We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

What Laryngoscope Blade Do You Use? – Why?


 

Which laryngoscope blade is your favorite?

Does length matter?

Does strength matter?[1]

Dr. Minh LeCong asks this at his blog PHARM – PreHospital And Retrieval Medicine.

There is also a video that provides some information on blade size.
 


Download | YouTube MP3 Converter
 

One of the problems with the video is the hand position. The laryngoscope should be held so that the hand is touching the blade. I prefer to have my ring finger touching the blade.

The higher the hand is on the handle, the more likely that the handle is used like a slot machine handle, as I demonstrate below.
 


Download | YouTube MP3 Converter
 

The way to intubate is to position the patient before even picking up the laryngoscope (and premedicating with oxygen and whatever else is appropriate), then only advance the blade as far as necessary for each step of laryngoscopy.

1. Find the tongue.

Yay! That was easy.

2. Advance the laryngoscope and find the epiglottis.

Not as easy, but just more important.

3. Lift up (either in the valecula or under the epiglottis – it does not matter) and find the arytenoid structures. The vocal cords are above the arytenoid structures, so there is no need to lift up any farther.

4. Advance the bougie/tube over the arytenoid structures without touching anything else. It isn’t about cleanliness. The biggest problem I see people have when trying to intubate is that they do not avoid everything else in the mouth and end up trying to force the tube.

Force should never be used in the airway.

We should not arm wrestle with the airway. We will lose.

Go ahead and try to force this airway. I double dog dare you.
 


Image credit. It is all in the positioning.
 

The goal of airway management is to out-think the airway, not to out-muscle the airway.

As with martial arts, strength improves with repetition due to the development of muscle memory, even if there is no increase in strength. Technique requires a lot of repetition.

If you have not intubated a mannequin over a thousand times, you are still learning technique. We can always learn more.

We tend to be satisfied with very little practice, as if the patient owes it to us to inhale the tube.

This is ridiculous, but I find that for almost every class I have taught, I intubated the mannequin more times than everyone else in the class combined. I offer to let students practice as much as they want. I offer to help or to leave them alone.

Why is intubation of the airway of another human being so unimportant to so many of us?

Why do so many of us pretend that we are good at intubation?
 

Intubation shouldn’t be that hard, but research repeatedly shows us that we become airway stupid when things do not go as planned – and we are often the cause of the problems with our plan. Even if our plan is not just having the patient inhale the tube.
 

Most adults can be intubated with a #2 Mac or a #2 Miller. A longer blade is only necessary for a patient with an unusually long mandible.

Understanding of the airway is more important than blade size. Any spatula will do.

A blade should be relatively wide and flat. A tongue depressor would work well, but this would require some practice to manipulate the tongue with a tongue depressor. A tongue depressor is wider and flatter than a Miller, so a tongue depressor is better designed than a Miller to lift the tongue out of the way.

Why isn’t the Miller blade designed to lift the tongue out of the way? Was Miller in cahoots with the trial lawyers?

I prefer a Grandview, but a lower profile Grandview would be nice.
 


Download | YouTube MP3 Converter
 

This is from Dr. Richard Levitan’s Airway Cam series.

Dr. Levitan is one of the top airway doctors in emergency medicine. Notice how low his hand is on the blade. It may be someone else manipulating the laryngoscope, but probably someone who has received input from Dr. Levitan on intubation technique.

The wrist is lower than the blade. This makes it more difficult to pull back on the blade and easier to lift up with the blade.

Intubation is not about a long blade, or a strong arm, or pulling back, but many people attempt to intubate using all three of these mistakes.

Intubation is about thinking, preparation, positioning, technique, and lifting the tongue up.

-

Footnotes:

-

[1] PHARM Poll : Blade choice in direct laryngoscopy – does length or strength matter?
by rfdsdoc
on May 2, 2013
PHARM – PreHospital And Retrieval Medicine
Article

.

