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

- Rogue Medic

We Never Looked

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Over at 9-ECHO-1 is a post from which I stole the title of this post. We Never Looked.

I do not think that it is important for the vital signs to be a part of the radio report, unless they are unusual in some way, or relevant to the presentation. I am not encouraging the use of Within Normal Limits to describe assessment findings. A much more appropriate term would be Unremarkable. Something that can be expressed by just not remarking on them.

How can we legitimately suggest that we have an understanding of what the limits of normal are for a particular patient? What is a normal heart rate, or blood pressure, for one patient may be an unstable heart rate, or blood pressure, for another patient, even though it falls into the WNL range of numbers.

Vital signs are just a part of a thorough patient assessment. Not even the most important part. If I assess the pulse of a patient as zero/unobtainable, do I progress to the blood pressure? Or is it more important to assess responsiveness?

Think. Think. Think.

The only reason to assess the blood pressure is if there is some sign of life. Some sign of responsiveness is one of the primary indications that an unobtainable pulse is not an accurate sign of vitality (life).

If vital signs are not even reliable in determining if the patient is alive, how important are they? I have had about a half dozen patients with no palpable pulse, even though these patients were awake and alert.

The reason we focus on vital signs appears to be that there are boxes to be filled out on the chart. If the boxes are not filled out, then the QA/QI/CYA people becomes apoplectic. Not because documented vital signs are important, but because QA/QI/CYA people seem to be afflicted with the curse of Kelvin.[1]

Just because the information can be presented in numbers, as vital signs are, does not mean that the information is important, relevant, or even truly objective. Among other things, the documented pulse depends on the fingers palpating it. Among other things, the documented blood pressure depends on the ears auscultating it. Among other things, the documented respiratory rate depends on the eyes watching it. Is machine measurement of these vital signs any more accurate by decreasing human involvement?

Assigning something a number does not make that thing objective. We assess pain by asking the patient to assign a number to his/her level of pain, but that does not make it objective. There is no way to make the pain score objective, yet it is often referred to as The Fifth Vital Sign.[2] The other vital signs depend on the person assessing them. The vital signs are no more objective than any other assessment.

Vital signs are secondary to the rest of a thorough physical exam. Vital signs are only a part of a thorough physical exam.

We assign too much importance to the vital signs. If we minimize the importance of the rest of the physical assessment, is it any wonder that medical directors demand that we assess the damage to a vehicle, rather than that we assess the actual patient?

Rather than We Never Looked, I think that WNL indicates that We Never Learned.

Footnotes:

^ 1 William Thomson, 1st Baron Kelvin, Lord Kelvin
Wikiquote page

I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.

Lecture on “Electrical Units of Measurement” (3 May 1883), published in Popular Lectures Vol. I, p. 73; quoted in Encyclopaedia of Occupational Health and Safety (1998) by Jeanne Mager Stellman, p. 1973

^ 2 Vital Signs – Fifth Sign
Wikipedia
Article

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Influence of Sex on the Out-of-hospital Management of Chest Pain – Part I

ResearchBlogging.org

Also posted at Research Blogging. Go read some of the other research there.

Why Part I? Because there is a lot to write about in this study. While the authors mean well, they end up demonstrating two things.

1. How not to do a study.

2. How a medical director can endanger patients by lowering standards to meet the perceived abilities of the available medics in an EMS (Emergency Medical Services) system.

Let’s start at the beginning. In spite of the title, this has nothing to do with the Influence of Sex on the Out-of-hospital Management of Chest Pain. It would be more appropriately titled – Are Women Treated Differently When Classified By EMS Dispatch As Having Chest Pain. Not as catchy a title, but this is not about intercourse-induced chest pain. Other problems with the title should be easy to spot as you read along.

We get all the way to the second paragraph, when the research problems scream Look at me!
 

Of the 16 million patients per year who are cared for and transported to the hospital by emergency medical services (EMS), 8% have a chief complaint of undifferentiated chest pain, possibly suggesting acute coronary syndrome (ACS).16 [1]

 

Reference number 16 is an interesting paper, but it is a study of ambulance diversion by the ED (Emergency Department). It is not a study of the incidence of potentially cardiac symptoms among those transported by EMS. From the abstract –
 

Study objective: We describe emergency department (ED) visits in which the patient arrived by ambulance and estimate the frequency of and reasons for ambulance diversion. Using information on volume of transports and probabilities of being in diversion status, we estimate the number of patients for whom ED care was delayed because of diversion practices.[2]

 

The authors did break patients down by Principal reason for visit, but why use a paper that is examining ambulance diversion as a reference?

I assume that the answer is that they saw a huge amount of data and figured more is better. It may not have occurred to the authors that patient’s presentation to EMS may not be the same as the patient’s presentation to the ED.

