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

- Rogue Medic

Today in Kansas, Some Witchcraft is Melting

Sat, 01 Mar 2014 08:00:55 -0500 by
 

Why are more medical directors abandoning the mythology of their ancestors?

Because it has become almost impossible to ignore the absence of evidence of any improved outcomes and the abundant evidence of harm.

Today, in Kansas, Johnson County Med-Act threw a bucket of water on their Long Spine Board Witchcraft and Kansas was not hit by a tornado. Kansas is only being hit with snow.
 


 

But there must be some good reason to use backboards!
 

The backboard has been a component of field spinal immobilization despite lack of efficacy evidence.[1]

 

When there is no evidence of benefit, then it is not an insult to call a treatment witchcraft, dogma, alternative medicine,
 

Other than historical dogma and institutional EMS culture we can find no evidence-based reason to continue to use the Long Spine board as it currently exists in practice today. The evidence that does exist regarding the Long Spine board is overwhelmingly negative.[2]

 

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it. Well, we’ll know better next time. – Tom Stoppard
 

Will we know better next time? Our history does not give us reason to be optimistic about our ability to avoid this error.

We should have said, No.

We should have insisted on evidence.

The history of medicine is full of things that seemed like a good idea at the time.

Seemed like a good idea at the time is just the slightly more respectable form of conbining alcohol, a dangerous idea, and Watch this!
 

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool. – Richard Feynman.
 

We never seem to tire of fooling ourselves.

Why am I so critical of tPA for acute ischemic stroke, backboards for potential spinal injuries, furosemide for acute heart failure, ventilations for cardiac arrest, all drugs for cardiac arrest, . . . ?

Because all of these treatments have become standards of care, even though they have not been adequately studied.
 


Original picture image credit of tPA alternative medicine pusher Dr. Patrick Lyden.
 

We fool ourselves and harm our patients.

If you disagree, provide some evidence of any of these treatments producing improved outcomes that matter.

We should assume every treatment is harmful, until there is valid evidence that the treatment is safe and effective.
 

Just like blood-letting and every other superstition-based treatment.
 

The ambulance stretcher is in effect a padded backboard and, in combination with a cervical collar and straps to secure the patient in a supine position, provides appropriate spinal protection for patients with spinal injury.[1]

 

Why not just leave out the harmful device that cannot be demonstrated to improve outcomes and cannot even be demonstrated to be safe?

But someone will sue and everyone will lose everything!
 

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.[3]

 

It is the EMS Nuremberg Defense when we do it.
 

it may be common or customary for EMS providers to use a long spine board or collar, decisions of standard of care and negligence are not based on what is the best, reasonable care, not on what is usually done.66 [4]

 

This witch is only mostly dead, but we can’t stop now.
 


 

To read more on the topic –
 

For You Disciples of Spinal Immobilization…
… Bryan Bledsoe debunks your religion in the August issue of EMS World Magazine. And in that same issue, I take a dump on your altar. Our karma ran over your dogma.
August 1, 2013
by Kelly Grayson
A Day in the Life of an Ambulance Driver
Article
 

The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World
Article
 

Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article
 

In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
December 15, 2012
Article
 

Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning
Article
 

Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World
Article
 

A Change of the Dogma – If spinal immobilization helps only one . . .
Sun, 15 Jan 2012
Rogue Medic
Article
 

C-Spine Death Knell with Rogue Medic
Tue, 22 Jan 2013
Rogue Medic
Article
 

Plastic Snake Oil – EMS Spinal Immobilization
February 24, 2014
Life Under the lights
Article
 

Some podcasts –

A Change of the Dogma: If it helps only one? Episode 36
First Few Moments
January 12th, 2012
Dr. Laurie Romig, Russell Stine, Bob Lutz, Kyle David Bates, Kelly Grayson, and me.
Podcast
 

C-Spine Death Knell with Rogue Medic.
John Broyles and me.
January 19, 2013
1-Union-801
Podcast
 

Immobilization or not that is the question – EMS Garage Episode 156
Chris Montera, Scott Keir, Dr. Dave Ross, Sam Bradley, Patrick Lickiss, and me.
Feb. 24, 2012
EMS Garage
Podcast
 

And the video that only makes sense if you work in EMS –
 


 

–

Footnotes:

–

[1] EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed – as supplied by publisher]
 

–

[2] Johnson County EMS System Spinal Restriction Protocol 2014
Ryan C. Jacobsen MD, EMT-P, Johnson County EMS System Medical Director
Jacob Ruthsrom MD, Deputy EMS Medical Director
Theodore Barnett MD, Chair, Johnson County Medical Society EMS Physicians Committee
Johnson County EMS System Spinal Restriction Protocol 2014 in PDF format.

