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

Pennsylvania Eliminating Backboards for Potential Spinal Injuries

Medical directors should already have every EMS provider in Pennsylvania following the new Statewide BLS Protocols, but the procrastinators have until July 1, 2015 to get everyone to aggressively avoid using backboards.

We should not be manipulating the potentially injured spines of patients to get them onto backboards for no known benefit, while possibly causing permanent disabilities or other significant harms.

Excessive motion of the spine may worsen spine fractures or spinal cord injuries (especially in patients with altered consciousness who can’t restrict their own spinal motion), but immobilization on a long spine board may also cause pain, agitation, respiratory compromise, and pressure ulcers. Patients with the following symptoms or mechanisms of injury should be assessed to determine whether restriction of spinal motion is required:[1]



What are the full steps to be performed for someone suspected of having an unstable spinal injury?

Restrict Spinal Motion

Apply Rigid Cervical Collar[1]


We are beginning to realize that collars are probably also not be such a great idea,[2] but this is only one step to decrease the harm we cause for no apparent benefit.

If ambulatory,

Allow patient to move to stretcher mattress with minimal spinal motion3 [1]


This is just recognizing that people have been walking to stretchers without sudden onset of paralysis, so manipulating the patient’s spine onto a flat board for no known benefit was never a good idea. It was just dogma, that went unquestioned for too long.

If nonambulatory,

Use backboard, scoop/orthopedic stretcher, vacuum mattress, or other device to move patient to stretcher with minimal spinal motion4,5 [1]


We could use a sheet, since manipulating the patient onto a backboard, or other device, may result in much more movement of the spine than sliding a sheet under the patient and using the sheet to lift the patient.

Use CID may be used to further restrict spinal motion[1]


The typo is not important, but we can consider putting some sort of blocks next to the patient’s head to keep the head of an unconscious patient from flopping around.

Transport on stretcher mattress without backboard if patient ambulatory or if scoop/orthopedic stretcher can be removed with minimal patient motion.[1]


Again, the use of a sheet to move the patient may be the preferred method, since the use of the sheet may produce the least manipulation of the spine. We are trying to minimize the manipulation of the spine, not trying to defend some dogma that there is only one right way of doing things, regardless of outcomes. The patients’ outcomes are what matter, not adherence to the protocol at the expense of the patients.

The protocol clearly does not limit us to using backboards, scoops, orthopedic stretchers, or vacuum mattresses.

Using a sheet to move the patient, so that it does not produce more manipulation that would be produced by using these other devices appears to be encouraged, if not required. We are supposed to use the method that is least likely to harm the patient, which probably makes a backboard the least acceptable method.

This protocol also applies to assessment of patients before inter-facility transfer for injuries from a traumatic mechanism unless a medical command physician agrees that the patient may be transported without restriction of spinal motion.[1]


Any suggestion that a patient is going to be manipulated back onto a backboard should result in a firm, No, thank you.

I am not a lawyer, but I wouldn’t be surprised to see law suits against EMS agencies/providers who continue to cause harm with backboards, when there are less harmful alternatives available and no protocol/standard of care to defend this abuse of patients by placing them on backboards.


Pennsylvania is the largest state (not all states have statewide protocols, so this is often only at the agency level) to do this and 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

Bend Fire and Rescue
Bend, OR

Bernalillo County Fire Department

CentraCare Health
Monticello, MN

Chaffee County EMS

Connecticut, State of

Durham County EMS

Eagle County Ambulance District

HealthEast Medical Transportation
St. Paul, MN

Johnson County EMS

Kenosha Fire Department
Kenosha, WI

Macomb County EMS Med Control Authority
Macomb County, MI

Maryland, State of

MedicWest Ambulance

Milwaukee EMS

North Memorial Ambulance & Aircare
Minneapolis, MN

Palm Beach County Fire Rescue

Pennsylvania, Commonwealth of

Pewaukee Fire Dept
Pewaukee, WI

Rio Rancho Fire Department

SERTAC (Southeast Regional Trauma Advisory Council)

Wichita-Sedgwick County EMS System

Xenia Fire Department
Xenia, OH

Outside of the US –

NHS (National Health Service)
England (UK?)

