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

- Rogue Medic

The Silver Lining of Epi – Organ Donation – Part 1

 

Is there really a silver lining to giving epinephrine for cardiac arrest? Scott writes about organ donation as one possible silver lining.
 

The next time you bring one of those cardiac arrest patients in who when you follow up on them, you are told that they have “no brain activity” do not look at it as a complete loss. Ask that follow up question, “Are they going to be able to donate any organs?” You might be pleasantly surprised at what the answer is. Although it’s not exactly what we are looking for, a life might have been saved.[1]

 

That seems reasonable, except that it assumes that the treatment that will produce the best survival, a return to normal life, is produced with epinephrine.

Epinephrine may produce more organ donors, but that is not what we base our treatment on. We treat patients based on what is expected to produce the best outcome for them, not what is expected to produce the best/most organs for donation. Even looking at organ donation, there are many different considerations.

What produces the best organs?

What produces the most organs?

What produces the mixture of quality and quantity that seems to be best for patients?

If we want to improve organ donation rates, one thing we should consider is addressing organ donation directly – not advocating for things that might produce increased organ donation as a side effect. Changing the law from the current opt in to opt out.

With opt in – if I have not made a choice, or if anyone objects to my choice, it is presumed that I object to organ donation and my organs are discarded.

With opt out – if I have not made a choice, it is presumed that I do not object to organ donation and my organs are available to those on the organ transplant lists.

Currently, the license to drive is the indicator and there would be no reason to change that. We are asked to select this if you want to be an organ donor. We would change the question to select this if you do not want to be an organ donor.

Donations are more complex than opt in vs. opt out, but changing one thing may lead to changes in other things because of increased attention.

Here are changes in various rates of organ donation in Belgium before and after a change from opt in to opt out.
 


 

 

 

 

 

 

 

 

 

 

 

Presumed consent alone is unlikely to explain the variation in organ donation rates between different countries. A combination of legislation, availability of donors, transplantation system organisation and infrastructure, wealth and investment in health care, as well as underlying public attitudes to and awareness of organ donation and transplantation, may all play a role, although the relative importance of each is unclear.[2]

 

Should we assume that epinephrine really improves the likelihood of organ donation without decreasing survival from cardiac arrest? I will discuss that in Part 2.

Footnotes:

[1] The Silver Lining of Epi
February 3, 2014
EMS in the New Decade
Scott
Article

[2] A systematic review of presumed consent systems for deceased organ donation.
Rithalia A, McDaid C, Suekarran S, Norman G, Myers L, Sowden A.
Health Technol Assess. 2009 May;13(26):iii, ix-xi, 1-95. doi: 10.3310/hta13260. Review.
PMID: 19422754 [PubMed – indexed for MEDLINE]

Free Full Text from National Institute for Health Research.

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Happy Organ Donation Day 2014

 


Image credit.
 

If you die today, will you just leave a card with a picture of a heart on it, or will you maybe leave your heart to a person who needs a heart?

You won’t need it any more, so why not share a little.

Skin, corneas, kidneys, lungs, . . . can help others to live.

Don’t save them for the worms.
 


Image credit.
 

That is what mine looks like, except I am a million times cuter. 😳

While we are alive, we can donate blood and/or blood products on a regular basis.

While we are alive, we can also donate bone marrow.

We do not have to die to donate.
 


Image credit.
 

Our biggest problem with organ donation is a lack of donors.

Nobody is encouraging you to die.

Nobody is going to give up on keeping you alive because you are an organ donor.

But – somebody may live a longer life if you suddenly die.
 


 

DonateLife.net
 

A little bone marrow can go a long way – in someone else.
 


Image credit.
 

Help someone get one of these –

 


Image credit.
 

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Discouraging Organ Donation Because of Political Nonsense


 

Even for those who think in the binary terms of good or evil, this is something that should have been strongly criticized.
 


 

Her face says You can trust me.

