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

- Rogue Medic

Why the Ivermectin Evidence is Pathetic

In a pandemic, which has killed almost a million Americans, you might expect that people would try to figure out the most effective treatment, rather than scam their fellow Americans, but you would be wrong.

There are some doctors, who do not understand the difference between good research and garbage, and are promoting bad research because they really really believe – and they were right lucky about steroids before the evidence was clear. Therefore they must be right about everything.

Except, reality does not care what you believe.

They believed in steroids before there was good evidence that steroids work, but their belief was based on wishful thinking and willful ignorance, not on good science. That they were right was purely coincidence. We have seen doctors kill tens of thousands of patients with antiarrhythmic drugs, because the drugs were widely prescribed without high quality evidence of safety and efficacy.

CAST – The Cardiac Arrhythmia Suppression Trial (the high quality evidence that was agreed to in order to prove which drug saved more lives) showed that the doctors fooled themselves, and killed their patients, by believing in something that only appeared to be an improvement in outcomes. Tens of thousands of deaths were not an improvement in outcomes.

If we have a story that seems to make sense, it is much easier to convince ourselves that we are not killing patients. After all, we mean well. At least some of us do. This is an example of misleading ourselves with a narrative fallacy. C A S T and Narrative Fallacy. Rudyard Kipling called these Just So Stories.

Dr. Pierre Kory (president of the Frontline COVID-19 Critical Care Alliance – FLCCC, which is different from the extreme quackery of America’s Frontline Doctors) may be a true believer, but if Dr. Kory really believes ivermectin works, he should be demanding large scale randomized double blinded placebo controlled research, rather than making excuses for low quality research.

Dr. Kory’s claims are so bad that even PolitiFact can’t find any truth in Dr. Kory’s claim – and PolitiFact tries to be as fair to every claim as possible.

What about the science? The promoters of ivermectin have claimed that the odds are over 2 trillion to 1 that the results of the latest meta-analysis are due to chance low quality research methods. Their research methods are almost as bad as their math.

Dr. David Gorski has written a long article that goes into detail about the problems with this latest paper. Ivermectin is the new hydroxychloroquine, take 2. Read the whole article, but here is a sample:

In fairness, the authors don’t actually say that meta-analyses of crappy studies do make good evidence, at least not in the paper. However, ivermectin advocates touting the study fans are certainly making that claim, and Dr. Kory sure did seem to me to imply the same in his interview with Bret Weinstein. In any event, one large, well-designed rigorous double-blind clinical trial for prevention, along with one large, well-designed rigorous clinical trial for treatment, could trump this entire meta-analysis.

Indeed, Gideon Meyerowitz-Katz did a reanalysis of the studies analyzed by the BIRD Group that shows that if you leave out the two studies that are as yet only preprints, are very small, and actually appear to have been miscategorized as higher quality than they are, the results are very different:

This basically shows that without those two studies, the analysis demonstrates no benefit for ivermectin at all compared to placebo, with a confidence interval that includes everything from a big benefit to a large harm from the drug.

If the study really had a 2 trillion to 1 chance of the results being by chance alone, it would not rely of such low quality research (preprints, tiny studies, studies without placebos, studies that are not double blinded, . . .).

There is no good reason to look at any research on treatment for COVID-19 that is not randomized placebo controlled and double blinded.

There are millions of patients to study, so the only reasons to avoid using the highest quality of research is a lack of confidence in the treatment.

As with promoters of alternative medicine, the actions of the promoters of ivermectin do not demonstrate confidence that what they are selling will survive high quality research.


Hydroxychloroquine – The More You Know, The Worse It Looks

Do you want to use a drug that was never based on any good evidence, but only a hunch? Try hydroxychloroquine. The president says, What have you got to lose?

Kitchen sink medicine is a remnant of the Dark Ages, but it has not been eliminated from medicine. It is the argument from ignorance. If you can’t prove that the treatment is harmful, the treatment is wonderful. If you can prove the treatment is harmful, you are part of a conspiracy.

This is further evidence that hydroxychloroquine is harmful. The higher the quality of the evidence about hydroxychloroquine, the worse hydroxychloroquine looks.

Today, Lancet published this study comparing almost 15,000 patients receiving several different experimental treatments with about 80,000 patients not receiving any of the experimental treatments. This should convince reasonable people that there is no justification for treating patients with hydroxychloroquine outside of a well controlled randomized trial.

