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

- Rogue Medic

2020 ACLS Repeats the Mistakes of 2015 ACLS

Wed, 21 Oct 2020 12:10:23 -0400 by

 

 

The International Liaison Committee on Resuscitation (ILCOR) has updated the ACLS (Advanced Cardiac Life Support) recommendations by making excuses for the evidence.

 

We have been using epinephrine for 50 years without evidence of improved outcomes that matter to patients.

 

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest (Paramedic2) shows that epinephrine does not improve outcomes for prehospital patients.

 

In conclusion, in this randomized trial involving patients with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of survival at 30 days than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.

 

Rather than limit treatments to those with high quality evidence that they improve outcomes that matter to patients, the recommendation is to keep giving epinephrine, because eventually someone might provide something – anything – to support epinephrine.

 

What about amiodarone?

 

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest (ALPS) showed that amiodarone also does not improve outcomes.

 

Conclusions Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

 

If amiodarone was mentioned, I missed it. Both epinephrine and amiodarone had large placebo-controlled research results released showing that the outcomes are worse with epinephrine and worse with amiodarone.

 

There is still no evidence that any ventilation produces better outcomes than compression-only resuscitation, but it looks like the intervention will continue to be recommended.

 

In the absence of evidence of benefit, inadequately tested interventions should be avoided.

 

The goal is to protect the patients, not to protect the interventions.

 

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Filed Under: ACLS, Defibrillation, Epinephrine, Ethics, Evidence, Heresy, Intubation, Naloxone, PALS, Pharmacology, Potentially Reversible Causes, Research, Superstition, Ventilation

New FDNY Cardiac Arrest Protocol is Reasonable

Fri, 03 Apr 2020 09:15:43 -0400 by

In New York City, the protocol for cardiac arrest during the coronavirus pandemic has been changed. The protocol now states to pronounce the patient dead after 20 minutes, if there is no return of spontaneous circulation (ROSC). If the patient remains pulseless after full paramedic treatment, the chances of any good outcome have dramatically dropped to zero. However, the dangers of transport and infection are only going to increase with transport for the purpose of pronouncement at the hospital, because that is all that is going to happen. A doctor will probably walk out to the ambulance, ask for a brief report, look at the monitor, and then tell the medics to stop compressions and ventilations.

Is there any reason to believe that an emergency physician, who is already overworked, is going to endanger the other patients in the emergency department, just to “make it look good” for a few more minutes?

Many communities already have these protocols in place. The American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) already recommend that resuscitation be terminated with no ROSC after 20 minutes.

FDNY (Fire Department of New York, which run EMS in New York City) has traditionally been, well . . . , very traditional in its approach to cardiac arrest. Cardiac arrest treatment doesn’t require much, but the traditionalists like to do a lot more than is good for the patient. For appearances? For unreasonable optimism?

Unfortunately, the president of the local union is misrepresenting this, in order to make a political point, or to demonstrate a lack of understanding, at a time when he should be trying to explain that this is protecting union members and protecting the public.


This is what the military does. They come. They check your pulse. No pulse – next. You know, we’re going to be leaving bodies behind, which is the exact opposite of what’s the oath we took.[1]


Oren Barzilay EMS Local 2507 President. Also identified by the news as a paramedic. If so he should know better.

What does the protocol state?


TEMPORARY Cardiac Arrest Standards for Disaster Response[2]


NYC REMAC (New York City Regional Emergency Medical Advisory Committee) does need to approve whatever N-95 masks have been donated, if the claim that the masks have not been approved is more accurate than the claim about resuscitation.

The NYC protocol has caught up with what many other states have been doing for decades. It is sad that the union leadership is fighting to keep EMS in the dark ages with misinformation and emotions. Misinformation thrives on emotions, so the emotional appeal is not surprising.

There is another protocol change that seems to escaped the notice of Oren Barzilay EMS Local 2507 President, or that part of the interview was cut. Intubation can be skipped – in favor of an extraglottic airway.


Use of Alternative Airways[3]


There is still no good evidence that the average paramedic is competent at intubation, but many agencies insist on intubation as if it is some sort of magical ability of paramedics. Just wave the laryngoscope and the tube goes into the trachea. Paramedics are not good at intubation, but we are good at whining about having intubation taken away, as if it is something we have earned.

