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

- Rogue Medic

New FDNY Cardiac Arrest Protocol is Reasonable


In New York City, the protocol for cardiac arrest during the coronavirus pandemic has been changed. The protocol now states to pronounce the patient dead after 20 minutes, if there is no return of spontaneous circulation (ROSC). If the patient remains pulseless after full paramedic treatment, the chances of any good outcome have dramatically dropped to zero. However, the dangers of transport and infection are only going to increase with transport for the purpose of pronouncement at the hospital, because that is all that is going to happen. A doctor will probably walk out to the ambulance, ask for a brief report, look at the monitor, and then tell the medics to stop compressions and ventilations.


Is there any reason to believe that an emergency physician, who is already overworked, is going to endanger the other patients in the emergency department, just to “make it look good” for a few more minutes?


Many communities already have these protocols in place. The American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) already recommend that resuscitation be terminated with no ROSC after 20 minutes.


FDNY (Fire Department of New York, which run EMS in New York City) has traditionally been, well . . . , very traditional in its approach to cardiac arrest. Cardiac arrest treatment doesn’t require much, but the traditionalists like to do a lot more than is good for the patient. For appearances? For unreasonable optimism?


Unfortunately, the president of the local union is misrepresenting this, in order to make a political point, or to demonstrate a lack of understanding, at a time when he should be trying to explain that this is protecting union members and protecting the public.


This is what the military does. They come. They check your pulse. No pulse – next. You know, we’re going to be leaving bodies behind, which is the exact opposite of what’s the oath we took.[1]


Oren Barzilay EMS Local 2507 President. Also identified by the news as a paramedic. If so he should know better.


What does the protocol state?


TEMPORARY Cardiac Arrest Standards for Disaster Response[2]


NYC REMAC (New York City Regional Emergency Medical Advisory Committee) does need to approve whatever N-95 masks have been donated, if the claim that the masks have not been approved is more accurate than the claim about resuscitation.


The NYC protocol has caught up with what many other states have been doing for decades. It is sad that the union leadership is fighting to keep EMS in the dark ages with misinformation and emotions. Misinformation thrives on emotions, so the emotional appeal is not surprising.


There is another protocol change that seems to escaped the notice of Oren Barzilay EMS Local 2507 President, or that part of the interview was cut. Intubation can be skipped – in favor of an extraglottic airway.



Use of Alternative Airways[3]


There is still no good evidence that the average paramedic is competent at intubation, but many agencies insist on intubation as if it is some sort of magical ability of paramedics. Just wave the laryngoscope and the tube goes into the trachea. Paramedics are not good at intubation, but we are good at whining about having intubation taken away, as if it is something we have earned.


We have not earned the right to make patients hypoxic, to tear up the airway, and to claim that we are improving outcomes. Hypoxia is bad for the patient. Tearing up the airway is bad for the patient. We have no good reason to believe we are providing a benefit to the patient, but we do have plenty of evidence that we are causing harm.


Why do so many of us refuse to practice?


Why do so many of us refuse to behave as if we believe any of the lies we tell about intubation being a life saving procedure?


If intubation really is “life saving”, why do paramedics refuse to engage in more than token intubation practice – and then brag about how much they practice?


Because we do not understand what we are doing and because our arguments are emotional, rather than rational.


We paramedics deserve ridicule for our repeated defenses of incompetence.


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


Here is the only evidence I know of demonstrating benefit from intubation:



Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65. doi: 10.1097/SLA.0b013e3181efc15f.
PMID: 21107105



Here is some of the evidence showing either a lack of benefit from intubation or evidence showing harm from intubation:



Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768


Free Full Text PDF



Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. doi: 10.1016/j.annemergmed.2012.02.013. Epub 2012 Mar 15.
PMID: 22424653


Free Full Text from Annals of Emergency Medicine.



A is for airway: a pediatric emergency department challenge. Green SM. Ann Emerg Med. 2012 Sep;60(3):261-3. doi: 10.1016/j.annemergmed.2012.03.019. Epub 2012 Apr 19. No abstract available. PMID: 22520991


The above is a comment on the previous article.



Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93. doi: 10.1213/ane.0b013e3181aa3063.
PMID: 19608824



Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364


The article above is commentary on the article below:


Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674



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.
Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA.
JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597.
PMID: 30167701


Free Full Text from PubMed Central® (PMC)



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.
Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G.
JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044.
PMID: 30167699


Free Full Text from PubMed Central® (PMC)



Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest.
Andersen LW, Granfeldt A.
JAMA. 2018 Aug 28;320(8):761-763. doi: 10.1001/jama.2018.10824. No abstract available.
PMID: 30167679



Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.
Wang HE, Simeone SJ, Weaver MD, Callaway CW.
Ann Emerg Med. 2009 Nov;54(5):645-652.e1. doi: 10.1016/j.annemergmed.2009.05.024. Epub 2009 Jul 2.
PMID: 19573949



Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.
Hasegawa K, Hiraide A, Chang Y, Brown DF.
JAMA. 2013 Jan 16;309(3):257-66. doi: 10.1001/jama.2012.187612.
PMID: 23321764


Free Full Text from JAMA



No evidence for decreased incidence of aspiration after rapid sequence induction.
Neilipovitz DT, Crosby ET.
Can J Anaesth. 2007 Sep;54(9):748-64. Review.
PMID: 17766743


Link to Abstract and Free Full Text PDF Download from Can J Anaesth



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



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



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



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. doi: 10.1016/j.annemergmed.2008.02.006. Epub 2008 Mar 28.
PMID: 18374452



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. doi: 10.1001/jama.299.10.1158.
PMID: 18334691


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. doi: 10.1016/j.annemergmed.2009.06.011. Epub 2009 Aug 6.
PMID: 19660833



Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, Bobrow B.
Acad Emerg Med. 2010 Mar;17(3):269-75. doi: 10.1111/j.1553-2712.2010.00689.x.
PMID: 20370759


Free Full Text from Acad Emerg Med.


And more.


That is a big difference. There is nowhere near enough evidence to justify allowing paramedics to intubate.



Footnotes:

[1] Grim New Rules for NYC Paramedics: Don’t Bring Cardiac Arrests to ER for Revival
By Tom Winter
Published April 2, 2020 • Updated on April 2, 2020 at 8:32 pm
nbcnewyork.com
Article with autoplay video

[2] TEMPORARY Cardiac Arrest Standards for Disaster Response
NYC REMAC
Advisory No. 2020-08
Issue Date: March 31, 2020
Effective Date: Immediate
Protocol in PDF format

[3] Use of Alternative Airways
NYC REMAC
Advisory No. 2020-05
Issue Date: March 20, 2020
Effective Date: Immediate
Protocol in PDF format

.

Do Emergency Physicians Intubate Often Enough to Maintain Competency?

 

    There is a study of the frequency of intubation among emergency physicians in the current Annals of Emergency Medicine. This study is accompanied by a discussion, which unfortunately does not question the assumption that intubation improves outcome. There is very little evidence to suggest that intubation improves outcomes. That evidence is only using paramedics with the highest success rates – much higher than your average paramedic.

 
Greater intubation experience in paramedics is associated with improved patient outcomes2; does a similar relationship exist for emergency physicians?[1]
 


Image credit.

The unquestioned assumption is that excellent intubation performance improves outcomes, rather than that excellent intubation performance causes less harm than average intubation performance, or below average performance. We do not have any good evidence to support the wishful thinking that paramedics, or even much more experienced emergency physicians, improve outcomes by intubating patients. We just assume this, because we don’t really want to know. If we decide to be honest and actually find out the effect of intubation, how will we handle it if the results show that we are harming more patients than we are helping?

The Cardiac Arrhythmia Suppression Trial was only started because the proponents of the different antiarrhythmics (encainide, flecainide, and moricizine) wanted to prove that their drug was better than all of the rest. They even agreed to include a placebo arm, although the doctors did not like the idea of depriving patients of such beneficial treatment.