Misunderstanding of Evidence-Based Medicine – Part II

 

I pointed out in Part I[1] that a critic of EBM (Evidence-Based Medicine) was claiming that each treatment we have discarded was based on evidence – not just any evidence, but on a “Definitive Research Study”.
 

Lets recall that almost every innovation- both good and bad, during my 40 year career has been the result of someones “Definitive Research Study”, including every AHA BCLS/ACLS Revision over that time period, the miracles of Bretyllium and MAST pants,prophylactic Lidocaine, Aminophylline, Ouabaine, Plasmanate, D5W, the use of Narcan for spinal injuries to the use of Leeches and Maggots.

 

What is a “Definitive Research Study”?
 


Image credit.
 

1de·fin·i·tive adjective \di-ˈfi-nə-tiv\

1   : serving to provide a final solution or to end a situation <a definitive victory>
 
2   : authoritative and apparently exhaustive <a definitive edition>
 
3   a : serving to define or specify precisely <definitive laws>
 
     b : serving as a perfect example : quintessential <a definitive bourgeois>
 
4   : fully differentiated or developed <a definitive organ>
 
5   of a postage stamp : issued as a regular stamp for the country or territory in which it is to be used
 
— de·fin·i·tive·ly adverb
— de·fin·i·tive·ness noun[2]

 

Then a “Definitive Research Study” would be one of the following –

Research that is a final solution (answer) to the question of whether the treatment works?

Research that is authoritative and apparently exhaustive.

Research that serves to define or specify precisely.

Research that serves as a perfect example : quintessential research.

Research that is fully differentiated or developed.
 

The examples provided by the EBM critic do not come close to fitting any of those definitions.
 


Download | YouTube MP3 Converter
 

Look here, brother, who you jiving with that cosmik debris?

What causes so many people to be so delusional about science?

Ignorance.

The problem is that this ignorance should result in the silence of these anti-science propagandists, but they regularly claim to know more than scientists about what scientists study.

The AHA (American Heart Association) does not use terminology like “Definitive Research Study”. According to the AHA, the highest level of evidence requires more than one study.

What kind of study would come close to being definitive?
 

In terms of external validity, the critical care transport setting may be different from other prehospital situations. In fact, although much of the literature describing fentanyl’s use comes from the air medical (high acuity) sector, perhaps the best study to date comes from a ground EMS service by Kanowitz et al. described above (8). This study was a retrospective chart review that differs from our prospective study with regards to design, but has similar conclusions. The authors of that earlier report found, for example, that of 2129 patients receiving fentanyl, only 12 had a vital sign abnormality that was possibly attributed to the opioid.[3]

 

Even a study with thousands of patients receiving the same treatment with no clear evidence of any adverse effects to any patients is not definitive.

What ACLS treatment is based on similar evidence?

Definitely not bretylium.

Definitely not prophylactic lidocaine.

Can anyone name even one emergency treatment, based on anything that could be considered definitive research, that has been discarded.

Not replaced by an improved (safer and/or more effective treatment), but discarded.

-

Footnotes:

-

[1] Misunderstanding of Evidence-Based Medicine – Part I
Sun, 17 Mar 2013
Rogue Medic
Article

-

[2] Definitive
merriam-webster.com
Definition

-

[3] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed - in process]

Full Text PDF Download at medicalscg.

.

Anti-Vaccine Legislator Trying to Raise the Cost of Vaccines

 

Representative Andrea Boland is trying to make it harder to vaccinate children.

Why?

She appears to be just another scientifically illiterate person who thinks that chemical names are scary, even though there is no medical justification for her alarmist bill.

Vaccines are probably the safest and most effective medicines we have.

 

Image credit.
 

The measure, LD 754, sponsored by Democratic Rep. Andrea Boland, ran into stiff opposition from doctors, who said that requiring ingredients be disclosed specifically for vaccines — while not imposing similar requirements for antibiotics and prescription drugs — would signal that vaccines are disproportionately dangerous.[1]

 

Is anyone trying to hide the ingredients of vaccines?

Absolutely not.