We have not earned the right to make patients hypoxic, to tear up the airway, and to claim that we are improving outcomes. Hypoxia is bad for the patient. Tearing up the airway is bad for the patient. We have no good reason to believe we are providing a benefit to the patient, but we do have plenty of evidence that we are causing harm.

Why do so many of us refuse to practice?

Why do so many of us refuse to behave as if we believe any of the lies we tell about intubation being a life saving procedure?

If intubation really is “life saving”, why do paramedics refuse to engage in more than token intubation practice – and then brag about how much they practice?

Because we do not understand what we are doing and because our arguments are emotional, rather than rational.

We paramedics deserve ridicule for our repeated defenses of incompetence.

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


Here is the only evidence I know of demonstrating benefit from intubation:


Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65. doi: 10.1097/SLA.0b013e3181efc15f.
PMID: 21107105


Here is some of the evidence showing either a lack of benefit from intubation or evidence showing harm from intubation:


Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768

Free Full Text PDF


Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. doi: 10.1016/j.annemergmed.2012.02.013. Epub 2012 Mar 15.
PMID: 22424653

Free Full Text from Annals of Emergency Medicine.


A is for airway: a pediatric emergency department challenge.
Green SM.
Ann Emerg Med. 2012 Sep;60(3):261-3. doi: 10.1016/j.annemergmed.2012.03.019. Epub 2012 Apr 19. No abstract available.
PMID: 22520991

The article above is a comment on the previous article.


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. doi: 10.1213/ane.0b013e3181aa3063.
PMID: 19608824


Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364

The article above is commentary on the article below:

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674


Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.
Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA.
JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597.
PMID: 30167701

Free Full Text from PubMed Central® (PMC)


Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.
Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G.
JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044.
PMID: 30167699

Free Full Text from PubMed Central® (PMC)


Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest.
Andersen LW, Granfeldt A.
JAMA. 2018 Aug 28;320(8):761-763. doi: 10.1001/jama.2018.10824. No abstract available.
PMID: 30167679


Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.
Wang HE, Simeone SJ, Weaver MD, Callaway CW.
Ann Emerg Med. 2009 Nov;54(5):645-652.e1. doi: 10.1016/j.annemergmed.2009.05.024. Epub 2009 Jul 2.
PMID: 19573949


Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.
Hasegawa K, Hiraide A, Chang Y, Brown DF.
JAMA. 2013 Jan 16;309(3):257-66. doi: 10.1001/jama.2012.187612.
PMID: 23321764

Free Full Text from JAMA


No evidence for decreased incidence of aspiration after rapid sequence induction.
Neilipovitz DT, Crosby ET.
Can J Anaesth. 2007 Sep;54(9):748-64. Review.
PMID: 17766743

Link to Abstract and Free Full Text PDF Download from Can J Anaesth


The Great Prehospital Airway Debate
August 31, 2018
Emergency Medicine Literature of Note
by Ryan Radecki
Article


EM Nerd-The Case of the Needless Imperative
August 31, 2018
EMNerd (EMCrit)
by Rory Spiegel
Article


Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2
The Resus Room
Podcast with Simon Laing, Rob Fenwick, and James Yates with guest Professor Jonathan Benger, lead author of AIRWAYS-2.
Podcast, images, and notes


Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies.
Okubo M, Schmicker RH, Wallace DJ, Idris AH, Nichol G, Austin MA, Grunau B, Wittwer LK, Richmond N, Morrison LJ, Kurz MC, Cheskes S, Kudenchuk PJ, Zive DM, Aufderheide TP, Wang HE, Herren H, Vaillancourt C, Davis DP, Vilke GM, Scheuermeyer FX, Weisfeldt ML, Elmer J, Colella R, Callaway CW; Resuscitation Outcomes Consortium Investigators.
JAMA Cardiol. 2018 Sep 26. doi: 10.1001/jamacardio.2018.3037. [Epub ahead of print]
PMID: 30267053

Free Full Text from JAMA Cardiology


Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776


Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. doi: 10.1016/j.annemergmed.2008.02.006. Epub 2008 Mar 28.
PMID: 18374452


Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65. doi: 10.1001/jama.299.10.1158.
PMID: 18334691

Free Full Text at JAMA


Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. doi: 10.1016/j.annemergmed.2009.06.011. Epub 2009 Aug 6.
PMID: 19660833


Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, Bobrow B.
Acad Emerg Med. 2010 Mar;17(3):269-75. doi: 10.1111/j.1553-2712.2010.00689.x.
PMID: 20370759

Free Full Text from Acad Emerg Med.

