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

- Rogue Medic

2009’s Top Threat To Science In Medicine


Science-Based Medicine, has a post by Dr. Val Jones – 2009’s Top 5 Threats To Science In Medicine.

I do not disagree with the list except, and what would one of my posts be without an except, the number one threat to science in medicine is much more of a problem. Our science education in grade school is where we fail our children. Before they even become adults, they are exposed to all sorts of magical thinking.

Full moons, speaking about something bad increasing the chances it will occur (a jinx), believing that something natural is safer than something manufactured – just because it is not man made, or just a belief in the stereotypical mad scientist bringing about horrors by using the scientific method of inquiry.

That is what science is. Science is a method of inquiry. Science is a tool we use to find out how the world works.

We see something that makes us think. Most people may form an opinion, but not look at this with a method designed to minimize the effect of our biases. And we all have biases.

It seems that there are more patients during a full moon. With a full moon falling at 19:15 GMT (Greenwich Mean Time) this past New Years Eve, this must have been a horrible night of death and destruction. Or was it?

We formulate a hypothesis.

The full moon causes accidents and/or illnesses, or makes accidents and/or illnesses even worse than they would be if there were no full moon.

We figure out what we need to control for to limit our variable to just the possible influence of the full moon. So, let’s look at a study that investigated the effect of a full moon on something that would be very difficult to misinterpret.

We postulated that on full moon days there would be more available moonlight, thus influencing individuals’ activities, and in turn, the propensity for cardiac arrest.[1]


Interesting. They are not really assuming that the cause of an increase in cardiac arrests would be due to some mystical property of the moon, but that it would be due to more moonlight. fortunately, it does not matter what the actual cause would be for an increase in cardiac arrests, if they set the experiment up properly.

What do they need to do?

This study was a retrospective analysis of a computerized billing database of ED visits.[1]


The study population consisted of CPR (CardioPulmonary Resuscitation) occurring daily at a cohort of seven hospital ED in northern New Jersey, USA, during the period of 1 January 1988 to 31 December 1998, comprising 4018 days over 11 years. Consecutive patients seen by an emergency physician were included. Emergency physicians see 80–95% of all ED patient visits and the vast majority of cardiac arrest patients. Private physicians see the remainder of the patients.[1]


Their theory was that the increased moonlight would lead to more activity; more activity would lead to more cardiac arrests; thus there would be more cardiac arrests during a full moon.

Did the investigators prove their hypothesis?

According to their table, which does not reproduce well, there is no increase in cardiac arrest incidence during a full moon. They actually recorded a decrease, but the difference is not statistically significant. The reported statistically significant difference in incidence of cardiac arrest is this. During the new moon, there is less likely to be a cardiac arrest treated by an emergency physician.

There were 2370233 patient visits in the database during the 4018-day (11year) period of study, with 6827 having the primary ICD-9 diagnosis of cardiac arrest.[2] Table 2 contains the time series regression results. Full moon days were not significantly different from other days (P=0.97). We had an 80% power to identify a difference of 4.5%. However, on average 0.12 fewer CPR occurred on new moon days than on other days (P=0.02). This translates into an average of 6.5% fewer CPR (95% confidence interval 1.3–11.7%) on new moon days than other days. In addition, the results for the potentially confounding variables are presented in Table 2.[1]


I left part of their original hypothesis off of the initial quote. The stated objective of the study is –

To determine the effect of the phase of the full and new moon on the variation in the number of daily cardiopulmonary resuscitations.


In the discussion, they elaborate on their purpose –

Our results show a small but statistically significant decrease in the incidence of CPR with new moon days. We speculate that this may be secondary to a decrease in activity because of less available light on these days, as it has been shown that increased activity is a risk factor for sudden death[39]. Our initial rationale sought to identify and determine the size of any effect on the occurrence of cardiac arrest and its attempted resuscitation (‘CPR’) by lunar influence as a potential insight into an aspect of the occurrence of cardiac arrest. In addition, we sought to identify patient volume variation by lunar cycle potentially to allow for staffing modifications; however, the effect identified did not warrant this.[1]


This –

We postulated that on full moon days there would be more available moonlight, thus influencing individuals’ activities, and in turn, the propensity for cardiac arrest.[1]


Becomes –

We speculate that this may be secondary to a decrease in activity because of less available light on these days, as it has been shown that increased activity is a risk factor for sudden death[39] [1]


They have found a way to stick with their initial hypothesis by reversing it.

More moonlight does not appear to lead to more cardiac arrests. Why this lack of correlation does not need to be explained is not in the paper. However, the correlation between fewer deaths during a new moon is something that they feel needs to be explained. Haven’t they just misappropriated a Willy Wonka quote? Strike that. Reverse it. Willy Wonka was reversing the meaning of what he was saying. That was the reason he needed to reverse the order.

The authors have not really changed the meaning, only the way they express it. More light/less light leads to more activity/less activity. This leads to more/fewer cardiac arrests.

While I do not dispute the results of this study, I do have a problem with the way they get from Point A to Point C. They seem to travel there by way of a study that shows that more activity leads to more cardiac arrest. Actually the study is of vigorous exertion, not just more activity, but the authors seem to have interpreted the study as couch potatoes live longer. The vigorous exertion study did show –

As expected, the base-line level of habitual exercise significantly attenuated the increase in the risk of sudden death that was associated with an episode of vigorous exertion in both the primary analysis and the three sensitivity analyses. Habitually active men had a much lower risk of sudden death in association with an episode of vigorous exertion than men who exercised less than once a week; however, the most active men’s risk remained significantly elevated during and after vigorous exertion in all analyses.[3]


There is no suggestion that these episodes of vigorous exertion occurred less frequently during the time of the new moon. According to the hypothesis of the full new moon study, the effect of the new moon should only be at night, when it would make a difference in the amount of available light. This might make more difference in rural areas, than in the suburbs, and more of a difference in suburbs, than in cities, due to the wonders of electrical lighting.

Is there any evidence to support this string of conclusions? I don’t think so.

That does not mean that this hypothesis is incorrect, just that their way of getting there is not supported by the information provided.

One very nice part of this study is the brief review of previous studies and whether they seemed to support, or refute, a connection between various activities and the full moon, but this post is already too long. I will write about other full moon research elsewhere.

Another problem is the way they define a full moon –

We identified full and new moon days that occurred during the study period from the United States National Oceanographic and Aeronautic Administration website. Using this information we created variables for full and new moon days to be used in a regression model of daily CPR, described below.[1]


So. What is their definition of a new moon, or a full moon? They have not made that clear, but it appears to be limited to one specific day during each lunar cycle.