The ingredients for every vaccine are available, but before you start making the mistake of assuming that scary sounding names are dangerous, take less than 4 minutes to watch the video below.
 


Download | YouTube MP3 Converter
 

Why only the ingredients of vaccines?

To make them seem scary.

In case you think that Rep. Boland is trustworthy, here is what she says about vaccine safety.

 

“When you read some of [the ingredients], it does sound kind of scary. The provider is there to counsel their patients, and they can assure them that they will not have any serious side effects and it’s the best thing to do.”[1]

 

It’s the best thing to do.
 

If vaccination is the best thing to do, why create obstacles to vaccination?

Is Rep. Bolton trying to push some sort of hidden agenda?

Here is the information provided on her government web page.

 

Occupation: Self-Employed Title Examiner; Independent Nutraceutical Distributor[2]

 

Rep. Bolton appears to be letting her personal nutraceutical business interests get between her and what is best for the children she is supposed to represent.

If you have a bit more time than the less than 4 minutes it took to watch the video, then listen to a 33 1/2 minute podcast, where Dr. Mark Crislip explains what is wrong with a silly claim by a naturopath.[2] “9 Questions That Stump Every Pro-Vaccine Advocate and Their Claims.” by David Mihalovic, ND. Really?

If you believe that vaccines are dangerous, then you need to listen to this podcast.

-

Footnotes:

-

[1] Sanford lawmaker wants doctors to disclose vaccine ingredients
By Matthew Stone, BDN Staff
Posted April 29, 2013, at 3:27 p.m.
Bangor Daily News
Article

-

[2] QuackCast 44. Nine questions.
Dr. Mark Crislip
Quackcast
Nine questions, none answers. An ND suggests there are 9 questions that pro-vaccine proponents can’t answer. Ha. My 12 year old can find the answers.
Podcast in mp3 format – click to play or right click and save to download.
 

QuackCast 44. Nine questions, none answers. An ND suggests there are 9 questions that pro-vaccine proponents can’t answer. Ha. My 12 year old can find the answers.

 

The print version, with links to the referenced research, is at the link below.

Nine Questions, Nine Answers.
Published by Mark Crislip
May 07, 2010
Science-Based Medicine
Article

.

Will IV Oxygen Save Lives?

ResearchBlogging.org
Image credit.
 

Intravenous oxygen delivery that works?

Maybe temporary oxygenation, but not yet.

Will this change the approach to CICV (Can’t Intubate, Can’t Ventilate) patients?

No, but it may change the approach to CICO (Can’t Intubate, Can’t Oxygenate) patients.

The distinction is important. If we can deliver oxygen without ventilation, we can avoid some of the problems of hypoxia, but we will still have to deal with the acidosis that results from the inability to eliminate CO2 (Carbon DiOxide).
 

In the early 1900s, intravenous administration of oxygen gas was used in attempts to relieve refractory cyanosis (4–7). Most reported that spontaneously breathing, cyanotic animals exhibited signs of pulmonary embolism at infusion rates in excess of 0.2 to 1 ml/kg per minute and required frequent pauses in the infusion (4, 5); . . . None of these studies documented an increase in oxygen content in the blood as a result of the intervention.[1]

 

Try walking up several flights of stairs while only breathing through your nose. You will become short of breath very quickly.

Unless you are in truly horrible shape, it is not a lack of oxygen that is causing you to become short of breath. It is the inability to remove CO2 (Carbon DiOxide) that is the problem.

Most of us breathe because of a buildup of CO2, not because of a lack of oxygen.
 

The reflexive response of some people might be to give the anti-acidosis drug NaHCO3 (sodium bicarbonate). We will ignore the sodium, which at 5.8% in NaHCO3 is over 6 times the concentration of the NSS (Normal Saline Solution – 0.9% sodium) we routinely give. The sodium in NaHCO3 may be effective for treating sodium channel blocking drugs, such as antidepressnts, antiseizure medications, antiarrhythmics, and antivirals.[2]

The sodium is not the real danger. The bicarbonate (HCO3-) is the problem. When binding with the excess hydrogen ions to neutralize metabolic acidosis, CO2 is produced.
 

