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

- Rogue Medic

What am I thankful for this Thanksgiving?


The violent crime rate continues to drop. In America the violent crime rate is less than half of what it was in 1992.

Not just the violent crime rate, but also the total number of violent crimes continues to drop. According to the FBI, 1,932,274 violent crimes were reported in 1992, but that number had decreased to 1,165,383 in 2014 – a decrease of 766,891.

There were 40% fewer violent crimes reported in 2014 than in 1992.

During the same time the US population has increased by over 60 million people. This is nowhere near perfect, but the trend has been a pretty steady decrease in the total number of violent crimes and the violent crime rate since 1992.

I became a paramedic in 1992, so the cause and effect should be obvious to everyone.

US Violent Crime rate - 1960 - 2014

The data are from the FBI.[1],[2]

While the violent crime rate is not as low as it was in 1960, the murder rate was the lowest in 2013 and 2014.

US Murder Rate - 1960 - 2014

The data are from the same FBI sources.[1],[2]

If you think that those were the good old days, half a century ago life expectancy and quality of life were much worse than they are now. They was even worse a century ago. They were even worse the century before that. And so on, back to the agricultural revolution about 10,000 years ago.

Happy Thanksgiving!


[1] Uniform Crime Reporting Statistics
National or State Level
Web page.

National or state offense totals are based on data from all reporting agencies and estimates for unreported areas.

The 168 murder and nonnegligent homicides that occurred as a result of the bombing of the Alfred P. Murrah Federal Building in Oklahoma City in 1995 are included in the national estimate.

The 2,823 murder and nonnegligent homicides that occurred as a result of the events of September 11, 2001, are not included in the national estimates.

The 2012 data is not from this source. It is from the revised data in the table in footnote [2] below. The violent crime rate was revised up from 386.9 per 100,000 population to 387.8 (an increase of 0.9). The total number of violent crimes was revised up from 1,214,464 to 1,217,057 (an increase of 2,593 reported violent crimes).

[2] Crime in the United States, 2014
Table 1
Crime in the United States
by Volume and Rate per 100,000 Inhabitants, 1995–2014
Web page.


The Fatal Flaw in Trial of Continuous or Interrupted Chest Compressions during CPR

Trial of Continuous or Interrupted Chest Compressions during CPR — NEJM

In conclusion, among patients with out-of-hospital cardiac arrest in whom CPR was performed by EMS providers, a strategy of continuous chest compressions with positive-pressure ventilation did not result in significantly higher rates of survival or favorable neurologic status than the rates with a strategy of chest compressions interrupted for ventilation.[1]


This is not a study that has a valid control group to determine if there is any benefit from ventilation. There is no group that does not receive ventilations, so it is like a study of one type of blood-letting vs. another type of blood-letting with the researchers taking for granted that blood-letting does improve outcomes. That is not a problem if blood-letting actually improves outcomes.

Should we take it for granted that blood-letting improves outcomes and that the only hypothesis worth studying is which brand to choose?

Should we assume that ventilations are too sacred to ever be doubted?

Should we assume that there are better arguments for ventilations than for blood-letting? That is not true.

If we ignore this fatal flaw, the study is very well done. I really like the study design. It is an excellent example of how to study two different versions of an intervention after that intervention has been demonstrated to improve outcomes, but ventilations have never been demonstrated to improve outcomes in adult patients with cardiac causes of cardiac arrest.

Should we have assumed that blood-letting was too sacred to ever be doubted?

We do know that outcomes for seizure patients improve when EMS gives benzodiazepines, because some people cared enough to find out.[2]

Assuming that a treatment is too important to study is like building on a foundation in a swamp.


We still do not know if there is any benefit from including ventilations, because the study design assumes that we don’t want to know.

There is no good reason to believe that ventilations improve outcomes for adult patients with cardiac causes of cardiac arrest. This study has not done anything to change that.

Our patients deserve better. Why aren’t we finding out what improves outcomes?


