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Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Extensive injury after use of a mechanical cardiopulmonary resuscitation device

Tue, 22 Dec 2009 20:38:55 -0500 by
Every now and then somebody goes out of their way to convince me that I am underpaid and under-appreciated. The authors of this paper decide to use subtlety to make their point.

To prevent the unique complications reported here, regular checking of proper position of the chest band during resuscitation is advised.[1]

This translates as – the liver bone ain’t connected to the heart bone.

The rescuer should compress in the center of the chest at the nipple line.[2]

Photo credit

Perhaps the device was applied while the patient was seated and the patient has large enough breasts, that the nipple line ended up somewhere in the neighborhood of the navel.

On their arrival, the initial rhythm was asystole and she was found gasping. Advanced cardiac life support was started immediately, but asystole remained despite high doses of epinephrine, atropine, and adequate cardiopulmonary resuscitation(CPR).[1]

They continued to resuscitate this patient beyond what is appropriate. But that is just the beginning.

Forty-five minutes after start of resuscitation, she arrived at the emergency department. Echocardiography confirmed cardiac standstill and a dilated right ventricle without other abnormalities. A massive pulmonary embolism was suspected and intravenous tenecteplase (8000IU) was administered as a bolus, after which chest compression was continued, using a mechanical CPR device (AutoPulse)[1]. Because asystole persisted after a total of 105 minutes, resuscitation was stopped and our patient died.[1]

I know what you are thinking – they used the word died, so I should be happy. Not exactly. While it is nice that they did not resort to the use of a euphemism for death, they did not accept that the patient was dead until over an hour after she’s not only merely dead, she’s really most sincerely dead. Delaying acknowledgment of death is also a continuation of euphemism by other means. Essentially, this is saying, She’s hanging in there. The reality is that she has long since left the building.

45 minutes of CPR prior to arrival at the ED? Hmmm. What does the AHA (American Heart Association) suggest in this situation?

Defibrillators are required standard equipment on ambulances in most states, so the absence of a “shockable” rhythm on the defibrillator after an adequate trial of CPR can be the key criterion for withdrawing BLS in the absence of timely arrival of ACLS.[3]

Asystole is as much absence of a “shockable” rhythm as you can get. You can cut the heart out of the patient and the rhythm will never become any worse than asystole. Just ask anybody, who is dead. They will not argue with that statement.

Refractory asystole defines stable.

EMS, in this case was able to deliver ACLS (Advanced Cardiac Life Support – almost all of the fancy treatments that have not been shown to improve outcome from cardiac arrest). If this had been an American BLS (Basic Life Support – just CPR and an AED for cardiac arrest) ambulance, then according to AHA, this patient should have been pronounced dead on scene, rather than transported. However, this was an ALS service and they still were required to transport to the hospital. It is true that it is difficult to accept a bad outcome on a 49 year old otherwise healthy patient. That does not mean that continuing past the end of the resuscitation algorithms is the right thing to do medically or ethically.

Because asystole persisted after a total of 105 minutes, resuscitation was stopped and our patient died. No. The patient was dead before transport. Other drivers were endangered in order for the doctors at the hospital to be able to pretend that they are gods. The EMS crew was endangered, too. How is any of this justified? I guess the only good thing is that they did not fly the patient in a helicopter.

If an EMS system does not allow nonphysicians to pronounce death and stop resuscitative efforts, personnel may be forced to transport to the hospital a deceased victim of cardiac arrest who proved to be refractory to proper BLS/ACLS care. Such an action is unethical.[3]

Such an action is unethical.

Not a lot of subtlety, there.

I do not disagree with the AHA on this.

Then they decide that a little bit of logic might be persuasive –

This situation creates the following dilemma: if carefully executed BLS and ACLS treatment protocols fail in the out-of-hospital setting, then how could the same treatment succeed in the emergency department? A number of studies have consistently observed that <1% of patients transported with continuing CPR survive to hospital discharge.[3]

But was there any potentially reversible cause of cardiac arrest that might have benefited from 45 minutes of prehospital CPR as a preparation for The Crusher?

At autopsy, no pulmonary embolus was found, but there were ruptures of liver (Fig.1) and spleen (Fig.2) with 1 L of abdominal blood. Added to bilateral dorsal rib fractures, a fractured manubrium of the sternum, and lateral cutaneous lacerations, this strongly suggested a relation with use of the device; however, a relation with previous manual external chest compressions cannot be excluded.[1]

Usually, I have to drive over a patient to produce that kind of extensive damage.

Microscopy showed recent and prolonged ischemic injury of the myocardium.[1]

But what if it really had been a massive pulmonary embolus?

The patient still would have been long dead before even consideration of transport.

Massive pulmonary embolus is an obstructive cause of cardiac arrest. Anybody who has taken even a beginner biology class should understand that a massive pulmonary embolus prevents circulation, even if some small amount of circulation could be maintained with compressions, it is not adequate to maintain a functioning brain. If blood cannot get through the lungs, then there is no oxygen/carbon dioxide exchange to prevent progressive organ failure, unless some sort of bypass machine is being used. The AutoPulse® does not do bypass.

