Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish


Dr. Edward Tobinick might not be a quack, but his behavior suggest otherwise.
 

Having a medical degree does not mean not a quack.

Using FDA (Food and Drug Administration) approved drugs does not mean not a quack.

Having a medical web site that does not have the word “quantum” all over the place does not mean not a quack.

Threatening to sue people for writing about the lack of evidence for his treatments does not mean not a quack.
 

Dr. Edward Tobinick is suing Science-Based Medicine for writing about Dr. Edward Tobinick’s dubious medical practices.

That strongly suggests that Dr. Edward Tobinick is a quack.
 

The claims and practice of Dr. Tobinick have many of the red flags of a dubious medical practice, of the sort that we discuss regularly on SBM. It seems that Dr. Tobinick does not appreciate public criticism of his claims and practice,[1]

 

Essentially, what Dr. Edward Tobinick is saying is, Your valid criticism of the way I apparently take advantage of patients might discourage patients from shelling out money for my untested treatment.

or –

Your valid criticism of the way I apparently take advantage of patients might encourage patients to ask reasonable questions about my untested treatment – questions that I cannot honestly answer.
 

Etanercept might work, but so might steroids, or ribavarin, or eye of newt, or a kick in the groin.

All of these treatments are equally valid. Oddly, the patients receiving a kick in the groin will probably report the fewest symptoms after treatment. 90% of the kick in the groin patients claimed to be cured and not in need of any further treatment.

Without evidence, and with his opposition to evidence, Dr. Edward Tobinick is just a quack with a brainstorm. Nothing original there.
 

Dr. Edward Tobinick injects etanercept (Enbrel) around the spine. This is not something he covered in his dermatology residency, so has he injected etanercept into the spine yet?

Why etanercept? Etanercept is an immune suppression/anti-inflammation drug. Inflammation is a problem with everything, so preventing/reversing inflammation is the simplistic cure. If this worked in real people, and not just in the hypotheses of pathophysiologists, steroids would have cured everything decades ago.

Perhaps Dr. Edward Tobinick is imitating Dr. Michael Bracken, who is able to produce improved outcomes with steroids (anti-inflammation drugs) for spinal injury, but only when he is in charge of the data.[2]

At least Dr. Michael Bracken published some research to support his claims. Dr. Edward Tobinick just wants us to believe that his interpretation of pathophysiology is miraculously prescient.
 

Evidence? We ain’t got no evidence. We don’t need no evidence! I don’t have to show you any stinkin’ evidence!
 

Maybe Dr. Edward Tobinick does have some valid evidence.

Maybe Dr. Edward Tobinick is just hiding the valid evidence because it is proprietary. ;-)

Here are a couple of comments by Dr. Novella on science and the importance of evidence. They probably were not directed specifically at Dr. Edward Tobinick, but they do apply to him.
 

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

 

Science is the way we learn what works.

Dr. Edward Tobinick’s criticism is evidence that he does not understand science.

Is any treatment, that is not based on evidence, likely to provide a benefit to patients?
 

History is strewn with ideas that were intuitive and made sense at the time, but were also hopelessly wrong.

 
Alternative medicine, opposition to EBM (Evidence Based Medicine), and opposition to SBM (Science-Based Medicine) are all the same mistake – evidence denialism.

Evidence denialism is devotion to being hopelessly wrong and remaining ignorant of being wrong.
 

Barbara Streisand?[3]

-

Footnotes:

-

[1] Another Lawsuit To Suppress Legitimate Criticism – This Time SBM
Posted by Steven Novella
July 23, 2014
Science-Based Medicine
Article

-

[2] Cochrane and a Significantly Biased Review of Steroids for acute spinal cord injury
Fri, 25 May 2012
Rogue Medic
Article

-

[3] Streisand effect
Wikipedia
Article

Maybe there is no such thing as bad publicity for a quack, but the publicity associated with this law suit means that people will associate the name quack with Dr. Edward Tobinick, or vice versa.

