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

- Rogue Medic

Andrew Wakefield and Cognitive Dissonance.

He made up a syndrome.

He performed unnecessary and risky medical procedures on children.

He received hundreds of thousands of pounds from lawyers for a study to look for that imaginary syndrome, because the imaginary syndrome could make the lawyers a lot of money.

He was horribly incompetent in his research methods.

He lied about what he did.

He sued Brian Deer, the investigative reporter who uncovered most of the fraud. He had to withdraw the law suit and pay the expenses of Brian Deer.

In 2004, when they became aware of the fraud, 10 of the 13 authors of the study had their names removed from that study.

On January 28, 2010, a little over a week ago, The General Medical Council released its verdict.

The Fitness to Practise Panel has heard this case under The General Medical Council Preliminary Proceedings Committee and Professional Conduct Committee (Procedure) Rules Order of Council 1988. It has considered which, if any of the facts not admitted by Dr Andrew Wakefield, Professor John Walker-Smith and Dr (now Professor) Simon Murch have been found proved and then went on to consider whether such facts found proved together with those admitted, would be insufficient to support a finding of serious professional misconduct.[1]

The Panel has accepted in full the advice of the Legal Assessor as to the approach to be taken. The three doctors have nothing to prove, the burden of proof is on the GMC throughout. If the Panel were not sure beyond reasonable doubt, the sub-head of charge was found not proved in favour of the doctor, in accordance with the criminal, as opposed to the civil, standard of proof.[1]

A lot of findings of Admitted and found proved.

A lot of findings of Found proved.

The occasional finding of Found not proved.

A lot of irresponsible – Found proved.

A lot of dishonest – Found proved.

Some crazy people are still defending Andrew Wakefield.

You would have to be crazy to defend that fraud.

Or dishonest and irresponsible.

These people have convinced themselves that vaccines cause autism, even though research has repeatedly shown no connection.

So, in order to protect themselves from having to admit that they endangered their children and other children, they need to defend this, even though Andrew Wakefield has admitted some of the fraud and a court has determined that he is guilty of a lot more.

When people should admit that they made a mistake, some will actually become even more defensive of their clearly mistaken position.

A clear case of cognitive dissonance.[2]

If you wish to read about the research that has been done on autism and vaccines, there are scores of studies.[3] Studies paid for by many different organizations – governments, universities, non-profit groups, and even drug companies. They don’t find any connection between vaccines and autism.

Andrew Wakefield was receiving hundreds of thousands of pounds from lawyers to show a connection. Is it surprising that he did?

Andrew Wakefield was working on a vaccine to compete with the MMR vaccine, so he has another reason he might benefit financially from making false accusations about the MMR.

Andrew Wakefield has shown that he is willing to subject children to risky procedures for no benefit to the children, as long as he makes his money.

There has been a lot written by others on the topic. In the comments the anti-vaccinationists will try all sorts of misleading approaches. Some will claim that they are not anti-vaccinationists, but that they only want safe vaccines.

Vaccines are safe.

How much safer could vaccines be?

There are a some examples in response to Dear Jenny McCarthy . . . at A Day In The Life Of An Ambulance Driver. Another is at Asshole doctor responsible for false MMR/autism claim gets his at Cranky Epistles.

In The martyrdom of St. Andy at Respectful Insolence, there is far more detail about the dishonest and irresponsible conspiracy to link autism and vaccines. A listing of a lot of posts on this topic, even some defending the fraud, can be found in On The Lancet’s Retraction of Wakefield’s 1998 Paper Alleging A Connection Between the MMR Vaccine and Autism at I Speak of Dreams.

The unfortunate thing is that Andrew Wakefield is still making over a quarter of a million dollars a year to spread his lies for Thoughtful House, an anti-vaccination organization in Texas. When it comes to Andrew Wakefield, follow the money – he does. He came to the US, but he is not a doctor in the US.

If you know of Andrew Wakefield pretending to be a doctor, call the police.

And vaccinate your children for their sake.

More information is available at Brian Deer’s website.


^ 1 Fitness to Practice Panel Hearing
UK General Medical Council
January 28, 2010
Free Full Text

^ 2 Cognitive dissonance

^ 3 Vaccines and Autism
Science-Based Medicine


The Blame Game

Over at Confessions of a Street Pharmacist, Divemedic has a post with the title, The blame game. That’s right. I showed absolutely no imagination in coming up with a title for this post. Go read the post, because I am only going to copy parts of the post here. I am assuming that everything in the post is accurate, but I have no reason to believe it is not, since I have encountered similar behavior to what Divemedic describes.