Think about a clogged toilet. Continuing to compress is similar to continuing to flush, but the problem is the blockage that prevents everything from getting where we want it. At least the clogged toilet has a nice feedback mechanism. The clogged toilet lets you know that things are not working by overflowing. Only the most obtuse individual does not recognize this. With a dead body, the signs that This ain’t workin’ are a bit more subtle.

Obstructions that cannot be cleared quickly, will not respond to prolonged resuscitation attempts.

In this case the AutoPulse® does appear to have done something more than just enable resuscitation to be prolonged. The AutoPulse® appears to have produced extensive tenderizing of the organs in an epinephrine and atropine marinade. Emeril Lagasse might even have Kicked it up a notch! and added a Bam! with each compression.

This patient was not a trauma patient, but these injuries are examples of severe multi-system trauma. I can’t imagine why this patient did not get better.

I have never really seen the need for mechanical compression devices. Maybe for severe hypothermia during rewarming, but that CPR is not supposed to be worse than the hypothermia. This case gives an example of some of the problems with mechanical compression machines.

When people are performing compressions manually, it is a lot easier to notice if there is something wrong.

When people are performing compressions manually, it is a lot easier to notice if the hand placement is a little off. Hands over the liver and/or spleen would be more than a little off, since the hands are supposed to be on the sternum.

When people are performing compressions manually, it is a lot easier to realize that the pool of sweat on the patient is an indication of a ridiculously prolonged, and futile, resuscitation.

Is it more likely that someone will admit the obvious, if there is no machine to make it easier to ignore the obvious?

Footnotes:

^ 1 Extensive injury after use of a mechanical cardiopulmonary resuscitation device.
Wind J, Bekkers SC, van Hooren LJ, van Heurn LW.
Am J Emerg Med. 2009 Oct;27(8):1017.e1-2.
PMID: 19857428 [PubMed – indexed for MEDLINE]

^ 2 AHA ACLS Guidelines – Part 3: Overview of CPR
Circulation. 2005;112 [Suppl I]:IV-12-IV-18;
published online before print November 28 2005,
doi:10.1161/CIRCULATIONAHA.105.166552
Free Full Text . . . . Free Full PDF

^ 3 AHA ACLS Guidelines – Part 3: Overview of CPR
Circulation. 2005;112 [Suppl I]:IV-12-IV-18;
published online before print November 28 2005,
doi:10.1161/CIRCULATIONAHA.105.166552
Free Full Text . . . . Free Full PDF

.

Filed Under: ACLS, Critical Judgment, Ethics, Heresy Tagged With: , ,

EMS EduCast/EMS Garage #48 Quality – comments

Wed, 23 Sep 2009 05:03:37 -0400 by

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the comments to EMS EduCast/EMS Garage #48 Quality, commenting about Dr. Eisenberg’s quote,[1] 30 ff/pm wrote –

“We’ve recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice.”

Great teaching tool but if an ambo chasing attorney gets hold of it, there could be some $$$ payed out even if no one did anything wrong.

My city attorney is great at throwing cash around just to avoid going to court.
The feeling is that the jury might be swayed by claims – even if they’re not true and didn’t really have anything to do with the outcome. Sucks and isn’t right, but that’s the world we live in.

Assuming that you are describing the activity of this city attorney accurately, the attorney appears to be encouraging law suits, rather than protecting the city or protecting the patients. If other lawyers realize that the lawyer representing the city is afraid to go to court, they will find any excuse to bring a suit.

As long as the city attorney will throw money at them to go away, what do they have to lose? A better question is, Why would the city hire someone like that?

The city managers hire somebody to provide a specialized service that they are not qualified to perform themselves, whether it is legal defense, or EMS, or something else. They trust these experts to provide them with competent services. It is possible that there were legitimate reasons to justify the lawyer settling in all of these cases, but even though I am not a lawyer, I would bet that it is more of a fear of going to court, than a valid claims on the parts of all of the plaintiffs. The city attorney probably does not understand a thing about EMS. Ignorance leads to fear. Fear leads to settlement out of court. Or whatever Yoda said about fear. It appears that the city attorney would rather pay out the city’s money. Rather than demonstrate his/her profound ignorance of all things EMS.

If their approach to EMS is how do we avoid getting sued, rather than how do we improve patient care, it is a bit of a Catch-22 situation. They are discouraging attempts to improve quality of care, because anything they find out about how bad the quality actually is, could be used against them. Ignore it, pay out money now and then, here and there, but pretend that you cannot improve things, because some things are too dangerous to know?

Stay the same?

Avoid change?

Ignore problems?

There is only one way to stay the same in medicine. Only in death do things stop changing. Even then there are changes, but the person no longer has any reason to care.

How does one form of medical record create more liability than other forms? And an audio recording of the events is just that – another form of medical record. In some places, video recordings are used.

The city attorney appears to be looking at this only from the perspective of the harm it might do. In other words, the city attorney has absolutely no understanding of risk management. A recording may help the jury to understand what happened better than they would with a paramedic mumbling through the reading of a chart. Paramedics are not hired for their ability to read out loud. Paramedics are hired for their ability to treat patients on scene. A recording of the paramedic doing what he/she has actually been trained and hired to do. This might work for the defense much better than anything else the city attorney could present. Yet, the city attorney would probably prohibit this, because of ignorance – a level of comfort hiding behind ignorance that is scary.

