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

- Rogue Medic

The NNT and Merit Badge Meds

Mon, 04 Oct 2010 10:22:51 +0000 By 2 Comments
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Perhaps I am too negative in my interpretation of the research on ACLS medications. What about a more objective assessment – one with a more statistical view of the harms and benefits?

How many patients have to be treated with ACLS (Advanced Cardiac Life Support) drugs in order for one patient to benefit (be resuscitated) from the treatment?

The NNT is a very interesting site. The information is prevented much more succinctly than I usually describe things.

Why NNT?

NNT is a common medical term.

NNT is the Number Needed to Treat – the average number of patients we would need to treat with something in order for one patient to benefit. The flip side is NNH.

NNH is the Number Needed to Harm – the average number of patients we would need to treat with something in order to harm one patient.

This is explained in more detail (including a less than 4 minute YouTube video for those who don’t want to read a lot) at the NNT Explained page. Understanding the material presented in the video is very important for understanding the actual benefit of a treatment, rather than the potential benefit that is given by those promoting any treatment.

Once you understand this, you will be able to see that many treatments require huge numbers of participants because the NNT is so large. A large NNT means a small benefit (in numbers). Just because only a small number of patients benefit, does not mean that the benefit is small. The amount of benefit for those who do benefit is also important. This is one of the reasons we spend so much time treating cardiac arrest.

While the NNT for cardiac arrest is large, the benefit is lives saved. There are few benefits as important as that. As the method of CPR improves, the NNT drops because the treatment helps more patients. The NNT is a great site to look around and get a quick idea of the relative benefits of many different treatments. Go browse the NNT.

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Filed Under: Critical Judgment, Heresy, Uncategorized Tagged With: , ,

National Sudden Cardiac Arrest Awareness Month — October 2010

Fri, 01 Oct 2010 06:30:40 +0000 By 1 Comment
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Good information.

October is National Sudden Cardiac Arrest Awareness Month, dedicated to educating patients and the public about what sudden cardiac arrest is and how to respond to a cardiac arrest.

Sudden cardiac arrest is when the heart suddenly stops beating, resulting in no blood flow to the brain and other vital organs. Approximately 300,000 out-of-hospital cardiac arrests occur each year in the United States, with a median reported survival-to-hospital-discharge rate of 8% (1).[1]

Here is where the 8% figure comes from (all of the cited references are listed in the free full text):

Out-of-Hospital Cardiac Arrest

There is a wide variation in the reported incidence of and outcome for out-of-hospital cardiac arrest. These differences are due in part to differences in definition and ascertainment of cardiac arrest data, as well as differences in treatment after the onset of cardiac arrest. Cardiac arrest is defined as cessation of cardiac mechanical activity and is confirmed by the absence of signs of circulation.17

Extrapolation of the mortality rate observed in the Resuscitation Outcomes Consortium to the total population of the United States suggests that each year, there are 295,000 (quasi confidence intervals 236,000 to 325,000) emergency medical services (EMS)–assessed out-of-hospital cardiac arrests in the United States.18

Approximately 60% of out-of-hospital cardiac deaths are treated by EMS personnel.19

Only 33% of those with EMS-treated out-of-hospital cardiac arrest have symptoms within 1 hour of death.20

Among EMS-treated out-of-hospital cardiac arrests, 23% have an initial rhythm of ventricular fibrillation (VF), ventricular tachycardia, or shockable by automated external defibrillator (AED); 31% receive bystander cardiopulmonary resuscitation (CPR).18

The incidence of cardiac arrest with an initial rhythm of VF is decreasing over time; however, the incidence of cardiac arrest with any initial rhythm is not decreasing.21

The incidence of lay-responder defibrillation is low (2.05% in 2002) but is increasing over time.22

If bystander CPR is not provided, a sudden cardiac arrest victim’s chances of survival fall 7% to 10% for every minute of delay until defibrillation.23 – 27

The median survival rate to hospital discharge after EMS-treated out-of-hospital cardiac arrest with any first recorded rhythm is 7.9%.18

The median survival rate after VF is 21%.18

Extrapolation of data from ARIC, CHS, and Framingham suggests that there are 138,000 CHD deaths within 1 hour of symptom onset (Thomas Thom, NHLBI, written communication, May 20, 2008).