[1] Trial of Continuous or Interrupted Chest Compressions during CPR.
Nichol G, Leroux B, Wang H, Callaway CW, Sopko G, Weisfeldt M, Stiell I, Morrison LJ, Aufderheide TP, Cheskes S, Christenson J, Kudenchuk P, Vaillancourt C, Rea TD, Idris AH, Colella R, Isaacs M, Straight R, Stephens S, Richardson J, Condle J, Schmicker RH, Egan D, May S, Ornato JP; ROC Investigators.
N Engl J Med. 2015 Nov 9. [Epub ahead of print]
PMID: 26550795

Free Full Text from NEJM.

[2] A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH.
N Engl J Med. 2001 Aug 30;345(9):631-7. Erratum in: N Engl J Med 2001 Dec 20;345(25):1860.
PMID: 11547716 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med. with link to PDF Download.

Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., Weisfeldt, M., Stiell, I., Morrison, L., Aufderheide, T., Cheskes, S., Christenson, J., Kudenchuk, P., Vaillancourt, C., Rea, T., Idris, A., Colella, R., Isaacs, M., Straight, R., Stephens, S., Richardson, J., Condle, J., Schmicker, R., Egan, D., May, S., & Ornato, J. (2015). Trial of Continuous or Interrupted Chest Compressions during CPR New England Journal of Medicine DOI: 10.1056/NEJMoa1509139

Alldredge BK,, Gelb AM,, Isaacs SM,, Corry MD,, Allen F,, Ulrich S,, Gottwald MD,, O’Neil N,, Neuhaus JM,, Segal MR,, & Lowenstein DH. (2001). A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus New England Journal of Medicine, 345 (25), 1860-1860 DOI: 10.1056/NEJM200112203452521


Baby with cancer improving using chemotherapy does not get worse after meeting Pope Francis


Doesn’t get worse with real medicine? Continues to get better with real medicine?

It’s a miracle!

Who would expect a baby with a benign tumor, that is improving with chemotherapy, to continue to get better after benign picked up by Pope Francis? Apparently, many in the news media expected the baby to deteriorate and die after meeting the pope, because they are claiming that this is a miracle.

Fairy Godmother image credit.

Cancer treatment saves lives and we need to improve the treatment of the many types of cancer that exist, especially the ones that do not respond well to medicine, yet. It is a mockery of medicine and science to avoid giving credit where it is due – to the doctors, nurses, and others involved in the care of this baby.

When the baby was born, she failed a hearing test — the reason her tumor was diagnosed — and doctors were concerned she might not be able to see, speak or swallow. But In December, doctors at The Children’s Hospital of Philadelphia determined that the rare tumor on her brain stem was benign but still pressing on vital nerves.[1]


She has been receiving treatment since long before meeting Pope Francis.

This summer, little Gianna pulled out her feeding tube, is starting to eat solid food and doctors know she can see. Chemotherapy treatments that she must undergo every couple of weeks have reduced the size of the tumor, though it is still causing paralysis on one side of her face.[1]


If the article is correct, she was getting better long before meeting Pope Francis.

Maybe they wanted to give credit to Pope Francis because of his recent record with cancer that is not benign.

A Phoenix-area teen with a rare form of cancer, and who was blessed by Pope Francis in June as part of a dream granted by the Make-A-Wish Foundation, died early Friday morning, her mother announced. Jazmin Negrete was 15.[2]


If you want to donate to someone helping children with cancer, there are plenty of cancer organizations genuinely improving the care of patients with cancer.

A miracle is something that is not yet explained by science.

Unless we expect people with cancer to suddenly get worse when meeting Pope Francis, there is nothing unexplained about a cancer patient improving with chemotherapy. It is also not a surprise that a child dying of stomach cancer continued to die after meeting Pope Francis.

What is the excuse for the death of Jazmin Negrete? Are the miracle advocates going to claim that she didn’t believe enough? That is what the alternative medicine pushers claim when their miracles don’t work and that is what a lot of religious people claim when prayers don’t work, but is anyone a jerk enough to use that excuse here?

The reality is that there is no reason to believe that Pope Francis had any effect on either of these cancer patients. He didn’t save the child who was getting better before he picked her up and he didn’t kill the child who was dying before he blessed her. That is not miraculous.

It is sad that people are this desperate to reject reality.

I expect that Gianna Masciantonio will continue to improve with appropriate medical care.

