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

- Rogue Medic

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest – Part I

 
Also to be posted on ResearchBlogging.org when they relaunch the site.

The results are in from the only completed Adrenaline (Epinephrine in non-Commonwealth countries) vs. Placebo for Cardiac Arrest study.
 


 

Even I overestimated the possibility of benefit of epinephrine.

I had hoped that there would be some evidence to help identify patients who might benefit from epinephrine, but that is not the case.

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.

More people survived for at least 30 days with epinephrine, which is entirely expected. There has not been any controversy about whether giving epinephrine produces pulses more often than not giving epinephrine. As with amiodarone (Nexterone and Pacerone), the question has been whether we are just filling the ICUs and nursing home beds with comatose patients.
 

There was no statistical evidence of a modification in treatment effect by such factors as the patient’s age, whether the cardiac arrest was witnessed, whether CPR was performed by a bystander, initial cardiac rhythm, or response time or time to trial-agent administration (Fig. S7 in the Supplementary Appendix). [1]

 

The secondary outcome is what everyone has been much more interested in – what are the neurological outcomes with adrenaline vs. without adrenaline?

The best outcome was no detectable neurological impairment.
 

the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment.

Our work with patients and the public before starting the trial (as summarized in the Supplementary Appendix) identified survival with a favorable neurologic outcome to be a higher priority than survival alone. [1]

 


Click on the image to make it larger.
 

Are there some patients who will do better with epinephrine than without?

Maybe (I would have written probably, before these results), but we still do not know how to identify those patients.

Is titrating tiny amounts of epinephrine, to observe for response, reasonable? What response would we be looking for? Wat do we do if we observe that response? We have been using epinephrine for over half a century and we still don’t know when to use it, how much to use, or how to identify the patients who might benefit.

I will write more about these results later

We now have evidence that, as with amiodarone, we should only be using epinephrine as part of well controlled trials.

Also see –

How Bad is Epinephrine (Adrenaline) for Cardiac Arrest, According to the PARAMEDIC2 Study?

Footnotes:

[1] A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators.
N Engl J Med. 2018 Jul 18. doi: 10.1056/NEJMoa1806842. [Epub ahead of print]
PMID: 30021076

Free Full Text from NEJM

All supplementary material is also available at the end of the article at the NEJM site in PDF format –

Protocol

Supplementary Appendix

Disclosure Forms

There is also an editorial, which I have not yet read, by Clifton W. Callaway, M.D., Ph.D., and Michael W. Donnino, M.D. –

Testing Epinephrine for Out-of-Hospital Cardiac Arrest.
Callaway CW, Donnino MW.
N Engl J Med. 2018 Jul 18. doi: 10.1056/NEJMe1808255. [Epub ahead of print] No abstract available.
PMID: 30021078

Free Full Text from NEJM

.

Baltimore Hospital Dumping Patients – Is it that simple?

 
You watch the video and wonder how could anyone be so callous and cold, to leave someone outside with only a hospital gown to wear – especially when it is so cold outside.

Is what we are seeing callous, or uncaring?

In the video farther down, there is a nice discussion of the problems, which are much more complicated than somebody being refused care for some bad reason.

I found a site that did mention her clothes being with her, but stated with her clothes and belongings scattered on the sidewalk. Here is the picture they posted. The clothes are in plastic patient belongs bags.
 


 

Psychotherapist Imamu Baraka was walking near the University of Maryland Medical Center’s midtown campus location when he saw a woman being dropped off by security at a bus stop with her clothes and belongings scattered on the sidewalk.[1]

 

Why didn’t she put her clothes on?

One of the first things discharged patients will do, if they can, is put their own clothes on.

There is no evidence that anyone was refused care. That would be an EMTALA (Emergency Medical Treatment and Labor Act) violation, resulting in a very big fine, which would be reported. Maybe I am wrong, but I do not expect that an investigation will end with any finding of any refusal to provide care.

But we saw it on the video!

