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

- Rogue Medic

Remote CPR Skills Testing Online – A Crazy Idea?

ResearchBlogging.org
 

On the MedicCast, Jamie Davis interviews Roy Shaw of SUMO about a method of remote CPR certification for health care providers.
 

The Single Use Manikin Option, or SUMO™, is an AHA-compliant way of getting certified in CPR completely online.[1]

 


BlendedCPR.com
 

It looks too simple, but how complicated should we make it?

One of the problems with EMS is that we do not maintain skills that we do not use frequently. We know that we lose our skills very quickly, but we only retrain every couple of years (or every year) for the skills considered most important. If we care about our patients’ outcomes, we need to do better.
 

Not only have varying rates of skill acquisition been documented after traditional American Heart Association (AHA) training classes, but also universally poor skill performance of varying providers 3 to 6 months after CPR training has been established.11,–,15 [2]

 

Supervised on-line mannequin practice may be the most practical way for us to increase the rate of providing hands-on practice. As cameras become cheaper and smaller, as cell phones become much more interactive, we may have a way to do the same for intubation. Is there any good reason for practicing intubation less than once a month?

We need to improve our intubation, but everyone seems to think that the problem is with other medics and they do not need any practice. When the research is done, the problems continue. We like to intubate. We assume we are good at it. We hate to practice. we really like to make excuses. Our patients are the ones who are harmed. Other than bad assessment, bad intubation is probably the most deadly skill we have.
 

Training sessions occurred at entry into the study (time 0: initial skill acquisition) and then 1, 3, and 6 months after study entry.[2]

 

Each training session was less than five minutes long (one minute of testing, then two minutes of training), so the interference with work would be minimal, while the benefit would be significant.
 

In this study, lower rates of retention were observed in the training group that did not use a live instructor (automated defibrillator feedback only) compared with the group that used an instructor without automated feedback (instructor-only training).[2]

 

They suggest that the participants relied on the feedback from the automated devices and may not have learned to assess their performance themselves. During testing, the lack of machine feedback may have put them at a disadvantage. If machine feedback can be provided at the time of initiating compressions, The machine feedback could help. currently, that does not seem likely, so the use of only machine feedback is not as good an option as feedback from an instructor or from an instructor and a machine.
 

Although the automated feedback provided was targeted to CPR psychomotor skill errors, these systems do not provide constructive positive feedback. Instructors have an advantage: they were able to comment not only on skills done incorrectly, but also praise good performance.[2]

 

How well would this work in EMS?

We could make this something that is done once a week, or even at the beginning of each shift, on a different skill each time. Intubation/Airway management is the weak spot of EMS, so we could use this to improve.

If are only retraining on intubation/airway management once a year, or once every other year, we obviously are not taking patient care seriously and are trusting our luck, rather than any skill.
 

Go listen to the podcast on the Single Use Manikin Option (SUMO™) and consider if that would be a better way of recertifying. Maybe it is one way of implementing brief low-dose, high-frequency booster training in addition to recertification.

Also check out the site –

BlendedCPR.com

-

Footnotes:

-

[1] SUMO Remote CPR Skills Testing Online and Episode 392
By podmedic
June 30, 2014
MedicCast
Podcast/videocast page

-

[2] Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers.
Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V.
Pediatrics. 2011 Jul;128(1):e145-51. doi: 10.1542/peds.2010-2105. Epub 2011 Jun 6.
PMID: 21646262 [PubMed - indexed for MEDLINE]

Free Full Text from Pediatrics.

-

Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. (2011). Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-Hospital Pediatric Providers PEDIATRICS, 128 (1) DOI: 10.1542/peds.2010-2105d

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Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?

ResearchBlogging.org
 

If we are going to give epinephrine (Adrenaline in Commonwealth countries) to patients with rhythms that are not shockable (PEA [Pulseless Electrical Activity] or Asystole), it appears that patients receiving epinephrine earlier have better outcomes than patients who receive epinephrine later in the hospital in the less acute care settings.

Does this mean that patients who receive epinephrine have better outcomes than patients who do not receive epinephrine?

We remain willfully ignorant of the answer to that question.
 

Apart from cardiopulmonary resuscitation, no intervention has been shown to be efficacious in patients with non-shockable cardiac arrest.[1]

 

Would a placebo group have had better outcomes than the patients who received epinephrine the earliest? We have no way of knowing, because we discourage asking about what we take for granted.