And more.


That is a big difference. There is nowhere near enough evidence to justify allowing paramedics to intubate.


Footnotes:

[1] Grim New Rules for NYC Paramedics: Don’t Bring Cardiac Arrests to ER for Revival
By Tom Winter
Published April 2, 2020 • Updated on April 2, 2020 at 8:32 pm
nbcnewyork.com
Article with autoplay video

[2] TEMPORARY Cardiac Arrest Standards for Disaster Response
NYC REMAC
Advisory No. 2020-08
Issue Date: March 31, 2020
Effective Date: Immediate
Protocol in PDF format

[3] Use of Alternative Airways
NYC REMAC
Advisory No. 2020-05
Issue Date: March 20, 2020
Effective Date: Immediate
Protocol in PDF format

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Filed Under: ACLS, Airway Management, Cardiac Arrest, COVID-19, Critical Judgment, Ethics, Evidence, Heresy, Intubation

Dr. David Price on How to Stay Healthy, While Treating COVID-19 Patients

Fri, 27 Mar 2020 19:40:10 -0400 by

Here is a quote from 2007, written about the response to the 1918 influenza pandemic.

 

Influenza pandemics have occurred regularly every 30 to 40 years since the 16th century. Today, influenza experts consider the possibility of another influenza pandemic, not in terms of if but when. Due to the high likelihood of an influenza pandemic, planning is underway in many U.S. states and other countries. We reviewed the responses of two neighboring Minnesota cities during the 1918–1919 pandemic to gain insight that might inform planning efforts today.[1]

 

We have chosen to forget what we had already learned. We can expect fewer deaths, this time, but this is a result of the arrogance and complacency that is our willful ignorance.

 

We work with patients who may not know that they have COVID-19 (novel COronaVIrus Disease identified in 2019), but we still have to treat them, just as we do for every other infectious disease. The same is true for patients who have tested positive for COVID-19. We are expected to take care of them, protect our other patients from transmission by us, and protect ourselves from infection.

 

Here is the advice, based on the best available evidence, from Dr. David Price of Weill Cornell Medical Center in New York City, currently the hottest spot of COVID-19 transmission in the world, but that will change. Dr. Price is a pulmonologist, treating COVID-19 patients full time, but he is not worried about becoming sick, because he uses evidence-based practices to protect himself. The quality of the video is not great, but the quality of the information is very high.

 

 

 

 

Some of this is not new. As I already stated, we knew this a century ago. We have chosen to forget how to deal with a pandemic.

 

We need to wash our hands.

 

We need to not touch our faces.

 

The most effective use of a mask may be to train yourself to not touch your face. We should have already been good at that, since we are not supposed to touch our faces, when we are wearing gloves, but many of us do touch our faces with gloves. When we have gloves on, the gloves should be considered to be contaminated, and anything everything we touch with our gloves should also be considered to be contaminated.

 

If you think that you need to be seen by a doctor, call first, because it can probably be handled over the phone.

 

If you think that you need to be seen in the emergency department, you probably do not.

 

Wash your hands before you put gloves on

 

Wash your hands after you take gloves off.

 

Clean everything you touch.

 

Wear an N95 mask, face shield, and a gown, when treating COVID-19 patients.

 

Be considerate of others and do not hoard medical supplies. The medical supplies do not do you any good unless you are treating COVID-19 patients and following these rules.

 

We need more accountability for giving bad dangerously incompetent medical advice.

 

President Trump has been promoting a poorly tested treatment as if he has a financial stake in the drug. A couple followed the “medical advice” of President Trump. One died. The other is in the hospital.[2]

 

In Iran, a bunch of people have consumed methanol to cure/protect against COVID-19. hundreds are reported to have died. Methanol ingestion is something that happens with children, who aren’t old enough to read the warnings on the label.[3]

 

Get your medical advice from a physician who understands evidence-based medicine.

 

We, in America, currently are producing too many new infections each day. We need to control our bad (infection-wise) behaviors in order to protect our patients, our neighbors, our families, and our selves. As health care providers, we should be better at this than everyone else. Too many of us are not.