–

[3] Thank You for Smoking
Movie, based on the book by Christopher Buckley
Wikiquote
Quote page

–

[4] Board to Death – The state of prehospital spinal injury care in 2013
Rommie L. Duckworth, LP
Created: July 15, 2013
EMS World
Article

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Filed Under: Ethics, Evidence, Heresy, Legal Medicine, Spinal Immobilization

Gathering of Eagles 2014

Thu, 27 Feb 2014 15:15:36 -0500 by

 

Here is a look at some of the presentations (and brief comments on what to expect) that are scheduled for this weekend’s Gathering of Eagles.[1]

Friday –
 

Indoctrination?
 

11:00 am-11:10am
Indoctrinating the Docs:
Training All First Year Medical Students to be NREMTs
– Thomas H. Blackwell, MD (Greenville)

 

That should be a negative presentation, since indoctrination is a means of changing minds when reason does not work. I am a fan of reason.
 

Ketamine (Ketalar)?
 

1:15pm-1:25pm
Another Way to Break the Ache:
Using Low Dose Ketamine for Pain Control
– Melissa W. Costello, MD (ACEP)

 

There seem to be a few reasons medical directors are hesitant to adopt ketamine (laryngospasm, which is manageable; vomiting, which is manageable; unfamiliarity, which is manageable; diversion, which is manageable), even though it is probably the most versatile EMS drug available.
 


EMCrit – Practical Evidence 014 – ACEP Procedural Sedation Update for 2013[2]
 

We endanger our patients with our contortions of extrication, when we could improve conditions for EMS and for the patients by decreasing the amount of screaming and thrashing about.

How does it help to protect the patient’s potentially injured spinal cord if we are providing intermittent stimuli of extreme pain and the patient is reacting by moving – including movement to the neck and back, far more than any capability of a collar and board might restrict movement.

We use backboards, which do not appear to be beneficial, while we avoid ketamine, which is beneficial.
 

Intranasal?
 

1:45pm-1:55pm
Care Ease Through the Nares
Nasal Fentanyl for Kids
– Peter P. Taillac, MD (NASEMSO)

 

IV (IntraVenous) is not the only route available for administration of medications, so why do we artificially limit EMS at the expense of our patients?
 

Too many medics?
 

3:00pm-3:10 pm
Are More Paramedics Elemental or Detrimental?
Lessons Learned from an ALS Expansion Program
– Andrew J. Harrell, MD (Albuquerque)

 

Because dilution of experience improves quality? 😳
 

EMS Palliative care?
 

4:30pm-4:40pm
Raising Questions about a Pain-Full Subject:
Survey Results Regarding Palliative Care Processes
–Arthur H. Yancey II, MD (Atlanta)

 

The patient is dying this year, so I have an excuse to ignore the patient’s pain.

No ethics for us, we’re EMS.
 

Saturday –
 

Airways in Cardiac Arrest?
 

8:30am-8:40am
Tracheal Deviants:
The Effect of Airway on Cardiac Arrest Outcomes
– Jason T. McMullan, MD (Cincinnati)

 

Using airways to treat cardiac arrest is not supported by any evidence, but maybe there is something that has been found to support our favorite mythology – or is it our second favorite mythology, after backboards?
 

EMS ECMO?
 

9:15am-9:25am
A Change in Scene-ery:
Re-Thinking On-Site Management of Cardiac Arrest
– Paul R. Hinchey, MD, MBA (Austin)

 

The idea of transporting dead people may have justification as a bridge to ECMO (ExtraCorporeal Membrane Oxygenation), but do we have any evidence that this improves outcomes?
 

Ketamine and ketamine analogues not perfect together?
 

