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

- Rogue Medic

Eureka – Conventional Treatment Plus Placebo Beats Conventional Treatment Alone – comment from RavenBlack

Also posted as part of the Skeptics’ Circle over at Pro-science. Go check out the rest of what is there.
 

In response to Eureka – Conventional Treatment Plus Placebo Beats Conventional Treatment Alone, there is a comment by RavenBlack.
 

You are mistaken, or at least the study (and other studies) doesn’t support what you say.

 

This study,[1] and other studies, make it clear that benefits of acupuncture are nothing more than the placebo effect. In the 2008 study,[2] the fake acupuncture was significantly more effective than real acupuncture.

How bad is a treatment, when faking the treatment is more effective than the real treatment?

At least, with real medicine, treatments that are demonstrated to be no more effective than placebo, are not adopted, or are discarded if they ever had been mistakenly adopted. To keep using these treatments would endanger patients. With alternative medicine, they just come up with excuses for continuing to use the failure. Alternative medicine is both a medical failure and an ethical failure.

Suppose the patient had subcutaneous emphysema, cysts in need of drainage, boils needing to be lanced, . . . there would be a medical benefit from the treatment? 😉

Back to the comment:
 

“Maybe, but it won’t make any more difference than any other placebo. Placebos can be helpful in treating pain. Why not go with something equally effective, but less expensive, less potentially infectious, and less involved?”

Different placebos have different levels of effect; in fact, between sugar pill A ($2, generic box) and identical sugar pill B ($10, posh-looking box) pill B is statistically significantly more effective. The cost (financial and otherwise) of your placebo makes it more effective, so you can’t just go with something equally effective, less expensive and less involved. The effectiveness is (to a point) proportional to the expense and involvement – which is why acupuncture is one of the better placebos!

 

It is true, that the perceived cost of the placebo influences the placebo effect. If you know that it is all placebo, the pill should not have any effect. The same is true for the acupuncture, since it is all in the mind, or changes produced by the mind. However, this is not true for some of the side effects of acupuncture, such as infection.

Why do proponents of alternative medicine continually defend telling lies to patients?

Look at the wonderful placebo effect!

Ooh! Ahh!

The study did not address cost, or at least did not mention it. I was just editorializing. I stick to generic medicines, because the added cost of name brand medicine is only an effective placebo if you believe that the more expensive it is, the better it is. I do not.

I have bills to pay, so there is no reason for me to waste money on something that is just an attempt to influence my perception of treatment.

There is already too much waste in health care. We should get rid of treatments that are nothing but placebo, or at least encourage lawyers to sue the practitioners for malpractice fraud. Malpractice would suggest that there was some medicine involved. Fraud is just an alternative name for alternative medicine.

Perhaps, people should buy expensive placebos from trusted family members.

Then there is the problem of whether treating with placebos is ethical. Of course, ethics is something that is a part of real medicine, but not a part of alternative medicine fraud. After all, treatment with alternative medicine is fraud.
 

(Also it has added “lying there and relaxing” over most placebos, which calls for a separate study since it may be the “lying there and relaxing” effect at play in this study, rather than [or in addition to] the placebo effect.)

 

The fake acupuncture had the same conditions as the real acupuncture, except that no needles were placed and in the first study. but not the second[2*] different sites were used for the imitation needles. The patients were not able to tell which treatment they were getting. Therefore, I do not see any reason to conclude that the fake acupuncture is anything other than an excellent imitation of real acupuncture. The real acupuncture, and even the super duper individualized acupuncture, did not do any better than imitation acupuncture.

Any untrained person was just as effective as the most highly trained acupuncturist. It is all about putting on a good show. Otherwise, there should have been some difference between the expert individualized acupuncture and the fake (intentionally wrong) acupuncture.

The older study showed that the real acupuncture did not even do as well as the fake acupuncture.

They could add in all sorts of treatments (such as relaxation) to compare them with acupuncture, but if real acupuncture is not as effective as an indistinguishable placebo, these studies would just be a waste of time, money, and opportunity. All of these could go toward treatments that might actually do some good – other than just doing good for the acupuncturists’ bank accounts.

This kind of rationalization only encourages the acupuncturists to keep trying, hoping that random variation in study participants will lead to them studying a very suggestible group that disproportionately falls into the treatment group.

The only reason to continue to study acupuncture would be the possibility that it does have a replicatable effect on some specific condition, but where is the evidence of that? And why keep trying with such a blatant failure? Time to give up and work on real medicine.
 

You seem to support the use of placebo, as long as it is expensive enough to bleed the patient, but not expensive enough to kill off the golden goose.

If the treatment becomes more effective as the price goes up, for some people, does that mean that we should raise the prices of all treatments, to get the most out of them.

You seem to suggest that an effect is all the justification needed for a cost, or even raising the cost. A treatment may be effective, but not worth the cost. An ineffective treatment is just not worth the cost, no matter how much you like alternative placebo medicine.

Patients with too much money, and not enough sense, may eventually find an equilibrium. With the health care reform proposals and the whining from Dr. Sen. Tom Harkin, that science us unfair to his alternative medicine nonsense, there will probably be more money wasted on this fraud. That deprives patients of effective treatments.

