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

Who would have thought that a vacancy on the Supreme Court would produce so much unintentional comedy

 

First the facts. On the night/morning of February 12-13, 2016, Justice Antonin Scalia died of apparently natural causes. This is not really off topic, since this points out the ways that rules are made and politics can come into play in the masking of rules, protocols, and guidelines.
 

Antonin_Scalia,_SCOTUS_photo_portrait
 

Average life expectancy for an American male is about 79 years. Justice Scalia died about a month before his 80th birthday. Justice Scalia is reported to have health problems, which may have contributed to his death. Is it unusual for a medical examiner to pronounce death over the phone? No. There may be many variations from state to state, but working as a paramedic, as long as the circumstances are not suspicious, pronouncing death is done over the phone and arrangements are often made for the body to go to a funeral home.

Ruth Bader Ginsburg is 82 and her birthday is also next month. She may die soon or she may live another 20+ years. It will probably be something between the two, but we do not know where it will be on that range. Doctors do not exist to predict when someone will die. Doctors are supposed to provide appropriate treatment with the consent of the patient, or the person with power of attorney for the patient.

Justice Scalia was not in the best of health, but nobody appears to have been predicting that he would die right now. On the other hand, nobody should be surprised that a man of his age, with his health problems, died suddenly in his sleep. If you ask young people if they would like to die in their sleep outside of a hospital, at about 80, after living an active and successful life, would it be surprising if many said, Yes.? Justice Scalia was very fortunate.

President Obama was discouraged from making an appointment to replace Justice Scalia, because it is unusual for a Supreme Court Justice to die in the last year of either term of a presidency (an election year). It is unusual for a Supreme Court Justice to die during any year of a presidential term. Most of the time a Supreme Court Justice will retire and will try to arrange to step down without the political hubbub of an election year.

Many opposed to President Obama have stated that he should not nominate anyone to replace Justice Scalia. It seems they do not considered it important to fill a vacancy on the Supreme Court for over a year.

Some have suggested that it is a tradition to delay nominations in the last year of a presidency, but where is the evidence to support this revolutionary approach to Supreme Court nominations? Has this tradition ever happened? What is an unprecedented tradition?

What about the original intent of the Founding Fathers? The Constitution does not have any wording to support a delay in nominating someone.
 

He (The President) shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur; and he shall nominate, and by and with the Advice and Consent of the Senate, shall appoint Ambassadors, other public Ministers and Consuls, Judges of the supreme Court, and all other Officers of the United States, whose Appointments are not herein otherwise provided for, and which shall be established by Law: but the Congress may by Law vest the Appointment of such inferior Officers, as they think proper, in the President alone, in the Courts of Law, or in the Heads of Departments.

The President shall have Power to fill up all Vacancies that may happen during the Recess of the Senate, by granting Commissions which shall expire at the End of their next Session.[1]

 

George Washington, nominated and appointed two Supreme Court Justices in his last full year in office. President Washington’s second term ended March 4, 1797.
 

President George Washington nominated (Samuel) Chase to the Supreme Court of the United States on January 26, 1796, and the Senate confirmed the appointment the following day.[2]

 

Followed by –
 

On March 3, 1796, Ellsworth was nominated by President George Washington to be Chief Justice of the United States, the seat having been vacated by John Jay. (Jay’s replacement, John Rutledge, had been rejected by the Senate the previous December, and Washington’s next nominee, William Cushing, had declined the office in February.) The following day, Ellsworth was unanimously confirmed by the United States Senate, and received his commission.[3]

 

Should we condemn the actions of President Washington as not reflecting original intent?

President Washington was succeeded by President John Adams, who nominated and appointed John Marshall with less than a month and a half to go in his term. President John Adams was also one of the Founding Fathers and George Washington’s choice for a successor. Should we condemn his nomination and appointment as contrary to original intent?
 

As the incumbent Chief Justice Oliver Ellsworth was in poor health, Adams first offered the seat to ex-Chief Justice John Jay, who declined on the grounds that the Court lacked “energy, weight, and dignity.”[31] Jay’s letter arrived on January 20, 1801, and as there was precious little time left, Adams surprised Marshall, who was with him at the time and able to accept the nomination immediately.[32] The Senate at first delayed, hoping that Adams would make a different choice, such as promoting Justice William Paterson of New Jersey. According to New Jersey Senator Jonathan Dayton, the Senate finally relented “lest another not so qualified, and more disgusting to the Bench, should be substituted, and because it appeared that this gentleman [Marshall] was not privy to his own nomination”.[33] Marshall was confirmed by the Senate on January 27, 1801, and received his commission on January 31, 1801.[4]

 

Those who support President Obama have pointed out that the nomination of Justice Anthony Kennedy was made in the final year of President Reagan’s term, but that was to fill a vacancy due to a retirement over a year and a half before the end of President Reagan’s term. Still, that did not stop President Reagan from continuing to nominate candidates until one was appointed.
 

On November 11, 1987, Kennedy was nominated to the Supreme Court seat vacated by Lewis F. Powell, Jr., who announced his retirement in late June.[11] His nomination came after Reagan’s failed nominations of Robert Bork, who was nominated in July but rejected by the Senate on October 23,[12] and Douglas Ginsburg,[13][14] who withdrew his name from consideration on November 7 after admitting to marijuana use.[15] Kennedy was then subjected to an unprecedentedly thorough investigation of his background, which he easily passed.[5]

 

Those are the facts.
 

