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

- Rogue Medic

This Rhythm is Hilarious


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.


Why do people deny they are having heart attacks? NSFW language in video


Why is this NSFW (Not Safe For Work)? Because some of the language in the video is not appropriate for some workplaces.

Why have Keven Smith talk about a heart attack?

Because we generally do not get an opportunity to have the patient explain what they were thinking while they were having the heart attack. We have to negotiate with the patient to be able to assess the medical condition properly, but we don’t usually have the time to have an extended discussion about why the patient is not feeling cooperative.


When did he realize that his significant family history of heart disease was causing his problems? Apparently, not until after the words heart attack were used by EMS.

How can people try to deny that the chest pressure, difficulty breathing, diaphoresis, nausea, et cetera are not a heart attack? Because it is natural for our species to assume either of two extremes – that bad things happen to other people or that bad things always happen to me. We are not good at being reasonable.

I had a cardiologist as a patient. He had the same presentation.

I was able to show him 9 of the 12 leads (not the augmented leads, because we did not have a 12 lead capable monitor). He admitted that the ST segment elevation was consistent with an acute myocardial infarction. He refused to leave.

As a cardiologist, he could easily explain that he understood cardiology better than I do, and therefore did understand the gravity of the situation.

He was answering all questions appropriately.

He felt that he would ruin the event he was attending if he left in an ambulance. His shirt was covered with what had been the contents of his stomach an little earlier. Nobody suggested that he should stay at the event.

Some men you just can’t reach.

How do you get someone to accept reality, when he adamantly insist that his opinion is real and that the evidence is wrong?

We did not end up back at that location the rest of the night and nobody else was dispatched to that location, so it appears that he did not drop dead right away. Beyond that, I don’t know. Maybe he was smart enough to see a fellow cardiologist soon after. Maybe it was something other than a heart attack. If it was a heart attack, maybe it was minor.


Cardiac arrest victim Trudy Jones ‘given placebo’ – rather than experimental epinephrine


As part of a study to find out if epinephrine (adrenaline in Commonwealth countries) is safe to use in cardiac arrest, a patient was treated with a placebo, rather than the inadequately tested drug. Some people are upset that the patient did not receive the drug they know nothing about.[1]

The critics are trying to make sure that we never learn.

We need to find out how much harm epinephrine causes, rather than make assumptions based on prejudices.

When used in cardiac arrest, does epinephrine produce a pulse more often?


When used in cardiac arrest, does epinephrine produce a good outcome more often?

We don’t know.

In over half a century of use in cardiac arrest, we have not bothered to find out.


We did try to find out one time, but the media and politicians stopped it.[2]

We would rather harm patients with unreasonable hope, than find out how much harm we are causing to patients.

We would rather continue to be part of a huge, uncontrolled, unapproved, undeclared, undocumented, unethical experiment, than find out what works.

Have we given informed consent to that kind of experimentation?

Ignorance is bliss.

The good news is that the enrollment of patients has finished, so the media and politicians will not be able to prevent us from learning the little that we will be able to learn from this research.[3]

Will the results tell us which patients are harmed by epinephrine?

Probably not – that will require a willingness to admit the limits of what we learn and more research.

What EMS treatments have been demonstrated to improve outcomes from cardiac arrest?

1. High quality chest compressions.
2. Defibrillation, when indicated.

Nothing else.

All other treatments, when tested, have failed to be better than nothing (placebo).


[1] Cardiac arrest victim Trudy Jones ‘given placebo’
BBC News
23 March 2018

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

Free Full Text PDF Download from semanticscholar.org

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


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


[3] Paramedic2 – The Adrenaline Trial
Warwick Medical School
Trial Updates

Trial Update – 19 February 2018:
PARAMEDIC2 has finished recruitment and we are therefore no longer issuing ‘No Study’ bracelets. The data collected from the trial is in the process of being analysed and we expect to publish the results in 2018. Once the results have been published, a summary will be provided on the trial website.


Edited 12-27-2018 to correct link to pdf of Jacobs study in footnote 2.


Is placebo better than aggressive medical treatment for patients NOT having a heart attack?

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

Is cardiac catheterization placebo better than aggressive medical treatment for patients not having a heart attack?


The answer is not really different from before. This should not be surprising for anyone who pays attention to EBM (Evidence-Based Medicine). We should all pay attention to EBM, because it is the best way to find out what works.