He complained that the pacing was painful, and so I gave him 2mg of valium to take the edge off. His BP was now 100/62, and I thought we had done OK.

Then he went into respiratory arrest.

Diazepam (Valium) is a benzodiazepine and has the potential for causing respiratory depression. You gave 2 mg. That is such a small dose that it is not likely to have a significant effect on respiratory drive, unless he was tiny. If the patient was ready to stop breathing from working too hard to breathe, then it was probably only a matter of time until he stopped breathing. The diazepam could have contributed, but the intubation may have been inevitable. The BP and CO2 numbers (below) suggest that he was still perfusing well, which indicates that his circulation received a benefit from your treatment with the pacemaker. I do not see any reason to place any blame on your actions.

I prefer fentanyl (Sublimaze) for pacemaker pain. It has less of an effect on blood pressure than morphine or benzodiazepines, but it can have even more of a respiratory depressant effect. If sticking to benzodiazepines, and many people prefer to to use them for pacemaker pain, I prefer to use midazolam (Versed), since it wears off much more quickly than lorazepam (Ativan) or diazepam. Similarly, a big advantage is that fentanyl wears off quickly. For EMS, we do not want drugs that last a long time. We want to be titrating to effect. We can always give more (depending on protocol and amount carried).

I tubed him, and his EtCO2 looked good, and over the next few minutes, his O2 sats went from the 70’s into the upper 90s. His lungs sounded wet, but the clinical signs were there. CHF, maybe? We delivered him to the ED with vitals of: HR 80(paced), Resp 12(BVM via ETT), BP 110/70, SaO2 96, EtCO2 42.

With a misplaced tube, it is extremely unlikely to have improved oxygen saturation. There are a couple of possible reasons for the number to increase with a misplaced tube.

1. The pulse oximeter was not getting a good reading before the intubation, but was afterward. Even though the sat may be slowly dropping, when there is at least one inaccurate reading, there may appear to be a positive trend, but that is just due to an error in one, or more, readings.

2. An esophageal intubation should not lead to improved oxygenation. However, the act of inserting a laryngoscope blade and a tube may provide enough painful stimulus to inspire the patient to breathe spontaneously and adequately around a tube that is placed in the esophagus and not obstructing the airway. The tube would not be providing any benefit other than painful stimulus. Painful stimulus may be all that the patient needs, but that does not justify an endotracheal tube misplaced and unrecognized in the esophagus. The pacing may have the same effect of painful stimulus, but the patient seems to have had the respiratory arrest after capture was obtained with the pacer.

On the topic of pacemakers, it is likely that the improved cardiac output from many paced patients is not due to successful capture, but to painful stimulus. That is a topic all to itself.

Wet sounding lungs can mean many different things, but if he does have CHF, positive pressure ventilation works wonders, as long as we do not drop the blood pressure by raising his intrathoracic pressure high enough to impair venous return.

The ER doc listened to the lungs, and consulted with the RT. They decided to extubate. I pointed them to the EtCO2, and the Doc said “That stuff isn’t accurate. You are in the stomach.”

“That stuff isn’t accurate. You are in the stomach.”

Strike One!

This clown doctor needs a big tattoo on his forehead to warn people to stay away.

Accuracy-wise, waveform capnography is the most reliable method of confirmation available. The false negative rate is very low. For example false negatives might from an obstructed sample port, equipment not connected properly, equipment malfunction, a very dead patient produces little, if any CO2, . . . .

The false positive rate is almost zero. For example from a lot of air in the stomach from a lot of mouth-to-mouth ventilation. The exhaled CO2 is going into the stomach, to be returned later, when oxygen is pumped into the stomach. The possibility that consuming a lot of carbonated beverages prior to intubation would similarly result in a reservoir of CO2. Not that anybody would ever substitute carbonated beverages for the almost mandatory pre-arrest Mylanta. The patient is hooked up to the nasal cannula form of CO2 sampling device and is still spontaneously breathing around an esophageal tube well enough to produce good CO2 numbers and waveform. The monitor is showing a waveform from a simulator, rather than the patient. Although I spend a lot more space on the false positives, they are much less likely than the false negatives.

He then ordered the nurse to discontinue the pacing, and give 0.5mg epinephrine and 0.5mg atropine. I showed him the original strip and pointed out the original rhythm.

Strike Two!

Discontinuing pacing that has both electrical and mechanical capture is a very bad idea, unless you are just doing so temporarily to assess the underlying rhythm before resuming pacing. Discontinuing pacing to give a toxic dose – perhaps a lethally toxic dose – is irresponsibly dangerous.