Suppose President Reagan had six months left in his second term and a vacancy developed on the Supreme Court. Should President Reagan have left that nomination for the winner of the next election? Nobody yet knew who would win the election. The choice between Vice President George H. W. Bush and Governor Michael Dukakis of Massachusetts would be half a year away and that is plenty of time for some unexpected news to affect the outcome of the election.

What would President Reagan do? What would President Bush (41) do? What would President Clinton do? What would President Bush (43) do?

While we can only speculate about what someone would do, there does not appear to be any reason to suspect that any American president would refuse to nominate someone under the same circumstances.

Please let me know if you are aware of any cases of any refusal to nominate a candidate to fill a vacancy on the Supreme Court.

What I expect to happen is that the process will be dragged out and eventually there will be a vote along party lines to reject the candidate. I would expect the same thing if the parties were reversed (the president Republican and Enough Democrats in the Senate to reject a candidate). The Constitution does not require the Senate to be reasonable. The Constitution and Bill of Rights were written because the Founding Fathers expect politicians to be unreasonable. The debate over this is nothing new.
 

The Supreme Court has become more polarized and the nomination process may have become even more polarized than the Court. Even Justice Scalia has stated that he would not expect to be approved in the current environment

How could the president use that understanding of politics in his favor?

1. Nominate someone who has a history of moderate in views, rather than liberal views.

2. Point out that the Senate is willing trying to keep the seat vacant for a year.

3. Frequently remind the eight justices, through others, that they are the full Court for the next year.

4. Remind the voters that the nomination is moderate, demonstrating that the opposition to the nomination is not moderate.

5. Use the Federalist Papers, and other writings of the Founding Fathers, to show that the original intent was never to support the rights of factions at the expense of individual rights.

6. Appealing to the judgment of the people who are appointed for their judgment is a way around the politics, but only if the nomination is not political.

Our next president will be just another politician, pandering to the polarized views that have been encouraged by the political propaganda of MSNBC, CNN, and Fox News. This is an opportunity to set an example of doing what is better, rather than what is political. Eventually America will move away from our current temporary infatuation with extremes.
 

How does that relate to making laws, protocols, or guidelines in EMS?

There are powerful people in EMS. Some understand and pay attention to evidence, while others put aside reason and are suckers for anecdotes. Some can be persuaded with evidence. Some will find excuses to reject evidence. By addressing those who are respected and can convince those driven by emotion, more can be accomplished.

Ask permission to forward a PDF, or a link to the full text, of a paper that supports your position. Mention that you are interested in their opinion of the paper. Maybe some of them will read the papers. Maybe some of those who do not read the papers (we don’t have enough time to read everything we should) will feel guilty about not reading it and go along out of guilt. Follow up by asking what they thought of the paper.

While it is disappointing to encounter a broad lack of familiarity with the relevant research, this is an opportunity to provide objective information, which should persuade most reasonable people. Repeat as often as necessary. Most unreasonable people find it difficult to remain unreasonable when presented with valid objective evidence.

Footnotes:

[1] Article II Section 2
U.S. Constitution
Transcript

[2] Samuel Chase
FindLaw
Supreme Court Center
Supreme Court Justices
Article

[3] The Ellsworth Court and later life
Oliver Ellsworth
Wikipedia
Article

[4] Nomination
John Marshall
Chief Justice (1801 to 1835)
Wikipedia
Article

[5] Appointment to Supreme Court
Anthony Kennedy
Wikipedia
Article

.

Happy Darwin Day 2016

 

Today is the 207th birthday of both Charles Darwin and Abraham Lincoln, two people who were condemned for their great works. One changed the way we treat other members of our species, while the other changed our entire understanding of species.

Lincoln held America together in spite of attempts to divide America into those who used the law to support equal treatment of Americans and those who would start their own country to be able to expand what may be the worst economic system ever seen in America – slavery. We don’t like communism, but when we condemn communism, we use slavery as a metaphor for how bad communism really is. We used to be worse than the communists. Some of us were willing to kill Americans to avoid having to deal with the possibility of giving up the horror that is slavery.

Darwin explained how life evolved into the many different species that exist and into those that no longer exist. The connection among those seemingly unconnected species of animals, plants, fungi, bacteria, . . . is DNA (DeoxyriboNucleic Acid). We can use DNA in a court room to demonstrate that one person is the parent of another person, or that one person had direct (or occasionally indirect) contact with another person and thus may have had the opportunity to commit a crime. Criminal DNA evidence is just a tool and its appropriate use does require judgment, just as with any other evidence. If used without judgment, DNA evidence can be just as unreliable as eyewitness testimony.[1]

DNA is able to tell us how people and species are related. DNA is able to tell us that we are very closely related to other apes. When we trace our ancestry back far enough, we have the same ancestors. If we trace our ancestry back even farther, we have the same ancestors as snails. We have all evolved, over billions of years, to exist in our current temporary state of evolution. Will we humans split into several species or remain just one species until we become extinct?

DNA had not even been identified at the time that Darwin explained evolution in On the Origin of Species, so he did not have the ability to explain how these changes were taking place, but he could show that the changes were taking place and that the changes favored adaptations that increased the probability of survival of the species. He wasn’t right about everything, but science is not perfection. Science is a method of increasing our understanding and Darwin is one of a handful of scientists who dramatically changed the way we understand biology.

Medicine is a branch of biology. We can go practice monkey see, monkey do medicine, but we will cause a lot of harm with our lack of understanding. We can try to understand as much as possible or we can make excuses for rejecting science.