HCO3- + H+

Produces:

CO2 + H2O
 

a patient with complex airway anatomy and difficulty maintaining oxygenation using basic airway maneuvers could avert a hypoxemic crisis during a prolonged intubation attempt. To date, safe and effective intravascular delivery of oxygen gas has not been realized.[1]

 

In the cute little bunnies used in the study (7 LOM [Lipidic Oxygen–containing Microparticles] and 6 Control), these were the results.
 


Click on images to make them larger.
 

Oxygen saturation remained between 40% and 60% with the LOM, but that was much better than the less than 20% for the controls. since the study animals received LOMs titrated to an arterial oxygen tension of greater than 30 mmHg, this is not a surprise. The controls just received fluid at a similar rate.
 


 

CO2 more than doubled for both groups.

Providing oxygen does nothing to remove CO2.
 


 

When CO2 increases, the pH will decrease (acidosis will increase).

Sodium bicarbonate will not decrease the acidosis for these patients.

Sodium bicarbonate will increase the acidosis for these patients.

Sodium bicarbonate produces CO2, which must be removed by ventilation. If we are giving LOM to patients we can adequately ventilate, maybe we do not understand what we are doing.

We should only give sodium bicarbonate to a patient who is well ventilated – unless we are trying to kill the patient.
 


 

In (F) and (G), data are means ±SEM. The blue lines end at 10.2 min because no animals treated as controls had spontaneous circulation after that time and received chest compression–only cardiopulmonary resuscitation (CPR) during the remainder of asphyxia. (H) Kaplan-Meier plot of animals experiencing cardiac arrest during asphyxia (left; P =0.0002, log-rank test), restoration of mechanical ventilation (shaded box), and subsequent recovery and observation (right).[1]

 


 

None of the bunnies reported any near-death experiences.

Consider the time involved. Many in the media have been reporting this as a way to provide half an hour of apneic oxygenation. That is ridiculously optimistic. This will be something that might provide an extra 5-10 minutes to manage a hypoxic patient, if the patient has not already died due to the hypoxia.

5-10 minutes can be the difference between life and death.

Don’t believe me?

Hold your breath for 10 minutes. Just stop breathing and hold your breath.[3]

Without LOMs, all of the bunnies were pulseless after a little more than 10 minutes, but at 15 minutes, when ventilation was resumed, almost all of the LOM bunnies still had pulses (6 out of 7).

LOMs are not just to make it possible to deliver a patient with a pulse to the hospital, so that we can say that They didn’t die in the ambulance.

That is not changing anything.

LOMs are to provide time for us to provide an airway – if this ever demonstrates safety and efficacy in humans.

-

Footnotes:

-

[1] Oxygen gas-filled microparticles provide intravenous oxygen delivery.
Kheir JN, Scharp LA, Borden MA, Swanson EJ, Loxley A, Reese JH, Black KJ, Velazquez LA, Thomson LM, Walsh BK, Mullen KE, Graham DA, Lawlor MW, Brugnara C, Bell DC, McGowan FX Jr.
Sci Transl Med. 2012 Jun 27;4(140):140ra88. doi: 10.1126/scitranslmed.3003679.
PMID: 22745438 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from medlive.cn
 

At the end of the asphyxial period, mechanical ventilation was restored with 100% oxygen until return of pulsations (in animals receiving chest compressions) and then titrated downward to achieve arterial saturations of >92%. Animals achieving return of spontaneous circulation after relief of asphyxia were treated with standard intensive care management, including inotropic support (dopamine, 2 to 10 mg/kg per minute, intravenous infusion) to maintain MABP of at least 40 mmHg during the follow-up period. Hyperthermia was avoided by passive ambient cooling (goal, 34 to 35° C). Animals were sacrificed 90 min after the end of asphyxia for lab and histology sampling.

Everyone seems to be using therapeutic hypothermia and trying to avoid giving too much oxygen.