While 7.9% of EMS patients did have a Principal reason for visit of “Chest pain and related symptoms (not referable to body system)”, that may have absolutely nothing to do with EMS management of Suspected Acute Coronary Syndrome. Acute Coronary Syndrome (ACS) is currently the preferred terminology a possible heart attack. One of the reasons for using this terminology is that Chest Pain is a typical male symptom of a heart attack. Women often present with other symptoms, such as tiredness for a number of days, difficulty breathing, weakness, nausea, and many other atypical symptoms. In Pennsylvania, there are statewide protocols. These protocols do not include a Chest Pain protocol, but the protocols do include one for Suspected Acute Coronary Syndrome.

Look at some of the other categories of Principal reason for visit.

* 5.7% Shortness of breath.

* 2.9% General weakness.

* 2.9% Labored or difficult breathing (dyspnea).

* 2.3% Fainting (syncope).

These are patients with potential acute coronary syndromes. Even more so for women, who are less likely to present with the male chest pain syndrome of crushing substernal pressure radiating to the neck, jaw, and/or arm.

Add these up, since they appear to be listed by only the primary Principal reason for visit, so there should be no overlap. All categories do add up to 100%.

The total for non-Chest Pain potential ACS is 13.8%.

Then you add in those with an actual Principal reason for visit of chest pain (7.9%) and you have 21.7%. They have excluded over 60% of patients with presentations that might be cardiac.

This is probably an insignificant difference and should be ignored. At least, that is what I would conclude from the way the authors treat this information. The Principal reason for visit was limited to 10 categories, of which half could be cardiac. The rest are lumped into All other reasons. Maybe nausea, vomiting, tiredness, arm pain, jaw pain, malaise, difficulty walking, et cetera. Many of these might be assessed as possible ACS, but the authors of the diversion study only specified the top 10 categories. This leaves 58.3% of patients.

How many of those would present with possible ACS?

Not wanting to leave well enough alone with this diversion study, they came up with some more inaccurate information.
 

Of all U.S. out-of-hospital (OOH) patients, nearly half are women.16 [1]

 

This is referencing the same study, so I do not have to look far to find their data –

* Female        8,763 patients, which works out to 54.2% Of all U.S. out-of-hospital (OOH) patients. Those arriving by ambulance were 14.4% of the total number of ED patients.

* Male           7,402 patients, which works out to 45.8% Of all U.S. out-of-hospital (OOH) patients. Those arriving by ambulance were 14.0% of the total number of ED patients.

Perhaps the authors need to be a bit more clear on what they mean by nearly half. Even if they were correct in concluding that 54.% is nearly half, what would that matter. What is important is whether women make up a significant proportion of those patients patients presenting with possible ACS.

I think that the title of this paper and two paragraphs are enough for Part I. I address some of the research on gender differences in ACS symptoms, as well as the rest of the paper, in Part II.

Edited at 15:30 on 5/16/2018 to update links, format, and to make a correction. I had incorrectly listed second citation from footnote 1 as being from footnote 2.

Footnotes:

[1] Influence of sex on the out-of-hospital management of chest pain.
Meisel ZF, Armstrong K, Mechem CC, Shofer FS, Peacock N, Facenda K, Pollack CV.
Acad Emerg Med. 2010 Jan;17(1):80-7. doi: 10.1111/j.1553-2712.2009.00618.x.
PMID: 20078440

Free Full Text from Academic Emergency Medicine

[2] Analysis of ambulance transports and diversions among US emergency departments.
Burt CW, McCaig LF, Valverde RH.
Ann Emerg Med. 2006 Apr;47(4):317-26. Epub 2006 Feb 17.
PMID: 16546615

Meisel, Z., Armstrong, K., Crawford Mechem, C., Shofer, F., Peacock, N., Facenda, K., & Pollack, C. (2010). Influence of Sex on the Out-of-hospital Management of Chest Pain Academic Emergency Medicine, 17 (1), 80-87 DOI: 10.1111/j.1553-2712.2009.00618.x

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National Registry of EMTs – Is it really that bad?

In the comments to Zero Tolerance III – Star of Life Law second comment, was a comment by Greg Friese,

Rogue medic, eliminating the NREMT (NR, or National Registry of EMTs) is a bold and radical suggestion. How can we assure some minimal knowledge and competency across all providers in all areas?

The way you write that, one might think that the NR had some way to assure some minimal knowledge and competency across all providers in all areas. The NR does not assure any level of competence. The NR claims to, but the NR fails.

Wouldn’t it be nice, if they did assure some level of competence? Wouldn’t it be even better, if it were actually a useful level of competence?

JCAHO (TJC, The Joint Commission, or the Joint Commission for Accrediting Healthcare Organizations) is just as dangerous to patients in the hospital. They are both about enforcing checklists rather than improving patient care. There are good uses of checklists. CRM (Crew Resource Management training) is something we need. CRM does not seem to be encouraged by JCAHO or NR, but JCAHO and NR love their irrelevant check off sheets.