 

We excluded patients with cardiac arrest in the emergency department, intensive care unit, or surgical or other specialty care or procedure areas,[1]

 


 

This does show an impressive association between giving epinephrine earlier and improved outcomes.

Does this mean that we should avoid giving epinephrine (a drug not yet adequately tested in humans) after a certain amount of time?

Does this mean that we should prioritize giving epinephrine (a drug not yet adequately tested in humans) before a certain amount of time?

Until we find out how harmful/beneficial epinephrine is compared to placebo, we do not know if we are helping with epinephrine, harming with epinephrine, or which patients we might be helping and which patients we might be harming. We have a half a century of I don’t know and I don’t care.
 

Despite a strong physiologic rationale and anecdotal reports of efficacy, there are no well controlled trials of epinephrine to assess endpoints such as improved survival and neurologically intact survival. A randomized trial failed to show efficacy for advanced cardiac life support drugs, and extrapolation to the potential lack of efficacy of epinephrine has been suggested; the dose, timing, and even use of epinephrine remains controversial.15-16 [1]

 

But some of the anecdotes are really good anecdotes!

Anecdote-based treatment is just ignorance-based treatment. We assume that we know what we are doing, but we are only imitating Skinner’s pigeons in our reaction to stimuli.
 


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

We have fancier uniforms than the pigeons, but we are just as unaware of the source of our stimuli.
 

The data was prospectively obtained using specifically defined variables, but the study was a retrospective analysis of that data.
 

Because data were used primarily as the local site for quality improvement, sites were granted a waiver of informed consent under the common rule.[1]

 

Because of the way the data are entered, any errors are likely to be at time of entry and may not be capable of being detected at the time of analysis for research. The numbers are very large – 25,095 patients – so that should correct for idiosyncratic errors, but what about cultural errors?

 

In the sensitivity analyses with adjustment for delays in initiation of cardiopulmonary resuscitation, time to epinephrine administration remained independently associated with survival to hospital discharge after multivariable adjustments.[1]

 

In the context of our findings, future investigations should consider timing of epinephrine administration in design and interpretation.[1]

 

We should also consider that epinephrine, if it is beneficial, is probably only beneficial to some patients. We need to try to identify those patients. Our current method of give epinephrine to everybody and let the emergency department sort them out is not reasonable.

This study ran from 2000 to 2009, so the improvements due to the focus on chest compressions might only affect a tiny portion of patients.[2]

Does epinephrine administration – at any time – produce better outcomes from PEA-asystole?

We still have no idea.

-

Footnotes:

-

[1] Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, Gautam S, Callaway C; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.
BMJ. 2014 May 20;348:g3028. doi: 10.1136/bmj.g3028.
PMID: 24846323 [PubMed - in process]

Free Full Text from BMJ.

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[2] Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care.
Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ; ROC Investigators.
Prehosp Emerg Care. 2010 Jul-Sep;14(3):355-60.
PMID: 20388032 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

On December 13, 2005, the AHA published “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”

ROC EMS agencies required an average of 416 days to implement the 2005 AHA guidelines for OHCA. Small EMS agencies, BLS-only agencies, and nontransport agencies took longer than large agencies, agencies providing ALS care, and transport agencies, respectively, to implement the guidelines.

How relevant is that to implementation in the less acute care settings studied in these hospitalized patients?

-

Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ, & ROC Investigators (2010). Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14 (3), 355-60 PMID: 20388032

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Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014). Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry BMJ, 348 (may20 2) DOI: 10.1136/bmj.g3028

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Who Needs a 12 Lead ECG?

ResearchBlogging.org
 

Do we do too many 12 lead ECGs on patients who do not have chest pain?

This is something that some people worry about.

Save the electrodes!

Those poor little electrodes are being abused!

Are electrodes being abused?
 

Women and the elderly with STEMI are particularly likely to present with atypical chief complaints such as dyspnea and weakness. Such patients experience significant delays in door-to-ECG time and treatment and have increased morbidity and mortality compared with patients who present with chest pain.5,9-12 [1]

 

Tiredness/weakness is the second best predictor of STEMI (ST segment Elevation Myocardial Infarction).

