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

- Rogue Medic

This Rhythm is Hilarious

Fri, 04 Jan 2019 12:46:23 -0400 by 4 Comments
 


Click on the image to make it larger.
 

Apparently, the second 12 lead was after 150 mg of amiodarone. The hilarity is the amiodarone.

I received this in an email. It is reported to have been posted on Facebook, but I choose not to have access to Facebook, so I do not have any more details. I am occasionally tempted to set up an account again, but I generally prefer intentional comedy.

Everything you need to know is in the first 12 lead.

Things that do not matter:

Distance to the hospital.

Time of onset.

Last meal.

National Registry certification.

Et cetera.

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Filed Under: ACLS, Assessment, Cardiology, Critical Judgment, Heresy, Pharmacology, Placebo, Understanding, V Tach

What Treatments May Be De-Emphasized by EM/EMS in 2019? Part I

Tue, 01 Jan 2019 22:56:04 -0400 by Leave a Comment
 

EM (Emergency Medicine) and EMS (Emergency Medical Services) have already started to eliminate/decrease use of a lot of our failed treatments, because people started to see through our excuses. Atropine for asystole stuck around for a long time, then just vanished.[1]. Calcium for cardiac arrest is also something that used to be standard of care, then we raised our standards.

We need to keep raising our standards, because our patients’ outcomes – their lives, their brains, their everything – depend on raising our standards.

We used to give antiarrhythmics to almost anyone with a cardiac complaint. Then there was CAST (The Cardiac Arrhythmia Suppression Trial[2]). While CAST did not study lidocaine, it did study longer term use of antiarrhythmics. Lidocaine is too dangerous for long term use, so the results of CAST may be much worse for lidocaine. We thought that the increased deaths among patients with frequent PVCs (Premature Ventricular Contractions) after having a heart attack was due to a problem with the conduction system. PVCs indicate a problem with conduction and antiarrhythmics cause the PVCs to go away.
 

Before receiving the antiarrhythmic (PVCs are circled in red).


 

After receiving the antiarrhythmic.


 

Problem solved.

Now the problem is, How do we get paid more? These drugs were the biggest selling drugs at the time. They making the drug companies a fortune. Whichever company made the drug that saved the most lives would make a lot more money then the others. Provide evidence that ______ saves more lives than all of the others.

The problem of the PVCs was solved, but the solution was killing many more patients than not giving drugs.

The result was not celebrated by the drug companies. The patients taking antiarrhythmics were dying at three times the rate of the patients taking placebos. A plausible physiological mechanism suggested the drugs would save lives, but that was based on an assumption that was not justified. This is the kind of reasoning that appeals to those who reject EBM (Evidence-Based Medicine). The evidence should convince these EBM opponents of the folly of relying on physiology and on a plausible explanation to justify not looking for the evidence that might expose their unreasonable assumptions. These otherwise reasonable people start making excuses for unreasonable assumptions, because they believe. They seem to need to convince others to join in and multiply their mistakes.[3]

The PVCs appear to have been just an indicator of an unhealthy heart.

Getting rid of the PVCs may have made the conduction in the heart less healthy.

Giving the drugs may have killed tens of thousands of patients.

Antiarrhythmic use decreased dramatically after the harm demonstrated in CAST, but some drug pushers are trying to get one of the worst antiarrhythmics (amiodarone, now in a new formula) to make a comeback, by creatively spinning research to claim results the research was never designed to evaluate.

Not having learned from the evidence, even though he has been the lead author on some of it, Dr. Peter Kudenchuk has been claiming that in EMS witnessed arrests, there was a significant improvement, even though his own published results contradict this claim. Here is what the results actually state:
 

Though prespecified, this subgroup analysis was performed in the context of an insignificant difference for the overall analysis, and the P value for heterogeneity in this subgroup analysis was not adjusted for the number of subgroup comparisons. Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration.[4]

 

Amiodarone has also been shown to be horrible for patients with ventricular tachycardia with a pulse. Amiodarone is so ineffective, that the rate of severe side effects is greater than the rate of improved outcomes. Amiodarone is more likely to make your patient’s medical condition much worse, but it is still considered to be the standard of care and amiodarone is still in EMS protocols.[5]

Maybe amiodarone can produce better results if it is used for execution by lethal injection.

I am expecting that there will be more failed treatments removed from our standards of care.

We need to raise our standards to improve outcomes, not lower our standards to make us look better than we are.

Continued in Part II. I will add Part III and others at some point and provide the links here.

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Footnotes:

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[1] Why Did We Remove Atropine From ACLS?
Rogue Medic

Part I
Sun, 13 Oct 2013

Part II
Wed, 16 Oct 2013

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[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.
 

CONCLUSIONS. There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.

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[3] Why US EMS will never get to sit at the adult table – The Appeal to Authority
Sun, 04 May 2014
Rogue Medic
Article

Since Mike cites the original parachute study, as if it is not satire, it is amusing to point out that there is a new Parachute Study! Read Dr. Radecki’s description of this satirical poke at those who do not understand research in the satire issue of the BMJ, which they put out every Christmas as sort of a British IgNobel.