The comments on articles about the study are full of the usual anti-science, anti-vax, alternative medicine propaganda. Their religion has failed, but they keep preaching.

After controlling for multiple confounding factors (age, sex, race or ethnicity, body-mass index, underlying cardiovascular disease and its risk factors, diabetes, underlying lung disease, smoking, immunosuppressed condition, and baseline disease severity), when compared with mortality in the control group (9·3%), hydroxychloroquine (18·0%; hazard ratio 1·335, 95% CI 1·223–1·457), hydroxychloroquine with a macrolide (23·8%; 1·447, 1·368–1·531), chloroquine (16·4%; 1·365, 1·218–1·531), and chloroquine with a macrolide (22·2%; 1·368, 1·273–1·469) were each independently associated with an increased risk of in-hospital mortality.[1]

The evidence shows that you are twice as likely to die if you receive hydroxychloroquine.

Don’t listen to anti-science, anti-vax, anti-medicine preachers, because they are not interested in your health.

What have you got to lose?

What are you treating, you politics/religion or your health?

If your goal is to treat your religion, go ahead and use the magic elixir and maybe you will not be harmed by it.

If your goal is to treat your health, avoid magic claims about treatments, regardless of the treatment. Use treatments that work in the real world.

What have you got to lose?

You are twice as likely to lose your life. Among survivors, the significant adverse effect rate was much higher in the hydroxychloroquine groups. This is the highest quality research so far and there is no good news for the hydroxychloroquine.

Read the full paper and think for yourself. Don’t listen to those making excuses to promote their agenda. Your health has never been important to those who reject science.

It is unfortunate that we do not have some treatment that works well, but that is not a good reason to bet your life on bad medicine. More people survive with better health with conventional treatment.


[1] Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis
Prof Mandeep R Mehra, MD, Sapan S Desai, MD, Prof Frank Ruschitzka, MD, Amit N Patel, MD
Lancet. Published:May 22, 2020

Free Full Text from Lancet.


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

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.

Also see –

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


[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 –


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


Baltimore Hospital Dumping Patients – Is it that simple?

You watch the video and wonder how could anyone be so callous and cold, to leave someone outside with only a hospital gown to wear – especially when it is so cold outside.

Is what we are seeing callous, or uncaring?

In the video farther down, there is a nice discussion of the problems, which are much more complicated than somebody being refused care for some bad reason.

I found a site that did mention her clothes being with her, but stated with her clothes and belongings scattered on the sidewalk. Here is the picture they posted. The clothes are in plastic patient belongs bags.


Psychotherapist Imamu Baraka was walking near the University of Maryland Medical Center’s midtown campus location when he saw a woman being dropped off by security at a bus stop with her clothes and belongings scattered on the sidewalk.[1]


Why didn’t she put her clothes on?

One of the first things discharged patients will do, if they can, is put their own clothes on.

There is no evidence that anyone was refused care. That would be an EMTALA (Emergency Medical Treatment and Labor Act) violation, resulting in a very big fine, which would be reported. Maybe I am wrong, but I do not expect that an investigation will end with any finding of any refusal to provide care.

But we saw it on the video!

No. I think that you saw someone being removed from private property for bad behavior in a hospital gown, and she refused to put on her own clothes on (the clothes in her bag) for reasons of her own.

Here is a video explaining this in more detail, but a couple of notes about people mentioned in the video.

Charlie Gard was an infant with irreversible MDDS (Mitochondrial DNA Depletion Syndrome). The doctors and nurses seem to have understood this, but parents, politicians, preachers, and the press thought that it would be a good idea to torture Charlie Gard with an experimental treatment with no expectation of a better outcome.

How would Solomon decide? To torture, on the ridiculously small chance of a better outcome, or to do not further harm?

Peter Gallogly is a doctor, who was selectively recorded on video to make it seem as if his unprofessional behavior was unprovoked. If you watch the video of Dr. Gallogly, realize that it is edited to distort reality. If you watch the ironically named Project Veritas videos of abortion clinics, they are similarly edited to distort reality, which is why they have been rejected as evidence in court. You might as well watch a Michael Moore film, if you want a highly edited distortion of reality.

The Delnor nurse protected staff from an escaped prisoner, when the corrections officer apparently fled. The nurse ended up being abducted for hours, grazed by a bullet, pistol whipped, and raped, but was reported as being unharmed after the inmate was killed.