Dr. Edward Tobinick is stating I am not a quack.

Reasonable people are hearing –

I, Dr. Edward Tobinick, am a quack.

.

When is a double dose of defibrillation a good idea?

 
In the comments to Double simultaneous defibrillators for refractory ventricular fibrillation, NCMedic and Ambulance Driver write that they have already begun using variations on double defibrillation.
 

That     is     excellent.

 


 

The changes in when to implement the change, as well as the vector to use, are reasons we need to have people publishing results on what is being done. Please, work with your medical directors and/or others to publish some results.

We have had epinephrine (Adrenaline in Commonwealth countries) in ACLS (Advanced Cardiac Life Support) guidelines, and our protocols, for decades, but we still do not know the best dose or even which patients benefit.

NCMedic writes –
 

Has been in our protocols for sometime now, we are finding it more beneficial sooner than later for obvious reasons, next protocol revision will most likely have it on the 4th shock with the 2nd set of pads placed A/P to cover from a different vector.

 

Epinephrine seems to be harmful when given later, or is epinephrine less beneficial later, or is epinephrine always harmful, just much more harmful later, or something else.[1]

The problem is that we do not know when, or for whom, epinephrine is indicated.

Epinephrine is probably indicated in some patients, but which patients, at what dose, and at what time? If epinephrine should be repeated all of the same questions apply to all further doses. Dr. Scott Weingart points out how little we know about the use of epinephrine, because his approach makes more sense than what ACLS recommends and the evidence is equally lacking.[2]

There are many things in the presentation to discuss, such as Dr. Weingart’s misunderstanding of what nihilism means, but that is for another time.
 

There does not appear to be any harm from double defibrillation. As we use more current more often, we should expect to learn of harms, as we do with almost every intervention. However, as NCMedic states, we may be doing harm by waiting too long to deliver the double dose.

Should it be a double dose?

What about 1 ½ times the maximum?

300 j bi-phasic or 540j mono-phasic or maybe some combination of bi-phasic and mono-phasic, and if a combination, what combination, with drugs or without, which drugs if with drugs, . . . ?

What about 3 times the maximum?

600 joules bi-phasic or 1,080 joules mono-phasic or . . . ?

Should the higher-dose defibrillation be after the fifth shock with a return to VF/pulseless VT (Ventricular Fibrillation/pulseless Ventricular Tachycardia)? After the fourth shock? After the third shock? After the second shock? After the first shock?

Is waiting longer to increase joules making it more likely that epinephrine will be given? Is epinephrine more harmful than a double shock, less harmful than a double shock, or roughly the same?

The amount we do not know is huge.

We should learn what we are doing to our patients and not arrogantly choose to remain ignorant, as we have chosen with epinephrine. That is changing, but some still defend the arrogance of ignorance at the expense of our patients.[3]

-

Footnotes:

-

[1] Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?
Sun, 25 May 2014
Rogue Medic
Article

-

[2] Podcast 125 – The New Intra-Arrest from SMACCgold
EMCrit
Dr. Scott Weingart
Web page with video and show notes.

-

[3] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com
 

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

 

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

 

.

IAFF’s Jack Reall faces discipline for delaying a 911 call in order to protest research he does not like


 

One of the advantages of fire department-based EMS is that there is a clear chain of command and that discipline is not a problem. The exceptions to this may be rare enough that they make headlines. Here is one.
 

A Columbus Fire battalion chief could face discipline for insubordination after an internal investigation found that he disrupted a pilot program intended to more efficiently respond to emergencies.[1]

 

The first oddity is that the Battalion Chief (Jack Reall) is also the president of Local 67 of the International Association of Fire Fighters. A management position and a union position – and not just any union position, but president. Jack Reall apparently cannot keep his priorities in order.