Don’t Bother With the Parachute!
Emergency Medicine Literature of Note
Dr. Ryan Radecki
December 21, 2018
Article
 

Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial.
Yeh RW, Valsdottir LR, Yeh MW, Shen C, Kramer DB, Strom JB, Secemsky EA, Healy JL, Domeier RM, Kazi DS, Nallamothu BK; PARACHUTE Investigators.
BMJ. 2018 Dec 13;363:k5094. doi: 10.1136/bmj.k5094. Erratum in: BMJ. 2018 Dec 18;363:k5343.
PMID: 30545967

Free Full Text from BMJ.

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[4] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.
N Engl J Med. 2016 May 5;374(18):1711-22. doi: 10.1056/NEJMoa1514204. Epub 2016 Apr 4.
PMID: 27043165

Free Full Text from NEJM.

CONCLUSIONS Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

 

Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article
 

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

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[5] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Rogue Medic
Wed, 17 Aug 2016
Article
 

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.
Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators.
Eur Heart J. 2016 Jun 28. pii: ehw230. [Epub ahead of print]
PMID: 27354046

Free Full Text from European Heart Journal.
 

Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.
 

Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed – indexed for MEDLINE]
 

Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed – indexed for MEDLINE]
 

Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction.
Kułakowski P, Karczmarewicz S, Karpiński G, Soszyńska M, Ceremuzyński L.
Europace. 2000 Jul;2(3):207-15.
PMID: 11227590 [PubMed – indexed for MEDLINE]

Free Full Text PDF + HTML from Europace
 

Adenosine for wide-complex tachycardia – diagnostic?
Thu, 23 Aug 2012
Rogue Medic
Article
 

Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia.
Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, Fontaine G.
World J Cardiol. 2012 Oct 26;4(10):296-301. doi: 10.4330/wjc.v4.i10.296.
PMID: 23110246 [PubMed]

Free Full Text from PubMed Central.

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Filed Under: ACLS, Cardiac Arrest, Critical Judgment, EBM, Ethics, Evidence, Heresy, Research

The Grinch Who Stole Reality

Fri, 28 Dec 2018 13:00:46 -0400 by 6 Comments
 

And the Grinch, with his Grinch-feet ice cold in the snow, stood puzzling and puzzling, how could it be so?

It came without ribbons epi.

It came without tags amio.

It came without packages oxygen, boxes tubes or bags.

And he puzzled and puzzled ’till his puzzler was sore. Then the Grinch thought of something he hadn’t before.

Maybe Christmas living, he thought…doesn’t come from a store drug.

Maybe Christmas living, perhaps…means a little bit more!

 

With apologies to Dr. Seuss (Theodore Geisel) for the modification of his parable.

There are important differences between the minimal criteria for life and the criteria for a meaningful life. Many of us don’t like to think about that, because many of us don’t like thinking. Thinking can be hard. Making excuses for not thinking – priceless (at least, as long as you don’t think about it).

We have been focusing on the least honest way of reporting outcomes – a pulse – Oooh!, or maybe even 30 days of a pulse – Oood-Ahhh! After all, reality does not support continuing to do what we have been doing. If we admit that we have been causing harm, then we may have to take responsibility for our actions.

We do not want to take responsibility for our actions. We were only following orders.

Doctors, PAs (Physician Assistants), NPs (Nurse Practitioners), nurses, paramedics, EMTs, techs, . . . do not want to take responsibility for what we get paid for. Accountability is for people who think – not for us.

We have blamed science/evidence for requiring that we confront reality. As explained by Dr. Seuss, we want simple answers that do not require understanding. Give us algorithms to mindlessly follow. Give us mnemonics.

We have been giving epinephrine (adrenaline in Commonwealth countries) for over half a century with no evidence of safety or improvement in the outcome that matters most.

Why?

We haven’t wanted to know.

The first study to look at the effect of placebo vs. epinephrine on neurological survival was cut short – with only a tiny fraction of what would be needed to produce any kind of statistically useful information, except for some of the true believers, who made the same kinds of mistakes that have been made for other discarded treatments – treatments discarded due to failure to work, discarded due to harm, or discarded due to both.

Don’t study this. Just believe. Belief makes us feel good. Attack science for encouraging understanding.
 

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.[1]

 

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.[1]

 

What was the conclusion produced by the Jacobs study?
 

CONCLUSION: Patients receiving adrenaline during cardiac arrest had no statistically significant improvement in the primary outcome of survival to hospital discharge although there was a significantly improved likelihood of achieving ROSC.[1]

 

As the homeopaths put their spin on studies that do not really support their claims, people who do not understand science put similar spin on the results of this. For example, if you take a Bayesian approach[2], but distort it to mean that you give extra weight to everything that supports your belief and take away credit from everything else, you can claim that this is an example of science proving that epinephrine works.

