You are here: Home / Archives for MedicCast

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

- Rogue Medic

Improving Cardiac Arrest Survival, and Provider Performance – MedicCast Episode 259

Wed, 16 Mar 2011 06:30:07 -0400 by
–

At EMS Today, I appeared on the MedicCast with Jamie Davis, Tom Bouthillet, and Dana Yost.

Improving Cardiac Arrest Survival, and Provider Performance Episode 259.

–

Some of the topics –

Can we improve what we do if we do not measure what we do?

What can we do to improve our resuscitation rates?

What can we do to improve the quality of our resuscitation attempts?

What can we do to make our codes run more smoothly?

Should waveform capnography be mandatory?

If we want to improve quality, should we treat what we want to improve as a sentinel event?

–

Who is Dana Yost and why was he there?

Dana is from Redmond Fire Department in King County, Washington. This is where you have to go to find the highest resuscitation rates in the US, so who better to talk about improving resuscitation rates?

–

Tom challenged me to compete against the automated compression devices, but I forgot all about it. There was a lot going on and I did not visit the booths to check out any of the equipment. I was just talking with people between episodes of the podcasts I appeared on.

I am not John Henry, but I do not think that we should assume that machines perform CPR better than well trained people. These devices may perform compressions more consistently, but is the quality consistently good?

One of the problems with these devices is that they make it easier to justify transporting patients with CPR in progress, rather than doing what is right for the patient.

Go listen to the podcast.

.

Filed Under: Heresy, MedicCast

Live Blogging from EMS Today and at EMS Office Hours

Fri, 04 Mar 2011 06:30:53 -0500 by

–

I will be appearing on the MedicCast (10 AM) and the EMS Research (2 PM) podcasts today at EMS Today. The webpage with the link to listen live is EMS Today Live Podcasts.

If you don’t see the listen live button on their page, click here.

Thursday, March 3, 2011
3:00 pm: JEMScast Pre-Show Spotlight
5:00 pm: EMS Garage and MedicCast Kickoff Show
6:00 pm: EMS EduCast

Friday March 4, 2011
10:00 am: MedicCast
11:00 am: JEMScast
12:00 pm: EMS EduCast
1:00 pm: First Few Moments
2:00 pm: EMS Research
3:00 pm: EMS Garage

Saturday March 5, 2011
9:30 am: GenMed
10:30 am: JEMScast
11:30 am: EMS Garage and MedicCast Wrap Show

Times are Eastern Time.

–

–

This is a turning into a busy live podcasting week for me. I was also Taking A Peek At The Latest EMS White Paper on EMS Office Hours a couple of nights ago. Along with Jim and Josh from WANTYNU, we discussed some initial thoughts on the latest EMS White Paper. This is the podcast I mentioned in Are You Ready For Real EMS Change. Jim writes –

It was just a peek since a short 45 minutes just isn’t enough time to even really begin to delve into this document.

Just a peek is certainly the case. I hope and expect that this will be covered on other podcasts and that Jim will cover this in more depth in more podcasts.

Go listen to some of the other topics on these podcasts and some of the podcasts I will not be on.

.

Filed Under: EMS Office Hours, EMS Research Podcast, Heresy, MedicCast

Josie Dimon was the Scapegoat of Public Safety Director Michael Huss in the Death of Curtis Mitchell

Wed, 16 Feb 2011 06:30:17 -0500 by
–

In the movie The Dark Knight, there is a wonderful quote.

Bruce Wayne (Batman): We all know how much you like to say: “I told you so.”
Alfred: On that day, Master Wayne, even I won’t want to… probably.

–

Well, the defenders of Public Safety Director Michael Huss and those trying to scapegoat Paramedic Josie Dimon are not Batman.

To those who claimed that Public Safety Director Michael Huss was not making a scapegoat out of Josie Dimon to protect himself –

I told you so.

To those who claimed that Josie Dimon was responsible for the death of Curtis Mitchell because she was having a bad day, used some inappropriate language on a recorded phone line, and did not disregard orders from dispatch to be reassigned to another call on a day when all ambulances were working non-stop in very unpleasant conditions –

I told you so.

I am not a fan of saying I told you so, but I think it is a well deserved response to the arrogance and incompetence displayed by Public Safety Director Michael Huss and Mayor Luke Ravenstahl.

