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

- Rogue Medic

Should you hold your breath while intubating?

 

This is one of the ancient bits of street wisdom common sense about intubating. If you hold your breath while intubating, you will know when the patient needs to take a breath.

As with much of common sense, it is based on mythology.
 

Never take more than 30 seconds per attempt at each intubation!
Hint: Hold your breath while intubating – when you need to take a breath, so does the patient!
[1]

 

60 pct of the time, it works every time 1
Typical intubation instructor?
 

Obviously, this idea came about long before apneic oxygenation. No, . . . . Wait, it could be that apneic oxygenation came first, since papers were being written about apneic oxygenation long before paramedics were sent out to spread the word of the benefits of unrecognized esophageal intubation close enough for prehospital intubation.[2],[3],[4]

It could be that some anesthesiologists thought breath holding while intubating was a good idea, but I did not find any papers.

Apneic oxygenation can prevent desaturation for much longer than 30 seconds, yet many of us still emphasize fast and bloody, rather than slow and benign.

If the patient can hold her breath for as long as I can, she may be breathing as well as I am breathing, and may not need to be intubated. How do I really know when my patient needs to take a breath?

If I can only hold my breath for as long as a patient who needs to be intubated, then I may be breathing as badly as she is, and I may need intubation more than she does. How long can a paramedic hold his breath before becoming hypoxic and/or confused? How good am I at recognizing this change when I am focused on putting the little plastic tube in the slightly larger cartilage and flesh tube?

If the patient does not need to be intubated, why intubate? If I need to be intubated, should I be the one intubating anyone else? If I can hold my breath longer than the average paramedic, should I take up smoking to make this technique work for me? Should we be testing paramedics on how long a breath can be held as part of the hiring process?

I am shocked that such a simple one size fits all approach fails to consider even one of the many variables that would affect its use. How could that possibly happen in EMS?

Footnotes:

[1] Widely circulated, unwritten paper
The Mythbuilders of EMS
Trust us.
We know what we’re doing.

[2] Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation.
ENGHOFF H, HOLMDAHL MH, RISHOLM L.
Acta Chir Scand. 1952 Jul 14;103(4):293-301. No abstract available.
PMID: 12985091

[3] Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea.
HOLMDAHL MH.
Acta Chir Scand Suppl. 1956;212:1-128. No abstract available.
PMID: 13326155

[4] Apneic oxygenation in man.
FRUMIN MJ, EPSTEIN RM, COHEN G.
Anesthesiology. 1959 Nov-Dec;20:789-98. No abstract available.
PMID: 13825447

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Why EMS Should Limit the Use of Rigid Cervical Collars

 
Well, should EMS limit the use of rigid cervical collars?

As with the rest of anecdote-based medicine, or hunch-based medicine, we have been doing this for decades without any evidence of benefit. Do we know what we are doing?

But you have to prove that this is harmful, otherwise we cannot withhold the standard of ignorance.
 


Image credit.     Regardless of brand. A perfect fit – every time. Right?
 

Where does the burden of proof rest? In medicine, it is supposed to be the responsibility of the person treating to convince the patient that the treatment is more likely to be beneficial than harmful. This is informed consent. Informed consent is often overlooked and replaced with a blanket consent for the doctor (or designee, such as nurse, EMT, medic, . . . ) to do whatever the doctor thinks is a good idea.

Is there any valid evidence that a backboard, or KED (Kendrick Extrication Device), or rigid cervical collar will improve any outcome?

Not for the backboard or KED, but we know that the rigid cervical collar is beneficial because it stabilizes the neck and we would not use it if it didn’t work.

That is the same excuse made for using a backboards, or a KED, without evidence. Is there any valid evidence?

Can I get back to you on that?
 

Even though there should be no need to go further in criticizing rigid cervical collars, in the medical fields, we like to believe that what we have been doing is good and not harmful, because we don’t want to think of ourselves as harming our patients. Ironically, this attitude stops us from eliminating harmful treatments. We harm our patients to protect ourselves from having to admit that we were harming our patients.

For those who insist on evidence of harm, Dr. Bryan Bledsoe and Dr. Dale Carrison have provided us with a thorough evidence-based explanation of the ways that rigid EMS collars can harm our patients.
 