I know what people are thinking – How do I know that is what the city attorney would do? I don’t know it. I am speculating. Unfortunately, I believe that 30 ff/pm is correct in concluding that the city attorney would act this way. I have dealt with attorneys in hospitals, where I taught ACLS. In 2 of these hospitals, I was informed that the attorneys had instructed the hospital emergency response teams to never touch anyone, who does not exhibit evidence of being a patient. The emergency response teams are only called to suspected emergencies. If a family member of a patient experiences cardiac arrest, they are not to touch the family member of the patient until after the patient is registered.

No wrist band, no treatment. You get treated the same as if you were trying to sneak into a night club. Actually, the night club staff would probably provide CPR if your heart were to arrest.

The attorneys believe that the potential harm is greater than the benefit. Yet, these are the same people, the paramedics and emergency response teams, who will be treating the patient visitor after the patient is registered.

Is the emergency response team’s care going to become better, just because the visitor has been registered?

No. Delaying CPR is possibly the worst thing they can do, but that is what the lawyers are insisting they do. The lawyers are making the medical decisions.

Is there any way the attorneys can claim that the unregistered patient is really not a patient?

No. According to EMTALA (the Emergency Medical Treatment and Active Labor Act), anyone presenting with a complaint within 250 yards of the hospital, or anywhere within the hospital, is automatically a patient. These patients may not be turned away, until after a medical screening and stabilizing treatment, even when being transferred to another hospital.

Cardiac arrest is one of the most time sensitive conditions. Delaying care is just as bad as refusing to deliver care, because there is a very limited time during which treatment is likely to be effective. Supposedly, the chance at resuscitation decreases 10% for every minute of delay in initiating treatment, or every minute of inadequate treatment. Such as an 80 year old Grandma performing compressions on her husband, while the emergency response team stands around digitally monitoring their own sphincter tone. Look Grandma, no prostatic hypertrophy!

While I am still not a lawyer, there is one word that comes to mind, when describing this approach – indefensible. OK, not just one word. There are plenty of adjectives that could go along with indefensible, but none of them are good.

A different approach might be to only hire competent personnel. I am not stating that the emergency response teams are not competent, or that the paramedic coworkers of 30 ff/pm are not competent. The problem is that the city attorney presumes that these medics are incompetent, or that more evidence would only work against the defense.

If the attorneys were comfortable with the competence of the paramedics and emergency response teams, then the attorneys should be much more confident that more facts will lead to a better defense, not the other way around. But they do not. If they are that uncomfortable with the employees, they either need to learn about what the employees do, demand higher standards, or find some other way to improve quality – such as using audio recordings of cardiac arrests. You know that I am in favor of both. Even if the standards are already high, make them higher. Quality is about improvement – never being satisfied. not in a 6 Sigma way, but in always looking for ways to improve patient care. Actively participating in research.

Dr. Eisenberg mentioned that some cities, that were studied, had ridiculously low resuscitation rates. The reaction, when the news was published? Apathy. nobody cared. Less than 1% successful resuscitation. While where Dr. Eisenberg works, the resuscitation rate is about 50%. This is not a minor difference, so how is it that people do not care? But, they don’t care.

The other comment was from Greg Friese, one of the hosts of the EMS EduCast, where the broadcast with Dr. Eisenberg started. Greg’s response to 30 ff/pm was –

I would rather defend a recording of the facts than speculate about facts based on the recollections of all involved.

Much more succinct than what I wrote. I completely agree. I think that 30 ff/pm also agrees, but his city attorney is the one, who does not agree.

Footnotes:

^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27

.

Filed Under: ACLS, EMS EduCast, EMS Garage, Heresy, Paramedicine 101 Tagged With: , ,

EMS EduCast/EMS Garage #48 Quality

Sun, 20 Sep 2009 03:47:17 -0400 by

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Again returning to the EMS Garage post with Mickey S. Eisenberg, MD on resuscitation,[1] the rest of the episode was great. One of the points brought up was, at about 52 minutes in, Buck Feris mentions a quality assessment/improvement method in a system, that has a supervisor respond to debrief the crew after every arrest. Reviewing what went right and what went wrong.

Dr. Mickey S. Eisenberg earlier had talked about methods of improving outcome and the approach of reviewing every unsuccessful resuscitation by asking, Why wasn’t this patient resuscitated?

These are excellent approaches. If we are not reviewing our calls, how do we expect to improve? I think that both of these approaches are still too limited. We should review all calls that fall into certain categories. For example, all cardiac/potentially cardiac calls, all respiratory calls, all calls involving any level of pain, et cetera. Maybe not right after the call, but as soon as is practical.

In my opinion, people who are opposed to continually improving patient care are not needed in EMS.

What kind of ignorance is needed to claim that we should not be improving our care of patients? Real medicine is about continually improving patient care.

Dr. Eisenberg goes on to make an essential point about a method used to improve quality. Audio recordings of cardiac arrests by the defibrillator. He states,

We have found that immensely valuable. We’ve used it in our system from day one. We’ve recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice. That has been a very valuable tool, to reconstruct for educational purposes, what exactly was going on in the resuscitation and when. Because, without it you can’t really tell when there are gaps in CPR, you can’t even tell when ventilations are occurring, you can’t tell reasons why there was the delay in this or that.