St. John Ambulance
New Zealand


Queensland, Australia


[1] Spinal Care
2015 Pennsylvania Statewide BLS Protocols
261 – BLS – Adult/Peds
pp 59 – 61
Protocols in PDF Download Format.

[2] Why EMS Should Limit the Use of Rigid Cervical Collars
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
Monday, January 26, 2015


Dextrose in Cardiac Arrest – More Kitchen Sink Medicine

Should we treat hypoglycemia in a dead person?

How do we determine hypoglycemia in a dead person?

Is there any evidence that giving dextrose, in any concentration, will help to resuscitate a dead person?

Should we treat patients based on the philosophy of Who knows? Maybe it could work? Bleach enemas are currently in fashion among the alternative to medicine crowd,[1] so we could use the same reasoning to give bleach enemas in cardiac arrest. Who knows? Maybe it could work.

Is Kitchen Sink Medicine significantly different from any other alternative to medicine?

The dead person is not breathing, so we have to provide ventilations.[2], [3], [4]

The dead person is dead, so we have to do something.

We do compressions and (when indicated) defibrillation, because those are the only treatments that have been demonstrated to work.



The foundation of successful ACLS is high-quality CPR, and, for VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.128–133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.31,33,134–138 [5]


Ventilations are only a part of high-quality CPR for children and people who have a respiratory cause of cardiac arrest.

But what about dextrose for hypoglycemic cardiac arrest?

We may already be raising the blood sugar with epinephrine.

Epinephrine causes a prompt increase in blood glucose concentration in the postabsorptive state. This effect is mediated by a transient increase in hepatic glucose production and an inhibition of glucose disposal by insulin-dependent tissues.[6]


We seem to have trouble understanding that dead people do not respond to treatments the same way that living people do.

Pharmacologic insults are just so massive and normal metabolism and physiology so deranged that no mere mortal can make a meaningful intervention. The seriously poisoned who maintain vital signs in the ED have the best, albeit never guaranteed, chance of rescue from a modicum of antidotes and intensive supportive care.[7]


Maybe we should find out what we are doing and not blindly throw kitchen sinks at dead people based on hunches.

Dr. Brooks Walsh gave a good review of the evidence in his article written three years ago.[8]

What about my original questions?

Should we treat hypoglycemia in a dead person?

There is no evidence that giving dextrose is safe or effective for any cardiac arrest patients.

How do we determine hypoglycemia in a dead person?

We guess or check a capillary blood sugar, which is not reliable.

Is there any evidence that giving dextrose, in any concentration, resuscitates a dead person?


Go read Using Dextrose in Cardiac Arrest at Mill Hill Ave Command.


[1] Bleaching away what ails you
Science-Based Medicine
David Gorski
May 28, 2012

[2] Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest.
Ewy GA, Bobrow BJ.
J Intensive Care Med. 2014 Jul 30. pii: 0885066614544450. [Epub ahead of print]
PMID: 25077491 [PubMed – as supplied by publisher]

[3] Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, Bobrow B.
Acad Emerg Med. 2010 Mar;17(3):269-75.
PMID: 20370759 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

[4] Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
Fri, 09 Dec 2011
Rogue Medic

[5] Management of Cardiac Arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8.2: Management of Cardiac Arrest
Free Full Text from Circulation.

[6] Effect of epinephrine on glucose metabolism in humans: contribution of the liver.
Sherwin RS, Saccà L.
Am J Physiol. 1984 Aug;247(2 Pt 1):E157-65.
PMID: 6380304 [PubMed – indexed for MEDLINE]

[7] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/
Roberts, James R. MD

[8] Using Dextrose in Cardiac Arrest
Wednesday, March 14, 2012
Mill Hill Ave Command
Dr. Brooks Walsh


Proposed 2015 ACLS Chest compression only CPR vs conventional CPR Recommendation

The AHA (American Heart Association) and ILCOR (International Liaison Committee On Resuscitation) 2015 resuscitation guidelines evidence reviews appear to be merely justifications for continuing to use treatments that do not improve survival with good neurological function, which is the only outcome that matters. What do the AHA and ILCOR intend to recommend for ventilation of patients who appear to be adults and pulseless due to non-respiratory conditions?