Of course, science is unfair to nonsense. Science is a way of identifying nonsense. The only surprise is that so many people are too gullible to understand that acupuncture is pure nonsense. The individualized acupuncture, which is the higher quality treatment from the acupuncture specialist, is also pure nonsense, just nonsense with better publicity.

The whole purpose of science is to be a nonsense detector (or a BS detector). Alternative medicine has been repeatedly failing its attempts to be categorized as anything other than nonsense, because alternative medicine is nonsense.

Science discriminates against nonsense.

Nonsense should be discriminated against.

Alternative medicine discriminates against patients.
 

Placebo Acupuncture = Acupuncture = Placebo

Placebo Acupuncture = Expert Acupuncture = Placebo
 

Remember, if alternative medicine worked, it would be able to get rid of the name alternative and just call itself medicine. Just the same as all of the other traditional treatments that have been able to show that they are better than placebo – more effective, fewer side effects, et cetera.

Alternative medicine is just another way of saying failure.

Alternative medicine practitioners are the Bernie Madoffs[3] of medicine – all fraud, all the time.

Acupuncture – It isn’t medicine, but the cost is real.

Footnotes:

[1] A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
Arch Intern Med. 2009 May 11;169(9):858-66.
PMID: 19433697

Free Full Text from PubMed Central.
 

In conclusion, acupuncture-like treatments significantly improved function in persons with chronic low back pain. However, the finding that benefits of real acupuncture needling were no greater than those of non-insertive stimulation raises questions about acupuncture’s purported mechanism of action.

 

[2] Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
Clin J Pain. 2008 Mar-Apr;24(3):211-8.
PMID: 18287826

[2*] Correction 01-07-2019 and 01-08-2019 – In this study real acupuncture sites were used, but not real needles, so this only examined the justification for using needles, not the effect of the locations. The other study[1] did use fake acupuncture locations and did show that the location also does not matter.

In a twist that the acupuncturist cannot explain, the patients outcomes were significantly better in the group that did not use real needles.
 

The sham group improved significantly more than the true acupuncture group during the treatment period, but this advantage was not sustained 1 month after treatment ended. The difference in pain between sham and true acupuncture groups at the end of treatment (0.75 points on 10-point scale), although statistically significant, probably does not represent a clinically discernible difference.

[3] Bernard Madoff
Wikipedia
Article

Added 01-10-2019 – In going through some old sources, I have been making a few corrections and occasionally adding updated information, such as this more recent study showing that acupuncture is just a placebo –
 

Acupuncture for Menopausal Hot Flashes: A Randomized Trial.
Ee C, Xue C, Chondros P, Myers SP, French SD, Teede H, Pirotta M.
Ann Intern Med. 2016 Feb 2;164(3):146-54. doi: 10.7326/M15-1380. Epub 2016 Jan 19.
PMID: 26784863

Free Full Text in PDF format from carolinashealthcare.org
 

CONCLUSION: Chinese medicine acupuncture was not superior to noninsertive sham acupuncture for women with moderately severe menopausal HFs. (Hot Flashes)

 

.

Jim Page – 5 Years Gone

Today is the 5th anniversary of the death of Jim Page. He was one of the people most influential in the shaping of EMS. He was the person continually pushing for progress in EMS. Dr. Bryan Bledsoe writes about Jim Page and talking with him at various points in his career. He quotes Jim Page a few times.

He said, “EMS needs to be pushed to a higher level.”[1]

Things have changed a lot in most places, but even in the more progressive places for EMS, there is no reason to stop pushing EMS to a higher level.

He then laid out a plan for what he thought I should do. He said, “Bryan, EMS is at a point where we need to move to the next level. Many of our practices are wrong — if not harmful. You are in a position now where it is your responsibility to the help make things better for the profession. You need to challenge the status quo.” Jim went on to detail some of the fallacies he saw in EMS. He specifically mentioned Critical Incident Stress Debriefing (CISD) and public-utility model EMS. So, I began to search the literature and eventually wrote a highly controversial eight-part piece called “Myths of Modern EMS” that was eventually published in EMS Magazine.

I never met Jim Page, but I feel some of his frustration. I have read The Magic of 3am.[2] This is a collection of essays he wrote over the years. I am amazed at how the same bad practices he criticized continue to be problems five years after his death. Why are we so resistant to making things better, not for ourselves, but for our patients?

While I never met Jim Page, from what I have read by Jim Page, I don’t know of anybody who does a better job of continuing to push for the improvement of EMS, than Dr. Bledsoe. He travels all over the place to talk at conferences, in spite of the opposition from the mindless, but very vocal, defenders of tradition.

In stead of an anniversary of the death of a giant of EMS, we should be celebrating the end of tradition in EMS. We are not there, yet.

Many of our practices are wrong — if not harmful.

EMS needs to change, continually. Tradition is resistance to change. Tradition is the enemy of our patients. The only tradition worth following in EMS would be to continually change to make things better, but that is an anti-tradition tradition.

