The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Valsalva the SVT or Shock the Monkey?


The Skeptics’ Guide to Emergency Medicine should be on your podcast list. The podcasts are short, so there is not much reason to avoid them. This one is 13 minutes.

Valsalva for SVT (SupraVentricular Tachycardia) is supposed to come before medication. At least that is the order of treatments of every EMS SVT protocol I have seen. Since medicine is expected to have more, and more serious, side effects, this is reasonable.

What medicines?

Adenosine has the side effects of -


Prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes



Central Nervous System

Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness.[1]


It appears to be reasonable to try to avoid those side effects.

Too much of this could become more of a problem than an SVT.

Click on images to make them larger. Image credit.[2] This is not the actual strip, but a strip of an adenosine pause edited to produce more asystole, which I have seen.

The side effect becomes much more of a problem when someone decides to treat the side effect, rather than wait for it to wear off.

We SLAM adenosine in because it wears off quickly. A minute, or two, of asystole is not a problem.

Giving a dose of epinephrine to a patient who had an SVT a minute ago and now has adenosine quickly wearing off – that may be a fatal problem.

But how effective is the Valsalva maneuver (VM)?

The VM is a non-invasive way to convert patients from SVT to sinus.It increases myocardial refractory period by increasing intrathoracic pressure thus stimulating baroreceptors in the aortic arch and carotid bodies Increases vagal tone (parasympathetic).[3]


Here is a big problem with the use of the Valsalva maneuver. It is just one method of attempting to stimulate the vagus nerve.

There are many other methods and they may be more successful. Carotid sinus massage (after auscultation for bruits), facial immersion in ice water (assuring that the airway does not become a problem), bearing down, blowing through a straw (even better may be a swizzle stick), digital circumferential sweep of the anus, coughing, . . . .

There are many ways of activating the vagal nerve, but my favorite is to act as if I have not started an IV before, go very s l o w l y with the insertion of the largest IV catheter I think I can get in the vein, and this has almost always broken the rhythm.

Yes, that is anecdotal, but I have only rarely needed to follow that with medication.

Yes, pain is not a nice thing, but it is much nicer than the side effects listed above.

Bottom Line: There is no standardized methods to perform a VM to terminate uncomplicated SVT that are evidence based.

Clinical Application: VM is a viable technique that is poorly researched for the conversion of SVT and should not be considered essential to attempt prior to chemical cardioversion.[2]


We need better vagal maneuvers.

We need good evidence on what works.

Go read the article and listen to the podcast.




[1] ADENOCARD (adenosine) solution
[Astellas Pharma US, Inc.]

FDA Label


[2] Atrioventricular Re-entrant Tachycardia
Thumbnail Guide to Congenital Heart Disease
edited version of their adenosine ECG strip


[3] SGEM#67: Shock the Monkey Tonight (Valsalva Maneuver for SVT)
Podcast Link: SGEM67
Date: March 23, 2014
Skeptics’ Guide to Emergency Medicine
Article and link to podcast


Drunk? or Auto vs. Pedestrian With Major Injuries?


Sometimes we miss things that we are expected to miss, such as an atypical presentation of an uncommon condition.

Other times we miss something that even a rookie should not miss.

A paramedic has been suspended for a year after he mistook as drunk a man who had in fact been victim of a hit-and-run, suffering a broken back and 12 broken ribs.[1]


Suspended for a year is a serious punishment, right?

Maybe not if the medic is retiring anyway – after 30 years on the job.

How does someone with 30 years of experience miss those injuries?

A passerby found Mr Wonnacott at 4am on November 20, 2011, and the paramedic failed to establish any of his injuries and made him walk into the ambulance.

While en route to hospital, Mr Gaiger called Mr Wonnacott’s parents and said he was “absolutely plastered” and it was only on arrival to the hospital that his injuries were discovered.[1]


Image credit.

4 AM on a Sunday morning is a time when we expect to see a higher percentage of drunks.

I have missed things on scene, only to identify them during transport, and I have continued to miss things during transport, but, . . .

Maybe if there were only 11 rib fractures, it would be understandable.

Maybe if it were only 2 vertebrae.

Maybe if both the liver and the spleen hadn’t been lacerated.

Maybe if there hadn’t been a pneumothorax.

Maybe these injuries were actually quite subtle.

David Rosenbaum was just another drunk in Washington, DC.[2]

Except that he wasn’t drunk. He had a head injury and died before anyone realized that he was not drunk.

“This is not a witch hunt. I just don’t want another family or patient to go through what we have been made to go through as a result of Mr Gaiger’s actions.”[1]


The Rosenbaum family said the same thing.