Using NOAA’s (United States National Oceanographic and Aeronautic Administration’s) website, I found a page that identifies new moons, full moons, and other phases by entering the time period I want to look at. The problem I see is that there is not much detail about how they used this information, or if they were using the same part of NOAA’s website.

Why no discussion of this?

Why no discussion of their definition of new moon and full moon?

If their hypothesis is one that depends on the available light, why does the day before a new moon not count, or the day after, or two days before (or after)?

However, if they are looking for a mystical connection between the full moon and bad events, a case can be made that the full power of the full moon would be on one specific date.

If they are claiming that they are examining the effects of the amount of moonlight, how much difference is there in the amount of moonlight from one day to the next? Where is your cut-off? Why?

I think that their conclusion should be that they find no apparent mystical connection between the full moon and cardiac arrests treated by emergency physicians. Their attempts at explaining their results wander into narrative fallacy, which I have written about here, here, here, here, here, here, here, here, here, and here.

As I have stated before about the way we should look at explanations for scientific results –

Bet that the explanation is wrong.

This is one of the failures of our basic education of students. We do not make this clear to them. Yes, this was where the post started, with the failure of science education in the grade schools.

The media report that a certain study means X, even though the authors of the study may not have suggested that this is true. It is later found that the conclusion popularized by the media is wrong. The blame goes, not to the reporters misrepresenting the science, but to the science. We need to avoid creating explanations that are unsupportable and likely to be found to be in error. We need to stop telling fairy tales. We need to stop talking to media members, who spin research results with misleading explanations.

We have people graduating from high school, but unable to recognize the difference between good science and bad science. Unable to look at a study and determine if there is something there that is meaningful. This continues through college, and even medical school. Number 3 on the list was – Academic Medical Centers, so I am not the only one critical of these ivory towers. The top threat to science in medicine is the lack of understanding of what science is. We fail before the students ever get started. This lack of understanding is due to a lack of education in grade school.

We need to change how we teach science. Some do it well, but the debates on scientific topics in the media suggest that few have been well taught. The ignorant mobs are trying to keep themselves in scientific debates for which they are not even remotely qualified. We need to make it so that more are qualified.

We need to improve our basic science education, because we cannot rely on people from other countries coming here to do the science that we have become too ignorant to handle. Eventually, the destination of smart foreign-born scientists will not be the United States. We do not develop enough of our talent. We remain a scientific power because import talent. We do the same thing with grape pickers and day laborers. These seem to be the jobs that we will no longer do for ourselves. Scientist and day laborer are both looked at as undesirable. We need to change this.

It is in the earlier grades that the problems of bad science education are established. After that point it is a much more difficult task to correct this creeping indoctrination in magical thinking.

I think that this is the number one threat to science in medicine. All of the others only contribute to this.

Magical thinking is a form of corruption. As with other types of corruption, it usually does not start with a cannonball into the deep end, but a gradual acclimatization to more and more corruption. At some point, critical judgment is only a fond memory.

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.Tom Stoppard.

We can still fix that problem in education for those in grade school.


[1] Effect of lunar cycle on temporal variation in cardiopulmonary arrest in seven emergency departments during 11 years.
Alves DW, Allegra JR, Cochrane DG, Cable G.
Eur J Emerg Med. 2003 Sep;10(3):225-8.
PMID: 12972900 [PubMed – indexed for MEDLINE]

[2] ICD-9 code definition from the study above

The physicians’ billing department assigns codes according to the International Classification of Diseases, Ninth Revision, and Clinical Modification [International Classification of Disease (ICD)-9 codes]. Patients were included as CPR if they contained any of the ICD-9 codes listed in Table 1 as one of their three primary diagnoses.

Table 1
International Classification of Disease 9 codes
427.4       Ventricular fibrillation
427.41     Ventricular fibrillation
427.5       Cardiac arrest
798.1        Death instantaneous
798.2      Death occurring less than 24h from onset of symptoms
798.9       Death unattended

[3] Triggering of sudden death from cardiac causes by vigorous exertion.
Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE.
N Engl J Med. 2000 Nov 9;343(19):1355-61.
PMID: 11070099 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM.

Alves, D., Allegra, J., Cochrane, D., & Cable, G. (2003). Effect of lunar cycle on temporal variation in cardiopulmonary arrest in seven emergency departments during 11 years European Journal of Emergency Medicine, 10 (3), 225-228 DOI: 10.1097/00063110-200309000-00013


Shaggy Comments on Some Research Podcasting Comments

In the comments to Some Research Podcasting Comments, Shaggy wrote,

I am beginning to think our definition of “why” in the educational arena is not the same. If it is, I will just conclude that either one of us is off our rocker. Explaining the importance of a certain treatment modality as well as anything else is considered very important as motivational.

Perhaps that is part of the problem with attaching questionable explanations to the results of research that was not designed to answer these questions.

Should we be more concerned with motivation, than with accuracy?

I could come up with many possible explanations for why something is happening. I would rather say, I don’t know.

Science is much better at showing what does not work, than what does work.

Science is much better at showing what does work, than at explaining why something works.

This was very important when I did occupational safety and health training for the Safety Council in Pa. as the “why” was part of Bloom’s three types of learning, and fell under the affective nicely. Why should you wear PPE?

Because people who do not wear PPE (Personal Protective Equipment) are over-represented in the morbidity and mortality statistics.

Why are safe work practices important?

Because going home to one’s family is more likely, when one follows these safe work practices.

Why is quick and continuous CPR necessary?

Research shows that without quick and continuous CPR, the resuscitation rate is significantly lower.

Maybe it is due to direct compression of the heart. Maybe it is due to increased intrathoracic pressure. Maybe it is due to a rebound effect after compressing the chest. Maybe it is due to some combination of these mechanisms. Maybe it is due to some other mechanism. Maybe it is due to a combination of some other mechanism and one or more of these mechanisms.

What do we need to know?

We need to know that quick and continuous CPR does work.

We do not need to make up stories that will likely be, at best significantly modified, and at worst completely discarded. Do we need to make up these stories just to motivate people to provide good treatment?

Maybe we will know what the mechanism is in a decade. Maybe in two decades. Right now, I think we are just spinning fairy tales to impress others with how smart we think we are. Or has there been research that conclusively shows the complete mechanism for CPR?

Regardless, the important point is that quick and continuous CPR works. How quick and continuous CPR works is not important in deciding whether we should provide quick and continuous CPR.

If you think these questions shouldn’t be answered, I may tend to think you finally went off the ledge.

How did I get on the ledge?

Why was I on the ledge?

How can I know if I fell off the ledge, if I don’t know the answers to the mechanism of my arriving on the ledge?

Then there is the question of whether I was actually on the ledge at all. Last thing I remember, I was nailed to a perch. Nice fish, the perch.