As we learn, science changes. The same is true for everything else. As we learn, we change. Change is unstoppable.

Could over 99% of biologists be wrong about evolution?
 

How Gavin Smythe Broke Science

How Gavin Smythe Broke Science


 
Go see the rest of How Gavin Smythe Broke Science here.
 

If you understand science, Tell Congress to Support Darwin Day 2016.

In addition, House Resolution 548 and Senate Resolution 337:
 

Footnotes:

[1] Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment
Fri, 05 Jul 2013
Rogue Medic
Article

.

The RAD-57 – Still Unsafe?

ResearchBlogging.org
 

Brandon Oto of EMS Basics and Degrees of Clarity organized The First EMS What-if-We’re-Wrong-a-Thon. I did not participate, because I was taking a break from blogging at the time. Brandon is doing it again, so I decided to look for something I wrote that I have been wrong about to contribute. I thought about Masimo. I had been very critical of Dr. Michael O’Reilly (then Executive Vice President of Masimo Corporation) for being an advocate of bad science. He has since been hired away by Apple.[1] He should be less dangerous with a telephone than he was with the RAD-57. At the time, he wrote –
 

Masimo stands by its products’ performance and knows that when SpCO-enabled devices are used according to their directions for use, they provide accurate SpCO measurements that provide significant clinical utility, helping clinicians detect carbon monoxide poisoning in patients otherwise not suspected of having it and rule out carbon monoxide poisoning in patients with suspected carbon monoxide poisoning.[2]

 

The problem is that there is no evidence that the RAD-57 is safe or effective at ruling out carbon monoxide poisoning in anyone.

There is evidence that the RAD-57 will fail, if used to try to rule out carbon monoxide poisoning. One study showed that the RAD-57 will miss half of the people with elevated carbon monoxide levels.
 

The RAD device correctly identified 11 of 23 patients with laboratory values greater than or equal to 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%).[3]

 

What if I was wrong?

Is there any evidence that the RAD-57 is able to rule out covert, but life threatening carbon monoxide poisoning?[4]
 


 
 

Was I wrong?

While there have been several studies of the RAD-57, I could not find any evidence that the RAD-57 is safe or effective at ruling out carbon monoxide poisoning.

There does not appear to be any research on the use of the RAD-57 to screen firefighters to rule out carbon monoxide poisoning, even though advertising shows using the RAD-57 to screen firefighters.

Was I wrong? No. That is why this is not a part of The First EMS What-if-We’re-Wrong-a-Thon.

However, I did find some interesting carbon monoxide poisoning papers –

One shows that we may be causing harm by aggressively providing oxygen. This is not enough of a reason to stop providing oxygen, but if this hypothesis is supported by further research, we will need to change treatment.
 

While CO’s affinity for hemoglobin remains undisputed, new research suggests that its role in nitric oxide release, reactive oxygen species formation, and its direct action on ion channels is much more significant. In the course of understanding the multifaceted character of this simple molecule it becomes apparent that current oxygen based therapies meant to displace CO from hemoglobin may be insufficient and possibly harmful.[5]

 

Another shows that the addition of catalytic converters seems to have dramatically decreased the car exhaust suicide rate and the level of carbon monoxide in survivors of these suicide attempts.
 

RESULTS:
Since 1985, the CDR for suicidal motor vehicle-related CO poisoning has decreased in parallel with CO emissions (R2 = 0.985). Non-fatal motor vehicle-related intentional CO poisoning cases decreased 63% over 33 years (p = 0.0017). COHb levels decreased 35% in these patients (p < 0.0001).
[6]

 

CO is Carbon monOxide.
CDR is Crude Death Rate.
COHb is CarbOxyHemoglobin.

There are still some papers that show that we do not understand what the RAD-57 can’t do –
 

The fact that all the Paramedic Rescue Squads were equipped with medical triage sets and were able to conduct non-invasive measurements of carboxyhemoglobin made it possible to introduce effective procedures in the cases of suspected carbon monoxide poisoning and abandon costly and complicated organisational procedures when they proved to be unnecessary.[1]

 

No. The Magic 8 Ball did not indicate a problem, but that does not mean that it is safe to rule out carbon monoxide poisoning with a Magic 8 Ball. The Magic 8 Ball RAD-57 is not accurate enough to rule out carbon monoxide poisoning.

The RAD-57 is only appropriate for sending more people to the hospital. While the extra cost of these false positives is a problem and will cause people to mock Masimo, this may save some lives or just prevent more serious consequences of carbon monoxide poisoning.

If you use the RAD-57 to determine that someone does not need to go to the hospital, get a lot of very good insurance, because eventually one of those patients will have a heart attack, or a stroke, or die and carbon monoxide will be part of the reason for the bad outcome. Your advice will have contributed.

If you send a firefighter back into a fire because you think you have ruled out carbon monoxide poisoning, eventually you will be the cause of death or disability of firefighters. Don’t do it.
 

CONCLUSIONS:
While the Rad-57 pulse oximeter functioned within the manufacturer’s specifications, clinicians using the Rad-57 should expect some SpCO readings to be significantly higher or lower than COHb measurements, and should not use SpCO to direct triage or patient management. An elevated S(pCO) could broaden the diagnosis of CO poisoning in patients with non-specific symptoms. However, a negative SpCO level in patients suspected of having CO poisoning should never rule out CO poisoning, and should always be confirmed by COHb.
[7]

 

Highlighting in bold is mine.

