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

- Rogue Medic

Should ACLS Recommend the Unknown Based on Weak Evidence?


 
The AHA (American Heart Association) and ILCOR (International Liaison Committee on Resuscitation) will be meeting tomorrow to finalize the recommendations for the 2015 ACLS (Advanced Cardiac Life Support) guidelines. Here is the comment I submitted on the proposed recommendation for epinephrine (Adrenaline in Commonwealth countries) in cardiac arrest.

I have not received any information about where to submit SEERS comments, so I am sending this to you. Please forward it to whomever is supposed to receive comments.

Vasopressors for cardiac arrest (1. Epi v Placebo)
 

Consensus on Science:
For all four long term (critical) and short term (important) outcomes, we found one underpowered trial that provided low quality evidence comparing SDE to placebo (Jacobs, 2001, 1138).
[1]

 

As a trial that is stated to be underpowered (through no fault of Dr. Jacobs),[2] is there any valid reason the Jacobs study should be considered to be superior to observational studies?
 

Among 534 subjects, there was uncertain benefit or harm of SDE over placebo for the critical outcomes of survival to discharge [RR 2.12, 95% CI 0.75-6.02, p=0.16] and good neurological outcome defined as CPC of 1-2 [RR 1.73, 95% CI 0.59-5.11, p=0.32].[1]

 

We do not have good evidence to tell us if this is harmful or beneficial and we do not have any way of determining which patients will be harmed or helped by administration of epinephrine.


 

However, patients who received SDE had higher rates of the two important outcomes of survival to admission [RR 1.95, 95% CI, 1.34-2.84, p=0.0004] and ROSC in the prehospital setting [RR 2.80, 95% CI 1.78-4.41, p<0.00001] compared to those who received placebo.[1]

 

Are these surrogate endpoints important?

How do we know?

If these surrogate endpoints are important, why is there no valid evidence to support this claim?

We have a history of being misled by surrogate endpoints. We used to bleed patients and that produced a number of clear benefits in surrogate endpoints.
 

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.[3]

 

We don’t do that any more, because medicine is not supposed to just create a superficial improvement.

We should not be making any recommendation to treat based on such weak evidence.
 

The evidence for the routine use of adrenaline is perceived to be at equipoise within the international community of resuscitation scientists requiring re-evaluation19 as suggested by this comprehensive systematic review and meta-analysis. There is a need for well-designed, placebo-controlled, and adequately powered RCTs to evaluate the efficacy of adrenaline and to determine its optimal dosing.11,16,54 The question as to the efficacy of adrenaline for OHCA remains unanswered.[4]

 

Since the question as to the efficacy of adrenaline for OHCA remains unanswered, we should avoid substituting a bad answer for We don’t know.

Maybe we should bring back the indeterminate class for these unanswerable questions.
 

Treatment Recommendation
Given the observed benefit in short term outcomes, we suggest Standard Dose Epinephrine be administered to patients in cardiac arrest.(weak recommendation, low quality)
[1]

 

The benefit is considered important, but that is just an expert opinion, which is the lowest level of evidence.

A weak recommendation to give a treatment of unknown benefit and unknown harm, based on evidence that is admitted to be of low quality, should not set the standard of care. Even if the guidelines are explicitly stated to not be standards of care, they are adopted as standards of care by the emergency medicine community and by the EMS community.

We don’t know enough to make a recommendation about epinephrine, or most other treatments, in cardiac arrest.

We do not need to keep making the same recommendation just because we have made it before. We can leave it up to the treating physician or to the medical director writing the protocols for EMS.
 
 

See also – Proposed 2015 ACLS Epinephrine Recommendation – Vasopressors for cardiac arrest (1. Epi v Placebo)

Footnotes:

[1] Vasopressors for cardiac arrest (1. Epi v Placebo)
ILCOR Scientific Evidence Evaluation and Review System
Questions Open for Public Comment
Closing Date – February 28, 2015
Question page

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

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

 

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

 

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

 

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

[4] Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials.
Lin S, Callaway CW, Shah PS, Wagner JD, Beyene J, Ziegler CP, Morrison LJ.
Resuscitation. 2014 Jun;85(6):732-40. doi: 10.1016/j.resuscitation.2014.03.008. Epub 2014 Mar 15.
PMID: 24642404 [PubMed – in process]

.

FDA takes steps to improve reliability of automated external defibrillators


 

Why improve the reliability of AEDs (Automated External Defibrillators)?

