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

- Rogue Medic

Alternative Medicine, Wishful Thinking, and Irresponsible Drug Pushers


Most emergency physicians avoid using homeopathy, acupuncture, Reiki, and other alternative medicine because there is no valid evidence that these treatments work, or because of they are not considered standards of care, or because there is no recommendation to give them from ACEP (American College of Emergency Medicine).

This is good, because alternative medicine is fraud.

Is there an alternative field of aerodynamics making planes for us to fly? Where is this alternative science?

Are people using alternative electricity to power their homes? Where is this alternative science?

According to the homeopathy hypothesis, the more dilute something is, the more powerful it is. We could solve the world’s energy problems – if the alternative science of homeopathy were anything more than wishful thinking.

How does that relate to emergency medicine?

When it comes to emergency treatments for cardiac arrest, stroke, heart failure, possible spinal cord injury, et cetera, many emergency physicians are just as superstitious as your local witch doctor. Currently, the most prominent example of alternative emergency medicine is tPA (Alteplase) for acute ischemic stroke.

But tPA, approved for strokes in 1996, only works if given within 4.5 hours of a stroke.[1]


That is an optimistic interpretation of the research –

The recent release of the American College of Emergency Physicians guideline recommending the use of tPA for ischemic stroke is remarkable. While it is unsurprising that a professional guideline flouts science, the publication is striking for its casual tone and its methodologically inexplicable review of evidence. Scientific thinking is absent.[2]


The evidence is horribly flawed, but the advocates respond just as we expect alternative medicine pushers to respond – with logical fallacies.

Ad hominem attacks on those who criticize the bad research.

These few persistent myths about thrombolytic therapy were first promulgated by self-appointed ‘expert critics’ who are unabashedly anti-intellectual in their opposition to this therapy. They decline to either read or attempt to understand data and rigorous analysis of that data.[3]

Alternative medicine pusher Dr. Patrick Lyden.

What is the appropriate time period for giving tPA?

IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[4]

Patients get better if tPA is begun within 3 hours, get worse if tPA is begun between 3 hours and 4 1/2 hours, but get better when tPA is begun after more than 4 1/2 hours.

Clearly, there is some strong evil magic that is working against tPA in that 3 to 4 1/2 hour time period, but it is all unicorns and rainbows the rest of the time.

Does that make sense?


That suggests that the evidence we have does not adequately assess the effects of tPA for acute ischemic stroke.

Reasonable people can disagree, but Dr. Lyden appears to be calling those who disagree biased just because they disagree. This is bad science and bad medicine.

We need research that is well controlled, not research that requires a lot of excuses.

MedPage Today is providing a good forum for discussion of this actual medical controversy and not just promoting the ad hominem criticisms of Dr. Lyden. There are links to plenty of other sites discuissing the problems with the evidence.[5]

I most recently wrote about this here – The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

I am not an emergency physician, so this is not something that affects my care of patients. I do not have to worry about being sued for not giving tPA and being accused of allowing a bad outcome. I do not have to worry about being sued for giving tPA and being accused of producing a bad outcome.

If you are an ACEP member, tell ACEP what you think of the evidence, or the flaws in the evidence.


[1] Few stroke patients get clot-busting drug
Liz Szabo,
10 a.m. EST February 13, 2014

[2] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman browngorilla540
Smart EM

[3] ER Briefs: tPA ‘Works’, ACEP on Target
Published: Feb 10, 2014
By Elbert Chu
Interview with Patrick D. Lyden, MD

[4] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] ER Briefs: Open Season on ACEP tPA Guidelines
Published: Jan 29, 2014 | Updated: Jan 30, 2014
By Elbert Chu

Bill Nye and Most Christians vs. Ken Ham and Creationism – Part II


Continuing, on Darwin Day, from Part I about the debate between Bill Nye and Ken Ham about whether Creationism should be taught in science classrooms.

Ken Ham’s Creationism is a religious belief that humans were placed on the Earth in their current form by Ken Ham’s interpretation of a Christian God about 6,000 years ago.