And if it’s done for the purpose of education and never for the purposes of discipline. We’ve never, ever, used these tapes for disciplinary reasons. They’ve always been used for education. You can learn an awful lot, and begin to piece together what went on.

If we want to improve quality, we need to make it safe for people to bring up and discuss mistakes. If the employees are afraid of punishment for raising concerns about things that went wrong, we will never learn about many of the problems in the system. We need more people in EMS, who understand this.

Again, in my opinion, people who are opposed to continually improving patient care are not needed in EMS.

Footnotes:

^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27

.

Filed Under: ACLS, Critical Judgment, EMS EduCast, EMS Garage, Heresy, Paramedicine 101 Tagged With: , ,

EMS Educast and EMS Garage Special Edition – more

Wed, 16 Sep 2009 01:30:32 -0400 by

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Back to the EMS Garage post with Mickey S. Eisenberg, MD on resuscitation,[1] the rest of the episode was great. One of the points brought up was, How do we strengthen the first links in the Chain of Survival?

Without the right start, how can we expect the later parts to be effective?

But we do.

We expect that this is all about paramedics, ACLS (Advanced Cardiac Life Support), EDs (Emergency Departments), drugs, and invasive procedures.

So, why have the Chain of Survival?

Because the stuff at the end, if it works at all depends on the stuff at the beginning. You do not put an egg and some cheese on a plate and declare that it is an omelette. The preparation is important.

Dr. Eisenberg addressed some of the questions that almost everybody else runs away from, while screaming obscenities ignores.

What are the best investments of money to improve resuscitation?

Do we need to have the public go through an entire AHA/ARC CPR course,[2] or can we provide the level of education needed to meet the needs of the patient by other means?

I wrote about this subject a bit before, in EMS Garage, CPR, Continuous Compressions, and Resuscitation. A link to a video that is not viewed enough (only a little over 2,000 total views listed by YouTube) was sent by Buck Feris. This video is an example of what we need to be using much more.

We need to get the attention of the people who might be in a position to perform CPR. Not the ones taking a course, because of a job requirement. They are a captive audience, and sometimes we make them feel exactly that way. That is not the right approach.

What is wrong with shorter courses, distance courses, and public service spots?

Do we need to delude ourselves that CPR is rocket science?

If you experience sudden cardiac arrest die in the area where Dr. Eisenberg has been improving resuscitation, you have almost a 50/50 chance of resuscitation. This is probably in large part due to the use of alternative educational methods to encourage by-standers to do CPR.

Or we could keep making excuses.

Footnotes:

^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27

^ 2 CPR
American Heart Association or American Red Cross course in CardioPulmonary Resuscitation.
Wikipedia
Article

Although I link to this article, there is something that I observed that is disappointing. There is only one mention of Dr. Eisenberg in the article, and that is a footnote. An article he wrote in 1985. Just because I am curious, I decided to see how many papers I could find by Dr. Eisenber in a PubMed search. For the most recent paper, I have to go all the way back to October of 2009 – we aren’t even there, yet. Going almost 150 articles further – to Staphylococcal food poisoning aboard a commercial aircraft from the Lancet, which was awarded the 1975 Alexander D. Langmuir prize by the Center for Disease Control. Wikipedia, you are missing a lot. More than a minor omission.

PubMed search of papers written by Mickey S. Eisenberg, MD.

Then there is Dr. Eisenberg’s new book:

Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
By Mickey S. Eisenberg, MD
Amazon.com link with a good video review by Greg Friese.

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Filed Under: ACLS, Critical Judgment, EMS EduCast, EMS Garage, Heresy, Paramedicine 101 Tagged With: , ,

Potentially Reversible Causes – Hypothermia

Wed, 10 Dec 2008 08:24:04 -0500 by
I suppose that I should stop procrastinating and complete start the potentially reversible causes of cardiac arrest.

Working through the potentially reversible causes mnemonic, COLD PATCHeD,[1] the first letter is C, the first word is COLD, so this should make it pretty clear that the C refers to being too cold – hypothermia.

C for Hypothermia.

But first, let me describe someone progressing from a normal healthy 14 year old to an unconscious hypothermia patient. Almost the full spectrum of temperature change.

At that age, many feel invulnerable. Riding a bicycle to the library is just a normal way to get around. Living on a long steep hill, riding much faster than the cars is inevitable tempting. Traveling fast in cold weather leads to wind chill factor effects. The wind chill factor means that the wind speed amplifies the feeling of cold. This also amplifies the process of heat loss.

From the Wind Chill Chart,[2] we’ll use 60 miles per hour to calculate the wind chill, because the chart only goes that high. Traveling up to 60 MPH on that hill is not difficult. The big problem is drivers of automobiles, who don’t look before turning. It only takes one. That was not the problem on this day.

A minute at zero degrees wearing a loose fitting down jacket, thin gloves, and no hat. Invigorating if you don’t prolong it. From the steep hill, there is a longer, more gradual hill. this allows you to prolong the contribution of gravity. Then the up hill part. This should cause enough heat production to ward off hypothermia, but not on this day. The energy is not there. The pedaling is not as coordinated as it should be. Lacking the energy to pedal and the coordination to ride, pushing the bicycle becomes the next best means of travel. Still up hill. Shivering. At that time, there are few businesses or residences in the area, but giving up on the trip to the library is not really an option, yet. The library is nice and warm. They even have a good selection of books. Worst case – call for a ride home from the library. Worst case.

