There are plenty who … claim to be competent at intubation even though their last intubation was months ago on the third attempt and if the patient had not already been dead – that would have finished the patient off …

- Rogue Medic

When logic fails, throw propane on the fire?

 

Many of us have had discussions that became heated, because the other person would not see reason, we would not see reason, or neither of us would see reason. And that is if there are just two opinions involved.

Here is an article about someone who got a bit carried away with making his point and lost perspective.
 

A family argument over whether the Earth is flat or round became so heated that one of the participants threw a propane cylinder onto a campfire, prompting an intervention by firefighters.[1]

 

Flat Earth Hitler 1aa
 

I know. Dramatic, but harmless

Don’t worry.

Everybody knows that propane tanks have safety valves, so they don’t blow up.

Right?
 


 

It turns out that propane tanks do not share that opinion.

The following video does an excellent job of explaining why a full tank may take a while to explode. This is a BLEVE (Boiling Liquid Expanding Vapor Explosion), which any first responder should be familiar with. We should know enough to not throw, or even gently place, containers of flammable material on fires, unless intending to cause an explosion.
 


 

What about the topic of discussion? Is the earth flat?

Common sense tells us that the earth is flat.

Science, a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results,[2] shows us that the earth is not quite flat.

There is an excellent short article explaining the way science has improved our understanding of the shape of the earth.
 

In the early days of civilization, the general feeling was that the earth was flat. This was not because people were stupid, or because they were intent on believing silly things. They felt it was flat on the basis of sound evidence. It was not just a matter of “That’s how it looks,” because the earth does not look flat. It looks chaotically bumpy, with hills, valleys, ravines, cliffs, and so on.[3]

 
 

Nowadays, of course, we are taught that the flat-earth theory is wrong; that it is all wrong, terribly wrong, absolutely. But it isn’t. The curvature of the earth is nearly 0 per mile, so that although the flat-earth theory is wrong, it happens to be nearly right. That’s why the theory lasted so long.[3]

 

There were observations that were not consistent with a flat earth. The rest of the article explains the way science showed us the more accurate answers.

Was the person right to throw a propane cylinder into a fire? No.

If the earth is not flat, does that mean that it is round? No.

Read The Relativity of Wrong and learn a bit about how science works and what it means to be wrong.

Footnotes:

[1] Police, firefighters called in after flat Earth debate turns heated – Man angered by suggestion Earth is flat threw propane tank into fire, police say
CBC News
Posted: Jun 14, 2016 5:09 PM ET
Last Updated: Jun 14, 2016 6:00 PM ET
Article

[2] Skeptical Quote of the Week
Quote by Dr. Steven Novella
The Skeptics’ Guide to the Universe
Podcast #410
May 25th, 2013
Synopsis
 

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? – Dr. Steven Novella.

 

[3] The Relativity of Wrong
By Isaac Asimov
The Skeptical Inquirer
Fall 1989, Vol. 14, No. 1, Pp. 35-44
Article from Tufts University

.

The Second EMS What-if-We’re-Wrong-a-Thon

 

Brandon Oto promoted The First EMS What-if-We’re-Wrong-a-Thon last year, but I was taking a break from blogging at the time, so I did not participate. The idea is to consider a position from the perspective of being wrong.

This is the way science works. An idea (hypothesis) is tested by attempting to prove that it is wrong, rather than attempting to prove that it is true. Unfortunately, not all science is done well. Ideology (politics, religion, nationalism, stereotyping, . . . ) is the opposite of science. The goal of ideologues is to defend the dogma, rather than to find the truth.

Since valid evidence to the contrary is all that I need to change my mind, as I have on ventilation in cardiac arrest, high flow oxygen for just about anything, epinephrine any drug for cardiac arrest, intubation as the gold standard of airway management, et cetera, is to look at something based more on opinion, rather than evidence.
 

What have I been wrong about that I have not yet corrected in writing? Romazicon (flumazenil) is a benzodiazepine antagonist which has the nasty side effect of producing seizures. I have condemned the suggestion that it should be used by EMS, because it is just an ALS (Advanced Life Support) means of trying to correct a BLS (Basic Life Support) problem with the potential for creating ALS problems that would result in even more ALS solutions.[1]
 

In considering the effects of flumazenil, have I put too much emphasis on the adverse effects and not enough emphasis on the ways that the side effects can be prevented or managed?
 

