Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Why We Need Blasphemy Laws

The people promoting blasphemy laws are telling us that they believe their gods are impotent in the face of criticism.

The gods don’t enforce blasphemy laws, so people have to correct that mistake of the gods.

“We have killed Charlie Hebdo. We have avenged the Prophet Mohammad.” – The claims of one of the murderers of blasphemous journalists. These claims were made while the murderers were bravely running away because their gods cannot protect them.[6]

Does anything mock the gods more than having to get people to kill in the name of the gods?

You can kill people, but you cannot kill ideas.

Charlie Hebdo cover following an attack by criticism of blasphemy – translation – “The Koran is shit at stopping bullets.”

Maybe the message is that the gods no longer care about criticism. Religion changes. We have tens of thousands of variations of Christianity just in America – and we aren’t even the home of Christianity. Many of America’s first settlers were fleeing persecution by Christians for slightly different interpretations of the One True GodTM.

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Should Christians emphasize the part of the Bible where Jesus tells us –

34“Do not suppose that I have come to bring peace to the earth. I did not come to bring peace, but a sword. 35For I have come to turn

“‘a man against his father,
a daughter against her mother,
a daughter-in-law against her mother-in-law—
36 a man’s enemies will be the members of his own household.’[a]
37“Anyone who loves their father or mother more than me is not worthy of me; anyone who loves their son or daughter more than me is not worthy of me.
Matthew 10:34-37


Or should we ignore these parts and be more moral than the Bible commands in this and its other bad parts?

Is that sentence an example of blasphemy?

That depends on the reader. When quoting the Bible is blasphemous, is it a problem with the Bible, with the quote, with the intent, with the offense taken by the reader, or with something else?

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Which Christians determine what is blasphemy to Christians?

Which Jews determine what is blasphemy to Jews?

Which Muslims determine what is blasphemy to Muslims?

Which Buddhists determine what is blasphemy to Buddhists?

Which Scientologists determine what is blasphemy to Scientologists?

Which Wiccans determine what is blasphemy to Wiccans?

Which Satanists determine what is blasphemy to Satanists?

If the Satanists blasphemy judges conflict with the branch of Christians established as the blasphemy judges for Christianity, can anyone break the tie without violating First Amendment?[2] Which part wins when there is conflict within an amendment?

Which is more important – protecting religion from the same criticism every other adult organization has to face or protecting the expression of ideas? If the ideas are unimportant, there is no need for laws or violence. If the ideas are important, suppression only protects the thoughtless and the willfully ignorant.

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Our beliefs need to be protected against criticism, because we might start to think for ourselves.

If we can’t critically examine the tens of thousands of different, and amusingly contradictory, interpretations of the absolute truths of Christianity, how are we supposed to identify the one true version of the absolute truth? Religion is a multiple choice test question in which we are told that there is one best answer, but that those giving the test are not required to explain their answer in order to protect the validity of the testing process.[3]

It probably is the religion our parents raised us to believe, because we were given those parents for a reason.

When faith is weak, it must be protected with laws and violence. When faith is real, it doesn’t need to be petty and vindictive and immoral.

Federalist 10[4], Federalist 51[5]

Blasphemy is a crime in search of victims. Try to claim – I was blasphemed!  If you are not a god, your claim would be a blasphemy.

Blasphemy is a thought crime intended to discourage thinking.

Thinking is bad – Blasphemy laws are good.

Someone considers your freedom of religion to be a blasphemy against their religion. We need to help them impose their blasphemy laws on you. Then we can pretend that blasphemy laws will stop violent people from killing, just as gun laws stop violent people from killing.

12 people were murdered by a bunch of people who ran away, because they knew their gods would not protect them for supposedly defending their gods.

Undaunted by the gunning down of its leading cartoonists, the French weekly Charlie Hebdo plans to print a million copies next Wednesday, almost 30 times more than usual.

French media rallied around the satirical paper on Thursday, a day after militants killed 12 people as journalists held an editorial meeting, to ensure its next edition appears on time by offering funds and office space.[6]


We must impose blasphemy laws to protect ignorance. Ignorance appears to be sacred to the gods.

We must attack blasphemy to increase the circulation of blasphemous ideas.

The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg. . . .

Reason and free enquiry are the only effectual agents against error. Give a loose to them, they will support the true religion, by bringing every false one to their tribunal, to the test of their investigation. They are the natural enemies of error, and of error only. Had not the Roman government permitted free enquiry, Christianity could never have been introduced. Had not free enquiry been indulged, at the aera of the reformation, the corruptions of Christianity could not have been purged away. If it be restrained now, the present corruptions will be protected, and new ones encouraged. . . .