A study conducted in New York City found the age-adjusted incidence of out-of-hospital cardiac arrest per 10,000 adults was 10.1 among blacks, 6.5 among Hispanics, and 5.8 among whites. The age-adjusted survival to 30 days after discharge was more than twice as poor for blacks as for whites, and survival among Hispanics was also lower than among whites.30[2]

Among EMS-treated out-of-hospital cardiac arrests, 23% have an initial rhythm of ventricular fibrillation (VF), ventricular tachycardia, or shockable by automated external defibrillator (AED); 31% receive bystander cardiopulmonary resuscitation (CPR).18

Do you remember what we are told about pediatric cardiac arrest?

Children do not often have VF as the initial rhythm.

From the same source:

Out-of-Hospital Cardiac Arrest: Children

The reported incidence of out-of-hospital pediatric cardiac arrest varies widely (approximately 8 per 100,000).31

There are more than 72 million individuals <18 years of age in the United States32; this implies that there are about 5,760 pediatric out-of-hospital cardiac arrests annually of all causes (including trauma, sudden infant death syndrome, respiratory causes, cardiovascular causes, and submersion).

Thirty-five percent of EMS-treated pediatric cardiac arrest patients had an initial rhythm of VF, ventricular tachycardia, or shockable by AED; 35% received bystander CPR.31

Studies that document voluntary reports of deaths among high school athletes suggest that the incidence of out-of-hospital cardiac arrest ranges from 0.28 to 1.0 deaths per 100 000 high school athletes annually nationwide.33,34 Although incomplete, these numbers provide a basis for estimating the number of deaths in this age range.

One report describes the incidence of nontraumatic pediatric cardiac arrest (among students 3 to 18 years of age) that occurs in schools and estimates rates (per 100 000 person-school-years) for elementary, middle, and high schools to be 0.18, 0.19, and 0.15, respectively, for the geographic area (King County, Washington) and time frame (January 1, 1990, to December 31, 2005) studied.35

The reported average rate of survival to hospital discharge after pediatric out-of-hospital cardiac arrest is 6%.

Most sudden deaths in athletes were due to CVD (56%). Of the cardiovascular deaths that occurred, 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, and only 11% occurred in females, although this increased over time.36 [3]

Thirty-five percent of EMS-treated pediatric cardiac arrest patients had an initial rhythm of VF, ventricular tachycardia, or shockable by AED; 35% received bystander CPR.31

VF in 35% of EMS-treated pediatric cardiac arrest patients.

vs.

VF in 23% of all EMS-treated cardiac arrest patients.

But this does not include VT (Ventricular Tachycardia) – that will show a big difference!

A total of 11,898 (58.0%) had resuscitation attempted; 2,729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954(4.6% of total) were discharged alive.[4]

22.9% had an initial rhythm of VF or VT or rhythms that were shockable by an AED.

Maybe an AED is even more important in pediatric cardiac arrest than in adult cardiac arrest.

Maybe, if we point this out to people, they will pay more attention to AEDs.

Many AEDs can accurately detect VF in children of all ages65,66 and differentiate shockable from nonshockable rhythms with a high degree of sensitivity and specificity.65,66 Some are equipped with pediatric attenuator systems (eg, pad-cable systems or a key), to reduce the delivered energy to a dose suitable for children.

For children 1 to 8 years of age the rescuer should use a pediatric dose-attenuator system if one is available.78,83,84 If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric attenuator system, the rescuer should use a standard AED.[5]

Highlighting is mine.


If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric attenuator system, the rescuer should use a standard AED.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

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To clarify –

CPR on a child;

No pediatric AED;

Use the adult AED.

Do not expect that to change with the new guidelines.

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According to the source provided -

Shockable rhythms make up 35% of pediatric cardiac arrests.

Shockable rhythms make up 23% of all cardiac arrests.

