Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

NYFD EMS Loses $172 Million Suit

 

What does a $172 million loss mean?

1. Something very bad happened.

2. The jury probably thought that the defense sucked.

3. The amount paid will probably be much lower.

4. We continue to face the opposite of intermittent reinforcement – intermittent negative reinforcement – and we continue to respond unwisely.[1]

5. This will be the excuse for a lot of bad management decisions.

What happened?
 

Image credit.
 

 

A girl who suffered brain damage while waiting for an ambulance won a $172 million judgment against New York City on Wednesday when a Bronx jury determined that Fire Department paramedics could be held liable for giving her mother bad advice.[2]

 

Bad advice?

Wait for the paramedics during a cardiac arrest, rather than transport to the hospital. The medics took 20 minutes to arrive. The child has brain damage.

Was the advice bad?

This took place in 1998, when transport was considered to be important by a lot of people, because the hospital can do so much more of the things that improve outcomes than EMS can, except that the only two treatments that we know improve outcomes are continuous chest compressions and defibrillation. We knew that back then. The main thing we have learned since then is that interruptions of compressions, such as for transport, worsen outcomes.
 

Tiffany’s mother, Samantha Applewhite, called 911, and the city sent two Fire Department medics in a basic ambulance, without the advanced life support equipment she needed, the documents said. One medic began cardiopulmonary resuscitation while the other called for an ambulance with the proper equipment. The city paramedics also failed to bring oxygen or a defibrillator, evidence at trial showed.[2]

 

ALS (Advanced Life Support) equipment has never been shown to improve outcomes, unless the BLS (Basic Life Support) ambulances did not carry defibrillators (AEDs – Automated External Defibrillators). This states that they did not bring their defibrillator, which suggests that they carried and AED, but left it in the ambulance with the oxygen.

Should they have brought the AED to the scene? What did dispatch tell them was going on? NYFD EMS (New York Fire Department EMS) probably had a policy describing what equipment is required for certain calls. Cardiac arrest should require an AED (and oxygen and especially suction [because everyone seems to forget suction]), but was this dispatched as a cardiac arrest? The article does not tell us.

Suppose they do transport. One person is doing compressions, while the other is driving, or did they have more personnel on scene? We do not know.

Was the rhythm shockable? We don’t know. If they had brought the AED, it should have recorded the rhythm and would be able to answer that question, but according to the article, they did not.
 

Ms. Applewhite begged the city paramedics to take her daughter to Montefiore Hospital, a few minutes away, but they advised her to wait for the private ambulance with advanced life support equipment to arrive, the evidence showed.[1]

 

Does it really matter how far away the hospital is?

No.

What about immunity from liability?
 

A trial court at first dismissed the lawsuit, ruling the Applewhites had failed to prove the city had assumed a special affirmative duty to take care of the girl by responding to the call.

But the appellate division disagreed, saying the mother “justifiably relied” on the emergency responders, “who had taken control of the emergency situation and who elected to await” the private ambulance.[2]

 

Maybe we should be a lot better at sharing information and decisions with patients.

Maybe our protocols should be a lot better at encouraging us to share information and decisions with patients.

Did the crew do a bad job? Did they coerce decisions from the mother?

I don’t know.

A bad outcome is not proof of bad patient care.

How much do law suits improve our care?

Do law suits lead to improved patient care?

Do law suits lead to worse patient care?

Maybe a bit of both. Maybe a lot more harm than benefit? The evidence on law suits is that they are unpredictable

Footnotes:

[1] Intermittent reinforcement
Wikipedia
Article

[2] Jury Awards $172 Million in Verdict Against New York City
By James C. McKinley Jr.
May 29, 2014
NY Times
Article

.

Man Sues Rescuers Because of Unreasonable Expectations


 

Who encourages these unreasonable expectations? Frequently, we do.

Jamie Davis makes some important points about how we may be able to decrease these law suits. The story begins at 7:15 of the podcast, but listen to/watch the whole podcast.
 

MedicCast Episode 377
 

There is a commercial for an insurance company that has the insurance agents magically appearing at the side of the insured person and then, just as magically, transporting the insured person away from whatever danger the person had gotten himself into.