-

[2] Management of sodium-channel blocker poisoning: the role of hypertonic sodium salts.
Di Grande A, Giuffrida C, Narbone G, Le Moli C, Nigro F, Di Mauro A, Pirrone G, Tabita V, Alongi B.
Eur Rev Med Pharmacol Sci. 2010 Jan;14(1):25-30. Review.
PMID: 20184086 [PubMed - indexed for MEDLINE]

Free Full Text in PDF format from EuropeanReview.org
 

As more substances having sodium-channel blocking properties become available, the incidence of this poisoning may be expected to increase, and clinician, particularly the emergency physician, should be familiar with this potential fatal condition.

A little evidence supports the treatment with hypertonic sodium salts, and current recommendations have not been based on randomized clinical trials.

-

[3] Longest time breath held voluntarily (male)
Guinness World Records
Web page.
 

The longest time holding the breath underwater was 22 min 00 sec by Stig Severinsen (Denmark) at the London School of Diving in London, UK, on 3 May 2012.

Stig was allowed to hyperventilate with oxygen prior to the attempt, and did this for 19 minutes and 30 seconds.

-

Kheir, J., Scharp, L., Borden, M., Swanson, E., Loxley, A., Reese, J., Black, K., Velazquez, L., Thomson, L., Walsh, B., Mullen, K., Graham, D., Lawlor, M., Brugnara, C., Bell, D., & McGowan, F. (2012). Oxygen Gas-Filled Microparticles Provide Intravenous Oxygen Delivery Science Translational Medicine, 4 (140), 140-140 DOI: 10.1126/scitranslmed.3003679

.

Tubes and Guns and Training, Oh No – Part II

 

EMS concealed carry of firearms has become a topic of discussion, again.[1]

One of the comparisons made was that firearms are like condoms. I don’t think that person understands the proper use of a condom.

A condoms is an effective tool for problems that might arise from something that is pretty common (sexual activity). There is no judgment about how to use the condom, while how to use a firearm during an EMS call is the most important part of carrying a weapon on the job in EMS.

Weapons are not effective tools for EMS to use, since too few of us seem to be capable of providing competent basic EMS care.

The most important weapon we have is our judgement. We regularly demonstrate that we do not have good judgment.
 

One example is needle decompression, which is used appropriately much more often than any weapon would be (if the weapon were used appropriately).

However, when needle decompression is used, the use appears to be almost always inappropriate.

Needle decompression does save lives when used appropriately.
 


Click on the image to make it larger.[2]

The chart is for all patients treated with needle decompression for suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

We do not know.
 

It is the responsibility of the EMT to make sure that his shooting skills – and decisions – are up to par better than par. Right?

Is it the responsibility of the EMT to make sure that his intubation skills are better than par?

No. It is the responsibility of everyone – the medical director, the employer, the supervisors, and the EMT. The life threatening skills we use on the job (intubation, needle decompression, cricothyrotomy, . . . ) affect much more than the individual, the individual’s reputation, and the individual’s income.

When I am at work, my First Amendment rights are limited.
 

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.[3]

 

The rights described above do change at work. The same is true for many of our other rights.
 

Tell your employer that you wish to participate in a public assembly on the job in uniform.

Tell your employer your unsolicited opinion of exactly what you think of the way things are run.

Tell your employer that you will share this unsolicited opinion with the press.
 

Our rights as citizens and our rights as employees are not the same.

This is not about protecting the Second Amendment.

-

Footnotes:

-

[1] Facebook discussion
Chance Gearheart
Facebook
Web page

After reading some of the EMS Forums and groups, I can safely say that I want to be nowhere near some of these people if they’re allowed to carry a handgun on the unit. They’ll be more of a danger to themselves than anyone else around them.

Barney Fife with a bullet in their pocket. Christ man.

-

[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]

Free Full Text from J Ultrasound Med.
 

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article
 

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article
 

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

-

[3] Bill of Rights to the US Constitution
National Archives
Web site.

.