Full Question:
Among adults who are in cardiac arrest outside of a hospital (P), does provision of chest compressions (without ventilation) by untrained/trained laypersons (I), compared with chest compressions with ventilation (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, bystander CPR performance, CPR quality (O)?


Do we really want to increase the rate of survival of permanently comatose patients?

Image credit.

That is not a goal. That is only a first step if we can do something to change the outcome for this comatose patient. There is no reason to believe that ventilations during CPR will do anything to improve the neurological outcome of these patients. We want to improve the survival of neurologically intact patients, not fill nursing homes with comatose patients until sepsis finishes them off.

We suggest performing chest compressions alone for trained laypersons if they are incapable of delivering airway and breathing manoeuvres to cardiac arrest victims (weak recommendation, very low quality of evidence).[1]


The AHA and ILCOR want us to provide this intervention that is based on tradition and disproven pathophysiology, rather than based on any valid evidence, except if we are incapable of providing the intervention.

Ventilations do not improve outcomes. However, ventilations may be harmful, so we should avoid using them in all cases where ventilations are not supported by valid evidence. Ventilations are not supported by valid evidence for non-respiratory causes of adult cardiac arrest.

We suggest the addition of ventilations for trained laypersons who are capable of giving CPR with ventilations to cardiac arrest victims and willing to do so (weak recommendation, very low quality of evidence).[1]


Each study cited to support ventilations showed no significant difference between compression only and standard CPR according to the AHA/ILCOR evidence review. That is the way to imitate Rube Goldberg. That is not support for any kind of medical intervention.

This recommendation places a relatively high value in [1] harm avoidance (not performing CPR or performing ineffective chest compressions and ventilations) and [2] simplifying resuscitation logistics, than potential benefit of an intervention of routine ventilations and compressions.[1]


That statement misrepresents harm avoidance and simplification of resuscitation logistics, since it encourages the potentially harmful treatment that has no valid evidence that the intervention increases any benefit that matters. How does adding ventilations simplify resuscitation logistics?

There is no evidence that passive ventilation provides inadequate oxygenation during chest compressions.

There is no evidence that passive ventilation provides inadequate removal of carbon dioxide during chest compressions.

Where is the need for any positive pressure ventilation to decrease blood return to the heart and increase the likelihood of vomiting?

Why continue to recommend doing something harmful for no benefit to the patient?


[1] Chest compression only CPR vs conventional CPR
ILCOR Scientific Evidence Evaluation and Review System
Questions Open for Public Comment
Closing Date – February 28, 2015
Question page


Why EMS Should Limit the Use of Rigid Cervical Collars

Well, should EMS limit the use of rigid cervical collars?

As with the rest of anecdote-based medicine, or hunch-based medicine, we have been doing this for decades without any evidence of benefit. Do we know what we are doing?

But you have to prove that this is harmful, otherwise we cannot withhold the standard of ignorance.

Image credit.     Regardless of brand. A perfect fit – every time. Right?

Where does the burden of proof rest? In medicine, it is supposed to be the responsibility of the person treating to convince the patient that the treatment is more likely to be beneficial than harmful. This is informed consent. Informed consent is often overlooked and replaced with a blanket consent for the doctor (or designee, such as nurse, EMT, medic, . . . ) to do whatever the doctor thinks is a good idea.

Is there any valid evidence that a backboard, or KED (Kendrick Extrication Device), or rigid cervical collar will improve any outcome?

Not for the backboard or KED, but we know that the rigid cervical collar is beneficial because it stabilizes the neck and we would not use it if it didn’t work.

That is the same excuse made for using a backboards, or a KED, without evidence. Is there any valid evidence?

Can I get back to you on that?