Her words say something entirely different.
 

I was a little startled to hear the former vice president express total indifference to questions about his heart donor in a revealing interview on Politicking with Larry King (it airs Thursday night; here’s a clip). It’s a window into his utter entitlement and self-absorption, and he comes off as an even bigger monster than I’d thought. Most people would at least feign interest in the donor; Cheney can’t manage it.[1]

 

As if that does not do enough to encourage disgust, the article includes this picture, which does not exactly capture him in a flattering expression.
 


 

How evil were Dick Cheney’s comments?
 

When King asks if he knows the identity of the person whose heart keeps him alive, Cheney, who is promoting a book about his transplant experience, says no, and adds, “it hadn’t been a priority for me.” Then he goes on:

When I came out from under the anesthetic after the transplant, I was euphoric. I’d had–I’d been given the gift of additional lives, additional years of life. For the family of the donor, they’d just been [through] some terrible tragedy, they’d lost a family member. Can’t tell why, obviously, when you don’t know the details, but the way I think of it from a psychological standpoint is that it’s my new heart, not someone else’s old heart. And I always thank the donor, generically thank donors for the gift that I’ve been given, but I don’t spend time wondering who had it, what they’d done, what kind of person.

“It’s my new heart, not someone else’s old heart.”

Consider the complete self-centeredness of that statement, and the utter lack of empathy. I shouldn’t be surprised at that — war criminals and torture-promoters aren’t known for their empathy — but I was.[1]

 

If we assume the bias of Joan Walsh, then we know that this is an expression of complete self-centeredness and an utter lack of empathy.

Assuming this bias allows us to suggest that there is something wrong with donating organs because they might go to someone who does not share our biases.

Several of the comments are from people expressing regret for having chosen to be an organ donor in the event of their death.
 

SanePerson                         7 days ago
The idea that a healthy heart from a decent human being could end up in monster like Cheney really makes one think twice about donating one’s organs.[1]

 

This comment received 4 likes.
 

sigtunafish                         10 days ago
This is why I refuse let my organs be donated if I die.[1]

 

This comment did receive some criticism
 

Saleem                         11 days ago
I am going to change the terms of my organ donor statement to say that none of my organs are to go to a registered Republican, especially Dick Cheney.[1]

 

This older comment received 7 likes.
 

If we would deprive someone of an organ that could keep the person alive, based on our biases about the person, how far would we go to prevent that person from receiving an organ transplant?

If we are willing to discourage organ donation, and this article clearly had that effect on several people commenting, why should anyone consider donating any organs that might help us?
 

More than 120,000 men, women and children currently need lifesaving organ transplants.

Approximately 1,851 Pediatric Patients*[2]

 

How many of those 120,000 people have something about them that we disagree with?

Should we deprive all of them of organs, just to avoid having some people we do not like receive organs?
 

An average of 18 people die each day from the lack of available organs for transplant.[2]

 

Die evil people (and good people)! Just so I can make a point!
 

In 2012, there were 14,013 Organ Donors resulting in 28,052 organ transplants.[2]

 

Maybe a bad person received a longer life because of the generosity a good person.

Should we insist on taking our organs with us to the grave?
 

90% of Americans say they support donation, but only 30% know the essential steps to take to be a donor.[2]

 


 

DonateLife.net
 

Don’t be a Joan. Be an organ donor and you may help someone immeasurably.

Footnotes:

[1] Dick Cheney: Even bigger monster than you thought
Listen to the man with a taxpayer-funded new heart wax indifferent to the life of his donor
Joan Walsh
Thursday, NOV 14, 2013 05:59 PM EST
Article

[2] Statistics
Understanding donation
DonateLife.net
Article

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ATT Buys Support from Non-Profits

The NAACP appears to be willing to sell out the poor for contributions.

The NEA (National Education Association) appears to be willing to sell out students for contributions.

Maybe it is for a noble cause, like true love.