We don’t want money. We want to fix the system so that this does not happen again.

Did anything really change at DC Fire and EMS?

Will anything really change at South East Coast Ambulance Service?

This is a medic they have employed for 30 years. Was this the first time something like this happened? Was this the first time that the news media became aware of the problem? Was he burned out after 30 years? Was he having a horrible day – although a day infinitely better than his patient was having? Out of sight, due to retirement, out of mind? The articles have not been very helpful.

Maybe Mr Wonnacott was gently run over, by someone who really was drunk, and suffered a brain injury that made him appear to be drunk, and only the hospital people could identify the multiple fractures and brain injury.

Maybe, but maybe we should discourage people from concluding a patient is just a drunk, or that the epigastic pressure is just indigestion, or that the hyperventilation of the young female is just hysteria, or . . . .

Hmmmm. Those are things I learned in my original paramedic class that have not changed.




[1] Chessington paramedic suspended for a year after treating seriously Esher injured man as though he were drunk
By Laura Proto
6:10am Thursday 20th March 2014
Elmbridge Guardian


[2] The Death of David Rosenbaum
By Colbert I. King
Saturday, February 25, 2006
Washington Post


Mounting Evidence Against the Long Spine Board in EMS – A Must Watch Video


Dr. Ryan Jacobsen explains that I have been using the wrong terminology for this piece of equipment. This is a picture of my padded spine board.

In this excellent video, he describes why and explains the problems with the use of backboards and the absence of any valid evidence to justify the use of backboards for transport.


The video is one hour and twenty-two minutes, so get comfortable, get some caffeine, and get ready to smile and learn.

And share this video.

There are currently only 188 views of the video. There need to be hundreds of thousands.

If you teach EMS, play this for your students, or just give them the link.

Download YouTube Video | YouTube to MP3: Vixy

What is the basis for the backboard?

Let’s blame the people who touched the patient first, because EMS will go along with that.

Mounting Evidence Against the Long Spine Board in EMS
Ryan C. Jacobsen, MD, EMT-P
Johnson County EMS System Medical Director
Assistant Professor of Emergency Medicine
Truman Medical Center/Children’s Mercy Hospital and Clinics
YouTube page

Thank you to Bill Toon, PhD for the link, for obtaining permission from Dr. Jacobsen to share this, and thank you to Dr. Jacobsen for making the video.


Homeopathic Product Recalled for Containing Real Medicine


Homeopathic products are supposed to be diluted down to where they contain nothing.

They definitely are not supposed to contain antibiotics, since antibiotics were not understood when Samuel Hahnemann made up the idea of homeopathy.

FDA has determined that these products have the potential to contain penicillin or derivatives of penicillin, which may be produced during the fermentation process. In patients who are allergic to beta-lactam antibiotics, even at low levels, exposure to penicillin can result in a range of allergic reactions from mild rashes to severe and life-threatening anaphylactic reactions.[1]


The law of similars. Find a poison that produces similar symptoms, preferably not the cause of the illness (not that a homeopath would know) and dilute the poison down to nothing.

The water (or alcohol) is expected to remember the poison, but forget everything else that has been in the water, and magically cure the illness by doing the opposite of what the poison would do.

The water is diluted to 1% of what was in it enough times that there should not be any poison left. The homeopath also hits the water a lot to teach the water to remember the poison. This is the magic memory of water.

The result is nothing.

Image credit.

When blood-letting was a common treatment, this was better than going to a doctor, but still not as good as staying at home and saving your money, because who needs to go buy nothing?

The idea that the more dilute the solution, the more potent the “medicine” is ridiculous. Somebody would be able to demonstrate the differences in strengths, but homeopathy is just another placebo with just another excuse to scam people.

At what concentration of nothing does it start to work?

At what concentration of nothing does it become dangerous?

Is it still a solution when there is nothing in it?


Hover text –

Dear editors of Homeopathy Monthly: I have two small corrections for your July issue. One, it’s spelled “echinacea”, and two, homeopathic medicines are no better than placebos and your entire magazine is a sham.[2]


One of the problems with dealing with a fraud is the inability to tell the difference between incompetence and intentional fraud.

Homeopath X is a true believer. He believes that homeopathy works, but is too incompetent to keep real medicine out of his nothing.

Homeopath XX is willing to sell anything that pays. He knows that homeopathy is nonsense, but wants to add real medicine to make it seem that the water is having some sort of effect beyond a placebo effect. He adds real medicine after the dilution for that effect. This is not rare.

Homeopaths claim that their medicines are safe and that real medicines are dangerous, so why add medicine?