You can find many of the papers Dr. Bledsoe has written on these topics at BryanBledsoe.com.

Some other people have written about Jim Page.

The EMT Spot A Man of Honor

Firegeezer Five years ago ….

JEMS.com Remembering Jim Page, which has several articles, including the one by Dr. Bledsoe.

Footnotes:

[1] I Miss Jim Page
Another Perspective
Bryan E. Bledsoe, DO, FACEP
JEMS.com
Article

[2] The Magic of 3am
James O. Page
Open Library page with links to libraries and book sellers.

.

Too Many Medics? comment from Anonymous

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

Sorry for the long post, but . . .

In the comments to Too Many Medics?, Anonymous wrote:

Grrr. Really trying to make an inflammatory post, aren’t we RM ?

Are you kidding? I tone it down to keep it nice and polite.

Couldn’t find a copy of the ACTUAL study, and I’m never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.

I don’t read horoscopes, but here is the abstract.

Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121:

Cardiac Arrest Survival Rates Depend on Paramedic Experience

Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.

The Ohio State University Medical Center, Columbus, OH,
University of Washington, Seattle, WA,
British Columbia Ambulance Service, Victoria, British Columbia, Canada,
University of Pittsburgh, Pittsburgh, PA,
Calgary Emergency Ambulance Service, Calgary, Alberta, Canada,
University of Washington, Seattle, WA,
St. Paul’s Hospital, Vancouver, British Columbia, Canada,
Calgary Emergency Medical Services, Calgary, Alberta, Canada

Objective

Out-of-hospital cardiac arrest (OOH-CA) survival varies widely among communities. We compared OOH-CA survival rates among 5 North American cities to identify factors that influenced survival.

Methods

The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) Trial was amulticenter randomized comparison of the effectiveness of manual chest compression versus AutoPulse during resuscitation of OOH-CA. Adults with OOH-CA were enrolled in five cities. Survival data collected in each city for patients in the manual arm of the trial were compared. Regression using generalized linear models was used to adjust for covariates.

Results

Younger women with witnessed ventricular fibrillation (VF) arrests in public locations who had short first response times had the best chance of survival. Victims receiving bystander cardiopulmonary resuscitation (CPR) had a trend to better survival. Time to advanced life support (ALS) vehicle arrival was not significant. The mean regression residual by site correlated with cases per paramedic per year (Pearson R = 0.97, p = 0.006).

Conclusions

Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.

Did, however find this nugget in ‘Emergency Medicine News’ from the MD that authored that study. Note his last comment in the excerpt.

Excerpt:

The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.”

“It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash.

For one thing, it’s a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive.

More Skilled?

He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don’t know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.

Nothing odd about it.

There is no evidence that any of the ALS treatments improve outcomes. So, why would it be important to have paramedics arrive at a cardiac arrest quickly?

The focus should be on excellent BLS care. ALS personnel should understand that and help with the BLS. Many probably do not. In stead, they interfere with the quality of the BLS.

BLS, unlike ALS, has been shown to improve outcomes from cardiac arrest. The longer they focus on the BLS, the better for the patient.

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD

Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

Study objective

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.

Methods

We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.

Results

We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.

Conclusion

In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

[Ann Emerg Med. 2009;xx:xxx.]

Benefit to the patient of these interruptions in BLS treatment?

No known benefit.

Cost to the patients of these interruptions in BLS treatment?

Whatever small chance at resuscitation they had is lowered dramatically.

Why?

We have to have more medics, so that they can interfere with BLS care.

Once everybody is a medic, we will probably continue to argue over who has to put up with doing the demeaning BLS stuff, even though that is all that works in cardiac arrest.

From the full text of this journal article:

Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difficult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States.26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion.13 Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions.29,30 The relative effectiveness of these techniques remains unknown.

Why interrupt compressions to intubate?

Why intubate, in cardiac arrest, if an alternative airway is faster?

Why intubate, in cardiac arrest, if an alternative airway is just as good at airway management?

Why rush a medic to a cardiac arrest if the medic makes things worse?

Also, the more medics you need, the less selective you can be in choosing the ones you end up with. If you are going to scrape the bottom of the barrel, because the supply cannot meet the demand, and you will not pay well, you will get bottom of the barrel quality.

Maintaining quality is also important. This study might suggest that PFD (Philadelphia Fire Department) would have an excellent resuscitation rate. From what I was last told, PFD is 250 medics short of being fully staffed. PFD has political obstacles to consistently providing quality care. PFD has some excellent medics, but not because of oversight. The excellent medics are excellent because they work at it on their own. They are balanced by others, who easily dredge up bottom of the barrel analogies.

So, it is not just about numbers. However, the more medics you have, the harder it becomes to maintain quality. The harder it becomes to obtain experience. The combination of quality and experience are important.

More medics means a need for more medical oversight.

Do these everyone a medic systems increase the number of medical directors to keep up with the increase in medics?

Do they aggressively work at simulations to make up for their lack of touch with reality?

This topic will eventually be studied and written about more fully. This particular study is not likely to be published in anything other than abstract form.