AEDs are important, much more important than the epinephrine I wrote about yesterday, because AEDs actually work – at least when the AEDs work as they are supposed to.

AEDs fail much more often than they should.
 

From January 2005 through September 2014, the FDA received approximately 72,000 medical device reports associated with the failure of these devices. Since 2005, manufacturers have conducted 111 recalls, affecting more than two million AEDs. The problems associated with many of these recalls and reports included design and manufacturing issues, such as inadequate control of components purchased from other suppliers.[1]

 

72,000 reports over ten years. In the US, there are about 300,00 cardiac arrests a year where treatment is considered and an AED might be applied. Out of those, how many times is an AED applied? 1/3?

If I use that ballpark number guess, then 72,000 out of 1,000,000 is 0.72%. The reporting of problems that are identified during equipment checks and maintenance should also decrease the rate of failure in the treatment of real patients. Maybe I decrease that guess at a failure rate during cardiac arrest treatment/assessment to 0.5% or 0.1%?

A decrease to 0.1% is one out of every 1,000 uses. Is that a tolerable level of failure for a device that has only two tasks, but has to remain ready to perform those tasks at all times? The two tasks are to differentiate between ventricular fibrillation/ventricular tachycardia and any other cardiac rhythm and to deliver a shock to the patient after ventricular fibrillation or ventricular tachycardia has been identified.
 


Image credit.
 

There are only a few moving parts and the designs may vary from what I describe. The wire that is manually attached to the defibrillator pads. The lids that is opened, turns on the AED, and triggers the voice prompts. The buttons that are pressed to turn on the AEDs not turned on by opening the lid, to analyze the rhythm, and to deliver the shock.

Would Do we accept a similar failure rate from an ambulance, which has many more moving parts?

Do we accept similar failure rates from our personal vehicles, which have many more moving parts?

Do we accept similar failure rates from aircraft, which has many more moving parts?

Yes and no.

We deal with the failures in these vehicles by building in redundancies and paying attention to maintenance, but the result is that the failures rarely cause death, or the lack of resuscitation that could have occurred with a properly functioning AED.
 

For example, NASA management claimed that they had an isty-bitsy teeny-weeny failure rate. They were shown to be wrong in a very dramatic, and deadly, fashion. Twice.
 

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

. . . .

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[2]

 

We need to understand what the actual failure rates are. We also need to work on the failure rate that comes from operator error.

The reason people are able to lie to us with statistics (statistics do not lie, but statistics can be used by liars) is that we choose to remain ignorant of the appropriate use of statistics. We ask to be lied to.
 

What is an acceptable failure rate? It isn’t zero, because a zero failure rate is a lie.

Footnotes:

[1] FDA takes steps to improve reliability of automated external defibrillators
January 28, 2015
Food and Drug Administration
FDA News Release

[2] Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
by R. P. Feynman
Conclusions
NASA report

.

Proposed 2015 ACLS Epinephrine Recommendation – Vasopressors for cardiac arrest (1. Epi v Placebo)


 
What do the AHA (American Heart Association) and ILCOR (International Liaison Committee on Resuscitation) plan to make their recommendation on use of epinephrine (Adrenaline in Commonwealth countries) in cardiac arrest (ACLS – Advanced Cardiac Life Support)?
 

Full Question:
Among adults who are in cardiac arrest in any setting (P), does does use of epinephrine (I), compared with placebo or not using epinephrine (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?

The information provided is currently in DRAFT format and is NOT a FINAL version[1]

 

Unless you are familiar with the way AHA/ILCOR ask questions, this may not seem to be a helpful way of addressing the question. Here is the format being used –

PICO:

Population/Patient/Problem

Intervention

Comparison/Control

Outcome
 

The Patients are adults who are in cardiac arrest in any setting.

The Intervention is use of epinephrine.

The Comparison is placebo or not using epinephrine.

The Outcome is a bit complicated – Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC. ROSC is Return Of Spontaneous Circulation.

Everything is reasonable – until they get to the outcome. Does anyone still think that it is really an improvement to get pulses back, be transported to the hospital, never wake up, and die in the ED (Emergency Department) or ICU (Intensive Care Unit)? What if the coma lasts for 30 days, 60 days, 180 days AND/OR 1 year. If you think that is an improvement, you may not have considered the cost. How much is it worth to give a family false hope? $10,000? Who pays for this deception?

Should we also try putting the patient in a helicopter to see if the magic rotor blades make the family feel that everything possible was done to deceive them?