10:15am-10:25am
Epidemic Proportions:
Dosing Ketamine in the Era of Mamba Dramas
– Christopher B. Colwell, MD (Denver

 

Methoxetamine (Mexxy), O-desmethyltramadol (an ingredient in Krypton), and synthetic cannabinoids (ingredients in Black Mamba and Annihilation and others may produce excited delirium and may not be best treated with ketamine, due to possible combined toxicity. Ketamine and methoxetamine suggest similarities and if it is a genuine chemical dosage problem, and the dose does make the poison, could we be contributing to the problem?

How might we ruin Reese’s Pieces?
 

Two opioids in one?
 

10:30am-10:40am
Double-Duty Dopers:
Managing Fentanyl-Laced Heroin Abuse
– C. Crawford Mechem, MD (Philadelphia)

 

Is it any surprise that the ingredients of street drugs are a surprise?
 

BLS naloxone (Narcan)?
 

10:45am-10:55am
Drugs Falling into the Wrong Hands – or Not ?
Naloxone Use by Non-EMS Personnel
– Jeffrey M. Goodloe, MD (Tulsa and OKC)

 

What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera?

What are the outcomes for these patients in systems that make naloxone a BLS treatment, or even just an advanced first aid treatment?
 

Repeated EMS-worthy inebriation?
 

1:30pm-1:40pm
Re-thinking the EMS ”Response” to Serial Inebriates:
Sobering Reflections from an EMS Medical Director
– S. Marshal Isaacs, MD (Dallas)

 

What do we do with the people who go out and have such an intoxicatingly good times, that they end up with us?
 

IO BP? IO PaO2?
 

2:00pm-2:10pm
New Skills From Drills:
Using Intraosseous Systems for Hemodynamic Monitoring
– R.J. Frascone, MD (St. Paul)

 

Interesting, but does it just make us more likely to treat surrogate endpoints and harm our patients?
 

Respect the Mythology?
 

3:15pm-3:25pm
It May Send Shivers Up Your Spine:
Taking Aim at Removing the Backboard Altogether
– W. Scott Gilmore, MD (St. Louis)

 

Pulling the board out from beneath the feet of the EMS myth makers.

Superstition vs. Reality?
 

3:30pm-4:00pm
The Great Debate
The Long and Short of It Being: To Spine Board or Not
The Bony Debaters Will Each Be Asked to Bring a Disc and then Back up Their
Statements with Pithy Remarks and Avoid Assertions that May Lead to Re-Tractions
of some Radicular Idea. They Must Follow Every Facet of the Debate Process
Carefully and take Precautions to Stay Neck and Neck with Their Opponents and
avoid Distracting Activities

– Raymond L. (“Sugar Ray”) Fowler, MD — the PRO (& ex-Con)
VS.
Terence D. (“The Terminator”) Valenzuela, MD, MPH — the CON (& ex-Pro)

 

Let’s hope they pay more attention to the absence of evidence – there is no evidence that justifies using Spine Boards to transport patients – than the abundance of puns they are so fond of.[3]

–

Footnotes:

–

[1] Gathering of Eagles – The EMS State of the Sciences Conference
Friday, February 28 and Saturday March 1, 2014
Dallas, TX
Agenda in PDF Download format.

–

[2] Practical Evidence 014 – ACEP Procedural Sedation Update for 2013
EMCrit
Dr. Scott Weingart
Written analysis of position statement and podcast.

–

[3] EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed – as supplied by publisher]
 

The backboard has been a component of field spinal immobilization despite lack of efficacy evidence.

 

Just like blood-letting and every other superstition-based treatment.
 

The ambulance stretcher is in effect a padded backboard and, in combination with a cervical collar and straps to secure the patient in a supine position, provides appropriate spinal protection for patients with spinal injury.

 

Why not just leave out the harmful device that cannot be demonstrated to improve outcomes or even to be safe?

.

Filed Under: Gathering of Eagles, Heresy, Spinal Immobilization

Another System Eliminates Backboarding for Potential Spinal Injuries

Wed, 19 Feb 2014 19:00:56 -0500 by
 
As of March 1st 2014, the Long Spine board will not be used by Johnson County EMS to transport patients.

Another system moves away from historical dogma – as a matter of fact, that is the language used to describe this change.
 