Here is a study from Boston, where the number of medics is low and the quality is high:

Volume 52, No. 4: October 2008; Annals of Emergency Medicine; page S153; abstract number 364:

Success Rates in Out-of-Hospital Intubation

Temin E, Harrington L, Mitchell P, Rebholz C, Dyer K, Doyle J, Hughes P, Moyer P/Massachusetts General Hospital, Boston, MA; Boston Medical Center, Boston, MA; Boston Emergency Medical Services, Boston, MA

Background

Previous literature has questioned whether out-of-hospital endotracheal intubation (ETI) success rates can be comparable to those performed in the emergency department (ED). Prior studies report ED success rates ranging from 80%–98% with success rates increasing with the experience of the provider. Large studies on ground out-of-hospital intubation report success rates ranging from 33%-100% and a 77% success rate for rapid sequence intubation (RSI), all after multiple attempts. Although Bulger et al 2002 has reported similar out-of-hospital ETI success rates to the ED, some question whether this success can be reproduced in other services. Boston Emergency Medical Services (BEMS) is a 2-tiered system with all advanced life support (ALS) trucks staffed by 2 paramedics. BEMS has a ratio of 0.5 paramedics to 10,000 population making it one of the lowest ratios in the country.

Study Objective

To assess the proportion of successful paramedic out-of-hospital ETI on adult and pediatric patients in a 2-tiered urban EMS system.

Methods

A retrospective chart review from 7/1/06 to 6/30/07 of ETI data from the Boston Airway Registry was conducted. The primary outcome was the success rate of ETI by number of attempts (blade passing through the lips) overall and for the following subgroups: Cardiac arrest prior to ETI, medically assisted intubation (MAI) (any medication), rapid sequence intubation (RSI) (paralytic and sedative), documented head trauma, and pediatric (age ≤ 12 years old) patients. We used descriptive statistics with 95% confidence intervals for analysis.

Results

ETI was attempted on 569 individuals by 61 paramedics. Two were excluded due to incomplete data. 361/567 (64%) of patients were male, mean age was 56 years. 455/567 (80%) had a cardiac arrest prior to ETI. 97/567 (17%) had ETI attempted with MAI. 77/567 (14%) had ETI attempted with RSI. 107/566 (19%) had documented traumatic injury, of those 73/104 (70%) had documented head trauma. Of the 10 pediatric ETI 4/10 were male, mean age was 2.6 years.

Conclusion

In this EMS system, paramedics achieved high success rates in all ETI, comparable to those reported in ED settings. Further research should determine provider and system factors that contribute to this success.

It is only a matter of time until the research is done. Until then we have to wade through a morass of intubation results from the everybody a medic systems.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.

Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.

Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]

Objectives

To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

Methods

Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an “endotracheal tube balloon below the cords” on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

Results

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

Conclusions

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

This is not a system with every person on every apparatus a medic, but their success rates are not good. Less than 80% success? 5% unrecognized esophageal tubes? We need to start improving quality or restricting skills to those who can actually demonstrate skill. Adding more medics only makes this quality problem worse. A system that is just doing more of the same is not one you want taking care of those you love.

Here is one from one of the happy everybody a medic Pollyanna places:

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed

Background

Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

Methods

A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

Results

One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

Conclusions

This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

From the full text of this journal article (PHI = Pre-Hospital Intubation):

The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews,1 support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

The 67% and 33% are a bit misleading. They are the percentages of the overall successful intubations, not the percentage of intubation attempts.

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

52% is still a number that should not be tolerated in intubation. There are 2 considerations not made clear.

How many of the failed intubations actually had intubation attempts?

How many intubation attempts did they have?

Maybe we need to include another data point? Total intubation attempts.

If almost all of the patients actually had intubation attempts and there were 2 attempts before moving to an alternative/rescue airway and some of the successful intubations were on the second attempt, then the success rate per attempt is possibly much lower than 1 in 3.

How many holes are we dealing with in the airway?

Hush. Let’s not be inflammatory. If we throw more medics at it maybe one of them will find the trachea.

In these everybody a medic systems a piñata might live for ever. The patients on the receiving end of the intubation attempts might be jealous of the piñata.

Even the flight crews only intubated 82% successfully. That is about the same as the ground medics in the Denver study above it. It is true that this is trauma, while the others are not limited to trauma.

At least to me, the most important conclusion from that study seems to be (PHI = Pre-Hospital Intubation):

Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

What about intubation in the system that had the highest resuscitation rate in the original study – Cardiac Arrest Survival Rates Depend on Paramedic Experience?

Here is an abstract from their 20 year study of intubations. These medics do use succinylcholine. So do the flight crews in Miami. They did break down their results into trauma intubations and medical intubations. How did this system do? They focus on keeping the number of medics low and the quality high. Let’s see:

Prehospital use of succinylcholine: a 20-year review.

Wayne MA, Friedland E.

Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Emergency Medical Services, Bellingham/Whatcom County Washington, WA 98225, USA. mwayne@cob.org

Objective

To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.

Methods

Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.

Results

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

Conclusion

Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.

