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

- Rogue Medic

How Effective Is Epinephrine for Improving Survival Among Patients in Cardiac Arrest?


There have been two studies comparing epinephrine with placebo to treat out of hospital cardiac arrest. The Jacobs study was stopped early, because of interference by those who do not want to know if their medicine actually works.[1] The purpose of research is to determine, as objectively as possible, if a treatment is better than placebo nothing.  

Click on the image to make it larger.  

Even the small sample size shows a impressive p values of <0.001 for both ROSC (Return Of Spontaneous Circulation) and being admitted to the hospital. Unfortunately, that does not lead to outcomes that are better than placebo.

The Perkins study (PARAMEDIC2) did not find a significant difference between adrenaline (epinephrine in non-Commonwealth countries) and placebo.[2] The Jacobs study also did not find a difference, but the numbers were small, due to the interference by the less than knowledgeable. Following the Jacobs study, some intervention proponents have suggested that the problem is not a lack of evidence of benefit, but need to look at the evidence from the right perspective. The inadequate evidence is not “inadequate”, but really just misunderstood. All we need to do is use a method of analysis that compensates for the tiny sample size. A Bayesian approach will produce the positive outcome that is not justified by so few patients.[3]

What happens when the numbers are combined, so that the sample size is large enough to eliminate the need for statistical chicanery to come up with something positive?

The outcomes do not improve.  

Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome.[4]

If the Bayesian approach were appropriate, then the much larger sample size would have provided more than enough patients to confirm the optimism of the epinephrine advocates. The result is still not statistically significant. Maybe a much, much larger study will show a statistically significant, but tiny, improvement in outcomes with epinephrine, but don’t hold your breath for that. It took half a century to produce the first study, then seven more years for the second. With the cost of research and the problems coordinating such a large study, it is more likely that the guidelines will continue to recommend spending a lot of time and money giving a drug that diverts attention from the interventions that do improve outcomes.

There is still no evidence that adrenaline provides better outcomes than placebo in human cardiac arrest patients.




[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  

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

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


[2] 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.


[3] Regarding “Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial”. Youngquist ST, Niemann JT. Resuscitation. 2012 Apr;83(4):e105; author reply e107. doi: 10.1016/j.resuscitation.2011.09.035. Epub 2012 Jan 18. No abstract available. PMID: 22266068

Free Full Text from Resuscitation.


[4] Adrenaline and vasopressin for cardiac arrest. Finn J, Jacobs I, Williams TA, Gates S, Perkins GD. Cochrane Database Syst Rev. 2019 Jan 17;1:CD003179. doi: 10.1002/14651858.CD003179.pub2. PMID: 30653257    


D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study


Why treat hypoglycemia with 10% dextrose (D10), rather than the more expensive, potentially more harmful, and less available, but traditional treatment of 50% dextrose (D50)? Why not? The only benefit of 50% dextrose appears to be that it is what people are used to using, but aren’t we used to starting IVs (IntraVenous lines) and running fluids through the IVs?

We should be much more familiar with running in fluid, than in pushing boluses of syrup.

What happens when we have temporary shortages of 50% dextrose? Do we stop treating hypoglycemia? Are we supposed to panic, because we can no longer follow tradition? No. We give the more appropriate, and lower, dose of the much lower concentration of dextrose. We provide better care because of our need.

Despite the traditional use of D50, there is a minimal amount of data to support it as the standard of care.[1]


Is 10% dextrose the perfect treatment for hypoglycemia? No, but it does appear to be less likely to cause harm than the current overtreatment with 50% dextrose.

Seven patients had a drop in blood glucose after D10 administration, all of 10 mg/dL or less except for one patient with a drop of 19 mg/dL who had an insulin pump infusing that was not removed by EMS personnel during D10 infusion.[1]


Is that any different from what happens with 50% dextrose? If this is different from D50, how does the potential harm from giving too much dextrose to most hypoglycemic patients compare to the potential harm of giving a first that is too small to fewer than 1% of hypoglycemia patients?

