The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

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

.

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

.

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.
 


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

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.

.

EMS Dinosaurs and the Slow Gazelles – EMS Office Hours

-
 

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a couple of topics kind of related to dinosaurs before I got on the show. We ended up discussing what a dinosaur is (all of us) and what a problem dinosaur is (someone who refuses to learn).
 

EMS Dinosaurs and the Slow Gazelles
 

I stated that dinosaurs, the problem people – those who refuse to learn, make excuses for the failure of their beliefs to be confirmed by reality (valid evidence of improved outcomes).

Here are some of the treatments that are routine in EMS, but are not supported by valid evidence of improved outcomes.

Backboards, a lot of saline for uncontrolled hemorrhage, ventilations for cardiac arrest, airways for cardiac arrest, drug for cardiac arrest, furosemide (Lasix, frusemide in Commonwealth countries) for acute CHF (Congestive Heart Failure), sodium bicarbonate is a good treatment for acidosis, high-flow oxygen in the absence of hypoxia, 50% dextrose for hypoglycemia, steroids for spinal injuries, et cetera.

All of these are based on an absence of evidence or on inadequate evidence. Most of them have evidence of more harm than benefit.

Why do we continue to add treatments to guidelines before there is evidence of benefit?

Because we believe that the treatments work because we are dangerous optimists. We refuse to learn that we harm patients by rushing treatments in to guidelines.

In the absence of evidence of benefit, we should assume that every treatment is harmful.

If reality does not agree with what we believe, then the problem is not reality, but our refusal to accept reality.
 

There was a discussion of prehospital therapeutic hypothermia with IV (IntraVenous) chilled saline, which has been clearly demonstrated to be not beneficial and possibly harmful. In-hospital therapeutic hypothermia does work, but having EMS start this was a bad idea and now needs to be removed from protocols.

There have been three studies of the effect of prehospital chilled saline for post-resuscitation therapeutic hypothermia. Dr. Bernard’s study showed no benefit and was stopped early because the results made it clear that there was no benefit.[1] Dr. Bernard talks with Dr. Scott Weingart on two EMCrit podcasts about the more recent studies.[2]
 


Click on images to make them larger. “Normal” temperature is 37°C and varies throughout the day, including when almost dead. The drop in the graph is not a temperature drop. It is the drop in survival for both groups.
 

After publication of the seminal trials of therapeutic hypothermia after cardiac arrest,2,3 this approach was recommended in international guidelines,4 despite arguments by some investigators that the evidence was weak, owing to the risk of bias and small samples.6,25 [3]

 

We are doing a lot to the patient that can cause complications with no expectation of any benefit.

This is a bad idea.

 


 

The intervention reduced core body temperature by hospital arrival, and patients reached the goal temperature about 1 hour sooner than in the control group. The intervention was associated with significantly increased incidence of rearrest during transport, time in the prehospital setting, pulmonary edema, and early diuretic use in the ED. Mortality in the out-of-hospital setting or ED and hospital length of stay did not differ significantly between the treatment groups.[4]

 

We need to wait for evidence of improved outcomes.

If we cannot provide evidence of improved outcomes, all we have is wishful thinking.

Wishful thinking kills.
 

Go listen to the podcast.
 

PS The story from Welcome to the Monkey House by Kurt Vonnegut is called Harrison Bergeron. It is only a couple of pages and beautifully written. The full text is on line for free here.
 

THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way. Nobody was smarter than anybody else. Nobody was better looking than anybody else. Nobody was stronger or quicker than anybody else. All this equality was due to the 211th, 212th, and 213 th Amendments to the Constitution, and to the unceasing vigilance of agents of the United States Handicapper General.

. . . . .

 

Go read Harrison Bergeron.

Footnotes:

[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

[2] Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I
EMCrit
Podcast page with links to research mentioned in the podcast.

Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II
EMCrit
Podcast page with links to research mentioned in the podcast.

[3] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed - indexed for MEDLINE]

[4] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed - as supplied by publisher]

.

DeMYTHifying Diagnosis – Part II

 

Continuing from Part I of my comments on what Kelly Grayson writes in Demystifying Diagnosis.

But diagnosis refers to definitive care!

We diagnose some patients as well enough to be left safely at home, even if we tell some people with abrasions that we think abrasions are deadly.[1] :oops:
 
Anaphylaxis

We treat anaphylaxis with epinephrine (and/or diphenhydramine, methylprednisolone, . . . ) and some patients refuse transport, while most are just observed in the ED before discharge.[2] Should we be leaving patients on scene with anaphylactic-like presentations, but without a diagnosis of anaphylaxis?

Bradykinin-mediated angioedema may look like anaphylaxis, but it does not respond well to epinephrine. Angioedema can be bradykinin-mediated (non-allergic) or histamine-mediated (allergic).[3],[4]
 
Hypoglycemia

We treat hypoglycemic emergencies and routinely leave patients on scene following a refusal of transport. This is only possible because the unresponsive/minimally responsive patient is now awake, alert, and has the capacity to make informed decisions to accept/refuse further treatment, assessment, and/or transport.[5],[6]
 
Opioid overdose

With some unresponsive opioid overdose patients, we can reverse their conditions. most of these patients may refuse further treatment, refuse further assessment, and/or refuse transport.[7],[8],[9]
 
Seizure

Seizure patients can awaken and be alert enough to refuse treatment and transport.[10]
 


Image credit.[11]
 

We do diagnose and leave patients on scene.

We do not seem to have major problems with patient-initiated refusals.

With increasing use of community paramedics, this will only become more common.

Those are examples of four conditions where we provide assessment, treatment, and a recommendation to follow up with the patient’s primary care provider (not necessarily a physician).
 
