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

- Rogue Medic

EMS Dinosaurs and the Slow Gazelles – EMS Office Hours


This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a couple of topics kind of related to dinosaurs before I got on the show. We ended up discussing what a dinosaur is (all of us) and what a problem dinosaur is (someone who refuses to learn).

EMS Dinosaurs and the Slow Gazelles

I stated that dinosaurs, the problem people – those who refuse to learn, make excuses for the failure of their beliefs to be confirmed by reality (valid evidence of improved outcomes).

Here are some of the treatments that are routine in EMS, but are not supported by valid evidence of improved outcomes.

Backboards, a lot of saline for uncontrolled hemorrhage, ventilations for cardiac arrest, airways for cardiac arrest, drug for cardiac arrest, furosemide (Lasix, frusemide in Commonwealth countries) for acute CHF (Congestive Heart Failure), sodium bicarbonate is a good treatment for acidosis, high-flow oxygen in the absence of hypoxia, 50% dextrose for hypoglycemia, steroids for spinal injuries, et cetera.

All of these are based on an absence of evidence or on inadequate evidence. Most of them have evidence of more harm than benefit.

Why do we continue to add treatments to guidelines before there is evidence of benefit?

Because we believe that the treatments work because we are dangerous optimists. We refuse to learn that we harm patients by rushing treatments in to guidelines.

In the absence of evidence of benefit, we should assume that every treatment is harmful.

If reality does not agree with what we believe, then the problem is not reality, but our refusal to accept reality.

There was a discussion of prehospital therapeutic hypothermia with IV (IntraVenous) chilled saline, which has been clearly demonstrated to be not beneficial and possibly harmful. In-hospital therapeutic hypothermia does work, but having EMS start this was a bad idea and now needs to be removed from protocols.

There have been three studies of the effect of prehospital chilled saline for post-resuscitation therapeutic hypothermia. Dr. Bernard’s study showed no benefit and was stopped early because the results made it clear that there was no benefit.[1] Dr. Bernard talks with Dr. Scott Weingart on two EMCrit podcasts about the more recent studies.[2]

Click on images to make them larger. “Normal” temperature is 37°C and varies throughout the day, including when almost dead. The drop in the graph is not a temperature drop. It is the drop in survival for both groups.

After publication of the seminal trials of therapeutic hypothermia after cardiac arrest,2,3 this approach was recommended in international guidelines,4 despite arguments by some investigators that the evidence was weak, owing to the risk of bias and small samples.6,25 [3]


We are doing a lot to the patient that can cause complications with no expectation of any benefit.

This is a bad idea.



The intervention reduced core body temperature by hospital arrival, and patients reached the goal temperature about 1 hour sooner than in the control group. The intervention was associated with significantly increased incidence of rearrest during transport, time in the prehospital setting, pulmonary edema, and early diuretic use in the ED. Mortality in the out-of-hospital setting or ED and hospital length of stay did not differ significantly between the treatment groups.[4]


We need to wait for evidence of improved outcomes.

If we cannot provide evidence of improved outcomes, all we have is wishful thinking.

Wishful thinking kills.

Go listen to the podcast.

PS The story from Welcome to the Monkey House by Kurt Vonnegut is called Harrison Bergeron. It is only a couple of pages and beautifully written. The full text is on line for free here.

THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way. Nobody was smarter than anybody else. Nobody was better looking than anybody else. Nobody was stronger or quicker than anybody else. All this equality was due to the 211th, 212th, and 213 th Amendments to the Constitution, and to the unceasing vigilance of agents of the United States Handicapper General.

. . . . .


Go read Harrison Bergeron.


[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

[2] Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I
Podcast page with links to research mentioned in the podcast.

Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II
Podcast page with links to research mentioned in the podcast.

[3] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

[4] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed – as supplied by publisher]


EMS Volunteers, Patient Stress and 200,000 Downloads for EMS Office Hours


Last week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a variety of topics before I got on the show. We ended up discussing a question Josh had posted on the WANTYNU Facebook page.

EMS Volunteers, Patient Stress and 200,000

I do not have a link to the original question, but it was along the lines of If you are 99% sure that your patient is having a heart attack, do you tell the patient?

My original comment was along the lines of

1. How did I develop so much certainty about this actually being a heart attack?

2. What is the benefit of telling the patient You are having a heart attack?


A. Do we track all of our heart attack patients and compare their final diagnoses with our diagnoses?

Would only STEMIs (ST segment Elevation Myocardial Infarctions) be considered for the You are having a heart attack, with 99% accuracy claim?