Other than historical dogma and institutional EMS culture we can find no evidence-based reason to continue to use the Long Spine board as it currently exists in practice today. The evidence that does exist regarding the Long Spine board is overwhelmingly negative.[1]

 

We need for more systems to place the care of patients above the care of historical dogma and institutional EMS culture.
 


Click on images to make them larger.
 

We need to stop basing decisions on What if . . . ?

Where is the evidence that transport on a Long Spine board is a good idea?

That is a healthy list of unhealthy side effects.

Consider giving the list above to patients and telling them that these are the risks we will subject them to if we transport them on Long spine boards. How often would would we obtain informed consent?

The first question should be – What is the possible benefit?

Well, . . . .

The hypothesis that transporting patients on Long Spine boards protects the unstable spine from further injury has been tested only one time.

That hypothesis failed miserably.

 


Out-of-hospital spinal immobilization: its effect on neurologic injury.[2]
 

The rate of disability doubled with spinal immobilization.

If we gave epinephrine (Adrenaline) and we cut our rate of resuscitation in half, how long would we continue to use epinephrine?

If we gave furosemide (Lasix) and we cut our rate of intubation doubled, how long would we continue to use furosemide? Ooopsy – some of us still do and furosemide probably produces a much greater increase in the rate of intubation than just doubling it.

How can we keep claiming that we are helping patients?
 


 

Thank you to Bill Toon, PhD of the recently ended EMS EduCast and the not so recently ended EMS Research Podcast for the information.

–

Footnotes:

–

[1] Johnson County EMS System Spinal Restriction Protocol 2014
Ryan C. Jacobsen MD, EMT-P, Johnson County EMS System Medical Director
Jacob Ruthsrom MD, Deputy EMS Medical Director
Theodore Barnett MD, Chair, Johnson County Medical Society EMS Physicians Committee
Johnson County EMS System Spinal Restriction Protocol 2014 in PDF format.

–

[2] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

.

Filed Under: Heresy, Mythology, Spinal Immobilization

Happy Friday the 13th

Fri, 13 Dec 2013 14:00:55 -0500 by
 
This is a day for superstitious people to pretend that there is some sense to their superstition.

The number 13 will somehow cause bad things to happen.

This is from the elevator of the local Best Hospital in the World. While it is an administrative decision, what about administrative decisions that affect patient care.
 


 

When we make decisions based on superstition, how much harm do we do to our patients?

We will probably never know, because we use superstition to justify ignoring evidence or to justify preventing research to obtain evidence.

A black cat crossing your path will somehow cause bad things to happen.

A backboard and collar forced on a patient will somehow protect the spine from forceful worsening of an injury.[1]

A broken mirror will somehow cause bad things to happen.

Giving fentanyl to someone in pain will prevent them from giving consent to treatment.[2]

Speak of the devil and he will appear.

Response times matter for patients who are not dead.

This is based on superstition, because the only response times that have been shown to matter are for cardiac arrest.[3]

How much less superstitious are people in medicine than anyone else?

Probably even more superstitious.
 


Identifying information obscured to protect the superstitious.
 

People will wave their hands around to manipulate your imaginary energy fields.

People fall for this at many hospitals that claim to be the Best Hospital in the World.[4]

They are just demonstrating their lack of understanding of the placebo effect, random variation, reversion to the mean, and other things that lead us to believe that nothing is something.

Nothing Superstition is harm.

–

Footnotes:

–

[1] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]
 

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.

 

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.

–

[2] Refusal of base station physicians to authorize narcotic analgesia.
Gabbay DS, Dickinson ET.
Prehosp Emerg Care. 2001 Jul-Sep;5(3):293-5. No abstract available.
PMID: 11446548 [PubMed – indexed for MEDLINE]
 

Nevertheless, the notion that a patient’s decision-making capacity may be compromised by “excessive” analgesia seemingly permeates medical practice, but is not evidently supported by the medical literature.11

 

Even a more disturbing possible coercion is the possibility that when pain medication is withheld prior to consent, the patient is either directly or indirectly made to understand that once he or she provides consent, that pain medication will be given as a “reward” for agreeing to the procedure.