Maybe I just wasn’t motivated to stay on the ledge.

If you think we are talking about two different things, then perhaps you need to clarify for the intellectually challenged like myself.

I think we are talking about the same thing.

I think that we disagree.

On the other hand, I am confident that almost everyone agrees with you.

We need to become much more comfortable with uncertainty.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines


Some Research Podcasting Comments

This Eve of Christmas Eve both EMS Garage and EMS EduCast.

I Hate People: EMS Garage Episode 67, which is really much more cheerful than it sounds – and it comes with beer recommendations. One warning is that everybody seemed to be having connection problems, so we couldn’t always hear each other. this led to people talking over each other more than usual and pauses, where nobody is talking since they think someone else is still talking. these problems are minor, but do pop up occasionally. Steve Whitehead of The EMT Spot even brings a surreal dimension to the show with mime podcasting.


Understanding EMS Research: Episode 42, which may have helped to provide some understanding of research. The problem is that there is far too much to the topic to be covered in one episode. This was expected to be a brief, year end episode. A brief episode? With me on it? What were they thinking?

The other problem is believing that research can be covered effectively and briefly.

A couple of points. I point out that I think that we should start EMS education with research. Only after the students understand research, should we move on to assessment and treatment.

The big disagreement was when we were discussing some of the old discarded EMS myths, which unfortunately have not been discarded everywhere. The old rule of thumb about what pressure is indicated by what pulses, that I wrote about in A Radial Pulse Means a Pressure of At Least . . . ., where I describe the research from the BMJ from 2000[1] (not 2001 as I stated on the show). There was a bit of discussion of this and somebody mentioned relying on heart rate as an indicator of blood loss. I pointed out that beta blockers and abdominal trauma are two of the confounders of this approach.

The abdominal trauma is something that I will have to do a post on, and I do not have the studies in front of me, but there have been several papers written about surgical patients losing significant amounts of blood, but not becoming tachycardic to indicate the blood loss. Some abdominal surgery patients even became bradycardic with significant blood loss. this is an important problem, because relying on heart rate alone would did cause the continuing uncontrolled bleeding in some of these patients to be missed.

This is something important that we need to be aware of. There are many things that may mislead us in our assessments. The more that we are aware of these confounders, the less likely we are to miss a significant problem. While part of the debate was about whether this happens in the majority of abdominal trauma (it probably does not), this approach is completely irrelevant to developing an awareness of a potentially significant problem. We stress over spinal cord injuries, while the incidence of spinal cord injuries is probably much lower than the incidence of exsanguination due to abdominal trauma that is unrecognized because there is no significant rise in heart rate. The outcome may be more likely to be fatal, as well.

Anyway, my biggest disagreement was when somebody started, based on less information than I already wrote, to try to figure out why this is happening. This is a bad idea.

Why is not important!

When we started to discuss this, that this may be due to vagal stimulus, someone stated that this is just a hypothesis for a study. I don’t have any problem with using that as the hypothesis for a study, but we were not designing a study. We were providing information for educators to use to teach students.

This is exactly where medical myths come from.

The students do not need to know why something works, only that it may work. To suggest anything more than that is suggesting that we know a lot more than we do know.

It is important to know as much about the limitations of our assessments.

It is not important to know why, until after we have a lot of information to support that idea.

Look at where the EMS myths started from. Somebody started explaining why something was happening, or maybe they were only wondering about the cause. Educators got a hold of the idea, and rather than say, I don’t know why, some gave an explanation that was repeated enough to become a myth. A myth that is almost impossible to get rid of, because people want certainty.

Certainty is nice, but it is a problem.

The only certainty in medicine is that we do not know as much as we think we know.

When we start taking explanations for granted, we find that somebody read too much into an observation, or a bunch of observations, or read too much into a study, or a bunch of studies.

This is the same thing that leads the general public to distrust science. We have research that provides limited information, but somebody decides to explain that limited information. If you want to bet on something that is almost a sure thing, here is what you should do.

Bet that the explanation is wrong.

This does not mean that the science was bad, or that the science was wrong, or that the study was not done well, et cetera. It means that somebody took a look at some science and decided to create some fiction, because they assume that they know what they are doing.

The safe bet certain bet is that the explanation is wrong.

The certainty in science and medicine is that our explanations will be wrong. These erroneous explanations will create distrust of science and medicine. these will not be the fault of the researchers, but of those explaining the research.

When we create explanations, we create a narrative – a story. We should start out with, Once upon a time . . . , or something similar, but we don’t. I have discussed this problem with narrative fallacy further in the links listed below. I will write about this more, because this is important.

I do not mean to put down anyone on the show. This is a problem that is almost universal. One of the reasons that it is so common, is that it is natural for us to explain things with stories. When life was simpler, that may have been effective. When the life of someone else is in our hands, we need to be better than that.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines


[1] Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study.
Deakin CD, Low JL.
BMJ. 2000 Sep 16;321(7262):673-4. No abstract available.
PMID: 10987771 [PubMed – indexed for MEDLINE]

Free Full Text . . . . Free PDF

Prepublication History of Manuscript


Second comment from Anonymous on Teaching Airway – Part I

Also posted over at Paramedicine 101. Go check out the rest of what is there.

There is also a thoughtful analysis of airway management and intubation in Airways and ET tubes… at 9-Echo-1.

In the comments to Teaching Airway – Part I – comment from Anonymous, Anonymous writes –

Hi, me again…Nothing brings out a good post from you better than BS. Your best posts come from you when you’re challenged.

Thank you.

So I get to respond to your post…

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.

Yes, but studies can’t be started and performed without anecdotal evidence to steer research. We have to do a few things wrong to figure out what’s right.

I agree. Although there may be some research that is begun without some anecdotal evidence to support it, that is probably rare.

We do have to do a few things wrong to figure out what’s right. We spend too much time on punishing mistakes, rather than looking for ways to avoid those mistakes. We are taking the wrong approach to figuring out what is right.

I see this as a reflection of insecurity and ignorance by those in charge. Those in charge are insecure because of their ignorance. Maybe they just do not know how to do things well, but they do not seem to be doing the right things to learn how to do things well. One easy way to learn how to do things well. Find somebody doing it well, and ask them for some ideas. In Too Many Medics? comment from Anonymous, I included the abstracts from 2 systems that demonstrate excellence at intubation.

One of our big problems is that we do not look at bad outcomes as opportunities to learn how not to keep making the same mistake. We look at bad outcomes as an excuse to punish somebody. Why learn from our mistakes, when we can deny that we made a mistake, and punish someone else for our mistake? Win – Win? Right?

That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.

I know and I really don’t expect anything less from you. I’m not doing this for the check.

