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

- Rogue Medic

What Can We Expect in the Upcoming Year?

Over the last several years, it has been more common to make excuses for ignoring high-quality evidence, while celebrating the low-quality evidence as if low-quality were desirable, because the evidence that reinforced prejudices was low-quality. We had to either admit that we were wrong or behave irrationally.

For many, the choice to abandon quality and reason was easy. The reward was immediate and was reinforced by people who were selling us those bad ideas. What could possible go wrong?

The answer to that question may be painful for some of the people selling immediate gratification.

Who would have thought that a corrupt dictator would be surrounded by similarly corrupt people, who are supported by other similarly corrupt people? That’s never happened before. When attempts to isolate a country for invasion fail and the military has to fight people defending their homes, that your dream army’s erosion by corruption becomes inescapable. Reality is looking as if it will provide abundant evidence of the effects of corruption to a lot of people who have been benefiting from corruption.

A lot of people have died and more will die before that happens, so that’s not really a Happy New Year, but it should reinforce that reality doesn’t care what we believe. It is a better new year.

Some people seem to never learn, no matter the amount and/or quality of the evidence.

The extreme rejection of evidence and rejection of rationality result in a former comedian (Volodymyr Zelenskyy) to exposing the corruption of a dictator (Putin), who has surrendered a lot of his country’s ability to corrupt influence other countries.

Putin’s actions are not funny. The actions of the science deniers (not ironically, often promoted by the Kremlin) are also not funny. Reasoning with the killers has not worked, but mocking them may help to encourage people to be more reasonable.


Management Killed the Patient, But the Nurse is Prosecuted as a Criminal

I wrote about this in 2019 and the only thing that has changed is that the prosecution continues. Is the title misleading? No.

The management of Vanderbilt University Medical Center created the system that killed the patient and the Nashville District Attorney’s Office is an accomplice after the fact.

Yes, the nurse, RaDonda Vaught, is was dangerous as a nurse, but that was fixed by taking away the license to work as a nurse. That doesn’t come close to bringing back the patient killed, but the patient was killed by a system that teaches incompetence. Vanderbilt University Medical Center, which should have prevented this death, rather than causing this death.

This is an example of the Dunning-Kruger effect being promoted by the hospital management. The management put a nurse, who does not know enough to safely administer sedation, in the position of teaching new nurses to sedate patients without monitoring the patients and to leave the patients in the care of people possibly even less qualified to monitor sedated patients.

How can anyone be less qualified than a nurse who killed a patient?

It may not be part of the training of the radiology technician to recognize and address (by calling for help, at a minimum) excessive sedation, so less qualified. On the other hand, the technician is working for the same hospital that put the dangerous nurse in the position of training other nurses to be dangerous.

The hospital management is telling patients that they have hired competent people, that the management values the lives of patients, and that the management is taking reasonable steps to provide the best care to patients, but the management is lying.

Accidents do happen, which is why there are rules for the administration of sedatives to protect patients.

Vanderbilt University Medical Center has repeatedly declined to comment on Vaught’s trial or its procedures.

Just as the nurse administered the wrong drug, and did not monitor the patient appropriately even for the drug that was supposed to be given, the Nashville District Attorney’s Office is prosecuting the wrong killer. If anyone should be prosecuted, it should be the people responsible – the management of Vanderbilt University Medical Center.

However, prosecuting doctors, PAs, NPs, nurses, paramedics, technicians, … for medical errors is the kind of abuse of power that harms patients. When medical professionals cannot report medical errors, without fear of being charged with crimes, more patients will die, because the errors will be covered up.

The Nashville District Attorney’s Office is telling medical professionals to cover up errors. If medical professionals do not report errors, we do not learn to avoid errors. We learn to hide errors.


Forcing Nurses Out of Nursing to “Save Money”

There are laws being proposed, and some have passed, to limit the pay for nurses, because the legislators assume that nurses are overpaid. The problem is that healthcare is expensive and that nurses are not treated well by employers – most of whom do not seem to be capable of providing the care that nurses provide.