I would suspect that the doctor, by giving both atropine and epinephrine, exacerbated an MI. A 500 mcg bolus (0.5 mg = 500 mcg), to a patient with a pulse, is way outside of the ACLS guidelines of 2 mcg/minute to 10 mcg/minute by infusion. I don’t know what happened, but I have never seen a slow push of epinephrine. Even assuming that the epinephrine was given over a full minute, that doctor still gave 50 times the maximum dose for a living patient.

I started the last paragraph with the assumption that he had both electrical and mechanical capture with the pacemaker. If there is any question about whether this is the case, the waveform capnography gives a pretty good indication of the quality of circulation. There is more that I would want to know to make a more definite statement, but I do not doubt that he had full pacemaker capture. That the patient coded after discontinuation of the pacing, and the addition of an extremely toxic dose of epinephrine only adds to the confirmation that the EMS treatment was appropriate.

Maybe the doctor placed the tube in the esophagus, since he clearly does not know how to confirm tube placement. Expecting correct placement (if he did attempt to re-intubate) from Dr. Deadly would be an example of unreasonable optimism. We might as well allow him to be the only unreasonable person in the room.

Picture Credit[1] You know how to make it bigger.

To create a continuous infusion of epinephrine hydrochloride for treatment of bradycardia or hypotension, add 1 mg (1 mL of a 1:1000 solution) to 500 mL of normal saline or D5W. The initial dose for adults is 1 µg/min titrated to the desired hemodynamic response, which is typically achieved in doses of 2 to 10 µg/min. Note that this is the nonarrest infusion preparation and dose (ie, for bradycardia or hypotension).[2]

What if Dr. Deadly was assessing the patient as pulseless and was giving the dose for cardiac arrest, so the dose could be appropriate.

Let’s see if the AHA has a mostly dead dose for doctors, who just can’t commit to a full milligram in cardiac arrest –

It is appropriate to administer a 1-mg dose of epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest (Class IIb). Higher doses may be indicated to treat specific problems, such as ß-blocker or calcium channel blocker overdose. If IV/IO access is delayed or cannot be established, epinephrine may be given by the endotracheal route at a dose of 2 to 2.5 mg.[3]

It looks as if Dr. Deadly was using a dose of epinephrine that is half of an adult cardiac arrest dose combined with a dose of atropine that is half of an adult cardiac arrest dose. Dr. Deadly appears to be a complete half wit.

Maybe he was giving the appropriate dose of atropine for a living patient combined with a ridiculously inappropriate dose of epinephrine for a living patient

Maybe he was, but I would rather not speculate about the motives of this malpractitioner. He could be 50 times more witless. At least if we use the ratio of his dosing to the actual recommended doses.

What about dopamine? The chart includes dopamine.

Dopamine is just epinephrine light. It is a little more complicated than that, but the dopamine is going to be much weaker than the epinephrine. Dopamine is also not to be given as a bolus to live patients.

As I was leaving, the doctor came out and informed her that her husband had passed away. He then told her, right in my presence, that if the paramedic had not placed the tube incorrectly, her husband may have lived. I felt about three inches tall.

Strike Three!

He blames others for his incompetence.

At least the doctors reviewing the case were able to recognize the signs of a properly placed tube.

Did you tell the family that the outcome of the complaint against you was that you did nothing wrong. If anyone killed this patient, I would suspect that the doctor, by giving both atropine and epinephrine, exacerbated an MI. A 500 mcg bolus, to a patient with a pulse, is way outside of the ACLS guidelines of 2 mcg/minute to 10 mcg/minute by infusion. I don’t know what happened, but I have never seen a slow push of epinephrine. Assuming that the epinephrine was given over a full minute, that doctor gave 50 times the maximum dose for a living patient.

It is difficult to tell a lot of what is going on without the strips and other information. Not that anyone needs to be blamed, but when those taking care of patients are clueless people, such as Dr. Deadly, patients seem to die more often.

While I intended to start by saying nice things about the review board for recognizing that you did the right thing, I am disappointed if they failed to report this doctor to the state medical board.

People, who automatically blame others for their mistakes, such as Dr. Deadly, seem to do this because they have a lot of practice making very bad mistakes. They also seem to be incapable of learning.