After chest pain (pressure, tightness, heaviness, squeezing, et cetera), the best predictor of STEMI is dyspnea in akll age ranges, but dyspnea indicates 20% of STEMIs in patients over 80 years old.

Are we helping anyone by avoiding 12 lead ECG (ElectroCardioGram) assessment?
 

Presenting chief complaints among 6,464 patients with STEMI. Chest pain decreased in frequency with age, whereas a chief complaint of dyspnea, weakness, syncope, or altered mental status all increased in frequency with age.[1]

 


Click on images to make them larger.
 


 

The advantage of a logarithmic chart is that there is greater distinction among the smaller numbers (such as the other complaints that make up less than 5% in the image above). The disadvantage is that large changes are flattened. I modified the dyspnea line to show how it would look on a linear scale (from 5% to 20%). As you can see, the ability to predict STEMI increases dramatically with age – more dramatically than the logarithmic scale suggests.
 


 

How should we remember all of this?

The authors came up with a nice simple flow chart (below).

This is for the ED, but is there a good reason for EMS to ignore these STEMIs?
 


 

Even in the 18-49 year old patients, dyspnea is about as likely to predict a STEMI as weakness is likely to predict a STEMI in an 80+ year old patient.

Chest pain still indicates about 50% of STEMI patients over 80, but we will miss half of STEMIs in this population if we only do 12 leads on chest pain patients.

Can an 80+ year old patient have a good quality of life after a STEMI?

Absolutely.

Also see When should you get an ECG? at Mill Hill Ave Command.

-

Footnotes:

-

[1] Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction.
Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, Glickman LT.
Am Heart J. 2012 Mar;163(3):372-82. doi: 10.1016/j.ahj.2011.10.021.
PMID: 22424007 [PubMed - indexed for MEDLINE]

-

Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, & Glickman LT (2012). Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. American heart journal, 163 (3), 372-82 PMID: 22424007

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The Failure of LUCAS to Improve Outcomes in the LINC Trial

ResearchBlogging.org
 

We love gadgets in EMS.

Dr. Bryan Bledsoe tells us that if we paint it orange and put a star of life on it, we can sell any product for a lot more money.

How much would you pay to not improve outcomes?

$10,000.00?

$20,000.00?

$30,000.00?

$40,000.00?

$50,000.00?

Why ask how much money we would pay for no improvement?

There is no price that justifies no improvement.
 


Image credit.
 

Experimental studies with the mechanical chest compression device used in this study have shown improved organ perfusion pressures, enhanced cerebral blood flow, and higher end-tidal CO2 compared with manual CPR, with the latter also supported by clinical data.9- 11 [1]

 

These are surrogate endpoints. What are surrogate endpoints? They are not outcomes that matter. Who cares if you got the pulse oximetry to 100% if the patient died? Survival matters.

There is good evidence that blood-letting improves surrogate endpoints.[2] We know that blood-letting kills.

Should we start bleeding patients based on improved surrogate endpoints?

Of course not. Treating patients based on surrogate endpoints kills patients.

There is good evidence that the LUCAS improves surrogate endpoints.

Should we start treating patients with the LUCAS based on surrogate endpoints?

Of course not. Treating patients based on surrogate endpoints kills patients.
 

The current sample size has a 95% confidence interval for the 4-hour survival ranging from −3.3% to +3.2%. Translated another way, while the point estimate for treatment effect was near 0.0, our study could not rule out the possibility of a 3.2% benefit or a similarly sized harm from mechanical CPR relative to standard CPR.[1]

 

What do you mean by this could be harmful?

The apparent benefit could be misleading and the device really could be more harmful than beneficial.

Anyone telling you otherwise is not being honest.

The authors are honest.
 

Thus, in clinical practice, CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.[1]

 

If you want to use the LUCAS because you believe in miracles, you are not discussing medicine. The LUCAS is a medical device that has failed to improve outcomes.

Dr. Brooks Walsh also explains the failure of the LUCAS in this study in “We had a LUCAS save!” – No, you didn’t.

Also see-

The LUCAS, Research, and Wishful Thinking.

In Defense of No Improvement by Medic Madness – Part I.

-

Footnotes:

-

[1] Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R.
JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538.
PMID: 24240611 [PubMed - indexed for MEDLINE]

-

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

-

Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, & Karlsten R (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311 (1), 53-61 PMID: 24240611

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If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part II

ResearchBlogging.org
 

Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.

