If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

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
 

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.

.

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]

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

.

DeMYTHifying Diagnosis – Part I

 

Kelly Grayson writes Demystifying Diagnosis, but I decided to add a little lisp to accentuate a point.

He starts out with an almost irresistible temptation.
 

Want to start a fight in an EMS social media forum?[1]

 

I tend to avoid the EMS social media, because there are few who understand what they are doing, and no matter how wrong they are, they congratulate themselves that they are absolutely right that high-flow oxygen saves lives, or that faster is better, or that backboards save spinal cords, or that more medics means better patient care, or that . . . .

EMS is not unique in this self-deception, but I do not need to be the one correct the lowest of our lowest common denominators.
 

Diagnosis is a word that will draw out many of these dregs of EMS to beat their chests in defense of their failure to understand.

We don’t diagnose!

We probably should not assume a diagnosis of lupus, but we do diagnose.
 


Image credit.
 

Once paramedics diagnose, it’s just a slippery slope to . . .

Having paramedics decide appropriate doses of pain medicine, or appropriate doses of sedative medicine, or appropriate doses of combinations of pain medicine and sedative medicine?

Having paramedics, basic EMTs, and even first responders clear potential spinal cord injuries without an X ray? If you have moved your neck, or your back, at any time – you have a potential spinal cord injury. If you have bumped into anything at any time – you have a potential spinal cord injury. If you have sneezed, coughed, vomited, eaten, or consumed a beverage – you have a potential spinal cord injury.

Having paramedics give enough sedative to knock down the agitated delirium patient? How can we give medications without a complete history and a list of medications and allergies?

Are we really that foolish?

We need to be told what to do!

We can’t think for ourselves!
 


Download YouTube Video | YouTube to MP3: Vixy
 

We don’t want to think!

We just want to be told what to think!

Thinking leads to responsibility and we just want to avoid responsibility, (oddly it is our responsibility to defend EMS myths)!
 

It appears to be true that diagnosis is the legal purview of doctors, but is it like Coke having to defend its brand name?

Sort of –

Doctors are not worried about EMS taking their jobs.

Doctors are definitely not worried about these defenders of irresponsibility taking their jobs. Doctors are worried about PAs (Physician Assistants) and NPs (Nurse Practitioners) – responsible, well educated people – taking their jobs.
 

Some nurses worry about EMS taking some nursing jobs, so you may see legal battles over licensure threatened by some nursing organizations. We are licensed, even if the license is called a certificate.[2]

We are not just licensed, we diagnose, even if we are taught that an EMS diagnosis is just a _________ diagnosis. Insert whatever lame excuse for why we are not really saying Voldemort diagnosis.
 

But diagnosis refers to definitive care!

We treat some patients with definitive enough treatment to bypass the ED (Emergency Department). STEMI is the most obvious example in the systems that do have EMS transport straight to the cath lab.

We need to be better at diagnosis and less afraid of diagnosis.

You want diagnosis? I will provide some of the most flagrant examples of EMS diagnosis in Part II.
 

Go read the rest of what Kelly wrote.

-

Footnotes:

-

[1] Demystifying Diagnosis
February 5, 2014
A Day in the Life of an Ambulance Driver
Article

-

[2] The Legal Differences Between Certification and Licensure
National Registry of EMTs
Legal opinion

.

Is it Good When Everybody Responds for a Call Involving Police/Fire/EMS?

-
 

Last week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a variety of topics before I got on the show. We had a bit of disagreement about whether everyone should be sent for police/fire/EMS patients.
 

EMS Rapid Fire | October 2013
 

Where is the evidence that there is a benefit to these patients?

If we are just putting on a show, we are fooling ourselves. Why can’t we be honest?

Why do we deserve such a show?

Does this show improve outcomes?
 

History has documented numerous cases of a pervasive medical problem come to be known as “The VIP Syndrome.” The entrance of a VIP or celebrity challenges the normal practices of physicians and their institutions. The result of treating VIPs differently than “common individuals” can sometimes be catastrophic. By not adhering to common practice guidelines, physicians risk compromising their basic powers of perception, judgement, and treatment. The “VIP Syndrome” is not well known in the medical community. This poses a risk to every health care institution encountering a VIP in a medical treatment setting.[1]

 

When we treat patients differently because of their status (MOS – Member Of Service), we are treating them as VIPs, which is harmful to the patients we are trying to help.

We need to understand what we are doing – rather than make a show out of doing something.