Many routine treatments are not beneficial to patients, but are considered to be standards of care. We continue to give these treatments out of unreasonable optimism, a fear of litigation, or fear of criticism for not following orders. The difference between the banality of evil and the banality of incompetence does not appear to be significant in any way that matters.

PCI (Percutaneous Coronary Intervention) treatment does not add any benefit – unless you are having a heart attack.

The placebo group received sham PCI in addition to optimized medical treatment. this did not provide any benefit over actual PCI in addition to optimized medical treatment. The patients in the placebo group received all of the same medications that the patients in the PCI group received.

Why is this news today?

A recent article in The Lancet is encouraging snake oil salesmen and snake oil saleswomen to claim that it shows the miracle healing power of placebos, but this is not true.

Apparently, Big Placebo (the multi-billion dollar alternative medicine industry) is trying to use this to promote their scams (homeopathy, acupuncture, Reiki, naturopathy, prayer, . . . ).

Big Placebo seems to think that this study shows that placebo is better than medical treatment. A placebo is an inactive intervention that is undetectable when compared with the active treatment. The placebo group received the same aggressive medications that the treatment group received.

All patients were pretreated with dual antiplatelet therapy. In both groups, the duration of dual antiplatelet therapy was the same and continued until the fial (unblinding) visit. Coronary angiography was done via a radial or femoral arterial approach with auditory isolation achieved by placing over-the-ear headphones playing music on the patient throughout the procedure.[1]


What is new about this?

A much larger study a decade ago showed that aggressive medical therapy was as good as PCI and aggressive medical therapy. The difference is the use of sham PCI to create a placebo group for comparison, rather than using a No PCI group for comparison.

As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.


Compare that with the conclusion (interpretation) of the new paper.

In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy.


The unfortunate outcome is that we will have fewer hospitals providing PCI, so patients with heart attacks (STEMI – ST segment Elevation Myocardial Infarctions) may have to wait longer for emergency PCI, which really does improve outcomes.

What other Standards Of Care are NOT supported by valid evidence?

Amiodarone is effective for cardiac arrest, whether unwitnessed, witnessed, or witnessed by EMS.

Kayexalate (Sodium Polystyrene) is a good treatment for hyperkalemia. Anything that causes diarrhea will lower your potassium level, but that does not make it a good treatment, unless you are in an austere environment (in other words – not in a real hospital).

Amiodarone is effective for VT (Ventricular Tachycardia).

Backboards are effective to protect against spinal injury while transporting patients.

Blood-letting is effective for anything except hemochromatosis (and some rare disorders).

More paramedics are better for the patient.

Prehospital intravenous lines save lives.

IV fluid saves lives in hemorrhagic shock.

Oxygen should be given to everyone having a heart attack.

The Golden Hour is important.

Driving fast saves lives. For only some rare conditions, it probably does – and that depends on traffic.

Flying people to the hospital saves lives. Again, for only some rare conditions, it probably does – and that depends on traffic and distance.

Tourniquets are dangerous. As with anything else, if used inappropriately, they are dangerous, but tourniquets save lives.

Prehospital intubation saves lives.

Ventilation in cardiac arrest improves outcomes (other than for respiratory causes of cardiac arrest, which are easy to identify).

Epinephrine improves outcomes in cardiac arrest. It does produce a pulse more often, but at what cost to the long-term survival of the patient and the patient’s brain? PARAMEDIC2 should help us to identify which patients benefit from epinephrine, since it is clear that many patients are harmed by epinephrine in cardiac arrest. If we limit treatment to patients reasonably expected to benefit from the treatment, we can improve long-term survival.

And there are many more.


[1] Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial.
Al-Lamee R, Thompson D, Dehbi HM, Sen S, Tang K, Davies J, Keeble T, Mielewczik M, Kaprielian R, Malik IS, Nijjer SS, Petraco R, Cook C, Ahmad Y, Howard J, Baker C, Sharp A, Gerber R, Talwar S, Assomull R, Mayet J, Wensel R, Collier D, Shun-Shin M, Thom SA, Davies JE, Francis DP; ORBITA investigators.
Lancet. 2017 Nov 1. pii: S0140-6736(17)32714-9. doi: 10.1016/S0140-6736(17)32714-9. [Epub ahead of print]
PMID: 29103656

[2] Optimal medical therapy with or without PCI for stable coronary disease.
Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group.
N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26.
PMID: 17387127

Free Full Text from N Engl J Med.


Normal Sinus Rhythm is Not a Good Description

What is the rhythm 1a

Is Normal Sinus Rhythm a good description of this rhythm?