At the end of Part I, I wrote that I would review the science that supports Creationism here.

Here is the valid science to support Creationism.

Nothing. 😳

In stead of science, we get excuses for ignoring valid science. We get misrepresentations of mathematics used to make evolution seem impossible.

Preachers will tell you that evolution is a form of atheism, but that is a lie.

Most religious people are not Creationists, so are most religious people lying about what they believe?

Even Pat Robertson rejects Ken Han’s Creationism.

“We have skeletons of dinosaurs that go back 65 million years,” Robertson said. “To say it all dates back to 6,000 years is just nonsense, and I think [it’s] time we come off of that stuff, and say this isn’t possible.”

“Let’s be real; let’s not make a joke of ourselves,” he said.[1]


Pew Researh Center poll.[2]

Are Creationist preachers being honest about what others believe?

Do Creationist preachers make a lot of unsupportable assumptions?

One of the scientists Ken Ham used as an example of Creationism and science being compatible is Andrew Fabich, Ph.D., who had to learn evolution to get his PhD, but rejects evolution and teaches for a Creationist school. He claims that the LTEE (Long Term Evolution Experiment – evolution demonstrated in the laboratory) is just an example of a simple gene being turned on and not an example of evolution.

Real scientists immediately saw the nonsense in the claim of Andrew Fabich, Ph.D. that this was just turning on a switch and not evolution, but this Creation scientist is still making the same debunked claim. Does misunderstanding become understanding when it is repeated enough? No.

Of course, if it were so easy as a single, simple mutation, then we would have seen that capability evolve in many or all of the populations. But after almost 60,000 generations to date, only one population has evolved that ability.[3]


If 12 computers required over 60,000 clicks of a mouse before just one computer would produce an effect they were designed to produce, would anyone call that an Intelligent Design?

Andrew Fabich, Ph.D. is supposed to be an example of a Creationist being able to be successful as a scientist. A similar example would be that Michael Phelps was caught smoking from a bong and he won more Olympic gold medals than anyone else. Bong hits and Olympic gold are compatible!

Unlike Creationists, Michael Phelps has apologized for his bad judgment.[4]


The most famous Creationist scientist is Michael Behe, Ph.D. He was an expert witness at the trial that examined whether Intelligent Design is science.

The case for the Creationists ID (Intelligent Design) proponents was to try to show that ID is science and not religion.

Q But you are clear, under your definition, the definition that sweeps in intelligent design, astrology is also a scientific theory, correct?

A Yes, that’s correct.[5]


Astrology is not science, but astrology is the same kind of science as Creationism Intelligent Design.

That is from the best scientist they could find to present their case. ID is as good as astrology.



[1] Pat Robertson rejects ‘young earth’ creationism. ‘Nonsense,’ he says. (+video)
By Harry Bruinius, Staff writer
February 6, 2014
Christian Science Monitor

[2] Public’s Views on Human Evolution
Pew Research Center
December 30, 2013

Free Full Text in PDF format from Pew Research Center.

[3] Zachary Blount on “Ham on Nye” Debate, Follow-up #3
February 7, 2014
Zachary Blount
Telliamed Revisited

[4] Phelps: Photo with marijuana pipe real
Updated: February 2, 2009, 7:40 AM ET
Associated Press

[5] Kitzmiller v. Dover Area School District – Trial transcript: Day 11 (October 18), PM Session, Part 1
Talk Origins


Bill Nye – Ken Ham ‘Debate’ Review


Skip to 13:00 for the beginning of the debate.

Is it impossible to be a scientist and a Young Earth Creationist? No, but good science did not come from the Lysenkoists[1] of the Soviet Union, who also opposed evolution. Lysenkoists were still successful scientists – in the Soviet Union.

Ken Ham (multimillionaire CEO of a corporation that exists to sell Creationism with the home field advantage of a Creationist-packed crowd at the Creation museum) suggests that the ability of a few Creationists to become successful scientists is proof that you do not need to understand evolution to be a successful scientist.