 
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.[2]
 

People who had frequent ectopic heart beats – PVCs (Premature Ventricular Contractions) after a heart attack were more likely to die than people who did not have frequent PVCs. The obvious solution – the equivalent of intubation and blood-letting – was to give drugs that will get rid of the PVCs. The problem is that the PVCs were not the problem. The PVCs were just a sign of the problem. The drugs made the actual problem with the heart worse, while making the heart appear to be better. The same is true of blood-letting and may be true of intubation. Abundant evidence for the obvious benefits of blood-letting are quoted in the footnotes.[3]

If intubation is harmful, do we want to know?

If intubation by the average paramedic is harmful, do we want to know?

If intubation by the average emergency physician is harmful, do we want to know?

It isn’t as if we take intubation seriously. If we did take intubation seriously, we would practice much, much more than we do. In stead, we make excuses for failing to practice something that we claim is life-saving, because we are too arrogant to admit that practice is important to develop and maintain any skill.

Practicing on even the most basic mannequin should be done before every shift, whether you are a paramedic or an emergency physician. Unless you have a 99%, or better, success rate on hundreds of patients.

Footnotes:

[1] Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364

The article above is commentary on the article below:

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674

[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

Free Full Text from N Engl J Med.

[3] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.
 

.

Does Room Air Reduce Mortality Among Term Neonates Requiring Respiratory Support at Birth?

     

The title of this meta-analysis suggests that it is important for us to have evidence in order to withhold treatments that are based on assumptions and anecdotes, rather than based on evidence. We should not even suggest this. Fortunately, the neonatal resuscitation guidelines have recommended not using the assumption-based and anecdote-based treatment since 2010.

 

Before 2000, resuscitation guidelines recommended 100% Fio2 for newborn respiratory support.6 However, hyperoxemia caused by high Fio2 results in the formation of free radicals, which can damage the lungs, brain, eyes, and other organs.7 Hypoxemia may also lead to harm. Literature in the early 2000s suggested no harm with room air resuscitation in term neonates, but also potentially an improvement in short-term mortality.8 In accordance with this literature, in 2010 and 2015 ILCOR recommended using room air for the initial resuscitation of term neonates.9, 10 [1]
 

The authors of this summary of the meta-analysis qualify this meta-analysis with a list of the weaknesses of the research. This is important for every analysis of research, but is it relevant, when there is no good reason to recommend the traditional intervention?  

According to these results with low evidence certainty, room air reduces short-term mortality compared with 100% Fio2 among term neonates requiring respiratory support at birth. Despite the low-quality evidence, these results are consistent across studies with low heterogeneity. The effect of intermediate Fio2 levels is not known and may benefit from further study. [1]
 

These are not reasons to reconsider, or oppose, the withholding of any treatments that are based on assumptions and anecdotes, rather than based on evidence.

The burden of proof is on those promoting any intervention. In the absence of valid evidence, we should limit ourselves to interventions that are supported by high quality evidence.

For epinephrine in cardiac arrest, there is no high quality evidence of benefit. The highest quality evidence is evidence of harm from epinephrine. The same is true for amiodarone, ventilation in cardiac arrest not due to a respiratory problem, furosemide in ADHF/CHF (Acute Decompensated Heart Failure/Congestive Heart Failure), and many other treatments we provide to patients, but definitely not for the benefit of patients.

We need to stop putting patients last in treatment decisions. The neonatal resuscitation guidelines are correct in their rejection of supplemental oxygen for neonatal resuscitation and the guidelines should not be changed.

Footnotes:

[1] Does Room Air Reduce Mortality Among Term Neonates Requiring Respiratory Support at Birth?

Brit Long, MD (EBEM Commentator), Michael D. April, MD, DPhil (EBEM Commentator) Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX

Annals of Emergency Medicine

October 2019, Volume 74, Issue 4, Pages 509–511

DOI:&nbps;https://doi.org/10.1016/j.annemergmed.2019.03.017

Free Full Text from Annals of Emergency Medicine. .

ILCOR wants the appearance of public comments with less than half the substance

 

The International Liaison Committee on Resuscitation (ILCOR) shows its priorities in the way it handles its problem with public comments.
 

Last week ILCOR posted the two new draft CoSTRs listed below for public comment. It became apparent that the commenting link was broken and those who visited the site could not comment. We apologize for the inconvenience. The commenting link is now fixed and we invite you to comment at ilcor.org/costr.