^ 1 Management of Symptomatic Bradycardia and Tachycardia
Circulation. 2005;112:IV-67 – IV-77.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text . . . . Free PDF

^ 2 Monitoring and Medications
Circulation. 2005;112:IV-78 – IV-83.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Medications for Cardiovascular Support
Free Full Text . . . . Free PDF

^ 3 Management of Cardiac Arrest
Circulation. 2005;112:IV-58 – IV-66.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Epinephrine and Vasopressin
VF and Pulseless VT
Free Full Text . . . . Free PDF


The Harm of Rituals in EMS

Over at Gomerville, it seems that Buck Feris has a life back and will be writing more often. In Remove the Rituals From Your Care, he writes about many of the ways that superstitions/rituals get in the way of doing a good job, many of the ways rituals endanger our patients.

I guess I never had a chance to develop these handicaps. Things such as setting the IV kit up just so, only using the one true type of needle, and all sorts of other ways of believing that if it isn’t just the right way, I can’t do it. That is just another example of all of the BS non-science nonsense I continually criticize on this blog.

My preceptor’s partner, back when I was a student, would be leaning over the patient’s shoulder, in the moving ambulance, holding the IV catheter backwards, while I was sitting next to the patient with everything as close to ideal as it gets in EMS. He would have the IV before I would. In too many cases, he would get the IV, while I would just create a little biohazard site. Sometimes not so little.

When you are dealing with that kind of setting, what excuse can you possibly come up with for bad performance? He was working on the same patient. In the same ambulance. Standing in a much less comfortable position. With a worse view of the vein he was sticking. Holding the catheter backwards. Et cetera. Still he was faster and better than I was, in spite of all of those handicaps.

There were 2 things that were potential excuses. He was sticking the right arm most of the time. Since most people are right handed, that is their most used arm and will have better circulation, which means healthier veins. The other is that sometimes it was distracting and difficult not to watch. And I did learn a lot from watching him stick people. Neither is a legitimate excuse.

He didn’t make any excuses, when he couldn’t get an IV. On the few occasions, when I would get the IV, but he would miss, he would compliment me on my ability and still not make any excuses. That is professionalism. It isn’t about the ego, but about taking care of the patient.

Well, what do people do wrong?


Does it matter what brand IV catheter you use? No. At least not after you get comfortable with each brand. The only way to get comfortable with them, before your boss decides that as of yesterday, we are switching to the ACME laser guided hydraulic catheters, is to look for opportunities to use things you never used before.

Also –

We insist on contaminating the site after we have cleaned the site.

This is just world class stupid.

Why bother to clean the site if you are going to make it dirty again?

If you have an excuse, do not bother to answer. If you think it is a good excuse, you have no idea of what you are talking about.

OK. Maybe you do know what you are talking about. But rather than put your answer in the comments and risk looking stupid, do this. Try explaining it to a trauma surgeon. They are easy going people, who take a win some, lose some approach to patient care. Give it a shot.

Explain to the trauma surgeon that your finger is clean, or that your glove is clean. I’ll wait.

And if you think that a trauma surgeon is really worried that you are going to kill his/her patient with the bacteria that you do not realize are there, just because you can’t see them and you consider ignorance of biology to be a virtue, you are also wrong. The trauma patient will receive a gram of cefazolin (Ancef) in the trauma room. A little bacteria from an incompetent IV start is not going to make much difference. The reason trauma surgeon will not be happy, because you are advocating doing something that is flat out wrong. And did I mention stupid?

All of this applies to the relatively stable patient, In the case of an unstable patient, cleanliness is much less important. Keeping the patient from dying is what is important.

Back around 1850, Dr. Ignaz Semmelweis was working in Vienna. He tried to get doctors to was their hands, because they were killing their patients. The doctors refused to listen, because they did not believe in germs. 160 years later and paramedics are making essentially the same argument. Only it isn’t the same argument, because the doctors did not have the benefit of all of the science that demonstrates the germ theory. All of the imaging capabilities to see these different germs that are everywhere, even on things that are clean.

We are demonstrating that we are stupid. We cannot be taught. The germ theory was confirmed a little over a decade later, almost 150 years ago. We still have not learned. It isn’t just EMS. You will see the same stupidity in the hospital, but we should be better.

It is as if we want to have big tattoos on our foreheads saying – Stupid, and proud of it!

Competent people do not need excuses.

We need to accept our limitations, but work to minimize them. We need to stop creating limitations. Science/skill vs. superstition/ritual? If you want to go with the superstition/ritual, we need to play poker. Maybe I won’t convince you, but I will at least be getting paid for my time.

If you think that I am being unfair in using the word stupid too much, then there is only one smart thing to do. Prove me wrong. change your behavior. Improve your skills. Improve the care you deliver to patients. If you change your behavior, then you are not stupid, because stupid people do not learn. I don’t mind being wrong. I’ve been wrong before. I’ll be wrong again.