Should we be encouraging people to expect magic?

EMS person come help!
 


 

A number of cars went into Rock Creek on Sept. 12, when Dillon Road washed out. Roy Ortiz, who was among those rescued from their vehicles, could sue emergency responders claiming they did not rescue him quickly enough. ( David R. Jennings )[1]

 

Should EMS have shown up, disregarded procedures that are based on what happens when rescuers rush in and end up needing to be rescued?

We cannot help if we are in need of rescuing. Other rescuers cannot help if they are busy trying to rescue us.

No plan survives first contact intact, but that does not mean that we should rush in recklessly.

What would be the expectations in your community?

If your community is like mine, the expectation is –

EMS person come help!
 

The document claims first responders, . . . , failed to see Ortiz was trapped in the car, and that he ended up spending two hours submerged in Rock Creek until he was rescued.

In the document, Ferszt stated Ortiz survived “by pure grace.”[1]

 

He blames everyone else for getting him in to trouble, but when they get him out, he does not give his rescuers any credit. He sues all of the rescuers involved. Magical thinking is something we ought to discourage.

The article does not mention whether a backboard was used appropriately as an extrication device or whether the patient remained on the extrication board and it became a magic transportation board. Our patients are not the only one who use magical thinking.
 

Go watch/listen to the podcast.
 

Footnotes:

[1] Broomfield man rescued from Rock Creek during September floods could sue his rescuers
By Megan Quinn, Enterprise Staff Writer
Posted: 03/05/2014 11:52:53 AM MST UPDATED: 13 DAYS AGO
Denver Post
Article

.

Today in Kansas, Some Witchcraft is Melting

 

Why are more medical directors abandoning the mythology of their ancestors?

Because it has become almost impossible to ignore the absence of evidence of any improved outcomes and the abundant evidence of harm.

Today, in Kansas, Johnson County Med-Act threw a bucket of water on their Long Spine Board Witchcraft and Kansas was not hit by a tornado. Kansas is only being hit with snow.
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

But there must be some good reason to use backboards!
 

The backboard has been a component of field spinal immobilization despite lack of efficacy evidence.[1]

 

When there is no evidence of benefit, then it is not an insult to call a treatment witchcraft, dogma, alternative medicine,
 

Other than historical dogma and institutional EMS culture we can find no evidence-based reason to continue to use the Long Spine board as it currently exists in practice today. The evidence that does exist regarding the Long Spine board is overwhelmingly negative.[2]

 

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it. Well, we’ll know better next time. – Tom Stoppard
 

Will we know better next time? Our history does not give us reason to be optimistic about our ability to avoid this error.

We should have said, No.

We should have insisted on evidence.

The history of medicine is full of things that seemed like a good idea at the time.

Seemed like a good idea at the time is just the slightly more respectable form of conbining alcohol, a dangerous idea, and Watch this!
 

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool. – Richard Feynman.
 

We never seem to tire of fooling ourselves.

Why am I so critical of tPA for acute ischemic stroke, backboards for potential spinal injuries, furosemide for acute heart failure, ventilations for cardiac arrest, all drugs for cardiac arrest, . . . ?

Because all of these treatments have become standards of care, even though they have not been adequately studied.
 


Original picture image credit of tPA alternative medicine pusher Dr. Patrick Lyden.
 

We fool ourselves and harm our patients.

If you disagree, provide some evidence of any of these treatments producing improved outcomes that matter.

We should assume every treatment is harmful, until there is valid evidence that the treatment is safe and effective.
 

Just like blood-letting and every other superstition-based treatment.
 

The ambulance stretcher is in effect a padded backboard and, in combination with a cervical collar and straps to secure the patient in a supine position, provides appropriate spinal protection for patients with spinal injury.[1]

 

Why not just leave out the harmful device that cannot be demonstrated to improve outcomes and cannot even be demonstrated to be safe?

But someone will sue and everyone will lose everything!
 