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Footnotes:

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[1] Announcement: National Sudden Cardiac Arrest Awareness Month — October 2010
Morbidity and Mortality Weekly Report (MMWR)
CDC (Centers for Disease Control and Prevention)
October 1, 2010 / 59(38);1243
Article

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[2] Heart disease and stroke statistics–2010 update: a report from the American Heart Association.
WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Circulation. 2010 Feb 23;121(7):e46-e215. Epub 2009 Dec 17. No abstract available. Erratum in: Circulation. 2010 Mar 30;121(12):e260. Stafford, Randall [corrected to Roger, Véronique L].
PMID: 20019324 [PubMed - indexed for MEDLINE]

Out-of-Hospital Cardiac Arrest
Free Full Text from Circulation with link to free full text PDF download

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[3] Heart disease and stroke statistics–2010 update: a report from the American Heart Association.
WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Circulation. 2010 Feb 23;121(7):e46-e215. Epub 2009 Dec 17. No abstract available. Erratum in: Circulation. 2010 Mar 30;121(12):e260. Stafford, Randall [corrected to Roger, Véronique L].
PMID: 20019324 [PubMed - indexed for MEDLINE]

Out-of-Hospital Cardiac Arrest: Children
Free Full Text from Circulation with link to free full text PDF download

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[4] Regional variation in out-of-hospital cardiac arrest incidence and outcome.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I; Resuscitation Outcomes Consortium Investigators.
JAMA. 2008 Sep 24;300(12):1423-31. Erratum in: JAMA. 2008 Oct 15;300(15):1763.
PMID: 18812533 [PubMed - indexed for MEDLINE]

Free Full Text from JAMA with link to free full text PDF download

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[5] Part 5: Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
AED Use in Children
Free Full Text from Circulation with link to free full text PDF download

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Filed Under: Critical Judgment, Heresy, Uncategorized

Chest Pain Refusals

Thu, 30 Sep 2010 16:47:19 +0000 By 2 Comments
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Further thoughts on EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights.

How do we determine what is low risk chest pain?

One of the most common judgment calls in the emergency department (ED) is also one of the thorniest: deciding whether to send home a patient who is complaining of chest pain but is highly unlikely to have heart disease. The person is an adult younger than 40 years and with no family history of cardiac problems, and both the ECG and blood test results for troponin are clear.[1]

Under 40? How old was the patient in the article referenced by Ckemtp?

I didn’t see an age.

The article I quoted above, cites this position statement (below) from the AHA. You know the American Heart Association, the people who write the guidelines we use as the basis for EMS cardiac protocols.

Assuming that this is a low-risk chest pain patient, what does the AHA consider to be the defensible way to approach this patient?

A high degree of suspicion and recognition of atypical presentations is important, because a significant number of patients present with “anginal equivalents” rather than chest pain. These symptoms include jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; and unexplained fatigue. These are seen more frequently in the elderly, women, and diabetic patients. Sharp, stabbing, or reproducible pain reduces but does not exclude the likelihood of ACS. Pleuritic chest pain is consistent with a pulmonary condition, musculoskeletal disease, or pericarditis. However, the Multicenter Chest Pain Study found that 22% of patients presenting with symptoms described as sharp or stabbing pain (13% with pleuritic pain and 7% with pain reproduced on palpation) were eventually diagnosed with ACS. 11 The National Heart Attack Alert Program recommends that patients with any of the aforementioned presenting symptoms should be assessed immediately and referred for rapid evaluation. 25 [2]

Jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; unexplained fatigue, and other symptoms.

These are seen more frequently in the elderly, women, and diabetic patients.

Perhaps this description of chest pain is more accurate –

Not the typical non-diabetic middle-aged man chest pain.

Why do we feel that we should assess every possible cardiac patient as if that patient is a non-diabetic middle-aged man?

When assessing female patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing young men, do we not understand that they are not non-diabetic middle-aged men?

When assessing diabetic patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing old men, do we not understand that they are not non-diabetic middle-aged men?