Another way of doing this is to claim that you don’t give the 1 mg dose of epinephrine, therefore the study does not apply to your patients. After all, you are just engaging in a poorly documented, unapproved study, which allows you to think of the survivors as examples of the drug working and make excuses for the rest. Of course, if you don’t give the 1 mg dose of epinephrine, is there any evidence that your treatment is safe or effective? No.

Rather than insisting that this method of dosing patients be studied, in order to determine if it really is safe or if it really is effective at anything other than getting a pulse in a brain-dead body, claim to be ahead of the science.

Why find out what is really best for the patients, when there are so many ways of declaring victory and running away?

In 2018, we had the results of the next study of placebo vs. adrenaline (epinephrine in non-Commonwealth countries, but only Commonwealth countries have bothered to do the research). The conclusion was the same as the conclusion for the only previous study.
 

CONCLUSIONS: In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.[3]

 

Has anyone else stated that the use of epinephrine should be limited to controlled trials?

Not that I know of.

Everyone else seems to be claiming that giving smaller boluses of epinephrine. or giving titrated infusions of epinephrine is different. Some claim that it is nihilism to refuse to believe in their slightly different treatment – at least until there is undeniable evidence of lack of benefit, or undeniable evidence of harm, or both.

Requiring evidence of benefit, before using a treatment on a patient is being reasonable.

Using inadequately studied treatments on people when they are at their most vulnerable is not good medicine.

A doctor’s oath to Apollo does not include a requirement to perpetuate dogma, but medicine is only slowly starting to focus on what is best for patients, rather than what is best for appearances.

Dr. Ryan Jacobsen addressed a similar dogma, when he got rid of the long spine board in the system where he was medical director. His description of the evidence applies to epinephrine (bolus, mini-bolus, infusion, patch, inhaler, down the tube, oral, whatever) –

Other than historical dogma and institutional EMS medical culture we can find no evidence-based reason to continue to use the Long Spine board epinephrine as it currently exists in practice today.[4]

I changed EMS to medical and the Long Spine board to epinephrine.

We have good evidence that if your loved one is a laboratory pig, rat, dog, . . . we can kill them and get them back neurologically intact with epinephrine – and with other treatments that have been discarded because they do not have the same effect on humans as on lab animals.

Let us treat your loved ones like the lab animals we think they are.

Don’t use EBM (Evidence-Based Medicine), because belief is more important than reality.

The world is a comedy to those that think; a tragedy to those that feel. – Horace Walpole.

Keep thinking. Keep demanding evidence. After the nonsense being preached by the believers is exposed, we can improve the outcomes for our patients, because medicine is about doing what is best for the patient, and not about protecting the dogma.

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Footnotes:

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[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. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2.
PMID: 21745533

Free Full Text PDF Download from semanticscholar.org

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[2] Bayesian inference
Wikipedia
Article

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[3] A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators.
N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.
PMID: 30021076

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[4] Johnson County EMS System Spinal Restriction Protocol 2014
Ryan C. Jacobsen MD, EMT-P, Johnson County EMS System Medical Director
Jacob Ruthsrom MD, Deputy EMS Medical Director
Theodore Barnett MD, Chair, Johnson County Medical Society EMS Physicians Committee
Johnson County EMS System Spinal Restriction Protocol 2014 in PDF format.

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Filed Under: 'Alternative' Medicine, ACLS, Cardiac Arrest, Critical Judgment, EBM, Epinephrine, Ethics, Evidence, Heresy, Pharmacology, Research, Science

Vaccines are probably the safest and most effective medical intervention available, so why do anti-vaxers lie about them

Sun, 16 Dec 2018 11:50:47 -0400 by Leave a Comment
 

Why does anyone lie?

Anti-vaxers lie for the same reason as other people – for personal benefit.

Many anti-vaxers claim that there is an international conspiracy of doctors and researchers, as if all of the doctors and researchers, or even the pediatric doctors and researchers, in the world could agree on much of anything. When you realize how ridiculously large this conspiracy would be, how much a doctor or researcher would gain from providing valid information to expose such a conspiracy, and how aggressively law enforcement would punish those behind such a conspiracy, you understand the use of ridiculous is appropriate as a description of the conspiracy theory.

This is just another example of some people thinking they know more than everyone else, based on a lack of understanding. This feeds the over-inflated egos of anti-vaxers.

The smallpox vaccine has saved hundreds of millions of lives. Anti-vaxers opposed the smallpox vaccine and delayed the eradication of smallpox. Anti-vaxers helped smallpox kill people..

Our children are no longer vaccinated against smallpox, because smallpox has been wiped out by vaccines. Millions of children’s lives, and adult lives, are saved every year by the smallpox vaccine, without even giving it to children, because enough people rejected the lies of anti-vaxers.

Vaccines continue to save millions of lives every year, in spite of opposition by anti-vaxers.

There is plenty of research showing that vaccines are effective and safe, but to give the single clearest example of the benefit of vaccines, look at the following paper from JAMA. The Journal of the American Medical Association is one of the most respected medical publications in the world. Use any search engine to find a list of the most respected medical journals and you will find JAMA near the top.