Does we have the statistics to back up that claim?

Are we overly confident of our diagnoses and unaware of the difference between our accuracy and reality?

Even if we do track our precision (when we state that it is a heart attack, it truly is a heart attack), do we assume that means that we avoid false negatives(when we do not state that it is a heart attack, there is no heart attack)?

Do we track false negatives?

How do we know if we miss false negatives?

How does awareness of these false negatives affect our confidence in claiming You are having a heart attack?

Do our misses count?

Is it a miss, if the machine analysis states ***STEMI***, we disagree, but it turns out to be a STEMI?

Is it a miss, if the machine analysis does not state ***STEMI***, we disagree, and it turns out to not be a STEMI?

Is it a miss, if the machine analysis does not state ***STEMI***, we disagree, but it turns out to be a STEMI? The machine was wrong, but we were right.

All of these affect our diagnosis of STEMI, but how much do we pay attention to any of them?

Is the excuse, Most doctors would have missed that, a valid excuse? We are wrong, but we are as wrong as another group of people would be expected to be.


If the goal is to be wrong less than 5% of the time, what evidence do we have that we are wrong less than 1% of the time?

In summary, broad awareness should exist regarding evidence-based triggers for appropriate Cath Lab activation. A diverse group of frontline clinicians making these time-pressured decisions need a comprehensive list of precise criteria, because not all “acute MIs” have classic ST-elevation on ECG (eg, STEMI-equivalents and certain OCHA scenarios), not all ST-elevation patterns represent “true STEMI” (ie, STE-mimics), and some “true STEMI” patients are not reasonable candidates for an aggressive treatment strategy involving PPCI. Optimal ECG interpretation proficiency by all clinicians in identifying both classic STEMI and STEMI-equivalents constitutes a major cornerstone of ongoing efforts to maximize STEMI system efficiency.[1]


And the most important question may be How much do we know about what we don’t know?

Am I 99% certain, or just convincing myself that I am much more certain than I have any right to claim?

Why should we assume that we do not need to know our limitations?

Go listen to the podcast.

Also see Tom Bouthillet’s slides from his presentation –

STEMI Mimics and STEMI Equivalents
EMS 12 Lead
Slide presentation.


[1] Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction.
Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW.
Am Heart J. 2010 Dec;160(6):995-1003, 1003.e1-8. doi: 10.1016/j.ahj.2010.08.011. Review.
PMID:21146650[PubMed – indexed for MEDLINE]

Free Full Text from Am Heart J.


Is it Good When Everybody Responds for a Call Involving Police/Fire/EMS?


Last week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a variety of topics before I got on the show. We had a bit of disagreement about whether everyone should be sent for police/fire/EMS patients.

EMS Rapid Fire | October 2013

Where is the evidence that there is a benefit to these patients?

If we are just putting on a show, we are fooling ourselves. Why can’t we be honest?

Why do we deserve such a show?

Does this show improve outcomes?

History has documented numerous cases of a pervasive medical problem come to be known as “The VIP Syndrome.” The entrance of a VIP or celebrity challenges the normal practices of physicians and their institutions. The result of treating VIPs differently than “common individuals” can sometimes be catastrophic. By not adhering to common practice guidelines, physicians risk compromising their basic powers of perception, judgement, and treatment. The “VIP Syndrome” is not well known in the medical community. This poses a risk to every health care institution encountering a VIP in a medical treatment setting.[1]


When we treat patients differently because of their status (MOS – Member Of Service), we are treating them as VIPs, which is harmful to the patients we are trying to help.

We need to understand what we are doing – rather than make a show out of doing something.

We need to be honest about the ways we are treating our patients and the ethical aspects of our actions.

Go listen to the podcast.


[1] Executive Health Care in the Air Force
Corporate Author : Air Univ Maxwell AFB AL
Personal Author(s) : Simpson, Carl G.
PDF Url : ADA397186
Report Date : APR 1998
Web page with link to Download in PDF format.


Too Much Oxygen, Too Many Backboards


This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and I discuss a variety of topics – quality in EMS, respect for EMS, the value of research and whether we should teach people to use research in EMS.

Too Much Oxygen, Too Many Backboards

Spinal immobilization can be done in many different ways. Strapping a curved spine to a flat piece of lumber/plastic is not the only way to do it and not even the only way that it is done in the US, nor in the rest of the world.