If your instructors know enough to teach EMS well, they should know enough to evaluate the knowledge of candidates for a license/certification. The NR has become so focused on the avoidance of the appearance of discrimination, that they have made even the appearance of the actual evaluation of competence secondary to the avoidance of discrimination. The NR seems to be headed toward the complete automation of their testing system.

If your instructors do not know enough to assess the the knowledge of medic candidates, the NR check off sheets do not make up for that deficiency.

The NR focus is on several prepared scenarios and a bunch of stations. stations with scripts. Scripts just to avoid any appearance of variation. Do your patients present this way? Mine sure don’t.

NR Medic – I’m calling to notify that we will be arriving with a number 5 in seven minutes. No, wait. Make that a number 7 in five minutes.

Incomprehensible doctor noises on the other end of the line.

Yes. I gave him the drug in the spray bottle. No. I’m too busy filling out check off boxes to look at the patient.

More doctor noises, but noticeably cranky.

You’re the doctor. You figure out what’s wrong with him.

Really high pitched doctor noises, like nails on a blackboard.

Well, he’d better still be alive. He hasn’t signed the billing sheet, yet.

Having a limited number of medical conditions to deal with is great. These order off the menu numbers make patient care so much easier. We don’t have to mess around with any of that thinking stuff. Thinking makes my head hurt. Some of those numbers can be kind of difficult to tell apart.

Ooops. gotta go. There’s a number 3 five blocks from here. Or is that a number 5 three blocks from here. Whatever! We just give them medicine off the menu. It isn’t as if there are real differences – yellow box, silver box, blue box. What difference does a color make?

I am so glad I don’t get paid to think. Being indiscriminate is the best part of the job. Well, that’s out motto, but I don’t know what it means.

This is all about preventing the possibility of having a human make a decision. How can you create a system to evaluate human decision making, but act as if human decision making is the enemy? You can’t, but that is the goal of the NR. Will they ever recognize the futility of this behavior? Who cares? They are making money off of it. That is what matters.

Teaching students to be good medics will almost always make them highly likely to pass the exam.

I agree. A good medic should pass the exam, but I have failed an excellent medic for a simple oversight, just because I was not allowed to ask what he meant. The NR rules are more important than the outcome.

The more important question is, does the NR test weed out the dangerous medics?

Absolutely not.

True, some dangerous prospective medics will fail, but passing does not correlate with competence. What independent evidence do we have that passing this test is something that correlates with the ability to work with minimal supervision and full standing orders.

Why full standing orders?

Because anything less is an indication of incompetence. If the medics are not capable of working without that mother-may-I phone call, they are not competent. Go to the best systems in the country. You will find that they have the fewest requirements to call for permission.

If OLMC (On Line Medical Command) permission requirements were correlated with quality, you would find exactly the opposite. OLMC requirements encourage incompetence – not in the medics, but in the medical director. The medical director has OLMC requirements, because of a lack of understanding of EMS oversight. The lack of understanding of EMS oversight leads to dangerous medics – unless the medics are motivated to police themselves. Of course, this attempt at responsibility by the medics can be discouraged by the medical director or management.

Teaching students how to be good test takers will increase the odds of them passing significantly.

Yes, but what does that have to do with competence?

You are starting by assuming that the NR test actually has something to do with competence. It does not. Then you are claiming that you have to teach the student how to take the test.

The result is that too much time is spent on training the medic students how to take the medic test, rather than training the medic students how to be medics. In other words, how to use critical judgment.

What are the most important skills that a medic should have?

1. Assessment.

If you do not know how to assess patients, how do you know what to treat? How do you know what protocol to apply?

2. Critical judgment.

Critical judgment helps in knowing where to go with an assessment. You won’t assess every patient the same way, but you do need to know what questions to ask and what places to look.

Having initially assessed the patient, you need to be able to decide what to do with the information you have obtained. NR does nothing to evaluate critical judgment.

But what about the critical/not critical decision in the patient assessment station?

Trust me, the patient is critical. I don’t even need to be there to know that. Or have they changed something?

NR encourages the cookbook approach to EMS, by their devotion to check off evaluations, rather than an interactive assessment of ability. If medic evaluators cannot be trusted to use judgment in assessing medic candidates, then they should not be trusted to treat patients.

NR behaves as if the use of medic judgment is the worst thing that could ever happen. This is the antithesis of good EMS. Any system that takes this approach should limit itself to BLS (Basic Life Support). There is no reason to have a Procrustean EMS system.

Procrustes is from Greek myth. He had an iron bed into which he required every passerby to lie down. If the traveler was too tall, he would cut the legs down to fit the bed. If they were too short, he would stretch them on the rack until they fit the bed. Similarly, we end up harming the patients to make their assessments fit the protocols we have. Rigid protocols are not good for patients.