Look at the decrease in the rates of illness and the rates of death for each vaccine-preventable illness after the introduction of the vaccine for that illness. Click on the image for a larger, easier to read version.
 


 

Table 1. Historical Comparison of Morbidity and Mortality for Vaccine-Preventable Diseases With Vaccines Licensed or Recommended Before 1980: Diphtheria, Measles, Mumps, Pertussis, Poliomyelitis, Rubella, Smallpox, Tetanusa [1]

 

This information has been simplified for those not comfortable with scientific research (I do not know the source of the image, it was not part of the paper in JAMA):
 


 

As you can see, these diseases are almost never a problem in America, where vaccination rates are still pretty high, although anti-vaxers are causing more and more outbreaks of diseases we had not seen in decades.

Some anti-vaxers will claim that the vaccines didn’t get rid of these diseases. These anti-vaxers claim that improved sanitation, improved hygiene, and improved diet got rid of these diseases. While these improvements are helpful, here is why that is just another anti-vax lie.

We have outbreaks of vaccine-preventable illnesses in America, when the rate of vaccination drops, even though sanitation, hygiene, and diet did not deteriorate. Yes, many of our diets are getting worse, but that is not what is causing outbreaks of whooping cough, measles, and other vaccine-preventable illnesses.

The rates of illness and death only have a dramatic change for each of the vaccine-preventable illnesses after the introduction of each vaccine. If sanitation, hygiene, and diet were the reasons, the illnesses would all start to go away at the same time, although not necessarily at the same rate. If that were the case, the decreases in these diseases could easily be shown to be due to improvements in sanitation, hygiene, and diet, but that is not the case.

Anti-vaxers cannot explain that, but anti-vaxers are not reasonable.
 

Why has the polio vaccine been so effective in India, when India has widespread problems with sanitation, hygiene, and diet?

Here is what the authors wrote:
 

India, a vastly diverse country with a 27 million birth cohort, undertook the largest vaccination drive against WPV (Wild Polio Virus) in the world. With high population density, poor civic infrastructure, poor sanitation, an almost nonexistent public health system, rampant malnutrition and diarrhea, difficult-to-reach locales, high population mobility, and extremely high force of WPV transmission in few states,3 the interruption of WPV transmission was extremely difficult and demanding. The interplay of these challenging factors provided a perfect milieu for the WPV to circulate, and the prospect of achieving zero-polio status seemed insurmountable.[2]

 

India completed a full 5 years as a “polio-free nation” on January 13, 2016.1 It was a remarkable feat considering the odds against achieving this status. [2]

Anti-vaxers will make excuses, but this clearly exposes the anti-vax lie that disease elimination being due to improved sanitation, hygiene, and diet, rather than due to vaccines.
 

The reason smallpox vaccine is no longer given to children, is the worldwide eradication of smallpox by vaccination.

Anti-vaers delayed the worldwide eradication of smallpox.

Anti-vaxers have prevented the worldwide eradication of polio.

Anti-vaxers continue to try to protect polio from eradication.

Children would no longer need polio vaccination, if it weren’t for anti-vaxers.

If you don’t like giving the polio vaccine to your child, blame the anti-vaxers.

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Footnotes:

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[1] Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States.
Roush SW, Murphy TV; Vaccine-Preventable Disease Table Working Group.
JAMA. 2007 Nov 14;298(18):2155-63.
PMID: 18000199

You can also read the full text of the article for free at JAMA at the link below, if you want to understand more of the details that the anti-vaxers don’t want you to understand.

Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States

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[2] Polio Eradication in India: The Lessons Learned.
Thacker N, Vashishtha VM, Thacker D.
Pediatrics. 2016 Oct;138(4). pii: e20160461. Epub 2016 Sep 2. Review. No abstract available.
PMID: 27590898

You can also read the full text of the article for free at Pediatrics at the link below, if you want to understand more of the details that the anti-vaxers don’t want you to understand. Pediatrics is one of the most respected pediatric medical publications in the world. Use any search engine to find what pediatric medical journals are the most respected and you will find Pediatrics near the top.

Polio Eradication in India: The Lessons Learned

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Filed Under: Anti-Science, Critical Judgment, Ethics, Heresy, Research Blogging, Vaccines

Anti-Vaccine Means Pro-Corruption

Fri, 30 Nov 2018 09:30:45 -0400 by Leave a Comment
 

Can you be opposed to vaccines and not be supporting corruption? What does it mean to oppose vaccines?

Vaccines are probably the safest and most effective medical intervention available. Anti-vaxers oppose that.

Vaccines save millions of lives every year. Anti-vaxers oppose that.

If you disagree, provide valid evidence that anything else is as safe as vaccines and provide valid evidence that anything else is as effective as vaccines. There is the small possibility that I am wrong and that vaccines are only second, or maybe even third, among the safest and most effective medical interventions available.

But aren’t the anti-vaxers trying to protect children from unnecessary risk?

That is one of many anti-vaccine claims, but it is just another anti-vax lie.