Maybe it is not news, but is there any reason to believe that this is not just to help AT&T decrease the amount of competition in the cellular phone market?

[youtube]soJpGKhbBT4[/youtube]

AT&T is lining up support for its acquisition of T-Mobile from a slew of liberal groups with no obvious interest in telecom deals — except that they’ve received big piles of AT&T’s cash.[1]

We don’t know a thing about AT&T’s business, but for the right price, we will say whatever AT&T wants us to say. 😳

The NAACP was one of the first groups to announce public support of the T-Mobile acquisition. It received a $1 million contribution from AT&T in 2009[1]

No possible conflict of interest. 😳

The foundation of the National Education Association — the nation’s largest teachers union — received a $75,000 grant from the AT&T Foundation last year, the foundation’s IRS filing shows. On Tuesday, NEA President Dennis Van Roekel issued a statement in support of the telecom merger. “Students who do not have access to high-speed Internet are disadvantaged in preparing for the 21st century workforce,” he said. “This merger will have positive and long-lasting effects, and America’s students will be among the biggest winners.”[1]

How would he know?

This is the head of a union that spends its time protecting bad teachers at the expense of students. 😳

Should anyone trust anything that comes out of his mouth?

AT&T’s corporate giving arm, the AT&T Foundation, doled out $62 million in 2009 to support a variety of arts and education programs, charities and organizations. Jim Cicconi, AT&T’s senior vice president and top lobbyist, chairs the foundation.[1]

And I think that this charity is a good thing, but it has nothing to do with whether AT&T should be able to eliminate one of its competitors.

My experience with T-Mobile and AT&T includes dealing with the customer service of both companies for problems that were the fault of the companies. AT&T still considers me to be the source of the problem when their representative forgot to enter the discount code when I switched to their lower cost long distance. I was paying 10 cents a minute with a competitor. AT&T offered 8 cents a minute, but the representative’s error meant that I was charged the default maximum possible rate of 25 cents per minute. This was over the phone, so I was not filling anything out and could not have made the error when accepting their service at 8 cents per minute. I dealt with half a dozen managers. One straightened it out. Or so I thought, until I received a call 6 months later about the same bill.

Why would I agree to switch to a plan that would cost me 2 1/2 times as much money? I would not. For less than $100 dollars they lost a customer. This is the customer service attitude of a monopoly.

Most of the AT&T people I talked with threatened to destroy my credit if I did not pay the overcharged amount.

Why alienate customers? Because they can.

With T-Mobile, I had a similar problem. For some reason the unlimited texting was listed as applying to all of the phones, but was only applied to the billing on one phone. One phone had been changed on the plan, but it was still supposed to include unlimited texting. The unlimited texting was still on the plan, but was not being applied to that phone. It took a few phone calls to customer service, but everyone was helpful. Never was I threatened. Never was I lied to.

I like to think that T-Mobile is just an acceptable level of customer service, but I have worked in customer service and I have had many dealings with customer service personnel. This is better than we do expect.

Why reward the thugs who do not understand that they work for their customers?

What kind of business model encourages threatening customers for the company’s errors?

Why are we surprised that AT&T appears to be pulling the strings that are not supposed to be attached to their donations?

AT&T could build exactly what they claim they are getting by buying T-Mobile, but that would still leave this competitor in place.

Why should AT&T leave a competitor that demonstrates good customer service, when AT&T can eliminate the expectation of good customer service?

Should we really believe that the reason AT&T has neglected to build this important part of their system is that they needed to buy a competitor to do it right?

If that is the case, maybe that is even more reason to keep AT&T from interfering with the competitor that is able to do what AT&T can’t do.

Footnotes:

[1] AT&T gave cash to merger backers
Politico
Article

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Cycles and More

First a few comments about bad customer service Cycles and More, then some comments on riding safety and some very good video on countersteering (possibly the least understood, most essential part of motorcycle riding). Braking comes in a close second. Then riding smoothly. These are the three most important parts of riding fast. You don’t have to ride fast, but most people do not understand that braking and riding smoothly are much more important than acceleration.