–

[3] Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort.
Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G; Resuscitation Outcomes Consortium Investigators.
Ann Emerg Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23.
PMID: 19783323 [PubMed – indexed for MEDLINE]

Free Full Text with link to Free Full Text PDF Download from PubMed Central
 

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.18,19 Despite the paucity of outcome evidence supporting rapid out-of-hospital times for the broader population of patients activating the 911 system, EMS agencies in North America are generally held to strict standards about intervals, particularly the response interval.

–

[4] Shock Trauma Infested With Evil Spirits
Wed, 10 Jun 2009
Rogue Medic
Article

.

Filed Under: Heresy, Spinal Immobilization, Superstition

FAA Giving in to Science – Without Which the FAA Would Not Exist

Fri, 01 Nov 2013 12:30:59 -0400 by
 

The FAA (Federal Aviation Administration) is beginning to embrace science.

By today, many of us should be permitted to use most electronic devices during all parts of an airplane flight.
 

Airlines have been racing for weeks to be first, gathering paperwork and setting up working groups to study the issue.

JetBlue Airways Corp. and Delta Air Lines Inc. were ahead of the pack on Thursday, applying for approval within hours of the new guidelines. The two carriers said they hoped to begin allowing fliers to use devices from gate to gate by Friday.[1]

 

The FAA exists because of the ability of science to demonstrate the ability of humans to create a safe means of travel through the air. The FAA originally could have decided that the prospect of putting people in metal (or wood) structures, traveling at hundreds of miles an hour, and landing safely on the ground is not something that humans can be expected to do safely, but they didn’t.

The FAA could have adopted unscientific approaches to flight safety . . . . Well, they did with electronic devices. Much of what the FAA has done has been based on good evidence, but as with the use of cell phones in hospitals, the evidence of harm is lacking. Science without evidence is rarely good science. The FAA has not been foolish enough to follow the rest of the world into exclusive use of GPS (Global Positioning System) navigation.
 

The FAA first restricted the in-flight use of devices out of an abundance of caution, in part based on anecdotal evidence that emissions from devices interfered with pilot instruments.[1]

 

An abundance of caution is often what is used to justify rules that are actually based on an abundance of ignorance.

The use of backboards for potentially unstable spinal injuries are not based on evidence of benefit, but on an abundance of faith in expert opinion, that’s the way we’ve always done it, and wishful thinking. The same is true the rest of abandoned medical treatments and many that have not yet been abandoned.
 

Other safety policies have been extremely successful. However, these policies have evidence that they work.
 

The Federal Aviation Administration’s decision, its first big shift on electronic devices since it restricted their use in flight in 1966, caps years of debate over whether electronic emissions from devices can interfere with cockpit instruments.[1]

 

Almost half a century of restriction without evidence.

Anecdotal evidence should not be ignored, but should prompt research. If valid research does not support the caution inspired by the anecdotes, then we should ignore the anecdotes. If no research is considered to be necessary to determine the necessity of the restrictions, then we should ignore the restrictions.
 

Airline travel is extremely safe, but can be made to look less safe by looking at the statistics with the wrong perspective.
 


Image credit.
 
By the number of trips, airline travel does not appear to be safe, but we do not take airlines to travel to the grocery store. We take airlines to travel long distances.
 


Image credit.
 

Since airline travel is much faster than most other forms of travel, the safety per hour (per billion hours) is also not a good metric.
 


Image credit.
 

If I am traveling a few thousand miles, and I am only interested in the safety of that trip, there is no difficulty deciding the safest means of making that trip.

Travel by air is 8 times safer than travel by bus.

Travel by air is 12 times safer than travel by train.

Travel by air is 62 times safer than travel by automobile.

Travel by air is 1,084 times safer than walking. Although there would we health benefits to walking, the benefits would not come close to the much larger fatality rate.

The type of air travel also matters.
 


Image credit. Click on images to make them larger.
 

Fly and during the flight do work on an electronic device, or relax with an electronic device, but do not worry that you will crash the plane with a cellular phone. If you could do that, we would not even allow cellular phones in checked luggage.
 

Also see –

Do FAA restrictions on electronic devices make flying safer? Part II
Thu, 11 Apr 2013
Rogue Medic
Article

–

Footnotes:

–

[1] FAA Says Fliers Can Use Devices During All Phases of Flight
Wall Street Journal
By Jack Nicas and Andy Pazstor
Updated Oct. 31, 2013 8:00 p.m. ET
Article

.