Prove me wrong. I double dog dare you.

As for doing everything just so, I always think of the beginning of this scene. Especially when the patient has huge veins. It is good to develop skill with your non-dominant hand, assuming that you have more than one hand. Instead we seem to prefer to make excuses. No, this is not a scene from My Left Foot.

I’m going to do him left handed. . . . It’s the only way I can be satisfied.

First rule of EMS. Everything in EMS can be connected to either The Princess Bride or Monty Python and the Holy Grail.

If you haven’t already, go read Remove the Rituals From Your Care. Buck presents things a bit differently.


CBS Neck and Neck with CNN for Most Incompetent Network

Also possibly posted as part of the Skeptics’ Circle over at The Mad Skeptic. I procrastinate and am late in sending this in. Maybe The Mad Skeptic has already finished this edition. Anyway, go check out the rest of what is there.


Complain to CBS: CBS resident anti-vaccine propagandist Sharyl Attkisson sucks up to anti-vaccine pseudoscientist Andrew Wakefield.

The most famous fraud in medicine, that Criminally Blundering Scientist, Andrew Wakefield, was praised on the television network that has decided to give CNN a run for its money in the category of incompetence.

The CBS (Comedic Bumbling Scaremonger) network decided that they would give some air time to an exposed fraud to promote his latest larceny. He has already been shown to have taken payoffs from trial lawyers to fake his research. Is he pushing a book? So, why does anyone pay any attention to him? One reason. He tells them what they want to hear. And if it is written in a book, it must be true. OK, 2 reasons. He tells them what they want to hear, he feeds their paranoia, and if it is written in a book it must be true. OK, 3 reasons. . . .

If you believe that the people reporting the news, such as Sharyl Attkisson, are objective, you probably were told that by a reporter. If you believe that Andrew Wakefield does anything that is not designed to make him money, you probably were told that by Andrew Wakefield or one of his accomplices. If you think that Generation Rescue Generation Revenue knows anything about medicine, you probably were told that by somebody at Generation Revenue – somebody trying to sell you something.

Anybody, who uses only bumper sticker slogans as their medical evidence, clearly is not worth listening to. Too much, too soon. Based on what? They don’t know. They only feel. Ignorance is their strength. Green the vaccines. That doesn’t even mean anything. And then they use the made up word, Toxics, as if it were a real word.

Because, when you don’t know what you are talking about, it doesn’t matter what you say. It only matters what you feel. And they want you to feel angry, so they can make money off of you.

You should be angry. They want you to sacrifice your children to satisfy their feelings. They also want to make money off of you. They are selling books and magical mystery treatments – guaranteed to lighten your wallet, but certainly not guaranteed to be safe. They demand more and more vaccine research. The research continually shows that vaccines are safe, but they keep asking for more research – hoping for the fluke grouping of autistic children in the treatment group, so they can claim that it was the vaccine that caused the autism. They already do make that claim, but all of the evidence shows that they are lying.

Of course, they will sell you some of their dangerous all natural products. They don’t have to show that they are safe, because they sell them as supplements, rather than medicines. Supplements will kill you. You have no way of knowing what you are getting, because the politicians (such as Sen. Tom Harkin) have minimized oversight in response to donations from the real big money supplement groups – Big sCAM. And they get a quarter of a billion dollars – each year – of our tax dollars to look for evidence to support alternatives to medicine that has evidence that it works. Talk about pork.

When your money is going to buy their untested supplements drugs, they do not care about safety. When your money is going to pay for well tested vaccines, to protect your children, they are ranting and raving about danger.

One thing that can be said about everything that these 2 recommend – Not Safe!

Not safe for adults – and definitely not safe for children.

Interviewer – And yet in many cases, vaccines have effectively eliminated diseases. Measles is among the top five killers in the world of children under 5 years old, yet it kills virtually no one in the U.S. thanks to vaccines.

Jenny McCarthyPeople have the misconception that we want to eliminate vaccines. Please understand that we are not an antivaccine group. We are demanding safe vaccines. We want to reduce the schedule and reduce the toxins. If you ask a parent of an autistic child if they want the measles or the autism, we will stand in line for the f___ing measles.

Jenny McCarthy on Autism and Vaccines
By Jeffrey Kluger; Wednesday, Apr. 01, 2009; Time Magazine

Reduce the schedule? Based on what?