Putting much more emphasis on the side effects, rather than on the benefits is important in pharmacology, because the benefits are usually less than we expect and the serious side effects should be much less frequent than the benefits. If the serious side effects are not much less frequent than the benefits, why use the drug?

The importance of large studies is less in quantifying the benefits, but in having enough data to identify the side effects. The second most famous example of this is the Cardiac Arrhythmia Suppression Trial,[2] which was intended to show which brand of antiarrhythmic drug saved the most lives. The one that saves the most lives is clearly the best and would be marketed aggressively as the best. The result was to demonstrate that the antiarrhythmic drugs were killing people. About 60,000 people, who would not have died at that time, were killed by these drugs. These drugs were the most frequently prescribed drugs in America at that time. All of the best doctors knew that the drugs improved survival – except the drugs were killing patients.

The most famous example of a small rate of serious side effects not being identified until a lot of people were affected is thalidomide.[3] This produced dramatic deformities in the children of mothers who had taken thalidomide for nausea and vomiting of pregnancy. Since the ideas of pure good and pure evil are ideological, rather than real, there are appropriate uses for thalidomide in the treatment of Hansen’s disease (leprosy) and multiple myeloma. Good medicine requires that we balance the benefits and risks in order to increase the probability of an improvement in outcome.
 

What if, in the case of flumazenil, the side effects are both known and manageable?
 
midazolam plus flumazenil = safer qm 2
 

Flumazenil is not as dangerous as I initially thought. I was giving too much emphasis to the problems. I also think that a reasonable case can be made that we should use benzodiazepines more aggressively, while managing airway compromise and oversedation with flumazenil as an occasional supplement to BLS methods such as proper positioning to maintain the airway and stimuli to promote respiratory drive. An IM (IntraMuscular) dose of 10 mg of midazolam (Versed) may be a good starting dose for a small or medium-sized person.

What about seizures? Seizures do occur, but they are not common. Flumazenil is a competitive antagonist, so more benzodiazepine can be given to stop a seizure, but we should not be getting anywhere near that complication. Seizures are not common and only one of the uses of benzodiazepines is to stop seizure activity. There is no good reason to expect seizure activity if we are giving tiny doses (smaller than the recommend doses of flumazenil) to patients who are being sedated with benzodiazepines (the wrong drugs, but often the only ones available to EMS) for agitated delirium and happen to become so sedated that a bad outcome is likely without intervention.[4]

The current issue of the British Journal of Clinical Pharmacology has the theme of the appropriate use of antidotes.
 

Themed issue Antidotes in Clinical Toxicology

Theophrastus Bombastus Paracelsus von Hohenheim (1493–1541) said it all with Dosis sola facit venenum or in modern language “It is the dose, stupid”. So, for a journal of Clinical Pharmacology that as a matter of principle deals with the relation between dose and effect, covering the high end of de (the?) dose – effect relationship is nothing out of the ordinary. This issue is largely about how to treat unfortunate patients who have reached the dark side of the dose–response curve. This can be done by antidotes.[5]

 

This can be done by antidotes.     Not – This must be done by antidotes.

It is the dose, stupid, is usually translated as The dose makes the poison, or –
 

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

Only one article in this issue addresses flumazenil, and that is only as part of a general discussion of antidotes (which also mentions the use of benzodiazepines as the antidote for overdose of amphetamines and other stimulants and for drug induced delirium). The article does encourage caution in the use of flumazenil –
 

For other antidotes, a clinical effect is pharmacologically expected, obvious and rapid (e.g. reversal of coma with flumazenil or naloxone, or resolution of delirium with physostigmine). However, this does not necessarily translate into improved clinical outcomes over supportive care [2]. [6]

 

What if the important safety criteria are using small doses, repeated reassessment, and critical judgment?

