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

- Rogue Medic

Merit Badge Courses: Who Benefits? 1

At EP Monthly, there is an interesting article – Merit Badge Courses: Who Benefits?

I will address this in several parts. First is the quality of the merit badge courses.

Why do we object?
After years of residency training and days of grueling written and oral boards, many EPs find ACLS and BLS to be kindergarten-level courses. The classes address an aspect of clinical practice that we handle on an almost daily basis. When somebody from The Joint Commission asks for your updated ACLS card, but ignores your board certification, it is at very least out of order in importance and frankly insulting to the effort required to obtain the latter. Certainly, ABEM and AAEM agree on this and both organizations have position statements indicating that ACLS or ATLS certification should not be required of board certified Emergency Physicians.

I disagree about the kindergarten-level. That depends on the instructor. If all you are getting is a memorization of guidelines, then it is kindergarten-level, but that is not the way ACLS should be.

That is not the way I have taught ACLS. I certainly did not fit in at every hospital where I taught, but I fit in very well at others. The administrator of the program has a lot to do with that.

If you read much of my blog, you should realize that you would leave my course with more questions than when you arrived at the ACLS class. That is the way it should be. We are faced with guidelines based on expert opinions of inconclusive research, or even based on expert opinion without research.

Anyone who tells you that there are more than a handful of definite answers to be drawn from the research is lying to you. Or they don’t know what they are talking about.

The guidelines are based on thousands of studies.

A lot are animal studies, which are important, but more often than not do not work out as well when applied to real human patients. One of the obvious reasons is that the human patient has a cardiac arrest due to underlying medical conditions, that are not easily recreated in a mouse, pig, or dog. The surrogate arrests we create in animals are no more relevant than the surrogate endpoints that are promoted as answering questions about survival.

A cardiac arrest due to ligation of an otherwise healthy coronary artery in a pig is not the same as a cardiac arrest due to an occlusion of a diseased coronary artery in a human.

The Return Of Spontaneous Circulation (ROSC) is not any better than the animal studies at indicating that a treatment will improve survival to discharge.

Both are necessary intermediate steps in arriving at a treatment that works.

What we know:

1. Chest compressions are important.

2. Fast compressions and deep compressions.

3. Interruptions to compressions are bad.

4. Defibrillation is important.

5. Therapeutic hypothermia also seems to be good.

If I try to tell you that anything more than that is definite, I am telling a lie.

We may even have to revise some of what I have listed as definite.

Revise, not remove.

We may have to revise something, but I don’t think we will have to remove any of it.

Some people will tell you about information that goes well beyond this. They will present it as certain.

They will be either lying, ignorant, or both.

Does epinephrine improve survival to discharge?

We need much larger placebo controlled studies to answer that question. If can’t tell without these extremely large studies to show an effect, then the effect is not large.

Why are we forcing the use of epinephrine?

If we are doing something, we convince ourselves that we are helping.

It is hard to have a bunch of us stand around and just watch someone doing chest compressions, especially if we are trained to give drugs and to do invasive procedures.

We can’t have doctors, nurses, and medics not using their ALS (Advanced Life Support) skills. There has to be something we can do that is better than what a 70 year old spouse can do. There has to be. Something other than those sweaty compressions – that’s what techs are for.

F*&# the research – I’m doing something! Give me an epi!

Look! A pulse! I did it!

If you feel like you are taking a kindergarten course, you should look at the way instructors are taught, hired, and paid.

Most of the ACLS teaching I have done has been for less per hour than what I would make working as a paramedic. Not only that, but it is for fewer hours. Never mind overtime, this is less than straight time. This is great for a single parent, which is a big part of why I did so much teaching, but it is not a way to get people who are not limited by daycare hours (or school hours). If I am making less per hour as a medic, what incentive is there for someone who makes more than a medic?

How many residents are mandated to teach ACLS as part of their program requirements? How many of them are any good at teaching in a classroom? If you want a kindergarten environment, put a mandated resident, with no interest in teaching, in front of a class with a PowerPoint. Ativan does more for your memory.


Too Much Information and Risk Management

Steve Whitehead discusses the problem of Too Much Information the problem of people avoiding learning by claiming that they are being presented with Too Much Information.

He gives 3 examples:

1) We like to keep the bar low.

2) We fear the limitless and undefined.

3) We are inherently insecure.

These are all genuine problems.