The fire department is studying whether 911 calls should receive an initial response from one paramedic with a basic EMT or from a pair of paramedics. There is no evidence that sending one paramedic and one EMT causes any kind of harm, or that two paramedics provide better care, so there is no basis to claim that anyone is being in any way endangered by this pilot program.

If there were a legitimate concern, then the time to address that was when the pilot program was being considered. It appears that Jack Reall is not happy with that and his union boss persona delayed a 911 response in violation of fire department rules.
 

The Fire Division launched a pilot program that morning to reduce the number of paramedics who respond to routine calls, allowing the division to disperse medics elsewhere. Instead of two paramedics on a truck, there would be one medic and a basic emergency-medical technician, or EMT.[1]

 

Is it possible that this was a complete surprise to Battalion Chief/Union President Jack Reall?

I don’t know what kind of preparations were made by the fire department, but I suspect that they began well in advance of BC/Pres. Jack Reall’s attempt at sabotage.

It is appropriate to study things when there is a state of equipoise about which is best.

Equipoise is just a fancy word for We do not know which is best.

When we do not know what is best, we should find out, rather than arrogantly assume that we know all that we need to know to force an uninformed opinion on others. That is the alternative – I don’t know, but I am going to force my opinion on everyone else because I am certain my opinion is more important than learning the truth.

Research means we learn more, even if we never learn the whole truth. Opposing research is opposing learning more – especially if the truth disagrees with opinion.

Equipoise means that we cannot be certain, because we do not know enough to be certain.
 

Reall was against the plan from the start and said fewer paramedics meant lower-quality service.[1]

 

The fire department and the union probably have worked out procedures for resolving these differences of opinion. They probably do not include delaying 911 responses to make a point.

If Jack Reall were behaving responsibly, he would have raised these concerns at an appropriate time and place.
 

Reall said the plan was not presented well to firefighters and paramedics and was “not well thought out.”[1]

 

He did raise them at the appropriate time, but he did not get what he wanted.

When I don’t get what I want, as a responsible adult, I should throw a tantrum.

True or False?

A Battalion Chief is supposed to be a person to turn to to resolve confusion, not to create confusion. One part of the job is to make a clear decision (such as to protect the interests of a patient) and to take responsibility for that decision.

It appears that Reall was doing the opposite.

-

Footnotes:

-

[1] Firefighters-union chief faces discipline from Fire Division
By Lucas Sullivan
The Columbus Dispatch
Wednesday July 9, 2014 5:51 AM
Article

.

Is First Responder Narcan the Same as First Responder AED?


Image credit.
 

Are these the same?

If one works, does the other work?
 


Image credit.
 

The idea that first responders can safely give naloxone (Narcan) is popular, but only based on things that we want to be true. Dr. Oz would love it.

It has been suggested that giving first responders naloxone is the same as giving them AEDs (Automated External Defibrillators).[1] AEDs are defibrillators that can deliver the same shock as a manual defibrillator, but AEDs do not require all of the education needed to become a paramedic, nurse, PA, NP, or doctor.

Unlike naloxone, AEDs are designed to do almost all of the assessment for the first responder. The AED is only supposed to be attached to a pulseless patient, so assessment for responsiveness and the presence of a pulse is expected by the first responder. Is naloxone assessment that simple?

When a patient actually has an opioid overdose, it can be that simple, but -

Not all patients who respond after naloxone, respond because of naloxone.

This is the concept that is difficult to explain to the advocates of first responder naloxone programs.

1. Some advocates deny that this happens, even though it is documented.

2. Some advocates claim that we already know all that we need to know about naloxone.

3. Some advocates also claim that we should not study this because we already know all that we need to know.

Since there is overlap among the groups, the failure to understand the problem of improper assessment, especially among paramedics, nurses, and doctors is a huge problem. If we do not understand naloxone, with all of our education in pharmacology, how can we expect first responders to understand naloxone without any education in pharmacology?

What kind of education can prevent mistakes? How do we know?

