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

- Rogue Medic


Go watch Episode 2 of Code STEMI – Understanding STEMI from the ground up.

Tom Bouthillet of EMS 12 Lead talks with Dr. Christopher Granger, Mayme Lou Rettig and Dr. Jamie Jollis from Duke University Medical Center. They discuss Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE).

It is nice to see that the doctors are getting what is important.

The dichotomy between STEMI and trauma triage criteria could probably keep a team of psychiatrists busy for decades.

We want EMS to call the trauma alerts and we want EMS to call a lot of them, because maintaining competence in medicine is about the number of cases you see. Less than 5% accuracy is considered acceptable, since it is a numbers game and sometimes the blind squirrel actually looks like he can see. We grant a magical exception from medical competence in EMS, where we try to dilute paramedic experience to homeopathic levels by making almost every responder a paramedic (and usually those medics are cross-trained as something else, because that almost makes sense).

Since we discourage medical competence, we have to be creative in the excuses we use. Every system is unique, so we can’t claim that a system is screwing up – they are just meeting the needs of their patients in a way that works politically, but not medically, and we have to stop getting hung up on the medical part of EMS.

We reverse the criteria for calling STEMI alerts, but revert to magic as far as activation of the STEMI alert is concerned. We can’t trust medics, because even 5% over-triage is unacceptable. Interventional cardiologists are much more important than trauma surgeons.

Rather than have the medic focus on patient care and have his partner notify the hospital that they have a STEMI, there is still this need to distract the medic from paying attention to the patient so that the medic can focus on what is important – the magic phone call.

Here is a group of people not obsessed with the sleep of the STEMI team, but is interested in what is best for the patient.

What is best for the patient is reducing delays.

We need to make sure that paramedics know what they are doing.

We need to make sure that paramedics are getting appropriate feedback on their 12 lead interpretation and their patient care.

Imagine if EMS were about excellent patient care, rather than about dumbing it down to the comfort level of the most anxious and misinformed absentee medical director.

How much of a difference could we make in survival?

Go watch Episode 2 of Code STEMI – Understanding STEMI from the ground up.

Apparently, none of the pdfs work. Disregard the links below.

For more information on RACE view the presentations below. All presentations have been converted to PDF Format. The PDF Download will begin automaticall when you click a link below

Ideal World Case Study, by Jenny Underwood, RN, BSN RACE Coordinator for Durham/Greensboro/Chapel Hill

ACS Update, by Christopher Granger, MD

Lytic Hospitals; Meeting the Mark, by Mary Printz, Eastern NC RACE Coordinator

Non PCI Featured Presenters

RACE for Reperfusion, NON PCI Center Focus
Presbyterian Hospital Matthews & Presbyterian Hospital Huntersville

North Carolina Emergency Medical Services, by Greg Mears, MD, NC EMS Medical Director

Winston Salem Regional Report EMS ECG Transmission

Optimizing Door-to-Balloon Time: Strategies for Success

Final 55 of 58 Non PCI Centers Aggregate Data


Another Reason to Vote for EMS 12 Lead as Blog of the Year

The number one post on the Life In The Fast Lane blog for 2011 –

One of the biggest and most respected emergency physician blogs in the world –

Rated on quality, not on number of page views –

Was the one in which Christopher Watford of My Variables Only Have 6 Letters and EMS 12 Lead pointed out a lead reversal on a 12 lead ECG that had not been pointed out by any of the doctors.

Nothing makes EMS look as good as when we can show that we understand what we are doing.

Christopher Watford did a great job of making EMS look good to a lot of people in EM (Emergency Medicine). I think that deserves a vote.


Greatest Hits 2011


When you see links on Life In The Fast Lane posts, they are often java script that will expose the information on the same page, rather than take you to a different page. This works on smart phones, too. Hold your mouse over the link and it should highlight the type of link. Usually, anything that would have a short answer will have a java script link.

1. Power Of Social Media Leads To Reversal

For me, this post exemplifies what social media in education is all about. Christopher Watford spotted an unusual finding on an ECG from a past emergency medicine exam question on LITFL, that wasn’t included in the model answer. We looked at it and had to agree. But to make sure, we got onto Twitter and asked a few of our cardiology/ electrophysiology buddies in the USA to check it out. This post tells the story of what unfolded and teaches important lessons about calling Emperors naked, the fallibility of any examination process, how to interpret ECG lead reversals and the undeniable power of social media.


Read it!


Also take a look at the rest of the 20 posts that they rated the best of the year.

Then there is the EMS 10 Award from EMS Today. Go read about it.

“Team EMS-12 Lead” (Christopher Watford, Tom Bouthillet and David Baumrind) at the EMS 10 Awards.

Tom Bouthillet, David Baumrind, and Christopher Watford make a great team and run a great blog at EMS 12 Lead.

As I wrote earlier – If we want to have people stop thinking of us as ambulance drivers, we need to convince others that we understand medicine.

OK, that is enough fanboy for me for a while. Go vote at the link below.


Vote on EMS1.com for the EMS Blog of the Year


Vote on FireRescue1.com for the Fire Blog of the Year


Complete rules are here

Thank you to Rhett for putting all of this work into the contest again this year.


Charging the Defibrillator While Continuing Chest Compressions – Part II

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

Continuing, after a 6 month delay, a discussion of an EMS 12 Lead article from Part I. ACLS (Advanced Cardiac Life Support) recommends charging the defibrillator during compressions. This is no less of a recommendation than giving epinephrine. How many people ignore ACLS guidelines for compressions during charging, but claim that it is evil to disobey anything ACLS recommends on epinephrine, amiodarone, or ventilations?

