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

- Rogue Medic

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

 

What changed, or almost changed in 2015?

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

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

paramedic2_logo
 

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

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

AVOID endotracheal intubation and patient packaging during initial 10 minutes

Ventilation Options6:

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

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

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

     

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

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

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

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

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

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

    Our current ambulance system is based on little scientific evidence.

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

    Elsewhere in medicine in 2015.

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

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

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

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

    Footnotes:

    [1] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
    Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
    Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
    PMID: 21745533 [PubMed – in process]

    Free Full Text PDF Download from semanticscholar.org
     

     

    This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

     

    In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

     

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

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

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

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

    Edited 12-27-2018 to correct link to pdf of Jacobs study in footnote 1.

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