Reduce the toxins? She is giving a chant, like a cheerleader, so repeating the word reduce works in the cheer. The toxins claim is just naming ingredients that are in microscopic quantities and are safe, even in children. Of course, this complaint about toxins is from someone who has botulism injected regularly, to maintain a youthful appearance. What does she understand about toxins?

Do you want the measles or the autism? Again, based on what?

These questions are nothing but a scare tactic.

There is no connection between vaccination and autism. You can look at all of the research, or you can listen to a stripper and an exposed fraud. A fraud who faked his research to make it appear that there is a link between vaccines and autism. Listen to real doctors? Or listen to these 2 ringleaders of a circus of ignorance and anger.

Why do people listen to such psychotic ranting? Mao was more compassionate than either of them and he tops the updated list of greatest mass murderers. Judging by the number of people skipping vaccines, we will probably not get people to realize just how dangerous her advice is until there are a lot of dead children. Probably not even close to Mao’s 73,000,000, but who knows how persuasive she can be.

So that you can keep track of how many people are being killed, because of people listening to the anti-vaccine mob, get the Jenny McCarthy/Anti-Vaccine Body Count widget. There are 2 other designs at the web site.

Jenny McCarthy Body Count

217 dead? The current numbers are actually 235 dead and 49,556 preventable illnesses. I don’t know why the widget is not up to date.

2007: Jenny McCarthy Begins Promoting Anti-Vaccination Rhetoric

Maybe it is just a coincidence. Maybe it is a coincidence that the number of cases of disease, and there are plenty of other diseases documented at the site, began dropping with the introduction of vaccinations, leveling off at very low numbers, and staying low until Jenny McCarthy started telling people that it is wrong to protect their children from these illnesses. Be fair to measles, or something like that.

Why is it wrong to protect my child from these vaccine-preventable diseases?

Loving parents should protect their children, not listen to a stripper giving deadly medical advice.

Am I being unfair?

Ask a parent who has had a child die because of Jenny McCarthy or Andrew Wakefield.

Then there is the big question.

Why was Andrew Wakefield being interviewed about an article appearing in a minor medical journal?

Do they normally cover all of the articles published in the more reputable medical journals, but are now adding to that extensive medical coverage?

Not at all. This is important news only to those who believe in the religion of Andrew Wakefield. The Lancet, which published the study that had to be retracted due to Andrew Wakefield’s fraud, is not going to believe that he had a sudden onset of honesty. JAMA (the Journal of the American Medical Association), the New England Journal of Medicine, Pediatrics, the British Medical Journal, et cetera, have reputations for quality that they need to maintain. Professional responsibility. Why even look at something from these frauds? Maybe the peer reviewers had no idea of the identity of the authors, but did not see anything about the paper to justify inclusion in a major medical journal.

Neurotoxicology? I never heard of the journal before, but maybe they wanted a bit of publicity. Dr. David Gorski goes into detail on the many conflicts of interest in this study. He also has links to the full study, which has been published at a couple of autism misinformation sites. Monkey business in autism research, part II.

For further information on Andrew Wakefield there is the reporting of Brian Deer:

Thoughtful House: Since the Royal Free ejected him in October 2001, Andrew Wakefield first re-emerged as “research director” of the self-styled International Child Development Resource Center, in Florida, which sells expensive products for autism, including enzymes and purported “genetic tests”. He was then installed at Thoughtful House in Austin, Texas, earning $280,000 a year.

Wakefield’s patents: Nine months before Andrew Wakefield and London’s Royal Free hospital medical school unleashed a global scare over the MMR vaccine, they filed, on June 5 1997, the first of a string of patent claims for theoretically vastly profitable products which could only succeed if MMR’s reputation was damaged. These included a purported safer measles vaccine – a potential competitor – and treatments for bowel disease and autism. All were based on claims that measles virus in MMR was at fault.

These are just 2 examples of the many sleazy activities of Andrew Wakefield. There are a lot more at http://briandeer.com/. Andrew Wakefield is not a doctor in the United States, although he works in the US. Has he been practicing medicine without a license? It would be a surprise if that were the one ethical part of his life.


What’s The Worst That Could Happen? Pain Management

Depends on your perspective.

Medical director: Extra paperwork, and a patient might suffer harm from incompetently delivered pain management vs. malpractice for neglect of a patient in pain.


Is it outside of the paramedic scope of practice to manage pain aggressively?

No. Although different states may prohibit the safest medications and/or may prohibit standing orders.

The medical director can still find ways to minimize the number of cases, where otherwise stable patients are transported with no effective treatment of their pain.

Maybe the medical director does not think that is worth the medical director’s time and effort.

That’s where it becomes malpractice.