My condolences to the family of Jazmin Negrete.


[1] Pope makes dream come true for parents of sick baby
Posted: Sunday, September 27, 2015 10:15 pm
By Peg Quann, Staff writer
Bucks County Courier Times

[2] Tolleson teen, blessed by pope, succumbs to cancer
Justin Sayers
The Republic |
5:35 p.m. MST November 20, 2015


Our current ambulance system is based on little scientific evidence


Our current ambulance system is based on little scientific evidence.

This is one comment by Prachi Sanghavi that has some paramedics very upset.

The video of her short speech at Harvard was posted on[1] and the responses suggested that there is something horribly wrong in the statement, or in any of what followed. There isn’t.


The problem is with the attitude of those who think that they know everything.

The problem is with the people who oppose finding out if treatments work.

The problem is with people who oppose protecting our patients from harmful treatments.

Prachi Sanghavi discusses the difference between BLS (Basic Life Support) treatment and ALS (Advanced Life Support) treatment. BLS includes all of the prehospital treatment that have evidence of benefit. All of them. ALS includes all of the cool things that paramedics and doctors do before getting to the hospital based on a wish and a prayer, but not on any valid evidence.


This is a comparison of cardiac arrest outcomes between two similar counties looking at the lack of expected benefit with ALS. There are more variables than just ALS vs. BLS, but we do need to ask Why are these cardiac arrest outcomes so bad with ALS?

Prachi Sanghavi is incorrect about a few things. Paramedics generally use a manual defibrillator, not a semi-automatic defibrillator. Taking longer at a cardiac arrest scene is probably not a problem. Those patients transported without pulses can be expected to end up in the morgue. Moving the patient with ineffective compressions, rather than staying on scene to do compressions well, is not recommended, because it is not supported by evidence. Rushing the patient to the hospital is just rushing the patient to ALS in a building. Yes, there is more ALS available at the hospital, but nothing that has good evidence of improving outcomes. Therapeutic hypothermia, is part of post-resuscitation treatment, not resuscitation treatment. That may change.[2]

Prachi Sanghavi also looked at trauma, stroke, and heart attack. The results were the same. Patients had better outcomes with Basic Life Support.

Our response should be to ask questions.

Are we doing something wrong?

What evidence do we have that ALS treatment improves outcomes?

The problem is that we ignore evidence and make excuses for our willful ignorance.

We are slow to adopt ALS treatments that have good evidence of improving outcomes and much, much slower to get rid of treatments that have only the weakest evidence of benefit – expert opinion. Expert opinion is the basis for all treatments that are later demonstrated to be harmful, so expert opinion isn’t worth bragging about. Real experts understand and learn from the evidence.

Should we trust the people criticizing the message that Maybe more is not better, or should we examine what we have been doing to find out what works?

Why are we opposed to providing the best care we can?


[1] Researcher: Is BLS better than ALS?
November 13, 2015

[1] Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).
Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM.
Resuscitation. 2015 Jan;86:88-94. doi: 10.1016/j.resuscitation.2014.09.010. Epub 2014 Oct 2.
PMID: 25281189

Free Full Text from Resuscitation.

This is a tiny study that suggests a grouping of treatments that may work (or that may include a treatment, or two, that may lead to improved outcomes. The results are good, but it is just one tiny study that needs replication and each of the treatments should be studied individually.


Happy Friday the 13th – New and Improved with Space Debris


This is not your regular scary old Friday the 13th. This one is new and improved with Death from the Skies! Not the great book by Phil Plait, just the fear and anxiety of the What if . . . ?

This debris will not cause any harm to anyone, but the whole idea of superstition is to fear the unknown and come up with other superstitions to provide a feeling of control over the unknown. But look at the bones name!


It’s got to mean something!

It couldn’t just be a coincidence!

Those phrases are the basis of a lot of superstition and conspiracy theories.

For example, psychics aren’t going to be completely wrong all of the time, so they claim that their vague prediction, that is almost right if you ignore most of what really happened, is proof of their abilities, when it is only to be expected that nobody will be completely wrong all of the time unless they make very few predictions. Psychics make a lot of predictions in order to be able to say they got something right. Nostradamus was given credit for this for centuries, but he is just another one who makes vague predictions that cannot all be completely wrong.