They intubated 94% of trauma patients successfully over a 20 year period.

From the full text of this journal article is the most likely explanation for the high success rate.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.

I will repeat that Paramedic Intubation. It may be that intubation is the easiest way to measure paramedic quality. On the other hand, it may be that a lack of intubation skills is a good indicator of a lack of overall paramedic quality, rather than the other way around. It seems that many systems have a significant problem with quality. In some of these low quality systems, the attitude does not appear to be to fix the quality problems, but to make everyone a medic. How is more of the same an improvement?

EMS in Boston and Bellingham/Whatcom County take airway management seriously, while the everybody a medic people in Miami average 1 – 3 intubation per medic per year. After however many attempts at intubation, they still only get it half right.

What do the everyone a medic systems do about quality?

Miss.

A lot.

.

More on Abandonment, OHP and EMS

In the comments to Oklahoma Highway Patrol, Creek Nation EMS, and Abandonment, there is some continuing disagreement about abandonment. New York City’s Watchdog writes:

I think I may have already said this, but I can understand why the paramedic was resistant to being placed under arrest, since there was no equal or higher medical authority for him to transfer care therefore leaving him as the responsible party.

As the responsible party, it is the medic’s duty to the patient to behave responsibly. Fighting with, or resisting, the police is not responsible behavior. The medic can do much more to de-escalate the situation if he remains calm and reasons with the troopers. Fighting does not do anything to provide for the safety of the patient. Fighting endangers the patient.

If you really think that the troopers cannot be reasoned with, then the troopers might not have any problem fighting with the medic in the patient compartment, on top of the patient. Would that be in any way helpful to the patient?

Choosing to fight with the police is abandoning the patient.

I suspect that the medic realized this and that is why he stopped resisting. He might have been successful at resisting, but what happens during that struggle?

If the troopers are controlling the medic, how is he helping the patient?

If the troopers feel they are not controlling the medic, do the troopers use weapons?

What weapons do they use?

What danger do these weapons present to not just the medic and the patient, but to everyone around them?

If you believe that the troopers cannot be reasoned with, then you have to consider that unreasonable troopers might not stop short of shooting somebody. For example, if the medic’s partner steps in and is shot. Accidentally or intentionally. Are things now better?

Escalating to violence does not help the patient, no matter how wrong the trooper is in attempting to arrest the medic.

I’m not sure what OK law is regarding transferring care to a lower level, so I’m assuming it has to be to an equal or higher.

Resisting arrest is a crime, regardless of whether the arrest is justified.

The police were making a big mistake. That does not justify EMS in making big mistakes, too.

You may think that common sense would dictate that if indeed he allowed himself to be taken into custody that he would no longer be held liable for the well being of the patient,

I never wrote that if indeed he allowed himself to be taken into custody that he would no longer be held liable for the well being of the patient. I wrote that he is more likely to do a good job of caring for the patient by not resisting the police.

Look again at the possibilities, when the medic resists.

1. The medic is injured to the point, where the medic cannot continue to care for the patient. This is not abandonment with your approach to being arrested? The medic chose to fight, rather than advocate for the patient.

2. Family members jump in and get seriously injured, possibly leading to dramatically increased distress for the patient, worsening of the patient condition, and resulting in more patients needing care.

3. Police are injured while the medic is resisting. When there is a 10-13 call, how long does it take for more police to arrive? Given that the number of police on scene was increasing during the few minutes recorded, it is unreasonable to expect that the troopers will not soon have more help. What about the medic? Is he going to be getting any reinforcements? Is the outcome likely to be different if the medic resists successfully?

Yes, the big difference is that then the police are less likely to listen to anything he says.

The most important word in this situation is De-escalation. That is the way to deal with violent/potentially violent situations. Is there an exemption for a chance to hit a cop?

but common sense would also dictate that a law enforcement officer should not delay an ambulance crew from delivering a patient to the emergency room. Apparently common sense is in very short supply from the Oklahoma Highway Patrol, and therefore it is safe to assume that it would also be in short supply in their other law enforcement and judicial agencies.

If I want to find excuses to be violent, I do not have to be very creative. I think that trooper 606 demonstrates that. How does this help my patient?

Considering your cab and “run for it” examples, had he been placed in the patrol car, and then driven away from the scene, would you consider that abandonment?

It is not a given that if he does not resist, he will be driven from the scene in the trooper’s car.

The result of the medic ceasing his resistance was what led to a dialogue. That dialogue led to a resolution of the situation with the medic continuing care of the patient. It could have been quite different if the medic had continued to resist.

Just because things did work out, this time, does not mean that there would be the same result in a different situation.

The trooper attempting to arrest a medic caring for a patient is something that should not happen anywhere. That does not justify the medic abandoning responsibility for the care of the patient to engage in a fight with troopers – even if the troopers really deserve a beating.

The medic realized that his initial response, to resist and go to the patient, was not going to work out in the favor of his patient. He chose to cease his resisting. In stead of physically resisting, he reasoned with the troopers, as he should. This was the best choice for the patient.

This is about what is best for the patient.