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.[3]

 

It is the EMS Nuremberg Defense when we do it.
 

it may be common or customary for EMS providers to use a long spine board or collar, decisions of standard of care and negligence are not based on what is the best, reasonable care, not on what is usually done.66 [4]

 

This witch is only mostly dead, but we can’t stop now.
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

To read more on the topic –
 

For You Disciples of Spinal Immobilization…
… Bryan Bledsoe debunks your religion in the August issue of EMS World Magazine. And in that same issue, I take a dump on your altar. Our karma ran over your dogma.
August 1, 2013
by Kelly Grayson
A Day in the Life of an Ambulance Driver
Article
 

The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World
Article
 

Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article
 

In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
December 15, 2012
Article
 

Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning
Article
 

Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World
Article
 

A Change of the Dogma – If spinal immobilization helps only one . . .
Sun, 15 Jan 2012
Rogue Medic
Article
 

C-Spine Death Knell with Rogue Medic
Tue, 22 Jan 2013
Rogue Medic
Article
 

Plastic Snake Oil – EMS Spinal Immobilization
February 24, 2014
Life Under the lights
Article
 

Some podcasts –

A Change of the Dogma: If it helps only one? Episode 36
First Few Moments
January 12th, 2012
Dr. Laurie Romig, Russell Stine, Bob Lutz, Kyle David Bates, Kelly Grayson, and me.
Podcast
 

C-Spine Death Knell with Rogue Medic.
John Broyles and me.
January 19, 2013
1-Union-801
Podcast
 

Immobilization or not that is the question – EMS Garage Episode 156
Chris Montera, Scott Keir, Dr. Dave Ross, Sam Bradley, Patrick Lickiss, and me.
Feb. 24, 2012
EMS Garage
Podcast
 

And the video that only makes sense if you work in EMS –
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

Footnotes:

[1] EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed - as supplied by publisher]
 

[2] Johnson County EMS System Spinal Restriction Protocol 2014
Ryan C. Jacobsen MD, EMT-P, Johnson County EMS System Medical Director
Jacob Ruthsrom MD, Deputy EMS Medical Director
Theodore Barnett MD, Chair, Johnson County Medical Society EMS Physicians Committee
Johnson County EMS System Spinal Restriction Protocol 2014 in PDF format.

[3] Thank You for Smoking
Movie, based on the book by Christopher Buckley
Wikiquote
Quote page

[4] Board to Death – The state of prehospital spinal injury care in 2013
Rommie L. Duckworth, LP
Created: July 15, 2013
EMS World
Article

.

The Power of the ‘Death’ Chant will protect Us

 

In response to Up To, and Including, DEATH – The Anguish of Happy Medic is this comment from Garrett –
 

Upfront, I will admit that I’ve used similar phrasing and thought it stupid at the time. I think a big part of this comes not just from the litigious nature of US society, but in the uncertainly in the litigation process.

 

In other words, it is based on fear of the unknown.

How does that produce a reasonable approach?
 

I can just see it now: a minor cut which is treated with a 2×2 and tape. Done. However, a small clot gets jostled and makes its way to the brain leading to COMA and DEATH!

 

Please provide a real example of coma death because EMS was providing accurate informed consent/refusal information, rather than a prophesy of the death of the patient.

Otherwise, I assume that the example is an urban legend, made up to justify superstitious behavior.
 


Image credit.
 

On the witness stand:
“Did you let my patient know that they could have died without advanced medical treatment?”
“No – that’s highly unlikely and would only cause extra anxiety for the patient.”
“So unlikely that it … happened this time? Tell me, how do you explain that to her Poor, Orphaned children?”

 

When did that happen?

We should stick to Happy Medic‘s intelligent description of the possible complications.

If I am in court, my defense will be real, not a fairy tale.

But I used the magic incantation! This is not likely to convince a jury that you are a responsible person, but it may convince them that you are responsible for a bad outcome.

Why ignore real risks to the patient over some fixation on imaginary risks to you?

We are there to take care of the real patient, not our phobias.

That’s the problem – the odds of death occurring are pretty much the same as the odds of me having to testify about it.

Please provide evidence to support your claim.

Since this is just making up stories to scare kids sitting around the camp fire, we are just being silly.

We are ignoring reality and looking for a magic incantation to provide a cone of protection from lawyers.
 

This is how we lower standards in EMS.