I need the paycheck, but I could probably make more in a different line of work. If I had gone into a different line of work, I would have less debt at the end of the month.

There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.

I agree 100%, but how do you sort them out, in a city wide system, with poor medical command, that sometimes barely has a budget to even staff trucks.

That is probably the thing that is going to have the greatest effect on who should intubate. A system, like the one you describe, will have a lot of horrible medics, but do nothing to get rid of them. Or just a little more than nothing.

A system that gets rid of maybe one bad medic a year, but has a couple dozen bad medics, and has them training new medics, is not likely to stop getting worse. That is a system that is not getting better, but getting much worse. Everybody sees that the bad medics are tolerated. Sure they sacrifice one every year, or maybe every other year, just so they can say that they do something about bad quality. They make it seem as if they are doing something significant, but what they really are doing is telling everyone that they are not serious, or that they really are too stupid to understand.

Who are they?

They are the medical director, the chief, the CEO, the City Manager, the QA/QI/CYA department, the union, and all of their accomplices.

Anyone, who has one of those jobs is responsible for eliminating bad patient care. All of them have that responsibility, but few seem to do anything significant to eliminate bad patient care.

The same medics that keep the CPAP (Continuous Positive Airway Pressure) stuffed under the seat because “we’re right down the street from the hospital, we’ll just use meds” attitude. I’ve seen it and it’s scary.

I’m NOT supporting these systems, but how do you change it?

That is a good question. There needs to be somebody who just insists that patient care be the priority. That needs to come from the top. When the bosses get on camera and defend horrible care, there is no reason to expect things to change until that boss is gone, and probably some others, too.

I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.

Yes, again I agree, in fact I use CPAP, NTG (NiTroGlycerin), and Ace inhibitors on a regular basis and I don’t drop a tube, in fact most, are turned around at the hospital. The CHF I described carried down on the Reeves was unresponsive and wasn’t going to fit in a stairchair, so yes, my partner bagged, I put in a line, NTG paste w/3 sprays in a foamy mouth (no IV NTG), Lasix (which I rarely give because CPAP works so well), and Captopril 125. Then I suctioned the pt and tubed while waiting for fire to help carry out my pt. The pt waited to long. Indicated for intubation. I saw that pt again, alive, and good for them. You’ve had that pt before, most medics have.

Was that pt saved by the tube? No idea, yep, no idea. Would CPAP work, no. Would a KingLT which we carry work, maybe, no idea, didn’t use it. I saw need for a tube and did it because it was indicated, could I have just bagged that pt, sure, would have been a bitch, but it could be done. I have even used the ramp on the KingLT to place a successful tube, it’s was pretty cool actually. The problem is these patients are still presenting while science and training catch up or figure out what’s best for the patient and when you FINALLY get people comfortable the rules change. Little and large systems seems to continue to fail, and most likely to “follow the dollar” where other systems seem to always be on top of things.

There are patients like that. Sometimes they do not have time to call, because the onset is so rapid. The train wrecks will not necessarily be any better, regardless of what we do. Positive pressure ventilation (CPAP) is probably the most important treatment for this patient. Next most important is high dose NTG. 10, 20, 50, 100 NTG sprays – whatever it takes. As long as the blood pressure does not dramatically drop. I have given over 50 NTG sprays and still not had the systolic pressure drop to even 200, in some patients. We are unnecessarily afraid of NTG. Hypertensive CHF patients tend to be resistant very resistant to the effects of NTG. The only reason not to be giving 3 to 5 sprays/tabs at a time to hypertensive CHF patients is having a bad protocol.

The NTG paste makes no sense. You are applying it to the skin to be absorbed by the circulation to the skin, but the patients skin signs indicate that the circulation to the skin is just not there.

Pale – due to a lack of hemoglobin reaching the skin.

Cool – due to a lack of the warmth from blood reaching the skin.

Diaphoretic Sweaty – due to the large amounts of adrenaline being released by a body in hypoxic panic. The adrenaline shunts the circulation away from the skin.

The circulation needs to pick up the NTG from the paste on the skin to take it to where it is needed in the pulmonary circulation. It is not needed on the outside of the skin, unless we are looking for ways to accidentally expose our coworkers to NTG.

A great example of this is when someone is suturing a laceration and injects lidocaine with epinephrine (epinephrine is adrenaline). The skin around the injection site becomes more pale, as you are watching. This is what is going on to all of the skin on the pale, cool, sweaty patient. This is one reason that it does not make sense to use NTG paste. The other reason is that the low dose of the NTG paste is like trying to make the tide rise by urinating in the ocean. With precise enough tools, we may be able to measure a minuscule difference, but it does not make any noticeable difference. The epinephrine is shunting the blood away from the skin, not the lidocaine. The lidocaine is for pain relief. The epinephrine is to minimize bleeding during suturing.

As far as educating residents and stopping them from pulling my KingLT, the second you find an answer to that then post it immediately, I’m up for anything with that.

The best way to educate the residents is to educate the attendings. Maybe I have been spoiled, but I have found that the attendings are willing to look at different ways of doing things, if you present it to them in a way that makes sense. You may find that it takes several years to get them to actually change things, but I have found that they are willing to listen. Then it becomes a matter of politics. How do you identify the attending most likely to do something about it? Doctors are more likely to listen to other doctors. Good reasons coming from a medic are less likely to persuade a bunch of doctors, than the same reasons coming from another doctor.

If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them.

I get that secret smile when I turned the pt prior to arrival also.

You lost me on that one.

As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating.

I really do know that, and I agree. I have family that I really wouldn’t want some of these medics even touching them.

I kind of figured that.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills.

True, but I have seen a few attendings reach for a LMA because they couldn’t get an ETT placed. What is their standard for maintaining skills? Are they are judge? I’ve taken many ACLS classes over the years and every ED doc shows up but shows no initiative and participates. Here’s your card doc, oh and did I mention your codes, run like 1998.

The hospital decides what their rules are. Some restrict some skills to only certain doctors, while others may not have any restrictions for any doctor, as long as the doctor maintains a state license and malpractice insurance. Most are probably somewhere in between these extremes. It has been my experience that some ED attendings, board certified in EM, are scary at intubation and airway management in general. Others are great. I have sat in the parking lot to intubate some patients, because they were not responding to medical treatment, I knew that they would be intubated soon, and I knew who was the on duty attending. Why subject the patient to that doctors obligatory 2 or 3 failed intubation attempts, followed by a call to anesthesia and a waltz-by intubation, when they could come in with a tube in place and have less iatrogenic harm?

Some doctors just do not seem to get airway management. We all have our blind spots. I keep trying to minimize mine.

As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.