Who has created this problem? It isn’t the nurses, who are overworked, underpaid, and abused by some of their patients.

But a nurse makes more than a paramedic, so they shouldn’t complain! A nurse generally has more education and more responsibility than a paramedic, so why shouldn’t a nurse make more? Before the pandemic, I told people not to go into EMS, because there are few options in what you do for work and the standards are low.

A quick way of eliminating people, while claiming to be making things better, is to put a pay cap on the people actually doing the work. But which people do we lose with a pay cap?

With a pay cap, we lose the people who hit the pay cap, which means the highest paid people. If pay is supposed to have something to do with ability, we will lose the best employees first – and it is not likely to stop with just a few people, because this is a system that has been failing for a long time.

The increased demands of the pandemic and the attacks from the people who demand that doctors, nurses, paramedics, EMTs, … put up with abuse from the least educated, because of the “Freedom” of the least intelligent, there are not many reasons to stay. We keep telling the best nurses, that it is time to find some other way to make a living, because we don’t want competence – we only want compliance.

The way to make healthcare better is not to cap the pay of the people who do the work.

Why aren’t we limiting at the pay of the people who run things and did a lot to get us into this mess?

If we want to decrease the number of people in beds in the hospitals, we should promote vaccination, masking, and social distancing. The corruption of some politicians, partying without masks, is not a reason to avoid wearing masks, but a reason to enforce the rules without exceptions for the politically powerful.

COVID-19 has killed millions with the help of the anti-vaxers and the anti-maskers. We shouldn’t be part of the group sickening/killing our neighbors, our families, or ourselves.

Vaccines and masks are safe and effective and save lives, if we are smart enough to use them.


Flipping the Patient the Bird

There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.


Use the gadget with the flashing light.


Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.


The NNT and Merit Badge Meds

Perhaps I am too negative in my interpretation of the research on ACLS medications. What about a more objective assessment – one with a more statistical view of the harms and benefits?

How many patients have to be treated with ACLS (Advanced Cardiac Life Support) drugs in order for one patient to benefit (be resuscitated) from the treatment?

The NNT is a very interesting site. The information is prevented much more succinctly than I usually describe things.

Why NNT?

NNT is a common medical term.

NNT is the Number Needed to Treat – the average number of patients we would need to treat with something in order for one patient to benefit. The flip side is NNH.

NNH is the Number Needed to Harm – the average number of patients we would need to treat with something in order to harm one patient.

This is explained in more detail (including a less than 4 minute YouTube video for those who don’t want to read a lot) at the NNT Explained page. Understanding the material presented in the video is very important for understanding the actual benefit of a treatment, rather than the potential benefit that is given by those promoting any treatment.

Once you understand this, you will be able to see that many treatments require huge numbers of participants because the NNT is so large. A large NNT means a small benefit (in numbers). Just because only a small number of patients benefit, does not mean that the benefit is small. The amount of benefit for those who do benefit is also important. This is one of the reasons we spend so much time treating cardiac arrest.

While the NNT for cardiac arrest is large, the benefit is lives saved. There are few benefits as important as that. As the method of CPR improves, the NNT drops because the treatment helps more patients. The NNT is a great site to look around and get a quick idea of the relative benefits of many different treatments. Go browse the NNT.


Furosemide and Drug Shortages 2

Also posted over at Paramedicine 101, which is now at EMS Blogs. Go check out the excellent material there.

I will keep pointing out the problems with furosemide (Lasix) and the evidence against it. Let’s ignore the problems with giving furosemide to patients who actually have CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Can medics correctly identify CHF/ADHF?

The EHS ePCR database identified paramedic reports in which furosemide was administered. As furosemide only appears in the CHF/pulmonary edema protocol, paramedic differential diagnosis of this was assumed by furosemide administration. Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard. Other data points collected included: demographic information; EHS treatment administered; treatment administered in the ED; adverse events and patient disposition.[1]

They do not describe their method of selecting the charts.