Switching to the side of the road facing oncoming traffic, since there is no possibility of riding any more. Now having trouble just walking in a straight line and way too tired. Don’t know how much longer this went on, but near the top of the hill, continuing was no longer an option. Not even shivering any more. The first house has some lights on inside. Knock on the door.

Unable to speak without dramatically slurring the words. The door is slammed shut, but there is no energy to continue. Don’t have the coordination to keep moving. Don’t really care at this point, because that is what hypothermia can do to you. Slump to the ground and wait.

Not really choosing to wait. Not caring. Not continuing.

Some people show up and get dragged inside. This is different. Not the usual bicycle ride. Not the usual trip to the library.

A mask is placed over the face. A bag being squeezed.

Next thing I remember is waking up in the hospital. The doctor can’t figure out what is wrong.

Doctor For Whom Temperature IS Confusing – What did you take?

Young RM – I was cold.

DFWTIC – Don’t lie to me. What did you take?

Young RM – I was very cold.

Repeat ad nauseam. Apparently the doctor went to a medical school that had not been introduced to the wonderful medical advance – the thermometer. If only there were an organization, like JCAHO, to make sure the clueless complied with a check sheet to be able to diagnose the obvious.

Just kidding. Everybody should realize that JCAHO exists to help the incompetent continue their careers.

I’d much rather have competent people providing care, than an organization that coddles the least common denominators. Least common denominators need to be remediated or terminated, but definitely not coddled.

That day I had a scared housewife call 911 the local emergency number, because in that county it took until the Clinton administration for them to get the various corrupt volunteers fire chiefs to agree to allow such progress despicable usurpation of their fiefdoms. Fortunately, the housewife was the wife of one of the ambulance volunteers and familiar with the numbers for the various departments.

Hypothermia comes from the Greek for low temperature. Cold. How cold is cold? When dealing with a hypothermic cardiac arrest, or severe hypothermia, a body temperature less than 86° Fahrenheit (less than 30° Celsius or centigrade). In EMS, we often do not carry a reliable thermometer, so how can we tell? Symptoms.

Treatment priorities are:

1. Stop the person from becoming colder.

If the patient is at all wet, this means get the wet clothes off of him, dry him off, then worry about warming him up.

You can try to warm the patient up while he is still wet. You can also try to fly by flapping your arms. Trying isn’t going to do it.

If you don’t dry the patient off, you might as well just drive a stake through his heart. Unless he is dry, he is losing more heat into the moisture than you will replace. Except maybe if you set him on fire. Just make sure you turn the oxygen off, first. And open some windows, burning patient leaves a really nasty smell.

What about #2? You only gave us one priority.

As far as EMS is concerned, that is all that really matters, unless you have extended transport times.

Assuming you have dried the patient off, they do not appear to be cooling down, now what?

2. Assuming that you have done a good job of protecting them from getting colder. Warm them up.

–

[youtube]PojH541L3ZY[/youtube]

–

My apologies for the comments made, at 2:48 and 2:58of the video, by one of the people looking at this. It is not uncommon for people to use these words to demonstrate that they are overwhelmed by what is going on.

The last couple of minutes show the survivors being pulled to the side of the river. Earlier the video showed a couple of people with the appropriate life vests in a metal row boat paddling around, looking ready to capsize. They did not seem to rescue anyone. The video showed a bunch of people carrying an inflatable row boat, that similarly was not able to rescue anyone. If you use boats as a part of a rescue, will you be any better prepared? Maryland/DC/Virginia does not get weather like this often, so it is not surprising that they did not do a good job navigating around the ice. They describe it as the worst storm in decades.

Notice the guy who jumped in the water, swam out to one survivor, and pulled her to shore. He was told to get behind the fire trucks. He is wet and needs to be dried off. He needs to be kept from getting cold. They sound as if (my interpretation of the comments) they are more worried about him making the professional rescuers look bad.

Everybody who was rescued was rescued by someone who appeared to be breaking the rules.

The helicopter probably should no have been there. Initially, visibility was very poor. They were involved, at least partially, in the rescue of every survivor. The by-stander, who jumped in and swam to the woman trying to drown, was just a by-stander. He was astute enough to realize that everybody was just going to watch her drown. No equipment was close enough to reach her. The only way for her to survive was for someone to jump in. It should have been someone with a life preserver on.

It appears she was less than 20 feet from the side of the river. It also appears that she was incapable of staying afloat on her own. If this by-stander had not jumped in, what would everyone have said about her death? Maybe she would have been resuscitated, but that is assuming that somebody has a way of grabbing her. It does look as if there is one person in a turn out coat has a life preserver that he is dragging out to her. Would he have acted if the by-stander had not jumped in? Why wear turnout gear in the water? More mindless observation of rules.

–

At 4:30 of the video – They were all just standing there looking at us with their lights going and their sirens going and all that. And eventually I realized they had no way to get to us.

We do spend a lot of time exerting our authority by using our sirens. Not very helpful when the sirens cannot make a bit of difference, but that never seems to stop some people.