Long spine board immobilization is continuing to be replaced by the lateral trauma position in Norway.[1],[2]

What about in America?

Going back to 2008 (the earliest protocols available on line, all of Pennsylvania has had spinal clearance.

Immobilize the entire spine3,4 in any trauma patient who sustains an injury with a
mechanism having the potential for causing spinal injury and who has at least one of
these clinical criteria:5
a. Altered mental status (including any patient that is not completely alert and oriented)
b. Evidence of intoxication with alcohol or drugs
c. A distracting painful injury (including any suspected extremity fracture)
d. Neurologic deficit (including extremity numbness or weakness- even if resolved)
e. Spinal pain or tenderness (in the neck or back)


Without altered mental status, evidence of intoxication, a distracting painful injury, neurologic deficit, and/or spinal pain or tenderness spinal immobilization is a violation of protocol in Pennsylvania.

Alameda County, California; Xenia, Ohio; and all of Connecticut are doing away with backboards.

Spinal clearance has been in place in many more places in various forms for years, or even for decades.

Don’t let local attitudes fool you. this is not new or limited to isolated areas.

Spinal immobilization is witchcraft. There is no evidence of benefit.

Oxygen was also discussed.

There is a lot to discuss about the absence of good evidence that supplemental oxygen improves outcomes when there is no known hypoxia.
For heart attack patients, why do we want to give a drug (oxygen) that causes vasoconstriction, when our goal is vasodilation?

If the goal is to improve blood supply, and oxygen decreases blood supply, then why are we giving oxygen in the absence of evidence of hypoxia?

Supplemental oxygen without evidence of hypoxia is also witchcraft.


[1] The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services.
Fattah S, Ekås GR, Hyldmo PK, Wisborg T.
Scand J Trauma Resusc Emerg Med. 2011 Aug 4;19:45.
PMID: 21816059 [PubMed – in process]

Free Full Text from PubMed Central with links to PDF Download

[2] The Lateral Trauma Position: What do we know about it and how do we use it
Sun, 04 Dec 2011
Rogue Medic

[3] Spinal Immobilzation – 261
2008 Pennsylvania Protocols
Page with links to protocols in PDF format.

[4] More Oxygen Can’t Hurt…Can It?
by William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Created: MAY 1, 2013
EMS World


Should we urinate on patients, because ‘What if it improves outcomes?’


This week on EMS Office Hours, Jim Hoffman, Josh Knapp, John Broyles in the chat room, and I discuss a variety of topics, but mainly the absence of any relationship between standards of care and evidence of improved outcomes for patients.

Merit Badges Determining Standard Of Care and…

How do we end up with the many organizations creating standards of care for us?

They do not create the standards of care. They write guidelines with recommendations only to consider what they claim is based on evidence. The problem is that the evidence they look for is improved surrogate endpoints, rather than improved outcomes.

If you are bleeding internally, do you want treatment that will provide a better looking blood pressure when you arrive at the hospital, even though that treatment does not appear to do anything to improve survival?[1]

If you collapse due to cardiac arrest, do you want treatment that will provide a better looking blood pressure when you arrive at the hospital, even though that treatment does not appear to do anything to improve survival?[2]

Would the outcomes be any worse, if I were to urinate on the patient?[3],[4]

Probably not – as long as we are providing appropriate BLS care.

Image credit.

The patients might even be better off, because the urine might help to keep the drugs and tubes people (paramedics, nurses, and doctors) away from the patient. The drugs and tubes seem to produce worse outcomes, so the urine would protect the patient from these worse outcomes.

Or we can use the excuse that is used for so many of our dangerous treatments –

We wouldn’t want anyone to be able to say that we didn’t try everything.

We don’t care how much harm we cause as long as we seem like we are doing something.

It’s the thought that counts – as long as the thought doesn’t require actual thinking.

Go listen to the podcast.

This part of the podcast was part of a discussion of what I wrote about in Should Merit Badge Organizations Define Standards of Care?


[1] Evidence of improved survival from uncontrolled hemorrhage due to administration of fluids

No evidence of improved survival.

[2] Evidence of improved survival from cardiac arrest due to administration of epinephrine

No evidence of improved survival.

[3] Evidence of improved survival from uncontrolled hemorrhage due to administration of urine

No evidence of improved survival.

[4] Evidence of improved survival from cardiac arrest due to administration of urine

No evidence of improved survival.