Can EMS do that? Our failures with airway management (it is still popular to claim that no evidence of benefit or safety is needed, in spite of the many studies showing harm from intubation) suggest that we cannot, but people keep pointing out that I am an optimist. I think that education can reach many of the dogmatic deniers of science and promoters of emotion over reality.

The use of tiny doses of naloxone (Narcan) to increase the respiratory drive, but not the alertness, of patients with opioid overdoses may result in a sudden increase in level of consciousness and aggression, but that is not typical.

Can we produce better outcomes with judicious use of antidotes in addition to supportive care as a way of managing aggressive use of benzodiazepines? Maybe, but it is not something people seem to want to study. We have given the drug to be reversed and know the dose we gave, so we are not dealing with an unknown overdose. The patient may have ingested other drugs that are unknown, but they tend to be stimulants, which is why we are giving a sedative. The patient may even have taken a benzodiazepine at some point, but more benzodiazepine is not a reason to avoid flumazenil.

The better question is can we improve outcomes for violent patients and for the people who deal with violent patients, with more aggressive use of benzodiazepines and judicious use of flumazenil to minimize the side effects of aggressive benzodiazepine use?

Benzodizepines are the wrong drugs to use for agitated delirium, unless combined with more effective medication. Some EMS providers do not have access to the most effective sedatives, or even the second most effective sedatives. I am limited to benzodiazepines and only in doses that are too low. Adding flumazenil to my scope of practice might help the medical directors to provide better EMS education and more aggressive standing orders.

There is more to write about flumazenil, but this is plenty for today.
 

Also writing in The Second EMS What-if-We’re-Wrong-a-Thon are –

Michael Morse (Rescuing Providence) — asks… what if community paramedicine really is the future of EMS?

Dale Loberger (High Performance EMS) — asks… what if emergency response times don’t really matter all that much?

Amy Eisenhauer (The EMS Siren) — wonders… whether the role of social media in EMS is such a good thing after all.

Ginger Locke — asks… what if video laryngoscopy really is the best first-pass technique for routine endotracheal intubation?

Footnotes:

[1] Flumazenil and EMS – A Box Pandora Should Not Open
Fri, 20 Mar 2009
by Rogue Medic
Article

[2] 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.

[3] Thalidomide: the tragedy of birth defects and the effective treatment of disease.
Kim JH, Scialli AR.
Toxicol Sci. 2011 Jul;122(1):1-6. doi: 10.1093/toxsci/kfr088. Epub 2011 Apr 19. Erratum in: Toxicol Sci. 2012 Feb;125(2):613.
PMID: 21507989

Free Full Text from Toxicol Sci.

[4] Excited Delirium: Episode 72 EMS EduCast
Wed, 29 Sep 2010
by Rogue Medic
Article

[5] Issue highlights
British Journal of Clinical Pharmacology
Special Issue: Antidotes in Clinical Toxicology
Volume 81, Issue 3, pages 398–399, March 2016
DOI: 10.1111/bcp.12909
Article

[6] Who gets antidotes? choosing the chosen few.
Buckley NA, Dawson AH, Juurlink DN, Isbister GK.
Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. Review.
PMID: 26816206

Free Full Text from Br J Clin Pharmacol.

.

Happy Darwin Day 2016

 

Today is the 207th birthday of both Charles Darwin and Abraham Lincoln, two people who were condemned for their great works. One changed the way we treat other members of our species, while the other changed our entire understanding of species.

Lincoln held America together in spite of attempts to divide America into those who used the law to support equal treatment of Americans and those who would start their own country to be able to expand what may be the worst economic system ever seen in America – slavery. We don’t like communism, but when we condemn communism, we use slavery as a metaphor for how bad communism really is. We used to be worse than the communists. Some of us were willing to kill Americans to avoid having to deal with the possibility of giving up the horror that is slavery.