–

Some additional reading on hypothermia (all provide excellent information):

Hypothermia
Circulation. 2005;112:IV-89 – IV-110.
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 10.4: Hypothermia

Hypothermia
eMedicine
Article
eMedicine

Hypothermia-Related Deaths – – United States – 1995 – 2002 and 2005
MMWR – Morbidity and Mortality Weekly Report March 17, 2006
55(10); 282-284
Free Full Text . . . . . Free PDF (type 14 or 282 in the page window when the pdf opens, depending on which it accepts. It begins at 14/32 pages.)

Other MMWR hypothermia pages

–

Footnotes:

–

[1] Potentially Reversible Causes of Cardiac Arrest – Another, Better, Mnemonic
Rogue Medic
Article

Again, thanks to JB of JB on the Rocks for this.
Cold (hypothermia), Oxygen deficit, ‘Lytes, Drugs, Pulmonary Embolus, Acidosis, Tension Pneumo, Cardiac Tamponade, Hypovolemia. I add epi and Distributive shock.

–

[2] National Climatic Data Center
Wind Chill Chart

–

Updated 8/12/2011 for links and formatting.

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Filed Under: ACLS, Critical Judgment, Heresy, Potentially Reversible Causes Tagged With: ,

Endotracheal Drug Administration in Cardiac Arrest – comment

Mon, 17 Nov 2008 14:51:00 -0500 by
Vince of Living La Vida Vince wanted to comment on Endotracheal Drug Administration in Cardiac Arrest. Where he works his Mojo, there are firewalls that do not like him, do not like my blog, or both. He asked me to post this comment. In between, I have responded.

Well, as much as I hate to, you know I cannot resist the urge to ‘poke the gorilla with the stick’, so here goes.

At least this gorilla is not locked up behind a firewall. 🙂

I agree, that given the widespread use of alternative venous access(IO), the ET route of medication administration during resuscitation is most likely of little value [and as you point out potentially harmful-although I would worry just as much about washing the ‘Mr. Bubbles’ away, as making it 😉 ]

A good point that I had not considered to be much of a problem, since I have seen ET drugs given more than occasionally in the ICU.

However, you know my feelings on retrospective studies in general, and this one is particularly horrible! In addition to all the patient disparity between the treatment arms, the ET group was 1.5 times more likely to be in asystole at the onset than the IV group! Might this impact the results? Furthermore, since this was retrospective, the medics doing the treating were not randomizing which patients were going to get ET vs. IV. My guess is that this was most certainly NOT random at all. A myriad of factors such as length of downtime, ability to attain IV access, Single provider vs. double provider etc. etc. etc. may have determined which route a provider chose and would most certainly skew any data.

As much as I am critical of bad research, I do not think this study should be dismissed entirely.

The researchers do make it clear that there are limitations. They discuss these limitations. And the most important reason we should not ignore it is that there is nothing else that is anywhere near as good in looking at ET drug administration in real patients. The patients were not randomized, but they probably did self select for the dosing route that would apply outside of the study. With use of IO (IntraOsseous) needles being common place, we could set up a study that randomizes patients to the IO route or the ET route. This study could be interesting, but would interesting justify doing this study, instead of something that would really matter in EMS?

So I would say that this “study” should be ignored, at least for the purposes of “ruling-out” the potential benefits of ET administration. Poor research is poor research. Trying to make chicken soup out of this chicken-shit is, at best, Quixotic.

This is unfortunately the nature of the beast when it comes to quality research surrounding resuscitation- there is a dearth of good data. Half-truths, anecdotes, bad ideas, and untested theories abound.

The lack of good research should lead us to prohibit this treatment, not permit it.

This study is not of the quality that should be required to advocate for a treatment. The level of evidence needed to eliminate a treatment should be significantly less than the level of evidence needed to recommend a treatment. If there is evidence of harm, you go back to the drawing board and figure out what can be done about the apparent harm. You do not say, Well, it is the standard of care and we need to have much more rigorous evidence to stop using this apparently dangerous treatment, because it is the standard of care.

This is part of my point in Narcan Solves Riddle – Part IV, How did this happen? – Research and Narrative Fallacy I. The level of evidence needed to discourage a treatment should be much lower than the level of evidence needed to treat.

The same is true in looking at an individual patient. We need to be much more rigorous about the things that lead us to be aggressive in treatment, than the things that lead us to be conservative in treatment.

On point of porcine lab testing- it has a valuable place in establishing that for certain formulations, the ET route can provide adequate absorption to approach blood levels established by IV routes – Charlotte and her web notwithstanding. Does this necessarily mean better outcomes? Of course not. Until we get some IRBs with a full compliment of testes*, this is the closest we are ever going to get to scientifically rigorous data on the subject.** (* sarcasm ** not sarcasm)

Perhaps we need to study testes implantation on IRBs.

As far as advocating for treatments because trying to make pigs fly is the closest to real research that we have, I disagree. The pigs do not adequately represent the nursing home patients who appear to be disproportionately selected for this treatment. That is just one of the significant differences. When performing research on other animals, to determine the effect on human animals, some animals are more equal than others. Animal studies do provide evidence to advocate for human testing. They do not provide evidence to advocate for human treatment outside of the well controlled study.