Even though there should be no need to go further in criticizing rigid cervical collars, in the medical fields, we like to believe that what we have been doing is good and not harmful, because we don’t want to think of ourselves as harming our patients. Ironically, this attitude stops us from eliminating harmful treatments. We harm our patients to protect ourselves from having to admit that we were harming our patients.

For those who insist on evidence of harm, Dr. Bryan Bledsoe and Dr. Dale Carrison have provided us with a thorough evidence-based explanation of the ways that rigid EMS collars can harm our patients.

Interestingly, one of the first protocols that significantly changed spinal immobilization practices came out of several EMS agencies in Northern California. In a rather sweeping protocol change, they elected to forgo rigid C-collars and use soft collars.[1]


Do rigid cervical collars decrease manipulation of the neck/spine? Do rigid cervical collars protect patients from disability?

Read the article for a discussion of the evidence and of what we assume.

The argument in favor of backboards and collars is similar to the argument in favor of mandatory vaccination for school. It is a minor inconvenience for many, that protects against death/disability of some.

There is plenty of evidence for the vaccine argument. Vaccines are safe. Vaccines save lives. Vaccines are worth it. What about rigid EMS collars? Do they protect against death/disability?

Go read the article and find out.

Dr. Bledsoe and Dr. Carrison provide plenty of evidence to support their conclusions. What do the supporters of rigid cervical collars have?


[1] Why EMS Should Limit the Use of Rigid Cervical Collars
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
Monday, January 26, 2015


The Kitchen Sink Approach to Cardiac Arrest

When faced with death, we can become desperate, stop thinking clearly, and just try anything.

Alternative medicine thrives on the desperation of people who are not thinking clearly. We should be better than that, but are we?

A recent comment on The Myth that Narcan Reverses Cardiac Arrest[1] proposes that I would suddenly give kitchen sink medicine a try, if I really care about the patient.

Kitchen sink medicine? It’s better to do something and harm the patient, than to limit treatment to what works. Throw everything, including the kitchen sink, at the patient.

Mike Karras writes –

I will leave you with this question sir and I am interested to hear your answer. You walk in to find your 14 year old daughter that intentionally overdosed on morphine in a suicide attempt and she is in cardiac arrest. How would you treat her? Would you give her Narcan? I think you would.[2]


Mike, I am thrilled to read that you do not think that I care about the outcomes of my patients, unless the patient happens to be my daughter. I am even more thrilled that you made my imaginary daughter suicidal.

No, I would not use naloxone (Narcan).

I would also not use homeopathy, acupuncture, sodium bicarbonate, incantations, or magic spells to treat my daughter during cardiac arrest. Voodoo only works on believers, because voodoo is just a placebo/nocebo.[3]

Image credit.

Does really wanting something to be true make it true? If you believe in magic, the answer is Yes, believing makes it true. If you examine the evidence for that belief, you have several choices. You can acknowledge your mistake, or you can employ a bit of cognitive dissonance, or . . . . Cognitive dissonance is the way our minds copes with the conflict, when reality and belief do not agree, and we choose to reject reality.[4]

According to the ACLS (Advanced Cardiac Life Support) guidelines –

Naloxone has no role in the management of cardiac arrest.[5]


If the patient is suspected of having a cardiac arrest because of an opioid overdose (overdose of heroin, fentanyl, morphine, . . . ), the treatments should include ventilation and chest compressions. If those do not provide a response, epinephrine (Adrenaline in Commonwealth countries) is added.

An opioid overdose can produce respiratory depression and/or vasodilation. I can counter both of those with chest compressions, ventilation, and maybe epinephrine. Naloxone works on opioid receptors. What does naloxone add?

Does naloxone’s stimulation of an opioid receptor produce more ventilation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more oxygenation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more vasoconstriction than chest compressions and epinephrine?*

Also –

Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.[6]


Dead people do not respond to treatments the same way living people do.

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

* Late edit – 02/17/2015 10:52 – added the word naloxone’s to the three sentences about the relative amount of stimulus provided by standard ACLS and by the addition of naloxone. Thanks to Brian Behn for pointing out the lack of clarity.