Darwin explained how life evolved into the many different species that exist and into those that no longer exist. The connection among those seemingly unconnected species of animals, plants, fungi, bacteria, . . . is DNA (DeoxyriboNucleic Acid). We can use DNA in a court room to demonstrate that one person is the parent of another person, or that one person had direct (or occasionally indirect) contact with another person and thus may have had the opportunity to commit a crime. Criminal DNA evidence is just a tool and its appropriate use does require judgment, just as with any other evidence. If used without judgment, DNA evidence can be just as unreliable as eyewitness testimony.[1]

DNA is able to tell us how people and species are related. DNA is able to tell us that we are very closely related to other apes. When we trace our ancestry back far enough, we have the same ancestors. If we trace our ancestry back even farther, we have the same ancestors as snails. We have all evolved, over billions of years, to exist in our current temporary state of evolution. Will we humans split into several species or remain just one species until we become extinct?

DNA had not even been identified at the time that Darwin explained evolution in On the Origin of Species, so he did not have the ability to explain how these changes were taking place, but he could show that the changes were taking place and that the changes favored adaptations that increased the probability of survival of the species. He wasn’t right about everything, but science is not perfection. Science is a method of increasing our understanding and Darwin is one of a handful of scientists who dramatically changed the way we understand biology.

Medicine is a branch of biology. We can go practice monkey see, monkey do medicine, but we will cause a lot of harm with our lack of understanding. We can try to understand as much as possible or we can make excuses for rejecting science.

As we learn, science changes. The same is true for everything else. As we learn, we change. Change is unstoppable.

Could over 99% of biologists be wrong about evolution?
 

How Gavin Smythe Broke Science

How Gavin Smythe Broke Science


 
Go see the rest of How Gavin Smythe Broke Science here.
 

If you understand science, Tell Congress to Support Darwin Day 2016.

In addition, House Resolution 548 and Senate Resolution 337:
 

Footnotes:

[1] Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment
Fri, 05 Jul 2013
Rogue Medic
Article

.

Happy Darwin Day 2015

 

Charles Darwin is one of the greatest scientists of all time. We should celebrate the tremendous work that he has done, but it is considered politically incorrect to point out that evolution is real and that we use science to learn about reality.

To celebrate Darwin Day, Ken Ham has decided to do even more to embarrass himself. You remember him. He is the guy who debated Bill Nye.
 


 

What would it take to change your mind?
Bill Nye – Evidence.
Ken Ham – Nothing.

Nothing? If God were to tell Ken Ham that evolution is true, that would not change Ken Ham’s mind, because his mind is made up? Or is Ken Ham telling us that he does not believe that God exists?
 

Ken Ham claims to understand science, but the scientists he employs are required to sign a statement that what Ken Ham believes sets a limit their science. Ken Ham is celebrating today as Darwin was wrong Day.[1]
 

The 66 books of the Bible are the written Word of God. The Bible is divinely inspired and inerrant throughout. Its assertions are factually true in all the original autographs. It is the supreme authority in everything it teaches. Its authority is not limited to spiritual, religious, or redemptive themes but includes its assertions in such fields as history and science.[2]

 

Ken Ham tells us that only his interpretation of the Bible is the truth. Science encourages us to look everywhere for the truth.

If you do not sign a Statement of Faith, you cannot work for Ken Ham. You only have to read the Bible to see that even the description of Creation has irreconcilable contradictions if Genesis is to be interpreted as science, rather than metaphor.
 

24 Then God said, “Let the earth bring forth living creatures after [ag]their kind: cattle and creeping things and beasts of the earth after [ah]their kind”; and it was so. 25 God made the beasts of the earth after [ai]their kind, and the cattle after [aj]their kind, and everything that creeps on the ground after its kind; and God saw that it was good.

26 Then God said, “Let Us make man in Our image, according to Our likeness; and let them rule over the fish of the sea and over the birds of the [ak]sky and over the cattle and over all the earth, and over every creeping thing that creeps on the earth.” 27 God created man in His own image, in the image of God He created him; male and female He created them.[3]

 
 

God made Adam and Eve after making the animals.
 
 

18 Then the Lord God said, “It is not good for the man to be alone; I will make him a helper [a]suitable for him.” 19 Out of the ground the Lord God formed every beast of the field and every bird of the [b]sky, and brought them to the man to see what he would call them; and whatever the man called a living creature, that was its name.[4]

 
 

God made Adam and Eve before making the animals.
 