Filed Under: Evidence, Heresy, Irrational Government Oversight, Science, Spinal Immobilization

Comment on ‘No More Comments on Popular Science’

Sat, 19 Oct 2013 08:00:35 -0400 by
 

In the comments to No More Comments on Popular Science is this from Duke Powell –
 

Rogue Medic says Epinephrine is no good.

 

I have been critical of epinephrine because we are routinely giving epinephrine in cardiac arrest, but we do not have any evidence that epinephrine improves any outcome that matters. ROSC (Return Of Spontaneous Circulation) is not an outcome that matters. Epinephrine does improve ROSC, but there is no increase in people leaving the hospital with good brain function (the outcome that matters and surviving for more time is better). There is evidence of harm.[1] The evidence of harm is not great, but the evidence of benefit does not exist.
 


 

More ROSC, but fewer survivors. That is not a benefit.

I do not claim that epinephrine is good, bad, or neutral. I point out that there is probably a subset of cardiac arrest patients who do benefit from epinephrine, but we have no way of knowing who those patients are.

I describe the lack of evidence of benefit and explain that standards of care should be supported by valid evidence of improved outcomes.
 

He says backboards are no good.

 

There is also no valid evidence of improved outcomes with backboards for unstable spinal fractures.

Where is the evidence that using backboards on patients with unstable spinal fractures results in fewer disabled patients (the outcome that matters)? There is evidence of harm.[2] The evidence of harm is not great, but the evidence of benefit does not exist.
 


 

Rogue Medic disagrees about a lot of things that scientists have said are “best practices” for EMS.

 

Scientists?

What scientists?

I disagree with using treatments that are not based on valid science.

I disagree even more strongly with standards of care that are not based on valid science.

I am also very critical of bad science, even if the results agree with what I think is true.[3],[4]
 

In most instances this medic with over 40 years experience agrees with Mr Rogue Medic. Not because of the science, but because of my experience.

 

That is not a very good reason for disagreeing with standards of care. It is a good reason for asking questions of the people who would know about the evidence, but even a 40 year career is just a series of anecdotal experiences. What kind of control has been used to minimize the effects of bias?

What has been done to make sure that confirmation bias does not limit recollection to those anecdotes that support individual bias?
 

But disagree with him on global warming? He calls you a science denier and says you can’t think for yourself.

 

I described some of the reasons you appear to be a science denialist above. That is science denialism on the topic of EMS.

You would get the same responses to EMS science denialism if you understood climate change. There are people who are willing to agree with science when it agrees with their prejudices, but are science denialists when science does not confirm their prejudices.

The problem is with the people, not with science.

Science does not care about prejudices.

Science just tells us what is real.

Science is not perfect.

Because science is not perfect, it depends on confirmation by different methods and by replication (preferably more than once). And most of all, science depends on rigorous attempts at objectivity, because everyone has biases.

Science does not exist to confirm biases.
 

Fact of the matter is, I am thinking for myself in terms of climate change. I’m not the guy following the crowd. Just as you are not the guy following the crowd with EMS best practice.

 

I am the guy basing decisions on science.

You appear to be the guy claiming that science does not matter. You appear to be the guy basing decisions on politics.

It isn’t the decision that matters, but the way we get there. Political decisions should be made based on valid science, rather than denying science or trying to make science fit political goals.
 

BTW, make sure your furnace is working, things are about to get colder, starting tomorrow.

Ha!!

Now you are discussing weather.

You do not appear to know the difference between weather and climate, but you seem to think that you know enough to tell scientists that they are wrong.

Thank you for reinforcing my point.

–

Footnotes:

–

[1] 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.

–

[2] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

–

[3] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part I, Part II, and Part III
Rogue Medic

02/20/2011
Part I

02/22/2011
Part II

03/01/2011
Part III

–

[4] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg

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Filed Under: Denialism, Evidence, Heresy, Science, Spinal Immobilization

One Laceration, Two Helicopters, Third Part

Wed, 25 Sep 2013 08:00:25 -0400 by
 

There is also a comment from steve mauch on Two Children Abducted by EMS Helicopter for One Laceration that deserves comment.
 

Rouge, I see what you’re getting at, but the problem is not so much with the medic, its what/how he was taught. If in his area they are taught if you see skull you fly, then he did everything right.