This is misleading, which is a common Ken Ham tactic. It is much more difficult to become a successful scientist with a major misunderstanding of science. A tall person to become a gymnast, or a jockey, but that is not proof that being tall is not an obstacle to success in both fields.

There are doctors who are claim that AIDS (Acquired Immune Deficiency Syndrome) is not caused by HIV (Human Immunodeficiency Virus),[2] historians who claim that the Holocaust is a myth,[3] and pediatricians who claim that vaccines are the root of all evil,[4] but these flaws in their understanding are obstacles that they have to overcome. Some will make their misunderstanding their source of income.

These conspiracy theorists claim to know the truth, while the rest of us are deceived. They claim to be misunderstood geniuses, just like Galileo.

However, Galileo’s opposition was from a political faction within the Catholic Church. This faction claimed that Aristotle’s ideas were not to be challenged, even though Galileo could demonstrate that Aristotle was wrong about some things, he could not demonstrate this for everything.

According to Ken Ham, Galileo was wrong, since the experimental conditions could not be produced to demonstrate that Galileo was right.

Galileo could not watch objects falling in a vacuum, but that did not mean that the rate of acceleration due to gravity was different for feathers and hammers.

Just because we cannot watch evolution happening quickly, does not mean that evolution is not happening, no matter how much Ken Ham wishes it were true.


The Catholic Church learned a lot about science in the hundreds of years since locking up Galileo. The Catholic Church accepts that evolution is real.

The Catholic Church has not eliminated Genesis from the Bible, but still rejects Ken Ham’s literal misinterpretation of Genesis.

Stuart Burgess, PhD states (at 30:55) –

I find that many of my colleagues in academia are sympathetic to the Creationist viewpoint, including biologists, however they are often afraid to speak out because of the criticisms they would get from the media and atheist lobby.


Maybe the biologists are just being polite to the Creationist. Maybe they are just sick of repeatedly trying to explain to an engineer (someone who is expected to see design in things) that not everything is designed.

Some of us will patronize (or ignore) a misguided colleague, rather than trying to reason with the obtuse, when we could be accomplishing something useful.

Where does this myth that scientists fear criticism by the media or the atheist lobby come from?

If scientists are more worried about the media than about evidence, then they are really just politicians.

Ken Ham claims that the laws of nature, laws of logic, and the uniformity of nature are evidence of Creationism.

Do nature and logic work differently in places that are not Christian?

Ken Ham asked where the laws of nature, laws of logic, and uniformity of nature came from?

Logic and uniformity?


Ken Ham is a literalist, but does not understand that a literal interpretation of the Bible does not support logic and uniformity.

Why argue with logic that is so illogical?

At 34:00, Ken Ham states –

When I was at the Goddard Space Center, I met Creationists and evolutionists who were both working on the Hubble Telescope. They agreed on how to build the Hubble Telescope. You know what they disagreed on? Well, they disagreed on how to interpret the data the telescope obtained in regard to the age of the universe.


What does evolution have to do with the age of the universe?

The age of the universe is determined by other fields of science.

However, Ken Ham’s science book does not define the length of a day and is not specific about what is intended by the word begat. This literalism seems to be an obstacle to understanding any meaning of generation.

The term Founding Fathers will baffle these literalists, if they approach it the same way they approach the Bible.

At 47:00 Ken Ham claims that the Bible does not support any view of different races, such as might be used to support slavery, or a chosen people.

OK, Ken Ham did not mention that a literal interpretation of the Bible actually does support slavery of other races and does spend a lot of time on the chosen people, but this is Ken Ham, so he is only literal when it suits him. 😳

I am less than an hour in, but this is more than enough to show that Ken Ham does not understand science.

The evidence just for human evolution is extensive (1,950 papers – over 100 papers each year since 2006) and well reviewed by scientists.

PubMed search for “human evolution.”

The evidence for Creation science is insignificant (only 19 papers) – and most of these papers are critical of this oxymoron.

PubMed search for “creation science.”

Evolution is a branch of science.

Creation science is a form of religion.

The debate is between religious people who understand science and religious people who do not understand science.