Physical Examination
The physical examination, although more specific than sensitive, can be useful to identify higher-risk patients. Signs of heart failure reflect left or right ventricular dysfunction. Bruits usually indicate peripheral arterial disease and increase the risk of concomitant CAD. The examination should also target potential noncardiac causes for the patient’s symptoms, such as unequal extremity pulses (aortic dissection), prominent murmurs (endocarditis), friction rub (pericarditis), fever and abnormal lung sounds (pneumonia), or reproduction of chest pain with palpation of the chest wall (musculoskeletal disorders). A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk. [2]

A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

Why do we lie to ourselves about chest pain?

EMS is not responding to 911 calls to look for reasons that the patient’s symptoms are not cardiac.

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Footnotes:

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[1] The Perils of Low-Risk Chest Pain: Emergency Physicians Struggle to Balance Risk With Overtesting
Jan Greene
Annals of Emergency Medicine
Volume 56, Issue 4 , Pages A25-A28, October 2010
Free Full Text from Annals of Emergency Medicine

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[2] Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research.
Circulation. 2010 Jul 26. [Epub ahead of print]
PMID: 20660809 [PubMed - as supplied by publisher]

Free Full Text PDF – Only Available as a PDF

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Filed Under: Critical Judgment, Heresy, Uncategorized Tagged With: , ,

EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights

Wed, 29 Sep 2010 19:16:53 +0000 By 8 Comments

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Ckemtp writes EMS case law? AMA Refusals, Death, and Documentation

It is important to read. This is also a job for Star of life Law – a real lawyer. I am not a lawyer, but looking at the legal paper, it seems that this is just a determination of whether the law suit can proceed. If the original judge ruled that there were no grounds for a suit, then there probably had not been a presentation of a defense. That would happen during discovery (which may have been concurrent) and trial.

This ruling seems to be – the plaintiffs can proceed with their suit. The trial may still be a long way off.

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What is described in this ruling from the Court of Appeals is superficially scary.

15 minutes on scene, for a patient who died less than a day later. Sounds bad, but we don’t have any of the information to explain why.

Did the medic incompetently blow this off as indigestion?

I don’t know.

Did the patient threaten them and chase them from the home?

Probably not. It doesn’t seem that way, but we do not know.

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I spend much more time on refusals than almost any other call, although I have spent over an hour on scenes getting patients’ pain to the level where it was not torture to move the patients.

I have even had a refusal from a patient presenting with what gave every sign of being an MI. I showed him the ST elevation. He was a cardiologist. He absolutely refused. I have no idea of the scene time, but I got everybody there to try to persuade the patient to go to the hospital. I got medical command to talk to him, even though this was in a place where the doctors don’t talk to refusals. I’ll talk to this patient, but we don’t do that here. WTF?

I never heard anything further about this patient. It was an ALS assist outside of our territory. I checked the obituaries a couple of times, but this was when that required buying the local paper, or going to the library. As a library addict, I stoned a couple of birds in one shot. No dead doctor.

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The part that does not look good is this.

What emergency physician is arrogant enough to discharge a patient with only a 12 lead ECG?

And we don’t even know if they did a 12 lead ECG.

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Can we diagnose an MI/STEMI/NSTEMI with just a 12 lead ECG?

Absolutely.

Does that mean that we can rule out an MI/STEMI/NSTEMI with just a 12 lead ECG?

Absolutely not.

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A positive finding means something.

A negative finding only means that at the time the 12 lead ECG is performed, the patient is not having a heart attack that can be detected by a 12 lead ECG. A negative finding does not mean that the patient is not having a heart attack.

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Consider that you are in the woods. It is cold and you are seeking shelter. You see a cave. It is dark in the cave. If you heard growling coming from the cave, you would have a positive finding that there is an animal in there.

If you cannot hear anything, or see anything, does that mean that there are no animals in the cage – nothing big enough to reach out and bite you?

Unless the test has excellent sensitivity, a negative finding only means that nothing was detected. It does not mean that nothing was there.