In a decade, or two, I expect each EMS provider to be wearing a reflective vest, a helmet (with a flashing light on the helmet), and something that makes a sound like a backup alarm at all times. Maybe there will be a warning of Danger! EMS provider. Danger! along with the beeping. Someone could trip over an EMS provider!

As for refusals, they will be done by video link with a PA (Physician Assistant), because we have demonstrated that EMS is not capable of providing appropriate information for a person to make an informed decision about accepting/refusing care.

If our goal to avoid responsibility, we are too irresponsible to be allowed near patients.

.

Face Down Restraint into a Pillow


 

This picture just shows one image from one direction at one instant. A 12 lead ECG provides much more data and many more perspectives.

but . . . .

What it appears to show raises some questions.
 

P is for pillow – best part of paramedic school.

The pillow may not completely obstruct the airway, but this is probably not part of their protocols.
 

The patient’s hands have a bit of a cyanotic appearance, but the ears do not, so I suspect that the hands are discolored due to wrist restraints, not the pillow airway maneuver.

Glove use is fantastic, although there is no apparent need for gloves, but Scene safety, BSI then airway?

Why is the patient is restrained? Probably some charm deficit.

The side of the ambulance has Advanced Life (and maybe Support outside of the image) written on the side, so they should have access to chemical restraints – charm in a syringe.

Are any medications being used for chemical restraint?

Have any medications been used for chemical restraint?

Do protocols allow for any chemical restraint?
 

If you do not think that chemical restraint is important – to protect us and to protect the patient – listen to the EMS EduCast Excited Delirium episode.[1]

After listening to the podcast, imagine how this picture might be used to persuade a jury that you are guilty of murder or negligent homicide.
 

And this is a good time to remind everyone that K is for ketamine – the fastest IM (IntraMuscular) chemical restraint drug we have (after succinylcholine [suxamethonium in Commonwealth countries]). Even laryngospasm should not produce more of an airway problem and laryngospasm is manageable.[2]
 

 

Since one of the reasons for chemical restraint is to protect the patient, since in custody deaths may be die to excited delirium, and restraint asphyxia is one possible cause, why is the airway apparently not being addressed more aggressively?

Only one person is holding a violent patient down?

If one person is capable of restraining the patient, all by himself and with just one knee, is that a good sign?

On the plus side – at least he isn’t hog tied.

Does anyone want to guess at the patient’s heart rate?

Maybe that is the next thing to be done. We cannot tell, but all we can do is guess at the heart rate.
 

The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress.[3]

 

Sedation is my friend.

Sedation is the patient’s friend.

If I cannot handle an overly sedated person, I should not be working in EMS.

Over-sedation (under-stimulation) is a small, but easy to manage problem.

Under-sedation (over-stimulation) is a big problem complicated by a failure to understand the relative risks.

Maybe this is the rhythm –
 


 

Maybe this is the rhythm –
 


 

Maybe it is some other rhythm.

We don’t know.

We can’t tell.
 

It’s all about the little things.

Airway?

Breathing?

Circulation?

All appear to be mysteries for this patient.

Face down restraint is a bad idea.

Obstructing the airway is a bad idea – even if the patient is spitting.
 

How’s that airway?

P is for pillow!
 

Footnotes:

[1] Excited Delirium: Episode 72 EMS EduCast
EMS EduCast
September 23, 2010
Web page with link to podcast

While on the topic of podcasts, Dr. Scott Weingart provides the view of the emergency physician on chemical restraint.

Podcast 060 – On Human Bondage and the Art of the Chemical Takedown
by EMCRIT
November 13, 2011
Podcast and page with research links

[2] Laryngospasm, hypoxia, excited delirium, and ketamine – Part I
Thu, 21 Jun 2012
Rogue Medic
Article

[3] Excited delirium, restraints, and unexpected death: a review of pathogenesis.
Otahbachi M, Cevik C, Bagdure S, Nugent K.
Am J Forensic Med Pathol. 2010 Jun;31(2):107-12. Review.
PMID: 20190633 [PubMed - indexed for MEDLINE]
 