Look at these heroes of the anti-vaccine propaganda industry. Mark and David Geier.

David Geier pretends to be a doctor, even though he never has been a doctor, or even been enrolled in a medical school.
 

As explained above, the Board concludes that David Geier practiced medicine in Maryland without being licensed by the Board to practice in violation of section 14-601 of the Health Occupations Article.[1]

 

Mark Geier did become a doctor, but the corruption of the anti-vax propaganda and treatment business led him to violate his responsibility to protect his patients. If you see Mark Geier working as a doctor, call the police.
 

Since 2011, Geier’s medical license has been suspended or revoked in every state in which he was licensed over concerns about his autism treatments and his misrepresentation of his credentials to the Maryland Board of Health, where he falsely claimed to be a board-certified geneticist and epidemiologist.[4] [2]

 

What is so bad about the Geiers and why do anti-vaxers continue to worship the Geiers?

Mark and David Geier castrate children with a chemical that has been approved for some medical uses, but definitely not to treat autism. The chemical has never been shown to be safe or even slightly effective for that purpose. If you think that autism is the worst thing ever – worse than smallpox, measles, polio, pertussis, et cetera, you may think that it is morally acceptable to torture children and to have faith in these quacks.
 


 

The fake doctor (David) is on the left and the revoked license doctor (Mark) is on the right.

But isn’t it an exaggeration to call this chemical castration.
 

Speaking about one teen he put on the drug, Mark Geier said: “I wasn’t worried about whether he would have children when he is 25 years old. If you want to call it a nasty name, call it chemical castration. If you want to call it something nice, say you are lowering testosterone.”[3]

 

For those who claim that this would be a short-term treatment, and the side effects would be minimized, that’s not the way quacks work – especially with paying customers. These are not reasonable people. Quacks will be expected to keep giving the magic treatment, possibly increasing the dose several times, until that treatment works, because they think that they know believe that it works. Reasonable people would be expected to stop never start this unapproved and dangerous treatment to begin with. Since the treatment does not work, and is expected to make the patients’ conditions worse, these people would not be expected to stop. As with other alternative medicine, treatment failures are blamed on the patient, or on the family. Quacks do not take responsibility for the incompetence of using chemicals that are dangerous and ineffective.

But what if it really does work?

Almost every proposed treatment, regardless of what it is, will be found to be more harmful than beneficial. Most are discarded long before they get to the point of being tested on actual humans. Poisoning patients, based on What if it works? is dangerous, unethical, and irresponsible.

If you have an autistic child, do not let the Geiers chemically castrate your child for fun and profit.

How do the same anti-vaxers, who claim that they are protecting their children from what is probably the safest and most effective medical intervention available, support this dangerous, unethical, and irresponsible treatment?

That is the way anti-vaxers think. Anti-vccine claims are arrogant rejections of competence, science, and reality. Protect your children from anti-vaxers.

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Footnotes:

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[1] In the matter of David A. Geier before the Maryland State Board of Physicians
Case Nos. 2008-0022 & 2009-0318
Maryland Department of Health
Final Decision and Order in PDF format.

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[2] Mark Geier
Wikipedia
Article

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[3] ‘Miracle drug’ called junk science
Trine Tsouderos
Tribune reporter
May 21, 2009
Article

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Filed Under: Anti-Science, Children, Conspiracy Theories, Corruption, Critical Judgment, Denialism, Evidence, Pharmacology, Research, Risk Management

Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies – Part I

Wed, 03 Oct 2018 15:01:07 -0400 by Leave a Comment
 

This is a look at the data from the paper I wrote about in Are We Killing Patients With Parochialism?

What differences can we see among the EMS agencies being studied?
 


 

The best half of EMS agencies are producing twice as many good outcomes as the worse half of EMS agencies.[1]

Most of us are bad at resuscitation and those of us treating the most cardiac arrests are doing the least good.

Why do so many of us refuse to improve our standards?

What is so much more important than patient outcomes?
 

Let’s start with Figure 2 C How is survival to the emergency department distributed among EMS agencies?
 


 

ROSC to the ED (Emergency Department) looks great. The results are skewed to the right, which is what we want to see in outcomes. Unfortunately, this is not an outcome that is important. Yes, you do need to have ROSC (Return Of Spontaneous Circulation) to survive, but it is important that we not cause irreversible harm in order to get very reversible ROSC.

How reversible is ROSC?
 


 

Those distributions are similar, although they are decreased by more than half. If leaving the hospital with a pulse were the outcome that mattered, it might not be so bad.

But these are not on the same scale. The ROSC to the ED figure continues to 46%, with a greater than symbol to indicate that some will do better, while the survival to discharge figure stops at 20%, with the same greater than symbol to indicate that there are some beyond that number. How many beyond the end of the figure? The authors decided that it was not enough to waste space on, because they cut it off there.

Where would the survival to discharge percentages be on the ROSC to the ED figure?
 


 

The arrow on the right is where the 46>% bar from the ROSC to the ED figure.

It is important to put these percentages in perspective, which means looking at the differences in the numbers at the bottom.