No. I think that you saw someone being removed from private property for bad behavior in a hospital gown, and she refused to put on her own clothes on (the clothes in her bag) for reasons of her own.

Here is a video explaining this in more detail, but a couple of notes about people mentioned in the video.

Charlie Gard was an infant with irreversible MDDS (Mitochondrial DNA Depletion Syndrome). The doctors and nurses seem to have understood this, but parents, politicians, preachers, and the press thought that it would be a good idea to torture Charlie Gard with an experimental treatment with no expectation of a better outcome.

How would Solomon decide? To torture, on the ridiculously small chance of a better outcome, or to do not further harm?

Peter Gallogly is a doctor, who was selectively recorded on video to make it seem as if his unprofessional behavior was unprovoked. If you watch the video of Dr. Gallogly, realize that it is edited to distort reality. If you watch the ironically named Project Veritas videos of abortion clinics, they are similarly edited to distort reality, which is why they have been rejected as evidence in court. You might as well watch a Michael Moore film, if you want a highly edited distortion of reality.

The Delnor nurse protected staff from an escaped prisoner, when the corrections officer apparently fled. The nurse ended up being abducted for hours, grazed by a bullet, pistol whipped, and raped, but was reported as being unharmed after the inmate was killed.

 


 

We need to learn how to find out accurate information for ourselves, rather than blindly accept propaganda from far left or far right news sources. Even the mainstream news will often get information in specialized fields wrong and not realize it. When the story is from a specialized field, such as medicine, we should obtain our information from trustworthy people in that field.

More information on Charlie Gard.

More information on Peter Gallogly.

More information on the Delnor nurse.

All of the videos are from ZDoggMD.com

Footnotes:

[1] Video shows Baltimore hospital discharging half-naked woman into cold winter night
Ana Valens
Jan 11 at 7:27AM | Last updated Jan 12 at 3:36AM
The Daily Dot
Article

.

Have a Slow, Quiet Friday the Thirteenth

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

 

Superstitious appears to be common among medical people, so this may be seen as offensive. If you doubt me, comment that it is slow or quiet and see how many respond negatively, while they do not receive any criticism for their superstition-based complaints. Rather, people will make excuses for coddling the superstitions of those who are entrusted with the lives of patients.

The evidence does not support their superstitions.

One study did appear to show that women die in motor vehicle collisions more often on Friday the 13th, but that appears to be due to a lack of understanding of statistics by many who cite the article.
 

An additional factor is anxiolytic medication, used by significantly more women than men in Finland (7), which has been reported to reduce attention span and worsen driving performance (8). . . . Why this phenomenon exists in women but not in men remains unknown, but perhaps the twice-as-high prevalence of neurotic disorders and anxiety symptoms in women (7) makes them more susceptible to superstition and worsening of driving performance.[1]

 

The author suspects that those people with conditions that could be diagnosed as neuroses or anxiety disorders may be disproportionately affected by superstition.

In other words, superstition is not an external force affecting you. You are doing it to yourself.

The sample size was national, but still small, and was not able to adjust for many possible confounding variables, so the study would need to be replicated using a much larger data base to be useful.

In other superstition news – the next apocalypse, in a long line of predicted apocalypses, is going to be this Sunday – the 15 of October, 2017, according to David Meade. Meade twice previously predicted that a magical planet would hit the Earth and kill us all. This time he claims that his calculations are accurate, because that was the problem with his previous calculations – inaccuracy, not that they were a superstition deserving of derision.

If you are superstitious, and feel that your neuroses/anxieties will cause you to harm others, or yourself, you may want to stay home today and Sunday – perhaps even until you are capable of grasping reality.

Of course, we would never base treatment on superstition in medicine.

Amiodarone is the go to antiarrhythmic drug for cardiac arrest and ventricular tachycardia, but there are much safer much more effective drugs available. We have our own prophets misrepresenting research results to make it seem that using amiodarone for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[2],[3]

Ventilation during cardiac arrest has been shown to be a good idea only for patients who arrested for respiratory reasons. We do a great job of identifying these patients. We have our own prophets misrepresenting research results to make it seem that providing ventilations for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[4]

Medicine is full of superstition and superstitious people.