Millions of innocent men, women, and children, since the introduction of Christianity, have been burnt, tortured, fined, imprisoned; yet we have not advanced one inch towards uniformity. What has been the effect of coercion? To make one half the world fools, and the other half hypocrites. – Thomas Jefferson.[7]



[1] Matthew 10:34-37
The Bible
New International Version (NIV)
Verses on BibleGateway.com

[2] First Amendment
US Constitution

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.


[3] Cognitive Examinations
National Registry of Emergency Medical Technicians
About NREMT Examinations

Consensus by the committee must be gained so that each question is in direct reference to the tasks in the practice analysis, that the correct answer is the one and only correct answer that each distracter option has some plausibility, and the answer can be found within commonly available EMT textbooks.


[4] The Federalist No. 10
The Utility of the Union as a Safeguard Against Domestic Faction and Insurrection (continued)
Daily Advertiser
Thursday, November 22, 1787
[James Madison]
Full Text

[5] The Federalist No. 51
The Structure of the Government Must Furnish the Proper Checks and Balances Between the Different Departments
Independent Journal
Wednesday, February 6, 1788
[James Madison]
Full Text

[6] Attacked satirical French weekly to print a million copies next week
by Tom Heneghan
Paris Thu Jan 8, 2015 1:02pm EST

[7] Notes on the State of Virginia.
by Thomas Jefferson.
Edited by William Peden.
Chapel Hill: University of North Carolina Press for the Institute of Early American History and Culture, Williamsburg, Virginia, 1954.
© 1987 by The University of Chicago
Free Full Text at The University of Chicago


The Most Misleading Medical News of 2014


The media are horrible at reporting medical stories, or any other science stories. They regularly report that some recent study shows a cure for cancer, as if cancer is just one illness. What were the media worst at covering this year?


They said Ebola was easy to catch, that illegal immigrants may be carrying the virus across the southern border, that it was all part of a government or corporate conspiracy.[1]


Image credit.

The part of that quote that affects EMS is the claim that ebola is easy to catch.

Ebola does require isolation precautions – and we are not good at using, or understanding, isolation precautions. Just watch your coworkers putting everything on. Even worse, watch them take them off. Much worse, watch yourself in a mirror.

We are far from good at using isolation precautions.

Ebola spreads through direct contact with bodily fluids such as blood, vomit and diarrhea. Coughing and sneezing are not symptoms.

Airborne viruses, meanwhile, have the ability to travel large distances propelled by a sneeze or cough. In those cases, people breathe in virus particles without even realizing it. Scientists say there is no evidence Ebola works like that.[1]


Back in August Dr. Anthony Fauci described how we should expect this outbreak to progress. Looking back, we should have ignored the news media and reread this article.

Although the regional threat of Ebola in West Africa looms large, the chance that the virus will establish a foothold in the United States or another high-resource country remains extremely small. Although global air transit could, and most likely will, allow an infected, asymptomatic person to board a plane and unknowingly carry Ebola virus to a higher-income country, containment should be readily achievable.[2]


Dr. Fauci predicted that in August (print edition September 18). His prediction was more accurate than the media reported it as it happened a month later (a week later than the print edition).

Perhaps we should pay as much attention to what Dr. Fauci wrote about our optimism in favor of inadequately studied treatments.

Among the therapies in development is a “cocktail” of humanized-mouse antibodies (“ZMapp”), which has shown promise in nonhuman primates. ZMapp was administered to two U.S. citizens who were recently evacuated from Liberia to Atlanta, and both patients have had clinical improvement. However, it is not clear whether ZMapp led to the recovery, and with only two cases, conclusions regarding its efficacy should be withheld.[2]


Perspective is important and we should apply it more often.

For example –

1. Restricting travel from Ebola-outbreak countries to the United States is the best way to prevent the spread of Ebola to our shores.


There is no evidence that restricting travel will prevent spread of Ebola to the U.S. Exposed and infected persons might reach our country undetected and thereby escape essential public health monitoring, which could worsen transmission risk. The key to controlling this epidemic is to stop Ebola at its source in West Africa.[3]


If we won’t take the risk of caring for these patients, we should not interfere with those who do understand appropriate treatment and do treat these patients.