Now we need to look at the percentage surviving with enough brain function to be able to take care of themselves – those probably not going to a nursing home. This is the group everyone wants to be in. Figure 2 B.
 


 

The percentages of patients able to care from themselves looks a lot different from the previous figures. The results are skewed to the left, which is not what we want to see. Skewed to the left means that the outcomes are mostly on the lower end of the scale – the bad end.

The percentages on the bottom of the figure have not been changed (from those used for survival to discharge), but the results have worsened (been skewed to the left).
 


 

Compared with the first image, this is a very different outcome. We should admit that ROSC to the ED and survival with the ability to take care of ourselves are very poorly correlated.

We need to stop focusing on the harmful distraction that is ROSC.

Most people consider healthy brain function to be important. There are people who insist that we give too much attention to the chemistry of brain function, as if changing a person’s brain does not change a person’s behavior. When our brain chemistry changes, we change. Similarly, when our brains are damaged, as often happens during resuscitation, the part of us that makes us the people that we are is damaged. We do not think with our hearts, nor with our guts, no matter what metaphors some of us like to use.

We are not good at resuscitating the part of the patient that matters the most to the patient.

We are not good at producing the outcome that matters the most to the patient.

We appear to be best at focusing on what matters the least.
 

If we could get the half of the EMS agencies that are not effective at producing survival with good neurological function to improve their patient care, that would result in a big increase in outcomes that matter to patients.
 

It is important that we not cause irreversible harm in order to get very reversible ROSC.
 

Also to be posted on ResearchBlogging.org when they relaunch the site.

In Part II I will look at the potentially significant differences between EMS agencies with good outcomes and EMS agencies with bad outcomes.

–

Footnotes:

–

[1] Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies.
Okubo M, Schmicker RH, Wallace DJ, Idris AH, Nichol G, Austin MA, Grunau B, Wittwer LK, Richmond N, Morrison LJ, Kurz MC, Cheskes S, Kudenchuk PJ, Zive DM, Aufderheide TP, Wang HE, Herren H, Vaillancourt C, Davis DP, Vilke GM, Scheuermeyer FX, Weisfeldt ML, Elmer J, Colella R, Callaway CW; Resuscitation Outcomes Consortium Investigators.
JAMA Cardiol. 2018 Sep 26. doi: 10.1001/jamacardio.2018.3037. [Epub ahead of print]
PMID: 30267053

Free Full Text from JAMA Cardiology

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Filed Under: ACLS, Critical Judgment, Heresy, Research Blogging

Are We Killing Patients With Parochialism?

Tue, 02 Oct 2018 15:00:29 -0400 by 2 Comments
 
The variation in approaches to resuscitation in EMS is tremendous.

Many excuses center around the need for local people to be able to claim that they know something that the evidence does not show, although they consistently fail to provide valid evidence for these claims. This local knowledge appears to be intuitive – they just know it, but cannot provide anything to support their feelings.

The latest research can be interpreted in many different ways, but it definitely does not support the claims of the advocates of parochialism.
 

Results We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]).[1]

 

MOR = Median Odds Ratio – how many times more likely is something to happen.

What is most commonly measured is what matters the least – ROSC (Return Of Spontaneous Circulation). Did we get a pulse back, for even the briefest period of time, regardless of outcomes that matter.

What matters? Does the person wake up and have the ability to function as they did before the cardiac arrest.

Those who justify focusing on ROSC claim that, If we don’t get a pulse back, nothing else matters, but that is the kind of excuse used by frauds. How we get a pulse back does matter. The evidence makes that conclusion irrefutable, but there will always be those who do not accept that they are causing harm. They will make excuses for the harm they are causing. Getting ROSC helps them to feel that they are not causing harm. ROSC encourages us to give drugs like epinephrine, which have been demonstrated to not improve any survival that matters.

The means of obtaining ROSC can be compared to the means of doing anything that requires finesse. Sure, it feels good to try to force something. Sure, you can claim that forcing something is the most direct way to accomplish the goal.

Can the advocates of focusing on ROSC produce any valid evidence that their approach leads to improvements in outcomes that matter? No. The evidence contradicts their claims. The evidence has caused us to eliminate many of their treatments – treatments they claimed had to work because of physiology. As it turns out, they were wrong. They were wrong about their treatments and wrong about their understanding of physiology.

If you want to win money, bet that any new treatment will not improve outcomes that matter.
 

This variation persisted despite adjustment for patient-level and EMS agency–level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]).[1]

 

Is presence of a pulse upon arrival at the emergency department an important outcome? Only for billing purposes. The presence of a pulse justifies providing more, and more expensive, treatments. Is the presence of a pulse upon arrival at the emergency department a goal worth trying for? As with ROSC, only if it does not cause us to harm patients to obtain this goal, which is just something that is documented, because it is a point of transfer of patient care.
 

After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]).[1]

 

There is a lot of variability.

What did they find?
 


 

Most of the people in EMS, who claim to be doing what is best for their patients, are making things worse.
 

