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

- Rogue Medic

Happy Darwin and Lincoln Day 2020

Wed, 12 Feb 2020 21:00:31 -0500 by

Happy Lincoln-Darwin Day!
 
Today is the birthday of two people considered enemies by the American slavery belt – Charles Darwin and Abraham Lincoln. The slavery belt was so afraid of Lincoln that most of the slave states seceded before Lincoln took office as president.

Charles Darwin wrote a book that exposed the slavery of human beings as immoral. The slaves were just as human as every slave owner. Bible quotations in defense of slavery were regularly provided by slave owners to justify their immorality, but it was not working as well as it used to. To be fair, many of the Founding Fathers opposed slavery, but this was a compromise that will always stain the Constitution. There was even an agreement in the Constitution to allow the importation of slaves at least until 1808.
 

The Migration or Importation of such Persons as any of the States now existing shall think proper to admit, shall not be prohibited by the Congress prior to the Year one thousand eight hundred and eight, but a tax or duty may be imposed on such Importation, not exceeding ten dollars for each Person.[1]

 

There was enough opposition to the importation of slaves that a law prohibiting importation went into effect the first day possible – January 1, 1808.

Opponents of Lincoln continue to make excuses for the treason of the slave states that seceded and made war on the United States of America.

Opponents of Darwin continue to make excuses for rejection of biology, even though genetics and evolution are essential for the understanding of biology. Denial of science has become a tenet of Creationist sects.

Currently the most popular method of denying science is the one made notorious by the exposure of private documents of the cigarette industry. Create the appearance of scientific doubt and scientific controversy, even though the only doubt and controversy is about minor details, rather than the broad conclusions.
 

The most important type of story is that which casts doubt in the cause and effect theory of disease and smoking. Eye-grabbing headlines should strongly call out the point[2]

 

 

Doubt is our product next hit since it is the best means of competing with the “body of fact” that exists in the mind of the general public. It is also the means of establishing a controversy. Within the business we recognize that a controversy exists. However, with the general public the consensus is that cigarettes are in some way harmful to the health. If we are successful in establishing a controversy at the public level, then there is an opportunity to put across the real facts about smoking and health. previous hit Doubt is also the limit of our ” product.” Unfortunately, we cannot take a position directly opposing the anti-cigarette forces and say that cigarettes are a contributor to good health. No information that we have supports such a claim .

Truth is our message because of its power to withstand a conflict and sustain a controversy. If in our pro-cigarette efforts we stick to well documented fact , we can dominate a controversy and operate with the confidence of justifiable self-interest [italic emphasis added]. {2111.01, pp. 4, 5}[3]

 

The point was to create the appearance of honesty, without the substance. This method is used by a lot of other science denialists – anti-vaxers, climate change deniers (both those who deny that climate change is real and those who claim that human activity is not responsible for the dramatic acceleration of global warming), flat earthers, alternative medicine promoters, anti-GMO activists, anti-abortion activists, anti-equality activists, geocentrists, et cetera.

Reality is their enemy.

Reality will always be their enemy.

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Footnotes:

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[1] Article 1 Section 9
U.S. Constitution
Link to Article 1 Section 9 at constitution.net

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[2] Tobacco Explained – The truth about the tobacco industry …in its own words
World Health Organization
Page 11/79 on the pdf counter, but marked as page 7 on the page
Free Full Text in PDF format from WHO
 

Carl Thompson from Hill and Knowlton writes a letter on the best angles for the
industry magazine, Tobacco and Health Research:
“The most important type of story is that which casts
doubt in the cause and effect theory of disease and
smoking. Eye-grabbing headlines were needed and
“should strongly call out the point – Controversy! Contradiction! Other Factors! Unknowns!” 31 (Hill and
Knowlton, 1968)

 

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[3] Using Cigarette Ads to Counter Health Information
The Cigarette Papers
Chapter 5 Public Relations in the “Safe” Cigarette Era
Resisting Government Regulation: Advertising Campaigns
Pages 190-191
University of California Press
Link to book with search for “Doubt is our product”

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Filed Under: Anti-Science, Common Sense, Creationism, Critical Judgment, Denialism, Heresy

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

Tue, 28 Aug 2018 16:05:09 -0400 by
 
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]

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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]

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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

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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.

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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
 

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Footnotes:

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[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.