The medic did what was right for the patient, although he seemed as if he wanted to take the troopers over his knee. The medic, Critical Care Paramedic Maurice White Jr., is to be commended for his self control and for putting his patient first.

The most complete information still seems to be from STATter911.

No charges to be filed in Oklahoma confrontation between trooper and EMS. DA wants incident to be used to open a dialogue. Urges OHP to release video.

STATter911 has half a dozen different links to statements from people involved. There are also links to news coverage.

OHP vs. Creek Nation EMS from the beginning, post by post:

Oklahoma Highway Patrol, Creek Nation EMS, and Abandonment 5/31/09

More on Abandonment, OHP and EMS 6/06/09

OHP Trooper Update 6/11/09

OHP Trooper Update II 6/11/09

OHP Trooper Update III 6/13/09

OHP Trooper Update IV – Holy Stammering Obscurantists 6/16/09

OHP Trooper Update V – Over an Hour of the Holy Stammering Obscurantist 6/17/09

OHP Trooper vs. EMS comment from anonymous 6/18/09

Some Corrections on OHP vs. Creek Nation EMS 6/20/09

OHP Trooper Update VI – A little Background on the Participants 6/22/09

OHP Trooper Update VII – A Little More Background on the Participants 6/22/09

Daniel Martin Suspended for 5 Days 6/22/09

Trooper Daniel Martin Subject of a Lawsuit 7/22/09

OHP Official Position – Don’t Get Caught On Camera, Otherwise Good Job. 7/23/09

An Interesting Development in the Daniel Martin Case 7/24/09

Trooper Daniel Martin In Trouble, Again 10/06/09

Maurice White Arrested 01/11/10

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Oklahoma Highway Patrol, Creek Nation EMS, and Abandonment

This is about the incident last week. You know the one. It is supposedly the second most watched video on YouTube. Everybody has been giving their opinions on it. Many commenters on news sites or on EMS forums claim that it is typical of the way police behave. Really? How many of you have been choked by the police while treating a patient?

Here is the video, for the few people, who might not yet have seen it. When the trooper’s dashboard camera is released, we will have much more information about what happened off camera (off camera as far as this video shot from a camera phone is concerned). The most information I have seen on this is at STATter911.[1]

There are plenty of things to comment on with the recent incident between OHP (Oklahoma Highway Patrol) and Creef Nation EMS.

Did the trooper get a bit carried away?

Yes. More than a bit, but not as much as many have suggested.

Should the trooper have waited until they arrived at the ED to interfere with the treatment of a patient by EMS?

Yes. Especially since it appears to be a crime that applies even to on duty OHP troopers. This should apply to any kind of assault/battery/interference with ED hospital personnel – doctors, nurses, techs, aids, janitorial staff, . . . . Nobody working in the ED hospital should be a free target for violence. No manager/administrator/accessory after the fact should ever be involved in this in any way that is not supporting hospital personnel. Everything should be reported. Interference with any report of violence in the the hospital should also be a crime, including especially if the person discouraging reporting is hospital administration. Discouraging the reporting of a crime is being an accessory after the fact, at least it should be, if that is not the interpretation of the law. Administration should be protecting employees, not using them as cannon fodder.

Should the medic have resisted being arrested?

No. He can more easily get the troopers to listen to him if he complies with everything they say. If he resists, things will not get any better. If he is compliant, and they listen, he may be able to convince the troopers to avoid making the biggest mistake of their careers. Others have stated that his partner should not have stopped for police. Again, I disagree. Not cooperating is only going to lead to escalation of the situation. Driving while trying to keep track of the police and trying to keep ahead of the police, while also not endangering other drivers is reckless. Is there any real difference between the medic resisting being arrested on scene and the partner refusing to stop for the police? If they arrest the medic on an ALS call, with no other medic on scene, the police are the ones depriving the patient of continuing care.

With an ALS patient, nobody other than that medic is able to continue care, until another medic shows up.

Should the medic stay in the patient compartment at all times, because leaving the patient compartment is abandonment?

Here is what the medic, Maurice White, responded to.

CowboyXXX wrote: 1st off what respectable Paramedic would get abandon his patient in the back of the ambulance to argue with an officer that was gonna ticket this partner. One key thing is if you have a bad patient in the back of your truck you will run lights and sirens. 2nd if an officer is gonna ticket you take the ticket and argue it in a court of law.[2]

The medic’s response is at the link in the footnote. Here are my comments, particularly on abandonment, which the medic does not really address.

I already mentioned that I agree about not resisting police.

What about using lights and sirens?

That is at the discretion of the medic. Since none of use were there, or even know a bit about the patient, we really are not in a good position to criticize not using lights and/or sirens. Then there is the lack of evidence that lights and/or sirens lead to reduced transport times. There are places where lights and/or sirens may make a significant difference, but where is the evidence to support this as a common style of transport? I rarely ask my partner to use lights and/or sirens during transport.

Lights and/or sirens?

Unless there is a requirement for using both at the same time, the driver should be deciding what is most appropriate for the traffic conditions, and modify that as traffic conditions change. State laws that restrict that judgment on the part of the driver, are dangerous laws. Discouraging critical judgment is dangerous.