69% means that there are two EMS agencies producing bad outcomes for every EMS agency producing good outcomes.

Correction – The text crossed out is not accurate. I should have thought that through a bit better before I posted it. My caption for Table 1 is accurate. However, what I should have written afterward is –

The worse half of EMS agencies are only producing half as many good outcomes as the better half of EMS agencies.

We are bad at resuscitation and those doing the most resuscitating are doing the least good.

Why do so many of us refuse to improve our standards?

What is more important than the outcomes for our patients?
 

Why are we so overwhelmingly bad at resuscitation?
 

What are the authors’ conclusions?
 

This study has implications for improvement of OHCA management. First, the analysis indicates that the highest-performing EMS agencies had more layperson interventions and more EMS personnel on scene.[1]

 

They do not conclude that we need more doctors, more nurses, or more paramedics responding to cardiac arrest.
 

Second, our findings justify further efforts to identify potentially modifiable factors that may explain this residual variation in outcomes and could be targets of public health interventions.[1]

 

We need to figure out what we are doing, because the people telling us that they know that we need intubation are lying.

We need to figure out what we are doing, because the people telling us that they know that we need epinephrine are lying.

We need to figure out what we are doing, because the people telling us that they know that we need amiodarone are lying.

We need to figure out what we are doing, because the people telling us that they know that we need ________ are lying.

How dare I call them liars?

Let them produce valid evidence that the interventions they claim are necessary actually do improve outcomes that matter.

Have them stop making excuses and start producing results.

I dare them.

The only time we have made significant improvements in outcomes have been when we emphasized chest compressions, especially bystander chest compressions, and when we emphasized bystander defibrillation.

It is time to start requiring evidence of benefit for everything we do to patients.

Our patients are too important to be subjected to witchcraft, based on opinions and an absence of research.

There is plenty of valid evidence that using only chest compressions improves outcomes.
 

Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed – indexed for MEDLINE]

–

Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed – indexed for MEDLINE]

–

Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed – indexed for MEDLINE]

Free Full Text at JAMA

–

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed – indexed for MEDLINE]

And more.

 

It is not ethical to insist on giving treatments to patients in the absence of valid evidence of benefit to the patient. We need to begin to improve our ethics.
 

Also to be posted on ResearchBlogging.org when they relaunch the site.

–

Footnotes:

–

[1] Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies.
Okubo M, Schmicker RH, Wallace DJ, Idris AH, Nichol G, Austin MA, Grunau B, Wittwer LK, Richmond N, Morrison LJ, Kurz MC, Cheskes S, Kudenchuk PJ, Zive DM, Aufderheide TP, Wang HE, Herren H, Vaillancourt C, Davis DP, Vilke GM, Scheuermeyer FX, Weisfeldt ML, Elmer J, Colella R, Callaway CW; Resuscitation Outcomes Consortium Investigators.
JAMA Cardiol. 2018 Sep 26. doi: 10.1001/jamacardio.2018.3037. [Epub ahead of print]
PMID: 30267053

Free Full Text from JAMA Cardiology

.

Filed Under: ACLS, Correction, Critical Judgment, Ethics, Heresy, Mythology, Research Blogging

Why are we still intubating, when there is no evidence of benefit and we refuse to practice this “skill”?

Tue, 28 Aug 2018 16:05:09 -0400 by 1 Comment
 
Also to be posted on ResearchBlogging.org when they relaunch the site.

The results are in from two studies comparing intubation with laryngeal airways. There continues to be no good reason to intubate cardiac arrest patients. There is no apparent benefit and the focus on this rarely used, and almost never practiced, procedure seems to be more for the feelings of the people providing treatment, than for the patients.
 

Patients with a short duration of cardiac arrest and who receive bystander resuscitation, defibrillation, or both, are considerably more likely to survive and are also less likely to require advanced airway management.22 This problem of confounding by indication is an important limitation of many large observational studies that show an association between advanced airway management and poor outcome in out-of-hospital cardiac arrest.23 This study found that 21.1% (360/1704) of patients who did not receive advanced airway management achieved a good outcome compared with 3.3% (251/7576) of patients who received advanced airway management.[1]

 

In other words, we are the least skilled, are the least experienced, and we have the least amount of practice, but we are attempting to perform a difficult airway skill under the least favorable conditions. Ironically, we claim to be doing what is best for the patient. We are corrupt, incompetent, or both.

We also do not have good evidence that any kind of active ventilation is indicated for cardiac arrest, unless the cardiac arrest is due to respiratory conditions. Passive ventilation, which is the result of high quality chest compressions, appears to produce better outcomes (several studies are listed at the end).

We need to stop considering our harmful interventions to be the standard and withholding harmful treatments to be the intervention. We are using interventions that have well known and serious adverse effects. This attempt to defend the status quo, at the expense of honesty, has not been beneficial to patients.
 

The ETI success rate of 51% observed in this trial is lower than the 90% success rate reported in a meta-analysis.29 The reasons for this discordance are unclear. Prior reports of higher success rates may be susceptible to publication bias.[2]

 

Is that intubation success rate lower than you claim for your organization? Prove it.
 