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[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.

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[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.

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

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest – Part I

Thu, 19 Jul 2018 14:40:46 -0400 by
 
Also to be posted on ResearchBlogging.org when they relaunch the site.

The results are in from the only completed Adrenaline (Epinephrine in non-Commonwealth countries) vs. Placebo for Cardiac Arrest study.
 


 

Even I overestimated the possibility of benefit of epinephrine.

I had hoped that there would be some evidence to help identify patients who might benefit from epinephrine, but that is not the case.

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.

More people survived for at least 30 days with epinephrine, which is entirely expected. There has not been any controversy about whether giving epinephrine produces pulses more often than not giving epinephrine. As with amiodarone (Nexterone and Pacerone), the question has been whether we are just filling the ICUs and nursing home beds with comatose patients.
 

There was no statistical evidence of a modification in treatment effect by such factors as the patient’s age, whether the cardiac arrest was witnessed, whether CPR was performed by a bystander, initial cardiac rhythm, or response time or time to trial-agent administration (Fig. S7 in the Supplementary Appendix). [1]

 

The secondary outcome is what everyone has been much more interested in – what are the neurological outcomes with adrenaline vs. without adrenaline?

The best outcome was no detectable neurological impairment.
 

the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment.

Our work with patients and the public before starting the trial (as summarized in the Supplementary Appendix) identified survival with a favorable neurologic outcome to be a higher priority than survival alone. [1]

 


Click on the image to make it larger.
 

Are there some patients who will do better with epinephrine than without?

Maybe (I would have written probably, before these results), but we still do not know how to identify those patients.

Is titrating tiny amounts of epinephrine, to observe for response, reasonable? What response would we be looking for? Wat do we do if we observe that response? We have been using epinephrine for over half a century and we still don’t know when to use it, how much to use, or how to identify the patients who might benefit.

I will write more about these results later

We now have evidence that, as with amiodarone, we should only be using epinephrine as part of well controlled trials.

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Also see –

How Bad is Epinephrine (Adrenaline) for Cardiac Arrest, According to the PARAMEDIC2 Study?

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Footnotes:

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[1] 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 Jul 18. doi: 10.1056/NEJMoa1806842. [Epub ahead of print]
PMID: 30021076

Free Full Text from NEJM

All supplementary material is also available at the end of the article at the NEJM site in PDF format –

Protocol

Supplementary Appendix

Disclosure Forms

There is also an editorial, which I have not yet read, by Clifton W. Callaway, M.D., Ph.D., and Michael W. Donnino, M.D. –

Testing Epinephrine for Out-of-Hospital Cardiac Arrest.
Callaway CW, Donnino MW.
N Engl J Med. 2018 Jul 18. doi: 10.1056/NEJMe1808255. [Epub ahead of print] No abstract available.
PMID: 30021078

Free Full Text from NEJM

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Filed Under: 2018 ACLS Guidelines, ACLS, Common Sense, Critical Judgment, Drug Shortages, Epinephrine, Ethics, Evidence, Heresy, Intubation, Lasix, Mythology, Narrative Fallacy, Oxygen, Pharmacology, Placebo, Potentially Reversible Causes, Probability, Research, Research Blogging, Resuscitation Theater, tPA

Have a Slow, Quiet Friday the Thirteenth

Fri, 13 Oct 2017 17:05:09 -0400 by
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.

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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.

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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.

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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

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Footnotes:

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[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.

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[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.

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

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

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Filed Under: 'Alternative' Medicine, Airway Management, Anti-Science, Common Sense, Conspiracy Theories, Conventional Ignorance, Critical Judgment, EBM, Evidence, Full Moon, Miracles, Mythology, Narrative Fallacy, Research Blogging, Science, Superstition

The Upside Down, in a Ditch, During a Tornado Intubation

Mon, 14 May 2012 18:00:52 -0400 by
–

Whenever pathetic intubation success rates are discussed, this complex, almost impossible intubation becomes one of the excuses for the low intubation success rates.

The problem with the example is that we are supposed to assume that intubation is the right thing for this patient.

 

Wrong.

 

How hypoxic are we trying to make the patient?

How long are we trying to delay extrication?

If the patient needs an airway right now, why are we messing around with an endotracheal tube, rather than using our heads?

Don’t we have more important things to do that stroke ourselves in public?