There were no reported adverse events related to dextrose infusion. Six patients who received intravenous D10 were pronounced dead in the field during the period of study. On investigator review, all patients had altered level of arousal or were in cardiac arrest prior to arrival of EMS personnel and their deaths were deemed to be unrelated to dextrose administration.[1]


Dextrose does not reverse death, so there is no reason to expect a better outcome for dead patients with a higher concentration of a drug that does not reverse death. Go read the excellent review of the evidence on hypoglycemia, death, and the potential of dextrose to improve outcomes from death.[2]

But is 10% really better? We don’t have any good research, but is there any good reason to give all 25 grams of dextrose in a syringe of 50% dextrose if the patient wakes up before the full dose has been administered? Would we continue to give the entire syringe of morphine, or fentanyl, or most of the other drugs that we give, if our assessment shows that the patient no longer meets the protocol criteria for administration of the drug?


76% of patients received only 10 grams of dextrose, rather than the usual 25 grams. While it is not known if any of these patients required any further dextrose, or oral glucose, while in the hospital, they should have been awake enough to take any further dextrose orally, as they would the rest of the time.

23% of patients received only 20 grams of dextrose, rather than the usual 25 grams.

Fewer than 1% of hypoglycemia patients received a dose as large as we traditionally give.

We do not appear to be concerned with harm from administering more aggressive treatment than is justified by the evidence.

We do appear to be concerned about our anxiety of deviating from the traditional too much is not enough approach to hypoglycemia.


[1] D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study.
Hern HG, Kiefer M, Louie D, Barger J, Alter HJ.
Prehosp Emerg Care. 2017 Jan-Feb;21(1):63-67. doi: 10.1080/10903127.2016.1189637. Epub 2016 Dec 5.
PMID: 27918858

Of the 1,323 patients administered D10 during the study period, the 452 patients excluded from the study cohort for the aforementioned reasons were similar demographically to the study cohort. The median initial blood glucose was the same at 37 mg/dL and the median age was also 66. There were slightly more women at 229 (51%) in the excluded group compared to the cohort.


[2] Using Dextrose in Cardiac Arrest
Wednesday, March 14, 2012
Mill Hill Ave Command
Dr. Brooks Walsh

Hern, H., Kiefer, M., Louie, D., Barger, J., & Alter, H. (2016). D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study Prehospital Emergency Care, 21 (1), 63-67 DOI: 10.1080/10903127.2016.1189637


Management of prehospital seizure patients by paramedics


Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Why look at seizures?

In a 2001 multicenter study, patients presenting with seizures or complaints related to seizures represented 1.2% of all ED visits.1 The majority of these patients (71%) utilized emergency medical services (EMS) for transport and care. An even greater number (84%) had interventions during EMS transport or in the ED that included airway attention, establishing intravenous (IV) access, and medication administration, and 55% received antiepileptic medications.[1]

It does seem as if seizures are over-represented in EMS and it seems that seizures require some very aggressive care.

The secondary objective was to identify other characteristics related to these cases that would help to ascertain the utility of specific ALS procedures.[1]

Of all of those interventions, such as 55% received antiepileptic medications, which ones are most important and why?

500 consecutive adult seizure patients over a period of 9 months produced only 97 patients for analysis. Seizures are frequent. One of the advantages of research is that it allows us to acquire some of the experience of much more frequent patient contact than we would in a busy career. 97 seizure patients is not a lot. If I only see one seizure patient a month, this is 8 years of experience, but does one seizure patient a month reflect your system? Would one a week be more like it? At one a week, this is only 2 years experience.

Why do I spend time explaining this?

These patients represent a heterogeneous group of patients including those with generalized seizures, focal seizures, and pseudo-seizures.[1]

With a very varied group, small numbers can be expected to produce results that are not representative of a much larger population. The idea is right, but the numbers are not. 500, or a thousand, would be much better for averaging the many variables. If your experience does not match what is described, here, don’t get upset. This does not match my experience, either.

You can click on the tables for larger versions.

That seems normal. I do not recall a lot of patients who are confused or who remain confused for more than a few minutes after arrival on scene.