Analyses of VF waveform characteristics predictive of shock success have documented that the shorter the time interval between the last chest compression and shock delivery, the more likely the shock will be successful.141 A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success.142 [1]

Extra pauses in compressions add to the time without compressions.

If the medic/nurse/doctor using a manual defibrillator recognizes a shockable rhythm, why not provide compressions while charging the defibrillator?

Some people will say that this is dangerous.

Image credit.

But if someone accidentally delivers a shock during compressions, people will be killed!

In a systematic review, Hoke et al. summarized 29 reports of accidental defibrillator discharges, of which only 15 occurred during resuscitation attempts.21 Symptoms included tingling sensations, discomfort, and minor burns, but no long term effects or major consequences were reported.[2]

Where are the dead bodies we hear so much about?

Where are the medics/nurses/doctors needing to be defibrillated back to life?

There was only one incident where a shock was delivered while a rescuer was actively performing chest compressions. However, the compression transcript continued without any visible change to CPR administration, suggesting that the rescuer was unaffected by the event. Review of clinical records and audio transcripts revealed no evidence of inadvertent shocks to rescuers. In addition, there was no significant difference in the incidence of inappropriate shocks to patients associated with charging during compressions (20.0% vs 20.1%; p = 0.97). [2]

In this study, there was one case of a shock being delivered during compressions, but nobody seems to have been affected by this shock.

What happened to the automatic death that ACLS instructors spend so much time describing?

Where is the evidence?

In the current study, charging during compressions decreased median pre-shock pause by over 10 s, which previous studies suggest could have a dramatic effect on clinical outcomes. We previously reported an almost two-fold increase in the chances of successful defibrillation for every 5 s reduction in the pre-shock pause.9 Similarly, Eftestøl et al. found that a 10 s hands-off period prior to defibrillation would roughly halve the probability of obtaining ROSC.6 [2]

The risk to rescuers appears to be minimal, but the possible benefit to patients may be dramatic.

Click on image to make it larger.

The difference in time without compressions is significant.

Interestingly, we found that the most efficient technique with regard to minimizing pauses was not the AHA recommended method of pausing to analyze, resuming CPR to charge, and then pausing again to defibrillate. Rather, charging at the end of every 2 min CPR cycle in anticipation of a shockable rhythm and then pausing only once, briefly, to both analyze and either shock or disarm was associated with significantly shorter total pause duration in the 30 s preceding defibrillation. [2]

If we see asystole, we do not deliver a shock. We cancel the shock.

If we see PEA (Pulseless Electrical Activity, such as sinus rhythm, sinus tachycardia, sinus bradycardia, or any other non-shockable rhythm), we do not deliver a shock. We cancel the shock.

Cancelling the shock is not going to be the same for each defibrillator, but we do need to know how to cancel the shock for each machine we use. We can read the instructions.


We can turn on the monitor, charge it up to the setting we would use to defibrillate, and try to figure out ways to get the charged defibrillator to turn the shock off. We should already know how to do this.

All that appears to be required is competence. Why is that so difficult?

Why do we keep making excuses for misbehavior?


[1] CPR Before Defibrillation
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Rhythm-Based Management of Cardiac Arrest
Defibrillation Strategies
Free Full Text from Circulation with links to Free Full Text PDF

[2] Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi-center study.
Edelson DP, Robertson-Dick BJ, Yuen TC, Eilevstjønn J, Walsh D, Bareis CJ, Vanden Hoek TL, Abella BS.
Resuscitation. 2010 Nov;81(11):1521-6.
PMID: 20807672 [PubMed – indexed for MEDLINE]

Edelson, D., Robertson-Dick, B., Yuen, T., Eilevstjønn, J., Walsh, D., Bareis, C., Vanden Hoek, T., & Abella, B. (2010). Safety and efficacy of defibrillator charging during ongoing chest compressions: A multi-center study Resuscitation, 81 (11), 1521-1526 DOI: 10.1016/j.resuscitation.2010.07.014


Syncope and sudden death in student athletes

Two recent podcasts about this topic. Pedi-U has Done Fell Out! Pediatric Syncope Episode 10 with Dr. Lou Romig, Dr. Peter Antevy, and Kyle David Bates.

From a different perspective, Tom Bouthillet, David Baumrind, and Christopher Watford inaugurate the first EMS 12 Lead Podcast with Dr. John Mandrola of Dr. John M as their guest. The first topic is syncope and sudden death of student athletes, which can be a dramatic and even overwhelming event.

EMS 12-Lead podcast – Episode #1 – Syncope and sudden death in student athletes.

There is a great group of references for information beyond what is included in the podcast.

Dr. Mandrola points out some of the problems in screening a population that has an extremely low incidence of pathology. The false positives may outnumber the true positives, so how much testing is indicated? What testing is indicated?

Screening seemingly healthy young athletes?

The feasibility of routine ECG screening of athletes?

Included in the links are posts on EMS 12 Lead that address conditions described on the podcast, so we can look at some of the ECGs being discussed.

Go listen to the EMS 12 Lead podcast.

Also go listen to the Pedi-U podcast.

Another podcast on the same topic, but covering it from a third perspective, is the ERCAST.

All three are important podcasts on a topic that we do not want to ignore. While the bad outcomes are rare, they make up for it in the impact they have on all involved.