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This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight.[1]

Also a difficult situation.

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The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation.[1]

They didn’t even try?

This is the end of intubation. How are paramedics supposed to have self respect, if one of our own is going to stab us in the back, like this?

We aren’t supposed to be doing what is right for the patient, but doing what is right to make sure that nobody ever takes our tubes away.

How are we going to be able to BS people with the upside down, in a ditch stories?

Sure, they do happen.

Rather than look at them as examples of great intubation skill, we should look at them as demonstrations of a need for remediation.

Next time, we should think about what is best for the patient, rather than what will make a good war story – at least a good war story for people who don’t understand patient care.

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[youtube]3I_Ds2ytz4o[/youtube]

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An endotracheal tube is not significantly more secure than other airways, nor does it do a great job of keeping detritus out of the lungs.

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The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.[1]

One sad part is that this was considered such a novel concept only five years ago.

A much sadder part is that this would still be novel in many places.

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Footnotes:

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[1] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]

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Filed Under: Common Sense, Heresy, Intubation

Nontraumatic out-of-hospital hypotension predicts inhospital mortality

Wed, 07 Mar 2012 08:00:33 -0500 by

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

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An interesting examination of something that we take for granted. Does any instance of hypotension increase the risk of death for patients with life-threatening or potentially life-threatening conditions? Hypotension is categorized as SBP (Systolic Blood Pressure) less than 100 mm Hg, rather than SBP <90.

They assessed patients with respiratory distress, syncope, chest pain, dizziness, altered mental status, anxiety, thirst, weakness, fatigue, or the sensation of impending doom.

Due to the difference in age of the groups, the non-hypotensive group was abbreviated (truncated) to match the significantly older (P<.0001, unpaired t test) hypotensive group within one standard deviation. This cut the non-hypotensive group from 2,733 to 1,362 – eliminating just over half of the group. This should do a good job of controlling for the age difference. There were two locations for the study, but the significant difference in ages was only observed at one location.

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Nonexposure patients were thus priority I or II transported patients, aged 48 to 84 years, with systolic blood pressure always more than 100 mm Hg and with 1 or more of 10 predefined symptom documented.[1]

That misrepresents the nonexposure (not hypotensive) patients. These patients did not have continual measurement of their blood pressures. A minimum of only one set of vital signs was required.

I do try to take vital signs when there is a change in patient presentation, but I have noticed that not everyone behaves as I do.

A lack of documentation of <100 SBP is not the same as systolic blood pressure always more than 100 mm Hg. Here are some of the problems with assuming that all <100 SBPs were identified by a random assessment of at least one set of vital signs –

Were vital signs assessed with every change in presentation?

Were all changes in presentation observed?

Is a drop in SBP always going to be accompanied by a change in presentation?

Is hypotension always going to be accompanied by a change in presentation?

The answers are – No, No, No, and No.

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Inhospital mortality was determined by first searching the Social Security Death Index.[1]

Is this a good method of differentiating between living people and dead people?

If the government thinks I am alive, that does not mean that I am alive. If the government thinks I am dead, that does not mean that I am dead, nor that I have a <100 SBP.

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Secondary analysis measurements were the relationship between age and inhospital mortality in hypotensive patients, the relationship between the initial out-of-hospital systolic blood pressure and inhospital mortality, the inhospital mortality rate of transient versus sustained hypotension, and a calculation of the sensitivity and specificity of out-of-hospital hypotension for inhospital mortality.[1]

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At one site, SBP from 91 to 99 appears to improve survival. This may be just the law of small numbers at work. Those with transient hypotension are probably going to have blood pressures that are close to the dividing line.

–

–

Venue 2 has similar results, except here there are larger increases in the death rates at 91 – 99 and <70.

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The sustained low blood pressure appears to be the real danger, while transient low blood pressure does not appear to be significantly different from zero assessments of low blood pressures.

the mortality rate among these 255 patients was 33% (95% CI 27% to 39%).[1]

The effect of a sustained low blood pressure would have been a good study to follow this study.

Is it predictive?

Does it predict something that we can reverse?

Does sustained low blood pressure mean sustained in spite of treatment?

What kind of treatment(s) would be appropriate?