Death

We also leave dead patients on scene. No doctor will ever see some of these patients, because we are transferring care to the family/funeral home/police.

The patient’s physician will sign the death certificate, but with no requirement that the doctor has seen the patient after the cardiac arrest. Do we misdiagnose death? Yes, but so do doctors.

Dead is about as definitive as a diagnosis will get.
 

Once we start using words like diagnosis, accountability, and research, it is just a slippery slope to better patient care. :idea:

Footnotes:

[1] The Power of the ‘Death’ Chant will protect Us
Wed, 29 Jan 2014
Rogue Medic
Article

[2] Clinical predictors for biphasic reactions in children presenting with anaphylaxis.
Mehr S, Liew WK, Tey D, Tang ML.
Clin Exp Allergy. 2009 Sep;39(9):1390-6. doi: 10.1111/j.1365-2222.2009.03276.x. Epub 2009 May 26.
PMID: 19486033 [PubMed - indexed for MEDLINE]
 

RESULTS:
There were 95 uniphasic (87%), 12 (11%) biphasic and two protracted reactions (2%). One child with a protracted reaction died. For the management of the primary anaphylactic reaction, children developing biphasic reactions were more likely to have received >1 dose of adrenaline (58% vs. 22%, P=0.01) and/or a fluid bolus (42% vs. 8%, P=0.01) than those experiencing uniphasic reactions. The absence of either factor was strongly predictive of the absence of a biphasic reaction (negative predictive value 99%), but the presence of either factor was poorly predictive of a biphasic reaction (positive predictive value of 32%). All biphasic reactors, in which the second phase was anaphylactic, received either >1 dose of adrenaline and/or a fluid bolus.

CONCLUSIONS:
Children who received >1 dose of adrenaline and/or a fluid bolus for treatment of their primary anaphylactic reaction were at increased risk of developing a biphasic reaction.

 

It appears to be safe to leave children at home as long as they have received only one epinephrine injection and have not received any IV (IntraVenous) fluids. Most of my 911 anaphylaxis calls have been refusals.

[3] Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema.
Bernstein JA, Moellman J.
Int J Emerg Med. 2012 Nov 6;5(1):39. doi: 10.1186/1865-1380-5-39.
PMID: 23131076 [PubMed]

Free Full Text from PubMed Central.

[4] Delayed takotsubo cardiomyopathy caused by excessive exogenous epinephrine administration after the treatment of angioedema.
Patankar GR, Donsky MS, Schussler JM.
Proc (Bayl Univ Med Cent). 2012 Jul;25(3):229-30. No abstract available.
PMID: 22754120 [PubMed]

Free Full Text from PubMed Central.

[5] Prehospital hypoglycemia: the safety of not transporting treated patients.
Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D.
Prehosp Emerg Care. 2003 Oct-Dec;7(4):458-65.
PMID: 14582099 [PubMed - indexed for MEDLINE]
 

CONCLUSIONS:
Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

[6] Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature.
Roberts K, Smith A.
Emerg Med J. 2003 May;20(3):274-6. Review.
PMID: 12748153 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

Read the whole paper (both pages) – especially the recommendations for limitations on refusals.

[7] Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport.
Vilke GM, Sloane C, Smith AM, Chan TC.
Acad Emerg Med. 2003 Aug;10(8):893-6.
PMID: 12896894 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from Academic Emergency Medicine.
 

RESULTS:
There were 998 out-of-hospital patients who received naloxone and refused further treatment and 601 ME cases of opioid overdose deaths. When compared by age, time, date, sex, location, and ethnicity, there were no cases in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opioid overdose.

[8] No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose.
Wampler DA, Molina DK, McManus J, Laws P, Manifold CA.
Prehosp Emerg Care. 2011 Jul-Sep;15(3):320-4. doi: 10.3109/10903127.2011.569854.
PMID: 21612385 [PubMed - indexed for MEDLINE]
 

CONCLUSION:
The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

[9] The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting.
Cantwell K, Dietze P, Flander L.
Resuscitation. 2005 Jun;65(3):315-9.
PMID: 15919568 [PubMed - indexed for MEDLINE]
 

CONCLUSIONS:
The concurrent use of alcohol with heroin resulted in the use of greater than standard doses of naloxone by paramedics in resuscitating overdose patients. It is possible that the higher dose of naloxone is required to reverse the combined effects of alcohol and heroin. There was also a link between initial patient presentation and the dose of naloxone required for resuscitation. In light of these findings, it would appear that initial patient presentation and evidence of alcohol use might be useful guides as to providing the most effective dose of naloxone in the prehospital setting.

[10] The diagnosis and management of seizures and status epilepticus in the prehospital setting.
Michael GE, O’Connor RE.
Emerg Med Clin North Am. 2011 Feb;29(1):29-39. doi: 10.1016/j.emc.2010.08.003. Epub 2010 Oct 15. Review.
PMID: 21109100 [PubMed - indexed for MEDLINE]
 

Such patients must demonstrate to providers the mental capacity to make an informed medical decision to refuse care. In patients who have just had a seizure, it is unlikely that they will demonstrate intact mental status and capacity for medical decision making.12,13 Because the risk of seizure recurrence is approximately 6%, prehospital care providers and medical command physicians should ensure that patients understand the risks of refusal.14

 

Pediatric patients present unique challenges in prehospital seizure management. Galustyan and colleagues15 studied the care of 1516 pediatric EMS calls with a chief complaint of seizure. Of those calls, 189 (17%) refused transport.

[11] Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation.
Mechem CC, Barger J, Shofer FS, Dickinson ET.
Acad Emerg Med. 2001 Mar;8(3):231-6.
PMID: 11229944 [PubMed - indexed for MEDLINE]

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