Why?

Too many of us believe the lie that, I’ve seen it work.

I have also written about the superstition of Friday the 13th here –

Acute coronary syndrome on Friday the 13th: a case for re-organising services? – Fri, 13 Jan 2017

The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

T G I Friday the 13th – Fri, 13 Nov 2009

Happy Equinox! – Thu, 20 Mar 2008

Footnotes:

[1] Traffic deaths and superstition on Friday the 13th.
Näyhä S.
Am J Psychiatry. 2002 Dec;159(12):2110-1.
PMID: 12450968

Free Full Text from Am J Psychiatry.

[2] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

There are a dozen links to the research in the footnotes to that article. There are also links to other articles on the failure of amiodarone to live up to its hype.

[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[4] Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
Fri, 09 Dec 2011
Rogue Medic
Article

.

Why We Deceive Ourselves With Explanations

I have been thinking a bit more about Walt Trachim’s comment on Answer to What is this Dangerous Treatment and How Long Did it Take to Stop Using it and my response.

2. You know me well enough, I think, to know that I’m not satisfied unless I know WHY something happens. And this is no different; I would like very much to know why this works. I’m not asking if you understand why it works. I’m just saying that I would simply like to know more. And I would like to see more studies done. If I run across anything else in literature I will share it.

The problem is the desire to have an explanation. We ask for plausible treatments. Plausible treatments come with explanations, even if these plausible treatments are very harmful. Plausible means that the explanation makes some sort of sense.

Plausible appears reasonable.

Plausible means that it might work –

if the explanation is valid.

Might work.

What if . . . ?

Plausible means having a story that some people find convincing –

just as some people are convinced by the stories of con artists.

Our patients deserve better than What if . . . ?

What is better than plausible? Probable is better than plausible.

Probable requires evidence, but not an explanation.

What matters is that it works, not that it has a convincing story.

The worst treatments have some of the best stories. The worst treatments convince people to be satisfied with inadequate evidence, because there is a good story.

Epinephrine is plausible – but don’t ask for evidence that epinephrine improves survival. We stimulate the heart back to life. After decades of use, there still is not any evidence of improved survival with a functioning brain.

If your patients do not use their brains, then epinephrine may seem attractive.

Spinal immobilization is plausible – but don’t ask for evidence that spinal immobilization protects the spinal cord. After decades of use, there still is not any evidence of decreased disability with the use of spinal immobilization. We just need to manipulate the patient’s neck and back to fit a collar and backboard.

If your patients needed someone to come along and manipulate their spines, but a chiropractor was not available, then spinal immobilization may seem attractive.

Atropine is plausible – but don’t ask for evidence that atropine actually addresses a real cause of cardiac arrest. After decades of use, there still is not any evidence of improved survival with atropine.

Nothing changed.

There was no new research.

We just acknowledged the lack of evidence for giving atropine.

Atropine sulfate reverses cholinergic-mediated decreases in heart rate and atrioventricular nodal conduction. No prospective controlled clinical trials have examined the use of atropine in asystole or bradycardic PEA cardiac arrest. Lower-level clinical studies provide conflicting evidence of the benefit of routine use of atropine in cardiac arrest.34,295,–,304 There is no evidence that atropine has detrimental effects during bradycardic or asystolic cardiac arrest. Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE B). For this reason atropine has been removed from the cardiac arrest algorithm.[1]

If your patients were just too relaxed to live, then atropine may have seemed attractive.

Maybe epinephrine, or amiodarone, or lidocaine, will be the next ACLS (Advanced Cardiac Life Support) drug to be removed from the guidelines due to lack of evidence of benefit (and for lack of evidence of safety).


Image credit.

Plausible means –

A duck!
An aquatic bird that, in medieval times, was used to find out if a person was a witch or not.