Cross-Training for More Diluted Skills


Image credit.
 
The ultimate in cross-training and fast.
 

There are many people who have wanted to be firefighters and paramedics since they were little kids. We should not ask them to grow up and make a choice. We should accommodate them and use that as an excuse to skimp on service.

Does cross-training as a firefighter improve the ability to provide medical care?

No.

Does cross-training as a paramedic improve the ability to fight fires?

No.

Does cross-training as a police officer improve the ability to fight fires?

No.

Does cross-training as a firefighter improve the power of the IAFF (International Association of Fire Fighters)?

Yes.

Does cross-training as a firefighter decrease the municipality budget for both services?

Yes.

This is about money – not about quality.
 

4. Our staff is dual-trained, as both firefighters and paramedics. This creates a faster response time to both fire and EMS calls.[1]

 

Even the editorial does not attempt to push the fiction that this does anything positive for quality of care.

Fast care, not high-quality care.
 

5. There will always be a paramedic in-house on duty to answer questions, take blood pressures, and be available to assist the residents of Ashburnham.[1]

 

Are they going to pay a paramedic just to sit in the station and take blood pressures, or is that for the inevitable times when there are second calls, or when a paramedic is fighting fires and unavailable for medical calls?

 

8. TIME! Full-time paramedic coverage in town can make, and has made the difference between life and death. Early ALS intervention, a faster response time, and the personal touch of familiar faces from our own town can make a huge difference in the outcome of an emergency situation, not only medically but emotionally as well. It will take the nearest private ambulance service about 12-14 minutes just to reach the center of town.[1]

 

Fast care, not high-quality care.

Again – there is no mention of quality.

This is the big problem with diverting training to things that are not medical.

It is extremely difficult to produce high-quality paramedics.

Coming up with non-medical tasks for paramedics does nothing to improve the quality of care – it interferes with quality.

Medical skills, assessments, and treatments are constantly increasing. Time is needed to maintain the quality of new graduates, provide them with experience, and develop expertise over their years as paramedics.

Irrelevant job duties do not contribute to excellence, they distract from excellence.

While fire departments have been using cross-training as an excuse to take over ambulance services for a while, we are beginning to see police departments take over fire departments using the same excuses.

It is no surprise that the IAFF, and others who advocate for fire departments taking over ambulance services, are suddenly opposed when their people are the ones being taken over. I do not defend the police take-overs, but I do appreciate the irony and the exposure of their hypocrisy.

We do not require nurses to be cross-trained. We do not require doctors to be cross-trained.

We consider medicine to be too important to require nurses and doctors to be cross-trained.

When will we consider prehospital medicine to be too important to require paramedics to be cross-trained?

-

Footnotes:

-

[1] Eight reasons to have 24/7 paramedic-firefighter coverage in Ashburnham
Sentinel & Enterprise
Posted: 04/22/2013 06:31:51 AM EDT
Editorial
Article

-

[2] Another Police and Fire Department Merger to Improve Law Enforcement and Fire Safety
Thu, 20 Dec 2012
Rogue Medic
Article

.

Back from the Dead – Rogue Medic Rants 2

 


 

There have been some problems with the Standing Orders site that appear to have been resolved and we have had some hacker attacks at EMS Blogs. Everything seems to be getting back to normal, or close enough for blogging purposes.

Last month on EMS Office Hours, Jim Hoffman, Josh Knapp, and I (with John Broyles and Tom Bouthillet in the chat room) discuss resuscitation.

Then we were jumping to the conclusion that something that sounds too good to be true is real.[1],[2]

I did not get to respond to Josh’s comments about how I am killing patients by not automatically adopting this unknown magic treatment that has people walking out of the hospital the next day – after being pulseless for 5 hours. It seems like homeopathy, prayer, acupuncture, Reiki, naturopathy, and chelation therapy rolled into one even bigger scam.
 

Back from the Dead – Rogue Medic Rants 2.
 

Image credit.
 
 

How should we respond to a demand to rush a treatment to standard of care status based on minimal evidence?