Sylvia Browne is one of the most famous people to take advantage of this. She gets everything wrong, but spins it so that those who want to believe can ignore reality and continue to believe pay her millions of dollars.

Is a bunch of WTF debris on Friday the 13th something to worry about? No.

Our lack of understanding of probability is what we should really worry about. People do lie with statistics, but people lie much more often with words. How often do people claim that we should not understand English, because people lie with English? Why should we choose willful ignorance of probability and statistics, when the same argument would be ridiculed if it were made for something we like?


How Bad is the Evidence for the New 2015 ACLS Guidelines?
    The new ACLS guidelines are out. How bad is the evidence?

    The short answer – The Advanced Cardiac Life Support guidelines could be worse.

How does the American Heart Association determine that a recommendation is not beneficial?

Class III: No Benefit, is a moderate recommendation, generally reserved for therapies or tests that have been shown in high-level studies (generally LOE A or B) to provide no benefit when tested against a placebo or control.[1]


The tobacco enema has been used successfully as a treatment for cardiac arrest, so the evidence of lack of benefit is poor.[2] Clearly, the Advanced Cardiac Life Support guidelines cannot claim that the tobacco enema is Class III. Successfully? The treatment was used and a dead person was no longer dead. In other words, just as successfully as most of the ACLS treatments.

From Eisenberg, MS. Life in the balance: emergency medicine and the quest to reverse sudden death. 1997; Oxford University Press. [betterworldbooks][3]


This is one way to make excuses for justify doing something just because of ideology. In the absence of good evidence of benefit, we should not harm our patients to protect our ideology. We used to do this with blood-letting, which was defended even after there was clear evidence of harm. That is just the best known example, but this dishonesty continues and continues to be defended.

Why don’t we hold anyone accountable, when we have the evidence that our treatments are harmful? Because we all seem to go along to get along.

The 2015 ACLS guidelines are not all bad, but they clearly do not encourage withholding harmful treatments until we have obvious evidence of harm. Should we assume that a treatment works just because the explanation appeals to some experts as much as the explanation for blood-letting appealed to the experts when that was in vogue?

This is not medicine. This is a fashion show. Our patients are the ones harmed.


[1] 2015 AHA Classes of Recommendation
2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 2: Evidence Evaluation and Management of Conflicts of Interest
Development of the 2015 Guidelines Update
2015; 132: S368-S382
Free Full Text from Circulation.

[2] Tobacco smoke enemas
Ghislaine Lawrence
Volume 359, No. 9315, p1442,
20 April 2002
Abstract with link to Full Text PDF download.

[3] Ever tried smoking?
by Chris Nickson
Life in the Fast Lane

Morrison LJ, Gent LM, Lang E, Nunnally ME, Parker MJ, Callaway CW, Nadkarni VM, Fernandez AR, Billi JE, Egan JR, Griffin RE, Shuster M, & Hazinski MF (2015). Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 132 (18 Suppl 2) PMID: 26472990

Lawrence, G. (2002). Tobacco smoke enemas The Lancet, 359 (9315) DOI: 10.1016/S0140-6736(02)08339-3


Benzodiazepines are often misused – Part I

The most commonly used benzodiazepines in EMS/EM (Emergency Medical Services/Emergency Medicine) are diazepam (Valium), lorazepam (Ativan), and midazolam (Versed). It should be relatively easy to look at the best research and determine –

1. Should benzodiazepines be the first parenteral medication given for seizures?

2. Should benzodiazepines be the first parenteral medication given for agitated delirium/excited delirium (it is a real condition that results in death in custody much more often than intentional police misbehavior)?

3. Should benzodiazepines be the first parenteral medication given for sedation?

In EMS/EM, some of the important things to consider are the time it takes for the drug to take effect, the likelihood that the drug will produce the desired effect, the seriousness of adverse effects and rate at which the most serious adverse effects occur.


Is there any evidence that anything works quicker than IM (IntraMuscular) midazolam, when the patient does not already have an IV (IntraVenous line)?

Is there any evidence that an initial dose of 10 mg IM midazolam is too high of an initial dose for an adult (over 40 kg) or that 5 mg is too high of an initial dose for a child (40 kg or less)?