This stems from the very logical idea that if a person weighs the same as a duck, then that person is made of wood (because both ducks and wood float in water). And since wood burns (just like witches) then that person must be a witch, because witches are made of wood.

Therefore, the accused person(s) would be placed on a scale next to a duck, and if they balanced, the person(s) would be burned.

So, if she weighs the same as a duck, then she’s made of wood. And therefore… A WITCH![2]

[youtube]zrzMhU_4m-g[/youtube]

Probable means –

Approach this from the opposite direction. Prove that the bad things happened. Prove that the accused person caused the bad things to happen. If that cannot be done, drop the charges. Either way, ignore the silliness about witches (even if there is good evidence, it is irrelevant).

Footnotes:

[1] Atropine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Interventions Not Recommended for Routine Use During Cardiac Arrest
Free Full Text from Circulation with links to Free Full Text PDF

[2] A duck!
urban dictionary
Article

Probably an urban legend, but it is the distorted logic of plausibility, that I am interested in.

.

Why Does Epinephrine Cause Brain Damage During Resuscitation

In the comments to The Danger of ROSC – Return Of Spontaneous Circulation is the following from Walt Trachim of Living in Manch Vegas.

I have a question, though. What is the actual pathophysiology that causes the damage to brain tissue?

If it were obvious that this would cause brain damage, there would not be people supporting the use of epinephrine. I do not see this as any kind of conspiracy, just the usual overestimation of our abilities that humans are so good at.

This is one of the reasons I try to avoid the Why explanations. We take the limited information and extrapolate from that to what happens in a much more general situation. The one thing we should count on is that the explanation is wrong.

As a species we want to know Why.

As people delivering patient care, we need to ignore the question Why and limit ourselves to Does it work?

Eventually we will have a much better understanding of the reasons Why, but if we understood that, we would not need to study treatments. We could just learn the pathophysiology and the answer would be clear. The many abandoned treatments make it very clear that our understanding of CPR is nowhere near good enough for that.

I don’t know Why. I could guess, but guessing (almost all of the recent explanations of Why the body does something) is just a way to come up with errors to be corrected later. I make errors, but I try to limit the frequency and significance of my errors.

We know that more people treated with epinephrine will die in the hospital.

We know that more people treated with epinephrine will have severe brain damage.

Do we need to know Why before we stop using epinephrine?

If I put my hand in a fire, do I need to understand the mechanisms of damage before I decide to pull my hand out of the fire?

Assuming that ROSC does happen, how does the Epinephrine that is given (and has a relatively short half-life) cause the kind of tissue damage that you’re talking about? Does it cause furthering hypoxia? Is it chemical? I’m trying to understand this a little better because I’m not sure why the relatively small doses that we use in the field could do the type of damage you describe.

See above for the Why explanations.

relatively small doses?

Epinephrine in live humans is given at 2 μg/minute to 10 μg/minute.

Epinephrine in dead humans is given at 1,000 μg all at once.

2 – 10 vs 1,000.

That is a huge difference.

There is nothing small about the epinephrine doses we give in cardiac arrest.

And this brings another question to mind: what about when Epinephrine is being used in a non-cardiac arrest situation? Specifically, if you’re dealing with someone who is in Anaphylaxis and is being given Epi in the 1:1000 concentration (albeit at a lower dose) for bronchodilation and vasoconstriction, would the concerns you’re talking about regarding tissue damage still apply? Based on the circumstances you’re detailing in your research and analysis, I’m inclined to think they would, but I’m definitely interested to read your thoughts on this.

We do give 300 μg IM (IntraMuscular) to anaphylaxis patients, but IM absorption is slower than IV and there is evidence that epinephrine is effective at preventing death in these patients.

What is the right dose of epinephrine for someone who is probably having a heart attack?

The most common cause of cardiac arrest is heart attack, so we should assume that these patients are having heart attacks.

I think that the right dose of epinephrine for a patient having a heart attack is zero μg.