 

 


Financial Times – Coronavirus: free to read
Click on the link for the full page of the latest graphs from Financial Times or click on the image for a larger version of the graph at the time I wrote this.

 

The countries with the most aggressive spread of COVID-19 are the countries that have not aggressively restricted movement among citizens. Anyone, including President Trump, telling you to ignore the social distancing recommendations is endangering the health of everyone. Most of us will probably become infected. Almost all of us will recover, but the rate of recovery drops if everyone becomes sick at the same time, since we do not have enough ventilators to adequately treat such a dramatic increase in very sick patients. The stock market will recover, although not immediately. The same thing happened a century ago, when dealing with the influenza pandemic.

 


This is a chart of what happened to the stock market before, during, and after the 2018 influenza pandemic.[4] Do not take this as trading advice – maybe if you get your medical advice from science deniers, you should trade, based on this. There are many differences between 2018 and now, such as the size, and importance, of other markets. This isn’t the end of the world, unless you don’t follow safe hygiene practices and get yourself infect. Crying about the economy and worshiping in a “traditional” way should not earn any sympathy for Texas Lt. Gov. Dan Patrick[5], First Things writer R.R. Reno, and Cardinal Raymond Burke.[6] Their promotion of immorality is despicable.

 

Social distancing was effective at limiting the spread of the pandemic.[7]

 

Do not expect a vaccine until 2021 or 2022.

 

Do not expect an effective treatment (something that significantly improves outcomes for patients, rather than just improves the sales for the manufacturers) for several months, at the earliest, because the drug President Trump has been promoting is not supported by good evidence. Ironically, HuffPost, which used to be Huffington Post and used to promote the science denialism of Jenny McCarthy, Dr. Oz, Oprah, and plenty of others, has a good article exposing the problems with the paper being cited by President Trump. Let’s hope that the name change is due to a dramatic change in their approach to reality.[8]

 

Footnotes:

[1] Lessons learned from the 1918-1919 influenza pandemic in Minneapolis and St. Paul, Minnesota.
Ott M, Shaw SF, Danila RN, Lynfield R.
Public Health Rep. 2007 Nov-Dec;122(6):803-10. No abstract available.
PMID: 18051673

Free Full Text from PubMed Central® (PMC)

 

[2] Husband and wife poison themselves trying to self-medicate with chloroquine – An Arizona man is dead and his wife is hospitalized after both of them self-medicated with chloroquine.
By Kimberly Hickok – Reference Editor
3 days ago
Live Science
Article

 

[3] Bootleg Liquor and Why You Should Not Drink Methanol
By Live Science
Staff September 19, 2012
Article

 

[4] Market action a century ago suggests worst could be over for stocks, if not for the coronavirus pandemic
Published: March 19, 2020 at 1:50 p.m. ET
By Shawn Langlois
MarketWatch
Article

 

[5] Texas Lt. Gov. Dan Patrick suggests elderly should die to save economy from coronavirus
By Kate Feldman
New York Daily News
March 24, 2020 | 11:46 AM
Article

 

[6] Editorial: May the lesson be indelibly inscribed — we need one another
Mar 24, 2020
by NCR Editorial Staff
National Catholic Reporter
Article

 

[7] Lessons learned from the 1918-1919 influenza pandemic in Minneapolis and St. Paul, Minnesota.
Ott M, Shaw SF, Danila RN, Lynfield R.
Public Health Rep. 2007 Nov-Dec;122(6):803-10. No abstract available.
PMID: 18051673

Free Full Text from PubMed Central® (PMC)

 

 

Influenza pandemics have occurred regularly every 30 to 40 years since the 16th century. Today, influenza experts consider the possibility of another influenza pandemic, not in terms of if but when. Due to the high likelihood of an influenza pandemic, planning is underway in many U.S. states and other countries. We reviewed the responses of two neighboring Minnesota cities during the 1918–1919 pandemic to gain insight that might inform planning efforts today.

 

Many of the components of current pandemic influenza plans were utilized to some degree in Minneapolis and St. Paul during 1918–1919. Coordination between different levels and branches of government, improved communications regarding the spread of influenza, hospital surge capacity, mass dispensing of vaccines, guidelines for infection control, containment measures including case isolation and closures of public places, and disease surveillance were all employed with varying degrees of success. We focus on medical resources, community disease containment measures, public response to community containment, infection control and vaccination, and communications.