Six patients had glucose levels (BGLs) less than 80 mg/dL (range 68–79 mg/dL), which was the protocol cutoff for treatment with dextrose or glucagon; blood glucose values at this level are herein referred to as hypoglycemia. All of these patients had an IV line attempted, though only one (BGL = 69 mg/dL) received dextrose and none received glucagon. However, only one of the untreated patients had a BGL less than 70 mg/dL (BGL = 68 mg/dL) and was in an alert, conscious state. The patient who did receive dextrose and one of two hypoglycemic patients with an unsuccessful IV attempt (BGL = 76 mg/dL) had recurrence of seizure activity in the prehospital setting.[1]

There is so much about this that raises questions, rather than answering questions. Were the seizures of any of these patients attributed to the hypoglycemia? Did any of these patients have a history of seizures due to hypoglycemia? What was learned about them in the hospital?

2/6 hypoglycemic patients (33.3%) had repeat seizures, but overall 28/97 patients (28.9%) had repeat seizures, only 17 of them (17.5%) out of the hospital.

Should we compare the hypoglycemic patients with the overall seizure patients? With only 6 hypoglycemic patients, and only 56 had BGL measured (64.4%), changes of just a single patient will completely change the apparent significance. What if, instead of 2 hypoglycemic patients having seizures, only 1 did (16.7%)? Or what if 3 did (50%)? Or what if 4 did (66.7%)? Or what if none of them did (0.0%)? And how many of the patients, who did not have BGL measured, had repeat seizures and hypoglycemia?

The hospital data are not helpful for learning more about the hypoglycemic patients. Did the hospital check BGL on every patient? Probably. Go to an ED (Emergency Department) for anything non-traumatic and expect to have a blood sugar checked.

Does that mean that we should make every medical EMS call ALS, just to check BGL?

This could be the Mechanism Of Idiocy Injury that could help minor medical calls leapfrog past trauma in ALS over-triage.

Just stop thinking and start making everything ALS, because what if we miss one?

If it saves just one life (even though maybe a dozen who would otherwise have lived will now die), it’s worth it! Go ALS!

Or we could fly all of these patients, just in case, because What if . . . ?

Anyway, back in the real world, we just don’t know what to do with the data on hypoglycemia. What about the data on repeat seizures? Some seize. Based on this study, are we able to predict which patients will have repeat seizures? No. Are we able to tell which patients have pseudo-seizures? No. Are we able to tell which patients need ALS, based on this study? No.

All but one of the 10 patients who were treated with diazepam had a less-than-alert level of consciousness (n = 7), additional prehospital seizure activity (n = 7), or both (n = 5).[1]

Maybe, we do have a good hypothesis for another study. Does the alert patient benefit from ALS?

Even if the repeat seizure patient has the full ALS workup of IV, ECG, and BGL before the repeat seizure, does it make any difference in outcome? Would any of this really prevent a seizure?

Overall, instead of revealing inappropriate care, this review emphasized the difficulty with creating a homogeneous protocol for such a diverse group of patients.[1]

That does appear to be the case.

We recommend further study with emphasis on concrete outcome measures to determine the impact that specific ALS interventions have on this group of patients.[1]

That is a good idea.

What is the right treatment for a seizure? This may be the wrong question. Maybe we should ask what the right treatment should be for a patient with no history of seizures and a decreased level of consciousness? Or what is the right treatment for a patient with a focal seizure that has been evaluated in the ED several times before? Et cetera.


[1] Management of prehospital seizure patients by paramedics.
Martin-Gill C, Hostler D, Callaway CW, Prunty H, Roth RN.
Prehosp Emerg Care. 2009 Apr-Jun;13(2):179-84.
PMID: 19291554 [PubMed – indexed for MEDLINE]

Martin-Gill, C., Hostler, D., Callaway, C., Prunty, H., & Roth, R. (2009). Management of Prehospital Seizure Patients by Paramedics Prehospital Emergency Care, 13 (2), 179-184 DOI: 10.1080/10903120802706229


Comment on ALS is Oxygen, IV, Monitor, and Transport – Part II

Continued from Part I.

Image credit.

I agree with a lot of what I read here. However, why is anyone going to give a medic with 18 months of technical school freedoms that ED docs with 8 years of medical education can’t always handle?

Because well trained medics have demonstrated that they do make good patient care decisions in the several limited areas that medics treat aggressively.

What medics do is very limited, but still cannot fit into any group of protocols, no matter how detailed.