Interestingly, one of the first protocols that significantly changed spinal immobilization practices came out of several EMS agencies in Northern California. In a rather sweeping protocol change, they elected to forgo rigid C-collars and use soft collars.[1]

 

Do rigid cervical collars decrease manipulation of the neck/spine? Do rigid cervical collars protect patients from disability?

Read the article for a discussion of the evidence and of what we assume.

The argument in favor of backboards and collars is similar to the argument in favor of mandatory vaccination for school. It is a minor inconvenience for many, that protects against death/disability of some.

There is plenty of evidence for the vaccine argument. Vaccines are safe. Vaccines save lives. Vaccines are worth it. What about rigid EMS collars? Do they protect against death/disability?
 

Go read the article and find out.
 

Dr. Bledsoe and Dr. Carrison provide plenty of evidence to support their conclusions. What do the supporters of rigid cervical collars have?

Footnotes:

[1] Why EMS Should Limit the Use of Rigid Cervical Collars
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
Monday, January 26, 2015
JEMS
Article

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If We Pretend that Anecdotes are Not Anecdotes, Do We Change Reality?

 

The following comment was written by Duke Powell in response to Where is the Evidence for Traction Splints?
 

I’ve been an urban paramedic for 34 years and, prior to that, a volunteer EMT for 9 years. For those who can’t add, ….that’s a long time.

How many times have I used a traction splint? …… I dunno, let’s guess 10 times.

 

That works out to an average of over four years between uses of the traction splint. That is plenty of time to have the memory of each use reconstructed many times, so that the memory and the reality may not have much in common. Each time we remember something, we recreate and modify the memory.
 

Several years ago, after several years of not even thinking about traction splinting, I found myself using it 3 times in 2 weeks.

Did it help? Yep, clinically, in my opinion, it helped.

 

Maybe it helped the patients. Maybe it harmed the patients. Maybe it helped some patients and harmed other patients. Maybe it helped the pain, but caused longer term harm. We do not know.

Without valid evidence, especially evidence of something more than the superficial appearance of improvement, we have no idea. We can use our imaginations and generate opinions, but we are merely discussing opinions.
 

Will Rogue Medic call my experience “anecdotal” and not worthy of consideration? Yes, he will.

Don’t care what the Rogue Medic thinks.

I care about what my patients and my Medical Director thinks.

 


Image credit.
 

Does calling an anecdote by a different name make it not an anecdote? It does not matter what you call it. A story is an anecdote. More than one story is just more than one anecdote.

What kind of follow up was there on the patients? What kind of comparison of the other variables was there?

Blood-letting looks like an excellent treatment – if we stick to anecdotes about blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[1]

 

How many patients did we kill with blood-letting? Thousands? Tens of thousands? Hundreds of thousands?

The opinions of medical directors have been in favor of many harmful treatments. Do you remember nifedipine?

Anecdotes do not become evidence of good patient care by telling the stories with style. Reality does not work that way, no matter how much we want to change reality. EMS shows us people who are having reality ignore their opinions about how the world should work. If reality is not going to change for a parent who wants their dead child back, how little is reality going to change for a paramedic who wants to put a positive spin on a treatment that he likes?

Reality does not care about our opinions.

Reality does not even care about the opinions of medical directors.

Science is the way we learn the difference between what is real and what is just a pleasing mirage.
 

What do you think science is? There is nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. So which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic? – Dr. Steven Novella.

Anecdotes are not thorough observations. Anecdotes do not use consistent logic. Anecdotes do not have anything to do with systematic evaluation.

Footnotes:

[1] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

.

Where is the Evidence for Traction Splints?

 

We eliminated tourniquets from ambulances because of anecdotes and some strong opinions, but not because of valid research. Valid research shows that tourniquets work. Tourniquets are back.

We added traction splints because of anecdotes and some strong opinions, but not because of any valid research. Will research result in the same reversal of opinion-based practice.

With so little evidence, devices that are frequently misused, and no apparent need for these Rube Goldberg devices, should we continue to use traction splints?
 


Image credit.
 

Does a traction splint work?

That depends on what we mean by the word work. If work means that it pulls on the leg, then it does work, but if work means that it improves outcomes, then the traction splint is about as effective as eye of newt. Maybe the eye of newt is more effective.