[1] The Myth that Narcan Reverses Cardiac Arrest
Wed, 12 Dec 2012
Rogue Medic

[2] Comment by Mike Karras
The Myth that Narcan Reverses Cardiac Arrest by Rogue Medic
Mon, 16 Feb 2015

[3] Nocebo

A nocebo is an inert agent that produces negative effects. What this means is that nocebo effects are adverse placebo effects. There is no reason to believe that placebos only produce positive effects or no effects at all.

[4] Cognitive dissonance

[5] 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

[6] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/
Roberts, James R. MD

Read the whole article about antidotes and cardiac arrest.


Happy Darwin Day 2015


Charles Darwin is one of the greatest scientists of all time. We should celebrate the tremendous work that he has done, but it is considered politically incorrect to point out that evolution is real and that we use science to learn about reality.

To celebrate Darwin Day, Ken Ham has decided to do even more to embarrass himself. You remember him. He is the guy who debated Bill Nye.


What would it take to change your mind?
Bill Nye – Evidence.
Ken Ham – Nothing.

Nothing? If God were to tell Ken Ham that evolution is true, that would not change Ken Ham’s mind, because his mind is made up? Or is Ken Ham telling us that he does not believe that God exists?

Ken Ham claims to understand science, but the scientists he employs are required to sign a statement that what Ken Ham believes sets a limit their science. Ken Ham is celebrating today as Darwin was wrong Day.[1]

The 66 books of the Bible are the written Word of God. The Bible is divinely inspired and inerrant throughout. Its assertions are factually true in all the original autographs. It is the supreme authority in everything it teaches. Its authority is not limited to spiritual, religious, or redemptive themes but includes its assertions in such fields as history and science.[2]


Ken Ham tells us that only his interpretation of the Bible is the truth. Science encourages us to look everywhere for the truth.

If you do not sign a Statement of Faith, you cannot work for Ken Ham. You only have to read the Bible to see that even the description of Creation has irreconcilable contradictions if Genesis is to be interpreted as science, rather than metaphor.

24 Then God said, “Let the earth bring forth living creatures after [ag]their kind: cattle and creeping things and beasts of the earth after [ah]their kind”; and it was so. 25 God made the beasts of the earth after [ai]their kind, and the cattle after [aj]their kind, and everything that creeps on the ground after its kind; and God saw that it was good.

26 Then God said, “Let Us make man in Our image, according to Our likeness; and let them rule over the fish of the sea and over the birds of the [ak]sky and over the cattle and over all the earth, and over every creeping thing that creeps on the earth.” 27 God created man in His own image, in the image of God He created him; male and female He created them.[3]


God made Adam and Eve after making the animals.

18 Then the Lord God said, “It is not good for the man to be alone; I will make him a helper [a]suitable for him.” 19 Out of the ground the Lord God formed every beast of the field and every bird of the [b]sky, and brought them to the man to see what he would call them; and whatever the man called a living creature, that was its name.[4]


God made Adam and Eve before making the animals.

It doesn’t matter which came first, if this is a metaphor, but if this is supposed to be literally true and accurate, then it does matter which came first.

Is your God incapable of telling the difference between before and after? Ken Ham’s God can’t seem to tell the difference. Ken Ham seems to prefer to mock his God.

Is your God limited by the restrictions Ken Ham arrogantly places on God?

Is your God capable of using metaphors?

Are there other places where your God uses metaphors in the Bible?



[1] #DarwinWasWrongDay
AiG (Answers in Genesis)
Ken Ham’s Twitter hashtag encouraging rejection of evolution
Page at AiG

[2] Statement of Faith
AiG (Answers in Genesis)
Section 2: Basics
Updated: December 12, 2012
Accessed on February 12, 2015
Page at AiG

[3] Genesis 1:24-27
New American Standard Bible (NASB)
Bible Gateway (a Christian site)

Pick up a printed Bible. Look at whatever version of the Bible you like. You can look up one verse at a time to compare among versions.

[4] Genesis 2:18-19
New American Standard Bible (NASB)
Bible Gateway (a Christian site)


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).


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)


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)


[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


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.


[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
NASA report