I’m asking these questions for a very simple reason: you made me think. You’re really good at that, by the way. And, as I said, I want to understand the “why” more clearly. And since I’ve been a full-time student again, my brain has been engaged much more than it usually is.

Merry Christmas, and thanks for putting up with pestilent questions. 🙂

These are not pestilent questions. Asking questions is the way we learn. When we stop asking questions, it will not be because we have the answers to everything, but because we have lost our curiosity.

We need to accept that almost always we do not know Why.

Why does gravity pull us toward massive objects?

Why does the Sun work by nuclear fusion?

Why are there mosquitoes?

Why do we die?

The Why questions are great for coming up with hypotheses, but they will also keep you decades behind in treating patients.

An empirical approach can be less satisfying, but only if we insist on knowing Why.

See also –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

.

Hindsight is always 20/20 or If had known then…


At Hot Lights & Cold Steel there is Hindsight is always 20/20 or If had known then…

While there are a few points that I do not completely agree with, overwhelmingly I do agree with what is written.

First, hindsight is NOT always 20/20.

Often hindsight is not remotely accurate. We recall things poorly. We tend to assume that we recall things accurately, but we also tend to assume that we are better than average drivers/politicians/singers/lovers/EMTs/medics/nurses/doctors/et cetera. At least some of us are wrong.

Even in looking back at events that are well documented, we tend to come to different conclusions. And our memories change. We want to deny this, but our experiences change our memories.

Here’s the thing that no one bothered to tell me – to understand a drug… ANY drug – you have to understand the physiological actions of the body process the drug effects FIRST in order to then understand how the drug alters that physiological action.

We know that NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries) is the most efficatious drug for hypertensive CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). NTG also appears to be very efficatious for normotensive and even hypotensive CHF/ADHD.

Do we need to understand the mechanism?

Too often we base our treatments on conclusions drawn from research that has been spun into a tale to explain why something works. This is narrative fallacy. I explain more in Some Research Podcasting Comments.

The only certainty in medicine is that we do not know as much as we think we know.

We get to the point where we believe that we understand all that we can about the way that a drug works. We believe that drug is great. We study that drug and find that the research does not agree with what we knew. The research can be wrong, but it is more likely that the theory, which is based on research and other theories, is wrong.

No matter how much we think we know about the ways the body works and the ways that drugs work in our bodies, we find more to learn and plenty of cases of people responding in ways the pharmacology books claim they should not.

This is one of the most important reasons to continually reassess.

There is a reason the word atypical is frequently used in medicine.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.
Paracelsus (1493 – 1541)

By continually reassessing, I can often prevent an adverse reaction from progressing to a bad outcome.

However, the most important point written is –

here’s what I do regret –

Listening to all the paramedics who told me I’d never need to know most of what I was learning. The Krebs cycle (now called the Citric Acid cycle) Action potentials, Ph… the list I’m sure by the end of school will be extensive.

Just because we do not understand everything about the body, or everything about pharmacology, does not mean that we should deliberately choose to be ignorant.

Ignorance kills.

 

Learn more.

 

Kill less.

 

.

Education Problems, Autism, and Vaccines

Monday I wrote about the problems that can result from national standards. We do need to raise our education standards. An excellent example can be seen in the faulty logic used by those claiming that vaccines cause autism.

Hypothesis: Vaccines cause autism.

Experiment: Compare the rate of autism in groups with differences in vaccination methods. There are many ways this can be done, depending on the way the vaccine is hypothesized to cause autism.

However, the people claiming that vaccines cause autism do not accept the research that has been done. They claim that it is obvious that vaccines are dangerous and no amount of science will change their minds.

Vaccines contain thimerosal. Thimerosal is mercury. Mercury causes brain damage. The brain damage caused by mercury is exactly the same as autism. Mercury is one of the most toxic substances on the planet, so we have to stop poisoning children with it.

Clearly, this is a problem. We have a substance so dangerous that it must produce close to 100% brain damage. It is good that these public spirited people have raised this alarm.

Wait!