Is it sinus?

Is it normal?

Dr. Steven Novella writes about normal and some of the meanings of normal.

This findings, if confirmed, has several implications. First, it is just good to know how our brains typically work. “Normal” is a combined judgment about what is actually happening and what “should” be happening. This confirms what was observed in health care, especially psychiatry, that there is a moral judgment in deciding what is normal.[1]


Too often, we seem to try to apply what we think something should be to our mistaken description of what something is.

As an example, an ECG (ElectroCardioGram) showing a regular, or slightly irregular, sinus rhythm is often described using the misleading term normal sinus rhythm.

Normal suggests that there is nothing wrong with the rhythm, or with the heart, when it is not unusual for a patient to have a heart attack with a normal sinus rhythm being accurately displayed on the ECG.

We are subconsciously telling ourselves, Nothing to see here. Move along.

We are fooling ourselves and discouraging investigation of what may be causing problems by unnecessarily adding the term normal.

In this setting, normal does not add any information, but suggests that we know more than we actually know.

Why lie to ourselves?

Because we trust ourselves and don’t bother to check our assumptions to see if they are valid.

What is the rhythm 1

It is clearly sinus, but what information do we add by calling it normal?


[1] What Is Normal?
Steven Novella
Feb 02, 2017


Valsalva the SVT or Shock the Monkey?


The Skeptics’ Guide to Emergency Medicine should be on your podcast list. The podcasts are short, so there is not much reason to avoid them. This one is 13 minutes.

Valsalva for SVT (SupraVentricular Tachycardia) is supposed to come before medication. At least that is the order of treatments of every EMS SVT protocol I have seen. Since medicine is expected to have more, and more serious, side effects, this is reasonable.

What medicines?

Adenosine has the side effects of –


Prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes



Central Nervous System

Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness.[1]


It appears to be reasonable to try to avoid those side effects.

Too much of this could become more of a problem than an SVT.

Click on images to make them larger. Image credit.[2] This is not the actual strip, but a strip of an adenosine pause edited to produce more asystole, which I have seen.

The side effect becomes much more of a problem when someone decides to treat the side effect, rather than wait for it to wear off.

We SLAM adenosine in because it wears off quickly. A minute, or two, of asystole is not a problem.

Giving a dose of epinephrine to a patient who had an SVT a minute ago and now has adenosine quickly wearing off – that may be a fatal problem.

But how effective is the Valsalva maneuver (VM)?

The VM is a non-invasive way to convert patients from SVT to sinus.It increases myocardial refractory period by increasing intrathoracic pressure thus stimulating baroreceptors in the aortic arch and carotid bodies Increases vagal tone (parasympathetic).[3]


Here is a big problem with the use of the Valsalva maneuver. It is just one method of attempting to stimulate the vagus nerve.

There are many other methods and they may be more successful. Carotid sinus massage (after auscultation for bruits), facial immersion in ice water (assuring that the airway does not become a problem), bearing down, blowing through a straw (even better may be a swizzle stick), digital circumferential sweep of the anus, coughing, . . . .

There are many ways of activating the vagal nerve, but my favorite is to act as if I have not started an IV before, go very s l o w l y with the insertion of the largest IV catheter I think I can get in the vein, and this has almost always broken the rhythm.

Yes, that is anecdotal, but I have only rarely needed to follow that with medication.

Yes, pain is not a nice thing, but it is much nicer than the side effects listed above.

Bottom Line: There is no standardized methods to perform a VM to terminate uncomplicated SVT that are evidence based.

Clinical Application: VM is a viable technique that is poorly researched for the conversion of SVT and should not be considered essential to attempt prior to chemical cardioversion.[2]


We need better vagal maneuvers.

We need good evidence on what works.

Go read the article and listen to the podcast.


[1] ADENOCARD (adenosine) solution
[Astellas Pharma US, Inc.]

FDA Label

[2] Atrioventricular Re-entrant Tachycardia
Thumbnail Guide to Congenital Heart Disease
edited version of their adenosine ECG strip

[3] SGEM#67: Shock the Monkey Tonight (Valsalva Maneuver for SVT)
Podcast Link: SGEM67
Date: March 23, 2014
Skeptics’ Guide to Emergency Medicine
Article and link to podcast


Who Needs a 12 Lead ECG?


Do we do too many 12 lead ECGs on patients who do not have chest pain?

This is something that some people worry about.

Save the electrodes!