 

[8] The Hucksters Pushing A Coronavirus ‘Cure’ With The Help Of Fox News And Elon Musk – Tucker Carlson, Glenn Beck and more have given a giant platform to a sketchy paper touting chloroquine.
03/20/2020 02:05 pm ET Updated Mar 20, 2020
HuffPost
By Nick Robins-Early
Article

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Filed Under: COVID-19, Critical Judgment, Heresy, Intubation, Risk Management

Do Emergency Physicians Intubate Often Enough to Maintain Competency?

Sat, 30 Nov 2019 23:55:16 -0500 by
 

    There is a study of the frequency of intubation among emergency physicians in the current Annals of Emergency Medicine. This study is accompanied by a discussion, which unfortunately does not question the assumption that intubation improves outcome. There is very little evidence to suggest that intubation improves outcomes. That evidence is only using paramedics with the highest success rates – much higher than your average paramedic.

 
Greater intubation experience in paramedics is associated with improved patient outcomes2; does a similar relationship exist for emergency physicians?[1]
 


Image credit.

The unquestioned assumption is that excellent intubation performance improves outcomes, rather than that excellent intubation performance causes less harm than average intubation performance, or below average performance. We do not have any good evidence to support the wishful thinking that paramedics, or even much more experienced emergency physicians, improve outcomes by intubating patients. We just assume this, because we don’t really want to know. If we decide to be honest and actually find out the effect of intubation, how will we handle it if the results show that we are harming more patients than we are helping?

The Cardiac Arrhythmia Suppression Trial was only started because the proponents of the different antiarrhythmics (encainide, flecainide, and moricizine) wanted to prove that their drug was better than all of the rest. They even agreed to include a placebo arm, although the doctors did not like the idea of depriving patients of such beneficial treatment.

 
CONCLUSIONS: There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide.[2]
 

People who had frequent ectopic heart beats – PVCs (Premature Ventricular Contractions) after a heart attack were more likely to die than people who did not have frequent PVCs. The obvious solution – the equivalent of intubation and blood-letting – was to give drugs that will get rid of the PVCs. The problem is that the PVCs were not the problem. The PVCs were just a sign of the problem. The drugs made the actual problem with the heart worse, while making the heart appear to be better. The same is true of blood-letting and may be true of intubation. Abundant evidence for the obvious benefits of blood-letting are quoted in the footnotes.[3]

If intubation is harmful, do we want to know?

If intubation by the average paramedic is harmful, do we want to know?

If intubation by the average emergency physician is harmful, do we want to know?

It isn’t as if we take intubation seriously. If we did take intubation seriously, we would practice much, much more than we do. In stead, we make excuses for failing to practice something that we claim is life-saving, because we are too arrogant to admit that practice is important to develop and maintain any skill.

Practicing on even the most basic mannequin should be done before every shift, whether you are a paramedic or an emergency physician. Unless you have a 99%, or better, success rate on hundreds of patients.

Footnotes:

[1] Intubation by Emergency Physicians: How Often Is Enough?
Kerrey BT, Wang H.
Ann Emerg Med. 2019 Dec;74(6):795-796. doi: 10.1016/j.annemergmed.2019.06.022. Epub 2019 Aug 19. No abstract available.
PMID: 31439364

The article above is commentary on the article below:

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A.
Ann Emerg Med. 2019 Dec;74(6):786-794. doi: 10.1016/j.annemergmed.2019.04.025. Epub 2019 Jun 24.
PMID: 31248674

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101

Free Full Text from N Engl J Med.

[3] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.
 

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Filed Under: Airway Management, Bougie, Cardiac Arrest, Critical Judgment, Ethics, Evidence, Experience, Heresy, Intubation, Physician Oversight, Waveform Capnography

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

Tue, 28 Aug 2018 16:05:09 -0400 by
 
Also to be posted on ResearchBlogging.org when they relaunch the site.

The results are in from two studies comparing intubation with laryngeal airways. There continues to be no good reason to intubate cardiac arrest patients. There is no apparent benefit and the focus on this rarely used, and almost never practiced, procedure seems to be more for the feelings of the people providing treatment, than for the patients.
 