 

It doesn’t matter which came first, if this is a metaphor, but if this is supposed to be literally true and accurate, then it does matter which came first.

Is your God incapable of telling the difference between before and after? Ken Ham’s God can’t seem to tell the difference. Ken Ham seems to prefer to mock his God.

Is your God limited by the restrictions Ken Ham arrogantly places on God?

Is your God capable of using metaphors?

Are there other places where your God uses metaphors in the Bible?
 


 

Footnotes:

[1] #DarwinWasWrongDay
AiG (Answers in Genesis)
Ken Ham’s Twitter hashtag encouraging rejection of evolution
Page at AiG

[2] Statement of Faith
AiG (Answers in Genesis)
Section 2: Basics
Updated: December 12, 2012
Accessed on February 12, 2015
Page at AiG

[3] Genesis 1:24-27
New American Standard Bible (NASB)
Bible Gateway (a Christian site)
Passage

Pick up a printed Bible. Look at whatever version of the Bible you like. You can look up one verse at a time to compare among versions.

[4] Genesis 2:18-19
New American Standard Bible (NASB)
Bible Gateway (a Christian site)
Passage

.

Emergency Cardiovascular Care Update (ECCU) 2014 Conference – What Will We Get?

 

What should we expect from the Emergency Cardiovascular Care Update (ECCU) 2014 Conference?

The brochure suggests that the next version of the guidelines will be based more on science than the current guidelines, but that is always the suggestion.
 


 

Will the AHA (American Heart Association) actually limit treatments to those that work?

Or will we get more wishful thinking-based guidelines?

There is an examination of the research that will affect the next decade of BLS (Basic Life Support) resuscitation.
 


 

There is also a session where questions are encouraged.
 


 

Will we continue to harm patients with ventilations?

There is still no evidence of benefit from ventilations prior to ROSC (Return Of Spontaneous Circulation). We would still ventilate those who arrested secondary to respiratory causes and children.
 

That format is repeated for ALS (Advanced Life Support).
 


 

And a session where questions are encouraged.
 


 

Will we still be giving eye of newt?

While eye of newt has not been shown to increase the rate of ROSC, it has not been studied, so we do not know if eye of newt does increase the rate of ROSC.

Epinephrine (Adrenaline in Commonwealth countries) is slightly more evidence-based than eye of newt, because it has been shown to increase the rate of ROSC, but who cares?

ROSC is not the goal.

Resuscitation of the heart and brain is the goal.

Epinephrine has failed to demonstrate improved resuscitation.
 

What works?

Teaching CPR effectively works.

Ventilations impair outcomes and impair education.
 


 

What can we do to improve the quality of CPR?
 


 

What can we do to improve the quality of EMS?

EMS resuscitation is not an ALS treatment.

EMS resuscitation is about keeping the medics out of the way of the people providing compressions and defibrillations.
 


 

Resuscitation does not come in a syringe, so prehospital therapeutic hypothermia is not going to be done with chilled IV fluids.

We know that does not work.
 


 

Stutter CPR looks promising, but we are not there, yet.
 


 

What do we do after ROSC?

Higher pressures seem to lead to higher resuscitation rates, but is that just an association of healthier hearts producing higher blood pressures, is it something we can improve with pressors (epinephrine, norepinephrine, phenylephrine – but probably not with dopamine), or is it something that we will make worse with pressors?
 


 

There is even a discussion of mechanical Compression devices.

Should we teach excellent chest compressions to bystanders, while we abandon quality EMS compressions to machines?

If quality is a problem, we should give the machines to bystanders and demand high quality from EMS.

Or is it possible that the machines can act as prehospital ECMO and improve outcomes? We do not know – yet.
 


 

It looks interesting.

I hope the results are a dramatic improvement over the current (2010) guidelines.

The 2005 guidelines made a big difference in compression quality and the resuscitation rates followed.

2015 could cause us to focus on what really works.

If it doesn’t work when we study it, then we were just fooling ourselves about whether it works. If it doesn’t work when we study it, it does not work.
 

Emergency Cardiovascular Care Update (ECCU) 2014 Conference

.