Since homeopathy is all lies, should we believe anything a homeopath says?

If you dilute a lie enough times, does it become truth?

We have enough problems with believing in magic with real medicines without adding the problems of homeopathy, where there is nothing real except fraud.




[1] Pleo Homeopathic Drug Products by Terra-Medica: Recall – Potential for Undeclared Penicillin – Includes Pleo-FORT, Pleo-QUENT, Pleo-NOT, Pleo-STOLO, Pleo-NOTA-QUENT, and Pleo-EX
Posted 03/20/2014
Safety Alert


[2] dilution


In Defense of No Improvement by Medic Madness – Part II


Continuing from Part I, in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -

No, there isn’t much data to suggest that using a LUCAS improves outcomes. Likewise, we aren’t discovering that it’s hurting people either. So at the very worst, it’s a luxury item.[2]



I am critical of treatments that do not work. Once we start making excuses to use these treatments, we take decades to get rid of them.

No difference in survival or neurological outcome was seen for up to 6 months after the cardiac arrest as, by then, the vast majority of survivors had CPC scores of 1 or 2, and most patients with initial CPC scores of 3 or 4 had either improved or died. The numbers of serious adverse events and device-related adverse events were low.[3]


The LUCAS failed.

Unless your idea of success is to make no difference in outcomes, because improving resuscitation outcomes is not important.

Moving out of the big city and going to work in an area that utilizes volunteers as first-responders means that I often find myself working a resuscitation with just me and my partner. If – and I emphasize the word “if” – we happen to get first-responders to these calls, we still have no idea what kind of training or experience they have.[2]


The LUCAS as an excuse to tolerate incompetence.

Over, and over, and over, . . . this has been the main argument for the LUCAS.

We can’t expect EMS to perform high quality CPR.

We are too busy doing other things that do not improve outcomes to make sure that compressions are done well.

There are only two things that a paramedic needs to make sure are done well – compressions and defibrillation.

What do paramedics want to do?

We want to do things that do not improve outcomes, because we do not understand what we are doing and are easily distracted by shiny things. Maybe they can put a flashing light on the LUCAS, or give out badges with each use, and raise the price by $5,000 $10,000.

Rather than courage, we can award a LUCAS Save! medal – a shiny one.

If I am to take Sean seriously, perhaps it will be because he has taken the same argument against intubation and advocated for protecting patients from incompetent EMS by replacing endotracheal tubes with almost foolproof LMAs (Laryngeal Mask Airways).

More consistent, frees up a set of hands, probably less liability, . . . .


Sean hasn’t applied the same logic to intubation in cardiac arrest?

I am shocked. :shock:

I too have been a volunteer and I know the value of the care they provide. Having said that, it’s hard to get strict on training when they are already going out of their way to provide service to their community.[2]


I don’t blame the volunteer for the quality of care they provide when working with a paramedic right there.

I blame the paramedic.

It is my job to make sure that what is going on is done well. Compressions and defibrillation are all that matter. If I can’t manage that, intubation is definitely beyond my capabilities.

What’s the harm of treatments that do not improve outcomes alternative medicine?

I look at the criticisms of the actual research in Part III and Part IV.

Dr. Brooks Walsh also explains the failure of the LUCAS in this study in “We had a LUCAS save!” – No, you didn’t.

Peter Canning describes the failures of judgment in advocating for the LUCAS in Whup Kits and Chihuahuas.




[1] The Failure of LUCAS to Improve Outcomes in the LINC Trial
Wed, 05 Mar 2014
Rogue Medic

The LUCAS, Research, and Wishful Thinking
Fri, 07 Mar 2014
Rogue Medic


[2] In Defense of the LUCAS
March 12, 2014
by Sean Eddy
Medic Madness


[3] Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R.
JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538.
PMID: 24240611 [PubMed - indexed for MEDLINE]

Free Full Text in PDF Download format from


Man Sues Rescuers Because of Unreasonable Expectations


Who encourages these unreasonable expectations? Frequently, we do.

Jamie Davis makes some important points about how we may be able to decrease these law suits. The story begins at 7:15 of the podcast, but listen to/watch the whole podcast.

MedicCast Episode 377

There is a commercial for an insurance company that has the insurance agents magically appearing at the side of the insured person and then, just as magically, transporting the insured person away from whatever danger the person had gotten himself into.

Should we be encouraging people to expect magic?

EMS person come help!


