expected the 2 paramedics to carry the stretcher?

He told how paramedics believed she was having a fit and gave her the painkiller diazepam when “everything seemed to go haywire.”[1]

Diazepam (Valium) is not a painkiller.

“everything seemed to go haywire.”

Is that supposed to mean that she was given the anti-seizure medicine diazepam because she was having a seizure? Or is it supposed to suggest that giving a seizure patient (fitting patient) anti-seizure medication is inappropriate according to the medical expertise of someone who leaves the patient on the freezing ground for an hour.

The first-aider, who owns the company, Spectrum, brought in to provide medical help at the event, said the paramedics questioned his qualifications and began asking bystanders if they knew how to provide lifesaving CPR.[1]

The owner of the company that was contracted to provide the wonderful medical care (as reported in the article) to the dead girl is trying to put the blame on someone else.

The race marshal appears to be doing the same thing.

Am I a bit jaded in doubting their objectivity?

Shannon was taken from Chase Farm Hospital, in Enfield, where she died of sudden death syndrome on January 18, this year.[1]

Was any CPR indicated at any time on scene or were the paramedics just giving Mr. Proctor a hard time? It is impossible to tell from the story.

The article finishes with –

The inquest continues.[1]

I would love to see the full transcript of the inquest. This is so badly reported that I have no idea how much of what is written in the article is true. The reporter does not appear to have a clue about how to report a story.

Footnotes:

[1] Paramedic refused to carry dying girl over safety fears
Telegraph
1:50PM GMT 08 Dec 2011
Article

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Ryanair Charges for Sandwich Used to Treat Passenger for Cardiac Arrest

With a title like this – Ryanair Charges for Sandwich Used to Treat Passenger for Cardiac Arrest – how could I resist adding my perspective? 😈


Picture credit.[2]

Although European flight attendants are mandated to know first aid, one family says that when a relative went into cardiac arrest during a flight, the baffled flight crew didn’t deliver life-saving CPR, but instead delivered a sandwich and soda…and charged for it.[1]

But did the sandwich work?

Once the Swedish man appeared to stabilize, the flight crew presented the family the bill for the soda and sandwich, she said, according to the paper.[1]

Clear evidence that sandwiches resuscitate people from cardiac arrest.

Now the only question is, What kind of sandwich?

OK, that is not the only question. It would be irresponsible to ignore the toppings. Was it toasted? On rye? Or was it the soda? And what about pickles, coleslaw, and other side dishes?

None of the articles I found provided information about the type of sandwich. Apparently, it is a secret recipe. So, what’s in your Lazarus Sandwich? Probably haggis. If epinephrine is not successful, we should skip amiodarone and go straight for the haggis. The only problems are the appropriate preparation and storage.

What else does the article say?

“They said he had low blood pressure and gave him a sandwich and a soda,” she told the paper. “And they made sure he paid for it.”[1]

Cardiac arrest is the ultimate in low blood pressure, but did anyone actually measure a blood pressure? There is no information in the article to suggest how they came to the conclusion he had low blood pressure? When I first read the article, I assumed it read low blood sugar, because a sandwich and maybe a non-diet soda would be considered for hypoglycemia (low blood sugar), but not for hypotension (low blood pressure).

All of those confusing medical words can make it difficult to determine what is going on. Sugar. Pressure. Blood. Low. 🙄

What clues do they provide about the actual medical condition?

Appleton is a nurse and apparently put her medical skills to use. She slapped her stepfather on the chest, which got him breathing again, she told the paper.

A precordial thump?[3] [4]

Not just a precordial thump, but it appears to be a successful seated precordial thump.

Why send a reporter with an understanding of medicine, when we can just write down what the daughter (Slugger) and the PR guy from the airline say? Or did an editor cut out all of that boring medical stuff?

“In line with procedures for such cases, a Ryanair cabin crew suggested a diversion to the nearest airport or to have an ambulance on standby on arrival at [Stockholm] so that the passenger could receive medical treatment,” he said.