We need to be honest about the ways we are treating our patients and the ethical aspects of our actions.
 

Go listen to the podcast.
 

-

Footnotes:

-

[1] Executive Health Care in the Air Force
Corporate Author : Air Univ Maxwell AFB AL
Personal Author(s) : Simpson, Carl G.
PDF Url : ADA397186
Report Date : APR 1998
Web page with link to Download in PDF format.

.

Ketamine Myths Debunked in Four Podcasts


 

Many people are still afraid of using ketamine in EMS, because of various myths.

Dr. Minh Le Cong of PHARM – PreHospital And Retrieval Medicine has four excellent podcasts debunking the scare stories told by people unfamiliar with ketamine.

Go listen to all four podcasts about these ketamyths medical urban legends –
 

PHARM Podcast 75 Ketamine MythBusters Part 1 – Blowing your mind
 

Ketamyth 1 –
 

It has traditionally been avoided in the management of patients with traumatic brain injury owing to concerns that it may increase intracranial pressure.[1]

 

Does ketamine dangerously raise ICP (IntraCranial Pressure) for patients with head injuries?
 

Concerns regarding the potential for ketamine to raise ICP stem from small case control series several decades ago in patients with abnormal CSF flow dynamics [53].[1]

 

Medical myths are based largely on anecdote and unreasonable extrapolation, rather than evidence.

This myth assumes the effect should be generalized beyond the abnormal subset of patients in the study to all head injured patients and possibly to those in the room when ketamine is given to patients with head injuries.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Was the abnormal subset of patients in that study representative of the entire study?

No.

Does ketamine cause increased damage to patients with head injuries?
 

Several recent studies have refuted the original findings and showed no statistically significant rise in ICP in brain injured patients who are sedated with ketamine [56].[1]

 

But we should still avoid ketamine just to be safe, right?
 

The antagonism of NMDA receptors decreases the release of neurotoxic glutamate and may impart a protective effect in patients with traumatic brain injury [60].[1]

 

But we were told by experts that ketamine is dangerous.
 

Therefore ketamine is indicated particularly as an induction agent in patients with TBI and haemodynamic instability. It may have a role for refractory seizure activity.[1]

 

But some expert once said that there is a danger, so I am afraid the lawyers will get me, because I know less about medicine than lawyers do!!!11!!!
 

Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head injured patients for intubation.[2]

 

We become dangerous when we base our decisions on politics, rumor, and bias, rather than valid evidence.

Go listen to the podcast.
 

And listen to the rest of the series of ketamine myth debunking -
 

Ketamyth 2 –
 

PHARM Podcast 76 Ketamine MythBusters Part 2 – Take the pressure down
 

Does it cause dangerous tachycardia and hypertension? How useful is it in the haemodynamically unstable patient?[3]

 

Go ahead. Bet that the myth is true. You know that your inner anecdotalist wants you to.
 

Ketamyth 3 –
 

PHARM Podcast 77 Ketamine MythBusters Part 3 – Are you mad enough?
 

Does it cause dangerous psychosis? How useful is it in the agitated patient? How common is the so called emergence delirium? What can you do if it happens? What can you do to prevent it from happening?[4]

Live dangerously. Bet on the myths. ;-)
 

Ketamyth 4 –
 

PHARM Podcast 78 Ketamine MythBusters Part 4 – A fitting end?
 

Ketamine and epilepsy. Does it cause seizures? can it be used to manage seizures?[5]

 

For non-Commonwealth readers, who may be unfamiliar with the term fitting, fitting means having a seizure.
 

Ketamine has advantages over traditional antiseizure medications with less respiratory depression and hypotension[5]

 

We can rely on anecdote-based myths, or we can look at the actual evidence and learn the truth.
 

The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. – Thomas Henry Huxley.
 

-

Footnotes:

-

[1] Sedation in traumatic brain injury.
Flower O, Hellings S.
Emerg Med Int. 2012;2012:637171. doi: 10.1155/2012/637171. Epub 2012 Sep 20.
PMID: 23050154 [PubMed]

Free Full Text from PubMed Central.

-

[2] Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury.
Filanovsky Y, Miller P, Kao J.
CJEM. 2010 Mar;12(2):154-7. Review. No abstract available.
PMID: 20219164 [PubMed - indexed for MEDLINE]

Free Full Text from CJEM.