Unexpected deaths periodically occur in individuals held in police custody. These decedents usually have had significant physical exertion associated with violent and/or bizarre behavior, have been restrained by the police, and often have drug intoxication. Autopsy material from these cases may not provide a satisfactory explanation for the cause of death, and these deaths are then attributed to the excited delirium syndrome. The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress. This syndrome develops secondary to the toxic effects of high levels of catecholamines on either cardiac myocytes or on the coronary microvasculature. Patients with stress cardiomyopathy have unique ventricular morphology on echocardiograms and left ventricular angiography and have had normal coronary angiograms. People who die under unusual circumstances associated with high catecholamine levels have contraction bands in their myocardium. Consequently, the pathogenesis of the excited delirium syndrome could be evaluated by using echocardiograms in patients brought to the emergency centers, and by more careful assessment of the myocardium and coronary vessels at autopsy. Treatment should focus on prevention through the reduction of stress.

 

.

1 + 1 = 3 Sometimes – Pharmacology Fun

 

Does 1 + 1 always equal 3?

No.

If you do not give all of the medication in a syringe, vial, ampule, you are rounding off. This is where significant figures matter.[1]

1+1 does equal 3 for sufficiently high values of 1.

For those who do not understand this –

Consider a morphine syringe with a volume of 1 ml that contains a total dose of 10 mg.

We intend to give 1 mg.

Can we give exactly 1 mg?

I cannot.

We give an approximation of 1 mg.

What is considered to be 1 mg?
 


 

0.50001 mg should be rounded to 1 mg if we are not using decimal places. We probably do not have the precision to measure that accurately. If we did, we should use all of the significant digits in our documentation.

I am using this as an example to point out that with no decimal places 0.50001 mg is 1 mg.

We round off to the nearest significant digit.

If we are not using decimals, then 1.49999 mg is also 1 mg.

We will not be measuring that as carefully, either.

What we will be doing is trying to get close to 1 mg, but that could be 1.4 mg, or 1.3 mg, or 1.2 mg, or 1.1 mg, 0.9 mg, or 0.8 mg, or 0.7 mg, or 0.6 mg, or 0.5 mg.

How precisely can we measure the amount?

If we tend to underestimate the doses we are giving, we could be giving a couple of doses of 1.3 mg.

1.3 + 1.3 = 2.6, which is rounded to 3.

1 + 1 = 3.

If I gave 1.3 mg and 1.3 mg to the same patient, I gave 1 mg + 1 mg and the

1.4 can be rounded off to 1.

If there are no significant digits beyond the 1, then the value of 1 is anywhere from 0.6 to 1.4.

Add a couple of 1s that add up to 2.5, or greater, and you have 3.

1.2 + 1.3 = 2.5, which is rounded to 3.

When rounded to one significant digit, 1.2 = 1, 1.3 = 1, 1.4 = 1, and 2.5 = 3.

That is not what we generally think of when we think of 1 + 1 = 3.

We assume a precision that may not be there.
 


 

Error bars do not always result in excess.

We can end up with a small number due to wide error bars.

1+1 can equal 1 for sufficiently low values of 1.
 


 

So,

      how

            accurate

                  are

                        we?

Footnotes:

[1] Significant figures
Wikipedia
Article

.

Mentally Ill Patient Escapes EMS and Sues for Injuries

 

A Bronx woman is suing police and emergency medical services providers for injuries that occurred when she escaped custody and ended up leaping from a third story window.[1]

 

What is our liability for the behavior of patients with behavioral problems?

What is our authority to control the behavior of patients with behavioral problems?

 

She has filed suit against the city, the ambulance service, and the police officers for not properly supervising and restraining her. She argues that she was clearly mentally ill and should have been immobilized for her own protection.[2]

 

While the police and EMS probably could not have predicted that she would jump from the third floor of the building if she escaped, that does make a pretty good case for her being off her rocker not being responsible for her actions. On the other hand, the LD50 for jumping from a building is 4 floors, so she did not jump from high enough to expect to die.
 

It’s unclear whether the officers called for an ambulance because Rodriguez suffered injuries from damaging the car or because they recognized that she might be mentally ill.[2]

 

We, and the police, are called to protect everyone else from patient like this, but we are also called to protect the patients from themselves.