Should we demand evidence?

Should we demand that the approval process be expedited to satisfy our gullibility?
 
 


Download | YouTube MP3 Converter
 

Arise and Walk, My Son!

New and Improved! Standard of Care!

We should implement this right away!

Or we could realize that our patients are real people, who deserve treatments that really work, rather than something that looks good in a newspaper article.

Resuscitation is not about instant gratification.

Resuscitation is not about getting a temporary pulse.

Resuscitation is about long-term survival.

 

Go listen to the podcast.
 

-

Footnotes:

-

[1] EMS, CPR, DNR and Hypothermia Treatment
March 20, 2013
EMS Office Hours
Podcast Page.

-

[2] Back from the dead – New York researchers are bringing people back to life hours after they pass. And it could change our definition of what ‘dying’ really is
By Maureen Callahan
Last Updated: 12:51 PM, March 10, 2013
Posted: 12:15 AM, March 10, 2013
NY Post
Article

.

Why Don’t We Use Rotating Tourniquets Any More – Part I

 

There are some treatments that were being discarded even before I began to work in EMS. The use of rotating tourniquets is one example of this appropriate elimination of a useless treatment – a treatment that was based on a reasonable physiologic mechanism for benefit, but without any valid evidence of improved outcomes.

Is that a good reason for routine use of a treatment?

No.
 

Rotating tourniquets were introduced more than 50 years ago1, ~ as a measure to decrease left ventricular preload in patients with acute left heart failure; they still are recommended3 as an effective therapy for this indication.[1]

 
That was not a good reason, then. That is not a good reason, now. That appears to be the most common reasons given for treatments that do not work.

What kind of effect is there on the body of the CHF (Congestive Heart Failure) patient?
 

Although we have had the opportunity to use rotating tourniquets in many hundreds of patients with acute heart failure due to myocardial infarction in the setting of mobile intensive care units and emergency departments, the efficacy of this therapeutic modality had remained unclear to us.[1]

 
In spite of being part of the standard of care, some people did realize that rotating tourniquets were not working.

If only we had required evidence of benefit before making this the standard of care.

Do rotating tourniquets decrease blood return to the heart in CHF?

If rotating tourniquets do decrease preload, does that effect improve outcomes?
 

In this study we attempted to evaluate the hemodynamic effect of rotating tourniquets in patients with new onset of dyspnea due to acute myocardial infarction (MI) and elevated pulmonary artery wedge pressures (PAWPs).[1]

 

There are some weaknesses to this study, but a greater weakness is the widespread use of a treatment without evidence of benefit.
 


Click on image to make it larger.
 

Forget about a statistically significant improvement, there is not even a slight trend toward improved vital signs with rotating tourniquets.

There is a reasonable physiologic mechanism for benefit.

What if we deprive patients of this standard of care?

Standards of care are only temporary – especially when they are only based on someone’s claimed understanding of physiology.
 

In contrast, the findings in our study and previous reports4,5 suggest that the application of rotating tourniquets for the treatment of acute heart failure due to MI is an outmoded procedure and should be deleted from the list of procedures recommended for the treatment of this disorder.[1]

 

How much of what we do now is based on similar wishful thinking?

IV furosemide (Lasix) for CHF, epinephrine (Adrenaline) for cardiac arrest, high-flow oxygen for patients who are not hypoxic, spinal immobilization for unstable spinal fractures, steroids for spinal injuries, SSM (System Status Management) for ambulance deployment, increasing the number of medics so that skills are decreased, amiodarone for cardiac arrest, . . . .

 

Thank you to Dr. Brooks Walsh for the paper.

-

Footnotes:

-

[1] Are rotating tourniquets useful for left ventricular preload reduction in patients with acute myocardial infarction and heart failure?
Roth A, Hochenberg M, Keren G, Terdiman R, Laniado S.
Ann Emerg Med. 1987 Jul;16(7):764-7.
PMID:3592330[PubMed - indexed for MEDLINE]

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