You do make a great point about arbitrary endpoints like presence of a pulse upon arrival.

Thank you.

Consider the pot stirred. It’s been a while! 😉

Always good to think about these things in different ways. For me, the narrative part that does not make sense is this –

Removing ventilation and circulation, just to provide medication, is not good medicine. Especially when the medication is of uncertain benefit when administered by the ideal route.

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Filed Under: Airway Management, Heresy, Narrative Fallacy Tagged With: , , , ,

Endotracheal Drug Administration in Cardiac Arrest

Sun, 16 Nov 2008 23:58:09 -0500 by
ET (EndotTracheal) drug administration in cardiac arrest is one resuscitation topic that refuses to die. People keep trying to bring ET drugs back to prominence in ACLS (Advanced Cardiac Life Support). In the absence of evidence of benefit of a treatment, the intervention should be studied in settings that are as controlled as possible. When the evidence suggests harm from the treatment, unless that apparent harm is outweighed by apparent benefit, the treatment probably should not even be used in controlled studies.

How does this apply to ET drug administration in cardiac arrest?

Before looking at the research, let’s look at the theory behind this.

ALS (Advanced Life Support – drugs, IVs, intubation, . . .) improves outcome from cardiac arrest.

In one recent and very large study of this, Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest[1], the claim that ALS saves lives in cardiac arrest is shown to be not supported, at least not with the ALS that was used at the time of the study. That ALS has not changed much, but the BLS (Basic Life Support – CPR, defibrillation, . . . generally non-invasive treatments) has changed significantly.[2] There is one ALS treatment that is promising, therapeutic hypothermia,[3] but that was not being used at the time and is not the reason for this post.

The research on ALS in cardiac arrest does not show an improvement in resuscitation. Resuscitation is the ability for the patient to leave the hospital with brain function similar to the brain function they had prior to the cardiac arrest. Resuscitation is not arriving at the hospital with a pulse.

While arriving at the hospital with a pulse is important for resuscitation, focus on this is bad patient care. If we were only interested in arriving at the hospital with a pulse, we could just shock the patient into asystole, use a pacemaker and drive fast. we might have to upgrade the pacemakers from milliAmps to Amps and use thicker rubber gloves, but this could improve the number of patients arriving at the hospital with pulses. That does not mean it would improve the number of patients leaving with good brain function. A focus on pulses is not good for patient care. Even Dr. Frankenstein would feel silly yelling, It’s Alive, for a monster with just a pulse. Even the fictional doctor, in a book almost 200 years old, knew that the brain was essential to resuscitation.

If you think that arriving at the hospital with a pulse is a big deal, you probably would have done well as a banker up until this year, thinking that making reckless loans is conservative, because you wear a suit and tie. Either way, other people pay for your mistakes. With all of the increase in resuscitation rates following the improved focus on continuous good compressions, how many thousands of deaths have the get a pulse back crowd been responsible for by distracting paramedics, nurses, and doctors with ineffective and harmful drugs?

So, what research is there on ET drug administration in cardiac arrest?

One study does compare IV (Intravenous) medication administration with ET medication administration in cardiac arrest. Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?[4] There are some differences between the groups. The endotracheal drug group was 5 times larger, 5 years older, much more likely to be female, twice as likely to be in a nursing home, much less likely to have VF and much more likely to have asystole as the initial rhythm. The results still should not be ignored.

Why not?

Although this is a retrospective study with a lot of variables that have not been controlled for, it is the largest only study to look at survival to discharge.

Why does that matter?

There is no other study on ET administration worth looking at. Unless you are interested in something that looks at the change in blood level of epinephrine in a pig in a laboratory. Since I do not treat pigs in a laboratory, this is not really relevant to what I do. Even if I do find a pig in cardiac arrest under a spider web that reads, Humble, I will not be regretting that I am not more familiar with these studies. Besides the IO (IntraOsseous) needle has become standard in cardiac arrest treatment.

What were the results of the study?

Of the IV drug group, 5% survived to discharge.

That sounds typical for the resuscitation rates back then. What about the ET drug group?

Nobody survived.

If you have good circulation, you may absorb medication from the lungs without complication.

If you have circulation by way of chest compressions, that may not be the case.

If you have to stop the compressions in order to deliver the medication, you are doing more harm than any possible good that could come from providing these drugs that are not research based. Since none of the drugs are research based, apparently not even oxygen, that means all of the drugs are a problem.

There is not even evidence that providing oxygen down the ET tube is good for the patient, but we still have people who think that making Mr. Bubble in the lungs is good patient care.

Footnotes:

^ 1 N Engl J Med. 2004 Aug 12;351(7):647-56.
Comment in:N Engl J Med. 2004 Dec 9;351(24):2553-4; author reply 2553-4.
Advanced cardiac life support in out-of-hospital cardiac arrest.
Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.
Free Full Text

One interesting aspect of the OPALS criteria is an attempt to evaluate the quality of the paramedics participating in the study. Listed among the criteria is “and paramedics had to successfully perform an endotracheal intubation in 90 percent of patients. These criteria were monitored regularly, and the three communities that failed to meet the standards were excluded.”

^ 2 Just one example of the improved resuscitation rates is provided in this post from Ambulance Driver and the comments.
Does This Mean I’m Fully Assimilated?