[1] Lysenkoism

[2] Denial, conspiracies, and misconceptions

[3] Holocaust denial

[4] Vaccine controversies


Bill Nye and Most Christians vs. Ken Ham and Creationism – Part I

Image credit.

Tuesday, February 4, 2014, Bill Nye, the Science Guy, debates a Ken Ham, a multimillionaire Creationist who makes his money selling Creationism as an alternative to science. This will be at the Creation Museum, which is a religious museum, not a science museum.

Should we teach only science in science classrooms?

Below is an example of Ken Ham using the appearance of science, but no real science, to push his products.

The link leads to a store to sell Ken Ham’ God products.

Image credit.

There is no scientific controversy about whether evolution is true. Scientists understand science and evolution is science. Evolution is not controversial among scientists. Evolution is not even controversial among scientists who are religious.

The controversy only exists among the various religious interpretations of Creation.

Each Biblical literalist (Creationist) seems to claim that his particular interpretations of the Bible is exactly the one God intended, no matter how many other interpretations of the Bible it contradicts. This includes the interpretations of Biblical scholars familiar with the origins of the Bible and interpretation of other literalists. There are about half a dozen different factions of Creationism.

The different flavors of Creationism may depend on what parts of the Bible the Creationists attempt to account for.

Some Creationists accept what they call microevolution, but claim that there is some magical barrier that prevents an accumulation of their microevolutionary changes from producing a change in species, while it accepts an evolutionary change of a smaller degree.

Other Creationists accept a change in species, but reject the possibility of a change in genus.

Some Creationists accept a change in genus and species, but reject a change in family.

24 And God said, Let the earth bring forth living creatures after their kind, cattle, and creeping things, and beasts of the earth after their kind: and it was so.

25 And God made the beasts of the earth after their kind, and the cattle after their kind, and everything that creepeth upon the ground after its kind: and God saw that it was good.[1]


There is no scientific controversy about whether evolution is true, only about the fine points of how evolution works, but that is true of any scientific theory.

Should we reject germ theory because Jesus told his followers not to wash their hands?

1 About this time some Pharisees and teachers of the Law of Moses came from Jerusalem. They asked Jesus, 2 “Why don’t your disciples obey what our ancestors taught us to do? They don’t even wash their hands[a] before they eat.”

. . . .

10 Jesus called the crowd together and said, “Pay attention and try to understand what I mean. 11 The food that you put into your mouth doesn’t make you unclean and unfit to worship God. The bad words that come out of your mouth are what make you unclean.”[2]


Germ theory makes it clear that some of the things that we put into our mouths (germs) can make us sick.

Should we demand that some religious alternative to germ theory be taught in science classrooms, because the Bible contradicts germ theory?

I don’t expect many Christians to advocate for that. I think the reason is that it is easier to demonstrate that germ theory is real than it is to demonstrate that evolution is real.

Pew Researh Center poll.[3]

Does science depend on worship of a God, or on worship of a literal Bible?

Which religious Creationism would be acceptable?

Thoughts about whether evolution is the best explanation for life on earth are also closely tied to individual religious beliefs and practices. Across many religious traditions, the more highly committed tend to be less likely to believe in evolution.[4]


What about scientists?

What is the percentage of scientists who reject evolution?

Pew Researh Center poll.[5]


Where is the claimed science behind Creation science?

I will look at Creation science in Part II.


[1] Genesis 1:24-25
Bible – Old Testament
American Standard Version (ASV)
Bible verse from BibleGateway

[2] Matthew 15:1-2 and 10-11
Bible – New Testament
(Contemporary English Version)
Bible verse from BibleGateway

[3] Public’s Views on Human Evolution
Pew Research Center
December 30, 2013

Free Full Text in PDF format from Pew Research Center.

[4] U.S.Religious Landscape Survey. Religious Beliefs and Practices: Diverse and Politically Relevant.
Pew Forum on Religion & Public Life / U.S. Religious Landscape Survey
June 2008
Free Full Text in PDF format from Pew Research Center.