  • Advanced Airway Management During Adult Cardiac Arrest
  • Vasopressors in Adult Cardiac Arrest
  • As a reminder, the public comment period will close on 4 April 2019.[1]

     

    ILCOR made a mistake that prevented public comments from being submitted for most of the public comment period.

    ILCOR is so interested in your public comments that they have decided to send out an email to let people know that they have the same drop dead date for the comments as before, but this time they might actually be able to get the comments to work. Maybe.

    The lack of evidence of benefit of epinephrine (adrenaline in Commonwealth countries) has lasted over half a century, so what is the rush to get these new guidelines out?

    There is only one outcome that matters – survival without severe brain damage.
     


     

    ILCOR evaluates 23 outcomes.

    ILCOR considers 15 of these outcomes critical, but they are really just 5 outcomes, with some of them repeated over different rhythms. These are (in increasing order of importance to the only one that matters):

    1. For the critical outcome of survival to hospital discharge, 2. For the critical outcome of survival at 3 months, 3. For the critical outcome of favorable neurologic outcome at hospital discharge, 4. For the critical outcome of survival with unfavorable neurologic outcome at 3 months, 5. For the critical outcome of favorable neurologic outcome at 3 months,

    Many of them are repeated for each cardiac arrest rhythm or for each vasopressor, or vasopressor cocktail:

    1. Epinephrine plus vasopressin compared to epinephrine only – Any rhythm 2. Initial vasopressin compared to initial epinephrine – Any rhythm 3. Epinephrine compared to placebo – Non-shockable rhythms 4. Epinephrine compared to placebo – Shockable rhythms 5. Epinephrine compared to placebo – Any initial rhythm

    There is only one outcome that matters – survival without severe brain damage.

    There is only one study that was large enough to answer this:
     

    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.[2]

     

    If the people at ILCOR really think that epinephrine is beneficial in cardiac arrest, they should encourage a much larger study.

    There were 4,000 patients in each group – 4,000 placebo and 4,000 epinephrine.

    Maybe with 8,000 patients in each group, the ever decreasing “trend toward better outcome” will reach significance. Maybe it will be shown to be just another insignificant appearance of a “trend” that is the result of having so few survivors to compare.

    There were only 161 survivors without severe brain damage out of 8,000 cardiac arrest patients – 74 placebo and 87 epinephrine.

    Those resuscitated before receiving epinephrine/placebo were excluded from the study, so this is not a case of EMS that only has a 2% resuscitation rate. The focus on epinephrine is a focus on the patients least likely to be resuscitated and a focus on counterproductive outcomes.

    Almost all of our good outcomes (without severe brain damage) will be without epinephrine, because these resuscitations happen before epinephrine can be give by even the most aggressive epi enthusiast.

    What we are doing is making excuses for memorizing ineffective interventions and requiring their application is a specific way, in order to determine the quality of care. We are promoting fantasy.

    We learned that distracting from the quality of chest compressions is the most deadly thing we can do in resuscitation.

    CPR = only chest compressions – the exception is when the arrest is believed to be due to a respiratory event, such as when the Smurf sign or a respiratory/choking history is present. Chest compressions provide all of the pulmonary resuscitation that a human needs for a non-respiratory event and the respiratory events are not easily missed.

    Why require a whole bunch of skills be applied for such a tiny portion of good outcomes among cardiac arrest patients?

    Why not give up on requiring these skills when the evidence makes it clear that there is no benefit?

    All we are doing is adding cognitive load to make us feel like we are doing something special.

    We could learn something that actually benefits patients, such as how to assess patients when giving high-dose NTG (NiTroGlycerin or GTN GlycerylTriNitrate in Commonwealth countries) for even hypotensive CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure), where we can make much more of a difference and prevent cardiac arrest, but we don’t.[3],[4],[5]
     


     

    Cognitive load is not just a problem for paramedics and nurses, or med/surg doctors, but also for emergency physicians:

    Cognitive Load and the Emergency Physician
    April 12, 2016
    James O’Shea
    emDocs
    Article

    Why are we distracting everyone from things that do improve the only outcome that matters, in order to promote things that do not improve any outcome that matters?

