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

- Rogue Medic

Dr. Nicholas DeRobertis, Improved Care for the Patients, Not for the Good Old Boys Club, Sudden Death at 60

 

One of my first medical directors was Dr. Nicholas DeRobertis. He tried to change the common practice of the local paramedics of dumping intoxicated, or otherwise undesirable patients, at Yonkers General Hospital regardless of which hospital was closest.

Sadly, this puerile EMS favoritism is still common in many places. He also tried to change other practices that are bad for patients and bad for EMS.
 


 

He was at St. Joseph’s on Sunday helping to implement a new electronic medical records system when he began to feel ill. He entered the emergency room he directed for many years – this time as a patient.

Friends said he suffered a heart attack. DeRobertis was later transferred to Montefiore Medical Center in the Bronx, where he died late Monday.
Dr. DeRobertis, and other attending physicians, would offer continuing education classes for free for EMS, but too often I was the only one attending. He had a lot of work to do to change EMS from the good old dangerous boys club to something that is focused on excellent patient care.
[1]

 

We had to call medical command for almost everything back then. I had one patient who was combative due to CHF (Congestive Heart Failure) and called for orders for aggressive NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries). The command doctor refused orders for NTG, with the excuse that “Prehospital nitro doesn’t work.” Even two decades ago, there was evidence that nitrates are the best medicine for CHF.

I talked with Dr. DeRobertis and he said that he would make sure that did not happen again. After talking with Dr. DeRobertis, I never encountered that problem again.

With Dr. DeRobertis it was clear that good patient care came first, not the doctors, not the nurses, not the most senior medics (often those who have been harming patients the longest), not even the protocol.

Back in the 1970s there was good evidence that furosemide (Lasix [frusemide in Commonwealth countries]) does not improve outcomes for CHF patients, but many of us still give furosemide to CHF patients.[2]

Back in the 1980s there was good evidence that aggressive treatment with nitrates (NTG, ISMN [IsoSorbide MonoNitrate], ISDN [IsoSorbide DiNitrate], . . . ) does improve outcomes for CHF patients, but many of us still only give small doses of nitrates to CHF patients.[3],[4],[5]

Dr. DeRobertis was making EMS evidence-based when even in-hospital emergency medical practice was still mostly traditional.

His death is is a great loss for his family, his patients, and all of the patients he affected through his recognition of the benefits treatment based on evidence, rather than tradition.

Footnotes:

[1] Dr. Nicholas DeRobertis, Westchester emergency medicine leader, dies
Jul. 2, 2013 11:01 AM
lohud.com
Jane Lerner
Article

[2] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed – indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format
 

The concept that acute heeart failure with pulmonary edema is associated with an increase in intravascular volume is therefore not supported. To the contrary, there is a reduction of blood volume during acute pulmonary edema.

This is just one of the studies from the 1970s showing the problems with furosemide.

[3] Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema.
Hoffman JR, Reynolds S.
Chest. 1987 Oct;92(4):586-93.
PMID: 3115687 [PubMed – indexed for MEDLINE]

Free Full Text from Chest.

Group A patients were the only patients not to receive morphine sulfate, group B patients the only ones not to receive nitroglycerin, and group D patients the only ones not to receive furosemide. Group

Group A patients (No morphine [received NTG and furosemide]) had the best outcome. No intubations when eliminating morphine.

Group B patients (No NTG [received morphine and furosemide]) had the worst outcome. 31% intubated when eliminating NTG.

[4] [The use of injectable nitroglycerin (a bolus of 3 mg) in the treatment of cardiogenic pulmonary edema].
Bosc E, Bertinchant JP, Hertault J.
Ann Cardiol Angeiol (Paris). 1982 Oct-Nov;31(6):477-80. French. No abstract available.
PMID: 6818888 [PubMed – indexed for MEDLINE]
 
This is in French, but PMID: 7662071 (1995) describes the results –

Bosc et al4 administered one 3-mg intravenous trinitroglycerin bolus to patients with CPE. There was improvement in 71% of the 35 patients studied. Five patients (13%) became hypotensive to an SBP <90; however, each recovered after a few minutes.

[5] Emergency treatment of severe cardiogenic pulmonary edema with intravenous isosorbide-5-mononitrate.
Harf C, Welter R.
Am J Cardiol. 1988 Mar 25;61(9):22E-27E.
PMID: 3348137 [PubMed – indexed for MEDLINE]
 

These data indicate that i.v. IS-5-MN is effective and safe for the management of severe acute cardiogenic pulmonary edema.

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