[1] 2014 Lie of the Year: Exaggerations about Ebola
Tampa Bay Times
By Angie Drobnic Holan, Aaron Sharockman
Monday, December 15th, 2014 at 3:08 p.m.

PolitiFact editors choose the Lie of the Year, in part, based on how broadly a myth or falsehood infiltrates conventional thinking. In 2013, it was the promise made by President Barack Obama and other Democrats that “If you like your health care plan, you can keep it.”


[2] Ebola–underscoring the global disparities in health care resources.
Fauci AS.
N Engl J Med. 2014 Sep 18;371(12):1084-6. doi: 10.1056/NEJMp1409494. Epub 2014 Aug 13. No abstract available.
PMID: 25119491 [PubMed – indexed for MEDLINE]

Free Full Text from New England Journal of Medicine.

[3] Ten Key “Facts” About Ebola: True or False?
Kristi L. Koenig, MD, FACEP, FIFEM
November 7, 2014
JournalWatch Emergency Medicine from NEJM


Florida County Eliminates Use of Magic Backboards for Possible Spinal injuries


More medical directors are rejecting the superstition that it is acceptable to harm patients to prevent fear of law suits.

There is no evidence that backboards do anything to protect the spine, but there is plenty of evidence that backboards cause harm.[1]

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All treatments have side effects, so we need to have evidence of benefit to justify exposing our patients to those side effects. A treatment that does not provide any benefit to the patient exposes the patient to the side effects, but does not provide any benefit. This is indefensible, but many doctors, nurses, paramedics, basic EMTs, and others continue to defend this magical thinking and oppose EBM (Evidence-Based Medicine).

Fortunately, the defenders of superstitious nonsense seem to be losing support for belief in the magical properties of backboards.

Palm Beach County Fire Rescue just became one of the first agencies in the state to stop the use of rigid backboards for spinal immobilization.[2]



Instead of using the backboard, patients will be placed on a padded stretcher. Cervical collars will still be used when necessary to provide cervical stabilization.[2]


“The new procedures will reduce pain and suffering of patients, reduce complications, decrease on scene times and reduce injuries to crews who are attempting to carry immobilized patients,” said Cpt. Albert Borroto in a news release.[3]


Palm Beach County Fire Rescue joins a growing list of EMS agencies that are putting patients ahead of superstition –

Agencies/EMS Systems Minimizing Backboard use -

Let me know if I should add your agency to this list.

Alameda County

Albuquerque-Bernalillo County Medical Control Board

Bernalillo County Fire Department

CentraCare Health
Monticello, MN

Connecticut, State of

Durham County EMS

Eagle County Ambulance District

HealthEast Medical Transportation
St. Paul, MN

Johnson County EMS

Kenosha Fire Department
Kenosha, WI

Maryland, State of

MedicWest Ambulance

Milwaukee EMS

North Memorial Ambulance & Aircare
Minneapolis, MN

Palm Beach County Fire Rescue

Rio Rancho Fire Department

SERTAC (Southeast Regional Trauma Advisory Council)

Wichita-Sedgwick County EMS System

Xenia Fire Department
Xenia, OH

Outside of the US –

St. John Ambulance
New Zealand


Queensland, Australia


[1] New Kansas EMS policy limits use of backboards
Tue, 01 Apr 2014
Rogue Medic

[2] Palm Beach County Fire Rescue changes the way first responders handle patients
Katie Johnson
5:57 PM, Dec 10, 2014
5:40 AM, Dec 11, 2014
WPTV5 West Palm Beach

[3] Palm Beach County Fire Rescue making changes for backboard use
WPTV Webteam
8:47 AM, Dec 10, 2014
7:35 PM, Dec 10, 2014
WPTV5 West Palm Beach


Anecdotes and the Appearance of Improvement

We like to give treatments that produce results that we can see and logically attribute to the treatments we gave.

We like to give IV (IntaVenous) furosemide (Lasix – frusemide in Commonwealth countries) for CHF (Congestive Heart Failure).

1. The patient had CHF.

2. I gave IV furosemide.

3. The patient produced urine.

4. The patient improved.

Anecdotes like this can lead us to the conclusion that the furosemide produced the improvement, even if we have been giving many other treatments along with the Lasix.

We can use logic to back up that conclusion.

1. CHF is fluid in the lungs.

2. CHF is too much fluid.

3. Getting rid of the fluid gets rid of the problem.

4. The patient improved, so the logic must be sound.

But is the logic sound? Is the conclusion justified or are we seeing what we want to see?