    Here is what I wrote –
     

    The primary source for the recommendation to keep things the same is a brand new study – PARAMEDIC2.

    This showed no statistically significant improvement in the only outcome that matter – survival without severe brain damage.

    A larger study might show that there is a real improvement – or it may put the epi hypothesis out of its misery.

    I will eventually have a cardiac arrest. If I am resuscitated, whom will ILCOR send to change my diaper, and attend to the other things I can no longer attend to?

    We need evidence of a significant benefit in order to justify distracting everyone from interventions that actually do improve survival without severe brain damage.

    .

     

    The commenting link is now fixed and we invite you to comment at ilcor.org/costr

    Maybe they will pay attention. Dr. Rory Spiegel of EM Nerd has a detailed comment that is also critical of ILCOR’s proposed “strong recommendation” of epinephrine.

    Footnotes:

    [1] Vasopressors in Adult Cardiac Arrest
    Time left for commenting: 11 days 15:49:49
    ILCOR staff
    Created: March 21, 2019 · Updated: March 21, 2019
    Draft for public comment
    Consensus on Science with Treatment Recommendations (CoSTR)
    Vasopressors in Adult Cardiac Arrest page for comments until April 04, 2019 at 06:00 Eastern Time

    [2] 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

    Free Full Text from N Engl J Med.
     

    In a Bayesian analysis that used an assumption of no benefit from adrenaline, the posterior probability that the absolute rate of survival was at least 1 percentage point higher in the epinephrine group than in the placebo group was 37% (Fig. S3 in the Supplementary Appendix). The probability that the absolute survival rate was at least 2 percentage points higher was 0.2%. With respect to the rate of survival with a favorable neurologic outcome at hospital discharge, the probabilities that the rate was at least 1 or 2 percentage points higher with epinephrine were 1.9% and 0%, respectively (Fig. S4 in the Supplementary Appendix).

     

    The probability of a good outcome (no severe brain damage) is not improved with epinephrine.

    If we want to improve outcomes, we need to look elsewhere, because there is nothing to be gained with epi.

    [3] Intravenous nitrates in the prehospital management of acute pulmonary edema.
    Bertini G, Giglioli C, Biggeri A, Margheri M, Simonetti I, Sica ML, Russo L, Gensini G.
    Ann Emerg Med. 1997 Oct;30(4):493-9.
    PMID: 9326864 [PubMed – indexed for MEDLINE]

    [4] Unreasonable Fear of Hypotension and High-Dose NTG – Part I
    Thu, 29 Aug 2013
    Rogue Medic
    Article

    [5] Unreasonable Fear of Hypotension and High-Dose NTG – Part II
    Wed, 04 Sep 2013
    Rogue Medic
    Article

    .

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

     
    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.

    .

    Have a Slow, Quiet Friday the Thirteenth

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

     

    Superstitious appears to be common among medical people, so this may be seen as offensive. If you doubt me, comment that it is slow or quiet and see how many respond negatively, while they do not receive any criticism for their superstition-based complaints. Rather, people will make excuses for coddling the superstitions of those who are entrusted with the lives of patients.

    The evidence does not support their superstitions.

    One study did appear to show that women die in motor vehicle collisions more often on Friday the 13th, but that appears to be due to a lack of understanding of statistics by many who cite the article.
     

    An additional factor is anxiolytic medication, used by significantly more women than men in Finland (7), which has been reported to reduce attention span and worsen driving performance (8). . . . Why this phenomenon exists in women but not in men remains unknown, but perhaps the twice-as-high prevalence of neurotic disorders and anxiety symptoms in women (7) makes them more susceptible to superstition and worsening of driving performance.[1]

     

    The author suspects that those people with conditions that could be diagnosed as neuroses or anxiety disorders may be disproportionately affected by superstition.

    In other words, superstition is not an external force affecting you. You are doing it to yourself.

    The sample size was national, but still small, and was not able to adjust for many possible confounding variables, so the study would need to be replicated using a much larger data base to be useful.