McNamara went on to say that the offer to divert the flight was turned down by Appleton. However, Appleton says there wasn’t an ambulance waiting for her family upon their arrival in Stockholm, meaning they had to drive Jonsson to the airport themselves.[5]

The family refused to have the plane divert to the closest hospital, because it is just a cardiac arrest. Why treat that as if it is an emergency? On the other hand, what would be the difference in time to a hospital. Did the family request that an ambulance meet them, or did they just assume that if they refused to divert there would be an ambulance called automatically? Maybe the crew thought that it was just an attempt to get out of paying for something – Dine and Dash on an airplane.

The most important thing about the article – no people with any kind of medical knowledge appear to have been contacted for any information about what happened. 😳

Footnotes:

[1] Ryanair Charges for Sandwich Used to Treat Passenger for Cardiac Arrest
Published August 04, 2011
FoxNews.com
Article

[2] Budget airline Ryanair allegedly gave cardiac arrest victim Per-Erik Jonsson a sandwich instead of CPR
news.com.au
August 05, 2011 12:15pm
Article

[3] Precordial Thump – For Asystole?
Rogue Medic
Article

[4] Precordial Thump – For Asystole? – ECG Strips
Rogue Medic
Article

[5] Man suffering cardiac arrest on plane offered sandwich
Digital Journal
Graeme McNaughton
Article

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Avoid the Stigma of Premature Press Release



Photo credit

There is so much wrong with this press release, that it might be used as an example of what to avoid, when making statements about medical treatment.

January 12, 2011 – CIRC Trial Concludes Successfully[1]

This raises a question.

What does concludes successfully mean?

Back in 2006, there was ASPIRE,[2] which was stopped early due to dramatically worse outcomes for the patients treated with the AutoPulse®. The great news is that this time the AutoPulse® did not appear to result in dramatically worse outcomes. Yay! Yippee! Yahoo!

Yawn.

What do the results show?

We don’t have the results, yet. They haven’t even completed entering the data. All we have is something that did not get kicked out of the study for being too dangerous for use on dead people, which is what happened last time.[2]

Double yawn.

What comes after the title, even before the dateline?

INVESTOR CONTACT:

A. Ernest Whiton
Chief Financial Officer
ZOLL Medical Corporation
+1 (978) 421-9655

MEDIA CONTACT:

Diane Egan
ZOLL Medical Corporation
+1 (978) 421-9637
degan@zoll.com
[1]

This is not a medical press release, but something to get investors to buy more stock. That is part of what the investor relations department does. They are also able to provide a lot of information about the company.

This press release is being sent around to medical people as evidence that the AutoPulse® is the answer to the prayers of someone who just found her father collapsed, unresponsive and pulseless, in the living room.

So, what does the press release say about the performance of the AutoPulse®?

First, there is a sub-headline –

CIRC (CIRCULATION IMPROVING RESUSCITATION CARE)TRIAL CONCLUDES SUCCESSFULLY
First Large Scale Resuscitation Trial to Reach a Statistically Significant Result
[1]

More yawning.

January 12, 2011─CHELMSFORD, MASS.–ZOLL Medical Corporation (Nasdaq GS: ZOLL), a manufacturer of medical devices and related software solutions, announced today the successful conclusion of the ZOLL-sponsored CIRC trial. The trial’s Data Safety Monitoring Board (DSMB) closed enrollment when an analysis of the data showed the load-distributing band (AutoPulse® Non-invasive Cardiac Support Pump) to be equivalent to manual chest compressions.[1]

As good as CPR?

WTF?

There is something else that is as good as CPR. It is called CPR.

Zoll, manufacturer of AutoPulse, has given the county 72 of the $15,000 machines. Each band is disposable and costs $125 to replace. Hillsborough Fire Rescue also gets $149,000 annually for training and personnel costs associated with the trial.[3]

“On behalf of all the CIRC investigators, we are excited about the conclusion of enrollment and look forward to presenting complete results later this fall. . . . ” said Dr. Wik.[1]

They have concluded enrollment and will not be able to present their results for at least 9 months.

This is kind of like a couple that is trying to conceive celebrating the birth of their child just because they had intercourse. This is more than a little premature.

Dr. Wik added, “EMS around the world will look at the CIRC result as positive for AutoPulse. They know how difficult it is to perform manual CPR on a regular basis. My gut feeling is that the CIRC results will increase AutoPulse interest.”[1]

OK. CPR is not easy, but does that mean that we should spend $15,000 for each ambulance and $125 for each patient, just to make things a little bit easier?