I’m not that old, and would NEVER disagree with that statement.


Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?

I’ve got none, and I’m not going to claim it, they are really new prehospital, around here anyway. LMA’s have been around for awhile but as far as I know no squad, at least in my area ever carried them. However I’m sure your reply will have a stat.

I will have to follow up with some posts on prehospital LMAs. There are services using them. There has been research on prehospital LMA use, but it is going to take a while to go through it and come up with something thorough.

Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.


After all, anesthesia seems to be leading the way in airway management, and they are increasing their use of LMAs. That may be where the rest of in-hospital airway management is headed.

You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.

I’ve suctioned enough of them, I am aware for long term, in my head I was focusing on pt’s that should have turned around and are only on a vent for a few days to a week. The patient that I knew would probably turn around if we were all aggressive on in the beginning, the CHF pt who was just to weak, but after being medicated, tubed, and cleared out, would allow the tube to be pulled assuming all the ABG values looked good.

Even that may change. VAP (Ventilator Associated Pneumonia) is a big concern in hospitals. It seems to fall into the never event category. As Ambulance Driver mentioned, hospitals are paying attention to the cost of care. They are going to try to cut down on costs, so I expect that we will see a lot more use of LMAs in the hospital, even if they don’t improve outcomes or expenses, but because they might and hospitals are all about saving money.

No waveform, then the tube is pulled, PERIOD.

Yeah, even I slapped myself for that statement, I got out of control. Let me explain what I was thinking. If I place a blind tube and don’t see a good waveform then the tube is pulled. This is on a patient that should show an ETCO2 reading. I could expand on it more but I think you get the jist.

Please send video of you slapping yourself. I am not above cheap sensationalist publicity. 😉

As I understand it, unless there are conflicting assessments, if there is no good wave form, the tube should be pulled. At least, that is the way I approach confirmation, and I get the impression that we agree.

Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating.

Again, how do we fix it?

I think the first thing is that we need agreement on what should be minimum standards, but that has to come mostly from the medical directors.

We need research to show what the differences are between places that intubate well and those that, even though the service may have some people who are great at intubation, the service overall does a horrible job of intubating patients. To do that we need well done research, which you get into below.

We need very well done research in places that intubate well, that are large enough to show what conditions are likely to benefit from intubation. There will always be good reasons for deviating from the typical treatment, but we do not even have research to clearly show that intubation does not cause harm.

We probably need a separate designation for medics permitted to intubate. I don’t know if it should be like the EMT-D add on for defibrillation, or whether it should be something like the critical care paramedic certification, with an broader scope of practice than whatever the regular paramedic would be. There are many ways of handling this.

I think this would be an important part of what Ckemtp is trying to do with EMS 2.0 over at Life Under the lights. My initial impression was that this is just going to be another passing fad, but I think he might be on to something. We need to transform EMS from a trade to a profession. Airway management is one of the areas, where EMS really needs to push the doctors to improve. We do not have the authority to change the rules, but I don’t see any reason to let that stop me. EMS 2.0 is also covered in Ckemtp, EMS 2.0 – Momentum Building, Happy Medic, Medic999, Too Old To Work, Too Young To Retire, Ambulance Driver, and even The Fire Critic and Firegeezer.

Waveform capnography?

EMS – Yes, usually. In Pennsylvania, it is mandatory for ALS.

ED – No. Some places have it, but most do not seem to use it.

One-on-one observation of patients for heavy sedation/aggressive pain management?

EMS – Yes, what are we going to do, leave?

ED – No, this requires rearranging staffing and will be done, if necessary, but is certainly not the baseline level of care. Generally, each ED nurse has 3 patients, or more.

These are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty – Now – Part I.

cont still…damn restrictions…

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

Scary stats, but failed why? Attempted but unable to place or, attempted and misplaced. That’s a big difference. If I miss a tube and I can’t get it, if I’m still able to oxygenate the pt to keep the stats up then it’s still successful, I just may not be able to move on to additional treatments. It sucks but it happens. If I misplace a tube then I’m killing my patient and think I’m helping. If I stick a blade in the patients mouth, it’s an attempt if I try to tube or not, even if it’s to suction to even clear an airway. If I have to do this on 5 of 10 patients then I’m at a 75% success/failure attempt rate. Data can be manipulated to favor for or against. It all looks bad on a pie chart, something we all learned in statistics at college.

I think there are plenty of problems with the data from Miami, but nobody has come out and provided documentation of these flaws. There is one very interesting rumor that I have heard. I do not like dealing in rumors, but I am hoping that somebody reading this will be able to document this, or get the medical director(s) involved to set the record straight, at least if the rumor is true.

The rumor is that in at least one of the services studied, the medical director strongly encouraged the use of alternative airways as true alternatives to intubation, rather than as back up airways, for airway management. However, the way the success/failure of intubation was determined was based on just two things. Was there any kind of airway intervention – BVM, CombiTube, LMA, crichothyrotomy, endotracheal tube, unrecognized esophageal tube. If any of those methods of airway management were being used, but there was not a properly placed endotracheal tube, this was considered a failed intubation.

After two ETI attempts, placement of a Combitube is considered as a rescue airway measure.

For this study, members of the Department of Anesthesiology assessed the airways of patients at their admission to the trauma bay. We defined prehospital airway management as paramedics having had an active role in managing the patient’s airway through a variety of approaches, including ETI, laryngeal mask airway (LMA), and Combitube and/or cricothyroidotomy.We defined a failed PHI as the improper localization of an endotracheal tube (ETT) on arrival at the trauma center or the need to use alternative rescue devices for airway management after intubation attempts.

Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

If the CombiTube is used as an initial airway measure, it is definitely not a rescue airway measure. If the doctors assessing the intubations were not familiar the way that airway management was being performed, then their determination of all CombiTubes as failed intubation attempts would be wrong.

From the way I read the study, if a CombiTube, or LMA, salesperson happened to stop at an accident scene and placed an airway, but the patient was transported by a BLS ambulance (no endotracheal tubes anywhere on the ambulance), this might have been classified as a failed endotracheal tube attempt. They might have presumed that paramedics were involved in the management of the airway, since they consider the ConbiTube to be only a rescue airway, rather than an alternative airway. I don’t think they would have done the same for a BLS crew transporting with just BVM airway managment if no ALS was available. From the system design, it is possible that all 911 ambulances have a medic on board. Still, there is no good reason why a BLS interfacility transport ambulance could not arrive on scene, deliver excellent care, realize that the closest ALS is at the hospital, and transport. BVM only. No possibility of endotracheal tube. According to the study, it might be classified as a failed intubation attempt.

Well, that is the thing that bothers me the most. Is the rumor true?