$16M on EMS Stroke Trial? Dr. Rick Bukata Wants His Money Back!


 

FAST-MAG[1] actually has good methodology, so why is Dr. Rick Bukata so upset? Is this just USC vs. UCLA off the field/court?

Should the hypothesis being tested have received the Queen for a Decade treatment?

He wants his money back? Roughly 160 million tax payers in the US, so $0.10 per tax payer, but he makes more than the average schlub, so maybe as much as 50 cents for him. He can’t even buy enough caffeine to raise his blood pressure with that.
 

In a commentary regarding the IMAGES trial by Larry Goldstein of the Duke Center for Cerebrovascular Disease in the same issue of the Lancet in which the study was published, he noted that of more than 40 clinical trials of “neuroprotectants” involving over 11,000 patients, none has shown any evidence of benefit. Ten years later, the same is true.[2]

 

But look at the animal studies!

But look at the time being saved!

The authors actually like to repeat the term Golden Hour – as if that is new or valid.
 

So, if you are still a believer in the potential of magnesium, why not try and give magnesium in a pilot clinical study involving stroke patients in the ED? It would have been a relatively simple study to do. It could have been performed in selected EDs throughout the country and the answer would have been established in a fraction of eight years and at a very small fraction of $16 million.

Instead, the Fast-Mag investigators decide that giving magnesium in the field (probably about 10-20 minutes faster than could be given in the ED) would be a reasonable study.[2]

 

Gosh, when he brings reason into the argument, it just seems that the other side has none.

What could the money have been spent on?

Epinephrine vs. placebo in cardiac arrest? The number of lives affected is large and we are currently treating based on philosophy, not science.

IV (IntraVenous) bolus NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) vs. SL (SubLingual) NTG for acute CHF (Congestive Heart Failure)? This affects even more patients than cardiac arrest and there is good evidence that IV bolus NTG dramatically improves outcomes, while SL NTG is not based on evidence.

Excited delirium treatment with various IM (IntraMuscular) medications to see what is safest and most effective and at what dose. A large trial would be necessary.

With no good reason to be optimistic about outcomes, why take this multimillion dollar long shot?

Maybe it has to do with tPA (tissue Plasminogen Activator) and the failure to get emergency physicians to accept the poor research on tPA – tPA showed harm, or no benefit, in 9 out of 11 studies.[3]

Ironically, if those studies used methodology similar to this study, that could be showed harm, or no benefit, in 11 out of 11 studies.

Dr. Jeffrey L. Saver, one of the authors, has a presentation on FAST-MAG that spends a lot of time on tPA, even prehospital tPA.

What does Dr. Sarver consider to be positive about FAST-MAG? Here are some of his slides.[4]
 


 

FAST-MAG means more tPA use.
 


 

FAST-MAG means doing a lot of things that have not been done before and expecting the outcome to be good.

This is the kind of person who starts turning all of the dials on a ventilator and then looks at the patient to see what the result is.

A reasonable approach to research is to limit variables, not brag about how much prudence has been abandoned.
 


 

FAST-MAG means time will be saved, but . . . .
 

Walter Koroshetz, MD, neurologist and deputy director of the National Institutes of Health’s (NIH’s) National Institute of Neurological Disorders and Stroke, sponsor of the FAST-MAG study, says that lessons can be learned from the trial.[5]

 

“The NIH have a new network to do more prehospital trials, but we need phase 2 studies first that demonstrate some biological effect before going into a large costly phase 3 trials.”[5]

 

This is a $16 million bet that time is the only factor that matters.

I hope these doctors do not drive the way they gamble.

What were the results?

The results were the same as all of the previous studies of magnesium – no improvement.

There is no Magnesium Golden Hour.
 

And, please, no – don’t even consider the idea of giving tPA in the field.[2]

 

Well, . . . .
 

Dr. Saver explained that tPA cannot be given at present in a prehospital setting because hemorrhagic stroke has to be ruled out with computed tomography (CT). The use of ambulances with a CT scanner on board has been studied in Germany and is now starting to be tested in the United States.[5]

 

Be very afraid.