I do not want to be treated by someone who embodies these three problems.

I know too many people who do make these mistakes and they are scary.

The people, who complain about Too Much Information, let’s call them TMIs, for the purposes of this post.

If the topic were TMI‘s favorite team, he would hardly be complaining that there is Too Much Information.

If the topic were TMI‘s favorite centerfold, he would hardly be complaining that there is Too Much Information.

The problem seems to be that TMI doesn’t care enough to obtain more information. Why have such a person in a job that involves caring.

A different problem with Too Much Information is in the ability to prioritize that information. This is not deciding that there is Too Much Information, rather determining how much information is important right now.

When we are on scene with a stable patient, how much information do we obtain before transport? What if the only source of the information is a family member – someone who cannot accompany the patient?

How much is too little information?

How much is enough information?

How much is too much information?

Are there other ways of obtaining the information? Can a nurse call from the hospital to gather more information after the patient is in the ED (Emergency Department)? How long do we delay transport to obtain more information?

Part of this can be dealt with by asking questions in a way to best obtain the most relevant information. However, we don’t always know what that way is. Which of the patient’s chronic illnesses – each with repeated complications that end with ED admissions – which of these do we not obtain a thorough history about with this stable patient?

We can come up with all sorts of BS excuses for not obtaining information, such as the need to get back in service quickly, but should we do an incompetent job just to keep to some imaginary schedule?

What about when we are on scene with an unstable patient? A lot of the information we would like is only available on scene. What do we do?

How much is too little information?

How much is enough information?

How much is too much information?

Since the patient is unstable, the option of camping out until we have all of the information we would like, is not one that will lead to the survival of the patient. We need to make certain decisions about how much is enough information right now.

What will a TMI do in that situation?

How would a TMI possibly understand?

TMIs are not understanding people.

TMIs are the people who should be working at jobs that do not require any decision making skill or any understanding of risk management, because TMIs are dangerous when permitted these responsibilities.

On what do TMIs base their decisions, if they have intentionally limited their preparation for the job?

Risk management has a lot to do with making decisions based on limited information.

Risk management requires an understanding of what is enough information given the limitations of the job.

Risk management for EMS involves working with limited equipment. limited personnel, and limited information.

Risk management for EMS cannot work with arbitrary traditional restrictions on the ability to exercise critical judgment, not if we are interested in doing what is best for the patient.

Some of us believe in luck.

Some of us pray to luck.

I prefer to make my own luck.

How do we make our own luck?

We don’t just prepare, we over-prepare.

That is luck?

No. That is preparation. That is having more than the lowest common denominator amount of information.

We do not know what we will be presented with on each call, so how do we know which information we will not need? How would we know, ahead of time, what is not necessary – what is too much?

Some people like using the 5 Ps to describe how to approach this.

Proper Planning Prevents Poor Performance.

Some extend it to 6 Ps.

Proper Planning Prevents Piss Poor Performance.

Either way, you get the idea. This is completely incompatible with claiming, Oh no. That is Too Much Information.

How do we know which information we will not need?

We don’t.

Only a fool would believe that he is smart enough to know what information he does not need, when he is still learning. Because of this prejudice, some never learn.

The problem seems to be that TMI doesn’t care enough to obtain more information. Why have such a person in a job that involves caring.

How do we know what we need to know?

Can someone, especially someone who intentionally limits the information he has, ever know?

From the quotes I have in the sidebar –

In the fields of observation chance favors only the prepared mind. – Louis Pasteur.

What these TMIs are saying is that they are too good to prepare to take care of patients, because the patients are not important to the TMIs.

EMS is not about the First Responder.

EMS is not about the EMT.

EMS is not about the Medic.

EMS is not about the Nurse.

EMS is not about the Doctor.

EMS is about the patient.

Competent EMS personnel insist on being prepared with more than enough information, in order to be best prepared for as much as is practical.


More on Drug Calculations

I am making a pun at my own expense. Not More on Drug Calculations, but Moron Drug Calculations.

And I am the moron.

In my last post, Current Drug Shortages, I was pointing out ridiculing concerns about the use of 1:1,000 epinephrine IV, since it should never be given through an IV to a live patient, except as a drip. This is true. It is not considered wrong by the FDA (Food and Drug Administration), but that is something the FDA should change.