If your have a lot of patients who have no other major injuries, then you may be able to set up a study of traction splints. A ski resort might be a good place for a study. On the other hand, if you are not an isolated femur fracture magnet, then your patients would probably be much better off if you focused on pain management, rather than pulling on their broken bones.
 

The fact is, there were no definitive studies demonstrating efficacy or decreased morbidity or mortality from prehospital use of traction splints 10 years ago, nor are there any now.3 So our use of traction splints is purely anecdotal.[1]

 

What is an anecdote?

An anecdote is misinformation from a know-it-all who doesn’t know what matters.

Anecdotes are just rumors. We believe some things because we want to believe, not because they are true. If we want to know the truth, we look for unbiased information. Unbiased information is the opposite of anecdotes and rumors.

There I was, standing on the corner, minding my own business, when all of a sudden . . .

He was dying and we gave the special sauce and he got better and ran a marathon last year.

These are examples of anecdotes. Anecdotes are what sells alternative medicine.

Footnotes:

[1] Sacred Cow Slaughterhouse: The Traction Splint
By William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Jul 31, 2014
EMS World
Article

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Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

ResearchBlogging.org
 

Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?

If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?

50% dextrose has problems.
 

Animal models have demonstrated the toxic effect of glucose infusions in the settings of cardiac arrest and stroke.2 Experimental data suggests that hyperglycemia is neurotoxic to patients in the setting of acute illness.1,3 [1]

 

Furthermore, extravasation can cause necrosis.
 


Image credit.[2]
 

I expect juries to look at this kind of image and say, Somebody has to take one for the 50% dextrose team. We can’t expect EMS to change.

Is 10% dextrose practical?
 

Won’t giving less concentrated dextrose delay treatment?
 

The median initial field blood glucose was 38 mg/dL (IQR = 28 mg/dL – 47 mg/dL), with subsequent blood glucose median of 98 mg/dL (IQR = 70 mg/dL – 135 mg/dL). Elapsed time after D10 administration before recheck was not uniform, with a median time to recheck of eight minutes (IQR = 5 minutes – 12 minutes).[1]

 

If that is going to slow your system down, is it because you are transporting patients before they wake up?

Did anyone require more than 10 grams of 10% dextrose, as opposed to 25 grams of 50% dextrose?
 

Of 164 patients, 29 (18%) received an additional dose of intravenous D10 solution in the field due to persistent or recurrent hypoglycemia, and one patient required a third dose.[1]

 

18% received a second dose, which is 20 grams of dextrose and still less than the total dose of 25 grams of dextrose given according to EMS protocols that still use 50% dextrose.

Only one patient, out of 164 patients, required a third dose. That is 30 grams of dextrose.

Only one patient, out of 164 patients, received as much as we would give according to the typical EMS protocol, which should be a thing of the past. If we are routinely giving too much to our patients, is that a good thing? Why?
 

Maybe the blood sugars were not that low to begin with.
 


 

The average was 38 mg/dL, which is not high.
 

Maybe the change in blood sugar was small after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) change was 67 mg/dL, which is enough to get a patient with a blood sugar of 3 up to 70.
 

Maybe the blood sugar was not high enough after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) repeat blood sugar was 106 mg/dL, which is more than enough.
 

Maybe it took a long time to treat patients this way.
 


 

The average (mean) time was 9 minutes, which is not a lot of time.
 

Is this perfect?
 

Three patients had a drop in blood glucose after D10 administration: one patient had a drop of 1 mg/dL; one patient had a drop of 10 mg/dL; and one patient had a drop of 19 mg/dL.[1]

 

All patients, even the three with initial drops in blood sugar (one had an insulin pump still pumping while being treated) had normal blood sugars at the end of EMS contact.

10% dextrose is cheaper, just as fast, probably less likely to cause hyperglycemia, probably less likely to cause rebound hypoglycemia, probably less likely to cause problems with extravasation, less of a problem with drug shortages, . . . .

Why are we still resisting switching to 10% dextrose?
 

Other articles on 10% dextrose.

Footnotes:

[1] Dextrose 10% in the treatment of out-of-hospital hypoglycemia.
Kiefer MV, Gene Hern H, Alter HJ, Barger JB.
Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15.
PMID: 24735872 [PubMed – indexed for MEDLINE]

[2] Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed – indexed for MEDLINE]

Kiefer MV, Gene Hern H, Alter HJ, & Barger JB (2014). Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29 (2), 190-4 PMID: 24735872

Levy SB, & Rosh AJ (2006). Images in emergency medicine. Dextrose extravasation causing skin necrosis. Annals of emergency medicine, 48 (3) PMID: 16934641

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Does a Medic Need Two Eyes to be Safe?