What about the abandonment charge?

If an EMS provider leaves the patient compartment and no other EMS provider is in the patient compartment, that EMS provider has abandoned the patient?

Or

If a paramedic transfers care to a basic EMT, the paramedic is guilty of abandonment?

Are these abandonment?

It can be abandonment if a medic transfers care of a patient to someone not authorized to continue the care that needs to be continued. If the medic assesses a patient, sees no need for ALS care, and transfers care to one or more basic EMTs, so what? I have done this many times. When I worked on a 911 responder vehicle, if the patient did not appear to need ALS care, I released the patient to the BLS crew and notified dispatch that I was available. When I have worked with a basic EMT partner, I would never have a break from patient care, if this were abandonment. If I am driving, I am not in the patient compartment.

What about leaving the patient alone in the patient compartment?

If a doctor or nurse walks out of a hospital room, leaving the patient unattended, is that abandonment? Do we need to lock up all of the doctors and nurses? Why would that be different? Do EMS workers smell better? Is it a pheromone treatment?

But doctors and nurses have more than one patient each, so it is different.

The number of patients determines if leaving the room is abandonment? So, if the nurse only has one patient assigned, that nurse may not leave the room until relieved or until another patient shows up. Is that even remotely realistic?

Don’t believe me? Here is a quote from an article on abandonment. The author is a lawyer, paramedic, and has been an administrator. Her assessment is more relevant than mine.

Abandonment is sometimes defined as the unilateral termination of the provider/patient relationship at a time when continuing care is still needed. It is a form of negligence that involves termination of care without the patient’s consent. To prove abandonment, a plaintiff must show that a patient needs care — that a medical provider has entered into a relationship to provide care to that patient, and then either stops providing care or transfers care to a person of lesser training when the patient needs the higher level of training.[3]

So stepping out of the patient compartment, to attempt to explain to the troopers that there is a patient in the back, is not abandonment?

If he got out and fled from police – that would probably be abandonment.

If he got out, flagged down a taxi, and left the scene – that would probably be abandonment.

Getting out of the patient compartment, while the patient is alone in the patient compartment, is not abandonment.

Why do we lie to our students about this? Is EMS so simple that we need to make up stupid stuff to worry about? More likely, we come up with all of these urban legends as a way of trying to have some certainty about the job. This is an absolute rule. Do not disobey. But there are no absolutes in EMS. We need to encourage the people spreading these urban legends to not talk/write without some evidence to support their tales.

Abandonment by leaving the patient compartment.

Trendelenburg.

Lights and Sirens.

MAST/PASG.

Controlled substances are dangerous.

ALS is important in resuscitation.

Et cetera. See my EMS Mythology Starter Kit post, which I need to follow up on.

Many of these lies can be found in the textbooks, state regulations, and protocols. We need to distrust everyone in EMS.

We need to have a better understanding of what we are doing. Maybe then we will not be so gullible when told these silly urban legends. When we are told something, we need to consider. Does that make sense? If we ask this more often; If we then followed up on the other questions raised; we might actually start to act like professionals. In stead we fall for any nonsense somebody tells us. We don’t limit the belief of nonsense to what comes from old timers and/or authority figures. If it is a rumor, it must be true. We always know what we are talking about.

OHP vs. Creek Nation EMS from the beginning, post by post:

Oklahoma Highway Patrol, Creek Nation EMS, and Abandonment 5/31/09

More on Abandonment, OHP and EMS 6/06/09

OHP Trooper Update 6/11/09

OHP Trooper Update II 6/11/09

OHP Trooper Update III 6/13/09

OHP Trooper Update IV – Holy Stammering Obscurantists 6/16/09

OHP Trooper Update V – Over an Hour of the Holy Stammering Obscurantist 6/17/09

OHP Trooper vs. EMS comment from anonymous 6/18/09

Some Corrections on OHP vs. Creek Nation EMS 6/20/09

OHP Trooper Update VI – A little Background on the Participants 6/22/09

OHP Trooper Update VII – A Little More Background on the Participants 6/22/09

Daniel Martin Suspended for 5 Days 6/22/09

Trooper Daniel Martin Subject of a Lawsuit 7/22/09

OHP Official Position – Don’t Get Caught On Camera, Otherwise Good Job. 7/23/09

An Interesting Development in the Daniel Martin Case 7/24/09

Trooper Daniel Martin In Trouble, Again 10/06/09

Maurice White Arrested 01/11/10

Footnotes:

^ 1 UPDATE: Oklahoma troopers officially identified. Medic seen being choked tells more in a comment posted on a website. Read Maurice White’s response.
STATter911
Dave Statter
He has been updating this very frequently. I have not found another site with so much information or such frequent updates.
Article

^ 2 UPDATE: Oklahoma troopers officially identified. Medic seen being choked tells more in a comment posted on a website. Read Maurice White’s response.
STATter911
Dave Statter
Article
The same as Footnote #1.