The problem is with my calculation of the drip rate. I wrote, not just once, that putting 1 mg of epinephrine in 250 ml NS (Normal Saline) would produce a concentration of 4 mg/ml.

I hope that everybody reading this has noticed the mistake I made. You don’t need to be a math whiz to be able to figure out that when you dilute 1 mg/ml by adding 250 ml, you do not get a more concentrated solution. Dilution produces a less concentrated solution.

If the same mistake were being made by a student in an ACLS (Advanced Cardiac Life Support) class, and this mistake has been made plenty of times, I would ask the student some questions, because many of these mistakes cannot be made with the supplies that are in a crash cart or EMS drug bag.

For example, plenty of students have stated that they would give one gram of epinephrine. I have never seen a crash cart or EMS drug bag with even 100 mg of epinephrine. You have to do some restocking to get that much. In the hospital, that means somebody running to the pharmacy to get 1,000 mg. If they state 1:10,000, that means 10 liters, and it is unlikely that the pharmacy carries epinephrine in 1:10,000 concentration in liter containers. 1,000 preloaded syringes of 1:10,000 epinephrine may be more than is available in the pharmacy. Anyway, once I state, A coworker points out that we do not have enough epinephrine to give 1 gram of 1:10,000 epinephrine, the student usually realizes the mistake and corrects the mistake without any further need for hint or for explanation.

I have seen several instructors immediately state that the student killed the patient. I don’t know what kind of dream world these instructors live in, but it appears to be a sadistic one with no grasp on the reality. If the student does not have the capability to actually give 1 gram of epinephrine, then how can the student kill the patient with 1 gram of epinephrine?

I hear the excuse that the student has to learn somehow. This suggests that pointing out the drug calculation is not embarrassing enough to make it memorable. This suggests that a petty and unrealistic comment by an instructor is in some way an example of great teaching. It is not.

However, what I did was much worse than a student making a simple mistake in a stressful moment – a mistake that could not lead to the administration of the wrong dose to the patient. Well, JCAHO might try to make it possible, just so they can penalize people for this.

What I did was tell people that this impossible concentration is the correct concentration.

This is going to mislead and confuse people. It will get others to laugh at me. I should be decreasing confusion, not contributing to confusion. I do not have the same excuse as a student being tested in an ACLS class. I had plenty of time to check everything and in the unreality of the internet anything is possible, right up until it is tried in the real world.

There is one other problem with the drug concentration of 4 mg/ml.

The concentration of 1:10,000 epinephrine is 0.1 mg/ml. I cannot create a concentration of 4 mg/ml, unless I add even more concentrated epinephrine to this 0.1 mg/ml concentration. 4 mg/ml is 40 times more concentrated than 1:10,000 epinephrine.

If you do not understand this, assume that you add 1,000 mg epinephrine to 250 ml NS, you get 4 mg/ml. That works, but only as long as you do not consider the amount of solution that is already included with the epinephrine. For 1:10,000 that means 10 liters of solution with the 1,000 mg, so you do not end up with 4 grams/250 ml or 4 mg/ml. You end up with 1 gram in 10,250 ml or 97.6 mcg (MICROgrams)/ml. Ordinary 1:10,000 epinephrine is 100 mcg/ml (0.1 mg/ml or 100 mcg/ml – not significantly different from what we end up with).

The concentration of 1:1,000 epinephrine is 1 mg/ml. The same concentration problem exists, except that 4 mg/ml is only 4 times more concentrated than 1:1,000 epinephrine.

For 1:1,000, assume that you add 1,000 mg epinephrine to 250 ml NS and you get 4 mg/ml. For 1:1,000 that means 1 liter of solution with the 1,000 mg, so you do not end up with 4 grams/250 ml or 4 mg/ml. You end up with 1 gram in 1,250 ml or 800 mcg (MICROgrams)/ml. Ordinary 1:1,000 epinephrine is 1,000 mcg/ml (1 mg/ml or 1,000 mcg/ml – there is a more significant difference between 800 mcg/ml [0.8 mg/ml] and 1,000 mcg/ml [1 mg/ml]).

Either way, I was suggesting something that is impossible with standard concentrations of epinephrine. It was suggested to me that I was trying to engage in a bit of homeopathy, by pretending that dilution leads to greater strength. 🙁

Dilution does not lead to greater strength.