Using faulty logic, we can prove almost anything. Here is one example.

Zeno’s paradoxes provide several. Here is just one.

In a race, the quickest runner can never overtake the slowest, since the pursuer must first reach the point whence the pursued started, so that the slower must always hold a lead.[1]

Once the pursuer reaches the spot where the slower runner was, the process repeats infinitely. Since distances can be made ever smaller – there is no distance so infinitesimal, that is not made up of an infinite number of even smaller infinitesimal distances. Therefore, the faster runner can never catch up to a slower runner, who has just a tiny head start.

Using a different paradox, Zeno proves that the runner cannot even first reach the point whence the pursued started.

That which is in locomotion must arrive at the half-way stage before it arrives at the goal.[2]

The same endlessly repeating problem of infinitely divisible space is the explanation.

However, we know that these are not impossibilities. It is only by proposing an explanation that sounds reasonable, that these become confusing.

The way we find out the truth is simple. We test the claim.

Anyone capable of walking can walk across a room. There is no need to break the motion up into smaller and smaller parts. The motion is continuous.

Similarly, the problem of thimerosal only appears insurmountable. The only way to determine the accuracy of the claim is to test it.

The single study, that has supported any connection between thimerosal and autism, had such fatal flaws that it was retracted by the journal that published it. In 2004, most of the authors of the study had their names removed from the study, when they became aware of the fraud involved. The study was funded by lawyers hoping to win a big settlement from drug companies. All the lawyers needed was a study that showed this connection. About half a million dollars later, Andrew Wakefield was able to produce just such a study.

One problem with the explanation that thimerosal is such a toxic substance is that the occurrence of autism is supposed to happen so quickly after the vaccination, that the connection is inescapable. Some parents describe the onset of autism symptoms resembling somebody turning off a switch.

This study investigated if the discontinuation of thimerosal-containing vaccines paralleled a decrease in the occurrence of autism. The incidence of autism remained fairly constant during the period of use of thimerosal in Denmark, and the rise in incidence beginning in 1991 continued even in the group of children born after the discontinuation of thimerosal. The amount of thimerosal used in vaccines changed during the study period with less amount of thimerosal administered in the period 1970–1992. Moreover, the thimerosal-containing vaccine was gradually phased out meaning that the incidence rates should decline gradually if thimerosal has any impact on the development of autism. However, an increase (rather than a decrease) in the incidence rates of autism was observed.[3]

So much for throwing a switch.

Using the logic of the anti-vaccinationists, this must be evidence that thimerosal protects against autism.

There are many reasons for using this chart. The chart is from the same study as the paragraph that is above it, so it was handy. It is dramatic. It makes it easy to see that there is no connection between when thimerosal was in the vaccines (up until the vertical line) and autism (begins to increase just as the thimerosal is removed). There are other studies that show the same information. The evidence is clear.

There is no reason to believe that vaccines cause autism.

Then there is the comment that is supposed to silence disagreement. If you don’t have an autistic child, you cannot understand anything about autism. Unless you agree with the anti-vaccinationists. It doesn’t matter if you know what you are talking about, if you agree with them.

Therefore, if I want to know what is the best treatment for something, I should ignore doctors and ask a parent of a child with the condition. Using this logic, the most knowledgeable parent would be one with a child sick for the longest time with that disease. If being a parent of a sick child confers expertise, then the longer that illness continues, the greater the expertise conferred by this faulty logic.

If my child is sick, I am not going to look for parents with the same condition. These parents may have a lot of useful information about many things. However, the abilities to understand assessment, diagnosis, and treatment are not infections transmitted from the children to the parents.

The doctor to go to is also not the one treating children who do not get better. The anti-vaccinationists might conclude that the greatest expert is a parent who had at least one child die from the illness. They are persuaded by emotion, not reason.

There is a further problem with, I refuse to listen to anyone who does not have an autistic child. These parents even ostracize other parents of autistic children unless those parents agree with the emotional claims of the anti-vaccinationists about thimerosal. Catch-22 has nothing on them.