We need to learn how to find out accurate information for ourselves, rather than blindly accept propaganda from far left or far right news sources. Even the mainstream news will often get information in specialized fields wrong and not realize it. When the story is from a specialized field, such as medicine, we should obtain our information from trustworthy people in that field.

More information on Charlie Gard.

More information on Peter Gallogly.

More information on the Delnor nurse.

All of the videos are from ZDoggMD.com


[1] Video shows Baltimore hospital discharging half-naked woman into cold winter night
Ana Valens
Jan 11 at 7:27AM | Last updated Jan 12 at 3:36AM
The Daily Dot


Have a Slow, Quiet Friday the Thirteenth

Also to be posted on ResearchBlogging.org when they relaunch the site.


Superstitious appears to be common among medical people, so this may be seen as offensive. If you doubt me, comment that it is slow or quiet and see how many respond negatively, while they do not receive any criticism for their superstition-based complaints. Rather, people will make excuses for coddling the superstitions of those who are entrusted with the lives of patients.

The evidence does not support their superstitions.

One study did appear to show that women die in motor vehicle collisions more often on Friday the 13th, but that appears to be due to a lack of understanding of statistics by many who cite the article.

An additional factor is anxiolytic medication, used by significantly more women than men in Finland (7), which has been reported to reduce attention span and worsen driving performance (8). . . . Why this phenomenon exists in women but not in men remains unknown, but perhaps the twice-as-high prevalence of neurotic disorders and anxiety symptoms in women (7) makes them more susceptible to superstition and worsening of driving performance.[1]


The author suspects that those people with conditions that could be diagnosed as neuroses or anxiety disorders may be disproportionately affected by superstition.

In other words, superstition is not an external force affecting you. You are doing it to yourself.

The sample size was national, but still small, and was not able to adjust for many possible confounding variables, so the study would need to be replicated using a much larger data base to be useful.

In other superstition news – the next apocalypse, in a long line of predicted apocalypses, is going to be this Sunday – the 15 of October, 2017, according to David Meade. Meade twice previously predicted that a magical planet would hit the Earth and kill us all. This time he claims that his calculations are accurate, because that was the problem with his previous calculations – inaccuracy, not that they were a superstition deserving of derision.

If you are superstitious, and feel that your neuroses/anxieties will cause you to harm others, or yourself, you may want to stay home today and Sunday – perhaps even until you are capable of grasping reality.

Of course, we would never base treatment on superstition in medicine.

Amiodarone is the go to antiarrhythmic drug for cardiac arrest and ventricular tachycardia, but there are much safer much more effective drugs available. We have our own prophets misrepresenting research results to make it seem that using amiodarone for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[2],[3]

Ventilation during cardiac arrest has been shown to be a good idea only for patients who arrested for respiratory reasons. We do a great job of identifying these patients. We have our own prophets misrepresenting research results to make it seem that providing ventilations for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[4]

Medicine is full of superstition and superstitious people.


Too many of us believe the lie that, I’ve seen it work.

I have also written about the superstition of Friday the 13th here –

Acute coronary syndrome on Friday the 13th: a case for re-organising services? – Fri, 13 Jan 2017

The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

T G I Friday the 13th – Fri, 13 Nov 2009

Happy Equinox! – Thu, 20 Mar 2008


[1] Traffic deaths and superstition on Friday the 13th.
Näyhä S.
Am J Psychiatry. 2002 Dec;159(12):2110-1.
PMID: 12450968

Free Full Text from Am J Psychiatry.

[2] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic

There are a dozen links to the research in the footnotes to that article. There are also links to other articles on the failure of amiodarone to live up to its hype.

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

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


Why We Deceive Ourselves With Explanations

I have been thinking a bit more about Walt Trachim’s comment on Answer to What is this Dangerous Treatment and How Long Did it Take to Stop Using it and my response.

2. You know me well enough, I think, to know that I’m not satisfied unless I know WHY something happens. And this is no different; I would like very much to know why this works. I’m not asking if you understand why it works. I’m just saying that I would simply like to know more. And I would like to see more studies done. If I run across anything else in literature I will share it.

The problem is the desire to have an explanation. We ask for plausible treatments. Plausible treatments come with explanations, even if these plausible treatments are very harmful. Plausible means that the explanation makes some sort of sense.

Plausible appears reasonable.

Plausible means that it might work –

if the explanation is valid.

Might work.

What if . . . ?

Plausible means having a story that some people find convincing –

just as some people are convinced by the stories of con artists.

Our patients deserve better than What if . . . ?