    In other superstition news – the next apocalypse, in a long line of predicted apocalypses, is going to be this Sunday – the 15 of October, 2017, according to David Meade. Meade twice previously predicted that a magical planet would hit the Earth and kill us all. This time he claims that his calculations are accurate, because that was the problem with his previous calculations – inaccuracy, not that they were a superstition deserving of derision.

    If you are superstitious, and feel that your neuroses/anxieties will cause you to harm others, or yourself, you may want to stay home today and Sunday – perhaps even until you are capable of grasping reality.

    Of course, we would never base treatment on superstition in medicine.

    Amiodarone is the go to antiarrhythmic drug for cardiac arrest and ventricular tachycardia, but there are much safer much more effective drugs available. We have our own prophets misrepresenting research results to make it seem that using amiodarone for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[2],[3]

    Ventilation during cardiac arrest has been shown to be a good idea only for patients who arrested for respiratory reasons. We do a great job of identifying these patients. We have our own prophets misrepresenting research results to make it seem that providing ventilations for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[4]

    Medicine is full of superstition and superstitious people.

    Why?

    Too many of us believe the lie that, I’ve seen it work.

    I have also written about the superstition of Friday the 13th here –

    Acute coronary syndrome on Friday the 13th: a case for re-organising services? – Fri, 13 Jan 2017

    The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

    Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

    Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

    Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

    2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

    T G I Friday the 13th – Fri, 13 Nov 2009

    Happy Equinox! – Thu, 20 Mar 2008

    Footnotes:

    [1] Traffic deaths and superstition on Friday the 13th.
    Näyhä S.
    Am J Psychiatry. 2002 Dec;159(12):2110-1.
    PMID: 12450968

    Free Full Text from Am J Psychiatry.

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

    There are a dozen links to the research in the footnotes to that article. There are also links to other articles on the failure of amiodarone to live up to its hype.

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

    [4] Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
    Fri, 09 Dec 2011
    Rogue Medic
    Article

    .

    Comment on Irresponsibility and Intubation – The EMS Standard Of Care

     

    I wrote about the petition to protect paramedic incompetence in Irresponsibility and Intubation – The EMS Standard Of Care

    Nathan Boone responded with the following comment
     

    You’re forgetting about the rural medic out there.

     

    No. I am not.

    Are you suggesting that bad airway management for a longer period of time is less harmful than bad airway management for a shorter period of time?
     


     

    Where we are with our patients for more then a hour, not 5 mintues.

     

    The harm from incompetent airway management does not depend on distance from the hospital. Intubation even kills patients in the hospital.

    You may believe that the efficacy of voodoo is directly related to the distance from the hospital, but it appears to be only your belief that increases.

    Voodoo does not work, regardless of the distance from the hospital.

    If the paramedic cannot manage an airway, the paramedic should not be permitted to intubate.
     

    Sometimes air- craft isn’t available if its raining or on another call.. You want us to use a bvm and take chance of filling the patients stomic up for over a hour.. Yes we can be extremely careful and do everything in our power not to fill the stomic but there’s some patients out there who have difficult airways where bagging can be extremely difficult and or impossible.

     

    Give incompetent paramedics dangerous tools to try to manage difficult airways because of distance? Wouldn’t it be better to try to make them competent – or to limit intubation to competent paramedics?

    Intubation and BVM (Bag Valve Mask) are not the only forms of ventilation.
     

    Rsi does save patients in rural areas, we need intubations..

     

    Maybe. Maybe not. Maybe RSI kills more patients than it saves.

    Actually, what I mean to write is, Maybe paramedics using RSI kill more patients than they save.

    If you want to claim otherwise, prove it with high-quality research.

    Unless you can provide high-quality research, your plastic airway religion is just another alt-med scam.

    If your patients are important, then you need to demand that we find out what is best for the patients.
     

    Do I believe that Rsi is risky and their is some medics out there who would rather make the patient more hypoxic then before until they give up and go to a secondary airway..absolutely.. But to take it away from Rural Medics when we can have anything to burn patients to anaphylactic reactions and to take our ONLY definitive airway;away from us..