If the rumor is true, how many patients classified as having missed endotracheal tube attempts, never had any endotracheal tube attempts?

If the rumor is true, how can the researchers publish this without disclosing that variable? A variable that should have been controlled for, but if the rumor is true, a variable that was not controlled for.

You claim that you know that it is necessary. How do you know?

Only by experience, discussions with our command doc, and in my training and education I’ve receive to date that I’m acting in the best interest of my pt.

This is one of the reasons we need to have good research. It is unfortunate, but apparently medical school does not do a good job of preparing doctors to interpret research. If they cannot even interpret the research correctly, what is the research they design going to look like? We need to start doing a much better job of educating people about research and the scientific method.

You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.

Again, results can be biased.


The difference between good research and bad research is that the good research goes to extremes to exclude the influence of bias. Bad research may not recognize bias, or may come up with pathetic excuses for using the biased methodology. Not that there aren’t other ways of creating bad research.

Some of the reasons I started this blog are:

To educate people about research.

To get people to discuss research.

To get people to look critically at research, rather than just say, That is too complicated for me.

To get people to seek out research to persuade doctors of better ways to provide patient care.

For your last regarding how medics should be trained and certified I agree, but is it possible and should MD’s/Residents be held to the same standards.

I think that doctors should be held to higher standards than medics. This is one of the reasons for having EMS as a separate medical specialty. Sort of a way of saying, If you want to make contributions to EMS, this is the background you need to have. If you do not meet the criteria for board certification as an EMS physician, then go away. We still have too many non-emergency medicine physicians in the EDs, but this would be a start.

We are facing a lot of misunderstanding/obstacles from doctors, who think they understand EMS, even though they do not. That is one thing holding EMS back. Our patients deserve better.

Should we add a new cert level?


Forget about EMS 2.0, we’re going straight to EMS 3.14159 . . . . Well Vince may enjoy the math humor, even if not many others do. 🙂

I think that we need to be continually assessing the appropriateness of the different levels. Just because this is the way things have been done, does not mean that it is the way things should be done. There will be a lot of change in EMS. We should be doing things to try to make the changes good for the patients. Maybe a different certification. Maybe just more widespread use/recognition of the EMP-CC (critical care) level. Maybe much fewer medics and a lot more medical directors growing a set (metaphorically only, since some are women). We need to have an organization with the authority and the understanding to keep us moving in the right direction. I do not see the DOT (Department of Transportation) as that organization. Anything that combines EMS with firefighting, police, homeland security, or any other Wouldn’t it be cool if we could be used as an excuse for them to syphon off money for their pet projects? agency.

Love your posts, I’ve read them all. You too AD.

Thank you. As you have noticed, I enjoy a good debate. I think that we will not change things until we have identified all of the problems. I certainly do not have all of the answers. I don’t even have all of the questions. You contribute a lot to the discussion.

I’m on your side I promise. You really could take my blade away, I really do only tube as a last resort and I like Mystery Medic’s idea. Glidescopes are nice.

You point out one of the problems. The ones in need of having intubation taken away are the ones who will fight to the death (the patient’s) to keep intubation, but will resist any refresher/retraining/minimum requirements. They do not get that this is about the patients, not about making medics feel good, briefly, before going back to the routine calls that we do not feel challenged by.

I have not used the Glidescope. I have read good things about it. I think that it has the same potential for leading to bad outcomes as anything else – too much focus on the airway, as if the airway is not connected to a patient. A patient, who might not even have primarilly an airway problem. How many patients suffer anoxic brain damage because of intubation attempts? This is something that we should be able to avoid with excellent oversight, but we do need that oversight.

What do you feel about walking a pt to the bathroom around a corner in the house after getting diltiazem for rapid Afib that reduces and refuses to go with you to the hospital unless she can pee, assuming she is is on O2 and the monitor. Had a partner almost have her own stroke on my decision.

I have probably induced a few TIAs in partners, nurses, doctors, et cetera. If the patient has the capacity to make informed decisions about her own care, she may do pretty much anything that we think is unwise/dangerous.

We can pretend that we know that allowing a patient to do something, that we think is a bad idea, will kill them or make them much worse, but we do not know that. We can present them with all of the information about why we think it is a bad idea, but unless we are abducting the patient, or been given power of attorney, or have involuntarily committed them, . . . we do not have the authority to force the patient not to do what we think is unwise, nor do we have the authority to force patients to do something that we think is essential.

I will write more about this, because it is important and we seem to be very poorly prepared to deal with patients who do not agree with us. I just graduated EMT/medic/nurse/doctor school and I know everything. Usually the person making such an assertion is demonstrating that they actually are the most ignorant person in the room, but they often get their way, because they are the most insistent/intimidating/arrogant person in the room. Except when I am there. 😉

Then the follow up to Ambulance Driver’s comment.

Yeah I gotta fess up. I worked very hard on that first post to A) piss you off a little because I enjoy your follow up to BS and trolls and B) because I think if shows what many medics still really think.

Nothing to apologize for. We need to have good debates about what is best for patients. We currently have to rely mostly on expert opinion, because the research is too often inadequate to answer the question of what is best for the patient or what are the right requirements for intubation.

I still believe current research is biased and I would love to see a wide scale study in direct favor of the patient with all aspects of the pros/cons of intubation.

Research will always have problems, but it is still the best method we have of answering the questions of what is best for the patient. I would like to see that research, too.

I see turmoil in our future. We as medics are expected to learn more every year and that makes it harder to be proficient in the skills we already perform. We do this all without getting a pay raise, my cost of living increase alone was frozen for another year.

That is a problem. We do need to have medics dedicated to EMS. Not cross-trained as anything else. There is too much that we need to do to maintain proficiency to have paramedic be something done in addition to another job that people think is interchangeable, or related, or a way of saving money. These are generally not people you would want providing care for any real patient, yet they make decisions about how that care is delivered. Politicians are the enemies of EMS.

Tom Peters writes about this problem, but not as an EMS topic. He asks the question, Do you suffer from too much talent?

In EMS, we seem to act as if we have such talented medics, that cross-training in another field is not going to interfere with their ability to provide excellent care.

Maybe we just don’t care about excellent care – until we are the patients (or our families). Isn’t a 52% intubation success rate, even if partially inaccurate (12% esophageal intubations is also ridiculous) worse than bad patient care?

Do we suffer from too much talent?

Hope no hard feelings, RM, great follow-up 🙂

I do not take criticism personally, so there would be no reason for hard feelings. I like it when you make me think.

Thank you.