What is better than plausible? Probable is better than plausible.

Probable requires evidence, but not an explanation.

What matters is that it works, not that it has a convincing story.

The worst treatments have some of the best stories. The worst treatments convince people to be satisfied with inadequate evidence, because there is a good story.

Epinephrine is plausible – but don’t ask for evidence that epinephrine improves survival. We stimulate the heart back to life. After decades of use, there still is not any evidence of improved survival with a functioning brain.

If your patients do not use their brains, then epinephrine may seem attractive.

Spinal immobilization is plausible – but don’t ask for evidence that spinal immobilization protects the spinal cord. After decades of use, there still is not any evidence of decreased disability with the use of spinal immobilization. We just need to manipulate the patient’s neck and back to fit a collar and backboard.

If your patients needed someone to come along and manipulate their spines, but a chiropractor was not available, then spinal immobilization may seem attractive.

Atropine is plausible – but don’t ask for evidence that atropine actually addresses a real cause of cardiac arrest. After decades of use, there still is not any evidence of improved survival with atropine.

Nothing changed.

There was no new research.

We just acknowledged the lack of evidence for giving atropine.

Atropine sulfate reverses cholinergic-mediated decreases in heart rate and atrioventricular nodal conduction. No prospective controlled clinical trials have examined the use of atropine in asystole or bradycardic PEA cardiac arrest. Lower-level clinical studies provide conflicting evidence of the benefit of routine use of atropine in cardiac arrest.34,295,–,304 There is no evidence that atropine has detrimental effects during bradycardic or asystolic cardiac arrest. Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE B). For this reason atropine has been removed from the cardiac arrest algorithm.[1]

If your patients were just too relaxed to live, then atropine may have seemed attractive.

Maybe epinephrine, or amiodarone, or lidocaine, will be the next ACLS (Advanced Cardiac Life Support) drug to be removed from the guidelines due to lack of evidence of benefit (and for lack of evidence of safety).

Image credit.

Plausible means –

A duck!
An aquatic bird that, in medieval times, was used to find out if a person was a witch or not.

This stems from the very logical idea that if a person weighs the same as a duck, then that person is made of wood (because both ducks and wood float in water). And since wood burns (just like witches) then that person must be a witch, because witches are made of wood.

Therefore, the accused person(s) would be placed on a scale next to a duck, and if they balanced, the person(s) would be burned.

So, if she weighs the same as a duck, then she’s made of wood. And therefore… A WITCH![2]


Probable means –

Approach this from the opposite direction. Prove that the bad things happened. Prove that the accused person caused the bad things to happen. If that cannot be done, drop the charges. Either way, ignore the silliness about witches (even if there is good evidence, it is irrelevant).


[1] Atropine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Interventions Not Recommended for Routine Use During Cardiac Arrest
Free Full Text from Circulation with links to Free Full Text PDF

[2] A duck!
urban dictionary

Probably an urban legend, but it is the distorted logic of plausibility, that I am interested in.


Why Does Epinephrine Cause Brain Damage During Resuscitation

In the comments to The Danger of ROSC – Return Of Spontaneous Circulation is the following from Walt Trachim of Living in Manch Vegas.

I have a question, though. What is the actual pathophysiology that causes the damage to brain tissue?

If it were obvious that this would cause brain damage, there would not be people supporting the use of epinephrine. I do not see this as any kind of conspiracy, just the usual overestimation of our abilities that humans are so good at.

This is one of the reasons I try to avoid the Why explanations. We take the limited information and extrapolate from that to what happens in a much more general situation. The one thing we should count on is that the explanation is wrong.

As a species we want to know Why.

As people delivering patient care, we need to ignore the question Why and limit ourselves to Does it work?

Eventually we will have a much better understanding of the reasons Why, but if we understood that, we would not need to study treatments. We could just learn the pathophysiology and the answer would be clear. The many abandoned treatments make it very clear that our understanding of CPR is nowhere near good enough for that.

I don’t know Why. I could guess, but guessing (almost all of the recent explanations of Why the body does something) is just a way to come up with errors to be corrected later. I make errors, but I try to limit the frequency and significance of my errors.

We know that more people treated with epinephrine will die in the hospital.

We know that more people treated with epinephrine will have severe brain damage.

Do we need to know Why before we stop using epinephrine?

If I put my hand in a fire, do I need to understand the mechanisms of damage before I decide to pull my hand out of the fire?