Instructors can do both things without teaching to the test.

There are people who need assistance with test taking skills, but why divert the whole class from paramedic education to teach basic test taking methods? Because the ritual is more important than the result.

One example of this ritual over result fascination is the intubation station. If you do not state that you see the vocal cords, do you pass intubation? It does not matter if you can place the tube in the mannequin better than the instructor, you do not pass unless you chant the chant.

What if you don’t see the tube go through the cords?

That does not matter. That is not one of the check off boxes. You really shouldn’t bring reality into this.

What about the written test?

How does asking trick questions with just a single best answer have anything to do with good EMS? How many patient care situations have just a single best answer? Almost none. Those that do are not the ones being asked on the multiple guess exam.

This multiple choice, trick question, setting requires a bunch of test preparation. This is poor testing, so we have to spend time making up for the horrible test design. I know they have a bunch of people with all sorts of classroom degrees to validate these farcical tests, but that does not seem to help them to screen out dangerous medics. They validated their test. Why doesn’t this validated test weed out the ones who do not understand?

Whenever I hear validated, I think of Inigo Montoya saying, You keep using that word. I do not think it means what you think it means. How do we end up with so many EMS invalids with such a well validated exam?

We will be talking with a NREMT rep on an upcoming episode of http://www.emseducast.com. We are working on using ustream.com to allow live listening and chatting.

I like the idea of the NR.

The execution leaves a lot to be desired. Sometimes I think that execution of those in the NR might be the solution. Just one, or two, ought to do the trick. How slow to catch on can they be?

EMS is not a computer simulation. Their validated Ivory Tower models do not apply. The ambulances are not all little boxes made of ticky tacky.

The patients are not little boxes. The patients are what EMS is all about – not the little boxes on the multiple choice test or the evaluation sheets.

As I stated, I like the idea of the NR. The problem is that the idea and reality are miles apart.

Having the ability to move, almost as if we were professionals, is a good idea. I have been a medic in several states. Getting reciprocity for each move was different. NR could assist those of us who do not manage to stay in one place. NR can have a lot of input on the way EMS is run.

NR could also facilitate reciprocity for out of state paramedic disaster assistance. The way it is now, paramedics are not really more useful than basic EMTs, once they have crossed a political boundary. Unless the receiving state has the capability to grant emergency authorization to medics in disaster situations. Many states do not have this ability. Reciprocity might take months, which is OK if the disaster is nice and patient. Even FEMA can get its act together faster than that.

From what I see, NR has a big effect on the way things are run. People look for a quick and cheap way to hand a medic card to people, but to avoid responsibility for giving medic cards to people who aren’t even good basic EMTs. NR provides that excuse.

The idiot passed NR. How bad can he be?

Sometimes the answer is very bad.

Why should a paramedic test be quick or easy or cheap?

We end up with a similar approach to medical oversight. Quick and easy and cheap.

Why should we be paying discount rates for medical directors? We have medical directors who authorize medics to treat patients, but never meet the medic. I have worked for some of them. This is the NR approach applied to medical direction.

EMS should be limited to BLS, except where there is a well compensated, well educated, aggressive medical director. A medical director who understands EMS. A medical director with appropriate support personnel depending on the size of the organization.

Medical directors who practice absentee medical direction should be locked up. There is no reason to allow patients to be subjected to that kind of abuse. BLS is safer than bad ALS (Advanced Life Support).

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How We Mess Up New Medics

In response to Bad Oversight – Part I, Mystery Medic wrote some interesting comments. These comments address a lot of the problems of EMS. My responses are in between his comments.

I love to throw in 2 cent when I can.

Nothing wrong with that. That is what we do. With my blog, I have probably exceeded my 2 cent quota.

1. Who says you always have to get to C in the ABC’s. If the A caused the C and you can’t correct A then who cares if you shock C.

It has been pretty clearly established that, in the case of cardiac arrest, unless you suspect airway obstruction as the cause, you start with C. It is one of the very few times that we change the order. Blood spurting from an artery is another reason to start with C. I can add oxygen, after the bleeding is controlled. I cannot add blood, after the airway is opened.

In this case, there was nothing about the patient to suggest that airway needed to be addressed first. After the tube was in, he still did not defibrillate. If the airway were obstructed, and could not be cleared, you would never move beyond A. In that case, you would be correct. Since he did get the tube/airway, that does not seem to apply, here.

2. No student that I know has ever graduated medic school with a grade of 100% at graduation.

Some do, but medic school is a different world from working as a real medic.

How many medics miss no questions on the written NREMT paramedic test?

I think that the NREMT-P test is one of the causes of incompetence in EMS. It is irrelevant to what a paramedic does. The main purpose of the NR seems to be to create the appearance of assessing students, but they avoid the substance.