This is probably the reason that I made this mistake, other than just not thinking, and I wasn’t thinking. We learn the lidocaine clock for calculating concentrations of drips that we use in EMS. Lidocaine commonly comes in a package of 100 mg/10ml for IV push in cardiac arrest. It doesn’t improve outcomes, but that is a different discussion. If you add 100 mg/10ml lidocaine to 250 ml NS, you end up with 100 mg in 260 ml or 3.85 mg/ml. This should also be rounded off to 4 mg/ml, even though it is a much bigger difference from the 4 mg/ml. The reason is that both are not significant differences.

Mixing 1 in 250 will give you a 4/1,000 concentration. Since we can move the decimal (by changing the prefix) to give a 4/1 concentration we need to remember to make sure we are still dealing with the right amounts when we have completed our calculations. Any time we end up with numbers that seem as if they require a lot of drug, or very little drug, we need to consider the possibility, even the likelihood, that we made a decimal point (prefix) error.

Thank you to Matt J for pointing out my huge mistake. I will correct it on the original post, too.


Education and Capturing the Interest of Students

Here is an important video about the necessity of capturing the imagination of children at a young age for science education. Without scientific literacy, what future do we have? Dr. Tyson is a great speaker and shows the importance of putting things in perspective. Less than 5 minutes.

The half a penny on a dollar is a reference to the budget of NASA being only one half of one percent of the federal budget. This is not to say that we should not critically examine anything that is only a half of a percent of the budget, but to say look at how much we get for so little. We should also not ignore NASA’s tiny sibling, DARPA (Defense Advanced Research Projects Agency).

In EMS, our problem seems to be that we capture the imagination of the children who never grow up. We need to get them to understand, as they grow up, that it is about much more than just the noise and the toys.

In a similar vein, Dr. Tyson presents a view of the role of politics in science. Not what most people might expect.

h/t Bad Astronomy.


Education Problems, Autism, and Vaccines

Monday I wrote about the problems that can result from national standards. We do need to raise our education standards. An excellent example can be seen in the faulty logic used by those claiming that vaccines cause autism.

Hypothesis: Vaccines cause autism.

Experiment: Compare the rate of autism in groups with differences in vaccination methods. There are many ways this can be done, depending on the way the vaccine is hypothesized to cause autism.

However, the people claiming that vaccines cause autism do not accept the research that has been done. They claim that it is obvious that vaccines are dangerous and no amount of science will change their minds.

Vaccines contain thimerosal. Thimerosal is mercury. Mercury causes brain damage. The brain damage caused by mercury is exactly the same as autism. Mercury is one of the most toxic substances on the planet, so we have to stop poisoning children with it.

Clearly, this is a problem. We have a substance so dangerous that it must produce close to 100% brain damage. It is good that these public spirited people have raised this alarm.


Using faulty logic, we can prove almost anything. Here is one example.

Zeno’s paradoxes provide several. Here is just one.

In a race, the quickest runner can never overtake the slowest, since the pursuer must first reach the point whence the pursued started, so that the slower must always hold a lead.[1]

Once the pursuer reaches the spot where the slower runner was, the process repeats infinitely. Since distances can be made ever smaller – there is no distance so infinitesimal, that is not made up of an infinite number of even smaller infinitesimal distances. Therefore, the faster runner can never catch up to a slower runner, who has just a tiny head start.

Using a different paradox, Zeno proves that the runner cannot even first reach the point whence the pursued started.

That which is in locomotion must arrive at the half-way stage before it arrives at the goal.[2]

The same endlessly repeating problem of infinitely divisible space is the explanation.

However, we know that these are not impossibilities. It is only by proposing an explanation that sounds reasonable, that these become confusing.

The way we find out the truth is simple. We test the claim.

Anyone capable of walking can walk across a room. There is no need to break the motion up into smaller and smaller parts. The motion is continuous.

Similarly, the problem of thimerosal only appears insurmountable. The only way to determine the accuracy of the claim is to test it.

The single study, that has supported any connection between thimerosal and autism, had such fatal flaws that it was retracted by the journal that published it. In 2004, most of the authors of the study had their names removed from the study, when they became aware of the fraud involved. The study was funded by lawyers hoping to win a big settlement from drug companies. All the lawyers needed was a study that showed this connection. About half a million dollars later, Andrew Wakefield was able to produce just such a study.

One problem with the explanation that thimerosal is such a toxic substance is that the occurrence of autism is supposed to happen so quickly after the vaccination, that the connection is inescapable. Some parents describe the onset of autism symptoms resembling somebody turning off a switch.