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Patients with a systolic blood pressure equal to 100 mm Hg were not included in the analysis; at venue 1 this was 23 patients, and at venue 2 it was 252 patients.[1]

Those patients would have had one or more measurements of SBP = 100, but no measurements of SBP <100. 5.8% (regardless of group) at venue 1 and 3.5% of the nonexposure group at venue 2. The 252 patients would have added almost another half (47.3%) to the exposure group at venue 2.

This raises an important question.

Why is this one SBP so commonly represented as the lowest blood pressure in the vital signs?

How often will 100 be the lowest documented SBP in any group?

Is <100 only a little more than twice as likely as 100 for the lowest documented SBP?

Does documentation of <100 SBP require treatment under a different protocol/algorithm?

There were 3,128 patients at venue 1 and only 23 SBP measurements of exactly 100.

There were 7,679 patients at venue 2 and 252 SBP measurements of exactly 100.

Venue 2 has only 2 1/2 times as many patients, but 11 times as many SBP measurements of exactly 100. Were the exclusions for SBP exactly equal to 100 done before truncation and matching? We cannot tell from the information provided.

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Footnotes:

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[1] Nontraumatic out-of-hospital hypotension predicts inhospital mortality.
Jones AE, Stiell IG, Nesbitt LP, Spaite DW, Hasan N, Watts BA, Kline JA.
Ann Emerg Med. 2004 Jan;43(1):106-13.
PMID: 14707949 [PubMed – indexed for MEDLINE]

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Jones, A., Stiell, I., Nesbitt, L., Spaite, D., Hasan, N., Watts, B., & Kline, J. (2004). Nontraumatic out-of-hospital hypotension predicts inhospital mortality☆ Annals of Emergency Medicine, 43 (1), 106-113 DOI: 10.1016/j.annemergmed.2003.08.008

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Filed Under: Assessment, Common Sense, Heresy, Paramedicine 101, Research Blogging

911 Call Abuse By The 911 Call Taker?

Fri, 17 Jul 2009 02:52:50 -0400 by

A 17 year old girl uses foul language.

Shocking?

No.

A 911 caller uses foul language.

Shocking?

No.

Yet, for some reason the 911 call taker for the Lincoln Park Police Department loses his cool and hangs up on the caller. Again and again.*

She runs down the street to the police station to try to get what she was calling for – an ambulance – and she is arrested.

That’ll teach her to call 911 about a medical emergency!

Here is the video with the recording of the 911 calls.

I agree that the girl, Adrianne Ledesma, sure does not seem to get the picture, either. Her father just had brain surgery and is now having a seizure, but she is worried about suing the guy on the phone. Maybe Dad should sue over this, but have a lawyer prevent his daughter from receiving any of this money.

It is not at all clear if the father is still seizing, or was ever seizing, or how often this happens, but this kid needs to start acting responsibly. If you have a family member with a medical condition, you need to learn to deal with it, not try to figure out whom you might sue for giving you a hard time.

The police officer, Seargent Robert McFarlan, must have a doozy of an excuse. He has been working for 20 years (5 years longer than Daniel Martin). He may not have any skeletons in his closet. He refused to comment.

What is his job?

His job is to dispatch the appropriate people to deal with whatever emergencies occur during his shift. His job is to calm down people on the other end of the phone, so that he may obtain the information he needs. Once he knows there is a request for an ambulance, he should start sending the ambulance. I am guessing that Lincoln Park has Enhanced 911, which is a form of caller ID. He does not know what is going on, but there has been a request for an ambulance.

Wouldn’t it be nice if I could refuse to deal with people if they used less than polite language. I wouldn’t even get to a lot of the calls with the language used by some of my partners.

Assuming that we did make it to the call without expletive, the families, by-standers, and patients have been known to use the occasional indelicate expression. I have been yelled at repeatedly for taking too long because the patient was not white. Not that dispatch provides that kind of information, or even asks for it, but some people have priorities that have nothing to do with the patient. They just use the patient as an excuse to cause trouble, such as to sue.

The malice of these by-standers is not the fault of the patient.

This is a part of the job. If we feel threatened, it is appropriate to leave until police arrive and deal with whatever violence/potential violence is there. Of course, if I am on the other end of a phone, am I in any danger?

The refreshing news on this is that the Chief of Police has been open about dealing with this. This is not the Oklahoma Highway Patrol.