     

    You seem to think that RSI (Rapid Sequence Induction of anesthesia) becomes less risky the farther you are from the hospital.

    Why?

    Incompetence for a longer period will be expected to cause more harm.

    Sometimes the incompetence of the paramedic doesn’t kill the patient.
     

    Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]

     

    The patient clearly did not need intubation.

    As with the crash of Trooper 2 in Maryland, the survival of the patient for hours in the woods, in the rain, following the helicopter crash that killed all of the other healthy people on board, was clear evidence that there was no reason to send this patient to the trauma center by air.

    The same argument was provided by people, including Dr. Thomas Scalea, the head of Shock Trauma – If you don’t let us have our toys, people will die![2]

    The rate of helicopter transport of trauma patients was dramatically cut.

    That was almost a decade ago and we are still waiting for the dead bodies.

    I expect that the same failure of prophesy will occur, when incompetent paramedics are prevented from intubating.

    I expect that the fatality rate will decrease, when incompetent paramedics are prevented from intubating.
     

    I think you’re out of your mind.

     

    Many religious fanatics do.
     

    In the city, I can maybe defend you. But the studies need to be done out in the sticks as well. I believe that we should have to go outpatient surgery every year or 2 or have number set of how many we need in that time period successfully to keep our skills sharp..

     

    Every year or two?

    WTF?

    You don’t want to be taken seriously, do you?

    This is something that requires a lot of skill and practice, so I get just a tiny bit, every other year. Trust me with your life.
     

    After a Rsi and I have no one in the back but myself for over an hour.., I can place the patient on a vent and care for my patient. If RSI is taken away. I loose the capability to monitor my patient, and would be more focused on bagging my patient, or making sure the secondary away isn’t failing and I’m filling the stomic on the vent, because it can happen.

     

    It is just a staffing issue.

    That is different.

    Competence isn’t needed when you are in the back by yourself.

    Why are you opposed to competence?

    Where is a single reasonable argument that intubation improves outcomes?

    Where is a single reasonable argument that rural paramedics have an intubation success rate that is above 95%?

    Even 95% means that some of your patients don’t end up with a properly placed endotracheal tube. What do you think happens to them?

    Does your EMS agency have a better than 95% intubation success rate?

    If you can’t manage at least 95%, why do you believe you can manage intubation?

    Is each intubation on video, or do they just believe whatever you tell them?

    If you want to be taken seriously, these are just some of the essential points to address.
     

    This is not a new topic. You might also read the series below:

    In Defense of Intubation Incompetence – Part I

    In Defense of Intubation Incompetence – Part II

    In Defense of Intubation Incompetence – Part III

    How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

    How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II

    Footnotes:

    [1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
    Katz SH, Falk JL.
    Ann Emerg Med. 2001 Jan;37(1):32-7.
    PMID: 11145768 [PubMed – indexed for MEDLINE]

    Free Full Text PDF

    [2] Helicopters and Bad Science
    Thu, 09 Oct 2008
    Rogue Medic
    Article

    .

    Irresponsibility and Intubation – The EMS Standard Of Care

     

    There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.
     


    Image source
    Details here and here.
     

    The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

    We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.
     

     
    We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.

     

    Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]

     

    Most effective?

    There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

    Most effective?

    No.

    This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.
     

    Please sign this petition so that these patients have a chance to live[1]

     

    Prove that requiring higher standards for intubation would take away a patient’s chance to live.

    Prove that intubation improves outcomes.

    This is a petition to keep standards low for paramedics.

    This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

    This is the Protect Incompetent Paramedics from Responsibility Petition.

    Responsibility is for professionals. In EMS, we reject responsibility.

    We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

    We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

    Most effective? Maybe intubation is the most effective theater.

    The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

    We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

    How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

    How much vomiting, and aspiration, do we cause?

    How much airway swelling do we cause?

    How many airway infections do we cause?

    How much harm do we cause?

    We don’t know. We don’t care. We oppose attempts to find out.

    We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

    Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

    If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.
     

    Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

    Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?

    Footnotes:

    [1] Allow paramedics to continue to save lives with endotracheal intubation!
    Anthony Gantenbein United States
    Petition site

    .