What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?
 

Intuitively, devices such as the indirect video laryngoscope should improve intubation performance. As such, this study tested the hypothesis that achieving better visualization during the intubation with the GlideScope Video Laryngoscope would result in a better airway management performance as measured by shorter intubation times.[1]

 

The authors also intuitively assume that shorter intubation times mean better airway management. This suggests that speed is the most important factor in airway management.
 


Image credit.
 

They are probably still preaching the myth of the Golden Hour at Shock Trauma.

Is speed more important than quality?
 

There is an excellent assessment of intubation attempt in this paper.
 

Confirmation of intubation attempt duration and success was identified using closed-circuit video.[1]

 

We should not be relying on self-reported intubation success, unless we aren’t interested in a study of fiction. We do not accurately report intubation success, so an objective measurement of success is essential. This should be applied to EMS, as well.
 

The failed intubation rate was less than 0.5%, but the participants had already excluded over a quarter of the patients, so how impressive is a half a percent failure on 3/4 of patients?

What is the success rate for all patients?
 

For all of the statistics regarding study measures, a p < 0.05 was chosen as the threshold for determining significance.[1]

 

Secondary outcome measures are free shots at finding something “significant,” so they should be required to achieve a higher standard than the 1 in 20 p value of < 0.05.[2]

 

To account for any potential bias from patients not enrolled owing to attending discretion, comparison analysis was performed between the eligible, enrolled patients and the eligible, nonenrolled patients. The data demonstrates that all groups were proportionally similar in their demographics, injury mechanism, ISS, and arrival vital signs (data not shown).[1]

 

And, according to Dr. Newman in the SMART EM podcast, the Mallampati scores of the excluded patients were similar to those of the included patients.
 

Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.[3]

 

We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.[4]

 

Do the demographics, injury mechanism, ISS, and arrival vital signs increase the ability of the Mallapati to predicting difficult intubation?
 


Image credit.
 

How do we know that the difficulty was similar between included patients and excluded patients?

Similar Mallampati scores.

How useful are Mallampati scores at predicting difficulty of intubation?
 

The pooled estimates demonstrated that only 35% of the patients, who underwent tracheal intubation with difficulties, were correctly identified with a modified Mallampati test.[4]

 

Does the Mallampati score work well for predicting difficulty of intubation with a video laryngoscope?
 

The clinical use of videolaryngoscopes may change the accuracy of predictors of difficult tracheal intubation and require a different definition of difficult tracheal intubation.[4]

 

The Mallampati score does not appear to be of much use in comparing the excluded patients from the included patients, but that is what the authors use to assure us that the patients are similar.

Mallampati scores compare one aspect of visibility, but how important is visibility for intubation?

To be continued in Part III.

-

Footnotes:

-

[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed - in process]

-

[2] Do multiple outcome measures require p-value adjustment?
Feise RJ.
BMC Med Res Methodol. 2002 Jun 17;2:8. Review.
PMID: 12069695 [PubMed - indexed for MEDLINE]

Free Full Text from BioMed Central.
 

Standard scientific practice, which is entirely arbitrary, commonly establishes a cutoff point to distinguish statistical significance from non-significance at 0.05. By definition, this means that one test in 20 will appear to be significant when it is really coincidental. When more than one test is used, the chance of finding at least one test statistically significant due to chance and incorrectly declaring a difference increases. When 10 statistically independent tests are performed, the chance of at least one test being significant is no longer 0.05, but 0.40.

 

-

[3] A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway.
Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.
Anesth Analg. 2006 Jun;102(6):1867-78.
PMID: 16717341 [PubMed - indexed for MEDLINE]

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[4] Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients.
Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J; Danish Anaesthesia Database.
Br J Anaesth. 2011 Nov;107(5):659-67. doi: 10.1093/bja/aer292. Epub 2011 Sep 26.
PMID: 21948956 [PubMed - indexed for MEDLINE]

Free Full Text from Oxford Journals.

-

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

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Lee A, Fan LT, Gin T, Karmakar MK, & Ngan Kee WD (2006). A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesthesia and analgesia, 102 (6), 1867-78 PMID: 16717341

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Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J, & Danish Anaesthesia Database (2011). Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107 (5), 659-67 PMID: 21948956

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Is Earlier Better for Therapeutic Hypothermia? Part I

ResearchBlogging.org
 

When is the right time to begin TH (Therapeutic Hypothermia) to produce the best outcomes?