-

[3] PHARM Podcast 76 Ketamine MythBusters Part 2 – Take the pressure down
PHARM – PreHospital And Retrieval Medicine
by rfdsdoc on July 20, 2013
Podcast page with links to evidence.

-

[4] PHARM Podcast 77 Ketamine MythBusters Part 3 – Are you mad enough?
PHARM – PreHospital And Retrieval Medicine
by rfdsdoc on July 31, 2013
Podcast page with links to evidence.

-

[5] PHARM Podcast 78 Ketamine MythBusters Part 4 – A fitting end?
PHARM – PreHospital And Retrieval Medicine
by rfdsdoc on August 14, 2013
Podcast page with links to evidence.

.

The Continuum of Care

 

 

For his 100th podcast, Dr. Scott Weingart (EMCrit Blog – A Discussion of the Practice of ED Critical Care) gives an explanation of what his blog/podcast is all about. This was the opening lecture of SMACC 2013.
 

My career goal and the purpose of this blog and podcast is to bring Upstairs Care, Downstairs-–that is to bring ICU level care to the ED, so our patients can receive optimum treatment the moment they roll through the door.

 

Podcast 100 – What is Critical Care and What is EMCrit?
 


 

Should appropriate patient care ever be limited by turf wars or limited by fears of liability or in any other way arbitrarily limited?

There will always be the financial limitation of care that we have always had to deal with. At some point, using all of the resources we have to try to prolong the death of one patient will deprive other patients of those same resources. We cannot have all resources available at all times to all possible patients. We live in a world of limited resources. Anyone who tells you otherwise is selling something, and that something is a lie.

What about joy of turf wars, the liability of providing appropriate care, and the frustration of being expected to provide high quality patient care regardless of arbitrary political boundaries?

Shouldn’t the critical care doctors decide what critical care is delivered and when it begins?

Shouldn’t the emergency physicians decide what emergency medicine is delivered and when it begins?

 

When I started in EMS, we used to believe that morphine was a horribly dangerous drug that could only be given in ineffective doses of 1 to 2 mg; that morphine should be given only after radio communication with a doctor; that this kind of prehospital morphine administration was pushing the limits of aggressive medicine.

There are still people who will repeat the unfounded warning that giving morphine (or fentanyl) for undifferentiated abdominal pain will kill the patient.
 

If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the delusive hope.[1]

 

Dr. Cope was just originating one of the many myths that persist in medicine.[2],[3]

As Dr. Weingart is opposed to interruptions and delay in the appropriate care for emergency patients in the hospital, I am similarly opposed to interruptions and delay in the appropriate care for emergency patients outside of the hospital.

Is there any reason to believe that physicians responsibility for emergency patient care is limited to that which happens only after the patient crosses the EMTALA[4] line?

Paramedics have repeatedly demonstrated their ability to give opioids, such as fentanyl, safely on standing orders.[5],[6]

Emergency physicians have repeatedly demonstrated their ability to provide deep sedation in the emergency department, in spite of being criticized as dabblers and poachers.[7],[8]

There are more examples of the ways we interfere with a smooth continuum of care for our patients. Dr. Weingart does not appear to disagree, but his focus is on improving care within the hospital and he can only do so much.

Those of us in EMS need to keep pushing for better appropriate care for our patients.

The Standard Of Care is the normal care that would be expected.

Why should we accept a Standard Of Care that is bad patient care?

We should be providing exceptional care, not limiting our patients to bad standards.

We need to reform the legal system that encourages coerces us to provide bad patient care.[9]
 


 

Go listen to the podcast or watch the video of the conference presentation.
 

-

Footnotes:

-

[1] The early diagnosis of the acute abdomen.
Cope Z, Silen W.
New York (NY): Oxford University Press; 1921.

Analgesia In The ED: Habits And Facts
Pain Management In The ED: Prompt, Cost-Effective, State-Of-The-Art Strategies
EB Medicine
Page with quotation from the book.

-

[2] Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain.
Thomas SH, Silen W.
Br J Surg. 2003 Jan;90(1):5-9. Review.
PMID: 12520567 [PubMed - indexed for MEDLINE]

-

[3] Analgesia in patients with acute abdominal pain.
Manterola C, Vial M, Moraga J, Astudillo P.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. Review.
PMID: 21249672 [PubMed - indexed for MEDLINE]

-

[4] EMTALA
ACEP (American College of Emergency Physicians)
News Room
News Media Resources
Fact Sheet

-

[5] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from MSTC.