If you could see through the walls of the cave, you could be sure if there were any animals inside, what kind of animals, how many animals, and many other things. In EMS, we do not have that kind of diagnostic equipment. Waveform capnography may be the closest we come.

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It may be nice to tell someone that everything is OK, but it is just a coin flip on whether we are right.

That is not even close to competent.

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Will an emergency physician also check cardiac enzymes and still worry that he may be discharging a patient with a real heart attack?

Absolutely.

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One other thing.

The cause of death was not a heart attack.

The cause of death was pulmonary embolism.

Maybe we do an excellent job of ruling out a heart attack. Yippee!

That does not mean that the only other cause of chest pain and difficulty breathing is indigestion.

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We should never approach a patient assuming that the cause of any complain, even abdominal pain, is indigestion. Even if the patient is mixing 5 alarm chili, donuts, beer, chocolate milk, whiskey, candy corn, a soufflé, and a bunch of other food that gives us indigestion just looking at the combination. Even if this patient has GERD and ulcers.

I do not believe in telling lies to patients.

If you don’t go to the hospital, you’re going to die!

If the patient does go to the hospital, the patient is still going to die. Everybody dies. So?

I explain the reasons the patient may want to go to the hospital.

I explain the limitations of my assessment.

I explain whatever they ask (related to the call).

Sometimes (frequently) my answer is – I don’t know.

Refusals require informed decisions.

Treatment and transport also require informed consent, but we seem to ignore that – a lot.

How many of us obtain informed consent for spinal immobilization, or even an IV start?

How many of us would be able to provide accurate information for a patient to be able to make an informed decision to consent to treatment/transport or to make an informed decision to refuse treatment/transport?

If we do not do a good job with informed consent, are we surprised that a lot of refusals are not well informed?

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Filed Under: Critical Judgment, Heresy, Uncategorized Tagged With: , ,

Evil Spirits, Shock Trauma, Anecdotes, and Gullibility

Sun, 26 Sep 2010 03:21:28 +0000 By 7 Comments
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In response to Shock Trauma Infested With Evil Spirits, One Hand Man writes the following:

First of all, If you are going to write an article about how bad and BS reiki is you should at least do even the slightest amount of research to learn what reiki actually is.

I have looked at the research. You are wrong to assume that I haven’t.

Do you expect that your unsupportable accusation will do anything other than convince people that you do not think about what you write?

Where is the evidence that reiki is anything other than a fraud?

The research does not support reiki.

Do you ignore the research?

Do you just not understand the research?

The research is clear. Reiki is just another placebo – in other words BS.

Reiki is about directing “Life Force Energy”. Now regardless if you believe in this “Life Force Energy” it doesn’t change the fact that it has nothing to do with “spirits” or “Ghosts”

There is no difference between the magical thinking of “Life Force Energy” and the magical thinking of “Ghosts.” Neither is real.

There is no difference between the magical thinking of “Life Force Energy” and the magical thinking of “spirits.” Neither is real.

Furthermore even if it is just a placebo it still helps!

Holding a patient’s hand helps, but we aren’t telling the patient lies about hand holding being some magic medicine – magic medicine is not real.

Does it actually cost anything extra? NO!

Yes. Magic medicine costs a lot.

Magic medicine, such as reiki, requires that doctors and nurses abandon honesty and ethics.

Is it honest to lie to patients?

Is it ethical to lie to patients?

Telling patients that reiki works is a lie.

I’m speaking from personal experience here!

An anecdote (your personal experience) is good for suggesting hypotheses for research. Once the research shows that the anecdote is just due to a placebo effect, we know that it is just wishful thinking. Wishful thinking leads us to deceive ourselves. It is even worse to deceive others.

Donna Audia who you openly bash in your article is not hired by the hospital specifically as a reiki specialist, as you seem to describe her but instead she is a nurse!

Deceiving patients is only one part of her job?

This is a defense?

Lying to patients is a violation of informed consent.

She does reiki as something extra! The hospital doesn’t pay her anything extra for doing it!

Oh, good. The fraud is FREE.

That is so much better than lying for money.

Hold on.