^ 3 Therapeutic Hypothermia
Wikipedia article

^ 4 Niemann JT, Stratton SJ, Cruz B, Lewis RJ.
Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?
Resuscitation. 2002 May;53(2):153-7.
PMID: 12009218 [PubMed – indexed for MEDLINE]

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Filed Under: ACLS, Airway Management, Critical Judgment, EBM, Heresy, Research, Unicorn Medicine Tagged With: , , ,

Narrative Fallacy I

Fri, 24 Oct 2008 12:51:49 -0400 by
In looking at the research on the ability of mechanism to predict actual severity of injury, we first have to look at some of the problems with research. One of these problems is the use of narrative fallacy to try to explain things that the research has no ability to explain.

What is narrative fallacy?

Narrative fallacy is the need to put information into a narrative, or story, to explain the unknown. Although, if we are explaining the unknown, it cannot be unknown. The problem is that we delude ourselves into believing that we understand what we are explaining. We convince ourselves that we know the unknown. A study comes out that shows that Drug X has a positive effect on Disease Y, so somebody feels the need to give explanation Z.

Why?

To satisfy that need for an explanation. We need to ignore the explanations as much as possible.

But we need to know why we are giving a treatment!

We give a treatment because research shows that it is effective for a specific condition. Everything that has not been shown to be effective is experimental. The explanation is not important. The explanation is often wrong and will probably be revised significantly, if not completely reversed.

The creation of a hypothesis is a necessary part of the scientific method. It is a way of generating testable ideas. We should not apply it to the results of experimentation, except to create more hypotheses to be tested.

Without the scientific method, we have magical thinking. The scientific method is the best way we have of protecting ourselves from the mistakes of magical thinking. Magical thinking is believing that something is happening by some mechanism that sounds good, may even make a lot of sense, but it is untested.

Explanations make it so that we feel better about what is happening. We feel that we have some ability to control things. Stories also help us to remember information. Try remembering a bunch of random information. It is difficult to remember random information. Put that information into a story and you will find that your ability to remember the information increases dramatically. The story doesn’t even have to be relevant. This is why we use mnemonics. They are memory aids.

One of the old mnemonics for ACLS (Advanced Cardiac Life Support) was Shock, shock, shock; Everybody shock; Little shock, Big shock. This was a way of memorizing the beginning of the Ventricular Fibrillation/Pulseless Ventricular Tachycardia algorithm. Shock, shock, shock = shock 3 times, or defibrillate at 200 joules, 200 – 300 joules, then 360 joules. Everybody shock = the E was a reminder that Epinephrine was the first drug after the initial shocks, then shock once again. Little shock = the L was a reminder that the first antiarrhythmic drug was Lidocaine, then we shocked again. Then you needed to remember to repeat epinephrine and a shock. You might give more lidocaine, or you might move on to the next antiarrhythmic – Big shock = the B was a reminder that the next antiarrhythmic drug was Bretylium.

These were just something that somebody thought up. They were just to help some people remember the order of drugs, but not the doses. The drugs from the mnemonic are mostly gone from the treatment of Ventricular Fibrillation/Pulseless Ventricular Tachycardia.

Why?

They weren’t based on real science, just expert opinion. For the time, expert opinion was the way to go. Now we have done quite a bit of research on these drugs and bretylium is not even used any more. Lidocaine is only used by places that do not use amiodarone. Epinephrine is still used, but not in the high doses that used to be encouraged. None of the drugs are supported by research that shows more patients surviving with a functioning brain, but we are so caught up in the narrative fallacy of epinephrine to get the heart going and antiarrhythmics to make the bad rhythms go away, that we continue to use these ineffective drugs. As we become more aware of the gaping holes in the narrative fallacy, we modify, or remove, the errors. This is how science progresses. We stumble along from one experiment to the next, with the occasional major revision.

The drugs are no longer the main focus, since they do not work. Still, in science politics does have a role. Some refuse to let go of the idea of a wonder drug of resuscitation. But this is a great example of the narrative fallacy.

How?

The drugs do not work, but there are wonderful scientific explanations of the way they work. Since they do not work, this is just wishful thinking. It may be great to help you remember the order of treatments, but you will have to learn some other mnemonic later, because they will eventually accept that the research is just not there to support using these drugs in cardiac arrest.

If you want to read the current narrative fallacy, the link at the bottom will give you all of the current explanation of how the drugs work. The older versions of ACLS explanations carry the narrative fallacy from that time period. The next revision will carry the new and improved narrative fallacy. At least the AHA (American Heart Association) starts out by admitting this lack of understanding in the ACLS text. Too many of the instructors just seem to use the algorithm charts, which do not include the following statement.

For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.[1]

Stories are great – as long as we realize that they are fiction. Even if printed in the most reputable scientific journal, they are not the truth. They are an approximation of how the current research might be explained. Science is not etched in stone. Science is constantly changing. Not every change is progress, but cumulatively there is tremendous progress.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines

Footnotes:

[1] (Circulation. 2005;112:IV-58 – IV-66.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Introduction

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Filed Under: ACLS, EMS EduCast, Heresy, Narrative Fallacy, Research, Science Tagged With: , , , ,