SpCO is Masimo’s registered trademark for their noninvasive indirect measurement of carbon monoxide using the RAD-57.

Was I wrong? I will find something else to write about, because there is even more evidence that the RAD-57 should not be used to try to rule out carbon monoxide poisoning now than when I originally criticized Masimo.
 

Also read the article by Dr. Brooks Walsh on the RAD-57 and screening for carbon monoxide poisoning in fire fighters – Checking firefighters for carbon monoxide – recent studies, persistent concerns.
 

Here is the rest of what I have written about the Dr. O’Reilly, Masimo, and the RAD-57

The RAD-57 Pulse Co-Oximeter – Does It Work – Part I
Fri, 12 Nov 2010

The RAD-57 Pulse Co-Oximeter – Does It Work – Part II
Wed, 17 Nov 2010

How Not to Respond to Negative Research
Fri, 26 Nov 2010

How Not to Respond to Negative Research – Addendum
Fri, 26 Nov 2010

How TO Respond to Negative Research
Sun, 05 Dec 2010

Bad Advice on Masimo’s RAD-57 – Part I
Fri, 18 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part II
Mon, 21 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part III
Thu, 24 Feb 2011

Bad Advice on Masimo’s RAD-57 – Part IV
Mon, 28 Feb 2011

Performance of the RAD-57 With a Lower Limit – Better?
Wed, 18 May 2011

Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients
Tue, 21 Feb 2012

Mass sociogenic illness initially reported as carbon monoxide poisoning
Wed, 22 Feb 2012

Psychic vs. RAD-57
Thu, 23 Feb 2012

Footnotes:

[1] Apple makes yet another medical field hire for unknown project
By AppleInsider Staff
Thursday, January 30, 2014, 04:04 pm PT (07:04 pm ET)
AppleInsider
Article

[2] Performance of the Rad-57 pulse co-oximeter compared with standard laboratory carboxyhemoglobin measurement.
O’Reilly M.
Ann Emerg Med. 2010 Oct;56(4):442-4; author reply 444-5. No abstract available.
PMID: 20868919 [PubMed – indexed for MEDLINE]

Free Full Text of letter and author reply from Ann Emerg Med.

[3] Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement.
Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P.
Ann Emerg Med. 2010 Oct;56(4):382-8. Epub 2010 Jun 3.
PMID: 20605259 [PubMed – indexed for MEDLINE]

Free Full Text Article from Ann Emerg Med.

[4] Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients
Rogue Medic
Tue, 21 Feb 2012
Article

[5] A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement.
Roderique JD, Josef CS, Feldman MJ, Spiess BD.
Toxicology. 2015 Aug 6;334:45-58. doi: 10.1016/j.tox.2015.05.004. Epub 2015 May 18. Review.
PMID: 25997893

[6] Suicidal carbon monoxide poisoning has decreased with controls on automobile emissions.
Hampson NB, Holm JR.
Undersea Hyperb Med. 2015 Mar-Apr;42(2):159-64.
PMID: 26094291

[7] False positive rate of carbon monoxide saturation by pulse oximetry of emergency department patients.
Weaver LK, Churchill SK, Deru K, Cooney D.
Respir Care. 2013 Feb;58(2):232-40. doi: 10.4187/respcare.01744.
PMID: 22782305

Free Full Text from Respir Care.

Weaver, L., Churchill, S., Deru, K., & Cooney, D. (2012). False Positive Rate of Carbon Monoxide Saturation by Pulse Oximetry of Emergency Department Patients Respiratory Care DOI: 10.4187/respcare.01744

Hampson NB, & Holm JR (2015). Suicidal carbon monoxide poisoning has decreased with controls on automobile emissions. Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 42 (2), 159-64 PMID: 26094291

Roderique, J., Josef, C., Feldman, M., & Spiess, B. (2015). A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement. Toxicology, 334, 45-58 DOI: 10.1016/j.tox.2015.05.004

Touger, M., Birnbaum, A., Wang, J., Chou, K., Pearson, D., & Bijur, P. (2010). Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 382-388 DOI: 10.1016/j.annemergmed.2010.03.041

O’Reilly, M. (2010). Performance of the Rad-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 442-444 DOI: 10.1016/j.annemergmed.2010.08.016

.

Is mixing Mountain Dew and racing fuel a new trend?

 

Is Dewshine (mixing Mountain Dew and racing fuel) what all the cool kids are doing?

Will it make me cool?
 
DewAndFuel_1453815893474_30645234_ver1.0_640_480
Image credit.
 

According to one article, one recent case of four teens getting together to drink this bad idea of a cocktail may be just the tip of some sort of epidemic iceberg –
 

And that’s just one state, and the just the cases that have been reported.[1]

 

While that is correct, it is also much more than an exaggeration of the facts.
 

She (Tennessee Poison Center Medical Director Donna Seger) says this is the first time she has seen this type of poisoning. The four cases are the only ones reported in Tennessee, and Seger is not aware of any cases in other states.[2]

 

Nationally, there was only one methanol poisoning fatality reported among teens aged 13-19 by the American Association of Poison Control Centers’ National Poison Data System in 2014, the most recent year data is available.[3]

 

Rudy Eugene was shot while eating the face of another person. This was supposed to be the beginning of a wave of attacks by abusers of bath salts, but . . .
 

Lab tests detected only marijuana in the system of a Florida man shot while chewing another man’s face, the medical examiner said Wednesday, ruling out other street drugs including the components typically found in the stimulants known as bath salts.[4]

 

We are still waiting for the bath salts zombie apocalypse.