Paramedic School Accreditation – Advanced Airways vs. BVM


This week on EMS Office Hours, Jim Hoffman, Josh Knapp, John Broyles, and I discuss a few topics. National Registry of EMTs accreditation of paramedic schools.

Paramedic School Accreditation | Advanced Airways vs. BVM

If we are going to have standards, they should be based on some evidence that they work.

Is something better than nothing?

Something is only better than nothing if the something is something good.

Is a grade better than 80% good for bragging rights?

What does the grade mean? Does the exam demonstrate that the person understands good patient care? I do not see evidence that this initial exam does that.

The NR exam is just an initial exam, but some benighted people think that there should be higher pay for people who have passed this particular brand of entrance exam. Are they supposed to remain beginners forever?

Is a structured way of doing things a good way to evaluate people for the unstructured, or minimally structured, job of paramedic.

We also discuss what I wrote in Advanced Airway vs. BVM During CPR – Which is Worse?

There is no evidence that ventilations improve outcomes.

I was at Dr. Banerjee’s presentation on cardiac arrest and how their treatment protocol produces better outcomes than the rest of the country. One person in the audience kept complaining that he is wrong to not follow the ACLS guidelines because he will be sued. Dr. Banerjee’s response should be obvious – You need to show evidence of harm to win a law suit. I produce better outcomes than the rest of the country.

John Broyles brought up the way we educate badly with our focus on verbalizing Gloves on – Scene safe! and not thinking about what we are doing as far as using gloves and continually assessing scene safety.

Gloves are often inadequate BSI (Body Substance Isolation), but we act as if wearing gloves will protect against everything; as if wearing gloves somehow produces a force field around the body that protects parts of the body not covered by the gloves; as if gloves do not tear or break down and need to be replaced on the job; as if gloves make up for not cleaning our hands; as if touching clipboards and other equipment with gloves on is doing anything other than spreading germs all over the equipment that we will later pick up without gloves on; as if gloves need to be worn for every patient.

Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings
CDC (Centers for Disease Control and Prevention)

According to the CDC – Not every patient.

According to the CDC – Not every time.

Go listen to the podcast.


Do You Have An EMS Fall Back Plan?

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and I discuss some of the options when we cannot work.

Do You Have An EMS Fall Back Plan?


Josh and I both disagreed with Jim’s suggestion that an EMS background is important in sales of EMS products. EMS sales is not selling very technical equipment. How much do you need to understand to sell drugs or intubation equipment? There experience will matter more, but to sell ambulances, stair chairs, stretchers, equipment bags, et cetera – sales skill is much more important.

Of the people I know who got out of EMS, most are nurses or doctors (some became both). Outside of medicine, most have gone into computer programming/repair.

What happens if you are fired, or put on unpaid leave?

I have always preferred to have several other jobs. At one point, I had a total of 10 teaching and EMS jobs. The frequency with which I worked at the different jobs varied from once every few months to once, or twice, a week and then my full-time job. I do tend to take things a bit farther than most.

On the other hand, I have been fired from a full-time job for trying to get the medical director to do something about an incompetent medic. This was not the only time I have opposed my employer on dealing with incompetence, but it is the only time I was fired for it.

Unemployment insurance can be very helpful. Having other jobs to work at occasionally does decrease the amount of money we receive, but not until after income reaches a certain level, so it is not designed to discourage work. More important is that we do not lose that money, but we extend the amount of time we are eligible for benefits.

Unemployment insurance is money we have paid into as part of our payroll deductions. Based on the amount of money we make, we are entitled to a certain amount of money over time. The time can be extended until all of the money is paid out, or until we are consistently making more than the amount that would allow us to receive payments.

Networking helps in getting another full-time job. Sometimes being fired by one employer is seen as a badge of honor by other employers. “Why did you ever go there? Of course they were going to fire you eventually.”

Unemployment insurance allows payments as long as we are actively looking for work. It is not an excuse to take a vacation, but it may allow time to get other training/education that may improve the quality of the next job.

In one particularly bad year for me, I was laid off from two of the best jobs I have had. In February/March, I was laid off from a regular part-time job because the paramedic services were being switched to the local hospital for political reasons. In August, I was laid off from my full-time job because the paramedic services were being switched from the local hospital for political reasons. I did receive a nice severance package from the hospital in addition to unemployment. The hospital also provided me with information about how to handle that so that I did not run into problems with unemployment – if we do not tell the unemployment office, it can be a very bad thing.

Unfortunately, we did not talk much about unemployment insurance on the show. Unemployment benefits will vary from state to state, so my experience may not be representative.