-

[6] Safety of prehospital intravenous fentanyl for adult trauma patients.
Soriya GC, McVaney KE, Liao MM, Haukoos JS, Byyny RL, Gravitz C, Colwell CB.
J Trauma Acute Care Surg. 2012 Mar;72(3):755-759.
PMID: 22491566 [PubMed - as supplied by publisher]

-

[7] The safety of single-physician procedural sedation in the emergency department.
Hogan K, Sacchetti A, Aman L, Opiela D.
Emerg Med J. 2006 Dec;23(12):922-3.
PMID: 17130600 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

-

[8] “Poachers and dabblers?”: ASA president’s incautious comment riles emergency physicians.
Flynn G.
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed - indexed for MEDLINE]

-

[9] Standard Of Care Project
Emergency Physicians Monthly
Web page.

.

Slaying the Immobilization Dragon – Free JEMS Podcast by Jon Politis

 

This is an apt metaphor for the way we handle spinal immobilization.

We will do anything, even sacrifice our children, ask us for anything!

Just don’t ask for evidence!

It appears that Jon Politis is going to be describing the abysmal state of evidence (all negative) that looks at the way EMS uses spinal immobilization.
 


Image credit.
 

The town had a pond, as large as a lake, where a plague-bearing dragon dwelled that envenomed all the countryside. To appease the dragon, the people of Silene used to feed it two sheep every day, and when the sheep failed, they fed it their children, chosen by lottery. It happened that the lot fell on the king’s daughter, who is in some versions of the story called Sadra.[8] The king, distraught with grief, told the people they could have all his gold and silver and half of his kingdom if his daughter were spared; the people refused. The daughter was sent out to the lake, dressed as a bride, to be fed to the dragon.[citation needed] [1]

 
 

George came along and rescued the damsel from the dragon, as Jon will probably be encouraging us to rescue our patients from our backboards.

Jon, not George, but why quibble?
 

Spinal immobilization is a hot-button topic in the prehospital setting. During this webcast, Jon Politis, MBA, NREMT-P, will delve into the latest science in order to slay the immobilization dragon and provide answers to the following questions:
Is spinal immobilization always necessary?
Are there “high-risk” mechanisms?
How much spinal movement is OK?
Sponsored by Hartwell Medical
[2]

 
 

Is this a ploy to defend spinal immobilization?

I come to bury Caesar, not to praise him.
 

Is this just a way to encourage EMS spinal clearance (limiting spinal immobilization to those most likely to be harmed by spinal immobilization)?

I do not know.
 

Will this change anything?

Immediately? Probably not.

This may become a part of the evidence used to convince EMS medical directors to ignore the PHTLS (PreHospital Trauma Life Support) dogma.

There is extensive commentary on spinal immobilization, the absence of evidence of benefit, and the abundant evidence of harm.
 

In the absence of evidence of benefit, we should be limiting treatment to research participants, since these patients are receiving an unexamined treatment.

These patients continue to be test pilots of spinal immobilization.

They are not receiving adequate information to make an informed consent, nor an informed refusal for this guinea pig treatment.

It is reasonable to assume that all treatments cause some harm, and spinal immobilization has well documented harms. We only assume that some benefit actually exists. There probably is no benefit, just as with the rest of our wishful thinking-based medicine.

All quacks seem to uses the same scam – But what if it works and we do not use it?

That kind of fraud would justify using anything that does not have good evidence of benefit – homeopathy or Reiki, but these frauds probably will not directly harm the patient. Spinal immobilization lacks that safety.

Why do we listen to such nonsense?

The stakes are high, and when the stakes are high, a lot of us turn out to be very superstitious.

We don’t know the truth and we do not want to know. We are not protecting our patients. We are harming our patients in order to protect our superstitions.

We are dangerous.
 

Slaying the Immobilization Dragon – Registration Page.

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Footnotes:

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[1] Slaying the Immobilization Dragon
DATE: May 2, 2013
TIME: 1 p.m. Eastern / 10 a.m. Pacific
COST: FREE

Registration Page.

Speaker:
Jon Politis, MPA, NREMT-P, is the retired chief of the Colonie EMS Department in upstate N.Y. An active EMT since 1971, he has been a career firefighter, state EMS training coordinator for Vermont and New York and a paramedic training program coordinator. He has served on the National Registry of EMTs board and on the Committee on Accreditation for the EMS Professions.

To access the live presentation, please click on the following link:
link.

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[2] Saint George and the Dragon
Wikipedia
Article

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