Patients with a short duration of cardiac arrest and who receive bystander resuscitation, defibrillation, or both, are considerably more likely to survive and are also less likely to require advanced airway management.22 This problem of confounding by indication is an important limitation of many large observational studies that show an association between advanced airway management and poor outcome in out-of-hospital cardiac arrest.23 This study found that 21.1% (360/1704) of patients who did not receive advanced airway management achieved a good outcome compared with 3.3% (251/7576) of patients who received advanced airway management.[1]

 

In other words, we are the least skilled, are the least experienced, and we have the least amount of practice, but we are attempting to perform a difficult airway skill under the least favorable conditions. Ironically, we claim to be doing what is best for the patient. We are corrupt, incompetent, or both.

We also do not have good evidence that any kind of active ventilation is indicated for cardiac arrest, unless the cardiac arrest is due to respiratory conditions. Passive ventilation, which is the result of high quality chest compressions, appears to produce better outcomes (several studies are listed at the end).

We need to stop considering our harmful interventions to be the standard and withholding harmful treatments to be the intervention. We are using interventions that have well known and serious adverse effects. This attempt to defend the status quo, at the expense of honesty, has not been beneficial to patients.
 

The ETI success rate of 51% observed in this trial is lower than the 90% success rate reported in a meta-analysis.29 The reasons for this discordance are unclear. Prior reports of higher success rates may be susceptible to publication bias.[2]

 

Is that intubation success rate lower than you claim for your organization? Prove it.
 

Another possibility is that some medical directors encourage early rescue SGA use to avoid multiple unsuccessful intubation attempts and to minimize chest compression interruptions.5 Few of the study EMS agencies had protocols limiting the number of allowed intubation attempts, so the ETI success rate was not the result of practice constraints.[2]

 

Is there any reason to interrupt chest compressions, which do improve outcomes that matter, to make it easier to intubate, which does not improve any outcomes that matter? No.
 

While the ETI proficiency of study clinicians might be questioned, the trial included a diverse range of EMS agencies and likely reflects current practice.[2]

 

This is the state of the art of intubation in the real world of American EMS. Making excuses shows that we are corrupt, incompetent, or both.
 


I no longer have the link, but I think that this image came from Rescue Digest a decade ago.
 

These results contrast with prior studies of OHCA airway management. Observational studies have reported higher survival with ETI than SGA, but they were nonrandomized, included a range of SGA types, and did not adjust for the timing of the airway intervention.9,10,31-34 [2]

 

We should start doing what is best for our patients.

We should not continue to defend resuscitation theater – putting on a harmful show to make ourselves feel good.

What would a competent anesthesiologist use in the prehospital setting? Something that offers a benefit to the patient.

There is also an editorial analyzing these two studies.[3]

It is time to start requiring evidence of benefit for everything we do to patients.

Our patients are too important to be subjected to witchcraft, based on opinions and an absence of research.

There is plenty of valid evidence that using only chest compressions improves outcomes.
 

Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed – indexed for MEDLINE]

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Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed – indexed for MEDLINE]

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Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed – indexed for MEDLINE]

Free Full Text at JAMA

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Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed – indexed for MEDLINE]

And more.

 

It is not ethical to insist on giving treatments to patients in the absence of valid evidence of benefit to the patient. We need to begin to improve our ethics.

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Also read/listen to these articles/podcasts released after I published this (I do not know the date of the Resus Room podcast) –

The Great Prehospital Airway Debate
August 31, 2018
Emergency Medicine Literature of Note
by Ryan Radecki
Article
 

EM Nerd-The Case of the Needless Imperative
August 31, 2018
EMNerd (EMCrit)
by Rory Spiegel
Article
 

Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2
The Resus Room
Podcast with Simon Laing, Rob Fenwick, and James Yates with guest Professor Jonathan Benger, lead author of AIRWAYS-2.
Podcast, images, and notes
 

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Footnotes:

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[1] Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial
Jonathan R. Benger, MD1; Kim Kirby, MRes1,2; Sarah Black, DClinRes2; et al Stephen J. Brett, MD3; Madeleine Clout, BSc4; Michelle J. Lazaroo, MSc4; Jerry P. Nolan, MBChB5,6; Barnaby C. Reeves, DPhil4; Maria Robinson, MOst2; Lauren J. Scott, MSc4,7; Helena Smartt, PhD4; Adrian South, BSc (Hons)2; Elizabeth A. Stokes, DPhil8; Jodi Taylor, PhD4,5; Matthew Thomas, MBChB9; Sarah Voss, PhD1; Sarah Wordsworth, PhD8; Chris A. Rogers, PhD4
August 28, 2018
JAMA. 2018;320(8):779-791.
doi:10.1001/jama.2018.11597

Abstract from JAMA.