If we listen to those who don’t know, but claim that they know all that they need to know, we will be ignoring the possibility of unintended consequences and assuming that we are too smart to make mistakes. Is that reasonable?

Do AEDs save lives?
 

CONCLUSION:

Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.[2]

 

The problem is not that AEDs do not work.

The problem is not that AEDs are not safe.

The problem is thinking that AEDs are a simple solution to a problem that is not as simple as some would like us to believe.
 

The concept of equipping as many emergency responders as possible with AEDs has been widely adopted,2 and 31 but it should not be blindly adopted without improving the EMS system at all levels. This decision should be individualized to each EMS system based on all of the variables in EMS response. As an isolated enhancement, it is doubtful that addition of AEDs will provide a measurable survival benefit.[2]

 

If first responder naloxone were limited to people found with needles in their arms, less thought would be required. As the presentation of overdose changes to prescription opioids, there is less clear evidence of overdose and more of a need for a good assessment and understanding of pharmacology.

First responder naloxone may save lives, when it is administered appropriately. We should study this before implementation. Discouraging us from studying the safety and efficacy of this type of use of naloxone is bad medicine.
 

Also see –

Is ‘Narcan by Everyone’ a Good Idea?

Should Basic EMTs Give Naloxone (Narcan)?

The Myth that Narcan Reverses Cardiac Arrest

To Narcan or not Narcan

What About Nebulized Naloxone (Narcan) – Part I

-

Footnotes:

-

[1] I’ve heard that PA is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone. . . .
Facebook
Narcan post

-

[2] EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.
Sweeney TA, Runge JW, Gibbs MA, Raymond JM, Schafermeyer RW, Norton HJ, Boyle-Whitesel MJ.
Ann Emerg Med. 1998 Feb;31(2):234-40.
PMID: 9472187 [PubMed - indexed for MEDLINE]

.

Why US EMS will never get to sit at the adult table – The Appeal to Authority

 

Do you like articles that inveigh against EMTs/paramedics and EBM (Evidence-Based Medicine)?

Here are some samples from a rant by my friend Mike.
 

Here is the bottom line, at the top of the page, they have too little education, do not understand science, and are too simple minded.[1]

 

Apparently, an EMT irritated him. I have occasionally been a source of irritation for Mike.

EMS does have too little education, but the problem is less about the quantity, than it is about the quality. If EMS education were more evidence-based that would improve the quality, but it would not make Mike happy.

People do not understand science. Things appear to be improving in both EMS and medicine. This article is an ironic example of the problems with medicine, with understanding science, and with the use of evidence.

There is really only one example of the use of valid evidence -
 

Maybe you were even one of those services that “forced” your local hospital to institute the now questionable practice of hypothermia based on “science?” More sad news, you were duped.[1]

 

I have written about the research which shows that prehospital therapeutic hypothermia with IV (IntraVenous) fluid does not work.[2],[3],[4],[5]

Mike does not explain how he came to the conclusion that the science pathophysiology was wrong. Was it a lucky guess?
 

You should do yourself a favor and go read some of the many websites on science based medicine compared to “evidence based medicine.”[1]

 

Mike follows this recommendation with a list of some of the potential problems with research. We do need to better understand research, but a lack of perfection affects everything, so imperfection is not a reasonable criticism of EBM or SBM (Science-Based Medicine).
 

I have yet to see an EMS provider pick up a study they like and try to reproduce it.[1]

 

How would having each individual reproduce each study, be relevant to anything? If I do not study something myself, I cannot use the research?

Later he exaggerates the problems with EMS research. Was he mocking himself here? Is he mocking himself there? Both? :oops:

What is important in interpreting medical research, is that we are able to read a study in a way that we can identify flaws in the study, see if the researchers found ways to control for as many variables as possible, recognize possible biases, et cetera.