The way we find out is by studying patients with similar enough presentations that they are treated the same way, except that not all patients are given Lasix.

When we study the results of furosemide on CHF, we see that the things we have been told about IV Lasix are not true.

Hypothesis #1. Acute CHF patients are overloaded with fluid. We have to remove the fluid to save them.

CHF = Pee or die!

Image credit.

This hypothesis was tested – all the way back in 1978, but the myth continues.


The concept that acute heeart failure with pulmonary edema is associated with an increase in intravascular volume is therefore not supported. To the contrary, there is a reduction of blood volume during acute pulmonary edema.[1]


The normal patients had 22% more total plasma volume.

The normal patients had 21% more total blood volume.

The need to remove fluids is based on what?

It is interesting that this study was of patients treated with oxygen, morphine, and furosemide. Only oxygen is still important in the acute treatment of CHF/ADHF.

Hypothesis #2. IV Lasix almost immediately causes vasodilation.


IV Lasix almost immediately causes vasoconstriction.

This hypothesis was tested – in 1985, but this myth also continues.


The use of intravenous furosemide in patients with chronic congestive heart failure, although well established, can promote further clinical hemodynamic deterioration during the first 20 minutes.[2]


Lasix raises blood pressure in emergency treatment of CHF.

Hypothesis #3. IV Lasix improves outcomes for acute CHF patients.


IV Lasix does not improve outcomes for acute CHF patients.

This hypothesis was also tested a long time ago (in 1987), and at other times, but the myth persists longer than the patients treated with Lasix.[3]


If we can eliminate a treatment and the outcomes of patients do not get worse, where is the benefit from the treatment?

Why expose the patient to the side effects of a treatment, if the patient is not expected to benefit from the treatment?


[1] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed – indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format.

[2] Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis.
Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, Cohn JN.
Ann Intern Med. 1985 Jul;103(1):1-6.
PMID: 2860833 [PubMed – indexed for MEDLINE]

[3] Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema.
Hoffman JR, Reynolds S.
Chest. 1987 Oct;92(4):586-93.
PMID: 3115687 [PubMed – indexed for MEDLINE]

Free Full Text from Chest.

Figueras J, & Weil MH (1978). Blood volume prior to and following treatment of acute cardiogenic pulmonary edema. Circulation, 57 (2), 349-55 PMID: 618625

Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, & Cohn JN (1985). Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Annals of internal medicine, 103 (1), 1-6 PMID: 2860833

Hoffman JR, & Reynolds S (1987). Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema. Chest, 92 (4), 586-93 PMID: 3115687


The Media are Just As Bad at Ethics As They are at Science

There is another article about the adrenaline (epinephrine in non-Commonwealth countries) vs. placebo in cardiac arrest trial that is about to start in England.[1] Media sites no longer seem to want to spend money to get valid information on science or ethics. Forbes provides another example of the writer completely missing the obvious.

It’s one thing to treat an incapacitated emergency patient without consent, when you’re administering a standard therapy already proven to be beneficial.[2]


Nobody is being deprived of anything that has been adequately tested on humans. Why assume that the untested and unknown standard treatment is beneficial?

The active drug (adrenaline) is an unknown. There is no good evidence that adrenaline improves outcomes.

If you disagree, provide some evidence that shows that adrenaline is better than placebo at anything that matters.

Adrenaline is an unknown because it has never been adequately studied. The only study that has tried to compare it to placebo was limited by politicians and the media – the people who know the least about how science works.

This is like being told that you will be put in a room with either a killer or a mannequin. Which one do you want. Except that we do not know if adrenaline is a killer. We do not have enough information. The only way to find out is to study it.

The research so far is negative. Is that because the adrenaline is given too late? Is that because too much adrenaline is given? Is that because we give it to everyone still dead after a few minutes?

We do not know.

We treat adrenaline like snake oil – Able to cure all kinds of cardiac arrest. Step right up and get your magic elixir. Cures baldness, too!

Image credit.

When the sales pitch is that the drug fixes everything, we should be very suspicious.

Cardiac arrest due to blood loss?   Give adrenaline.

Cardiac arrest due to slow heart rate?   Give adrenaline.

Cardiac arrest due to fast heart rate?   Give adrenaline.

Cardiac arrest due to irritated heart?   Give adrenaline.

Cardiac arrest due to not enough stimulus to the heart?   Give adrenaline.