We need to hold medics to high standards, not pretend that restrictive protocols make incompetent medics safe.

According to Joe Paczkowski (EMT-Medical Student), one of the 4 Phrases That Should Never Be Said on an Ambulance is –

We’re not doctors.

. . .

Is it any wonder that there are so many problems in EMS when EMS is one of the few, if any, fields that actively teaches their students to not think about what they’re doing past the cookbook? After all, why question any of the care you’re providing if you’re “not a doctor?”

He is going to medical school, but he does not seem to think that those who do not go to medical school should not think.

Unless you work for a service that practices “different rules for different medics”, you’re going to have to stay within protocol – not necessarily throw the protocols at every patient, but at least remain within them, or know enough to convince a reasonable doctor to agree with you.

Which is exactly what I am stating. In my response to MOE Medic, I explained a practical way to deal with protocol deviations. Why should we let paramedics make decisions about whether protocol deviations are appropriate?

I am all for taking it to the medical director. I used to make these calls about once a week to explain each deviation I made from our protocols.

I had doctors in the local emergency departments who were willing to listen.

I had even more doctors in the university hospital emergency departments willing to listen.

I also had medical directors willing to listen.

What they cared about was whether I was taking care of the patient appropriately, not whether I was taking care of the protocol appropriately.

The doctors are not usually the ones opposed to having paramedics think. This objection seems to come from the paramedics.

As in, Stop making the rest of us look bad!

I’m willing to give up some freedoms that I might be able to handle so they won’t be abused by a lazier or less proficient medic, and call med control. It’s all about doing the greatest amount of good for the largest amount of people, not stroking our ego by allowing us to declare C/P non-cardiac or do sutures.

We need to remediate, or teminate, the lazier or less proficient medics.

We do not need to dumb down the system to whatever level deceives people into believing that they are protecting patients from the lazier or less proficient medics.

Punishing patients in order to avoid remediating, or terminating, the lazier or less proficient medics is dangerous management.

Punishing patients in order to avoid remediating, or terminating, the lazier or less proficient medics is probably one of the reasons so many competent medics leave EMS.


There is no protocol that can make a lazy and/or incompetent medic safe.


There is no drug that is safe in the hands of a lazy and/or incompetent medic.


Making the protocols safe for the incompetent is the wrong approach.

1. It is guaranteed to fail.

2. What kind of Luddites are we that we oppose progress and oppose thinking?

Am I happy about that – no, but I didn’t go to medical school or do an internship either.

If you want to be a doctor, you should go to medical school and you should think.

If you want to be a paramedic, you should go to paramedic school and you should think.


Thinking is within the paramedic scope of practice.


Thinking is an essential part of the paramedic scope of practice.


This is not about what makes medics happy.

This is about what is best for patients.

To be continued later in Part III.


Comment on ALS is Oxygen, IV, Monitor, and Transport – Part I

In response to my post, ALS is Oxygen, IV, Monitor, and Transport, there is a comment from Prmedc.

Quite a few of the problems I see in the local ED come from the ED doc “practicing medicine”. Hey, I’m a doctor! Let’s just drop ten of Versed on this patient and try to intubate, instead of following my well established RSI protocol developed by ACEP.

There are appropriate reasons to deviate from any protocol – even one written by an ACEP committee.

There are many different RSI (Raped Sequence Induction/Intubation) protocols. One protocol does not fit all patients.

The 10 mg midazolam decision does not appear to make sense, but there may be legitimate reasons for using midazolam alone. It would be a mistake to assume that just because research has consistently shown that midazolam alone leads to worse outcomes, midazolam alone is never appropriate.

This is why protocol deviations should be reviewed afterward, rather than automatically punished.

Or, hey, I’m a doctor! Let’s shock sinus tach at 140 instead of giving fluids and pain meds for that fractured femur!




Image source.


Plus this –


Image source.


Is NOT an example of THINKING!


Anyone who thinks that shocking sinus tachycardia is a good idea should not be a doctor, should not be a nurse, and should not be a medic.

Sinus tachycardia is a symptom, rather than an arrhythmia to treat. We treat sinus tachycardia by treating the underlying cause(s) – the underlying cause(s) could be hypovolemia, fever, pain, inappropriate vasodilation, stimulant medication, physical exertion, et cetera.