What about the mercury?

Thimerosal is C9H9HgNaO2S or sodium ethylmercurithiosalicylate. Mercury is Hg. Thimerosal is not mercury, but a compound that contains mercury. Being in a compound changes the characteristics and the effects of elements.

An example that people in EMS should understand is chlorine (Cl). This is so toxic, that it was used as a poison gas. Mix it with sodium (Na), which is also extremely toxic, and you have sodium chloride. Sodium chloride (NaCl) is known as common table salt. Sodium chloride is also the ingredient in normal saline, which we inject into the veins of just about every patient with a serious medical condition.

According to the anti-vaccinationists, No amount of mercury is safe. Based on what? Using the same criteria (Because I say so!), no amount of sodium or chlorine would be safe in the body. After all, they are toxic.*

The video below is less than 10 minutes long, but does a great job of explaining ways in which science keeps us from attributing too much to anecdotes, such as this. He was a normal little boy, until he received the vaccine. Autism is diagnosed at the time that children receive vaccinations. This is true, even for children who do not receive vaccinations. Since the vaccines do not cause autism, the only thing avoiding vaccination does is to endanger children.

The explanations that sound good, but are not supported by research are examples of narrative fallacy. I have written more than a little bit about narrative fallacy, because it is important. Using this devotion to reasonable sounding explanations, even though research demonstrates that these explanations are wrong, is a problem. Fortunately, in medicine there is more of an understanding of science. If that were not the case, we might be still bleeding patients to get rid of bad humors.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines

Footnotes:

^ * This does ignore the obvious problem that both hyponatremia and hypocalcemia are fatal conditions, even though sodium and calcium are toxic. If only there were some kind of medical expert to explain cutting edge toxicology. Somebody like Paracelsus.

^ 1 Zeno’s paradoxes
Wikipedia
Achilles and the tortoise
Article

^ 2 Zeno’s paradoxes
Wikipedia
The dichotomy paradox
Article

^ 3 Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data.
Madsen KM, Lauritsen MB, Pedersen CB, Thorsen P, Plesner AM, Andersen PH, Mortensen PB.
Pediatrics. 2003 Sep;112(3 Pt 1):604-6.
PMID: 12949291 [PubMed – indexed for MEDLINE]

Pediatrics has the free full text and free PDF available at their site.
Free Full Text                 Free PDF

.

EMS EdUCast – Journal Club 2: Episode 43

A week ago on the EMS EdUCast the topic was resuscitation. The big disagreement was about the IV vs No IV epinephrine study.[1]

One of the criticisms of the study is that Blair Bigham states that therapeutic hypothermia would lead to improved outcomes. However, the Oslo hospitals started routinely using therapeutic hypothermia only four months after the start of the study. So, almost all of the eligible patients did receive therapeutic hypothermia.[2] The therapeutic hypothermia study does show a doubling of survival to discharge with good neurological function at one year after discharge, so this does not appear to be any justification for doubting the effectiveness of treatment in Oslo.

Another concern is that PCI (Percutaneous Coronary Angiography or cardiac catheterization) might affect outcomes, but cardiac catheterization was also part of standard treatment in Oslo at the time.

Bill Toon mentions that some of the ambulances are staffed by physicians, but what difference is there between what a physician will do on scene and what a medic will do on scene? Physician staffed ambulances were present at 37% of no IV patients and 38% of IV patients, so this should not have affected either group more than the other.

A concern raised by Rob Theriault was the change in the CPR (CardioPulmonary Resuscitation) and ACLS (Advanced Cardiac Life Support) guidelines during the study period.