–

“In concluding that Dimon should be returned to work, the arbitrator found that despite that a major winter snowstorm had been forecast, the mayor of the city and the director of public safety Huss had gone to a resort about 50 miles away to celebrate the mayor’s 30th birthday and only discharged Dimon two months after the incident, following media criticism of the city’s failure to deal well with the snow emergency,” the union said.[1]

–

Were any plows used to assist crews in getting to Mr. Mitchell or getting Mr. Mitchell to an ambulance?

No.

Were any 4 wheel drive vehicles used to assist crews in getting to Mr. Mitchell or getting Mr. Mitchell to an ambulance?

No.

Were ambulance crews expected to ignore the orders of dispatch to go to the next call, but also transport the next patient while digging to Curtis Mitchell?

Yes.

Were ambulance crews expected to take themselves out of service for hours and endanger other patients to make up for the lack of planning of Public Safety Director Michael Huss and Mayor Luke Ravenstahl?

Yes.

Would a few 4 wheel drive vehicles have made it possible to transport Curtis Mitchell to the hospital the first time he called?

Yes.

Would a few 4 wheel drive vehicles have dramatically cut the waiting time of patients that was sometimes 10 hours long?

Yes.

Was this a failure on the part of Josie Dimon?

No.

Was this a failure on the part of Public Safety Director Michael Huss and Mayor Luke Ravenstahl?

Yes.

Is this an excellent case study of how not to prepare for a disaster?

Yes.

Is this an excellent case study of how not to deal with a preventable death?

Yes.

–

We all had ample time to prepare.

– Cecil County Director of Emergency Services Richard Brooks.[2]

This is from an excellent podcast covering this same storm. The podcast describes how to prepare for potential disasters. –

–

Thank you to The Social Medic for bringing this to my attention.

See also Common Sense Prevails from Too Old To Work, Too Young To Retire.

–

For the I told you so part. I have also written about this here –

City may discipline EMS workers – Public Safety Director Michael Huss – 02/18/10

Where Was Public Safety Director Michael Huss during the Death of Curtis Mitchell? – 02/20/10

Public Safety Director Michael Huss and Others Continue to Blame the Medics for the Snow – 02/22/10

The Need for Evidence Before Assessing Guilt – 02/24/10

Anonymous Comments on the Death of Curtis Mitchell – 03/02/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part I – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part II – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part III – 03/22/10

What kind of punishment do you get for NOT disobeying dispatch? – 03/23/10

The Scapegoats Will Be Punished – 03/23/10

Pittsburgh – Punishment, not Planning – 03/24/10

Josie Dimon was the Scapegoat of Public Safety Director Michael Huss in the Death of Curtis Mitchell – 02/16/11

Michael Huss – Pittsburgh EMS Only Needs Someone Good With a Shovel – 02/16/11

Links updated 02/16/11.

–

Footnotes:

–

[1] Union says reinstated paramedic was a scapegoat
Tuesday, February 15, 2011
By Joe Smydo
Pittsburgh Post-Gazette
Article

–

[2] From Mitigation Journal –

EMS Under the Bus in Pittsburgh – 02/28/10

And in the Mitigation Journal podcast –

MJ156: Winter Storms: Interview with Mr. Richard Brooks, Director Cecil County MD, Emergency Services – 02/23/10

From the MedicCast –

Snow Storm 2010 Response and Episode 208 of the MedicCast – 02/28/10

.

Filed Under: Critical Judgment, Ethics, Fraud, Heresy, MedicCast, Mitigation Journal

More Podcasting on the 2010 AHA Guidelines – Part I

Mon, 01 Nov 2010 07:17:09 -0400 by
–
At the MedicCast Jamie Davis (the host of MedicCast) and Tom Bouthillet (of Prehospital 12 Lead ECG) followed up their interview of Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the American Heart Association (Heart.org/cpr) that is posted in Emergency Cardiovascular Care 2010 Update Interview, with a podcast of the conversation that Jamie and Tom had after the end of the show with Dr. Kleinman posted at CPR ECC 2010 Updates with Tom Bouthillet and Episode 243. There is video, which includes PowerPoints of important supplemental information.

They start out discussing the field termination recommendations. I do not see termination guidelines as new. I see this as just an escalation of what they have been encouraging. Here is what the AHA included in the 2005 guidelines.

Terminating a Resuscitation in a BLS Out-of-Hospital System
Rescuers who start BLS should continue until one of the following occurs:

  • Restoration of effective, spontaneous circulation and ventilation.
  • Care is transferred to a more senior-level emergency medical professional who may determine that the patient is unresponsive to the resuscitation attempt.
  • Reliable criteria indicating irreversible death are present.
  • The rescuer is unable to continue because of exhaustion or the presence of dangerous environmental hazards or because continuation of resuscitative efforts places other lives in jeopardy.
  • A valid DNAR order is presented to rescuers.