It is important to note that Sgt. McFarlan has had a career of meritous service, has never had a disciplinary action until this incident, and was suspended without pay for two weeks and sent for training after this incident.[1]

Never had a disciplinary action in 20 years? How many people can claim that? But what happened on this call?

As part of this post, I would like to include another pointer. The times when you should probably not get yelled at for using foul language include just about every legitimate reason to call 911. There is no justification for 911 acting as Miss Manners, especially since Seargent McFarlan uses obscenity during the 911 call, too.

Here is an imaginary call to the 911 Hypocrisy Line.

911 – Hello, 911 Hypocrisy Line, how may I help you?

Caller – I need a *&%$#@ ambulance.

911 – Hold on there, Missy. I’m not gonna put up with that $#!+. You’re going to have to call back again and act like a professional this time.

911 call takers do put up with a lot of abuse on the phone. I am not defending abuse of 911 in any way. I wonder how many times they hear the words, Thank you, at the end of a call. They deserve our thanks. They do not deserve to be lumped in with the few who make the news for bad judgment.

Hat tip to Medic(three).

The Wall Street Journal has a story about this and a couple of law suits about two other 911 calls in Michigan. What’s Going On With 911 Operators In Michigan?

Footnotes:

^ * David Konig has a different take on whether the hang up is by the 911 call taker or the caller. If the caller hung up, what was she thinking? That is a rhetorical question. We all know that she was not thinking. Maybe it is due to the emergency, but what does hanging up accomplish? The link is below [1]

^ 1 Lincoln Park 911 Operator Denies Service Over Swear Words
David Konig
Article

For those not familiar with the Oklahoma Highway Patrol and Daniel Martin references, use the search box in the upper left of the browser window. You will get more information than you ever wanted on OHP and Daniel Martin.

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Filed Under: Common Sense, Critical Judgment, Heresy, Oklahoma Highway Patrol Tagged With: , , ,

Happy Independence Day – Thank You Thomas Paine

Sat, 04 Jul 2009 02:22:35 -0400 by

Perhaps the sentiments contained in the following pages, are not YET sufficiently fashionable to procure them general favour; a long habit of not thinking a thing WRONG, gives it a superficial appearance of being RIGHT, and raises at first a formidable outcry in defense of custom. But the tumult soon subsides. Time makes more converts than reason.[1]

So begins the publishing success that was the equivalent of Harry Potter in the 18th Century. This is not a work of fiction. This is not something that deals with magic and fantasy. And yet it persuaded many people to risk everything for a goal that was considered pure fantasy at the time. A bunch of colonies were going to unify and rebel against Great Britain. The opinion of many of the colonists was that such a plan would be nothing but a Great Folly.

What convinced these colonists to risk everything?

Let me be clear on everything. Their lives. Their property. The lives and property of their family members. Torture. Not waterboarding, but the organ failure producing torture of places that are not America. This was not simply going all in in a game of poker. This all in was limited only by the imagination of one’s captors. They were going to engage in treason.

You don’t really think they were endangering their families by rebelling, do you?

Section. 3. Treason against the United States shall consist only in levying War against them, or in adhering to their Enemies, giving them Aid and Comfort. No Person shall be convicted of Treason unless on the Testimony of two Witnesses to the same overt Act, or on Confession in open Court.

The Congress shall have Power to declare the Punishment of Treason, but no Attainder of Treason shall work Corruption of Blood, or Forfeiture except during the Life of the Person attainted.[2]

Corruption of Blood?

It sounds dramatic. It is.

English Crim. Law. The incapacity to inherit, or pass an inheritance, in consequence of an attainder to which the party has been subject

When this consequence flows from an attainder, the party is stripped of all honors and dignities he possessed, and becomes ignoble.[3]

Of course, all of that presumes that the family is still alive to contest this in court. It also presumes that their property hasn’t been given away, or sold. That probably presumed too much for the time.

The best selling book in the colonies in the 18th Century. Common Sense.

Every thing that is right or natural pleads for separation. The blood of the slain, the weeping voice of nature cries, ‘TIS TIME TO PART.[1]

Some writers have so confounded society with government, as to leave little or no distinction between them; whereas they are not only different, but have different origins. Society is produced by our wants, and government by our wickedness; the former promotes our happiness POSITIVELY by uniting our affections, the latter NEGATIVELY by restraining our vices. The one encourages intercourse, the other creates distinctions. The first a patron, the last a punisher.