Was it completely random?

Was it sequential?

How did they select their sample?

There were three objectives of this study. The first was to determine agreement between paramedic administration of furosemide with EP diagnosis of CHF. The second was to examine differences in interventions administered by paramedics and in the ED by EP diagnosis of CHF. The third objective was to identify any adverse events that occurred during patient care.[1]

How much agreement on CHF/ADHF diagnoses?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question, as it appears CHF may have been in the differential diagnosis for many patients not ultimately diagnosed with CHF. Secondary diagnoses were not sought out and included. Therefore, paramedic accuracy reported in this study may be falsely low, if CHF was part of the EP secondary diagnoses. It should also be noted that there were two patients with a diagnosis of “shortness of breath not yet diagnosed.” It is possible that these patients did indeed have CHF, but were not diagnosed until a later time during hospital care. This needs to be considered when determining paramedic diagnostic accuracy.[1]

OK. For some reason, the emergency physicians gave furosemide to 21% of the patients they diagnosed with something other than CHF/ADHF. That may be explained by the CHF/ADHF being a secondary diagnosis.

This is something that should have been included in the study. What was being treated and for what reason. From the way they describe their data, they had the actual ED physician chart, not just a diagnosis. This is something they should include in a follow-up study, especially with a larger sample size.

Since two of the patients had the diagnosis shortness of breath not yet diagnosed I will move them to the CHF/ADHF side of the graph. After all, most of the patients were diagnosed with CHF/ADHF.

That looks so much better.

On the other hand, there are problems with the way they conclude that some patients do not have CHF/ADHF. How much higher would things be if secondary diagnoses were included?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question[1]

What does NTG (NiTroGlycerin) have to do with ACS (Acute Coronary Syndrome), when examining CHF/ADHF treatment?

NTG is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be studied.

NTG is not just for chest pain.

Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard.[1]

Maybe. Maybe not. And don’t get me started on Gold Standards.

ED mortality was higher in patients with an alternate diagnosis than those diagnosed with CHF by the EP (2/60 vs. 6/34, p=0.017). As documented on ED charts, eight patients in this sample suffered adverse events other than death. These adverse events were: hypotension (n =3), heart rate problem (n =3), electrolyte imbalance (n =1), and respiratory effort decline (n = 1). All of the patients who suffered adverse events were diagnosed with CHF by the EP. Adverse events were not associated with the amount of nitroglycerin, morphine or furosemide administered.[1]

Adverse events in the ED were documented as occurring as often as death in the ED. Almost all of the deaths were in the group not diagnosed with CHF/ADHF, but all of the adverse events occurred in the group diagnosed with CHF/ADHF.

Of the six patients with an alternate diagnosis who had an outcome of death, three were diagnosed with pneumonia. Eight adverse events other than death were identified in this sample. Interestingly, all these patients were correctly identified as having CHF, which contradicts previous research which has found adverse events were more likely in patients incorrectly treated for CHF by paramedics.11,12 This indicates that furosemide should be administered with caution, even in cases where diagnosis of CHF is correct.[1]

Where is the evidence that furosemide should be administered, even if the diagnosis of CHF/ADHF is correct?

What would we want to know?

Did the patients have peripheral edema when given furosemide by EMS. Even with peripheral edema, furosemide is far from the first line drug, but without peripheral edema, it is not going to do anything good.

These patients need the best treatment possible, not the most persistent hold out from the Dark Ages.

We have known that CHF/ADHF is not primarily a fluid overload problem since the 1980s.

Why is EMS still using furosemide?

Is there any problem with a shortage of furosemide?

Not at all, but this isn’t the study to prove it.

I hope the authors use what they learned from this to design a definitive study of the prehospital use of furosemide.

Updated 02-07-11 to correct the uselessness of the original charts I made for this post.