Ambulance Driver is a bit less than gruntled with these turds and writes Dear Cycles and More . . . – about this motorcycle dealership/service center. The way he describes it, the dealing they are doing might be crack, because the only way they could see their customer relations in a positive light is if they are sampling their own product. Who knows, maybe Cycles and More is getting some stimulus money from the government our pockets. That would make sense. The companies that are too incompetent to succeed are the ones that seem to be getting the money. Usually, only in a state run business would this kind of attitude be tolerated.

Even state run organizations can be more customer friendly than this. Go to DMV (Department of Motor Vehicles – I use this term generically, since each state calls it something different) in California. The customer service is excellent. I’m from NY. DMV in NY is a couple of notches above standing in a stress position for hours. You set aside an entire day to register a vehicle. Then you still have to come back. I always bring something to read. So I was prepared when I moved to California. I never got a chance to do any reading – at least not in the DMV. They even let you make appointments, which remain on schedule. Private companies could learn from CA DMV.

Maybe Cycles and More is a bunch of escapees from NY state DMV. I wonder if their is a reward out for their capture.

If you ride a motorcycle, you need to be prepared to make the occasional emergency maneuver. If you expect to survive a bunch of these emergency maneuvers, you need to have somebody you can trust working on your bike. You can do it yourself – maybe you do not trust yourself. Or you can find out who the local experts are.

Even if you live in Shangri-La, and nobody in a car ever misbehaves, you should be practicing emergency maneuvers on a regular basis. Go to a local parking lot – when it is empty – and practice some swerves and some emergency stops. If you do not know how to do this, Take a class from the MSF (Motorcycle Safety Foundation). They have 2 excellent courses. The Beginner Rider Course and the Experienced Rider Course. I don’t mean to talk down to anybody, but you should start with the Beginner Rider Course, if you have never taken an MSF course before. There is a lot for even experienced rides to learn from the course.

One nice thing about the Beginner Rider Course is that you do not ride your own bike. So, if you just bought a bike, you will be much more likely to keep it upright after taking this course and if you drop the bike during the course, it isn’t your bike. My recommendation is to buy a used bike as first bike. A small, or medium sized used bike. You will drop it. Better to drop a used bike, than a brand new bike. A bike that you knew you couldn’t justify buying when you bought it.

There is nothing wrong with dropping a bike. There is a problem if you are not wearing the right protective gear. Trust me. I have left some skin on some asphalt. I have also left leather on asphalt several times. I still have a scar from the skin donation. I don’t have any marks from the leather donations. They actually add some character to the leathers, although I generally add character to anything I do. 🙂

Get good riding gear. Wear it. Learn to ride. Practice.

Always ride aggressively.

Riding aggressively does not mean riding fast, or riding recklessly. Riding aggressively means aggressively looking for problems and aggressively looking for ways out of those potential problems. You cannot ride a motorcycle the way you drive a car – you need to be much more alert. You are much more vulnerable, but you have a lot of control over that vulnerability.

Here are a couple of really good videos on countersteering:

Why is countersteering important? It is the fastest way to steer a motorcycle or bicycle. If somebody does something bad in front of you, you need to be able to change direction quickly. Practice this until you do not even think about it.

This is somebody who can countersteer with the best of them. You cannot maneuver a motorcycle this quickly without countersteering.

You may be thinking that you could never ride like that. Watch this video from a Beginner Rider Course. 2 days of riding. Not a great video or presentation of the course, in my opinion. The course is actually much better than the video suggests. At 1:50 into the video the new riders are practicing a slalom around cones. Not as difficult a course as the rider in the video above. Not as fast. These are mostly people with little or no previous riding experience. That is the impressive part of the MSF course. They take people who never rode before, spend some time in the classroom and on their closed riding course, and have them leave riding better than most people who have been riding for decades. Consistently.