Society in every state is a blessing, but government even in its best state is but a necessary evil; in its worst state an intolerable one; for when we suffer, or are exposed to the same miseries BY A GOVERNMENT, which we might expect in a country WITHOUT GOVERNMENT, our calamity is heightened by reflecting that we furnish the means by which we suffer. Government, like dress, is the badge of lost innocence; the palaces of kings are built on the ruins of the bowers of paradise. For were the impulses of conscience clear, uniform, and irresistibly obeyed, man would need no other lawgiver; but that not being the case, he finds it necessary to surrender up a part of his property to furnish means for the protection of the rest; and this he is induced to do by the same prudence which in every other case advises him out of two evils to choose the least. WHEREFORE, security being the true design and end of government, it unanswerably follows, that whatever FORM thereof appears most likely to ensure it to us, with the least expense and greatest benefit, is preferable to all others.[1]

We have taken this idea of security and expanded it to mean a security blanket. Those who fought to separate from England would be embarrassed at the depths to which we have sunk in our risk paranoia. There is no freedom that some many would not sacrifice for the delusion of complete safety.

I draw my idea of the form of government from a principle in nature, which no art can overturn, viz. that the more simple any thing is, the less liable it is to be disordered, and the easier repaired when disordered;[1]

Outside of Corruption of Blood and a few other technical terms, the document creating the eventual government of the United States of America is simple and resistant to disorder. Contemporary legislation is in a whole different category.

The Bill of Rights is a bunch of restrictions on the government. These restrictions make it more difficult for the government to lock you up. A side effect is that it is also more difficult for the government to lock up bad people. Pick pockets, embezzlers, thieves, rapists, child rapists, murderers. All of them are protected by the Bill of Rights.

Did the people, who just risked everything, not realize the consequences of what they were doing? Did child rapists not exist back then?

They understood.

They understood that the rights of the citizens are more important than the desire to punish the guilty. When we become more concerned with punishing the guilty, than with protecting the Constitution that protects us, then the tyrants have won.

When something is presented as being for the children, it is because this is an attempt to get around logical debate and appeal to emotion. There are places where the people have little, or no, protection from their government.

China.

North Korea.

Cuba.

China may need to give up some of that control. Why? The benefits of a market that is open to countries with more freedom. The inability to suppress information. The desire, of so many of their citizens, for freedom. Maybe we should have an exchange program with China.

Send us your citizens, who are yearning to be free. We will send you our citizens, who are yearning to avoid risk.

Win and Win.

We are a nation of immigrants that has given up and decided to play it safe. We are trying to trade off our liberty for the illusion of safety. We do not deserve that liberty. We need to bring in people who do – the Chinese, the North Koreans, the Cubans, and others. What do we lose by sending them our people – people who do not understand what they have?

We are having a mid-life crisis. Rather than trying to recapture freedoms, we have given up. We want to crawl back into the womb and hide. What if somebody hurts my feelings with mean words. What if somebody hurts my child? What if somebody hurts me? That is the price of being an adult. That is the price of living in the real world.

There are plenty of people, who will tell us they can protect our feelings.

Liars.

There are plenty of people, who will tell us they can protect our children.

Liars.

There are plenty of people, who will tell us they can protect us from the big bad terrorists.

Liars.

Maybe we should educate our citizens. Most of these citizens are just citizens because of the accident of being in the US when they took their first breath. Maybe we should educate our citizens about what others gave up for their freedoms.

Visit some war memorials. Read of the mistreatment that led people to move here. Read of the mistreatment that led people to fight for freedom. Freedom can just as easily be lost. Too many people sacrificed everything they had for us to barter away freedoms for a little temporary safety.

Freedom isn’t easy.

Footnotes:

^ 1 Common Sense
by Thomas Paine, initially published anonymously
Links include the postscript, which is dated 2/14/1776, only just more than a month from the first printing.
Full Text, in several formats, from Gutenberg
Maybe you don’t want to read this, but would prefer to listen to someone else reading.
Full Text Audio, in several formats, from Librivox

^ 2 Constitution for the United States of America
Article. III.
Full Text

^ 3 Corruption Of Blood
The ‘Lectric Law Library’s Lexicon
Definition

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Filed Under: Common Sense, Heresy Tagged With: ,
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