Shocking sinus tachycardia seems to be an example of not thinking.

Shocking sinus tachycardia seems to be an example of trying to make the protocol fit the patient.

Thinking should prevent this.

We should not be memorizing faulty and nonsensical rules, such as over 150 cannot be sinus tachycardia. Or that over the maximum calculated heart rate cannot be sinus tachycardia.

These overly simplified tachycardia rules are neat, plausible, and wrong, but they are to be expected of some EMS cardioversion protocols.

Someone who thinks should not make this mistake. Someone who thinks should not obey such a protocol.

The protocol monkey does not know what to think.

The protocol monkey follows the dumbed down protocols that say to shock whatever is too fast.

The protocol monkey cannot be trusted to do anything else.

We “require” ED docs to think,

Yet you give an example of a doctor not thinking as a reason to prohibit medics from thinking.

“requiring” medics to think won’t fix the legal system or increase our knowledge base or skill level.

Let’s take a look at these suggestions:


1a. Will requiring medics to think fix the legal system?


No. Why would anyone think that it would? Medics do not run the legal system. Requiring medics to think will also not fix the banking system.


1b. Will preventing medics from thinking fix the legal system?


Of course not. This is not relevant to what I wrote.


2a. Will requiring medics to think increase our knowledge base?


Requiring medics to think can be expected to force medic programs to do a better job of teaching, which should increase our knowledge base.


2b. Will preventing medics from thinking increase our knowledge base?


No. I believe that it has the opposite effect in the places where medics are prohibited from thinking.


3a. Will requiring medics to think increase our skill level?


Probably. As medical directors have seen the ability of competent medics to handle several limited emergency conditions, they have generally expanded what paramedics are permitted to do and the medical directors have increased what paramedics are permitted to do on standing orders.

The medical directors most involved in EMS keep showing us that they want us to think.

What kind of medical director is foolish enough to prohibit medics from thinking?


3b. Will prohibiting medics from thinking increase our skill level?



Why would these medics, who are prohibited from thinking, need any skills other than skill at not thinking?

To be continued later in Part II and even later in Part III.


ALS is Oxygen, IV, Monitor, and Transport

In response to a question about a complicated ECG strip, someone responded that Oxygen, IV, Monitor, and Transport are all that is needed. Perhaps this was meant sarcastically. Perhaps not.

I do know people in EMS who think this way.

I also know people who think about people in EMS this way.

If Oxygen, IV, Monitor, and Transport define ALS in EMS, we are in trouble.

Why isn’t this blood pressure, along with the rest of the vital signs, enough?

I rarely give oxygen.

We should be giving drugs only for a specific effect.

We should not be giving drugs just to satisfy a protocol.

We should not be giving drugs to satisfy a mnemonic.

A mnemonic is a memory aid.

A mnemonic is not a standing order.

How often do we give anything other than a flush through an IV, or a saline lock?

If we are only using it to make the mnemonics Nazis happy, are we helping our patients?

Does an asthmatic need an IV to receive a bronchodilator?

What about getting an ECG for every ALS patient?

Let’s consider that the origin of this post was a comment that medics do not need to be able to interpret complex rhythms, because we just do Oxygen, IV, Monitor, and Transport.

If the medic cannot figure out what the rhythm is, why hook the patient up to the monitor? Satisfying billing? Satisfying QA/QI/CYA gnomes? Something else?

Should we transport every ALS patient?

What if this conflicts with informed consent?

What if we insist that patients agree to transport in order to receive treatment?

What about ALS treatment requires transport?

In other words, Oxygen, IV, Monitor, and Transport are not essential to ALS in EMS.

Is a doctor required to give oxygen for treatment to be ALS?

Is a doctor required to have an IV for treatment to be ALS?

Is a doctor required to have an ECG for treatment to be ALS?

Maybe we need to allow medics to think.

Maybe we need to encourage medics to think.

Maybe we need to require medics to think.


Dealing with Grief

In the comments to On the Clock: Dead, there are some great thoughts, but one is an idea that many people ignore. ERP, of ER Stories, points out:

I remember when I first was able to just put this sadness out of my mind and get back to work. I was an intern and have to say, it was pretty weird. Strange how you can just adapt to these feelings and push them aside in order to be functional.