This study investigated if the discontinuation of thimerosal-containing vaccines paralleled a decrease in the occurrence of autism. The incidence of autism remained fairly constant during the period of use of thimerosal in Denmark, and the rise in incidence beginning in 1991 continued even in the group of children born after the discontinuation of thimerosal. The amount of thimerosal used in vaccines changed during the study period with less amount of thimerosal administered in the period 1970–1992. Moreover, the thimerosal-containing vaccine was gradually phased out meaning that the incidence rates should decline gradually if thimerosal has any impact on the development of autism. However, an increase (rather than a decrease) in the incidence rates of autism was observed.[3]

So much for throwing a switch.

Using the logic of the anti-vaccinationists, this must be evidence that thimerosal protects against autism.

There are many reasons for using this chart. The chart is from the same study as the paragraph that is above it, so it was handy. It is dramatic. It makes it easy to see that there is no connection between when thimerosal was in the vaccines (up until the vertical line) and autism (begins to increase just as the thimerosal is removed). There are other studies that show the same information. The evidence is clear.

There is no reason to believe that vaccines cause autism.

Then there is the comment that is supposed to silence disagreement. If you don’t have an autistic child, you cannot understand anything about autism. Unless you agree with the anti-vaccinationists. It doesn’t matter if you know what you are talking about, if you agree with them.

Therefore, if I want to know what is the best treatment for something, I should ignore doctors and ask a parent of a child with the condition. Using this logic, the most knowledgeable parent would be one with a child sick for the longest time with that disease. If being a parent of a sick child confers expertise, then the longer that illness continues, the greater the expertise conferred by this faulty logic.

If my child is sick, I am not going to look for parents with the same condition. These parents may have a lot of useful information about many things. However, the abilities to understand assessment, diagnosis, and treatment are not infections transmitted from the children to the parents.

The doctor to go to is also not the one treating children who do not get better. The anti-vaccinationists might conclude that the greatest expert is a parent who had at least one child die from the illness. They are persuaded by emotion, not reason.

There is a further problem with, I refuse to listen to anyone who does not have an autistic child. These parents even ostracize other parents of autistic children unless those parents agree with the emotional claims of the anti-vaccinationists about thimerosal. Catch-22 has nothing on them.

What about the mercury?

Thimerosal is C9H9HgNaO2S or sodium ethylmercurithiosalicylate. Mercury is Hg. Thimerosal is not mercury, but a compound that contains mercury. Being in a compound changes the characteristics and the effects of elements.

An example that people in EMS should understand is chlorine (Cl). This is so toxic, that it was used as a poison gas. Mix it with sodium (Na), which is also extremely toxic, and you have sodium chloride. Sodium chloride (NaCl) is known as common table salt. Sodium chloride is also the ingredient in normal saline, which we inject into the veins of just about every patient with a serious medical condition.

According to the anti-vaccinationists, No amount of mercury is safe. Based on what? Using the same criteria (Because I say so!), no amount of sodium or chlorine would be safe in the body. After all, they are toxic.*

The video below is less than 10 minutes long, but does a great job of explaining ways in which science keeps us from attributing too much to anecdotes, such as this. He was a normal little boy, until he received the vaccine. Autism is diagnosed at the time that children receive vaccinations. This is true, even for children who do not receive vaccinations. Since the vaccines do not cause autism, the only thing avoiding vaccination does is to endanger children.

The explanations that sound good, but are not supported by research are examples of narrative fallacy. I have written more than a little bit about narrative fallacy, because it is important. Using this devotion to reasonable sounding explanations, even though research demonstrates that these explanations are wrong, is a problem. Fortunately, in medicine there is more of an understanding of science. If that were not the case, we might be still bleeding patients to get rid of bad humors.

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


^ * This does ignore the obvious problem that both hyponatremia and hypocalcemia are fatal conditions, even though sodium and calcium are toxic. If only there were some kind of medical expert to explain cutting edge toxicology. Somebody like Paracelsus.