These are considered to be important, because we do not seem to know what is important.

Why are ROSC and survival to admission considered important?

Where is the evidence that these measurements lead to better outcomes?
 

 

Studies that look at these outcomes show that real world patients treated with epinephrine are more likely to die in the hospital – and those who do not die in the hospital are more likely to have severe neurological impairment.
 

Click on image to make it larger.[2] The studies are in the footnotes.[3],[4],[5],[6],[7],[8],[9],[10]
 

Is Adrenaline beneficial in cardiac arrest?

Probably, but only for some patients and we do not know which patients benefit.

Is Adrenaline harmful in cardiac arrest?

Probably, but only for some patients and we do not know which patients are harmed.

The evidence evaluation focused on the Jacobs study,[8] which is randomized and placebo controlled, but only reaches the level of fair according to the analysis of all of the evidence. The reason is that politicians and the media combined to sabotage the study. Most of the ambulance services dropped out of the Jacobs study because of this interference. This is not the fault of Dr. Ian G. Jacobs, who deserves credit for setting up the first randomized placebo controlled study of this important topic.
 

For all four long term (critical) and short term (important) outcomes, we found one underpowered trial that provided low quality evidence comparing SDE to placebo (Jacobs, 2001, 1138).[1]

 

We need to bring back the Indeterminate class of recommendation for ACLS, because that is the best that we can come up with for epinephrine, unless we ignore the evidence or we just don’t understand the evidence.
 

Table 3.
Applying Classification of Recommendations and Level of Evidence

. . .

Class Indeterminate.
• Research just getting started
• Continuing area of research
• No recommendations until further research (eg, cannot recommend for or against)[11]

 

Does the proposed ACLS recommendation on epinephrine makes sense?

Consider that we do not know which patients benefit from epinephrine. The treatment for every cause of cardiac arrest includes epinephrine as the first drug, even if the cause of cardiac arrest is known to be an overdose of epinephrine.

Is epinephrine better than nothing for some patients in cardiac arrest? Yes.

Is epinephrine worse than nothing for some patients in cardiac arrest? Yes.

We do not know which patients we are harming with epinephrine and we don’t seem to want to stop harming those patients.

Footnotes:

[1] Vasopressors for cardiac arrest (1. Epi v Placebo)
ILCOR Scientific Evidence Evaluation and Review System
Questions Open for Public Comment
Closing Date – February 28, 2015
Question page

[2] Vasopressors in cardiac arrest: a systematic review.
Larabee TM, Liu KY, Campbell JA, Little CM.
Resuscitation. 2012 Aug;83(8):932-9. Epub 2012 Mar 15.
PMID: 22425731 [PubMed – in process]
 

CONCLUSION: There are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.

[3] High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest.
Woodhouse SP, Cox S, Boyd P, Case C, Weber M.
Resuscitation. 1995 Dec;30(3):243-9.
PMID: 8867714 [PubMed – indexed for MEDLINE]

[4] Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?
Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, Holmberg S.
Resuscitation. 1995 Jun;29(3):195-201.
PMID: 7667549 [PubMed – indexed for MEDLINE]

[5] Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.
Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A; Cardiac Arrest and Resuscitation Epidemiology Study Group.
Ann Emerg Med. 2007 Dec;50(6):635-42. Epub 2007 May 23.
PMID: 17509730 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from prdupl02.ynet.co.il

[6] Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed – indexed for MEDLINE]

Free Full Text from JAMA

[7] Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial.
Olasveengen TM, Wik L, Sunde K, Steen PA.
Resuscitation. 2011 Nov 22. [Epub ahead of print]
PMID: 22115931 [PubMed – as supplied by publisher]

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

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

 

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

 

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

 

[9] 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.

[10] Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest.
Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, Kai T.
Circ J. 2012;76(7):1639-45. Epub 2012 Apr 5.
PMID: 22481099 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation Japan.

[11] Table 3. Applying Classification of Recommendations and Level of Evidence
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 1: Introduction
Table 3

I have modified this table solely for the purpose of clarity of presentation, by modifying color and font. None of the words have been changed.

.

Narcan in Cardiac Arrest – Safe as Long as I Don’t Understand Safety


 
How can I justify exposing patients to the risks of a treatment that has no known benefit?

Here is one way –
 

I give Narcan in arrest. You might not. Neither of us are wrong. Yet.
 