Is there any evidence that this dosing increases the rate of airway compromise above what would occur with lower doses?

The Rampart study[1] strongly suggests that 10 mg of IM midazolam is the best approach for the seizing patient who does not already have an IV, when IM midazolam is available. If midazolam is not available, such as due to poorly written protocols, midazolam is not an option and delaying less effective care to wait for the ideal treatment would be reckless.

There do not appear to be any studies that show any better outcomes with any other benzodiazepoines or with any other doses.

What about when an IV is already in place?

Should IV midazolam be used?

Should IV lorazepam be used?

Should IV diazepam be used?

Should some other drug be used?

The evidence is not clear, but is there any reason to believe that lorazepam, or diazepam, works as quickly as midazolam, when given intravenously?

Is there any reason to believe that lorazepam, or diazepam, produce fewer, or less serious, adverse effects than midazolam, when given IV?

I don’t know of any valid evidence to suggest that midazolam is inferior to either diazepam or lorazepam.

There is also the benefit in EMS of a much shorter time of effect for midazolam.

A drug that wears off quickly is going to be the safer EMS drug – unless there is a good reason to use a drug that lasts longer.

I will explain why wearing off quickly is important in EMS treatment of seizures in Part II (not yet posted).


[1] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.

I have written about this in Intramuscular Midazolam for Seizures – Part I,
Part II,
Part III,
Part IV,
Part V,
Part VI,
Misrepresenting Current Topics in EMS Research from EMS Expo – RAMPART,
and Images from Gathering of Eagles Presentation on RAMPART.


Will the Upcoming Pennsylvania Paramedic Protocols Eliminate Our Use of Not-So-Therapeutic Hypothermia?

Will Pennsylvania continue its trend of rejecting treatments that do not work and medicine that is not medicine?

One place to get a clear indication is the Post-resuscitation Care protocol, which has encouraged testing the ice waters of therapeutic hypothermia as an optional treatment that requires medical command orders. Backing away from further use of cold IV fluid for no known benefit to patients should be easy to do without political backlash from those more interested in doing something than in protecting patients from treatment for the sake of treatment.

Possible Medical Command Orders:

A. In adult patient, cold (4º C) NSS bolus of 20-30 mL/kg, if available, may be ordered if patient not following commands after ROSC from nontraumatic cardiac arrest.[1]


But wait.

      I know that therapeutic hypothermia works.

That is misleading. There is plenty of evidence that cooling patients in the hospital improves outcomes, but for prehospital patients the use of cold IV fluids has only been shown to improve outcomes for asystole/PEA (Pulseless Electrical Activity) patients and only in one study.[2]

For the patients most likely to survive cardiac arrest, the initial rhythm is V Fib (Ventricular Fibrillation). For these patients we need to stop the ice water infusions. Prehospital cold IV fluids following resuscitation of V Fib patients has been studied to death – more deaths in the treatment groups than in the no treatment groups. There has been no evidence of any benefit from IV ice water.[3],[4],[5]

Image credit.

This method of administration would probably be better for V Fib patients than IV ice water, because the adverse effects of IV ice water appear to be due to fluid overload.

I do not mean that prehospital therapeutic hypothermia is always a bad idea for V Fib patients – only that we need to find a way that is less harmful than dumping ice water into these recently dead patients for no benefit.

Click on image to make it larger.[3]

First, do no harm.

If the treatment is not beneficial, there is no good reason to expose patients to the adverse effects of the treatment for no known benefit.

Will we stop making excuses for endangering our patients with treatments that do not work?

Science teaches us to learn from our mistakes, while human nature encourages us to make excuses and continue to make the mistakes. Will we make the mistake of continuing to dump cold ice water into these recently dead patients for no good reason?


[1] Post-Resuscitation Care
Pennsylvania Statewide ALS Protocols 2013
pp. 34-36 – 3080 – ALS – Adult/Peds
Protocols in PDF Download format.

[2] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed – indexed for MEDLINE]

[3] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

[4] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed – as supplied by publisher]

Free Full Text from JAMA.

[5] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

Free Full Text from NEJM.