Kelly Grayson just posted on Facebook about the difference between a couple of behavioral problem patients.
 

What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?

Dealing with the *potentially* violent, hulking behemoth with a tenuous cheese-cracker interface, that’s what.[3]

 


Image credit.
 

If they all looked like this, it would be easy to treat aggressively and avoid problems, but that is not the way many will present – especially after being restrained by police.

The article does not provide many details, but that is the essence of the problem Kelly is describing – these patients are unpredictable unknowns. Many will sit calmly and cooperate at all times. Others are just waiting for the opportunity to do something creative, which is not good for us.

These patients are the known unknowns, but their future behaviors are the unknown unknown.[4] Often, they do not even know what they are going to do.
 

I started out by asking –

What is our liability for the behavior of patients with behavioral problems?

That may be up to a jury. We also have to live with the adverse outcomes we could have prevented.
 

The responders erred in “not restraining or immobilizing [Rodriguez] to ensure that she was not capable of hurting herself” and were negligent in “allowing her to leave the ambulance without fully assessing her mental state,” the complaint states. It cites a line in Article 9 of the New York Mental Hygiene laws, which notes the “Powers of Certain Peace Officers and Police Officers to take into custody any persons who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others.”[2]

 

Interesting assertions, but we do not have anywhere near enough information to know if they are true. In Pennsylvania, I do not have the authority to involuntarily commit patients.

My preference is to sedate patients. Safer for everyone involved, including the techs, nurses, PAs, and doctors at the hospital.

What is our authority to control the behavior of patients with behavioral problems?

That is often up to the medical director – state, county, service – and the ability of the medical director to understand how unstable these patients can be.
 

I think this is a cautionary tale for all of us. We need to be aware of what our patients are doing once we have them in our care and should not leave them unattended in the back of an ambulance especially when perhaps they are mentally disturbed. I want to make it clear that I’m not second guessing these EMTs.[1]

 

There is a lot to discuss.

Footnotes:

[1] Mentally Ill Patient Escapes EMS and Sues for Injuries
By podmedic
August 2, 2013
MedicCast
Article

Social Media, EMS and Public Health on Episode 344
By podmedic
July 29, 2013
MedicCast
Article with link to podcast.

[2] Woman Sues EMTs, Police for Letting Her Leave Ambulance and Jump Out Apartment Window
By Albert Samaha
Tue., Jul. 16 2013 at 10:30 AM
The Village Voice Blogs
Article

[3] What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?
Facebook
Kelly Grayson
Post

[4] Secretary Rumsfeld Press Conference at NATO Headquarters, Brussels, Belgium
Secretary of Defense Donald H. Rumsfeld
June 06, 2002
Transcript

Q: Regarding terrorism and weapons of mass destruction, you said something to the effect that the real situation is worse than the facts show. I wonder if you could tell us what is worse than is generally understood.

Rumsfeld: Sure. All of us in this business read intelligence information. And we read it daily and we think about it and it becomes, in our minds, essentially what exists. And that’s wrong. It is not what exists.

Now what is the message there? The message is that there are no “knowns.” There are things we know that we know. There are known unknowns. That is to say there are things that we now know we don’t know. But there are also unknown unknowns. There are things we do not know we don’t know. So when we do the best we can and we pull all this information together, and we then say well that’s basically what we see as the situation, that is really only the known knowns and the known unknowns. And each year, we discover a few more of those unknown unknowns.

It sounds like a riddle. It isn’t a riddle. It is a very serious, important matter.

There’s another way to phrase that and that is that the absence of evidence is not evidence of absence. It is basically saying the same thing in a different way. Simply because you do not have evidence that something exists does not mean that you have evidence that it doesn’t exist. And yet almost always, when we make our threat assessments, when we look at the world, we end up basing it on the first two pieces of that puzzle, rather than all three.

.

Should We Use Immobilization For Penetrating Injuries To The Neck – Comments at Paramedic’s Edge

ResearchBlogging.org
 

Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting? [1]

 

That is the entire question that was asked at The Paramedic’s Edge.

There are really several questions being asked.

1. If there is a minor injury, with no neurological deficits, is there any reason to immobilize the patient?

Many responded with variations of – We don’t know where the bullet is, so we must immobilize the patient.