What did I write about it at the time?[5]
 

This appears to be the first time that mixing Mountain Dew and racing fuel has been reported, so is it the tip of an iceberg or just an example of click bait?

Why mix racing fuel with anything and drink it? Racing fuel contains methanol, a type of alcohol that is much more poisonous to humans than ethanol (the type of alcohol that is sold for to be drunk by humans).

Why drink methanol, rather than ethanol? The dead were both 16 years old. Suppose that you are 16 and you want alcohol. Ethanol is not legally available. You probably do not know much about chemistry or toxicology. You may know that methanol is a form of alcohol. You skip right by due diligence. You draw the wrong conclusion. Four of you are hospitalized, but only two survive.

Teens tend to choose to experiment with marijuana, rather than methanol. Both are much easier to obtain than ethanol, but the dangers of marijuana are more likely to be legal, while the dangers of methanol are more likely to be medical.[6]

Mixing products containing methanol with Mountain Dew may be new, but the use of methanol for intoxication is not new, accidental ingestion of methanol by smaller children is also not new, and inhalation of products containing methanol (such as huffing carburetor cleaner) appears to be more even more common than ingestion of methanol.

The hospital treatment for methanol toxicity is hemodialysis and fomepizole (Antizol) and/or 10% ethanol. The EMS treatment is supportive care.[7]

Patients with initial blood sugar measurements above 140 mg/dL appear to be much more likely to die, which means that we should be especially vigilant with these patients, not that those with blood sugar measurements below 140 mg/dL will not die.[8]

Breath alcohol analyzers may mistake methanol for ethanol, so do not conclude that a positive breath test means drunk, rather than methanol poisoning.[9],[10],[11]

Don’t drink, or inhale, methanol. Methanol is neither fashionable nor healthy.

I hope you don’t come here for fashion advice, but I have provided valid evidence for my health advice.

Footnotes:

[1] Kids Are Dying From Drinking Racing Fuel Because For Fuck’s Sake, Don’t Drink Racing Fuel
Jason Torchinsky
Yesterday (01/27/2016?) 10:00pm
Article

[2] 2 teens die after drinking racing fuel, soda – The teens evidently thought they could drink methanol, which is extremely toxic, as a substitute for ethanol
EMS1.com
Yesterday (01/27/2016?) at 12:56 PM
AP
Article

[3] No ‘dewshine’ trend, Tennessee officials say
Anita Wadhwani
11:42 p.m. CST January 27, 2016
The Tennessean
Article

[4] Tests find only marijuana in face-chewer’s system
Boston Globe
Suzette Laboy
June 28, 2012
AP
Article

[5] Police fatally shot a naked man chewing on the face of another naked man
Tue, 29 May 2012
Rogue Medic
Article

 

Will I be surprised if the lab results show drugs in his system? No.

Will I be surprised if the lab results do not show drugs in his system? No.

There are other causes of excited delirium. Drugs are most common, so a wise bet would be to bet on there being drugs in his system, but enough patients experience excited delirium without drugs that we would be behaving inappropriately if we did not consider other causes of altered mental status, such as hypoglycemia, head injury, either a clot or a bleed in the brain, or any of the other possible causes of excited delirium.

We do not know what caused this.

 

[6] Cannabis-related hospitalizations: unexpected serious events identified through hospital databases.
Jouanjus E, Leymarie F, Tubery M, Lapeyre-Mestre M.
Br J Clin Pharmacol. 2011 May;71(5):758-65. doi: 10.1111/j.1365-2125.2010.03897.x.
PMID: 21204913

Free Full Text from PubMed Central
 

We estimated that in 2007 the incidence of cannabis-related AEs in the Midi-Pyrenees region ranged from 1.2 per 1000 regular cannabis users (95% confidence interval (CI) 0.7, 1.6) to 3.2 (95% CI 2.5, 3.9).

 

[7] American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning.
Barceloux DG, Bond GR, Krenzelok EP, Cooper H, Vale JA; American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning.
J Toxicol Clin Toxicol. 2002;40(4):415-46. Review.
PMID: 12216995
 

CONCLUSION:
The management of methanol poisoning includes standard supportive care, the correction of metabolic acidosis, the administration of folinic acid, the provision of an antidote to inhibit the metabolism of methanol to formate, and selective hemodialysis to correct severe metabolic abnormalities and to enhance methanol and formate elimination. Although both ethanol and fomepizole are effective, fomepizole is the preferred antidote for methanol poisoning.

 

[8] Hyperglycemia is a strong prognostic factor of lethality in methanol poisoning.
Sanaei-Zadeh H, Esfeh SK, Zamani N, Jamshidi F, Shadnia S.
J Med Toxicol. 2011 Sep;7(3):189-94. doi: 10.1007/s13181-011-0142-x.
PMID: 21336799

Free Full Text from PubMed Central
 

Considering the cutoff level of 140 mg/dL for blood glucose and using logistic regression analysis, and adjusting according to the admission data with significant statistical difference in the two study groups, the odds ratio for hyperglycemia as a risk factor for death was 6.5 (95% confidence interval = 1.59-26.4). Our study showed that blood glucose levels were high in methanol poisoning and even higher in those who died in comparison with the survivors. Therefore, hyperglycemia might be a new prognostic factor in methanol poisoning, but further studies are needed to determine whether controlling hyperglycemia has therapeutic consequences.