Would the medical director decide that we should not treat other conditions appropriatelty?

Is it difficult to manage pain appropriately?

Is it dangerous to manage pain appropriately?

Paramedic: Similar to the medical directors concerns, but add in being an accomplice in the torture of a patient in pain.

Accomplice in torture?

The medic has the ability to treat the pain (the training, the medications, everything), but the medical director says, No! Do not help that patient! Make that patient worse!


Moving a patient, without managing the pain is making things worse. The pain increases. The vital signs are responding to the pain in a way that may be harmful to the patient. The patient may move in ways that worsen the injury, by attempting to minimize the pain. The patient is distracted from providing an accurate history by the focus of the pain.

This teaches the paramedic to ignore the patient. What could be worse, from a patient care perspective?

Patient’s family: “Why won’t they do anything for my mother/father/sister/brother/daughter/son/. . . ?”

“Why don’t they care?”

Patient: Has nothing nice to say about people ignoring his/her pain and making it worse. He/She called for help. Instead he/she is receiving the same level of service that a taxi driver could provide, and the taxi driver would charge much less for the abuse.

We are horrible at managing pain, not because we endanger the patients’ respirations, but because we do not treat the pain. There is no right dose for everyone. The right dose is whatever provides significant relief.

For some patients, significant relief might be 2 mg morphine, although morphine is the wrong drug. For some patients that might be 500 mcg fentanyl combined with 10 mg midazolam. If the patient is still awake and alert, with no signs of respiratory depression, and in significant pain, then we have not given too much.

And the lies we tell our patients –

This won’t hurt.

Or the even worse lie –

This won’t hurt a bit.

Then the after the fact insult and lie –

That didn’t hurt.

And the infantile justification, which is also a lie –

You can’t be too safe.

The scary part is that some of the people actually believe this BS they tell patients. They need to be on the receiving end of some of, This won’t hurt a bit.

Why do we abuse our patients like this?


Risk Management – Why is it so difficult?

Here are some clips on the recent downturn in the economy. Yesterday on CNBC, Nouriel Roubini and Nassim Taleb were guests. That Dr. Taleb would put up with the silliness that is CNBC, is surprising in itself. He has been very critical of CNBC for insisting on explanations for what is happening in the market today and for predictions of what will happen tomorrow. If you can’t give CNBC a stock tip, they aren’t interested. Maybe they should watch Jim Cramer’s show on CNBC, where Mr. Cramer explains how dangerous stock tips are. As you can tell from the video, the CNBC talking heads are incapable of learning. They ask the same questions that were foolish years ago, are foolish in the video, and will continue to be foolish centuries from now.


Added 01/22/2013 –

Image modified from BigCharts.

That is what the S&P 500 index looked like at the time of the broadcast – and at the time I wrote this.

Dr. Taleb and Dr. Roubini were predicting that things would not look good for the next two years.

Below is what the same S&P 500 index looked like after two years of not listening to Dr. Taleb and Dr. Roubini.


Dr. Roubini and Dr. Taleb share the opinion that one big problem is that the same people are still in charge. Both wrote about the current financial problems long before others admitted that there were problems. Rather than get rid of the leaders, who are herding the economy over a cliff, we give these leaders more authority and more money. Ben Bernanke has suggested something similar to the current economic stimulus plan. Dr. Bernanke suggested throwing money from a helicopter to fix the economy, earning him the nick name Helicopter Ben.

Photo source

This is not much different from listening to a couple of scientists trying to get some anti-vaccinationists to understand that denying their children immunity (refusing to vaccinate) is a bad idea. Since the talking heads do not understand, the talking heads try to come up with reasons to ignore what they do not want to hear.

Giving money to the people who caused the problem is still not the solution. The economists and bankers caused the problem. Here is another clip of Dr. Taleb explaining the scientific basis for economic science.

That clip is no longer available.

If you like listening to what Dr. Taleb is saying, there is a much longer video (almost an hour and a half long) called The Future Has Always Been Crazier Than We Thought. I strongly recommend the whole thing.

How does this relate to EMS?

We also never seem to get rid of the people at the top. The people who create the environment for failure. At least when we do get rid of the people at the top, it is not for the right reasons. We tend to replace them with similar failure generators. We get rid of the individual who behaved as expected in the failure environment. We need to change to an environment that makes it difficult to ignore problems.

We believe in all sorts of dangerous ideas about EMS. See the post above this for examples.


Guilty As Charged

Herbie writes Pocono Paramedic. He makes a serious accusation. Herbie states that Rogue Medic Made Me Do It.