I’m sure none. So if you graduated with a 92% like I did (I was number two)in my class that was 8% of my textbook that I didn’t learn. There are students that graduate with 80% so that’s 20% of the education they missed.

Remember, the written test has nothing to do with your knowledge of patient care. It is an assessment of your ability to answer often unrealistic multiple choice questions, in a classroom. A much better assessment of knowledge would be to have a version of oral boards. You are required to prove that you understand the material. Of course, that requires having knowledgeable people to ask the right questions and assess the answers correctly. People smart enough to shut up and listen to what the medic student is actually saying, and not read a bunch of what they expect into what the medic student is saying. NR would never accept that – there is the possibility of discrimination. Which clearly demonstrates their incompetence in assessment of ability. They are more worried about discrimination in testing, than about the quality of the medics they allow to treat patients. I have written about NR here and here.

Is that the teachers fault?

In the NR world of No Medic Left Behind, they might agree with you. Their answer might be that you cannot reach 100% for everybody. Their answer might be that you can only do so much. Their answers, while true, truly fail. The NR is all about teach to the test, but not teach the material so the students understand.

So when do you learn the rest? You get your certification, go to work, and hopefully your employeer will make up the remaining difference with a good mentor program and con-ed.

I believe that what makes the difference between a medic and a basic EMT is not any of the skills, but the ability to make the difficult decisions. Should I treat the patient now, and with this treatment, or should I wait. Continuing to assess is often a better choice, but we do not seem to place much value on not doing something. Better to do something – Better to appear to be in control – than to do what appears to be nothing.

Assessment is the one most important skill in EMS, but if you are not providing a treatment, you are seen as not doing anything. You are seen as not helping.

Assessment is a treatment.

Without assessment, all of the other skills are useless. If, for an imaginary example, I am able to intubate 100% of the patients on the first attempt and in less than 15 seconds. In this imaginary example, I am an airway tubing god. Yet, if I do not make good decisions about when to intubate patients, I will be making things worse for some patients. I will end up killing some patients. It is important to be able to intubate well, but it is much more important to be able to assess the need for intubation. Since things change, I need to be continually assessing the need for intubation. I need to be continually assessing for changes in the airway and breathing.

I need to be assessing the appropriateness of the patient’s airway. I need to be considering a bunch of other factors. Should I spend time, here, to intubate? Should I move the patient to the hallway, the ambulance, or the hospital for intubation? I am not an airway god. Nobody gets every tube, at least not if they have been around a while. Sometimes recognizing that the patient has an unstable airway, maintaining it the best that you can, and transporting to a more stable environment, is the right thing to do. Sometimes avoiding intubation, entirely, is the right thing to do. Sometimes RSI of a patient with a well controlled airway, is the right thing to do, because things change.

His system failed him and tossed him under the bus.

That does seem to be the EMS way. We eat our young. EMS isn’t really about the patients. It’s about the cuisine.

I also have a wee rant about assessment here.

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A Radial Pulse Means a Pressure of At Least . . . .

Look at this! My picture on the cover of tomorrow’s British Medical Journal. Maybe they are naming me person of the year. Maybe I’m receiving recognition for writing the blog of the year. Does this mean that I have to start using a lot more of the letter U to make my spelling moure British? Does this mean that when I describe a scene as bloody, I’m being obscene?

While they do not come right out and state it on the cover, I’m sure that I am the focus of attention inside. As Arlo Guthrie was sure that the time missing from the Watergate tapes and the length of Alice’s Restaurant, both being 18 1/2 minutes, was not a coincidence.[1] The focus, on the outside, was a bit too extreme. Where are my eyes? Now, I completely understand Carmen Electra.[2]

I’m just going to be patient about looking inside. If they write too glowingly about me, I’d be embarrassed. I don’t want this to go to my head. Yeah! That’s the ticket.

Anyway, it is time for some more medical mythology. From the apparently endless supply of misinformation taught by those experts in misunderstanding science and medicine.

We’ve almost all been taught that the presence of a radial pulse means that the patient has an SBP (Systolic Blood Pressure) of at least 80, or 90, or something like that. It is a rule of thumb, although these same people will tell you not to take the pulse with your thumb. That would be a thumbless rule and that will be fodder for a different post. I did mention an endless supply, didn’t I?

So, where is the research to support the radial pulse equals SBP of . . . ?

In this study,[3] they refer to some correspondence from 1988 and the 1985 version of ATLS [Advanced Trauma Life Support® (ATLS®)]. With such scant evidence to support this claim, how did it become so commonly taught?

When the topic of assessing blood pressure comes up, I like to cover alternative methods of evaluating perfusion. After all, blood pressure is just a means of evaluating perfusion.