More details are in Corrections of Misleading Charts.


[1] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF


Chest Pain Refusals

Further thoughts on EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights.

How do we determine what is low risk chest pain?

One of the most common judgment calls in the emergency department (ED) is also one of the thorniest: deciding whether to send home a patient who is complaining of chest pain but is highly unlikely to have heart disease. The person is an adult younger than 40 years and with no family history of cardiac problems, and both the ECG and blood test results for troponin are clear.[1]

Under 40? How old was the patient in the article referenced by Ckemtp?

I didn’t see an age.

The article I quoted above, cites this position statement (below) from the AHA. You know the American Heart Association, the people who write the guidelines we use as the basis for EMS cardiac protocols.

Assuming that this is a low-risk chest pain patient, what does the AHA consider to be the defensible way to approach this patient?

A high degree of suspicion and recognition of atypical presentations is important, because a significant number of patients present with “anginal equivalents” rather than chest pain. These symptoms include jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; and unexplained fatigue. These are seen more frequently in the elderly, women, and diabetic patients. Sharp, stabbing, or reproducible pain reduces but does not exclude the likelihood of ACS. Pleuritic chest pain is consistent with a pulmonary condition, musculoskeletal disease, or pericarditis. However, the Multicenter Chest Pain Study found that 22% of patients presenting with symptoms described as sharp or stabbing pain (13% with pleuritic pain and 7% with pain reproduced on palpation) were eventually diagnosed with ACS. 11 The National Heart Attack Alert Program recommends that patients with any of the aforementioned presenting symptoms should be assessed immediately and referred for rapid evaluation. 25 [2]

Jaw, neck, or arm discomfort; dyspnea; nausea; vomiting; diaphoresis; unexplained fatigue, and other symptoms.

These are seen more frequently in the elderly, women, and diabetic patients.

Perhaps this description of chest pain is more accurate –

Not the typical non-diabetic middle-aged man chest pain.

Why do we feel that we should assess every possible cardiac patient as if that patient is a non-diabetic middle-aged man?

When assessing female patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing young men, do we not understand that they are not non-diabetic middle-aged men?

When assessing diabetic patients, do we not understand that they are not non-diabetic middle-aged men?

When assessing old men, do we not understand that they are not non-diabetic middle-aged men?

Physical Examination
The physical examination, although more specific than sensitive, can be useful to identify higher-risk patients. Signs of heart failure reflect left or right ventricular dysfunction. Bruits usually indicate peripheral arterial disease and increase the risk of concomitant CAD. The examination should also target potential noncardiac causes for the patient’s symptoms, such as unequal extremity pulses (aortic dissection), prominent murmurs (endocarditis), friction rub (pericarditis), fever and abnormal lung sounds (pneumonia), or reproduction of chest pain with palpation of the chest wall (musculoskeletal disorders). A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

A normal physical examination is present in the majority of uncomplicated cases of ACS and contributes to the initial impression of low clinical risk.

Why do we lie to ourselves about chest pain?

EMS is not responding to 911 calls to look for reasons that the patient’s symptoms are not cardiac.


[1] The Perils of Low-Risk Chest Pain: Emergency Physicians Struggle to Balance Risk With Overtesting
Jan Greene
Annals of Emergency Medicine
Volume 56, Issue 4 , Pages A25-A28, October 2010
Free Full Text from Annals of Emergency Medicine

[2] Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research.
Circulation. 2010 Jul 26. [Epub ahead of print]
PMID: 20660809 [PubMed – as supplied by publisher]

Free Full Text PDF – Only Available as a PDF


EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights

Ckemtp writes EMS case law? AMA Refusals, Death, and Documentation

It is important to read. This is also a job for Star of life Law – a real lawyer. I am not a lawyer, but looking at the legal paper, it seems that this is just a determination of whether the law suit can proceed. If the original judge ruled that there were no grounds for a suit, then there probably had not been a presentation of a defense. That would happen during discovery (which may have been concurrent) and trial.