Other blog posts commenting on this, by others and by me, in order of posting, have been –

The Airway Continuum at EMS1.com by Kelly Grayson, AKA Ambulance Driver. 11/06/07

Teaching Airway: EMS Educast Episode 33 at EMS EduCast. 10/02/09

Teaching Airway – Part I at Rogue Medic. 10/10/09

Teaching Airway – Part I at Paramedicine 101. 10/10/09

Teaching Airway – Part I – comment from Anonymous at Rogue Medic. 10/11/09

Teaching Airway – Part I – comment from Anonymous at Paramedicine 101. 10/11/09

Rogue Medic’s Comment Section… at A Day In The Life Of An Ambulance Driver. 10/11/09

Paramedics and intubation at 9-Echo-1. 10/12/09

Attention all Companies at The Happy Medic. 10/12/09

Snapshot from the Paramedic Battlefield at Firegeezer. 10/12/09

Have You Seen This? at The Fire Critic. 10/12/09

Comment On A Comment at Too Old To Work, Too Young To Retire. 10/13/09

Airways and ET tubes… at 9-Echo-1. 10/14/09

EMS as a Profession? at The Fire Critic. 10/20/09

Airway comments by Rachel at Rogue Medic. 10/21/09

Airway comments by Rachel at Paramedicine 101. 10/21/09


Teaching Airway – Part I

Also posted over at Paramedicine 101. Go check out the rest of what is there.

On Teaching Airway: EMS Educast Episode 33, they have Kelly Grayson as their guest. The first of many times they will have Kelly Grayson as a guest. Hint! Hint!

Kelly says (50 minutes into the 1 hour show, so I am starting at the beginning) –

If you are going to allow paramedics to intubate, and I happen to agree with Bryan Bledsoe on this, . . . unless things change in the way we educate and regulate our EMS providers, within 10 years you are going to see intubation disappear from the paramedic skill set, except for a relatively few very well trained providers.

Since I have made similar comments, I want to point out the way that a lot of paramedics seem to interpret this sentence.

They are going to take our tubes away!

That ignores the really important part of the sentence. The part of the sentence that comes before and after the part I highlighted. That important part is this – unless things change in the way we educate and regulate our EMS providers, . . . except for a relatively few very well trained providers.

The way to prevent having the tubes taken away? If we really want to have intubation in our scope of practice, we need to continually prove that we can intubate well. We need to continually practice and work on learning more, if we expect to be able to prove that we can intubate well.

Many paramedics do not want to be told that. They want to be able to intubate, just because they think wanting to is enough. They want their Nobel Intubation Prize. Well, this isn’t politics, you actually need to do something.

What do we need to do?

Kelly’s immediately follows that with –

If we would pull the trigger and do what is necessary to make every paramedic like those well trained providers we envision intubating in the future. That’s what needs to be done. We need to have far more stringent requirements for intubation in the initial clinical experience. It needs to be far more than 6, or 8, or 10 tubes. If it takes an extra 6 months to get those tubes, then so be it. That’s the price we’re going to have to pay to be taken seriously. And once on the street, if you are not getting say X number of tubes – a tube a month, call it 12 a year – if you don’t get 12 successful intubations, or at least 12 attempts, in a 12 month period, there should be a clinical re-education requirement.

This was followed by Buck Feris saying, Agreed.

Can any of us disagree? Unfortunately, for many a medic/medic wanna be, that is asking too much.

Why should we have to be competent? Isn’t sitting through the classes, getting food for the preceptors as a bribe, and following all of the rules that I agree with – isn’t that enough?

Sure. That is good enough, but only if you work in a really unimportant job, not one where incompetence can kill patients.

We cannot demonstrate that prehospital intubation improves outcomes, but we insist on intubating.

Except for a few, we cannot demonstrate competence (pick almost any EMS intubation study), but we insist on intubating.

Why do we insist on harming our patients?

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

We do have to want it. We have to want to work at competence – not whine about being victims and whine about not being given what we want.


Taking Notes in Paramedic Class

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I have been listening to some of the old episodes of the EMS EduCast. There has been a bit of discussion of note taking, even criticism of the inadequate methods of taking notes.

Why are you in a class room?

To learn.

How do you learn?

Everybody learns a little bit differently There are several different ways of learning, but if the paramedic class is designed to teach you how to take notes, then note taking is important. If the paramedic class is designed to teach you how to understand how to be a paramedic, then note taking is only important, if that is the method that works to help you understand.

The purpose of the class is to have an understanding of the material. Writing, while the teacher is talking, does not help me to understand the point the teacher is trying to make. Note taking is to help reinforce later, what was learned in the class room.

Too many times I have had questions from students, who copied down what was said, but had absolutely no idea what it meant, because they were busy writing, rather than listening.

If I am talking to someone, and the person is sitting there writing, should I assume that the person is listening to me?

If I am talking to a boss, and the person is sitting there writing, should I assume that the boss is paying close attention to what I am saying, because what I am saying is so important that he/she needs to write it down?

No. I would assume that the boss, writing something down, is doing something else. Writing and listening are not all that compatible.

Note taking should probably only take place after the concept is understood.

Note taking is to reinforce understanding.

Note taking is not a substitute for understanding.

If we spend a lot of time on note taking, are we making sure that they understand, first? Too often, we do not, in my opinion.


EMS EduCast/EMS Garage #48 Quality – comments

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the comments to EMS EduCast/EMS Garage #48 Quality, commenting about Dr. Eisenberg’s quote,[1] 30 ff/pm wrote –

“We’ve recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice.”

Great teaching tool but if an ambo chasing attorney gets hold of it, there could be some $$$ payed out even if no one did anything wrong.

My city attorney is great at throwing cash around just to avoid going to court.
The feeling is that the jury might be swayed by claims – even if they’re not true and didn’t really have anything to do with the outcome. Sucks and isn’t right, but that’s the world we live in.

Assuming that you are describing the activity of this city attorney accurately, the attorney appears to be encouraging law suits, rather than protecting the city or protecting the patients. If other lawyers realize that the lawyer representing the city is afraid to go to court, they will find any excuse to bring a suit.

As long as the city attorney will throw money at them to go away, what do they have to lose? A better question is, Why would the city hire someone like that?

The city managers hire somebody to provide a specialized service that they are not qualified to perform themselves, whether it is legal defense, or EMS, or something else. They trust these experts to provide them with competent services. It is possible that there were legitimate reasons to justify the lawyer settling in all of these cases, but even though I am not a lawyer, I would bet that it is more of a fear of going to court, than a valid claims on the parts of all of the plaintiffs. The city attorney probably does not understand a thing about EMS. Ignorance leads to fear. Fear leads to settlement out of court. Or whatever Yoda said about fear. It appears that the city attorney would rather pay out the city’s money. Rather than demonstrate his/her profound ignorance of all things EMS.