It is an unusual individual, who does not start reciting these numbers, as if they were based on something reliable. Maybe some of that science stuff. Apparently the basis for this is as sound as the basis for the Bogus Hour. So it is not a big surprise that we are dealing with trauma.

Is this a problem in trauma?

Many people use blood pressure to determine when to flush out the little bit of blood the hypotensive patient has remaining. This false assessment paradigm of radial pulse equal to whatever, may actually have worked in the favor of patients, since it leads people to overestimate the blood pressure. If they overestimate the blood pressure, maybe they will hold off on the fluid that the patient does not really need. That, alone may be several posts. So, No. This is not really a problem in trauma.

The basis of this appears to be some old discarded teaching by the ACS (American College of Surgeons). The 1985 version of ATLS, but not any of the later versions. The ACS does nothing, that I can see, to correct their promotion of this myth. Just ignore it an it will go away. Sometimes this works. Spouses, bleeding, . . . . Navigating the ACS web site is not very helpful, either. Many of those commenting were very critical of the authors for using an out of date version of ATLS.

Well, if the ACS is doing such a good job of teaching, why do people still recite this? Some of the rote reciters were not even born in 1985. A little responsibility might be in order. The ACS started a rumor, a completely unfounded rumor, and passed it off as based on medical research. The ACS has some responsibility for making it clear that this is inaccurate, once they believe that it is inaccurate. Silence is not an acceptable means of clarifying things. Silence only perpetuates the myth. This is just a bunch of doctors whining that they are being misunderstood. Let me grab a tissue.

Of course, why they started teaching this silliness, is not explained. Neither is why they stopped teaching it. This is the kind of medicine that leads people to believe that an idiot, like Jenny McCarthy, knows what she is talking about. She doesn’t, but does the ACS? We do not have sufficient information to make that determination, but they seem to have been doing their best to cast doubt on that, at the time of this study.

Other than that, the comments rapid responses[4] are very good. Reading the article, then reading the rapid responses, and the prepublication history of the manuscript, is like a nice seminar in the research process. One extra point is that they keep writing about people being under-resuscitated. I do not believe that is the case. I believe that we over-resuscitate.

What does a pulse indicate?

Perfusion. Perfusion up to, and including, the location of the pulse point.

Nothing else?

That is not unimportant, but it is only conjecture to go beyond that. Other indicators of perfusion are level of consciousness, as a way of assessing cerebral perfusion. Again it involves a lot of conjecture. Is the confused individual confused because of a lack of perfusion, because of any of the AEIOU TIPS[5] conditions, because this is normal for this patient, . . . ?

It is often a good bet that perfusion at the radial artery means good perfusion in all of the areas that matter. However, that does not mean that you should not perform a thorough exam of the patient. If you end up in court, stating that something is often a good bet is probably the legal equivalent of, I never inhaled. This is not a rule, so there are plenty of exceptions. Then there are the half a dozen patients I have had, who were awake, alert, and oriented, but did not have any palpable pulses.

Dot plot showing the distribution of systolic blood pressure according to palpable pulses (group 1: radial, femoral, and carotid pulses present; group 2: femoral and carotid pulses only; group 3: carotid pulse only; group 4: radial, femoral, and carotid pulses absent); shaded areas indicate blood pressures expected according to advanced trauma life support guidelines.[6]

Read the study. It is nice and short. Then read the rapid responses and the prepublication history of the manuscript.

Most important – there needs to be a study to assess this more thoroughly. BMJ lists no other studies citing this study, so this may be the only study ever published on the topic.

In a letter, one unpublished study addressed this. This was one of the 2 citations for the study in footnote [3], the other was the 1985 ATLS text. Here is part of that letter.

Blood pressures ranged from 36 to 89 torr systolic. In only five of the 20 patients did the ATLS guidelines correctly predict the range of patient’s blood pressures. In three cases, the ATLS rules underestimated the actual blood pressure, while in ten, the blood pressure was falsely overestimated. False overestimation of blood pressure was greatest in patients whose blood pressures were the lowest. There were four patients with systolic blood pressures less than or equal to 50 torr (two less than 40 torr); in each of these, the ATLS rules predicted the blood pressure to be more than 70 (more than 80 in three). Of the ten patients whose blood pressures were falsely overestimated, the mean difference between actual and estimated blood pressures (using the midpoint of the predicted range) was 34 torr.[7]

Clearly, there should be some research on this.

Footnotes:

^ 1 “Guthrie later wrote a follow-up recounting how he learned that Richard Nixon had owned a copy of the song, and he jokingly suggested that this explained the famous 18½ minute gap in the Watergate tapes. Guthrie rerecorded his entire debut album for his 1997 CD Alice’s Restaurant also known as Alice’s Restaurant: The Massacree Revisited, on the Rising Son music label, which includes this expanded version.”
Wikipedia – links are from the Wikipedia quote
Alice’s Restaurant Massacree

If I remember correctly, Mr. Guthrie stated that others may disagree with his conclusion, but he prefers his own interpretation. So it is with the BMJ cover and my interpretation. Don’t even try to explain to me that the cover might not be about me.