^ 1 Zeno’s paradoxes
Achilles and the tortoise

^ 2 Zeno’s paradoxes
The dichotomy paradox

^ 3 Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data.
Madsen KM, Lauritsen MB, Pedersen CB, Thorsen P, Plesner AM, Andersen PH, Mortensen PB.
Pediatrics. 2003 Sep;112(3 Pt 1):604-6.
PMID: 12949291 [PubMed – indexed for MEDLINE]

Pediatrics has the free full text and free PDF available at their site.
Free Full Text                 Free PDF


National Standards for Education

In today’s news there is a story about mandatory voluntary national standards for education. These are not EMS standards/protocols, but the issues are not significantly different. I will specifically address EMS standards/protocols in other posts, but the parallels should be pretty clear.

The Patrick administration will not adopt national academic standards if they are lower than those established in Massachusetts, long championed as having among the most rigorous expectations, according to the state’s education secretary.[1]

That is a sensible response, but maybe we need to consider it from the opposite direction. Is any other response sensible?

There is an advantage to being able to move from state to state and have a child transfer directly into the same grade. As a parent, I have moved across state lines several times. In my case, this advantage would have been minimal. The advantage does not seem to justify a national standard, unless that national standard produces very little harm in its unintended consequences.

“We are trying to sound the alarm,’’ said Jim Stergios, the institute’s (The Pioneer Institute, a conservative-leaning public policy research organization in Boston) executive director. “Massachusetts has the highest standards in the nation. Why would you want to change course?’’[1]

That is the big problem with the idea of national standards. National standards seem to place more value on uniformity, than on quality.

As with EMS, there are plenty of advantages to national standards. There is a big drawback when statewide standards, or nationwide standards, are proposed. Promises of benefits are the focus, but when the everybody standards are enacted, a mindless devotion to uniformity replaces many of the benefits.

Rather than have the standards raise up the places with lower quality, there is a backpedaling on raising the standards. The new goal is to prevent the standards from becoming a hardship for those who might benefit the most from standards.

The result is often a set of standards that makes improvement for the places of low quality optional. After all, it would somehow be elitist to insist that poor educators significantly improve their quality.

Here is an important point on standards from the article.

While adopting the standards would be voluntary, the Obama administration has said that it intends to withhold millions of dollars in grants for low-income students in states that refuse to join the effort — regardless of the quality of their existing standards.[1]

We’re here to offer you some protection. There are some dangerous people in the neighborhood. We would really hate to see anything bad happen to your nice store. Of course, this is completely voluntary.

What kind of miscreant would possibly decline an offer to join the effort?

Or decline to volunteer?

I avoid the left wing/right wing political parties because I could hurt myself from laughing too hard. This is just another example. The left wing trying to improve schools by cutting off funding for low-income students. Are they trying to put The Onion out of business?

You will lower your standards, so that you are just like all of the other states. Otherwise we will deprive you of your share of education funding for low income students. We will cut your budget until you lower your standards. Of course, this is completely voluntary.

The administration also says states that embrace the standards will have a better chance of receiving potentially hundreds of millions of dollars in its “Race to the Top’’ competition, which rewards education innovation. Massachusetts has applied for $250 million from that program.[1]

A quarter of a billion dollars of bribery incentive. This does not even include the grants for low-income students being threatened redistributed to more worthy causes. Causes more worthy than keeping the poorest children from growing up too ignorant for anything more than jobs as political appointees.

Of course, it would be ignorant, vulgar, and completely unfair to label these tactics as anything other than helpful.

One member — Sandra Stotsky, a former associate education commissioner who oversaw the development of the state’s standards — ridiculed the national benchmarks, saying they rely too heavily on broad “empty skills’’ and lack rich academic content at each grade level.[1]

Empty skills. As in skills testing devoid of any context? It is as if she is referring to the National Registry of EMTs examination. If uniformity were the quintessence of education, NR would produce excellent beginner medics, since NR places uniformity above all else.

It is unclear whether states would have to adopt the national standards word for word or whether they could augment them with existing ones so long as the state standards were higher. Adopting new standards is unappealing in lean economic times because it can require the wholesale replacement of textbooks and additional training for teachers.[1]

Don’t worry. These will always be flexible standards. We would never change a policy after everyone is committed to using this standard.

Trust us.

We’re from the government.

We’re here to help.

Trust us.

Then there are the educators, the ones supposed to be familiar with reading comprehension. Such a person is Glenn Koocher, executive director of the Massachusetts Association of School Committees. Maybe not an educator, but a spokesperson for administrators of educators?