I confess. I encouraged this. I would do it again. I shall not repent.

You will just have to read what Herbie wrote. I wish I had written it.


Star of Death

Vince writes about a shocking unexpected rare not exactly every day occurrence in EMS. Star of Death is a criticism of the approach to patient care in a large EMS agency.

Vince’s post raises several questions.

First, here is his summary of the events that were described in the article.[1]

A 39 year old man who was having chest pain and shortness of breath had complete resolution of his symptoms after about 6 hours. The bad news is that the symptoms went away right along with that nagging heartbeat he had.

Does it seem as if he left out some detail? Something that might show the paramedics in a more favorable light?

It sure does seem that way. Vince can be a rather harsh critic Vince can be a rather harsh observer. Reading the entire article does not make things look any better. The point of view is mainly from the family, but most of what I copy is attributed to people speaking for EMS. This incident has not been fully investigated. There has not yet been an article that I have read, about an incident I was involved in, that did not have inaccuracies.

Paramedics are required by department protocol to transport by ambulance a patient who asks to go to a hospital, said Alan Etter, a spokesman for D.C. Fire and Emergency Medical Services.[1]

This may surprise some people, but that is the job. That and providing patient care.

checked his vital signs and performed an electrocardiogram, the results of which they said were normal.[1]

If they actually said that, who trained these clowns? Who is providing oversight to allow such idiocy to persist.

The term Normal Sinus Rhythm is one I do not believe should be used in the patient care setting. The word normal is inappropriate in describing anything about a patient with a medical complaint. To say that it may be normal is entirely different.

People get upset with EMS using the word diagnose. Even though we diagnose and treat all of the time. We use a bit of medical terminology sleight of hand to change it to working diagnosis, or some other demonstration of placing appearances before substance.

If diagnosis is outside of the scope of practice of EMS, why is it that so many in EMS are comfortable pronouncing a diagnosis of normal? Pronouncing does appear to be the wrong word in this case.

The EMTs asked Givens whether he had eaten or had anything to drink that evening, and he said he had eaten a burger, Givens said. They told him and his mother that he probably was suffering from acid reflux and suggested he take antacid.[1]

As long as he isn’t on a starvation diet, we’re out of here and back to bed in 5 minutes!

Why is it that doctors, medics, and nurses are so quick to ignore the serious condition and focus on something that means less work? The job is to prepare for the worst and hope for the best. To approach patient care in any other way, is just plain wrong. This does not mean that you follow the defensive medicine approach of a CAT scan for every head ache, but that you fully assess the patient in the way that a competent professional would. Jumping to the conclusion, that a patient does not have a legitimate cardiac complaint, without a full assessment is wrong. Too bad it isn’t rare.

“As per protocol, we are conducting a thorough quality assurance case review, and we will determine whether proper care was provided and if the two medical events are related,” Rubin said in a written statement.[1]

Rubin is Fire Chief Dennis L. Rubin. How would the two be unrelated? If they had transported him to the hospital, he might have died in the hospital. He may have had a heart attack or it may have been something not cardiac. If he had been transported, there would have been some documentation to help them come to a conclusion. They cannot prove that the 911 call and his death are unrelated. Will they try?

Is 39 too young to have a heart attack?

Should 39 be considered young? Since I am older than 39, I say yes. The question should be, is any age too young to have a heart attack? Since I have treated teenagers who have had heart attacks, I say no.

Conversely, there is no age at which a heart attack becomes mandatory. We are dealing with likelihoods. Knowing just the age, I would say a heart attack is unlikely. When you add chest pain and difficulty breathing, I would have to be a fool to say a heart attack is unlikely.

Jack Benny claimed to be 39 years old for most of his life, so it isn’t a bad age, but it does not rule out heart attack. And heart attack vs indigestion is not the extent of the differential diagnosis. Did EMS get a thorough history? I do not know, but I do not suggest to a patient that chest pain is probably just indigestion.

Is there any research to suggest that 39 year olds, with chest pain and difficulty breathing, should be considered to have agita, rather than angina?

I’d ask them how comfortable they are with saying, Would you like fries with that? I would, but they would probably try to discourage the customer from purchasing the fries, since fries might cause indigestion.

On L & D calls, does the medic suggest, You probably just need to sit on the toilet and have a good bowel movement?

On CHF calls, You’re hyperventilating. Just breathe into this paper bag.

On amputations, Pull yourself together?


^ 1 Man Dies at Home After Paramedics Diagnose Acid Reflux
By Elissa Silverman
Washington Post Staff Writer
Thursday, December 4, 2008; Page B04