Those poor little electrodes are being abused!

Are electrodes being abused?

Women and the elderly with STEMI are particularly likely to present with atypical chief complaints such as dyspnea and weakness. Such patients experience significant delays in door-to-ECG time and treatment and have increased morbidity and mortality compared with patients who present with chest pain.5,9-12 [1]


Tiredness/weakness is the second best predictor of STEMI (ST segment Elevation Myocardial Infarction).

After chest pain (pressure, tightness, heaviness, squeezing, et cetera), the best predictor of STEMI is dyspnea in akll age ranges, but dyspnea indicates 20% of STEMIs in patients over 80 years old.

Are we helping anyone by avoiding 12 lead ECG (ElectroCardioGram) assessment?

Presenting chief complaints among 6,464 patients with STEMI. Chest pain decreased in frequency with age, whereas a chief complaint of dyspnea, weakness, syncope, or altered mental status all increased in frequency with age.[1]


Click on images to make them larger.


The advantage of a logarithmic chart is that there is greater distinction among the smaller numbers (such as the other complaints that make up less than 5% in the image above). The disadvantage is that large changes are flattened. I modified the dyspnea line to show how it would look on a linear scale (from 5% to 20%). As you can see, the ability to predict STEMI increases dramatically with age – more dramatically than the logarithmic scale suggests.


How should we remember all of this?

The authors came up with a nice simple flow chart (below).

This is for the ED, but is there a good reason for EMS to ignore these STEMIs?


Even in the 18-49 year old patients, dyspnea is about as likely to predict a STEMI as weakness is likely to predict a STEMI in an 80+ year old patient.

Chest pain still indicates about 50% of STEMI patients over 80, but we will miss half of STEMIs in this population if we only do 12 leads on chest pain patients.

Can an 80+ year old patient have a good quality of life after a STEMI?


Also see When should you get an ECG? at Mill Hill Ave Command.


[1] Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction.
Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, Glickman LT.
Am Heart J. 2012 Mar;163(3):372-82. doi: 10.1016/j.ahj.2011.10.021.
PMID: 22424007 [PubMed – indexed for MEDLINE]

Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, & Glickman LT (2012). Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. American heart journal, 163 (3), 372-82 PMID: 22424007


A Recalled AED is Better Than No AED

Cardiac arrest. CPR in progress. Do not use the AED, because it has been recalled!



HeartStart automated external defibrillators from Philips Healthcare have been recalled.

What does the FDA (Food and Drug Administration) mean by recall?

Well, why was the recall issued?

Certain HeartStart automated external defibrillator (AED) devices made by Philips Medical Systems, a division of Philips Healthcare, may be unable to deliver needed defibrillator shock in a cardiac emergency situation, the U.S. Food and Drug Administration said today in a new safety communication for users of these previously recalled devices.[1]


A shock might not be delivered.

What does the FDA recommend?

“The FDA advises keeping all recalled HeartStart AEDs in service until you obtain a replacement from Philips Healthcare or another AED manufacturer, even if the device indicates it has detected an error during a self-test,” said Steve Silverman, director of the Office of Compliance in the FDA’s Center for Devices and Radiological Health.[1]


Do not take these AEDs out of service service until a replacement is present.


What about the lawyers?

But it’s defective!

Thinking is dangerous!

“Despite current manufacturing and performance problems, the FDA considers the benefits of attempting to use an AED in a cardiac arrest emergency greater than the risk of not attempting to use the defibrillator.”[1]


The benefit is greater than the risk.

There is risk with everything.

Anyone who tells you otherwise is selling something.

There is not benefit with everything.

Since the detection of an error during the self-test does not guarantee that the AED will not deliver a shock when needed, removing the AED without a replacement is more dangerous than leaving the AED in service.

These recalled AEDs are better than no AED.

Of course, if needed for use in an emergency, make every attempt to clear the error and use the device normally, as described in the Owner’s Manual.[2]


The manufacturer and the FDA agree that, in the case of these AEDs, something is better than nothing.

Are we really going to make a dead patient more dead by using a defective AED?


[1] FDA issues safety communication on HeartStart automated external defibrillators from Philips Healthcare
FDA News Release
For Immediate Release: Dec. 3, 2013
Media Inquiries: Jennifer Rodriguez, 301-796-8232, jennifer.rodriguez@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA
News Release

[2] Philips HeartStart FRx and OnSite (HS1) automated external defibrillators (AEDs)
Phillips Healthcare
Maintenance Advisory