If their approach to EMS is how do we avoid getting sued, rather than how do we improve patient care, it is a bit of a Catch-22 situation. They are discouraging attempts to improve quality of care, because anything they find out about how bad the quality actually is, could be used against them. Ignore it, pay out money now and then, here and there, but pretend that you cannot improve things, because some things are too dangerous to know?

Stay the same?

Avoid change?

Ignore problems?

There is only one way to stay the same in medicine. Only in death do things stop changing. Even then there are changes, but the person no longer has any reason to care.

How does one form of medical record create more liability than other forms? And an audio recording of the events is just that – another form of medical record. In some places, video recordings are used.

The city attorney appears to be looking at this only from the perspective of the harm it might do. In other words, the city attorney has absolutely no understanding of risk management. A recording may help the jury to understand what happened better than they would with a paramedic mumbling through the reading of a chart. Paramedics are not hired for their ability to read out loud. Paramedics are hired for their ability to treat patients on scene. A recording of the paramedic doing what he/she has actually been trained and hired to do. This might work for the defense much better than anything else the city attorney could present. Yet, the city attorney would probably prohibit this, because of ignorance – a level of comfort hiding behind ignorance that is scary.

I know what people are thinking – How do I know that is what the city attorney would do? I don’t know it. I am speculating. Unfortunately, I believe that 30 ff/pm is correct in concluding that the city attorney would act this way. I have dealt with attorneys in hospitals, where I taught ACLS. In 2 of these hospitals, I was informed that the attorneys had instructed the hospital emergency response teams to never touch anyone, who does not exhibit evidence of being a patient. The emergency response teams are only called to suspected emergencies. If a family member of a patient experiences cardiac arrest, they are not to touch the family member of the patient until after the patient is registered.

No wrist band, no treatment. You get treated the same as if you were trying to sneak into a night club. Actually, the night club staff would probably provide CPR if your heart were to arrest.

The attorneys believe that the potential harm is greater than the benefit. Yet, these are the same people, the paramedics and emergency response teams, who will be treating the patient visitor after the patient is registered.

Is the emergency response team’s care going to become better, just because the visitor has been registered?

No. Delaying CPR is possibly the worst thing they can do, but that is what the lawyers are insisting they do. The lawyers are making the medical decisions.

Is there any way the attorneys can claim that the unregistered patient is really not a patient?

No. According to EMTALA (the Emergency Medical Treatment and Active Labor Act), anyone presenting with a complaint within 250 yards of the hospital, or anywhere within the hospital, is automatically a patient. These patients may not be turned away, until after a medical screening and stabilizing treatment, even when being transferred to another hospital.

Cardiac arrest is one of the most time sensitive conditions. Delaying care is just as bad as refusing to deliver care, because there is a very limited time during which treatment is likely to be effective. Supposedly, the chance at resuscitation decreases 10% for every minute of delay in initiating treatment, or every minute of inadequate treatment. Such as an 80 year old Grandma performing compressions on her husband, while the emergency response team stands around digitally monitoring their own sphincter tone. Look Grandma, no prostatic hypertrophy!

While I am still not a lawyer, there is one word that comes to mind, when describing this approach – indefensible. OK, not just one word. There are plenty of adjectives that could go along with indefensible, but none of them are good.

A different approach might be to only hire competent personnel. I am not stating that the emergency response teams are not competent, or that the paramedic coworkers of 30 ff/pm are not competent. The problem is that the city attorney presumes that these medics are incompetent, or that more evidence would only work against the defense.

If the attorneys were comfortable with the competence of the paramedics and emergency response teams, then the attorneys should be much more confident that more facts will lead to a better defense, not the other way around. But they do not. If they are that uncomfortable with the employees, they either need to learn about what the employees do, demand higher standards, or find some other way to improve quality – such as using audio recordings of cardiac arrests. You know that I am in favor of both. Even if the standards are already high, make them higher. Quality is about improvement – never being satisfied. not in a 6 Sigma way, but in always looking for ways to improve patient care. Actively participating in research.

Dr. Eisenberg mentioned that some cities, that were studied, had ridiculously low resuscitation rates. The reaction, when the news was published? Apathy. nobody cared. Less than 1% successful resuscitation. While where Dr. Eisenberg works, the resuscitation rate is about 50%. This is not a minor difference, so how is it that people do not care? But, they don’t care.

The other comment was from Greg Friese, one of the hosts of the EMS EduCast, where the broadcast with Dr. Eisenberg started. Greg’s response to 30 ff/pm was –

I would rather defend a recording of the facts than speculate about facts based on the recollections of all involved.

Much more succinct than what I wrote. I completely agree. I think that 30 ff/pm also agrees, but his city attorney is the one, who does not agree.


^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27


EMS EduCast/EMS Garage #48 Quality

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Again returning to the EMS Garage post with Mickey S. Eisenberg, MD on resuscitation,[1] the rest of the episode was great. One of the points brought up was, at about 52 minutes in, Buck Feris mentions a quality assessment/improvement method in a system, that has a supervisor respond to debrief the crew after every arrest. Reviewing what went right and what went wrong.

Dr. Mickey S. Eisenberg earlier had talked about methods of improving outcome and the approach of reviewing every unsuccessful resuscitation by asking, Why wasn’t this patient resuscitated?

These are excellent approaches. If we are not reviewing our calls, how do we expect to improve? I think that both of these approaches are still too limited. We should review all calls that fall into certain categories. For example, all cardiac/potentially cardiac calls, all respiratory calls, all calls involving any level of pain, et cetera. Maybe not right after the call, but as soon as is practical.

In my opinion, people who are opposed to continually improving patient care are not needed in EMS.

What kind of ignorance is needed to claim that we should not be improving our care of patients? Real medicine is about continually improving patient care.

Dr. Eisenberg goes on to make an essential point about a method used to improve quality. Audio recordings of cardiac arrests by the defibrillator. He states,

We have found that immensely valuable. We’ve used it in our system from day one. We’ve recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice. That has been a very valuable tool, to reconstruct for educational purposes, what exactly was going on in the resuscitation and when. Because, without it you can’t really tell when there are gaps in CPR, you can’t even tell when ventilations are occurring, you can’t tell reasons why there was the delay in this or that.

And if it’s done for the purpose of education and never for the purposes of discipline. We’ve never, ever, used these tapes for disciplinary reasons. They’ve always been used for education. You can learn an awful lot, and begin to piece together what went on.

If we want to improve quality, we need to make it safe for people to bring up and discuss mistakes. If the employees are afraid of punishment for raising concerns about things that went wrong, we will never learn about many of the problems in the system. We need more people in EMS, who understand this.

Again, in my opinion, people who are opposed to continually improving patient care are not needed in EMS.


^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27