On the other hand, the authors did not rush this treatment into EMS protocols, as we recently have in EMS in so many places with therapeutic hypothermia, based entirely on research done in the ED (Emergency Department). It works in the ED, but not in the ambulance. 😳

FAST-MAG was approved in 1999, several years after the EMS nifedipine (Procardia) for hypertensive crisis crisis. There was no study in the EMS setting of a treatment for the EMS setting. This involved treatment of the surrogate endpoint of blood pressure numbers, which makes for an easy win, such as a systolic drop of 250 -> 90 in ten minutes. 😳

We need a balance between rushing to add the new cool treatment (and the predictable removal of the treatment decades later) and the inappropriate rush to a large scale trial of something that has repeatedly failed smaller studies.
 

Go read Dr. Bukata’s full article.

Footnotes:

[1] Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 2 – prehospital study methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):220-5. doi: 10.1111/ijs.12242.
PMID: 24444117 [PubMed – in process]

Methodology of the Field Administration of Stroke Therapy – Magnesium (FAST-MAG) phase 3 trial: Part 1 – rationale and general methods.
Saver JL, Starkman S, Eckstein M, Stratton S, Pratt F, Hamilton S, Conwit R, Liebeskind DS, Sung G, Sanossian N; FAST-MAG Investigators and Coordinators.
Int J Stroke. 2014 Feb;9(2):215-9. doi: 10.1111/ijs.12243. Epub 2014 Jan 13.
PMID: 24444116 [PubMed – in process]

[2] $16M on EMS Stroke Trial? I Want My Money Back!
by Rick Bukata, MD
March 24, 2014
Emergency Physicians monthly
Article

[3] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

[4] Treat Stroke in the Field:
Lessons from the NIH FAST-MAG Trial

Jeffrey L. Saver, MD, Professor of Neurology
UCLA Stroke Center
2012
Presentation Slides in PDF Downoad format.

[5] FAST-MAG: No Benefit of Prehospital Magnesium in Stroke
Sue Hughes
February 14, 2014
Medscape
Article

.

Comment on Bill Nye and Most Christians vs. Ken Ham and Creationism – Part I

 

In reply to Bill Nye and Most Christians vs. Ken Ham and Creationism – Part I is the following from Jon –
 

Part of the issue is that we are making science square off against religion.

 

We?

Don’t blame science for this problem with religion.

Some religious preachers are claiming that evolution denialism Creationism should be taught as science.

Promotion of bad science is justifiably opposed by scientists.

Preachers should not promote bad science.
 


Original Creationist ‘watch as proof of design’ image credit.
 

The superficial appearance of design in living things is not proof that evolution is wrong and is not proof of intelligent design Creationism.

Science is not satisfied with the superficial.

Creationism is contradicted by almost all of science and is not even supported by most religious people.
 

The Inquisition threatened Galileo (a very religious scientist) with torture, forced Galileo to shut up, and placed Galileo under house arrest for the rest of his life.

Why?

Galileo showed that the real world ignores the Biblical literalists.

Science eventually prevailed, but the Biblical literalists were able to hold back science for years decades centuries.

The Bible did not change, but many literal interpretations of the Bible evolved.

 


Image credit.
 

Should we change the Bible to match science?

Should we change science to match the Bible?

Should we just keep scientifically illiterate preachers out of science classrooms, so that they are less likely to embarrass themselves?

Science does not care what is revealed about the world, as long as it is true, but Creationists only care about the end justifying their interpretations of the Bible.
 

If Genesis said, “And God caused there to be something from nothing, and this something went “kaplowie”, and God caused the things from the kaplowie to start swirling and condensing into globs of matter, and those globs of matter hardened, and on one of those globs came forth water and land, and a microbe developed into an animal and a plant, and reproduced, and evolved into myriad forms” would that be acceptable to those that hold fast to evolution?

 

Changing the Bible does not change reality.

What if the Bible said, The Earth is not the center of everything?

Would Galileo’s prosecution by Biblical literalists go away?

Eventually, Biblical literalists will also admit the error of their ways about evolution.

For our children, grandchildren, great grandchildren, . . ., let’s hope the Biblical literalists repent more quickly this time.
 