A number of cars went into Rock Creek on Sept. 12, when Dillon Road washed out. Roy Ortiz, who was among those rescued from their vehicles, could sue emergency responders claiming they did not rescue him quickly enough. ( David R. Jennings )[1]


Should EMS have shown up, disregarded procedures that are based on what happens when rescuers rush in and end up needing to be rescued?

We cannot help if we are in need of rescuing. Other rescuers cannot help if they are busy trying to rescue us.

No plan survives first contact intact, but that does not mean that we should rush in recklessly.

What would be the expectations in your community?

If your community is like mine, the expectation is –

EMS person come help!

The document claims first responders, . . . , failed to see Ortiz was trapped in the car, and that he ended up spending two hours submerged in Rock Creek until he was rescued.

In the document, Ferszt stated Ortiz survived “by pure grace.”[1]


He blames everyone else for getting him in to trouble, but when they get him out, he does not give his rescuers any credit. He sues all of the rescuers involved. Magical thinking is something we ought to discourage.

The article does not mention whether a backboard was used appropriately as an extrication device or whether the patient remained on the extrication board and it became a magic transportation board. Our patients are not the only one who use magical thinking.

Go watch/listen to the podcast.




[1] Broomfield man rescued from Rock Creek during September floods could sue his rescuers
By Megan Quinn, Enterprise Staff Writer
Posted: 03/05/2014 11:52:53 AM MST UPDATED: 13 DAYS AGO
Denver Post


In Defense of No Improvement by Medic Madness – Part I


I wrote about treatment with the LUCAS CPR machine and stated that There is no price that justifies no improvement.[1]

There are plenty people who want to justify the use of placebo treatments – treatments that do not improve outcomes. Here is one –

Before writing this response, I took some time to examine the equipment I use on a daily basis. Needless to say, I was shocked to discover that we spend a lot of money of items that really don’t improve patient outcomes at all. One example is the Stryker Power Cot.[2]


The LUCAS is a treatment that is a potential substitute for manual chest compressions.

The selling point was supposed to be that the LUCAS improves outcomes – survival with a working brain – that is the whole purpose of the research I have been writing about.

Thus, in clinical practice, CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.[3]


The LUCAS failed.

However, Sean is taking my statement about the outcome of a treatment and applying it to the choice of equipment.

Does a power stretcher improve the survival of patients?


I do not know of any studies that examine this question, but the stretcher is not used as a treatment. The stretcher is used as a means of moving the patient.

What Sean appears to be asking is – since I am going to use a stretcher (is there any state that does not require a stretcher in an ambulance), shouldn’t I use the cheapest stretcher that meets the requirements? Or am I going to base my decision on something other than outcomes?

Is the choice to pay more for a power stretcher based on the outcomes of patients?

Although I tried, I couldn’t find any studies that compared patient outcomes to those transported using a manual cot.[2]


It is not based on the outcomes of patients, but the choice is based on outcomes.

In a study comparing the injury rate among FTEs (Full-Time Employees), the rate of injury was cut in half after the introduction of a powered stretcher.[4]

Maybe EMS should not consider the outcomes for employees when making decisions?

What is Sean’s next gotcha?

Another major purchase was the LifePak 15 ECG monitor / defibrillator. Once again, I couldn’t find anything showing improved patient outcomes.[2]


Sean couldn’t find any evidence that waveform capnography improves outcomes for patients?[5] :sad:

Sean couldn’t find any evidence that an EMS 12 lead ECG (ElectroCardioGram) improves outcomes for patients?[6] :oops:

Sean couldn’t find any evidence that EMS defibrillation improve outcomes for patients?[7] :shock:

Perhaps Sean works in a state that does not require a defibrillator, 12 lead capability, and/or waveform capnography as minimum paramedic equipment and thinks these are just fun to have toys.

Sean appears to be suggesting that the choice of brand and options, except as mandated by EMS regulatory organizations, must be limited to the cheapest available item. Otherwise, I am misleading people by stating – There is no price that justifies no improvement.

Should I be worried at Sean’s failure to find the valid evidence, when I only provided a small sample of the valid evidence?

Does this affect Sean’s argument? The argument is really just a bait and switch – a logical fallacy known as a straw man.[8] I wrote about one thing and Sean represented my argument as something else, because he has an argument against the argument I did not make. However, his argument does not address the claim I actually did make.

That is not the only argument Sean makes. I address the rest in Part II, Part III, and Part IV.

Dr. Brooks Walsh also explains the failure of the LUCAS in this study in “We had a LUCAS save!” – No, you didn’t.