That would make sense – if there were any reason to believe that backboards and/or collars do anything to keep bullets from moving, or if they did anything to protect the spine from bullet injuries.

2. If there are life-threatening injuries to the neck, how will application of a collar help?

3. If the airway is severely compromised, will a collar and board make things better?

4. Why do we think that a simple splint is the correct treatment for a potential injury to a complex series of bones and joints?

I do not know the position of ITLS (International Trauma Life Support Courses), but PHTLS (PreHospital Trauma Life Support) has made their position clear on this.

 

Present prehospital management of penetrating injuries to the head, neck, and torso is based on the premise that the spine is injured until proven otherwise and full immobilization will prevent further propagation of any injury. A review of the trauma literature does not support this practice.[2]

 

What is the policy of PHTLS on immobilization for penetrating injuries?

 

PHTLS Recommendations

  • There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.
  • There are no data to support routine spine immobilization in patients with isolated penetrating trauma to the cranium.
  • Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.
  • Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.[2]

 

This is very interesting.

There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.

What about the absence of data to support routine spine immobilization in patients with penetrating blunt trauma to the neck or torso or anywhere else?

Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.

But immobilization is more important than life when it is for blunt trauma?

Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.

Where is this little evidence of benefit?

The authors spend some time describing the different levels of evidence, but where is the evidence that spinal cord injury due to blunt trauma is prevented, or lessened, with backboards and EMS collars?

Here is the only place the authors appear to give a reference supporting the use of backboards and EMS collars for blunt trauma.
 

Although blunt spinal column injuries will occasionally produce unstable vertebral injuries, which may result in subsequent neurologic propagation if not managed appropriately in the field, this has not been demonstrated to be the case with penetrating trauma.1 [2]

 

Does the referenced paper actually support the use of backboards and EMS collars for blunt trauma?
 

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.[3]

 

The patients got worse after cervical immobilization?
 

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.[3]

 

Neurologic deterioration during the application of cervical immobilization is not evidence that immobilization with backboards and EMS collars improves outcomes.
 

In the other patient with ankylosing spondylitis the injury progressed from C5 to C3 ASIA A CSCI during traction and immobilization. The third patient had an incomplete central cord injury (C4 ASIA D) after a fall. In the emergency department, the patient was extremely agitated and would not remain recumbent while immobilized in a rigid cervical collar. The injury quickly ascended to a C4 complete CSCI with the patient’s selfmanipulation of his neck. The fourth patient was an obese woman with a C8 ASIA A severe central cord injury after a fall whose injury ascended to a C5 ASIA A level after halo vest placement because her body habitus precluded adequate immobilization.[3]

 

The best than can be said about immobilization for blunt trauma based on this paper is –

We need to figure out what we are doing.

The status quo is more of a status FUBAR.

The paper is from a regional spine center, so these are not a bunch of Yahoos.

Back to the original question – Should we be using backboards and EMS collars on patients with penetrating trauma?

No.

The more important question is Should we be using backboards and EMS collars on patients with any trauma?

I don’t see any evidence to justify this intervention.

Footnotes:

[1] Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting?
The Paramedic’s Edge
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[2] Prehospital spine immobilization for penetrating trauma–review and recommendations from the Prehospital Trauma Life Support Executive Committee.
Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE.
J Trauma. 2011 Sep;71(3):763-9; discussion 769-70. doi: 10.1097/TA.0b013e3182255cb9. Review. No abstract available.
PMID: 21909006 [PubMed - indexed for MEDLINE]

[3] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed - indexed for MEDLINE]

Stuke, L., Pons, P., Guy, J., Chapleau, W., Butler, F., & McSwain, N. (2011). Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee The Journal of Trauma: Injury, Infection, and Critical Care, 71 (3), 763-770 DOI: 10.1097/TA.0b013e3182255cb9

Harrop, J., Sharan, A., Vaccaro, A., & Przybylski, G. (2001). The Cause of Neurologic Deterioration After Acute Cervical Spinal Cord Injury Spine, 26 (4), 340-346 DOI: 10.1097/00007632-200102150-00008

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