Defibrillators are required standard equipment on ambulances in most states, so the absence of a “shockable” rhythm on the defibrillator after an adequate trial of CPR can be the key criterion for withdrawing BLS in the absence of timely arrival of ACLS. State or local EMS authorities must develop protocols for initiation and withdrawal of BLS in areas where ACLS is not rapidly available or may be significantly delayed. Local circumstances, resources, and risk to rescuers should be considered.[1]

The first field pronouncement I was involved in was in 1991. Found down. Asystole. 45 minute code. The On Line Medical Command doctor agreed that the patient would not benefit from transport.

The current termination criteria are just a logical continuation of what the AHA was already encouraging.

This is not a surprising new position.

What did the AHA have to say about the ethics of mega-decibel high speed relocation of dead people?

Transport of Patients in Cardiac Arrest
If an EMS system does not allow nonphysicians to pronounce death and stop resuscitative efforts, personnel may be forced to transport to the hospital a deceased victim of cardiac arrest who proved to be refractory to proper BLS/ACLS care. Such an action is unethical.

This situation creates the following dilemma: if carefully executed BLS and ACLS treatment protocols fail in the out-of-hospital setting, then how could the same treatment succeed in the emergency department? A number of studies have consistently observed that <1% of patients transported with continuing CPR survive to hospital discharge.

Delayed or token efforts, a so-called "slow-code" (knowingly providing ineffective resuscitation), that appear to provide CPR and ACLS are inappropriate. This practice compromises the ethical integrity of healthcare providers and undermines the physician-patient/nurse-patient relationship.

Many EMS systems authorize the termination of a resuscitation attempt in the out-of-hospital setting. Protocols for pronouncement of death and appropriate transport of the body by non-EMS vehicles should be established. EMS personnel must be trained to focus on dealing sensitively with family and friends.[2]

Again, this is what the 2005 guidelines state –

If an EMS system does not allow nonphysicians to pronounce death and stop resuscitative efforts, personnel may be forced to transport to the hospital a deceased victim of cardiac arrest who proved to be refractory to proper BLS/ACLS care.

Such an action is unethical.

How can medical directors justify ignoring the 2005 AHA guidelines?

Everybody dead gets epi is a guideline that medical directors refuse to violate.

Compassionate care is a guideline medical directors refuse to obey.

Why?

Both are from the same guidelines.

–

Maybe we think that transport is more important than quality of compressions.

That is wrong.

Maybe we think that we can provide high quality compressions during transport.

That is a lie.

–

A lack of training in grief counselling is not a reason to play high speed musical chairs with dead people.

A lack of training in grief counselling is a reason to initiate training in grief counselling.

For medical directors to require that EMS force high cost, high risk, high decibel, high speed transport of family members, rather than provide compassionate care is not defensible.

Go listen to the podcast. There is more there that I will write about.

–

Footnotes:

–

[1] Terminating a Resuscitation in a BLS Out-of-Hospital System
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 2: Ethical Issues
Issues Related to Out-of-Hospital Resuscitation
Free Full Text Article with links to Free Full Text PDF download

–

[2] Transport of Patients in Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 2: Ethical Issues
Issues Related to Out-of-Hospital Resuscitation
Free Full Text Article with links to Free Full Text PDF download

.

Filed Under: 2010 AHA Guidelines, ACLS, Critical Judgment, Ethics, Fraud, Heresy, MedicCast

Podcasting on the 2010 AHA Guidelines

Wed, 27 Oct 2010 06:27:54 -0400 by


Also posted over at Paramedicine 101. Go check out the rest of the excellent material there.

–

There are three podcasts discussing the new AHA (American Heart Association) guidelines. I am not on any of them, but I strongly encourage you to listen to all three of these. Each focuses on different changes, so there is minimal repetition from listening to all three.

–

No One Ever Died of Cardiac Arrest: EMS Garage Episode 108

The audio is a bit rough, but the discussion is excellent. If you want to know what is important, all of these podcasts contribute important information to our understanding of the new AHA (American Heart Association) guidelines.

–

Emergency Cardiovascular Care 2010 Update Interview

A great interview by Jamie Davis Tom Bouthillet and with Dr. Monica Kleinman, a representative of the AHA.