 

Don’t make the mistake of treating the blood sugar in the belief that you are improving outcomes. There is no evidence to support that hypothesis. In the absence of evidence of benefit or safety, we should expect that treating the blood sugar would be more harmful than beneficial.

[9] Breath alcohol analyzer mistakes methanol poisoning for alcohol intoxication.
Caravati EM, Anderson KT.
Ann Emerg Med. 2010 Feb;55(2):198-200. doi: 10.1016/j.annemergmed.2009.07.021. Epub 2009 Oct 14.
PMID: 19833410
 

A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL,

 

[10] Methanol ingestion: prevention of toxic sequelae after massive ingestion.
Lushine KA, Harris CR, Holger JS.
J Emerg Med. 2003 May;24(4):433-6.
PMID: 12745047

[11] Observations on the specificity of breath-alcohol analyzers used for clinical and medicolegal purposes.
Jones AW.
J Forensic Sci. 1989 Jul;34(4):842-7.
PMID: 2760587
 

Three different methods of alcohol analysis are reported: semiconductor sensing (Alcotest 7310), electrochemical fuel cell (Alcolmeter SM-1), and infrared (IR) absorptiometry (IR Intoximeter 3000). Methanol could not be distinguished from ethanol with any of these breath-test instruments. When nonspecific techniques of ethanol analysis are used, the results must be considered with caution when interfering substances expelled in breath cannot be excluded.

 

.

Should you hold your breath while intubating?

 

This is one of the ancient bits of street wisdom common sense about intubating. If you hold your breath while intubating, you will know when the patient needs to take a breath.

As with much of common sense, it is based on mythology.
 

Never take more than 30 seconds per attempt at each intubation!
Hint: Hold your breath while intubating – when you need to take a breath, so does the patient!
[1]

 

60 pct of the time, it works every time 1
Typical intubation instructor?
 

Obviously, this idea came about long before apneic oxygenation. No, . . . . Wait, it could be that apneic oxygenation came first, since papers were being written about apneic oxygenation long before paramedics were sent out to spread the word of the benefits of unrecognized esophageal intubation close enough for prehospital intubation.[2],[3],[4]

It could be that some anesthesiologists thought breath holding while intubating was a good idea, but I did not find any papers.

Apneic oxygenation can prevent desaturation for much longer than 30 seconds, yet many of us still emphasize fast and bloody, rather than slow and benign.

If the patient can hold her breath for as long as I can, she may be breathing as well as I am breathing, and may not need to be intubated. How do I really know when my patient needs to take a breath?

If I can only hold my breath for as long as a patient who needs to be intubated, then I may be breathing as badly as she is, and I may need intubation more than she does. How long can a paramedic hold his breath before becoming hypoxic and/or confused? How good am I at recognizing this change when I am focused on putting the little plastic tube in the slightly larger cartilage and flesh tube?

If the patient does not need to be intubated, why intubate? If I need to be intubated, should I be the one intubating anyone else? If I can hold my breath longer than the average paramedic, should I take up smoking to make this technique work for me? Should we be testing paramedics on how long a breath can be held as part of the hiring process?

I am shocked that such a simple one size fits all approach fails to consider even one of the many variables that would affect its use. How could that possibly happen in EMS?

Footnotes:

[1] Widely circulated, unwritten paper
The Mythbuilders of EMS
Trust us.
We know what we’re doing.

[2] Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation.
ENGHOFF H, HOLMDAHL MH, RISHOLM L.
Acta Chir Scand. 1952 Jul 14;103(4):293-301. No abstract available.
PMID: 12985091

[3] Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea.
HOLMDAHL MH.
Acta Chir Scand Suppl. 1956;212:1-128. No abstract available.
PMID: 13326155

[4] Apneic oxygenation in man.
FRUMIN MJ, EPSTEIN RM, COHEN G.
Anesthesiology. 1959 Nov-Dec;20:789-98. No abstract available.
PMID: 13825447

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Deja vu all over again in segregation

 

I was just a little kid when Alabama Governor George Wallace gave his famous inauguration speech announcing segregation now, segregation tomorrow, and segregation forever.[1] I had hoped that we, in America, had matured and improved our morality in the last half century.
 


 

Alabama Supreme Court Chief Justice Roy Moore wants to prove that segregation, and other immoral acts, still get votes in Alabama.[2] The Alabama Supreme Court is elected and today the Chief Justice demonstrated that he will continue to pander to the immorality of voters. He was removed from office in 2003 for idolatry, but the voters support idolatry – as long as it is their version of the golden calf. Because tradition has arbitrarily limited the rights of some Americans, some Americans think that immoral tradition should continue.

These defenders of immorality claim that they are defending Biblical marriage. With so many forms of God-endorsed Biblical marriage, why do they defend only one form? Why not the polygamy that God approved of in the Bible? Why not the selling of a daughter into sexual slavery that God approved of in the Bible? Why do they leave out the parts of the Bible that they find embarrassing?
 

7 “If a man sells his daughter as a female slave, she is not to [a]go free as the male slaves [b]do. 8 If she is [c]displeasing in the eyes of her master [d]who designated her for himself, then he shall let her be redeemed. He does not have authority to sell her to a foreign people because of his [e]unfairness to her. 9 If he designates her for his son, he shall deal with her according to the custom of daughters. 10 If he takes to himself another woman, he may not reduce her [f]food, her clothing, or her conjugal rights. 11 If he will not do these three things for her, then she shall go out for nothing, without payment of money. Exodus 21:7-11[3]

 

What about all of the other forms of Biblical marriage that the God of the Bible endorses?
 

biblical marriages
Image credit.
 