Is she off duty when she is practicing this mumbo jumbo?

If not, then the hospital has to pay other nurses to do her nursing work, while she is waving her magic wand and engaging in other deception.

Is she doing this completely on her own time, or are you telling another lie?

How gullible do you think we are?

I was a patient at this hospital for many months and during that time Donna was my nurse but she also did reiki on me in the PACU (if you don’t know what the is you have no right to be bashing this hospital or even writing this blog) and on my parents while I was in surgery. All of us agree that is does help.

Somehow the anecdote is multiplying, still the plural of anecdote is Myth.

I am familiar with the Post-Anesthesia Care Unit, but all one needs to know to point out that reiki is just a scam, is that there is no good research demonstrating that reiki is any better than a placebo. In other words, it is just another placebo.

And as a final note the title of this article is ridiculous.

When writing about things as ridiculous as reiki, ridicule is completely appropriate.

It creates an image of ghosts and poltergeists which i assume was another ploy of yours to make this hospital and the people in it look incompetent and unsafe.

These charlatans ridicule themselves by promoting reiki and acupuncture and other placebos. I am only pointing out that their actions are ridiculous.

I don’t know what your problem is with this hospital and there staff but they are providing a WAY more important public service than you are.

I am not telling lies about the treatments I provide.

Why do you claim that dishonesty is an important public service?

Treatment with reiki is no different from talking with ghosts, or performing psychic surgery, or promoting any other sham.

No reputable hospital should be so irresponsible.

This isn’t medicine.

When doctors and nurses betray the trust of their patients, these doctors and nurses deserve much more than ridicule.

Of course, if there is any valid evidence that reiki is better than placebo, then just provide it and I will retract what I wrote.

I’ll wait.

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Filed Under: Critical Judgment, Heresy, Uncategorized

The Real Gold Standard Of Airway Management at 510Medic

Fri, 24 Sep 2010 06:30:31 +0000 By 2 Comments
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510Medic has a nice post about The Real Gold Standard Of Airway Management.

The way he started out, I expected a riff on Nixon taking us off the Gold Standard – $35 an ounce due to price control then – now just under $1,300 an ounce. Last week, there was this – Gold Bet: $2500 Over/Under 2012. Even I am not cynical enough to take the over on that.

The Gold Standard 510Medic is writing about should be just as dead as the monetary gold standard.

There are some similarities. Both are inflexible and artificial limitations on change.

The idea that intubation is a gold standard only demonstrates an inability to adapt to what is best for the patient.

The gold standard is supposed to mean what is best for the patient, but does it?

In the emergency department, cardiac arrest patients are only intubated in the old fashioned Bretton Woods style of treatment. I expect the new guidelines to continue to de-emphasize intubation as a method of airway management.

In the operating room, intubation has become much less common.

If the emergency physicians and anesthesiologists are switching to more appropriate airway management methods, why isn’t EMS?

Because we are EMS. It sometimes seems as if you have to kick us in the head to get us to use our heads for anything.

As with helicopter abuse, we are not doing what is best for patients.

As with restrictive protocols, we are not doing what is best for patients.

As with on line medical command permission requirements, we are not doing what is best for patients.

As with cardiac arrest drugs, we are not doing what is best for patients.

As with spinal immobilization, we are not doing what is best for patients.

As with restrictions on prehospital pain management, we are not doing what is best for patients.

Are we surprised that, when it comes to airway management, we are not doing what is best for patients?

Let’s put an end to the Gold Standard terminology.

Airway management is about Ventilation – not Intubation.

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Filed Under: Critical Judgment, Heresy, Uncategorized Tagged With: , ,

Appropriate Morphine Dosing for Opioid Tolerant Patients

Wed, 22 Sep 2010 22:20:40 +0000 By 13 Comments
What do we do, when treating a patient already taking opioids? When the patient is already taking a large dose of an opioid and has a valid prescription for the doses of opioid being taken?

Remember that there is no maximum dose for morphine. There is no maximum dose for any opioid – as long as there are no adverse effects, such as depressed respirations, altered mental status, hypotension, or bradycardia.