It is not necessary for each person reading/citing a study to reproduce that study. What matters is that the therapeutic hypothermia research has been replicated.[6],[7],[8],[9]

I did not set up any studies to reproduce the therapeutic hypothermia studies, because the information is in the paper. When the information is not there, that is a flaw. I did explain that prehospital therapeutic hypothermia with IV fluid is an example of why it is wrong to extrapolate from pathophysiology about untested treatments.
 

If it was possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation, why would we need healthcare providers at all?[1]

 

There is a website that creates quotes like this for the wisdom of Deepak Chopra. It generates random fictional quotes that sound like what Chopra would say (e.g. – “Interdependence belongs to the flow of bliss”). See what you get. Maybe I should create a quote generator for Mike.[10]

Would any reasonable person suggest that it is possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation?

Why does Mike?
 

That’s right, no double blind random placebo controlled studies on the validity of CPR. No prospective treatment studies on unconscious people who cannot be advised on and consent to the risks. No deviating from “the standards” or “commonly accepted” modalities of care. Sometimes you can get a waiver, but it is easier to walk on water and part seas.[1]

 

The therapeutic hypothermia patients were conscious and gave consent to participate in the study?

Think about that and how much Mike understands what he is writing about.

Consciousness was a reason for exclusion from these studies. Why doesn’t Mike know this?

Pick up any study with human patients. It will explain how the ethical consent was handled for the patients in that study.
 

Nazi Germany is the closest anyone has come to unbiased human experimentation.[1]

 

The Nazis were obtaining consent?
 

This is followed by some brave attacks on straw men, then praise for the parachute study – a satire paper that is based on a logical fallacy.[11],[12]

There is nothing wrong with using logical fallacies for satire. Did Mike intend his manifesto as satire or as spectacular irony? :oops:
 


Volunteers eager to participate in unbiased Nazi experiments?
 

Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff. They read a study, and assume this evidence has been met.[1]

 

That may apply to most doctors, too. It isn’t the right way to approach research, but it is a criticism of the reader, not the evidence.

Then Mike valiantly lashes out at some more straw men.
 

What can EMS, and doctors, do to better understand research?

Read some of the many analyses of evidence that are available for free on the internet. I frequently write about the problems with research, but I do not make the mistake of claiming that EMS research is useless.

Many others write about EMS and emergency medicine research. I described some of the best sites a year ago.[13]
 

Read some of these –

Life in the Fast Lane Research Review

The EMSB Digital Research Library

Skeptical Medicine

Mill Hill Ave Command

EMS Patient Perspective

Street Watch: Notes of a Paramedic

A Day in the Life of an Ambulance Driver

EMS 12 Lead

SMART EM

EM Crit

Emergency Medicine Literature of Note

Canadian Prehospital Evidence Based Protocols

SOCMOB Blog – Standing on the corner, minding my own business in the ER

prehospitalresearch.eu

The Poison Review

PHARM – PreHospital And Retrieval Medicine

EM Lyceum

Emergency Medicine Ireland

Skeptics’ Guide to Emergency Medicine

Dr. Bryan Bledsoe
 

For an accurate description of SBM, read the site that originated the concept –
 

Science-Based Medicine

-

Footnotes:

-

[1] Why US EMS will never get to sit at the adult table
The5Conflicts
April 26, 2014
Article

-

[2] The Relentless Optimism of a Stalker Applied to Medicine
Wed, 23 Apr 2014
Rogue Medic
Article

-

[3] EMS Dinosaurs and the Slow Gazelles – EMS Office Hours
Wed, 12 Feb 2014
Rogue Medic
Article

-

[4] What Can EMS Expect From 2014? #2 Prehospital Therapeutic Hypothermia
Tue, 31 Dec 2013
Rogue Medic
Article

-

[5] Is Earlier Better for Therapeutic Hypothermia? Part I
Wed, 20 Nov 2013
Rogue Medic
Article

-

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

-

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

-

[8] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed - indexed for MEDLINE]

-

[9] 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.