“The rest of the nation will finally march to the same beat as Massachusetts,’’ Koocher said.[1]

Inflexible standards will force everyone to march to the same beat, but it is unlikely to be the same beat that Massachusetts is currently marching to. All A is B may not be the same as All B is A.

If the standards are completely inflexible, it is not clear that Massachusetts will agree to the offer to voluntarily use the national standards. That offer is beneficent, and clearly without the possibility of any ulterior motive. Depending on how much Massachusetts has come to rely on these federal grants might profit from the generosity of those redirecting low-income education funds, Massachusetts may feel compelled to cooperate with these voluntary tactics.

Glenn Koocher may not be rejoicing once Massachusetts is marching to the same beat as the rest of the nation. Glenn Koocher may even develop a better understanding of syllogism, although I wouldn’t count on it.

Metaphor-wise,Huh? Harrison Bergeron[2] is essential to any discussion of standards that are potential ceilings.


^ 1 State firm on school quality. Will reject US standards if they don’t measure up.
By James Vaznis
Globe Staff / March 15, 2010
The Boston Globe
Page 1
Page 2

^ 2 Harrison Bergeron
Harrison Bergeron is a short and excellent story in the collection Welcome to the Monkey House by Kurt Vonnegut. It has been turned into a film, but the story is much better in print. This is one story that should be mandatory reading in all schools. Kurt Vonnegut has created perhaps the most horrifying, most banal dystopia.

^ Huh? The Apartment
I blame Billy Wilder (and/or I. A. L. Diamond) for this not-so-new neologism method.
1, 2, 3 and 4, 5, 6 and 7 and 8.


Shaggy Comments on Some Research Podcasting Comments

In the comments to Some Research Podcasting Comments, Shaggy wrote,

I am beginning to think our definition of “why” in the educational arena is not the same. If it is, I will just conclude that either one of us is off our rocker. Explaining the importance of a certain treatment modality as well as anything else is considered very important as motivational.

Perhaps that is part of the problem with attaching questionable explanations to the results of research that was not designed to answer these questions.

Should we be more concerned with motivation, than with accuracy?

I could come up with many possible explanations for why something is happening. I would rather say, I don’t know.

Science is much better at showing what does not work, than what does work.

Science is much better at showing what does work, than at explaining why something works.

This was very important when I did occupational safety and health training for the Safety Council in Pa. as the “why” was part of Bloom’s three types of learning, and fell under the affective nicely. Why should you wear PPE?

Because people who do not wear PPE (Personal Protective Equipment) are over-represented in the morbidity and mortality statistics.

Why are safe work practices important?

Because going home to one’s family is more likely, when one follows these safe work practices.

Why is quick and continuous CPR necessary?

Research shows that without quick and continuous CPR, the resuscitation rate is significantly lower.

Maybe it is due to direct compression of the heart. Maybe it is due to increased intrathoracic pressure. Maybe it is due to a rebound effect after compressing the chest. Maybe it is due to some combination of these mechanisms. Maybe it is due to some other mechanism. Maybe it is due to a combination of some other mechanism and one or more of these mechanisms.

What do we need to know?

We need to know that quick and continuous CPR does work.

We do not need to make up stories that will likely be, at best significantly modified, and at worst completely discarded. Do we need to make up these stories just to motivate people to provide good treatment?

Maybe we will know what the mechanism is in a decade. Maybe in two decades. Right now, I think we are just spinning fairy tales to impress others with how smart we think we are. Or has there been research that conclusively shows the complete mechanism for CPR?

Regardless, the important point is that quick and continuous CPR works. How quick and continuous CPR works is not important in deciding whether we should provide quick and continuous CPR.

If you think these questions shouldn’t be answered, I may tend to think you finally went off the ledge.

How did I get on the ledge?

Why was I on the ledge?

How can I know if I fell off the ledge, if I don’t know the answers to the mechanism of my arriving on the ledge?

Then there is the question of whether I was actually on the ledge at all. Last thing I remember, I was nailed to a perch. Nice fish, the perch.

Maybe I just wasn’t motivated to stay on the ledge.

If you think we are talking about two different things, then perhaps you need to clarify for the intellectually challenged like myself.

I think we are talking about the same thing.

I think that we disagree.

On the other hand, I am confident that almost everyone agrees with you.

We need to become much more comfortable with uncertainty.

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


Some Research Podcasting Comments

This Eve of Christmas Eve both EMS Garage and EMS EduCast.