Another possibility is that some medical directors encourage early rescue SGA use to avoid multiple unsuccessful intubation attempts and to minimize chest compression interruptions.5 Few of the study EMS agencies had protocols limiting the number of allowed intubation attempts, so the ETI success rate was not the result of practice constraints.[2]

 

Is there any reason to interrupt chest compressions, which do improve outcomes that matter, to make it easier to intubate, which does not improve any outcomes that matter? No.
 

While the ETI proficiency of study clinicians might be questioned, the trial included a diverse range of EMS agencies and likely reflects current practice.[2]

 

This is the state of the art of intubation in the real world of American EMS. Making excuses shows that we are corrupt, incompetent, or both.
 


I no longer have the link, but I think that this image came from Rescue Digest a decade ago.
 

These results contrast with prior studies of OHCA airway management. Observational studies have reported higher survival with ETI than SGA, but they were nonrandomized, included a range of SGA types, and did not adjust for the timing of the airway intervention.9,10,31-34 [2]

 

We should start doing what is best for our patients.

We should not continue to defend resuscitation theater – putting on a harmful show to make ourselves feel good.

What would a competent anesthesiologist use in the prehospital setting? Something that offers a benefit to the patient.

There is also an editorial analyzing these two studies.[3]

It is time to start requiring evidence of benefit for everything we do to patients.

Our patients are too important to be subjected to witchcraft, based on opinions and an absence of research.

There is plenty of valid evidence that using only chest compressions improves outcomes.
 

Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed – indexed for MEDLINE]

–

Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed – indexed for MEDLINE]

–

Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed – indexed for MEDLINE]

Free Full Text at JAMA

–

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed – indexed for MEDLINE]

And more.

 

It is not ethical to insist on giving treatments to patients in the absence of valid evidence of benefit to the patient. We need to begin to improve our ethics.

–

Also read/listen to these articles/podcasts released after I published this (I do not know the date of the Resus Room podcast) –

The Great Prehospital Airway Debate
August 31, 2018
Emergency Medicine Literature of Note
by Ryan Radecki
Article
 

EM Nerd-The Case of the Needless Imperative
August 31, 2018
EMNerd (EMCrit)
by Rory Spiegel
Article
 

Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2
The Resus Room
Podcast with Simon Laing, Rob Fenwick, and James Yates with guest Professor Jonathan Benger, lead author of AIRWAYS-2.
Podcast, images, and notes
 

–

Footnotes:

–

[1] Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial
Jonathan R. Benger, MD1; Kim Kirby, MRes1,2; Sarah Black, DClinRes2; et al Stephen J. Brett, MD3; Madeleine Clout, BSc4; Michelle J. Lazaroo, MSc4; Jerry P. Nolan, MBChB5,6; Barnaby C. Reeves, DPhil4; Maria Robinson, MOst2; Lauren J. Scott, MSc4,7; Helena Smartt, PhD4; Adrian South, BSc (Hons)2; Elizabeth A. Stokes, DPhil8; Jodi Taylor, PhD4,5; Matthew Thomas, MBChB9; Sarah Voss, PhD1; Sarah Wordsworth, PhD8; Chris A. Rogers, PhD4
August 28, 2018
JAMA. 2018;320(8):779-791.
doi:10.1001/jama.2018.11597

Abstract from JAMA.

–

[2] Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial
Henry E. Wang, MD, MS1,2; Robert H. Schmicker, MS3; Mohamud R. Daya, MD, MS4; et al Shannon W. Stephens, EMT-P2; Ahamed H. Idris, MD5; Jestin N. Carlson, MD, MS6,7; M. Riccardo Colella, DO, MPH8; Heather Herren, MPH, RN3; Matthew Hansen, MD, MCR4; Neal J. Richmond, MD9,10; Juan Carlos J. Puyana, BA7; Tom P. Aufderheide, MD, MS8; Randal E. Gray, MEd, NREMT-P2; Pamela C. Gray, NREMT-P2; Mike Verkest, AAS, EMT-P11; Pamela C. Owens5; Ashley M. Brienza, BS7; Kenneth J. Sternig, MS-EHS, BSN, NRP12; Susanne J. May, PhD3; George R. Sopko, MD, MPH13; Myron L. Weisfeldt, MD14; Graham Nichol, MD, MPH15
August 28, 2018
JAMA. 2018;320(8):769-778.
doi:10.1001/jama.2018.7044

Free Full Text from JAMA.

–

[3] Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest
Lars W. Andersen, MD, MPH, PhD1; Asger Granfeldt, MD, PhD, DMSc2
August 28, 2018
JAMA. 2018;320(8):761-763. doi:10.1001/jama.2018.10824

Abstract from JAMA.

.

Filed Under: ACLS, Airway Management, Cardiac Arrest, Common Sense, Critical Judgment, Ethics, Heresy, Intubation, Research Blogging, Resuscitation Theater
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