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[2] Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial
Henry E. Wang, MD, MS1,2; Robert H. Schmicker, MS3; Mohamud R. Daya, MD, MS4; et al Shannon W. Stephens, EMT-P2; Ahamed H. Idris, MD5; Jestin N. Carlson, MD, MS6,7; M. Riccardo Colella, DO, MPH8; Heather Herren, MPH, RN3; Matthew Hansen, MD, MCR4; Neal J. Richmond, MD9,10; Juan Carlos J. Puyana, BA7; Tom P. Aufderheide, MD, MS8; Randal E. Gray, MEd, NREMT-P2; Pamela C. Gray, NREMT-P2; Mike Verkest, AAS, EMT-P11; Pamela C. Owens5; Ashley M. Brienza, BS7; Kenneth J. Sternig, MS-EHS, BSN, NRP12; Susanne J. May, PhD3; George R. Sopko, MD, MPH13; Myron L. Weisfeldt, MD14; Graham Nichol, MD, MPH15
August 28, 2018
JAMA. 2018;320(8):769-778.
doi:10.1001/jama.2018.7044

Free Full Text from JAMA.

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[3] Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest
Lars W. Andersen, MD, MPH, PhD1; Asger Granfeldt, MD, PhD, DMSc2
August 28, 2018
JAMA. 2018;320(8):761-763. doi:10.1001/jama.2018.10824

Abstract from JAMA.

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

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

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

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


 

Even I overestimated the possibility of benefit of epinephrine.

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

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

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

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

 

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

The best outcome was no detectable neurological impairment.
 

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

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

 


Click on the image to make it larger.
 

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

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

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

I will write more about these results later

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

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Also see –

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

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Footnotes:

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[1] A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators.
N Engl J Med. 2018 Jul 18. doi: 10.1056/NEJMoa1806842. [Epub ahead of print]
PMID: 30021076

Free Full Text from NEJM

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

Protocol

Supplementary Appendix

Disclosure Forms

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

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

Free Full Text from NEJM

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

Comment on Irresponsibility and Intubation – The EMS Standard Of Care

Wed, 16 Aug 2017 04:07:12 -0400 by
 

I wrote about the petition to protect paramedic incompetence in Irresponsibility and Intubation – The EMS Standard Of Care

Nathan Boone responded with the following comment –
 

You’re forgetting about the rural medic out there.

 

No. I am not.

Are you suggesting that bad airway management for a longer period of time is less harmful than bad airway management for a shorter period of time?
 


 

Where we are with our patients for more then a hour, not 5 mintues.

 

The harm from incompetent airway management does not depend on distance from the hospital. Intubation even kills patients in the hospital.

You may believe that the efficacy of voodoo is directly related to the distance from the hospital, but it appears to be only your belief that increases.

Voodoo does not work, regardless of the distance from the hospital.

If the paramedic cannot manage an airway, the paramedic should not be permitted to intubate.
 

Sometimes air- craft isn’t available if its raining or on another call.. You want us to use a bvm and take chance of filling the patients stomic up for over a hour.. Yes we can be extremely careful and do everything in our power not to fill the stomic but there’s some patients out there who have difficult airways where bagging can be extremely difficult and or impossible.

 

Give incompetent paramedics dangerous tools to try to manage difficult airways because of distance? Wouldn’t it be better to try to make them competent – or to limit intubation to competent paramedics?

Intubation and BVM (Bag Valve Mask) are not the only forms of ventilation.
 

Rsi does save patients in rural areas, we need intubations..

 

Maybe. Maybe not. Maybe RSI kills more patients than it saves.

Actually, what I mean to write is, Maybe paramedics using RSI kill more patients than they save.

If you want to claim otherwise, prove it with high-quality research.

Unless you can provide high-quality research, your plastic airway religion is just another alt-med scam.

If your patients are important, then you need to demand that we find out what is best for the patients.
 