A long time ago, in a life far, far away, I was experiencing a bit of grief. Not the first time. Won’t be the last time. I was just driving along, and not at all crying, because I am much too manly for that. Anyway, there I was, minding my own business, when all of a sudden these two cars collide in front of me.
A K-car full of little old ladies, apparently driven by one with poor depth perception, turned in front of me. I, being an experienced driver, used the middle pedal to decelerate quickly and avoid pointing out this driving flaw. The driver of the minivan next to me was less tactful. Sumdood was not driving. The driver was a very distraught soccer mom.
One LOL received some serious head trauma. The others did not appear to have any serious injuries, but did have exacerbations of underlying medical conditions. Particularly the driver with chest pain. I was off duty, but did what I could to help. Eventually, about 40 minutes after the collision, the head injured passenger was transported by helicopter. We were only about 10 minutes from a trauma center, but the medic needed to follow all of the protocols that might be relevant. 
The patient also had her chest decompressed – after the medic spent over 5 minutes off scene on the phone with medical command for permission to perform something that I doubt she needed. Of course permission was granted. It is the stuff that might actually help the patient that is turned down. I wasn’t involved in her care at that point, since I don’t know what her vital signs were, but the EMT bagging her did not seem to be experiencing difficulty and the patient did seem to tolerate the delay. 10 minutes from the trauma center and extrication of less than 5 minutes, but a scene time of close to 40 minutes (the medic was not there at the time of the crash). EMS at its finest.
Well, after the medic transferred care of the head injured patient to the helicopter crew, he was getting ready to leave. I asked him what he intended to do about the driver with chest pain, the passenger feeling weak, and the other passenger with arm pain. He seemed to blame me for his lack of awareness of the other patients in the car, even though I had updated him on them earlier. He called for more ambulances and suggested that I not make his day any more pleasant.
I gave my information to the police, in case they needed anything for their report. I returned to my vehicle and considered the question that kept returning to Leonard in Memento

Now… where was I?

Well, as I mentioned, I was just driving along, and not at all crying, because I am much too manly for that. Anyway, there I was, minding my own business, . . . . Pleased to be moving to a different state. Maybe EMS is not the same everywhere.
It is pretty amazing how easily we can put aside grief in order to do what needs to be done. The grief isn’t gone. Grief doesn’t ever seem to completely go away, just to diminish with time. Maybe it is replaced with more painful grief. Maybe it is overshadowed by joy. Maybe it just begins to fade. It does not control our lives, even though it may seem to. It sure does interfere with our lives, but we do not give up control to the grief or we would not be able to function in times like this.

On the Clock: Hole

On the Clock: Hole

With all of the recent discussion of the research and the pathophysiology of massive hemorrhage, Medic61 at On The Clock does a great job of making it real and showing how the ALS personnel can easily get caught up in things that cause them to ignore more direct methods to control the bleeding. A manual blood pressure cuff is a tourniquet – one that is often overlooked.

A blood pressure cuff, the fancy name is sphygmomanometer, works by blocking the arterial flow of blood. It allows for the slow release of the pressure applied, usually to the brachial artery, so that the return of arterial blood flow can be observed as the systolic blood pressure. If it were not an effective tourniquet, it would not be effective at measuring the systolic blood pressure.

Or, as the often used saying states –

Paramedics save lives.

EMTs save paramedics.

At some point everybody ignores the basics. If we are lucky, we have someone with more sense around. If we are even luckier, they remind us gently.

If we are unlucky, really the patient is the unlucky one, we have more certification than sense and this is not challenged by anyone around.

On The Clock is a great blog for putting patient care into a well written narrative, not something that is easy to do or easy to find.

Here are a bunch of recent posts on tourniquets, Trendelenburg, bleeding control, and hubris.


Tourniquets, Trendelenburg, Tampons, Toilet Paper

Standing Trendelenburg on it’s Head

Too Old To Work, Too Young To Retire:


And my own posts:

New Series of Rants – ParaCynic

New Series of Rants follow up

New Series of Rants Second follow up