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Helicopter EMS Meetings at NTSB

This week the NTSB (National Transportation Safety Board) will have a series of four hearings looking at HEMS (Helicopter EMS) safety.

Here is a link to their Public Hearings page.

Live Webcast – Captioned!

Details
Press Release
> Update
EMS Announcement

HEMS Links

Webcast Information

Here is a copy of the Press Advisory from yesterday:

The National Transportation Safety Board today released additional information about the Board’s scheduled public hearing on the safety of Helicopter Emergency Medical Services (HEMS) operations.

The four-day hearing will convene at 9:00 a.m. on February 3, 2009 at the NTSB’s Board Room and Conference Center, 429 L’Enfant Plaza, S.W., Washington, D.C.

Helicopter EMS operations provide an important service to the public by transporting seriously ill patients or donor organs to emergency care facilities. The pressure to safely and quickly conduct these operations in various environmental conditions (for example, inclement weather, at night, and unfamiliar landing sites for helicopter operations) has the potential to make HEMS operations more at risk than normal passenger carrying operations.

There will be witnesses from many EMS communities including pilots, medical personnel, managers, and FAA. The issues that will be discussed during the hearing include:

  • Operational Structure and Models
  • Flight Operations
  • Aircraft Safety Equipment
  • Training
  • Oversight

The goal of the upcoming hearing is for the Safety Board to learn more about helicopter EMS operations so that it can better evaluate the factors that lead to accidents. The Board will invite expert witnesses to provide sworn testimony. The majority of these witnesses will participate as part of small panels addressing particular safety issues. Additionally, several organizations will be granted party status to the hearing so that they may question the witnesses directly.

Note to Media: ABC News has been designated to provide the pool coverage of the hearing proceedings for the television networks for Tuesday, February 3. For questions regarding the pool, please call Fox News, the pool Chair, at 202-824- 6369.

The hearing will be webcast. An agenda and webcast are posted on the Board’s website, http://ntsb.gov/events/Hearing-HEMS/default.htm. To report any problems, please call 703-993-3100 and ask for Webcast Technical Support.

In the event of inclement weather please check our website for hearing cancellations and postponements.

Directions to the NTSB Board Room: Front door located on Lower 10th Street, directly below L’Enfant Plaza. From Metro, exit L’Enfant Plaza station at 9th and D Streets escalator, walk through shopping mall, at the CVS store (on the left), and take escalator (on the right) down one level. The Board room will be to your left.

Media Contact: Keith Holloway, 202-314-6100
hollowk@ntsb.gov

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PlayPlay

Respiratory Therapy 101 – What? – More Responses

PJ Geraghty wrote:

I was described by a colleague as a “non-interventional paramedic.” It was the rare patient who received ALS treatment in my ambulance, and even then some of them got an IV because it was marginally indicated and I knew the wrath of the ED staff if I delivered the patient without what they would consider “appropriate” interventions.

I’ve taken that “wait-and-see” attitude into my organ donor management field as well…I’ll get calls from my staff or hospital staff asking what to do when a donor’s BP is “patent pending over 150 (Shem, House of God). Usually the answer is “let it go for now” and the problem resolves itself.

Medical personnel should intervene when necessary, of course, but should also consider how “necessary” that intervention is, and whether it’s likely to make a clinical difference in patient outcomes (including patient comfort).

That is precisely the point.

We have too much medical theater and not enough good medical care.

In the recent post by TOTWTYTR, From the Journal of Iatrogenic Medicine*, the discussion of the merits of giving dopamine and Lopressor is an example.

The main part of the debate was on adding the controversial Lopressor to the expected treatment with the not controversial dopamine. I wouldn’t even recommend giving the dopamine to this patient.