In the ICU (Intensive Care Unit)?

In the ED (Emergency Department)?

In the ambulance?

While the patient is still pulseless?

This question was asked in 2010.
 


Click on image to make it larger.
 

Favorable outcomes – 47.5% EMS TH vs 52.6% ED TH.

Worse outcome, but not statistically significant.

Discharge to home – 20.3% EMS TH vs 29.3% ED TH.

Worse outcome, but not statistically significant.

Discharge to rehabilitation – 27.1% EMS TH vs 23.3% ED TH.

Worse outcome, because these patients are not well enough to go home, but not statistically significant.

Dead – 52.5% EMS TH vs 46.6% ED TH.

Worse outcome, but not statistically significant.
 

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

EMS TH was added to many EMS protocols because of a lack of clear evidence of harm. EMS needed to Just do something.

The results did not support EMS administration of chilled IV (IntraVenous) fluid for prehospital therapeutic hypothermia, but the study was stopped early, because –
 

At the interim analysis of the first 200 patients, the Steering Committee noted that there was no difference in the primary outcome measure and that it was extremely unlikely that such a difference would emerge between the groups. Therefore, the study was stopped because of futility after 234 patients had been enrolled.[1]

 

In other words – We will not let the numbers convince us that there is no benefit, because numbers that do not support a positive effect are futile?

If the data would have indicated a negative effect, but had not reached statistical significance, should we expect the Steering Committee to support continuing the study, or would they support discontinuing the study early to protect the enrolled patients, but leave the question unanswered?

When studies are discontinued early to protect patients, do they discourage further studies?

When studies are discontinued early to protect patients, do they only endanger future patients?

Or does early termination encourage further studies because there is not clear evidence of harm and we want to believe that our interventions are beneficial?
 

What if it works?

Most proposed treatments do not work, so this is just an excuse to continue using something dangerous. What if it works? is the logical fallacy that is used to justify harming patients with alternative medicine.

We should not harm vulnerable patients because of our unreasonable belief in wishful thinking.
 

If it helps just one patient it is worth it.

This is another logical fallacy, because it completely ignores the harm that the treatment causes.

Some patients will improve after almost any treatment – even cyanide.

That means that alternative medicine advocates could should endorse the use of cyanide, because if it helps just one patient . . . .

We need to have unbiased information about the real benefits (if any) and the real harms (if any), before we encourage using anything on vulnerable patients.
 

Is it good to just do something?

Or

Is it good to help patients?

If our responsibility is to help patients, one of the best ways to help patients is to avoid causing harm.

Just doing something, with no evidence of benefit, is causing harm.

How many EMS agencies have prehospital therapeutic hypothermia protocols because of a desire to just do something?

I have been criticized for not being a supporter of treatments that do not have evidence of benefit.

Am I a killjoy, desiring bad outcomes?

No.

I understand that treatment that does not have evidence of benefit is almost always going to do more harm than good.

Just do something?

No.

Just demand valid evidence of improved outcomes.

-

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.

-

Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W, & Rapid Infusion of Cold Hartmanns (RICH) Investigators (2010). Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation, 122 (7), 737-42 PMID: 20679551

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If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I

ResearchBlogging.org
 

This study starts out looking good, but there is a huge problem with the design.

If the person intubating felt that he needed to use the video laryngoscope to get the tube, then the patient was not randomize into the study.

How was this paper accepted for publication with such an obviously violation of research methodology?

Did the authors at least track the violations of ethics, so that some analysis of all patients could be attempted?

Maybe this is not really GVL (GlideScope Video Laryngoscope) vs. DL (Direct Laryngoscopy), but a comparison of intubation of the not-so-difficult airway with GVL vs. DL.

What is not-so-difficult? Whatever did not get the doctor to cry, I could not possibly manage that airway safely with a regular laryngoscope!

833 patients would have been randomized, but the person in charge of the airway cried uncle in 210 (just over 25%) of these cases.
 


Image credit.[1]
 

Has airway management really deteriorated to the point where doctors do not feel competent managing 25% of airways without an electronic toy because they are superstitious and believe the toy has magical powers?
 


 

Maybe.