^ 2 The Simpsons
The Frying Game
Carmen Electra: “Homer my eyes are up here.”
Homer, while staring at her chest: “I’ve made my decision and I’m sticking to it.”

^ 3 Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study.
Deakin CD, Low JL.
BMJ. 2000 Sep 16;321(7262):673-4. No abstract available.
PMID: 10987771 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

Prepublication History of Manuscript

^ 4 Rapid Responses to:
PAPERS:
Charles D Deakin and J Lorraine Low
Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study
BMJ 2000; 321: 673-674
Scroll down from the list to all of the rapid responses printed in line. There are some very good points in these comments.
Apparently Free Full Text

^ 5 Here is a look at the mnemonic AEIOU TIPS (I have repeated several of the words, since there are several ways to use this mnemonic. You may eliminate the ones that are duplicates, that do not help you remember. Endocrine, Insulin, OverDose, UnderDose, and Pharmacy overlap. Infection, Sepsis, and Temperature overlap, too – but they get you to think about similar things differently. That may be helpful.)

A – Alcohol

E – Electrolytes and Encephalopathy and Endocrine

I – Infection and Insulin

O – OverDose and Oxygen

U – Uremia/UTI and Underdose (not taking medications that should be taken)

T – Temperature (Hypo/HyperThermia) and Toxidromes (OverDose) and Trauma

I – Infection and Insulin, again

P – Pharmacy and Psych and Porphyria

S – Sepsis and Space occupying lesion and Stroke and Subarachnoid Bleed and Seizure

^ 6 same source as footnote [3] – Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study.
Deakin CD, Low JL.
BMJ. 2000 Sep 16;321(7262):673-4. No abstract available.
PMID: 10987771 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

^ 7 ATLS paradigm fails.
Poulton TJ.
Ann Emerg Med. 1988 Jan;17(1):107. No abstract available.
PMID: 3337405 [PubMed – indexed for MEDLINE]

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Some Pulse Oximetry Posts

At Ne Obliviscaris there is an excellent post on pulse oximetry – My own pulse ox rant….

My only caution about this is that sometimes a low pulse oximetry reading, with no other apparent assessment findings, does need treatment. Covert hypoxia is a problem that is occasionally encountered. It is the most useful part of the application of the pulse oximeter. I will try to dig up the references on this, but the search terms I have been using are coming up with nothing. One was a study of anesthesiologists at a German helicopter EMS agency, if I recall correctly.

TOTWTYTR also has a great post in The one where he rants about Pulse Oximetry.

Both posts are worth reading. Remember, our job is not to treat the vital signs, but to treat the patient. Since many people seem to view pulse oximetry as a vital sign, they also feel the need to make it pretty. EMS is not about making the vital signs fit our idea of what can safely be ignored. It is not our job to ignore the patient. Ignoring the patient is not patient care.

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How did this happen? – Research

Part of the problem with research is the same as the problem with all prediction. We are not good at it. We remember the things we were right about, but we conveniently forget the things we were wrong about.

Nassim Nicholas Taleb[1] describes part of the problem by reversing the situation. Do not try to predict the future, but try to predict the past. Imagine an ice cube placed on a table and try to imagine the way that it will melt. What will the result look like? The result will be a puddle of water.

Now, don’t imagine the situation as one of predicting the future. Imagine you are faced with a puddle of water like the one from the first example. Now, try to imagine what that puddle came from. Was it an ice cube? Was it condensation from a cold glass? Was it something entirely different that produced this puddle? If it did come from a piece of ice, was it an ice cube, a small ice sculpture containing the same amount of water, did some of the water evaporate before you saw the puddle? Is the substance that forms this apparently clear puddle actually water?

When performing research we need to try to control variables, so that we know as much as possible, what happened at each step of the experiment. If we put an ice cube down on a table, then leave, and come back and see a puddle, do we know that the puddle is the result of the ice cube melting? 

No, we do not. Is it reasonable to assume this? Yes, it is a reasonable thing to assume, but research is not about assuming things that are likely. Research is about controlling for all variables, especially those that can easily be controlled for.

When performing research, we need to control everything that we can reasonably control. If we are going to see what happens to an ice cube, we need to sit and watch the ice cube melt. Or we can record the events, so that we can examine the events later. If we are sitting there, watching the ice cube, and somebody comes along, puts the ice cube in a glass with a lot of other ice, puts the glass in the same spot, and the condensation from the glass forms the puddle, we need to know this. This would completely change our results. 