Until January 2006, ACLS was performed according to the International Guidelines 2000,14 with the modification that patients with ventricular fibrillation received 3 minutes of CPR before the first shock and between unsuccessful series of shocks.15 [1]

While they were not using the 2005 guidelines prior to January 2006 in Oslo, they were using a form of CPR that could be described as closer to the 2005 guidelines than the 2000 guidelines. According to the study –

Both groups had adequate and similar CPR quality with few chest compression pauses (median hands-off ratio, 0.15 for the intravenous group and 0.14 for the no intravenous group) and the compression and ventilation rates were within the guideline recommendations (Table 1).[1]

It appears that the compression interruptions are much less than what we would expect from a similar study done in the US, except where CCR (Continuous Compression Resuscitation or CardioCerebral Resuscitation) is being used correctly.

If you believe, as Blair appears to, that the improved outcomes in the US after the 2005 guidelines are at least partially due to epinephrine, likewise the improvements in the places using CCR, then you anticipate that when the first large enough randomized placebo-controlled study of drugs during cardiac arrest is published, it will show significantly better outcomes for those receiving epinephrine.

I doubt it. I expect something similar to the many studies of traditional treatments that could only be shown to improve surrogate end-points. Surrogate end-points are like alcohol. In moderation, the effects can be pleasant, while intemperate use distorts reality.

Some examples of being misled by surrogate end-points are the routine use of antiarrhythmic medication in post-MI (Myocardial Infarction) patients with PVCs (Premature Ventricular Contractions). The drugs did a great job of getting rid of the nasty looking PVCs, but making the rhythm look better did not improve outcomes. In spite of the wonderfully improved heart rhythms, the fatality rate more than tripled.[3]

We used to give furosemide (Lasix) to almost all patients presenting with symptoms of CHF (Congestive Heart Failure). Single-mindedly, we would try to remove as much water from CHF patients, because fluid in the lungs is a sign of fluid overload. Research, going back to the 1980s, shows that fluid in the lungs and fluid overload are not the same thing. Giving furosemide causes the body to dump water almost as dramatically as if we gave the patient an enema. Medical directors have responded to research showing harm from furosemide, and many have restricted the use of furosemide.

MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment) was the answer to blood loss. The same argument, that you have to have a pulse to leave the hospital alive, reared its head. Rather than focus on pulses in the ED, medical directors chose the meaningful outcome of more patients leaving the hospital able to care for themselves.

At one point, Buck Feris points out that post-resuscitation care is largely a matter of dealing with the side effects of epinephrine. Blair presents a paper that suggests that there are no post-resuscitation guidelines (not his conclusion). No post-resuscitation guidelines? There is an entire section of the ACLS guidelines on post-resuscitation care.[4] Just because there is no particular flow sheet to be memorized, does not mean that there are no guidelines. When I taught ACLS, post-resuscitation care was one of the essential parts I covered.

CPR/CCR, defibrillation, potentially reversible causes, and post resuscitation care are the things that make a difference in outcome. Why do we spend so much time on trying to resuscitate people, if we are not going to prepare them to actually deal with what happens after the return of a pulse?

Post-resuscitation care is not just about treating vital signs. Perhaps part of our problem is that we do not see this as part of resuscitation. If we understood this, maybe we would see that giving epinephrine is just about vital signs. Giving epinephrine is not about resuscitation. When we produce a pulse with epinephrine, we need to switch from resuscitation to trying to counter epinephrine toxicity.

Perhaps, if epinephrine were in any way considered good for the heart, I would be less cynical. There are not many drugs more toxic to the heart than epinephrine.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines

Updated 9/14/2012 at 03:00 for formatting.

Footnotes:

[1] Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed – in process]

I wrote about this in Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. If you want to read the full text of the study, it is available in PDF at the EMSEdUCast page for this episode.

[2] Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest.
Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, Draegni T, Steen PA.
Resuscitation. 2007 Apr;73(1):29-39. Epub 2007 Jan 25.
PMID: 17258378 [PubMed – indexed for MEDLINE]

[3] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.

N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.

CONCLUSIONS. There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.

I have written about this in C A S T and Narrative Fallacy and elsewhere.

[4] 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Circulation. 2005;112:IV-84 – IV-88.
Part 7.5: Postresuscitation Support
Free Full Text       Free PDF

.