A study could be set up with some sort of objective criteria for excluding the most difficult airways and still be valid, but how do we objectively assess the need for an electric rabbit’s foot?

Did the doctors read their horoscopes and determine that it was a bad day and they needed to use all of their voodoo powers that day?

Did the doctors consult with psychics?

We do not know, because the criteria for superstition are not explained.

This is just a reminder that medicine, and perhaps especially trauma medicine, is still a very superstitious field. It wasn’t that long ago that these patients would have been treated with blood-letting to get rid of the bad humors that prevent healing. Humorous medicine.

Dr. David Newman and Dr. Ashley Shreves describe this in a SMART EM podcast.[2] Dr. Newman corresponded with one of the authors and states that some of the anesthesiologists at Shock Trauma are biased in favor of the video laryngoscope and refuse to use anything else. Were the 210 patients excluded just because some attending anesthesiologists are too biased to learn what works and those anesthesiologists were just throwing a tantrum for all of their patients?

The mythology of I know it works because I’ve seen it work.[3]

Are 25% of the attending anesthesiologists at Shock Trauma too biased to learn?[4]

Or have we improved to the point where only 25% of attending physicians in a specialty are to biased to learn?

To be continued in Part II.

-

Footnotes:

-

Image credit for witch’s hat.

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[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed - in process]

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[2] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

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[3] I’ve Seen It Work and Other Lies
Tue, 21 Jun 2011
Rogue Medic
Article

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[4] It would be the anesthesiologists managing just over 25% of the intubations, rather than 25% of the anesthesiologists, but no information is provided to clarify how many anesthesiologists that would be.

The result of the bias affects just over 25% of patients.

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Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

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Unreasonable Fear of Hypotension and High-Dose NTG – Part II

ResearchBlogging.org
 

Continuing from Part I to look at the results of the study of high-dose SL (SubLingual) NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) by EMS for CHF (Congestive Heart Failure) that Peter Canning wrote about.[1]
 

For CHF, more NTG does not produce more of a drop in blood pressure.
 

If you disagree, provide evidence.

I tend to get anecdotes, with excuses, rather than any kind of evidence.

Anecdotes are often indications that the person telling the anecdote does not understand and is trying to make up for that lack of understanding with bravado.
 


 

Therefore, we will continue to look at the evidence.
 


Click on images to make them larger.
 

You can see that some patients did have large drops in systolic blood pressure with only a double dose of NTG. To clarify, I highlighted the large drops in red below.
 


 

Only six large drops in systolic blood pressure.

Three systolic blood pressures dropped below 100 mmHg.

The expected happened with these dramatic drops in blood pressure and cases of hypotension –

Nobody had any bad outcomes.

The patients recovered without any intervention, such as fluid bolus, epinephrine, or whatever other placebo might be suggested.

Placebo?

A treatment that does not do anything more than doing nothing (benign neglect) is a placebo.

All these patients needed was a paramedic smart enough to use benign neglect.

Anecdotalists give a lot of treatments, because they mistakenly feel that that their intervention improve outcomes. Where is their evidence? In their overactive imaginations.

Those drops with double doses of NTG are scary. How bad was the outcome with triple doses of NTG?
 


 

Again, I highlighted the single big drop – only one – only dropped to about 130 mmHg systolic – in red below.

I added green to highlight the increases in systolic blood pressure after triple dose NTG. There were plenty of increases in systolic blood pressures after double dose NTG, but there were so many increases that it would have made the graph more difficult to read.
 


 

Multiple dose NTG every 5 minutes was clearly safe in this study.

Multiple dose anecdotes about Oh, no! What if . . . ? – continue to be wrong.

Forget the anecdotes.

There is plenty of evidence of safety.

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Footnotes:

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[1] Safety of High Dose Nitro in CHF
StreetWatch: Notes of a Paramedic
August 29, 2013
Peter Canning
Article

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[2] Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension.
Clemency BM, Thompson JJ, Tundo GN, Lindstrom HA.
Prehosp Disaster Med. 2013 Aug 21:1-4. [Epub ahead of print]
PMID: 23962769 [PubMed - as supplied by publisher]

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Clemency BM, Thompson JJ, Tundo GN, & Lindstrom HA (2013). Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension. Prehospital and disaster medicine, 1-4 PMID: 23962769

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