Fortunately, we live in America, so these examples of Biblical immorality are prohibited.

Justifications of slavery are rooted in the Bible and an economic system that is so obscene that it is used as a metaphor for other, less bad economic systems, such as communism and Nazism. We had to defend America against a rebellion by those who wanted to expand slavery. It took half a million deaths in a war to end this Biblical immorality.
 

Justifications of laws prohibiting contraception are rooted in the Bible. Struck down by the American Supreme Court in Griswold v. Connecticut in 1965.[4]
 

Justifications of laws prohibiting interracial marriage are rooted in the Bible. Struck down by the American Supreme Court in Loving v. Virginia in 1967.[5]
 

Justifications of laws prohibiting marriage equality are rooted in the Bible. Struck down by the American Supreme Court in Obergefell v. Hodges in 2015.[6]
 

To paraphrase what has been written elsewhere, The fact that I can no longer sell my daughter as a sex slave means that we have already redefined marriage. It is just one of many parts of eternal and unchanging laws of the God of the Bible that are illegal in civilized countries.

On the other hand, maybe these Christians are right. Maybe we should return to Biblical marriage. I don’t make much money as a paramedic and my daughter got her looks from her mother. The bidding starts at . . . well, make me an offer. It is the moral thing to do, according to the Bible.

When will we stop listening to Bible thumpers promoting immorality in the name of their interpretation of their Bible?

The American Constitution is in conflict with the Bible, because the Founding Fathers were more interested in fair play than in promoting persecution by the religious. The Founding Fathers could have limited the vote (and political office) to Protestants, but they explicitly forbade such discrimination.[7]

So many of these segregationists claim to disapprove of big government, but demand a big government to enforce their rules of watered down sharia. Hypocrisy seems to be required to defend such blatant immorality.

Footnotes:

[1] George Wallace’s 1963 Inaugural Address
Wikipedia
Article

[2] The Quixotic Adventures of Roy Moore – Alabama’s chief justice issued an order on Wednesday to keep the state’s same-sex marriage ban intact despite the Supreme Court’s landmark ruling last year.
The Atlantic
Matt Ford
5:15 PM ET
Article
 

Alabama Supreme Court Chief Justice Roy Moore issued an administrative order Wednesday that effectively banned same-sex marriages in the state, less than seven months after the U.S. Supreme Court ruled that same-sex marriage bans violated the Constitution.

 

[3] Exodus 21:7-11
New American Standard Bible (NASB)
Bible Gateway – A Christian site that allows you to use any other version if you like.
God
Link to these holy words of the God of the Bible

[4] Griswold v. Connecticut
U.S. Supreme Court
Decided: June 7, 1965
FindLaw
Transcript

[5] Loving v. Virginia
U.S. Supreme Court
Decided: June 12, 1967
Cornell University Law School
Transcript

[6] Obergefell v. Hodges
U.S. Supreme Court
Decided: June 26 2015
SCOTUSblog
Transcript

[7] Article VI Section 3
U.S. Constitution
Transcript
 

The Senators and Representatives before mentioned, and the Members of the several State Legislatures, and all executive and judicial Officers, both of the United States and of the several States, shall be bound by Oath or Affirmation, to support this Constitution; but no religious Test shall ever be required as a Qualification to any Office or public Trust under the United States.

 

Highlighting is mine.
 

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2015 In Review – Superstitious Standards of Care Suffer Small Losses, But Continue to be Favorites

 

What changed, or almost changed in 2015?

Withholding epinephrine (adrenaline in Commonwealth countries) in cardiac arrest is still heresy. This use of epinephrine is not based on evidence of improved outcomes that matter to patients – unless the patient is a pig/dog/rat with no heart disease having an artificially produced cardiac arrest.

The Jacobs trial ways sabotaged by politicians, the media, and other opponents of science claiming that depriving patients of the standard witchcraft is unethical.[1] Using inadequately tested hunches on uninformed patients, as long as everyone else is doing it, appears to be their idea of ethical behavior. However, the Paramedic2 trial has been underway for about a year and should provide results in 2018.[2]
 

paramedic2_logo
 

There probably is some benefit for cardiac arrest patients who are not having heart attacks, but we do not currently try to identify them. We also do not know what dose or frequency is best or when to give epinephrine. Paramedic2 will only be able to answer some of those questions.
 

Withholding ventilation is a less defended heresy, at least in Pennsylvania.
 

AVOID endotracheal intubation and patient packaging during initial 10 minutes

Ventilation Options6:

  • No Ventilation
  • 1 ventilation every 10-15 compressions8 (Monitor Perfusion with Capnography[3]
  •  

    However, the AHA (American Heart Association) and ILCOR (International Liaison Committee On Resuscitation) 2015 resuscitation guidelines double down on baseless fears –
     

    2015 Evidence Review
    There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases.
    [4]

     

    There is no evidence to support this fear, but using reason against irrational beliefs is often unsuccessful, since the irrational appeals to emotion and avoids reason.
     

    Medical directors have been recognizing that backboards were used because of irrational fear and assumptions of benefit that were based on hunches. Therefore many medical directors now recognize the absurdity of the use of this malpractice device and discourage the use of backboards.
     

    Pennsylvania has also removed chilled IV fluid from protocols following the failure of the treatment to improve outcomes for cardiac arrest patients, when given by EMS.

    Chilled IV fluid therapeutic hypothermia does work in the hospital, but not when provided by EMS.