This ruling seems to be – the plaintiffs can proceed with their suit. The trial may still be a long way off.

What is described in this ruling from the Court of Appeals is superficially scary.

15 minutes on scene, for a patient who died less than a day later. Sounds bad, but we don’t have any of the information to explain why.

Did the medic incompetently blow this off as indigestion?

I don’t know.

Did the patient threaten them and chase them from the home?

Probably not. It doesn’t seem that way, but we do not know.

I spend much more time on refusals than almost any other call, although I have spent over an hour on scenes getting patients’ pain to the level where it was not torture to move the patients.

I have even had a refusal from a patient presenting with what gave every sign of being an MI. I showed him the ST elevation. He was a cardiologist. He absolutely refused. I have no idea of the scene time, but I got everybody there to try to persuade the patient to go to the hospital. I got medical command to talk to him, even though this was in a place where the doctors don’t talk to refusals. I’ll talk to this patient, but we don’t do that here. WTF?

I never heard anything further about this patient. It was an ALS assist outside of our territory. I checked the obituaries a couple of times, but this was when that required buying the local paper, or going to the library. As a library addict, I stoned a couple of birds in one shot. No dead doctor.

The part that does not look good is this.

What emergency physician is arrogant enough to discharge a patient with only a 12 lead ECG?

And we don’t even know if they did a 12 lead ECG.

Can we diagnose an MI/STEMI/NSTEMI with just a 12 lead ECG?


Does that mean that we can rule out an MI/STEMI/NSTEMI with just a 12 lead ECG?

Absolutely not.

A positive finding means something.

A negative finding only means that at the time the 12 lead ECG is performed, the patient is not having a heart attack that can be detected by a 12 lead ECG. A negative finding does not mean that the patient is not having a heart attack.

Consider that you are in the woods. It is cold and you are seeking shelter. You see a cave. It is dark in the cave. If you heard growling coming from the cave, you would have a positive finding that there is an animal in there.

If you cannot hear anything, or see anything, does that mean that there are no animals in the cage – nothing big enough to reach out and bite you?

Unless the test has excellent sensitivity, a negative finding only means that nothing was detected. It does not mean that nothing was there.

If you could see through the walls of the cave, you could be sure if there were any animals inside, what kind of animals, how many animals, and many other things. In EMS, we do not have that kind of diagnostic equipment. Waveform capnography may be the closest we come.

It may be nice to tell someone that everything is OK, but it is just a coin flip on whether we are right.

That is not even close to competent.

Will an emergency physician also check cardiac enzymes and still worry that he may be discharging a patient with a real heart attack?


One other thing.

The cause of death was not a heart attack.

The cause of death was pulmonary embolism.

Maybe we do an excellent job of ruling out a heart attack. Yippee!

That does not mean that the only other cause of chest pain and difficulty breathing is indigestion.

We should never approach a patient assuming that the cause of any complain, even abdominal pain, is indigestion. Even if the patient is mixing 5 alarm chili, donuts, beer, chocolate milk, whiskey, candy corn, a soufflé, and a bunch of other food that gives us indigestion just looking at the combination. Even if this patient has GERD and ulcers.

I do not believe in telling lies to patients.

If you don’t go to the hospital, you’re going to die!

If the patient does go to the hospital, the patient is still going to die. Everybody dies. So?

I explain the reasons the patient may want to go to the hospital.

I explain the limitations of my assessment.

I explain whatever they ask (related to the call).

Sometimes (frequently) my answer is – I don’t know.

Refusals require informed decisions.

Treatment and transport also require informed consent, but we seem to ignore that – a lot.

How many of us obtain informed consent for spinal immobilization, or even an IV start?

How many of us would be able to provide accurate information for a patient to be able to make an informed decision to consent to treatment/transport or to make an informed decision to refuse treatment/transport?

If we do not do a good job with informed consent, are we surprised that a lot of refusals are not well informed?