 

When this story first was reported, there were plenty of social media comments about the lack of safety of having only one eye.

Is there any difference in outcomes for patients treated by two-eyed medics and one-eyed medics? What about medics who wear glasses? Should a three-eyed medic be given preference over two-eyed medics?

Is there any evidence of a difference in job performance?

Is there any evidence of a difference in driving?

Is there any evidence of a difference in anything that is a part of the job?

Provide some valid evidence.

If we are going to make these decisions without evidence, we should admit that we are basing our decisions on prejudice.
 

A Queens woman with a prosthetic eye is suing the FDNY because it won’t hire her as a paramedic.[1]

 

The article lacks information. There may be other reasons she has not been hired, but NYFD is not likely to discuss those directly in the media, because that might also lead to a law suit. If this does go to court there should be more information available.

This topic has generated a lot of righteous indignation from those who insist that two eyes are necessary for the safety of patients. I have not yet seen any evidence to support their attitude.

If there is valid evidence that I am wrong, I am willing to learn from that.
 

See also –

Improving EMS By Hiring Deaf EMTs

Footnotes:

[1] FDNY won’t hire woman with fake eye as paramedic: suit
By Kathianne Boniello and Georgett Roberts
July 6, 2014 | 4:37am
NY Post
Article

.

Mounting Evidence Against the Long Spine Board in EMS – A Must Watch Video

 

Dr. Ryan Jacobsen explains that I have been using the wrong terminology for this piece of equipment. This is a picture of my padded spine board.

In this excellent video, he describes why and explains the problems with the use of backboards and the absence of any valid evidence to justify the use of backboards for transport.
 


 

The video is one hour and twenty-two minutes, so get comfortable, get some caffeine, and get ready to smile and learn.

And share this video.

There are currently only 188 views of the video. There need to be hundreds of thousands.

If you teach EMS, play this for your students, or just give them the link.
 


 

What is the basis for the backboard?

Let’s blame the people who touched the patient first, because EMS will go along with that.
 

Mounting Evidence Against the Long Spine Board in EMS
Ryan C. Jacobsen, MD, EMT-P
Johnson County EMS System Medical Director
Assistant Professor of Emergency Medicine
Truman Medical Center/Children’s Mercy Hospital and Clinics
YouTube page
 

Thank you to Bill Toon, PhD for the link, for obtaining permission from Dr. Jacobsen to share this, and thank you to Dr. Jacobsen for making the video.

.

Another System Eliminates Backboarding for Potential Spinal Injuries

 
As of March 1st 2014, the Long Spine board will not be used by Johnson County EMS to transport patients.

Another system moves away from historical dogma – as a matter of fact, that is the language used to describe this change.
 

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.[1]

 

We need for more systems to place the care of patients above the care of historical dogma and institutional EMS culture.
 


Click on images to make them larger.
 

We need to stop basing decisions on What if . . . ?

Where is the evidence that transport on a Long Spine board is a good idea?

That is a healthy list of unhealthy side effects.

Consider giving the list above to patients and telling them that these are the risks we will subject them to if we transport them on Long spine boards. How often would would we obtain informed consent?

The first question should be – What is the possible benefit?

Well, . . . .

The hypothesis that transporting patients on Long Spine boards protects the unstable spine from further injury has been tested only one time.

That hypothesis failed miserably.

 


Out-of-hospital spinal immobilization: its effect on neurologic injury.[2]
 

The rate of disability doubled with spinal immobilization.

If we gave epinephrine (Adrenaline) and we cut our rate of resuscitation in half, how long would we continue to use epinephrine?

If we gave furosemide (Lasix) and we cut our rate of intubation doubled, how long would we continue to use furosemide? Ooopsy – some of us still do and furosemide probably produces a much greater increase in the rate of intubation than just doubling it.

How can we keep claiming that we are helping patients?
 


 

Thank you to Bill Toon, PhD of the recently ended EMS EduCast and the not so recently ended EMS Research Podcast for the information.

Footnotes:

[1] 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.

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

Free Full Text from Academic Emergency Medicine.

.