Cardiac arrest due to drug over-dose?   Give adrenaline.

Cardiac arrest due to drug under-dose?   Give adrenaline.

Cardiac arrest due to diabetes problem?   Give adrenaline.

Cardiac arrest due to infectious disease?   Give adrenaline.

Cardiac arrest due to lightning strike?   Give adrenaline.

Cardiac arrest due to drowning?   Give adrenaline.

Cardiac arrest due to asthma?   Give adrenaline.

Cardiac arrest due to stroke?   Give adrenaline.

Cardiac arrest due to cancer?   Give adrenaline.

Cardiac arrest due to adrenaline overdose?   Give adrenaline.

We do not discriminate. We just give adrenaline. All of the other drugs have failed to produce a benefit, but we still believe in adrenaline without good evidence. We have been using adrenaline for over half a century on unsuspecting people and we still have no evidence that it works.

However, the more important issue is what you as a patient think. Should scientists be able to enroll you in a life-or-death medical experiment without your consent?[2]


Adrenaline has worked in laboratory animals, but every drug that is tested in humans is supposed to have worked in animals. Why doesn’t adrenaline work in humans? If it does work, where is the evidence?

The standard of care is an experiment that is not controlled and not even acknowledged. The guidelines clearly state that we do not know what works and that we should only consider adrenaline, but that we do not have any good evidence that adrenaline improves outcomes for anyone.

The ethical failure is that we have failed to find out if what we are giving is harmful.

We have only improved outcomes when we have ignored the drugs and paid attention to chest compressions and defibrillation.

We are lying to patients when we tell them that we know what works in cardiac arrest.

How much worse than placebo is adrenaline? We don’t know. Failing to find out is what is unethical.


[1] Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?
Wed, 27 Aug 2014
Rogue Medic

[2] UK To Experiment on Cardiac Arrest Patients Without Their Consent
8/27/2014 @ 3:55PM
Paul Hsieh – Contributor


If We Pretend that Anecdotes are Not Anecdotes, Do We Change Reality?


The following comment was written by Duke Powell in response to Where is the Evidence for Traction Splints?

I’ve been an urban paramedic for 34 years and, prior to that, a volunteer EMT for 9 years. For those who can’t add, ….that’s a long time.

How many times have I used a traction splint? …… I dunno, let’s guess 10 times.


That works out to an average of over four years between uses of the traction splint. That is plenty of time to have the memory of each use reconstructed many times, so that the memory and the reality may not have much in common. Each time we remember something, we recreate and modify the memory.

Several years ago, after several years of not even thinking about traction splinting, I found myself using it 3 times in 2 weeks.

Did it help? Yep, clinically, in my opinion, it helped.


Maybe it helped the patients. Maybe it harmed the patients. Maybe it helped some patients and harmed other patients. Maybe it helped the pain, but caused longer term harm. We do not know.

Without valid evidence, especially evidence of something more than the superficial appearance of improvement, we have no idea. We can use our imaginations and generate opinions, but we are merely discussing opinions.

Will Rogue Medic call my experience “anecdotal” and not worthy of consideration? Yes, he will.

Don’t care what the Rogue Medic thinks.

I care about what my patients and my Medical Director thinks.


Image credit.

Does calling an anecdote by a different name make it not an anecdote? It does not matter what you call it. A story is an anecdote. More than one story is just more than one anecdote.

What kind of follow up was there on the patients? What kind of comparison of the other variables was there?

Blood-letting looks like an excellent treatment – if we stick to anecdotes about blood-letting.

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[1]


How many patients did we kill with blood-letting? Thousands? Tens of thousands? Hundreds of thousands?

The opinions of medical directors have been in favor of many harmful treatments. Do you remember nifedipine?

Anecdotes do not become evidence of good patient care by telling the stories with style. Reality does not work that way, no matter how much we want to change reality. EMS shows us people who are having reality ignore their opinions about how the world should work. If reality is not going to change for a parent who wants their dead child back, how little is reality going to change for a paramedic who wants to put a positive spin on a treatment that he likes?

Reality does not care about our opinions.

Reality does not even care about the opinions of medical directors.

Science is the way we learn the difference between what is real and what is just a pleasing mirage.

What do you think science is? There is nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. So 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.

Anecdotes are not thorough observations. Anecdotes do not use consistent logic. Anecdotes do not have anything to do with systematic evaluation.


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


Where is the Evidence for Traction Splints?