What do we do when this patient has something like a femur fracture that produces severe pain?

This patient is opioid tolerant, so the standard doses of opioid are unlikely to produce a satisfactory effect. By standard doses, I mean doses that would be appropriate for a patient who is not currently taking opioids. That would be a starting dose of 0.05 mg/kg morphine to 0.1 mg/kg morphine – repeated as necessary until the pain is managed to the patient’s satisfaction or until side effects interfere with treatment.

The patient will probably receive more relief by releasing some flatulence than he will from 2 mg morphine. The flatulence may even provide more benefit than 10 mg morphine for an opioid tolerant patient.

Standard doses are not going to work, so do we just ignore this patient’s pain?

Do we tell this patient that our medical director does not trust us to give larger doses of morphine/fentanyl/hydromorphone than standard, because the medical director either has not really considered this possibility or doesn’t think that patients, who are legally prescribed high doses of opioids, deserve to have their severe pain treated effectively. Or maybe the medical director is just so irrationally afraid of opioid medications that he is not interested in understanding opioid tolerance.

It isn’t necessarily the medical director who is the obstacle to treatment. I know of plenty of medics who would not even start treatment of this patient’s pain. Maybe out of fear of causing respiratory depression. Maybe out of fear of causing addiction, in which case they really need to work on their response time, because it is a bit late to be considering addiction or tolerance.

What do you think are the chances of causing dangerous respiratory depression for this patient:

With 10 mg morphine?

Low Medium High

With 20 mg morphine?

Low Medium High

With 30 mg morphine?

Low Medium High

With 40 mg morphine?

Low Medium High

With 50 mg morphine?

Low Medium High

With 60 mg morphine?

Low Medium High

With 70 mg morphine?

Low Medium High

With 80 mg morphine?

Low Medium High

With 90 mg morphine?

Low Medium High

With 100 mg morphine?

Low Medium High

Why?

What would be considered dangerous respiratory depression for this patient?

Why?

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Filed Under: Critical Judgment, Heresy, Uncategorized Tagged With: , , ,

Rather than one excellent medic making everyone look better

Wed, 22 Sep 2010 18:23:45 +0000 By 4 Comments
What if the medics in the chart in my last post were not the bunch of bad apples with one good apple?

With these numbers representing the grade that an independent person, who understands what high quality EMS really is, gave to each of the medics in an organization?

Using the same chart, but switching the 50s to 90% quality scores, assuming that 60% (or even 65%) is the minimum passing score, what would this say about the medics in this organization?

What happens to the quality of care delivered by this organization, if the below average medic leaves?

Why do so many organizations seem to cherish the below average medics?

What is it that the other medics will say to this medic, if they recognize that the dangerous medic is dangerous?

Don’t be mean!

He’s got a family to feed!

Is that important?

Of course not.

Dangerous medics kill.

Dangerous medics kill people.

Dangerous medics kill people with families.

Dangerous medics kill people with families to feed.

Why is that so hard to understand?

Why is protecting the job of the dangerous medic considered so much more important than protecting the lives of the victims of the dangerous medic?

The dangerous medic is also making the good organization look bad.

Will the dangerous medic be remediated or fired?

Maybe, but how many patients will be harmed/killed by that one dangerous medic?

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[1]

With the addition of a technology (waveforem capnography) that is capable of dramatically cutting the unrecognized esophageal intubation rate to zero, the unrecognized esophageal intubation rate still did not drop to zero. Because one medic chose to ignore a zero capnography reading when the tube was in the esophagus. Did other medics do the same thing, except that they were lucky enough to have missed the esophagus?

Why?

At least one dangerous medic.

The average for the organization may look pretty good, but the few dangerous medics will still do a lot of damage – damage to defenseless patients. These patients are defenseless, because they depend on the EMS system to protect them from the dangerous medic the EMS system is sending to them. Patients who depend on EMS for emergency care maybe only one time, but that is all it takes.

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Footnotes:

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[1] Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]

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Filed Under: Critical Judgment, Heresy, Uncategorized
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