Finally, let’s say that those that understand Scripture’s “six days of creation” are mistaken, . . . .

 

Science makes it clear that preachers of Scripture’s “six days of creation” are mistaken.

Most people believe in God and ignore these literal interpretations of the Bible advocated by some preachers.

There is no valid evidence to support Creationism.

This is only a controversy among religious sects.

This is not a controversy among scientists.

.

Alternative Medicine, Wishful Thinking, and Irresponsible Drug Pushers

 

Most emergency physicians avoid using homeopathy, acupuncture, Reiki, and other alternative medicine because there is no valid evidence that these treatments work, or because of they are not considered standards of care, or because there is no recommendation to give them from ACEP (American College of Emergency Medicine).

This is good, because alternative medicine is fraud.

Is there an alternative field of aerodynamics making planes for us to fly? Where is this alternative science?

Are people using alternative electricity to power their homes? Where is this alternative science?

According to the homeopathy hypothesis, the more dilute something is, the more powerful it is. We could solve the world’s energy problems – if the alternative science of homeopathy were anything more than wishful thinking.
 

How does that relate to emergency medicine?

When it comes to emergency treatments for cardiac arrest, stroke, heart failure, possible spinal cord injury, et cetera, many emergency physicians are just as superstitious as your local witch doctor. Currently, the most prominent example of alternative emergency medicine is tPA (Alteplase) for acute ischemic stroke.
 

But tPA, approved for strokes in 1996, only works if given within 4.5 hours of a stroke.[1]

 

That is an optimistic interpretation of the research –
 

The recent release of the American College of Emergency Physicians guideline recommending the use of tPA for ischemic stroke is remarkable. While it is unsurprising that a professional guideline flouts science, the publication is striking for its casual tone and its methodologically inexplicable review of evidence. Scientific thinking is absent.[2]

 

The evidence is horribly flawed, but the advocates respond just as we expect alternative medicine pushers to respond – with logical fallacies.

Ad hominem attacks on those who criticize the bad research.
 

These few persistent myths about thrombolytic therapy were first promulgated by self-appointed ‘expert critics’ who are unabashedly anti-intellectual in their opposition to this therapy. They decline to either read or attempt to understand data and rigorous analysis of that data.[3]


Alternative medicine pusher Dr. Patrick Lyden.
 

What is the appropriate time period for giving tPA?
 


IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[4]
 

Patients get better if tPA is begun within 3 hours, get worse if tPA is begun between 3 hours and 4 1/2 hours, but get better when tPA is begun after more than 4 1/2 hours.

Clearly, there is some strong evil magic that is working against tPA in that 3 to 4 1/2 hour time period, but it is all unicorns and rainbows the rest of the time.

Does that make sense?

No.

That suggests that the evidence we have does not adequately assess the effects of tPA for acute ischemic stroke.

Reasonable people can disagree, but Dr. Lyden appears to be calling those who disagree biased just because they disagree. This is bad science and bad medicine.

We need research that is well controlled, not research that requires a lot of excuses.
 

MedPage Today is providing a good forum for discussion of this actual medical controversy and not just promoting the ad hominem criticisms of Dr. Lyden. There are links to plenty of other sites discuissing the problems with the evidence.[5]

I most recently wrote about this here – The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

I am not an emergency physician, so this is not something that affects my care of patients. I do not have to worry about being sued for not giving tPA and being accused of allowing a bad outcome. I do not have to worry about being sued for giving tPA and being accused of producing a bad outcome.

If you are an ACEP member, tell ACEP what you think of the evidence, or the flaws in the evidence.

Footnotes:

[1] Few stroke patients get clot-busting drug
Liz Szabo,
USA TODAY
10 a.m. EST February 13, 2014
Article

[2] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

[3] ER Briefs: tPA ‘Works’, ACEP on Target
Published: Feb 10, 2014
By Elbert Chu
Interview with Patrick D. Lyden, MD
Article

[4] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] ER Briefs: Open Season on ACEP tPA Guidelines
Published: Jan 29, 2014 | Updated: Jan 30, 2014
By Elbert Chu
Article
.