Narcan (naloxone) is one of the safer drugs we use. Suppose that I give a drug in a way that has not been found to be beneficial because I think it is safe as long as I can’t think of a specific problem I can cause. Does that make the inappropriate drug administration safe? Or is it just an example of my ignorance?

If a lack of knowledge were a good thing, we should not teach anything about pharmacology.

The less I know, the safer it is. Ignorance is safety.

We should not teach about the adverse effects of drugs, because as long as I don’t know about the danger, there is no danger. It is only after the danger is known that the danger is real, so don’t tell me about any dangers.
 

In the ACLS (Advanced Cardiac Life Support) guidelines, the American Heart Association tells us that it is wrong to give Narcan during cardiac arrest.
 

Naloxone is a potent antagonist of the binding of opioid medications to their receptors in the brain and spinal cord. Administration of naloxone can reverse central nervous system and respiratory depression caused by opioid overdose. Naloxone has no role in the management of cardiac arrest.[1]

 

Naloxone has no role in the management of cardiac arrest.
 

Why did I give Narcan? Because ACLS told me not to.

Don’t think, just do something. If I do not know of a danger, there is no danger. If I have been told that it is wrong, do it anyway.
 


Image credits – 123
 

Repeat the mindless sequence as often as necessary, until the desire to understand patient care has been destroyed.
 


 

But Narcan reverses respiratory depression and apnea.

Narcan can reverses respiratory depression or apnea in a living patient. A patient in cardiac arrest due to a heroin overdose should be treated for a respiratory cause of cardiac arrest. Children and patients with respiratory causes of cardiac arrest should be ventilated and oxygenated. These patients will also be receiving epinephrine (Adrenaline in Commonwealth countries) in the early part of the standard treatment of cardiac arrest. Narcan does not add anything to these treatments the patient is already receiving.
 

But Narcan is safe – and I can’t make the patient any worse.
 

Naloxone is one of the safer drugs we can give to a patient when there is an indication to give naloxone. Even when given inappropriately, naloxone is not very likely to cause harm.

There are several problems.

If I am pushing drugs because I don’t know what to do, I should be trying to figure out what treatments I can give that might actually help the patient. There is no reason to believe that naloxone might actually help the patient. If I am giving drugs that provide no benefit, I am distracting myself from assessment, which might provide information that can help me resuscitate the patient.
 

As long as I don’t know what I’m doing, I am not wrong.
 

No.

As long as I don’t know what I’m doing, I am both wrong and dangerous.
 
 

See also –
 

Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions – Tue, 01 Nov 2011

Naloxone in cardiac arrest with suspected opioid overdoses – Thu, 05 Apr 2012

The Myth that Narcan Reverses Cardiac Arrest – Wed, 12 Dec 2012

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest – Sun, 03 Aug 2014

Footnotes:

[1] Opioid Toxicity
2010 ACLS
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12.7: Cardiac Arrest Associated With Toxic Ingestions
Free Full Text from Circulation

.

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.
 


 

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
[1]

 

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?
 


 

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.
 


 

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]

 

Footnotes:

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

[2] First Amendment
US Constitution
Wikipedia
Text
 

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
Article
 

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
Reuters
Article

[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

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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?

Ebola.
 

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.

FALSE

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.

Footnotes:

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

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
Article

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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]
 


 

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
CA
 

Albuquerque-Bernalillo County Medical Control Board
NM
 

Bernalillo County Fire Department
NM
 

CentraCare Health
Monticello, MN
 

Connecticut, State of
CT
 

Durham County EMS
NC
 

Eagle County Ambulance District
CO
 

HealthEast Medical Transportation
St. Paul, MN
 

Johnson County EMS
KS
 

Kenosha Fire Department
Kenosha, WI
 

Maryland, State of
MD
 

MedicWest Ambulance
NV
 

Milwaukee EMS
WI
 

North Memorial Ambulance & Aircare
Minneapolis, MN
 

Palm Beach County Fire Rescue
FL
 

Rio Rancho Fire Department
NM
 

SERTAC (Southeast Regional Trauma Advisory Council)
WI
 

Wichita-Sedgwick County EMS System
KS
 

Xenia Fire Department
Xenia, OH
 
 

Outside of the US –
 

St. John Ambulance
New Zealand
 

Norway
 

QAS
Queensland, Australia
 
 

Footnotes:

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

[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
Article

[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
Article

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Anecdotes and the Appearance of Improvement

ResearchBlogging.org
 
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.

No.

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.

No.

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?

Footnotes:

[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

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