PS Be wary of scientists offering gut feelings.

I try not to think with my gut. If I’m serious about understanding the world, thinking with anything besides my brain, as tempting as that might be, is likely to get me into trouble. Really, it’s okay to reserve judgment until the evidence is in.[4]

So why are we having a press release when the evidence is not in?

Richard A. Packer, CEO of ZOLL commented, “We are pleased to see the CIRC trial successfully concluded and the AutoPulse equivalent to a Class I AHA recommended therapy. While we would have liked to have seen a superior outcome, this finding unequivocally confirms the AutoPulse’s role in improving resuscitation.”[1]

To clarify what he means. CPR is a Class I recommendation –

Generally for Class I recommendations, high-level prospective studies support the action or therapy, and the benefit substantially outweighs the potential for harm.[5]

The AutoPulse® does not appear to be statistically worse than CPR, but this is premature, since they haven’t even finished entering the results into their database.

Mr. Packer continued, “It will be some time before the complete picture unfolds as there are still some 400 patients that have yet to be entered into the database, and numerous sub-analyses to be completed. We look forward to publication of the trial’s details.[1]

We look forward to actual results, but right now we are celebrating not being kicked out of the study early as a danger to dead patients.

We believe the CIRC trial is the largest privately funded trial ever undertaken in the field of resuscitation. We introduced this technology to the market on the strength of earlier studies and with FDA clearance.”[1]

We have spent so much on this that we can’t image anything less than success.

“The AutoPulse is currently included in the just released 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science as a Class IIb intervention with a recommendation for additional studies,” he added. Mr. Packer concluded, “This outcome, had it been available, could have improved the recommendation related to the AutoPulse in the Guidelines.[1]

That still depends on what the outcome of this study actually is. We won’t know what the results are for about a year.

Suppose this expensive device is as good as CPR.

Does being as good as CPR mean that the AutoPulse® deserves a Class I recommendation?

Absolutely not.

Then there is this from the standard disclaimer required for investment advice – remember that this press release is not medical advice, this is investment advice

Because such statements are subject to risks and uncertainties, actual results may differ materially from those expressed or implied by such forward-looking statements.[1]

In other words, wait for the research to be published, otherwise you may end up just another example of PPR (Premature Press Release).

Does anyone remember Cold Fusion?[6]

There may be something useful to be gained from work on cold fusion, but the stigma as a result of the exaggerated claims made at a press conference continues to discourage many scientists from working on cold fusion.

Misleading expectations can produce a very negative backlash.

I will write more about the original study (ASPIRE[2]) that found the AutoPulse® to be unsafe for use on dead people.

I also wrote Extensive injury after use of a mechanical cardiopulmonary resuscitation device.

This patient treated with the AutoPulse® was not a trauma patient, but the injuries produced are examples of severe multi-system trauma. Why wouldn’t the patient get better when treated with a device that produces these injuries?

Maybe waiting for good evidence is a very good idea.

Footnotes:

[1] January 12, 2011 – CIRC Trial Concludes Successfully
Zoll
Press Release

[2] Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.
Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN Jr, Van Ottingham L, Olsufka M, Pennington S, White LJ, Yahn S, Husar J, Morris MF, Cobb LA.
JAMA. 2006 Jun 14;295(22):2620-8.
PMID: 16772625 [PubMed – indexed for MEDLINE]

Free Full Text from JAMA with link to Free Full Text PDF

[3] Life or death question: Is man or machine better at CPR?
Rebecca Catalanello, Times staff writer
In Print: Saturday, January 10, 2009
St. Petersburg Times
Article

[4] The Demon-Haunted World : Science as a Candle in the Dark (1995)
by Carl Sagan
Ch. 11 : The Dragon in My Garage, p. 180
Quote from Wikiquote

[5] AHA Classes of Recommendations and Levels of Evidence
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 2: Evidence Evaluation and Management of Potential or Perceived Conflicts of Interest
Medications for Arrest Rhythms
Development of the AHA Guidelines
Free Full Text Article with links to Free Full Text PDF download

[6] Cold Fusion
Wikipedia
Article

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