–

EMCrit Podcast 34 – 2010 ACLS Guidelines

The shortest podcast, and the first 3 minutes are a discussion of questions related to the previous podcast on stroke.

This is supplemented by a detailed summary of the new guidelines created by Dr. Weingart. If you want one document to read to cover all of the new AHA guidelines, this one is very well done.

–

Updated 02/08/11 to reflect the new blog address for EMCrit. http://emcrit.org/ The old links did not redirect appropriately.

.

Filed Under: 2010 AHA Guidelines, ACLS, Critical Judgment, EMCrit, EMS Garage, Heresy, MedicCast, Paramedicine 101

The Blind Leading the Assessment

Mon, 25 Oct 2010 22:14:48 -0400 by
–

Jamie Davis, the Podmedic, writes GCS, It’s Fine Until Your Patient Has No Eyes!. Go read it.

Jamie makes excellent points about assessment being important in the context of everything else. In the case of vital signs, GCS (Glasgow Coma Score – the criteria are included at the bottom), and other numerical assessments, the change is what is important – not the absolute number.

–

What if the patient has no eyes?

Oh well. I put the number in the right place on the chart and explain it in the narrative. Just as I would for an intubated patient, who is awake and appears oriented, but has no verbal response because the tube is between the vocal cords. If we are documenting a verbal response, we are documenting that the tube is not between the vocal cords – we are documenting that the tube is misplaced.

We can play all sorts of philosophical games with these numbers, but the important point is that the numbers are not important. Anyone who tells you otherwise, such as the QA/QI/CYA department, does not know what he/she is talking about. If you really have a problem with this, ask some doctors to come up with a definitive answer. As a group, they probably will not agree, unless they agree that the number is not important.

–

Late entry – 10-25-10 – 22:26. And I forgot that the patient receiving a paralytic is not going to be able to be assessed by any of these, unless we use the wrong dose.

–

What if the patient does not speak the same language(s) I speak?

How can I document orientation?

I cannot honestly document orientation.

How can I document disorientation?

I cannot honestly document disorientation.

Documenting disorientation means that I am asserting that the person is not oriented. That would be a lie.

–

All that matters is the ability to assess a trend in patient presentation, not the ability to make the paperwork look pretty. If the purpose were to make the paperwork look pretty, they would give us more colorful pens and/or software for documentation.

–

Jamie also points out the error of the rule mnemonic, Less than 8, Intubate!

We should only be intubating when it is appropriate for that patient.

–

The Glasgow Coma Score

Best eye response

4. Spontaneous.
3. To voice.
2. To pain.
1. None.

Best verbal response

5. Oriented.
4. Confused.
3. Inappropriate words.
2. Incomprehensible sounds.
1. None.

Best motor response

6. Obeys commands.
5. Localizes pain.
4. Withdraws to pain.
3. Decorticate flexion.
2. Decerebrate flexion.
1. None.

.

Filed Under: Assessment, Critical Judgment, Heresy, MedicCast

ECC 2010 Update Interview – MedicCast – Part II

Wed, 20 Oct 2010 06:34:17 -0400 by
–
Part II of what I started in Emergency Cardiovascular Care 2010 Update Interview – MedicCast – Part I – At the MedicCast Jamie Davis (the host of MedicCast) and Tom Bouthillet (of Prehospital 12 Lead ECG) interview Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the American Heart Association (Heart.org/cpr).

Emergency Cardiovascular Care 2010 Update Interview.

There is a lot to discuss. Everybody does a great job of examining the changes. However, I have some comments on the changes. If you haven’t already, go listen to the show.

–

Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the AHA states –

It is hard to make a major change like (eliminating ventilations) without having solid enough evidence that it is superior to what we are doing now. In other words, the fact that there may be a technique that’s just as good is encouraging and is something that we need to consider but the changes to the guidelines need to be made on evidence that shows ‘here’s a better way to do things.

No.

We have found that the evidence for continuing the standard of care is not as solid as we thought it was does not exist.

Where is the evidence that cardiac arrest patients benefit from ventilation?
 


Original cartoon
 

This is the problem with the approach the AHA (American Heart Association) takes. They are advocating the continuation of unproven treatments. Not just unproven treatments, but treatments that are more invasive and more risky than alternatives supported by better evidence.

Even given two equally beneficial treatments, we should choose the one with less risk, not the one with more evidence. Especially when that evidence is just evidence of less benefit and more side effects.

The evidence that ventilation improves survival does not exist.

Outside of respiratory arrests, the delivery of ventilations only seems to contribute to adverse effects.