[1] The Failure of LUCAS to Improve Outcomes in the LINC Trial
Wed, 05 Mar 2014
Rogue Medic

The LUCAS, Research, and Wishful Thinking
Fri, 07 Mar 2014
Rogue Medic


[2] In Defense of the LUCAS
March 12, 2014
by Sean Eddy
Medic Madness


[3] Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R.
JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538.
PMID: 24240611 [PubMed - indexed for MEDLINE]

Free Full Text in PDF Download format from


[4] Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers.
Studnek JR, Mac Crawford J, Fernandez AR.
Appl Ergon. 2012 Jan;43(1):198-202. doi: 10.1016/j.apergo.2011.05.001. Epub 2011 May 31.
PMID: 21632034 [PubMed - indexed for MEDLINE]


[5] The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J.
Ann Emerg Med. 2005 May;45(5):497-503.
PMID: 15855946 [PubMed - indexed for MEDLINE]


[6] Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction.
Sivagangabalan G, Ong AT, Narayan A, Sadick N, Hansen PS, Nelson GC, Flynn M, Ross DL, Boyages SC, Kovoor P.
Am J Cardiol. 2009 Apr 1;103(7):907-12. doi: 10.1016/j.amjcard.2008.12.007. Epub 2009 Feb 7.
PMID: 19327414 [PubMed - indexed for MEDLINE]


[7] Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians.
Eisenberg MS, Copass MK, Hallstrom AP, Blake B, Bergner L, Short FA, Cobb LA.
N Engl J Med. 1980 Jun 19;302(25):1379-83.
PMID: 7374695 [PubMed - indexed for MEDLINE]


[8] Straw man


More EMS Agencies Eliminating Backboards


All of these departments are going to get in trouble for not using backboards – aren’t they?


For not harming patients with witchcraft?

Does that really happen?

Or is it just another EMS myth?


RIO RANCHO, N.M. (KOB) – When the call is made, firefighters and paramedics quickly respond to the scene of an accident. Their goal: get the victim out of harm’s way and to the hospital. Most first responders in the country still pick up a person and strap them onto a board similar to this one no matter what. That will no longer be the case in the City of Vision. Dr. Darren Braude, the Medical Director for the Rio Rancho Fire Department, says the feedback has been excellent regarding the new method.[1]


The typical response is –

But I could be sued and then the patient will own the department and this magic treatment prevents badness!!!11!!!!

Is there any truth to that?

I could be sued?

We can be sued for anything. The backboard has nothing to do with whether we can be sued. Frivolous law suits are expected to be dismissed by the judge. The plaintiff needs to convince a jury that there was harm as a result of our actions to win a law suit. I am not a lawyer, but this is what lawyers tell me.

The backboard, and the harm it may cause, may be what justifies a law suit being successful against us and our departments.

The backboard is a magic treatment.

Magic = belief that X works, even though there is no valid evidence that X works.

Using that definition, we can see that backboards are no better than magic.

There is no evidence that backboards prevent injury.

There is no evidence that backboards protect patients with unstable spinal injuries from disability.

There is evidence that backboards make disability more likely – disability is twice as likely with backboards.

Since there is no evidence of benefit, and plenty of evidence of harm, should we just stop pretending that we are good witches and helping patients? Clearly, we are not helping patients.

Image credit from Voodoo Medicine Man.


There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).


What is our liability?

We need to understand what we are doing, because ignorance is not a good defense.

If our defense is – I am too stupid to be competent – we should not expect to win any law suit.

If we were constantly asking, Is this going to be on the test? – well, real patient care situations are the test that really matter. Life is the test.


it may be common or customary for EMS providers to use a long spine board or collar, decisions of standard of care and negligence are not based on what is the best, reasonable care, not on what is usually done.66 [3]


If we are providing bad patient care, because that is what everyone else is doing, we are failing our patients.

We are failing the test.

Rio Rancho Fire Department, Albuquerque Fire Department, and Bernalillo County Fire Department will be making this change.

Thanks to Dr. Darren Braude and everyone else involved.

If I have not written about your system, tell me about how your system has eliminated the requirement to use a magic backboard for trauma.

Here is what I have written about other systems that do not require backboards for trauma –

Another System Eliminates Backboarding for Potential Spinal Injuries

The Lateral Trauma Position: What do we know about it and how do we use it

The Slow, Agonizing Death of Conventional Spinal Immobilization

Stop the Madness! Reducing Unnecessary Spinal Immobilizations in the Field – Part I




[1] NM Fire Department Using Alternative to Backboards – Rio Rancho looks at new evidence on immobilization
Monday, March 10, 2014


[2] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.


[3] Board to Death – The state of prehospital spinal injury care in 2013
Rommie L. Duckworth, LP
Created: July 15, 2013
EMS World