[5] Public Praises Science; Scientists Fault Public, Media – Scientific Achievements Less Prominent Than a Decade Ago
Pew Research Center
July 9, 2009

Free Full Text in PDF format from Pew Research Center.


Why Do We Have So Little Respect For Our Patients?


Informed consent should require that we provide our patients with honest information about the treatment we are pushing.

Even implied consent assumes that an informed patient would make the decision to take the treatment if the patient had the capacity to make an informed decision and had honest information about the treatment.

What medical treatment do we use during cardiac arrest?

We use chest compressions and defibrillation.

Nothing else qualifies as medicine.


Ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, and procainamide, are witchcraft.

There is no evidence that ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, or procainamide improve survival from cardiac arrest.


Why don’t we limit treatments to what actually works, rather than what makes us feel like we are helping?

We are only exposing our patients to adverse effects for no benefit to the patient.

Nature has demonstrated a strong bias in favor of reality.

Our bias in favor of superstition is unnatural and unhealthy.

All treatments should be limited to high-quality controlled trials until there is valid evidence of improved outcomes with the treatment.

Surrogate endpoints do not count.

If we wish to develop an understanding of what we are doing, we need to study what we use.

If a treatment does not work under controlled conditions, why believe that it works in uncontrolled conditions?

Research gives the best opportunity to see the difference in outcome that is due to the just the treatment being studied.

If we think the treatment works, we should be insisting on showing off.

We are all talk.

We run away when challenged.

If we accept excuses for not finding out what we are doing, we end up with epinephrine for cardiac arrest – 50+ years of use, but we still do not know if it is beneficial, if it is beneficial in some patient populations and harmful in other patient populations, or if the effect is neutral.

There is no outcomes research that has shown improved outcomes, but epinephrine is the standard of care and research has been discouraged because it would be unethical to deprive patients of this witchcraft.

Any treatment that is used outside of controlled trials, without evidence of improved outcomes, is witchcraft. Why can’t we be honest about that?

I was a baby, when we started using epinephrine for cardiac arrest. I am a cantankerous old coot, now. There has been only one placebo controlled trial of epinephrine for cardiac arrest,[1] but that was crippled by political pressure because it would be unethical to deprive patients of the eye of newt.

Someday, medicine will grow up and start treating patients with something that actually works.


[1] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed – in process]

Free Full Text PDF Download from semanticscholar.org

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

Edited 12-27-2018 to correct link to pdf of Jacobs study in footnote 1.


FAA Giving in to Science – Without Which the FAA Would Not Exist


The FAA (Federal Aviation Administration) is beginning to embrace science.

By today, many of us should be permitted to use most electronic devices during all parts of an airplane flight.

Airlines have been racing for weeks to be first, gathering paperwork and setting up working groups to study the issue.

JetBlue Airways Corp. and Delta Air Lines Inc. were ahead of the pack on Thursday, applying for approval within hours of the new guidelines. The two carriers said they hoped to begin allowing fliers to use devices from gate to gate by Friday.[1]


The FAA exists because of the ability of science to demonstrate the ability of humans to create a safe means of travel through the air. The FAA originally could have decided that the prospect of putting people in metal (or wood) structures, traveling at hundreds of miles an hour, and landing safely on the ground is not something that humans can be expected to do safely, but they didn’t.

The FAA could have adopted unscientific approaches to flight safety . . . . Well, they did with electronic devices. Much of what the FAA has done has been based on good evidence, but as with the use of cell phones in hospitals, the evidence of harm is lacking. Science without evidence is rarely good science. The FAA has not been foolish enough to follow the rest of the world into exclusive use of GPS (Global Positioning System) navigation.

The FAA first restricted the in-flight use of devices out of an abundance of caution, in part based on anecdotal evidence that emissions from devices interfered with pilot instruments.[1]


An abundance of caution is often what is used to justify rules that are actually based on an abundance of ignorance.

The use of backboards for potentially unstable spinal injuries are not based on evidence of benefit, but on an abundance of faith in expert opinion, that’s the way we’ve always done it, and wishful thinking. The same is true the rest of abandoned medical treatments and many that have not yet been abandoned.