I Hate People: EMS Garage Episode 67, which is really much more cheerful than it sounds – and it comes with beer recommendations. One warning is that everybody seemed to be having connection problems, so we couldn’t always hear each other. this led to people talking over each other more than usual and pauses, where nobody is talking since they think someone else is still talking. these problems are minor, but do pop up occasionally. Steve Whitehead of The EMT Spot even brings a surreal dimension to the show with mime podcasting.


Understanding EMS Research: Episode 42, which may have helped to provide some understanding of research. The problem is that there is far too much to the topic to be covered in one episode. This was expected to be a brief, year end episode. A brief episode? With me on it? What were they thinking?

The other problem is believing that research can be covered effectively and briefly.

A couple of points. I point out that I think that we should start EMS education with research. Only after the students understand research, should we move on to assessment and treatment.

The big disagreement was when we were discussing some of the old discarded EMS myths, which unfortunately have not been discarded everywhere. The old rule of thumb about what pressure is indicated by what pulses, that I wrote about in A Radial Pulse Means a Pressure of At Least . . . ., where I describe the research from the BMJ from 2000[1] (not 2001 as I stated on the show). There was a bit of discussion of this and somebody mentioned relying on heart rate as an indicator of blood loss. I pointed out that beta blockers and abdominal trauma are two of the confounders of this approach.

The abdominal trauma is something that I will have to do a post on, and I do not have the studies in front of me, but there have been several papers written about surgical patients losing significant amounts of blood, but not becoming tachycardic to indicate the blood loss. Some abdominal surgery patients even became bradycardic with significant blood loss. this is an important problem, because relying on heart rate alone would did cause the continuing uncontrolled bleeding in some of these patients to be missed.

This is something important that we need to be aware of. There are many things that may mislead us in our assessments. The more that we are aware of these confounders, the less likely we are to miss a significant problem. While part of the debate was about whether this happens in the majority of abdominal trauma (it probably does not), this approach is completely irrelevant to developing an awareness of a potentially significant problem. We stress over spinal cord injuries, while the incidence of spinal cord injuries is probably much lower than the incidence of exsanguination due to abdominal trauma that is unrecognized because there is no significant rise in heart rate. The outcome may be more likely to be fatal, as well.

Anyway, my biggest disagreement was when somebody started, based on less information than I already wrote, to try to figure out why this is happening. This is a bad idea.

Why is not important!

When we started to discuss this, that this may be due to vagal stimulus, someone stated that this is just a hypothesis for a study. I don’t have any problem with using that as the hypothesis for a study, but we were not designing a study. We were providing information for educators to use to teach students.

This is exactly where medical myths come from.

The students do not need to know why something works, only that it may work. To suggest anything more than that is suggesting that we know a lot more than we do know.

It is important to know as much about the limitations of our assessments.

It is not important to know why, until after we have a lot of information to support that idea.

Look at where the EMS myths started from. Somebody started explaining why something was happening, or maybe they were only wondering about the cause. Educators got a hold of the idea, and rather than say, I don’t know why, some gave an explanation that was repeated enough to become a myth. A myth that is almost impossible to get rid of, because people want certainty.

Certainty is nice, but it is a problem.

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

When we start taking explanations for granted, we find that somebody read too much into an observation, or a bunch of observations, or read too much into a study, or a bunch of studies.

This is the same thing that leads the general public to distrust science. We have research that provides limited information, but somebody decides to explain that limited information. If you want to bet on something that is almost a sure thing, here is what you should do.

Bet that the explanation is wrong.

This does not mean that the science was bad, or that the science was wrong, or that the study was not done well, et cetera. It means that somebody took a look at some science and decided to create some fiction, because they assume that they know what they are doing.

The safe bet certain bet is that the explanation is wrong.

The certainty in science and medicine is that our explanations will be wrong. These erroneous explanations will create distrust of science and medicine. these will not be the fault of the researchers, but of those explaining the research.

When we create explanations, we create a narrative – a story. We should start out with, Once upon a time . . . , or something similar, but we don’t. I have discussed this problem with narrative fallacy further in the links listed below. I will write about this more, because this is important.

I do not mean to put down anyone on the show. This is a problem that is almost universal. One of the reasons that it is so common, is that it is natural for us to explain things with stories. When life was simpler, that may have been effective. When the life of someone else is in our hands, we need to be better than that.

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


[1] 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]

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