We eliminated tourniquets from ambulances because of anecdotes and some strong opinions, but not because of valid research. Valid research shows that tourniquets work. Tourniquets are back.

We added traction splints because of anecdotes and some strong opinions, but not because of any valid research. Will research result in the same reversal of opinion-based practice.

With so little evidence, devices that are frequently misused, and no apparent need for these Rube Goldberg devices, should we continue to use traction splints?

Image credit.

Does a traction splint work?

That depends on what we mean by the word work. If work means that it pulls on the leg, then it does work, but if work means that it improves outcomes, then the traction splint is about as effective as eye of newt. Maybe the eye of newt is more effective.

If your have a lot of patients who have no other major injuries, then you may be able to set up a study of traction splints. A ski resort might be a good place for a study. On the other hand, if you are not an isolated femur fracture magnet, then your patients would probably be much better off if you focused on pain management, rather than pulling on their broken bones.

The fact is, there were no definitive studies demonstrating efficacy or decreased morbidity or mortality from prehospital use of traction splints 10 years ago, nor are there any now.3 So our use of traction splints is purely anecdotal.[1]


What is an anecdote?

An anecdote is misinformation from a know-it-all who doesn’t know what matters.

Anecdotes are just rumors. We believe some things because we want to believe, not because they are true. If we want to know the truth, we look for unbiased information. Unbiased information is the opposite of anecdotes and rumors.

There I was, standing on the corner, minding my own business, when all of a sudden . . .

He was dying and we gave the special sauce and he got better and ran a marathon last year.

These are examples of anecdotes. Anecdotes are what sells alternative medicine.


[1] Sacred Cow Slaughterhouse: The Traction Splint
By William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Jul 31, 2014
EMS World


Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?

 Some in the media have been critical of the upcoming British study of adrenaline (epinephrine) vs. placebo for cardiac arrest.[1] They assume that the guidelines require that we give adrenaline, but that is not true.

The guidelines only state that adrenaline may be considered.

If you are a dog, pig, or rat in a laboratory and you have had an artificially induced cardiac arrest, then adrenaline will help resuscitate you. If you are a human who has a cardiac arrest for any one of a variety of reasons, then there is not a good reason to give this rat resuscitation drug, which has not been adequately studied in humans.

There probably are some human patients who do benefit from adrenaline in cardiac arrest, but we have no idea which patients those are and there probably are humans who are harmed by adrenaline. The most common cause of cardiac arrest is heart attack, but you were having a heart attack while still alive, is there a worse drug we could give you than adrenaline? Does adrenaline suddenly become sugar and spice and everything nice, just because we cannot feel a pulse? Maybe, but should we assume that?

What if you have lost so much blood that your heart is not able to produce a pulse, even though your heart is beating as hard as it can? Adrenaline is indicated according to the same guidelines. Why? Unreasonable optimism.

Which patients benefit from adrenaline? We don’t know.

Which patients are harmed by adrenaline? We don’t know.

How do we find out? Research, such as the upcoming study of adrenaline (epinephrine).

What do the guidelines say about conducting this research?

Given the observed benefit in short-term outcomes, the use of epinephrine or vasopressin may be considered in adult cardiac arrest.

Knowledge Gaps

Placebo-controlled trials to evaluate the use of any vasopressor in adult and pediatric cardiac arrest are needed.[2]


Vasopressors are adrenaline, vasopressin, norepinephrine, and phenylephrine. We need evidence to find out if any of them work.

When the 2010 guidelines were written there was an inescapable need for placebo studies.

Has anything changed?


There was a placebo study in 2012 that was aborted by pressure from media and politicians before any useful results could be obtained.[3]

There is evidence that adrenaline improves the return of a pulse, but that appears to just produce comatose patients who die in the hospital without waking up, so the initial improvement appears to be very misleading.

We could try real medicine, where we find out what the right treatment is and give the right treatment to the right patient, but that seems to be asking too much for some people.

The Media are Just As Bad at Ethics As They are at Science


[1] The Controversy of Admitting ‘We Do Not Know What Works’
Wed, 13 Aug 2014
Rogue Medic

[2] Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TL, Böttiger BW, Drajer S, Lim SH, Nolan JP; Advanced Life Support Chapter Collaborators.
Circulation. 2010 Oct 19;122(16 Suppl 2):S345-421. doi: 10.1161/CIRCULATIONAHA.110.971051. No abstract available.
PMID: 20956256 [PubMed – indexed for MEDLINE]

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

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


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