Other safety policies have been extremely successful. However, these policies have evidence that they work.

The Federal Aviation Administration’s decision, its first big shift on electronic devices since it restricted their use in flight in 1966, caps years of debate over whether electronic emissions from devices can interfere with cockpit instruments.[1]


Almost half a century of restriction without evidence.

Anecdotal evidence should not be ignored, but should prompt research. If valid research does not support the caution inspired by the anecdotes, then we should ignore the anecdotes. If no research is considered to be necessary to determine the necessity of the restrictions, then we should ignore the restrictions.

Airline travel is extremely safe, but can be made to look less safe by looking at the statistics with the wrong perspective.

Image credit.
By the number of trips, airline travel does not appear to be safe, but we do not take airlines to travel to the grocery store. We take airlines to travel long distances.

Image credit.

Since airline travel is much faster than most other forms of travel, the safety per hour (per billion hours) is also not a good metric.

Image credit.

If I am traveling a few thousand miles, and I am only interested in the safety of that trip, there is no difficulty deciding the safest means of making that trip.

Travel by air is 8 times safer than travel by bus.

Travel by air is 12 times safer than travel by train.

Travel by air is 62 times safer than travel by automobile.

Travel by air is 1,084 times safer than walking. Although there would we health benefits to walking, the benefits would not come close to the much larger fatality rate.

The type of air travel also matters.

Image credit. Click on images to make them larger.

Fly and during the flight do work on an electronic device, or relax with an electronic device, but do not worry that you will crash the plane with a cellular phone. If you could do that, we would not even allow cellular phones in checked luggage.

Also see –

Do FAA restrictions on electronic devices make flying safer? Part II
Thu, 11 Apr 2013
Rogue Medic


[1] FAA Says Fliers Can Use Devices During All Phases of Flight
Wall Street Journal
By Jack Nicas and Andy Pazstor
Updated Oct. 31, 2013 8:00 p.m. ET


You had me at ‘Controversial post for the week’ – Part II

In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]


Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]


We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.

Image credit.

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]


PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. 😳

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.


We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]


The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.


[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser


You had me at ‘Controversial post for the week’ – Part I

What kind of trouble would an Ambulance Chaser be up to?


Time to stir up some controversy here.

I would no longer require any resuscitation “card courses.” No more ACLS, CPR, or PALS.[1]


The saddest part about this is that this is controversial.

Image credit.

First, I disagree with some of the points about how slow the AHA (American Heart Association) is. The AHA is not as bad as portrayed, but much of this is the failure of the AHA to communicate effectively.

Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.[1]


To protect against unrecognized esophageal intubation, confirmation of tube placement by an expired CO2 or esophageal detection device is necessary.[2]


That is from the 2000 ACLS (Advanced Cardiac Life Support) guidelines.

Necessary is not an ambiguous word, but the guidelines were not taught this way by many people.

If our attitude is that unrecognized esophageal intubation is only a problem for our patients, then we can get away with lesser means of tube confirmation.

The following is from the 2005 ACLS guidelines.

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.[3]


The AHA guidelines did not stress continuous waveform capnography until 2010. Maybe the attitude of the AHA was unrecognized esophageal intubation is only a problem for someone else’s patients.

    Key changes from the 2005 ACLS Guidelines include

  • Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.[4]


What is the key change?



quantitative waveform




confirmation and monitoring

of endotracheal tube placement.

Why was the AHA not stressing this Class I, LOE (Level Of Evidence) A assessment?

There is no good reason.

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[4]


If a medic, emergency nurse, emergency physician, . . . disconnects waveform capnography from an intubated patient is that a sign of incompetence?

EtCO2 in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.


Feel free to disagree, but any such argument should avoid logical fallacies.

What else?

What else will be covered in Part II.


[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser

[2] Tracheal Intubation
2000 American Heart Association Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control
Free Full Text from Circulation.

[3] End-Tidal CO2 Monitoring
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Monitoring Immediately Before, During, and After Arrest
Free Full Text from Circulation.

[4] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Free Full Text from Circulation.