Assuming that ROSC does happen, how does the Epinephrine that is given (and has a relatively short half-life) cause the kind of tissue damage that you’re talking about? Does it cause furthering hypoxia? Is it chemical? I’m trying to understand this a little better because I’m not sure why the relatively small doses that we use in the field could do the type of damage you describe.

See above for the Why explanations.

relatively small doses?

Epinephrine in live humans is given at 2 μg/minute to 10 μg/minute.

Epinephrine in dead humans is given at 1,000 μg all at once.

2 – 10 vs 1,000.

That is a huge difference.

There is nothing small about the epinephrine doses we give in cardiac arrest.

And this brings another question to mind: what about when Epinephrine is being used in a non-cardiac arrest situation? Specifically, if you’re dealing with someone who is in Anaphylaxis and is being given Epi in the 1:1000 concentration (albeit at a lower dose) for bronchodilation and vasoconstriction, would the concerns you’re talking about regarding tissue damage still apply? Based on the circumstances you’re detailing in your research and analysis, I’m inclined to think they would, but I’m definitely interested to read your thoughts on this.

We do give 300 μg IM (IntraMuscular) to anaphylaxis patients, but IM absorption is slower than IV and there is evidence that epinephrine is effective at preventing death in these patients.

What is the right dose of epinephrine for someone who is probably having a heart attack?

The most common cause of cardiac arrest is heart attack, so we should assume that these patients are having heart attacks.

I think that the right dose of epinephrine for a patient having a heart attack is zero μg.

I’m asking these questions for a very simple reason: you made me think. You’re really good at that, by the way. And, as I said, I want to understand the “why” more clearly. And since I’ve been a full-time student again, my brain has been engaged much more than it usually is.

Merry Christmas, and thanks for putting up with pestilent questions. 🙂

These are not pestilent questions. Asking questions is the way we learn. When we stop asking questions, it will not be because we have the answers to everything, but because we have lost our curiosity.

We need to accept that almost always we do not know Why.

Why does gravity pull us toward massive objects?

Why does the Sun work by nuclear fusion?

Why are there mosquitoes?

Why do we die?

The Why questions are great for coming up with hypotheses, but they will also keep you decades behind in treating patients.

An empirical approach can be less satisfying, but only if we insist on knowing Why.

See also –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy


Hindsight is always 20/20 or If had known then…

At Hot Lights & Cold Steel there is Hindsight is always 20/20 or If had known then…

While there are a few points that I do not completely agree with, overwhelmingly I do agree with what is written.

First, hindsight is NOT always 20/20.

Often hindsight is not remotely accurate. We recall things poorly. We tend to assume that we recall things accurately, but we also tend to assume that we are better than average drivers/politicians/singers/lovers/EMTs/medics/nurses/doctors/et cetera. At least some of us are wrong.

Even in looking back at events that are well documented, we tend to come to different conclusions. And our memories change. We want to deny this, but our experiences change our memories.

Here’s the thing that no one bothered to tell me – to understand a drug… ANY drug – you have to understand the physiological actions of the body process the drug effects FIRST in order to then understand how the drug alters that physiological action.

We know that NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries) is the most efficatious drug for hypertensive CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). NTG also appears to be very efficatious for normotensive and even hypotensive CHF/ADHD.

Do we need to understand the mechanism?

Too often we base our treatments on conclusions drawn from research that has been spun into a tale to explain why something works. This is narrative fallacy. I explain more in Some Research Podcasting Comments.

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

We get to the point where we believe that we understand all that we can about the way that a drug works. We believe that drug is great. We study that drug and find that the research does not agree with what we knew. The research can be wrong, but it is more likely that the theory, which is based on research and other theories, is wrong.

No matter how much we think we know about the ways the body works and the ways that drugs work in our bodies, we find more to learn and plenty of cases of people responding in ways the pharmacology books claim they should not.

This is one of the most important reasons to continually reassess.

There is a reason the word atypical is frequently used in medicine.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.
Paracelsus (1493 – 1541)

By continually reassessing, I can often prevent an adverse reaction from progressing to a bad outcome.

However, the most important point written is –

here’s what I do regret –

Listening to all the paramedics who told me I’d never need to know most of what I was learning. The Krebs cycle (now called the Citric Acid cycle) Action potentials, Ph… the list I’m sure by the end of school will be extensive.

Just because we do not understand everything about the body, or everything about pharmacology, does not mean that we should deliberately choose to be ignorant.

Ignorance kills.


Learn more.


Kill less.