^ 3 Patient Abandonment: What It Is — and Isn’t
EMS and the Law
W. Ann Maggiore, JD, NREMT-P
2007 Oct 4
JEMS
Article

Then there is a second part on abandonment that is on a different part of abandonment and some of the difficult decisions that need to be made. The most important aspect seems to be – act in the best interest of the patient without endangering yourself.

Patient Abandonment Part Two
EMS and the Law
W. Ann Maggiore, JD, NREMT-P
2008 Feb 7
Article

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EMS Mythology Starter Kit

We believe in all sorts of dangerous ideas about EMS:

OLMC (On Line Medical Command requirements) protect patients.

RLS (Red Lights and Sirens) saves a lot of time.

Replacing blood with NSS (Normal Saline Solution) or LR (Lactated Ringer’s solution) saves lives.

Long board immobilization protects patients from spinal injuries.

Basic EMTs cannot safely apply a spinal clearance protocol.

It is more important to stabilize the head and neck, than it is to assess and treat the patient.

High flow oxygen is good for everybody. If some is good, more is better.

Furosemide (Lasix) is a good treatment for ADHF (Acute Decompensated Heart Failure).

Naloxone (Narcan) is harmless and it helps to identify heroin overdoses.

Intubation is airway control.

Without an OPA (OroPhayngeal Airway) or NPA (NasoPharyngeal Airway), we cannot provide a good BLS (Basic Life Support) airway.

Helicopters are used appropriately in EMS.

Most patients transported by HEMS (Helicopter EMS) are seriously injured patients.

HEMS use does not delay arrival at the trauma center.

CISM (Critical Incident Stress Management) is a good way to deal with stress.

Steroids are good for spinal injuries.

Sedation and pain management are things that EMS cannot do safely and effectively on standing orders.

SSM (System Status Management) is wise use of resources.

Traction splints protect against femoral artery lacerations.

Real medics/nurses/doctors do not need Waveform Capnography to confirm tube placement.

NTG (NiTroGlycerin) is just for chest pain, not ADHF.

A protocol, that limits what a medic can do, is safe.

Beta natriuretic peptide (Natrecor) is the future if ADHF treatment.

CPAP (Continuous Positive Airway Pressure) is too heavy to bring in to the patient.

CPAP is just an ALS (Advanced Life Support) treatment.

MAST (Medical Anti-Shock Trousers) saves lives.

MAST acts just like a transfusion of blood.

ASA (Aspirin – Acetyl Salacylic Acid) is not an important treatment.

Amonia inhalants should be used in EMS.

Epinephrine improves cardiac arrest outcomes.

Amiodarone improves cardiac arrest outcomes.

Lidocaine improves cardiac arrest outcomes.

Atropine improves cardiac arrest outcomes.

Sodium Bicarbonate has been moved so far down in the ACLS (Advanced Cardiac Life Support) guidelines because it has no real uses.

Sodium Bicarbonate is the first drug for hyperkalemia.

Sodium Bicarbonate is the first drug for acidosis.

Prehospital treatments are effective at warming up hypothermic patients.

The Golden Hour is not just a marketing tool.

Eclampsia only happens during pregnancy.

Heat stroke is when the overheated patient can no longer sweat.

We carry naloxone for opioid overdose, so we should carry flumazenil (Romazicon) for benzodiazepine overdose.

Endotracheal drug administration is not harmful.

An experienced medic can tell right away, whenther someone is faking being sick.

Paramedic-initiated refusals are a good idea.

Morphine is dangerous for cardiac chest pain.

On an infant we should assess the brachial pulse.

Pulse oximetry is used properly by EMS.

If it wheezes it is asthma.

If it crackles it is ADHF.

ADHF will have pink frothy sputum.

Benzodiazepines need to be given slowly to actively seizing patients.

D50W (50% Dextrose in Water) is the right treatment for adult hypoglycemia.

We need to use a credit card, or razor, to remove a bee stinger.

CO (Carbon Monoxide) Poisoning will produce cherry red skin.

If you really want to restrain a patient, you have to hog tie them.

Medics can’t intubate well.

Medics can’t intubate children well.

Medics can’t use RSI (Rapid Sequence Induction/Intubation) well.

TASERs cause VF (Ventricular Fibrillation).

Diminished breath sounds mean a tension pneumothorax.

Cross-training is not dangerous.

More medics means better EMS.

Fire Department EMS is good for EMS.

We have to clear from this call quickly, so we can keep ambulances available for the next call.

HIPAA means the hospital cannot share information with you.

This won’t hurt.

That didn’t hurt.

We don’t do that.

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

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

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

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

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

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

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

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

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

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

Is this a problem in trauma?

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

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

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

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

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

What does a pulse indicate?

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

Nothing else?

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

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

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

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

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

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

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

Clearly, there should be some research on this.

Footnotes:

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

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

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

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

Prepublication History of Manuscript

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

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

A – Alcohol

E – Electrolytes and Encephalopathy and Endocrine

I – Infection and Insulin

O – OverDose and Oxygen

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

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

I – Infection and Insulin, again

P – Pharmacy and Psych and Porphyria

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

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

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

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