Do I believe that Rsi is risky and their is some medics out there who would rather make the patient more hypoxic then before until they give up and go to a secondary airway..absolutely.. But to take it away from Rural Medics when we can have anything to burn patients to anaphylactic reactions and to take our ONLY definitive airway;away from us..

 

You seem to think that RSI (Rapid Sequence Induction of anesthesia) becomes less risky the farther you are from the hospital.

Why?

Incompetence for a longer period will be expected to cause more harm.

Sometimes the incompetence of the paramedic doesn’t kill the patient.
 

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]

 

The patient clearly did not need intubation.

As with the crash of Trooper 2 in Maryland, the survival of the patient for hours in the woods, in the rain, following the helicopter crash that killed all of the other healthy people on board, was clear evidence that there was no reason to send this patient to the trauma center by air.

The same argument was provided by people, including Dr. Thomas Scalea, the head of Shock Trauma – If you don’t let us have our toys, people will die![2]

The rate of helicopter transport of trauma patients was dramatically cut.

That was almost a decade ago and we are still waiting for the dead bodies.

I expect that the same failure of prophesy will occur, when incompetent paramedics are prevented from intubating.

I expect that the fatality rate will decrease, when incompetent paramedics are prevented from intubating.
 

I think you’re out of your mind.

 

Many religious fanatics do.
 

In the city, I can maybe defend you. But the studies need to be done out in the sticks as well. I believe that we should have to go outpatient surgery every year or 2 or have number set of how many we need in that time period successfully to keep our skills sharp..

 

Every year or two?

WTF?

You don’t want to be taken seriously, do you?

This is something that requires a lot of skill and practice, so I get just a tiny bit, every other year. Trust me with your life.
 

After a Rsi and I have no one in the back but myself for over an hour.., I can place the patient on a vent and care for my patient. If RSI is taken away. I loose the capability to monitor my patient, and would be more focused on bagging my patient, or making sure the secondary away isn’t failing and I’m filling the stomic on the vent, because it can happen.

 

It is just a staffing issue.

That is different.

Competence isn’t needed when you are in the back by yourself.

Why are you opposed to competence?

Where is a single reasonable argument that intubation improves outcomes?

Where is a single reasonable argument that rural paramedics have an intubation success rate that is above 95%?

Even 95% means that some of your patients don’t end up with a properly placed endotracheal tube. What do you think happens to them?

Does your EMS agency have a better than 95% intubation success rate?

If you can’t manage at least 95%, why do you believe you can manage intubation?

Is each intubation on video, or do they just believe whatever you tell them?

If you want to be taken seriously, these are just some of the essential points to address.
 

This is not a new topic. You might also read the series below:

In Defense of Intubation Incompetence – Part I

In Defense of Intubation Incompetence – Part II

In Defense of Intubation Incompetence – Part III

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II

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Footnotes:

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[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

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[2] Helicopters and Bad Science
Thu, 09 Oct 2008
Rogue Medic
Article

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Filed Under: Airway Management, Critical Judgment, Evidence, Intubation, Mythology, Research, RSI

Irresponsibility and Intubation – The EMS Standard Of Care

Wed, 09 Aug 2017 11:00:03 -0400 by
 

There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.
 


Image source
Details here and here.
 

The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.
 

 
We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.

 

Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]

 

Most effective?

There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

Most effective?

No.

This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.
 

Please sign this petition so that these patients have a chance to live[1]

 

Prove that requiring higher standards for intubation would take away a patient’s chance to live.

Prove that intubation improves outcomes.

This is a petition to keep standards low for paramedics.

This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

This is the Protect Incompetent Paramedics from Responsibility Petition.

Responsibility is for professionals. In EMS, we reject responsibility.

We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

Most effective? Maybe intubation is the most effective theater.

The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

How much vomiting, and aspiration, do we cause?

How much airway swelling do we cause?

How many airway infections do we cause?

How much harm do we cause?

We don’t know. We don’t care. We oppose attempts to find out.

We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.
 

Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?

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Footnotes:

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[1] Allow paramedics to continue to save lives with endotracheal intubation!
Anthony Gantenbein United States
Petition site

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Filed Under: Airway Management, Assessment, Critical Judgment, Education, Evidence, Heresy, Intubation, Malpractice, Risk Management, RSI
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