-

[10] The enigmatic wisdom of Deepak Chopra
random fictional Deepak Chopra quotes
Quote generator
 

It has been said by some that the thoughts and tweets of Deepak Chopra are indistinguishable from a set of profound sounding words put together in a random order, particularly the tweets tagged with “#cosmisconciousness”. This site aims to test that claim! Each “quote” is generated from a list of words that can be found in Deepak Chopra’s Twitter stream randomly stuck together in a sentence.

 

-

[11] Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20;327(7429):1459-61. Review.
PMID: 14684649 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

-

[12] Does the parachute study prove that research doesn’t matter? Part I
Wed, 22 Aug 2012
Rogue Medic
Article

-

[13] Some Excellent New Medical-Research Sites
Fri, 24 May 2013
Rogue Medic
Article

.

The Silver Lining of Epi – Organ Donation – Part 2

 

Continuing from Part 1. In writing about why we should not get rid of epinephrine, Scott makes the following statement –
 

Patients who receive epinephrine in cardiac arrests have worse outcomes.[1]

 

Go read the full paragraph. I am not taking that out of context.

Scott suggests that this is acceptable, because some of these patients will be brain dead and some of those brain dead patients will end up being organ donors.

While it is true that some of those resuscitated from cardiac arrest following administration of epinephrine will end up being organ donors, should that affect our attempts to resuscitate the patient? Currently, the AHA (American Heart Association) does not encourage using treatments that may produce worse outcomes just for the purposes of increasing the number of organ donors.[2]
 

Even hearts can be transplanted from cardiac arrest patients can produce good outcomes.[3]
 


 

So far, so good.
 

Maybe it is time to look at them from a different angle. We need to look at dealing with a cardiac arrest in stages. Stage one, of course, is to work as hard as we can to achieve ROSC. ROSC is an absolute: there is a pulse, or there is not a pulse.[1]

 

How much harm do we do in order to get more ROSC (Return Of Spontaneous Circulation)?

ROSC is binary, but there are many ways to obtain ROSC.

The way we obtain ROSC seems to affect the survival of the patient and the brain function in those who do survive.
 

This is comparing three different treatments HDE (High-Dose Epinephrine), SDE (Standard-Dose Epinephrine), and NE (NorEpinephrine). The lines for the HDE and NE are so close to each other, that you may not be able to see the gold line.[4]
 

Compare that chart of HDE, SDE, and NE with this chart comparing Epinephrine and No Epinephrine.[5]
 


 

More ROSC, but fewer survivors.[6]

More organs, because of fewer survivors of cardiac arrest?

Is this our goal?

We could take the extreme utilitarian approach of Your organs can benefit far more people – if they are not in you.

Scott wouldn’t advocate for that with any other patient, so why head that way with cardiac arrest?
 

Patients who receive epinephrine in cardiac arrests have worse outcomes.[1]

 

Is epinephrine the cause of the harm? We do not know and we are perversely not trying to find out.

If giving epinephrine decreases survival from cardiac arrest, then giving epinephrine increases the pool of available organs at the expense of our original cardiac arrest patients. That is not the goal.

Organ donation is important. Harming patients, in order to obtain more organs, is not the goal of organ donation.

-

Footnotes:

-

[1] The Silver Lining of Epi
February 3, 2014
EMS in the New Decade
Scott
Article

-

[2] Organ Donation After Cardiac Arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 9: Post–Cardiac Arrest Care
Free Full Text from AHA.

-

[3] Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation.
Ali AA, Lim E, Thanikachalam M, Sudarshan C, White P, Parameshwar J, Dhital K, Large SR.
Eur J Cardiothorac Surg. 2007 May;31(5):929-33. Epub 2007 Mar 26.
PMID: 17387020 [PubMed - indexed for MEDLINE]

Free Full Text from Eur J Cardiothorac Surg.