 

Exactly.

That is what I am criticizing.

We are supposed to be doing what is best for the patient.

We are not supposed to be blindly following protocol, nor blindly following the local culture of fly everyone and let the trauma center discharge them right away.

We need to hold the medical directors and the EMS agencies accountable for this ridiculous approach to patient care.
 

Where is your outcry against the flight crew that made the decision to fly the second child?? Why not crucify the flight nurse too?!

 

It was not my intent to crucify the medic.

It is my intent to crucify the system.

I just need some people with hammers and nails and we can nail the system to a Star of Life. 😉

OK. I will settle for metaphorical crucifixion, but we didn’t have to settle for metaphor in the good old days.
 

I agree with rick in the fact that we should not be ridiculing each other, we get enough of that.

 

Sometimes ridicule is an excellent way to expose a problem.

Again, I was not focused on the medic, but on the actions that are commonplace in EMS.

Look at that mechanism!

We can’t be out of service for an hour! What if a call comes in and our dangerous neighboring service has to cover for us? Many of the people in the neighboring service work for both EMS services, because that is the way EMS works. So how dangerous is the neighboring service, if they have the same employees?

This encourages us to take a helicopter out of service for real emergencies, so that we can fly someone for vehicular damage, yet vehicles are designed to deform to protect the occupants of the vehicle – and that kind of design works very well.

My response to the doctors in the trauma center who have questioned me about why I did not fly a patient, why I did not call for a trauma alert, and/or why we took our time driving with traffic, rather than using lights and sirens is this –

Assess the patient and tell me what you find that is unstable, then we will talk.

I also am familiar with the research. There is no valid research that supports flying patients within a 45 minute drive of a trauma center.

There is no valid research supporting the idea that we are not using HEMS enough.

The helicopters are often in the wrong place. Many are close enough to the trauma centers that EMS should be driving patients, but that is not where a helicopter would make a difference in outcomes. Helicopters make a difference in outcomes for unstable patients who are well over an hour drive time from the trauma centers.

We are encouraging the helicopters to flock near the trauma centers, so that they can service the medical directors who write mechanism-only flight protocols that endanger patients.

Maryland changed their protocols so that medical command permission is required for a mechanism-only flight. Helicopter transports were cut by over half. Where are the dead bodies that Dr. Thomas Scalea predicted would be the result of this cut in flights?
 

But I agree with you that issues DO need to be addressed, but we need to look at the initial educators. As a fairly recent paramedic graduate, I can tell you that medics are being taught to be cookbook medics, we are not taught to think.

 

I agree.

But, each paramedic program is different.

We need to encourage those medic programs that do a great job. There are many out there.

We need to discourage those medic programs that teach people to be protocol technicians, IV technicians, monitor technicians, alarm technicians – Oh, look! The asystole alarm is going off. I need to start CPR. There are many out there.
 

[youtube]sao-uEKgJ6Q[/youtube]
 

How much have we changed from the days of calling for orders and being told to give one amp of the yellow box?

If we do not understand pharmacology, we do not understand the most important part of pharmacology – when not to give a drug.

The same is true for procedures. We need to understand when not to use a procedure. Defibrillation, as in the video, or cricothyrotomy, or intubation, or synchronized cardioversion, . . . .

When needle decompression is used, the use almost always appears to be inappropriate.

Needle decompression does save lives when used appropriately.
 


Click on the image to make it larger.[1]

The chart is for all patients stuck in the chest at least once with a needle in an attempt to decompress a suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

Maybe. Maybe not. We do not know.

It seems that many in EMS need a lot of work in learning when not to attempt needle decompression.
 

One of the biggest things I recall is SVT. I was “taught” greater than 150=SVT. I went on thinking this was fact. I was not taught svt is a class of rhythms, not a rhythm by itself.

 

SVT – SupraVentricular Tachycardia.

The sinus node is supraventricular.

Sinus rhythms do not benefit from adenosine or synchronized cardioversion.
 

Do not blame the medic for not knowing what someone else never took the time to pass along.

 

Yes and No.

We need to take responsibility for our own education.

Education does not stop once we put on a patch or get authorized to work on our own.