The protocol may state that the patient should receive dopamine, but my job is not to treat the protocol. My job is to treat the patient. I can twiddle my thumbs for the 4 minute ride and not even break a sweat. Although, with that patient, I would probably be sweating. And I would continuously be reassessing – all of the time.

As long as no further treatment appears to be indicated, I am reassessing – looking for a reason to change treatments.

Is the fluid accumulating in the lungs?

Stop fluids and reconsider dopamine.

Is the pressure no longer coming up?

Reconsider dopamine.

Looking at the ECG again, is there a reason to suspect that this is an SVT?

Consider vagal maneuvers and adenosine or sedation and cardioversion.

Unless I have some clear indication for a treatment, not just vital signs that will not look good on the paperwork, I prefer to watch and wait.

Benign neglect is much better than malignant attention.

A recent exchange between a nurse/medic and lovable old me.

Nurse/Medic – Why doesn’t your patient have an IV?

Rogue Medic – Are you going to use the bloods I draw?

N/M – No. Our lab will not accept EMS bloods.

RM – So, why should I stick this patient to provide an IV ten minutes earlier than you would and then have you stick the patient again to draw blood samples for your lab?

N/M – The patient has chest pain.

RM – No. The patient had chest pain several hours ago. The patient is currently asymptomatic.

N/M – Well he should have an IV.

RM – Go right ahead. At least he will not be getting stuck one extra time for this.

He is at a hospital that has Level One intravenous capability. They also have an excellent cath lab. He has received aspirin. He denies chest pain, difficulty breathing, weakness, dizziness, nausea, vomiting, . . . . He is pink, warm, and dry with a brisk capillary refill. His vital signs do not indicate any problems.

His only complaint is that he misses his recently deceased wife. A lot.

If he does join his wife during this hospital stay, it won’t be because he didn’t have a prehospital IV. If he suddenly becomes symptomatic and dramatically deteriorates during his hospital stay, likewise the lack of a prehospital IV will not be the cause. At most it will delay treatment for a couple of minutes. About the amount of time it would take to get a doctor in the room and give a report prior to the doctor giving treatment orders.

Treatment priorities for this patient will not generally be resolved by the intravenous route. RVI (Right Ventricular Infarction)[1] would, but he has no signs of RVI. Pain might. Arrhythmia won’t. Cardiac arrest won’t. STEMI (ST segment Elevation Myocardial Infarction)[2] might.

Cardiac arrest is treated by good CPR and rapid defibrillation. There is still no scientific support for all of the IV drugs we give. ACLS (Advanced Cardiac Life Support) does not even encourage rushing to start an IV.

The fanaticism of starting an IV life line is an old medic’s tale that is dying a slow painful death. As more and more realize the uselessness of the IV in many cases where it has been mandatory, more protocols are taking the emphasis off of the IV start and appropriately directing it toward accurate assessment/reassessment, appropriate care, and the right destination.

I suspect that N/M is upset that when working as a medic, she would be written up for not starting an IV on this patient. I will not.

One of the reasons is that I am quite comfortable discussing patient care with medical directors. I will make my case without wandering into irrelevant details. I will make a case for the patient. N/M would be making a case with something else in mind.

I have found that violating protocols, even in very dramatic ways, is acceptable to many medical directors – as long as I understand what I am doing and can explain how it is in the best interest of the patient. I have also learned that it is important to have a medical director who understands EMS.

Should we approach patient care with anything other than the best interest of the patient as our priority?

Footnotes:

^ 1 Recognition and Treatment of Right Ventricular Myocardial Infarction
By William E. Gandy

Updated: July 8th, 2008 05:26 PM GMT-05:00
From the March 2008 Issue of Emergency Medical Services

Free Full Text

^ 2 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
(Circulation. 2005;112:IV-89 – IV-110.)
© 2005 American Heart Association, Inc.
Part 8: Stabilization of the Patient With Acute Coronary Syndromes
Free Full Text . . . . . Free PDF

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