    This is one of the reasons EMS should not automatically adopt treatments that work in the hospital. It is difficult for many in EMS to understand, but many in EMS still think that occasionally intubating a patient makes a paramedic as good as an anesthesiologist.
     

    In general, the state of EMS is best summed up by this statement by Prachi Sanghavi –

    Our current ambulance system is based on little scientific evidence.

    The scary thing for patients is that many in EMS are proud of our ignorance.
     

    Elsewhere in medicine in 2015.

    Thousands of Americans travel to regions with outbreaks of Ebola and help to stop the spread of infection. This was in spite of the panic being encouraged by the scientifically illiterate. We should have welcomed them home as we welcome home out military. Both of these groups of Americans risk their lives to protect others and should be treated better. They are far more ethical than our isolationist politicians.

    We learned that we need to add rats to the growing list of the non-human animals that exhibit empathy and will sacrifice to help others.[5] It appears that comparing those who opposed sending Americans to rats is unfair to the rats.
     

    Finally, 2015 was the 100th anniversary of Albert Einstein explaining that Isaac Newton was wrong about gravity, but that is the way science improves.
     

    PS – We also had push dose pressors added to the Pennsylvania protocols in 2015.

    Footnotes:

    [1] 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.

     

    [2] Paramedic2 – The Adrenaline Trial
    Warwick Medical School
    About

    [3] General Cardiac Arrest – Adult
    3031A – ALS – Adult
    Pennsylvania Emergency Health Services Council
    PA ALS Protocols in PDF format

    [4] 2015 Evidence Review
    2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality
    Adult BLS Sequence—Updated
    2015 Evidence Review

    [5] Rats forsake chocolate to save a drowning companion
    Science Magazine
    By Emily Underwood
    12 May 2015
    Article

    .

    Natural Alternatives to the EpiPen, Because We Believe in Parachutes

     

    The evidence for epinephrine (Adrenaline in Commonwealth countries) in anaphylaxis is not the highest quality available, but that does not mean that the use of epinephrine to treat anaphylaxis is not EBM (Evidence Based Medicine).
     

    Evidence Pyramid

    Evidence Pyramid


    Image credit.
     

    The patients are not randomized to placebo vs. epinephrine treatments, but EBM is not limited to placebo studies[1] – unless you believe that the Parachute Study is valid evidence, rather than just satire.[2]

    It is entirely appropriate to use logical fallacy for satire, since humor is not expected to be based on valid evidence. It is definitely not appropriate to use logical fallacy as scientific evidence. Logic is essential to science, while logical fallacy and the avoidance of rational analysis are essential to deception.

    What does the Parachute study have to do with Natural Alternatives to Epipen?[3] The evidence supporting epinephrine is even weaker than the evidence supporting parachutes, since one of the advantages of parachutes is that their use can be adequately studied without using human subjects. Therefore we actually have excellent evidence that parachutes will deploy as expected (with the obvious error bars that apply to valid science), will slow the descent (again, with the obvious error bars that apply to valid science), et cetera.
     

    Even the most dimwitted purveyor of “natural” cures should know that and stay away from “natural” treatments for anaphylaxis, while the smarter snake oil salesmen also know that you can’t afford to mess around with a medical condition that can cause such rapid deterioration from seemingly perfectly health to dead. It’s not good for business.[4]

     

    Ignoring the pathetic absence of evidence for alternative medicine, what is the evidence that epinephrine does improve outcomes?

    There is an excellent discussion of the evidence in an article available for free at PubMed Central.
     

    International guidelines concur that epinephrine (adrenaline) is the medication of first choice in anaphylaxis because it is the only medication that reduces hospitalization and death.[5]

     

    There is no reduction of hospitalization and death with Benadryl (diphenhydramine), with any of the steroids, or with any alternative medicine. Go read the full paper.

    Also, go read the analysis of the problems in the article advocating the use of Natural Alternatives to Epipen at Respectful Insolence.

    Footnotes:

    [1] Evidence based medicine: what it is and what it isn’t.
    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
    BMJ. 1996 Jan 13;312(7023):71-2.
    PMID: 8555924 [PubMed – indexed for MEDLINE]

    Free Full Text from PubMed Central.
     

    Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

     

    Maybe the opponents of Evidence Based Medicine do not understand that using judgment to apply the best evidence to the patient is essential to EBM.

    [2] Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
    Smith GC, Pell JP.
    BMJ. 2003 Dec 20;327(7429):1459-61. Review.
    PMID: 14684649 [PubMed – indexed for MEDLINE]

    Free Full Text from PubMed Central.

    The authors searched the literature for parachute research, but eliminated all studies without control groups, which suggests that EBM has some sort of requirement that all research include a control group. That is one of the logical fallacies employed by the authors for humorous intent.
     

    We excluded studies that had no control group.

     

    Those who cite the parachute study as valid evidence do not seem to understand this sleight of hand. EBM does not exclude studies that have no control group. EBM even includes expert opinion.

    [3] Natural Alternatives to Epipen
    Gazette Review
    Dec 18, 2015
    Adam Trent
    Cached article

    [4] Worst idea ever: “Natural” alternatives to the Epipen
    Respectful Insolence
    Posted by Orac
    December 22, 2015
    Article

    [5] 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines.
    Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A.
    World Allergy Organ J. 2015 Oct 28;8(1):32. doi: 10.1186/s40413-015-0080-1. eCollection 2015.
    PMID: 26525001

    Free Full Text from PubMed Central.

    .