Why do we continue with ventilation in spite of a lack of evidence of benefit?
 

Bias.
 

Could ventilations worsen outcomes?

There is no could about it, ventilations do lead to complications –

Interruption of, and distraction from, the important task of excellent chest compressions (chest compressions improve survival).

Gastric insufflation leading to vomiting and aspiration of vomit.

Increased pulmonary pressure leading to decreased venous return, in other words interfering with compressions.

General complication of the resuscitation that only increases the chance of mistakes being made.

Here is what the AHA guidelines state –

Passive Oxygen Delivery During CPR
Positive-pressure ventilation has been a mainstay of CPR but recently has come under scrutiny because of the potential for increased intrathoracic pressure to interfere with circulation due to reduced venous return to the heart. In the out-of-hospital setting, passive oxygen delivery via mask with an opened airway during the first 6 minutes of CPR provided by emergency medical services (EMS) personnel was part of a protocol of bundled care interventions (including continuous chest compressions) that resulted in improved survival.6–8 When passive oxygen delivery using a fenestrated tracheal tube (Boussignac tube) during uninterrupted physician-managed CPR was compared with standard CPR, there was no difference in oxygenation, ROSC, or survival to hospital admission.9,10 Chest compressions cause air to be expelled from the chest and oxygen to be drawn into the chest passively due to the elastic recoil of the chest. In theory, because ventilation requirements are lower than normal during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway.2 At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers.[1]

Bold highlighting by the AHA.

In other words –

The experiments must continue until we cannot ignore the evidence of harm any longer.

Without valid research, this is just unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away. And without any attempt at informed consent.

A perverse result of the new guidelines is that patients will receive better CPR from lay rescuers, assuming the lay rescuers maintain good technique, than they will from professional rescuers – even if the professional rescuers use good technique.

–

Footnotes:

–

[1] Passive Oxygen Delivery During CPR
Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.1: Adjuncts for Airway Control and Ventilation
Oxygen During CPR
Free Full Text Article with links to Free Full Text PDF download

.

Filed Under: 2010 AHA Guidelines, ACLS, Airway Management, Critical Judgment, Heresy, MedicCast

Emergency Cardiovascular Care 2010 Update Interview – MedicCast – Part I

Tue, 19 Oct 2010 15:22:07 -0400 by
–
At the MedicCast Jamie Davis (the host of MedicCast) and Tom Bouthillet (of Prehospital 12 Lead ECG) interview Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the American Heart Association (Heart.org/cpr).

Emergency Cardiovascular Care 2010 Update Interview.

There is a lot to discuss. Everybody does a great job of examining the changes. However, I have some comments on the changes. First, go listen to the show.

–

How do they address changes, or the lack of changes?

Tom Bouthillet asks about how important is it to know the specific rates in your EMS system for each part of the chain of survival?

Dr. Kleinman says, “You have to be able to be measure what you’re doing.” She points out that it is odd that it’s not something we do for emergency cardiac care, even though we track water quality, police response, and other aspects of public services in our communities.

Evaluation of the effect of our treatments is much more important than that.

As I stated in Ethics, Research, and IRBs – Part I –

Without valid research, this is just unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away. And without any attempt at informed consent.

The most important word there is experimentation.

Without evidence that a treatment improves outcomes, we are just experimenting on patients, but we are not being honest and telling people that we are experimenting on patients.

Experimentation is important. Experimentation is the way we learn what works.

–

In cardiac arrest, we have evidence of improved outcomes with good chest compressions and with defibrillations. This is due to experimentation.

These guidelines are based almost exclusively on weak evidence.

These guidelines are based on animal experimentation, which is a preliminary form of experimentation, that should be followed up with high quality human experimentation.

These guidelines are also based on human experimentation that is not often of high quality. The human experimentation has generally been poorly controlled, too small, or just not addressed important questions. Most of the well done experimentation has shown that the things we thought were improving survival were not improving survival.

We insist that using treatments right up until we have evidence of harm is good patient care.

We claim that we need clear evidence of harm before we eliminate any harmful treatment.

This is backwards.

This is the antithesis of ethical behavior.

–

Measuring what we are doing is just the beginning of evaluating this huge unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away – without any attempt at informed consent.

For example, where is the evidence that ventilating cardiac arrest patients improves outcomes?

That is in Part II.

.

Filed Under: 2010 AHA Guidelines, ACLS, Critical Judgment, Heresy, MedicCast
Next Page »