I was supposed to be writing about the presentations at EMS Expo this week, but it is looking as if that will be next week. If we attend EMS conferences, we can learn about the things our instructors misinformed us about.

Backboards probably do more harm than good, especially for the patients with unstable spinal injuries.

Helicopters do save lives, but probably only for unstable trauma patients over an hour from the trauma center.

How to interpret 12 lead (and 15 lead and 18 lead, . . .) ECGs and how to identify unusual rhythms.

Now I am off to once again demonstrate that a heart rate faster than my calculated maximum heart rate is possible and can still be sinus tachycardia. When I wake up, my heart rate will be a respiratory arrhythmia sinus bradycardia. All of these are arrhythmias/dysrhythmias, but they are not bad rhythms and they are not the absence of rhythm.[2]

These arrhythmias/dysrhythmias are better than normal sinus rhythm.

Arrhythmias/dysrhythmias are treatable, but most do not benefit from treatment.

Should anyone ever use the term normal sinus rhythm?

What do we base normal on?

Does that mean that the patient’s heart is healthy?

How much beat-to-beat irregularity is permitted while still calling the rhythm normal?

What is the difference between normal and healthy?

If a patient is having a normal episode of angina, is that a good thing?

If a patient is having a normal seizure, is that a good thing?

If a patient is having a normal case of hypoglycemia, is that a good thing?

Based on what?

We often use terms we do not think about. Does that mean that it is not normal for us to think?

Is normal good?
 

In all of that I forgot to mention, I agree that they should not have been flown, ESPECIALLY since mom was against it, but I wasn’t there and it wasn’t my call. I do think way too many people are flow, and even more people are backboarded that don’t require it. We need to improve critical thinking and assessments BEFORE applying devices and treatments, but that’s a whole new blog!

 

Again, this is about highlighting the problem, not the person.

We have a big problem. Making a scapegoat out of one individual does not change the problem.

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Footnotes:

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[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.
 

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article
 

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article
 

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

–

[2] dys-
The Free Dictionary
Definition
 

dys-
pref.
       1. Abnormal: dysplasia.
       2.
               a. Impaired: dysgraphia.
               b. Difficult: dysphonia.
       3. Bad: dyslogistic.
[Latin dys-, bad, from Greek dus-; see dus- in Indo-European roots.]
The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.

 

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Filed Under: Critical Judgment, Education, Ethics, Helicopters, Heresy, Spinal Immobilization

My Response to A Discussion on Evidence from EMS Expo

Tue, 24 Sep 2013 08:00:15 -0400 by
 

Last week I wrote A Discussion on Evidence from EMS Expo about one of the conversations that I had at EMS Expo about evidence and patient care.

What were the conditions for the treatment being discussed?
 

Everybody knows the treatment works.

If the treatment is not used, the patient dies.

If the treatment is used, the patient lives.

We should ignore demands for evidence, because evidence-based medicine does not exist in this primitive culture.

Who are we to question the ways of this culture?

Isn’t it arrogant to try to impose our values on this culture?

It works for them, so shouldn’t we accept that?

 

The primitive culture being discussed was not EMS, but everything about the discussion does apply to the primitive culture of EMS.

We are Emergency Medical Shamans.
 


Original source of edited image.
 

We choose to ignore evidence and use magic rituals that do not work.

We use these magic rituals to harm patients.

We claim that these magic rituals are so beneficial that we should not deprive patients of the magic, because that would be dangerous.

We insist that intubation saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that spinal immobilization saves lives and protects spines and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that ventilation in cardiac arrest saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that epinephrine in cardiac arrest saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

We insist that IV fluid for uncontrolled hemorrhage saves lives and claim that evidence of improved survival should not be obtained, because it would deprive patients of the standard of care harm by EMS. Too many people would be harmed by not receiving the standard of care.

If the treatment is not used, the patient dies.

If the treatment is used, the patient lives.

Ask for the evidence and the absence of evidence becomes Everybody knows that . . .
 


 

Why do we believe the people who tell those EMS lies?

We are reckless and refuse to look at the evidence that shows how dangerous we are.

We are primitives who pretend that science does not work, because science does not support our biases.

When will we stop killing our patients with this ignorance?

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Filed Under: Critical Judgment, Ethics, Evidence, Heresy, Risk Management, Spinal Immobilization
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