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[4] A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.
Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J.
JAMA. 1992 Nov 18;268(19):2667-72.
PMID: 1433686 [PubMed - indexed for MEDLINE]

-

[5] Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
PMID: 22436956 [PubMed - indexed for MEDLINE]

Free Full Text from JAMA.

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[6] Are We Killing People With ROSC?
Wed, 05 Jun 2013
Rogue Medic
Article

.

The Silver Lining of Epi – Organ Donation – Part 1

 

Is there really a silver lining to giving epinephrine for cardiac arrest? Scott writes about organ donation as one possible silver lining.
 

The next time you bring one of those cardiac arrest patients in who when you follow up on them, you are told that they have “no brain activity” do not look at it as a complete loss. Ask that follow up question, “Are they going to be able to donate any organs?” You might be pleasantly surprised at what the answer is. Although it’s not exactly what we are looking for, a life might have been saved.[1]

 

That seems reasonable, except that it assumes that the treatment that will produce the best survival, a return to normal life, is produced with epinephrine.

Epinephrine may produce more organ donors, but that is not what we base our treatment on. We treat patients based on what is expected to produce the best outcome for them, not what is expected to produce the best/most organs for donation. Even looking at organ donation, there are many different considerations.

What produces the best organs?

What produces the most organs?

What produces the mixture of quality and quantity that seems to be best for patients?

If we want to improve organ donation rates, one thing we should consider is addressing organ donation directly – not advocating for things that might produce increased organ donation as a side effect. Changing the law from the current opt in to opt out.

With opt in – if I have not made a choice, or if anyone objects to my choice, it is presumed that I object to organ donation and my organs are discarded.

With opt out – if I have not made a choice, it is presumed that I do not object to organ donation and my organs are available to those on the organ transplant lists.

Currently, the license to drive is the indicator and there would be no reason to change that. We are asked to select this if you want to be an organ donor. We would change the question to select this if you do not want to be an organ donor.

Donations are more complex than opt in vs. opt out, but changing one thing may lead to changes in other things because of increased attention.

Here are changes in various rates of organ donation in Belgium before and after a change from opt in to opt out.
 


 

 

 

 

 

 

 

 

 

 

 

Presumed consent alone is unlikely to explain the variation in organ donation rates between different countries. A combination of legislation, availability of donors, transplantation system organisation and infrastructure, wealth and investment in health care, as well as underlying public attitudes to and awareness of organ donation and transplantation, may all play a role, although the relative importance of each is unclear.[2]

 

Should we assume that epinephrine really improves the likelihood of organ donation without decreasing survival from cardiac arrest? I will discuss that in Part 2.

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Footnotes:

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[1] The Silver Lining of Epi
February 3, 2014
EMS in the New Decade
Scott
Article

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[2] A systematic review of presumed consent systems for deceased organ donation.
Rithalia A, McDaid C, Suekarran S, Norman G, Myers L, Sowden A.
Health Technol Assess. 2009 May;13(26):iii, ix-xi, 1-95. doi: 10.3310/hta13260. Review.
PMID: 19422754 [PubMed - indexed for MEDLINE]

Free Full Text from National Institute for Health Research.

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In Defense of No Improvement by Medic Madness – Part IV

ResearchBlogging.org
 

Continuing from Part I, Part II, and Part III in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -
 

Another issue I have with this data, is that it doesn’t address the following variables:

  • Down time
  • Whether or not bystander CPR was performed
  • Medications used
  • Whether or not an advanced airway was placed
  • Length of resuscitation

All of these things are important when looking at the effectiveness of the LUCAS. Had all of these cases been witnessed full-arrests with immediate intervention, then I might feel differently. Perhaps they did look at these things, but from the data that’s available to the general public, I can’t determine whether or not the LUCAS doesn’t “do any good”. From what we can see, at the very worst it keeps up with some of the best-trained responders out there. Not bad, if you ask me.[2]

 

Did you look at the paper?

Are you guessing at what the study shows based on intuition?