Go listen to the podcast.


Tubes and Guns and Training, Oh No

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Kelly Grayson, Russell Stine, John Broyles, and I discuss the pros and cons of concealed carry in EMS.

This is not an issue of camouflage uniforms, or concealed carry of endotracheal tubes, or of RSI drugs, but concealed carry of guns.

Stethoscope, penlight, O2 Wrench, GUN…. wait a sec.

Do we need inadequate initial, and ongoing, training in another way of harming patients? This has almost no chance of benefit.

This is like homeopathy. EMS concealed carry is a placebo, but it is potentially a more directly harmful weapon than homeopathy.

We need to be better at what we are supposed to be doing (providing emergency medical care), not coming up with excuses for distracting ourselves from patient care.

Where is a gun useful?


If the attacker is 0 to 20 feet away, that is where the patient usually is. That is where I can expect to lose, if I attempt to draw a concealed weapon. If I am attacked by the patient, a concealed weapon is the wrong response. See the video at the end.

If the attacker is 20 to 60 feet away, I have time to draw and fire and I am within the expected accuracy of a concealable weapon.

Outside of 60 feet, the attacker and I might as well just taunt each other for all the accuracy of a weapon that can be concealed.

I don’t want to talk to you no more, you empty headed animal food trough whopper! I fart in your general direction! You mother was a hamster and your father smelt of eldeberries.[1]

RULE I: All guns are always loaded.

RULE II: Never let the muzzle cover anything you’re not willing to destroy.

RULE III: Keep your finger off the trigger until your sights are on the target.

RULE IV: Be sure of your target, and what’s beyond it.[2]

Is there any reason to treat carrying on duty as anything other than a placebo?

When would EMS concealed carry make any difference?

Other than those times it makes things worse, when would it make a difference?

I’ve got this completely under control. Freeze varmint!

I’ve worked with plenty of people who are quite dangerous without a gun. Do I want to make them even more dangerous?

Is there a benefit to the patients?

Is there a benefit to us?

Will we start to include attack dogs on our trucks?

I have not been on any call that I see having a better outcome if my partner, or I, were to carry.

The only case I know of where EMS personnel were shot on the job was back at the station by an ex-spouse/ex-lover/ex-something. I don’t know where any lives will be saved.

We are supposed to be carrying equipment, and training with that equipment, to save lives. Few of us train enough on the equipment we have.

Better to be raped in prison by a dead guy’s friends, than to back away and leave the room to go home at the end of the day.

When is the scene safe?

The scene is NEVER safe.

Scene safety is just another EMS myth.

Do the police have to protect citizens, or is that another myth?[3]

EMS concealed carry is a limited solution to a problem that is similar to what we face, but it isn’t the same problem and it does not appear to be the right solution.

20 feet?


The most important part of surviving violence in EMS is mentioned by Kelly Grayson – situational awareness.

Go listen to the podcast.

See also –

Should ambulance crews be allowed to carry weapons? – Kelly Grayson at ems1.com

Will Virginia EMT’s Be Granted Right To Carry Firearms? – A Day in the Life of an Ambulance Driver

Part I – CCW on duty… and the conversation we SHOULD be having – EduMedic

Part II – CCW on duty… and the conversation we SHOULD be having – EduMedic

Concealed Carry for EMS: 2 Questions – Everyday EMS Tips

EMS Providers Carrying Guns – A terrible idea – Life Under the Lights

Should EMS Providers Be Carrying Guns on the Job? – 510 Medic

Arming EMS? The Debate Continues – Medic Madness

Surviving the Next Shift – Standing Orders podcast

EMS Situational Awareness – EMS Office Hours

Ohio Debate Continues about EMS Providers Carrying Guns

Surviving the Next Shift – Part I – Rogue Medic

Surviving the Next Shift – Part II – Rogue Medic


[1] Monty Python and the Holy Grail
Scene 8
Guard taunting Arthur, King of the Britons
Sacred Texts
Unofficial screenplay

[2] maybe some people shouldn’t own guns.
the munchkin wrangler.

[3] Warren v. District of Columbia

Warren v. District of Columbia[1] (444 A.2d. 1, D.C. Ct. of Ap. 1981) is an oft-quoted[2] District of Columbia Court of Appeals (equivalent to a state supreme court) case that held police do not have a duty to provide police services to individuals, even if a dispatcher promises help to be on the way, except when police develop a special duty to particular individuals.