Is this far fetched? It does seem to be, but how do we know until we perform the experiment? If we assume things because we think we already know what is going to happen, then we are fooling ourselves. We can assume all sorts of things, just because the seem like common sense. That is not research. Anybody claiming that it is research is wrong. Unfortunately, this kind of carelessness is not uncommon in EMS research.

Do we really care about an ice cube? No. At least, I do not. This is just a very simple example of how we can assume things in research that will lead to a result that is worse than worthless. Why worse than worthless? Because the resources that could have been used to perform a valid experiment have now been wasted. Because the patients who have been exposed to the experimental treatment will never know if they might have benefited from the study – and neither does anyone else.

Of course the investigators will claim that they were able to demonstrate all sorts of useful information, but this is only because they are incompetent. We should not encourage them.

Actually, we should punish them.

Let’s look at the biggest problem of EMS research – quality.

All sorts of criteria are examined, when performing EMS research. Rarely examined is the quality of the providers participating in the study. Are they typical for the organization? A large enough study can take care of that. Are the providers in the organization representative of excellent, or even just competent, EMS ability? 

To many people, just asking that question is an insult. This should give you a hint of what the answer is for that organization. If they are not constantly questioning their quality, how do they have any idea?

Just because an EMS organization is questioning their quality, does not mean that they are asking the right questions, but it is a good start.

What should we ask?

Was this result from an EMS organization with aggressive medical oversight? Requirements for OLMC (On Line Medical Command) permission are not an example of aggressive oversight. This would better be compared to the Wizard of Oz pulling all kinds of levers and making loud noises to create an impressive spectacle. A spectacle that does not have any substance and is supposed to disguise the reality. We need to avoid the smoke, the mirrors, the man behind the curtain, and look for real indicators of quality.

What can we look for to indicate that an EMS organization is able to provide the kind of quality oversight that would recommend them as a site for evaluation of trauma triage criteria?

If the question is – Can EMS safely triage trauma patients by physical assessment, rather than by mechanism criteria? – then these are some of the questions we should be asking – 

Do they have feedback from the trauma center about patients transported to the trauma center?

If not why not?

HIPAA does not forbid this. 

Do they have feedback from the local hospital about patients transported to the local hospital? 

If not why not?

Again, there is no HIPAA problem, here. If anybody is claiming HIPAA, they are telling you a lie. 

Is the medical director following up on all of the trauma alerts, potential trauma alerts, mechanism alerts, patients who should have gone to a trauma center (which is a huge can of worms on its own – does an ICU admission mean a sick patient or a clueless ED?), . . . ?

If not why not?

Are there continuing education classes available?

If not why not? 

Are opportunities available to spend time in the trauma center performing assessments?

If not why not?

If you believe that Dr. Scalea is correct, that we should not be frugal when it comes to people’s lives (I do agree with this), then why aren’t we making sure that we have excellent EMS providers taking care of these patients? 

Are only trauma center patients deserving of excellent care?

Are only trauma patients deserving of excellent care?

Medical patients require much more critical judgment by EMS. They will only be flown to Shock Trauma when they also have a trauma complaint. Are they unimportant?

Certainly not.

What about feedback on medical patients?

How many pneumonia patients receive furosemide from EMS?

How many pneumonia patients receive furosemide from the hospital?

All that crackles is not CHF.

CHF should not be treated by EMS with furosemide anyway.

This is another way of finding the organizations that not only should not be participating in research, but should not be participating in EMS. 

But this is not trauma and we are only interested in trauma.

Not true. CHF patients are victims of trauma, too. Medical decision making does not limit itself to trauma, or medical, or IV skills, or intubation skills, or . . . . We need to look at the capabilities of those we seek to use as our example of EMS providers. The mediocre need not apply.

If the assessment skills are not common, we need to improve them, so that they become more common. We cannot throw our arms up and whine about it being impractical. This high quality is demonstrated in some EMS organization. 

High quality is not too expensive. If it is considered too expensive, then the organization should be limited to BLS care only.

Narrative Fallacy –

Narrative Fallacy I

How did this happen? – Research

Narrative Fallacy II

CAST and Narrative Fallacy

C A S T and Narrative Fallacy comment from Shaggy

Some Research Podcasting Comments

Shaggy Comments on Some Research Podcasting Comments.

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

EMS EdUCast – Journal Club 2: Episode 43

Education Problems, Autism, and Vaccines

Footnotes:

[1] The Black Swan: The Impact of the Highly Improbable
By Nassim Nicholas Taleb
A must read book. If you have anything to do with risk management, then uncertainty/randomness/the unexpected are important parts of what you do. He deals with them better than anyone else. Too many misunderstand his writing, perhaps because they cannot abandon their own biases and accept their lack of control of events. While I find his prose to be awkward (perhaps he does not appear to be awkward, when compared to my writing, so maybe it is just me), his conclusions are essential to the understanding of risk management. Risk management people include any of us who treat patients.
Article about The Black Swan.

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