The information is there. This will be mostly a picture book response.

Down time?

Whether bystander CPR was performed?
 


Click on images to make them larger.[3]
 

Medications used?
 


Study design.[4]
 

In both groups, ventilation and drugs were given according to guidelines.16 [3]

 

There is no breakdown for medications.

Of course, medications have not been demonstrated to improve any outcome that matters.

The best way to determine this would be by –

Length of resuscitation or time to ROSC (Return Of Spontaneous Circulation).?
 


 

Whether an advanced airway was placed?
 


 

This may favor the LUCAS, since airways seem to interfere with survival.

Maybe manual compressions really are not the same during an intubation attempt. Maybe people back off on compressions. Therefore, maybe it is easier to intubate under those circumstances. We do not know. The LUCAS may make intubation more difficult.

Worse CPR may mean better intubation, but since intubation doesn’t improve anything, is that a good compromise?

Which is our no improvement device of choice? :oops:
 

Conclusion

We need to be looking at the whole picture here. If we can design a machine to do textbook-perfect CPR, and it doesn’t produce textbook results, then maybe we need to re-evaluate our textbook. Even if the studies do prove that the device isn’t improving survival rates, we still can’t discard the device as “worthless”. It has its place in situations with limited responders. And yes, the data supports that.[2]

 

Why assume that a textbook is right?

How often do I cite any textbook? The only textbook I regularly (and usually negatively) cite is ACLS.

Textbooks tend to be the last to change, but textbooks do change. The change is because research demonstrates that the textbook is wrong and needs to be revised. Textbooks are expected to be revised as we learn more from research.

When you suggest that the research does not confirm the biases of the textbook writers as evidence of a problem with the research, there is the possibility that you are right. This research may be providing evidence that the assumptions of the textbook writers are wrong. The way we find out is by looking closely at the quality of the research and looking at similar research.

However, LINC is good research.
 

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 [3]

 

Why is it that improving these surrogate endpoints does not improve what matters – survival? What do we not understand?

We should be more interested in doing no harm.

We seem to be more interested in throwing the kitchen sink at the patient, because what if the arrest is due to a kitchen sink deficiency?
 

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

Peter Canning describes the failures of judgment in advocating for the LUCAS in Whup Kits and Chihuahuas.

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Footnotes:

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[1] The Failure of LUCAS to Improve Outcomes in the LINC Trial
Wed, 05 Mar 2014
Rogue Medic
Article

The LUCAS, Research, and Wishful Thinking
Fri, 07 Mar 2014
Rogue Medic
Article

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[2] In Defense of the LUCAS
March 12, 2014
by Sean Eddy
Medic Madness
Article

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[3] 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]

Free Full Text in PDF Download format from PEHSC.org.

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[4] The study protocol for the LINC (LUCAS in cardiac arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation.
Rubertsson S, Silfverstolpe J, Rehn L, Nyman T, Lichtveld R, Boomars R, Bruins W, Ahlstedt B, Puggioli H, Lindgren E, Smekal D, Skoog G, Kastberg R, Lindblad A, Halliwell D, Box M, Arnwald F, Hardig BM, Chamberlain D, Herlitz J, Karlsten R.
Scand J Trauma Resusc Emerg Med. 2013 Jan 25;21:5. doi: 10.1186/1757-7241-21-5.
PMID: 23351178 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

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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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Rubertsson S, Silfverstolpe J, Rehn L, Nyman T, Lichtveld R, Boomars R, Bruins W, Ahlstedt B, Puggioli H, Lindgren E, Smekal D, Skoog G, Kastberg R, Lindblad A, Halliwell D, Box M, Arnwald F, Hardig BM, Chamberlain D, Herlitz J, & Karlsten R (2013). The study protocol for the LINC (LUCAS in cardiac arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scandinavian journal of trauma, resuscitation and emergency medicine, 21 PMID: 23351178
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