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

- Rogue Medic

MedicCast – EMS and Health Care Workplace Violence on Federal Radar


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

Jamie Davis at the MedicCast writes – EMS and Health Care Workplace Violence on Federal Radar. He also refers to a MedicCast podcast that has not yet been posted, but will be worth listening to when it is posted.

I completely agree with what he writes.

As with people who are not convicted of crimes, because of extenuating circumstance (such as a low blood sugar), the lack of conviction does not mean that the violence did not happen. The lack of a criminal conviction does not mean that nobody was hurt or killed. The lack of a criminal conviction does not even mean that an arrest was inappropriate.

We are covering up violence by not reporting violence.

We are encouraging violence by not reporting violence.

We are pretending that violence that did not result in hospitalization did not happen. Then we are surprised when there is violence that results in hospitalization. When we provide excuses, we encourage excesses.

This is also a problem in the hospital. Nurses are discouraged from reporting violence and from pressing charges. We need to do a much better job of reporting violence.

I continually criticize Zero Tolerance Laws, because the idea that everything in the same category should be treated with at least some punishment completely ignores that the category will include things that do not deserve punishment. On the other hand, I support Zero Tolerance reporting of violence.

Translated from French, the painting states, This is not a pipe. This is true, since it is a picture of a pipe. Rene Magritte’s The Treachery Of Images is often used to make this point.

If a picture of something were the same as the object portrayed, I would take this picture of gold bars from Fort Knox to someone who could pay me for the gold. This would quickly destabilize civilization, which would not be a good thing. As it turns out, the image is from an article about fake gold bars in Fort Knox. How would we be able to tell the difference between a picture of the real thing and a picture of a fake? Since a fake is creating an image of the real thing, would it matter?

How is this relevant?

One of the problems with Zero Tolerance Laws is that they do not make this distinction between reality and appearance.

Zero Tolerance Laws mandate punishment for a politically incorrect appearance.

Zero Tolerance Laws discourage judgment – Sentence first, verdict afterward.

Zero Tolerance Laws are designed to prevent us from thinking, because What if somebody makes a bad decision?

Zero Tolerance Laws are excellent examples of extremely bad decisions.

Zero Tolerance reporting helps to make us aware of the problem and helps to do something about the problem.

Zero Tolerance reporting of violence is a way to learn just how bad a problem is.

Zero Tolerance reporting of violence is a way to prevent violence from being ignored.

Assaults on medical personnel are a real problem.

Assaults on medical personnel are not imaginary.

We need to start acting as if the lack of reporting of violence means that violence is not real.

Today, Magritte might paint a picture of an assault on a doctor/nurse/EMT and write This is not a reported assault. Imagine if we were to do something completely crazy – imagine if we were to face reality.

Go read what Jamie wrote. He is the one providing the details about workplace violence and medical personnel.

.

Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients


ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

The EMS Garage also covers pain management on the 5/08/10 podcast. Pain Management: EMS Garage Episode 85. Go listen to that, as well. Chris Montera, Dr. Keith Wesley, Will Dunn, Kyle David Bates, Kelly Grayson, and I discussed several aspects of prehospital pain management.

I have been meaning to cover the research on prehospital pain management for a long time. I did write about one excellent study of fentanyl.[2] Currently, the big obstacle is that there is now so much research to cover. Back in the 1990s, when I would try to persuade doctors that prehospital pain management was safe, there was very little to show to support that statement. A common medical command order was for 0 mg morphine, but we could repeat that as often as we liked. Some times we would get orders for 2 mg morphine and sometimes have the possibility of repeating that dose one time.

From the title of this, you can see that the authors take a dim view of that kind of dosing. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. This study was just on adults, so we should consider the size of an adult. I consider ballpark figures for a small adult to be 50 kg (110 pounds), a medium sized adult to be about 80 kg (176 pounds), and a large adult to be about 110 kg (231 pounds), although there does not seem to be any shortage of people significantly larger than that.

Using these very rough estimates, 0.1 mg/kg would be 5 mg morphine for a small adult with severe pain. The title of the article states that this dose would be inadequate for most patients with severe pain. If the common doses of morphine that used to be given were 0 mg, 2 mg, and 4 mg, were we doing anything more than relying on the placebo effect for the majority of pain relief?

If 5 mg is inadequate for a small patient with severe pain, 8 mg is inadequate for a medium patient, 11 mg is inadequate for a large patient, and there are plenty of much larger patients, what good was a typical dose of 2 mg morphine, assuming that the doctor would be generous enough to even give orders for this dose? Another reason for putting off writing about this has been my attempt to avoid making this just a rant about neglect of patients with severe pain.

Let’s assume that you are not a misanthrope. You are not the kind of person to hurt strangers, just because you can get away with it. You might even occasionally apply the Golden Rule of Do to others as you want them to do to you. What would you want done to you?

0 mg morphine? This can be roughly translated to non-medical terminology as, What are you crying about? I am the one who has to listen to your crying!

2 mg morphine? Even for the small adult, this does not come close to the 0.1 mg/kg that the authors state is inadequate.

2 mg morphine with a repeat dose of 2 mg morphine? At least we are moving away from a complete placebo dose in the small patient, but in the medium sized patient, this is not much different from the single dose of 2 mg for the small patient. For the large patient, this is still just a placebo. For the extra-large patient this is just a very bad joke.

After all of that, what does the actual study state?

A standard means of taking into account the heterogeneity of analgesic response in treatment is titration of dosage, with small increases of dose over short periods of time. Some emergency medicine texts recommend a range of doses (eg, 0.05 to 0.15 mg/kg)6; others provide a single dose (eg, 10 mg)7 or a single weight-based dose (0.1 mg/kg)8 with the proviso that the dose should be titrated to desired analgesic effect. There is little evidence about whether these recommendations are routinely followed in ED care.

Although titration is a goal for optimal management of acute pain, a first step is to assess the recommended starting dose. Given the various recommendations for intravenous morphine, ranging from 0.05 mg/kg to 10mg, we chose to assess the analgesic response to the recommended weight-based dose of 0.1 mg/kg. The purpose of this investigation was to quantify the proportion of patients in acute pain who had less than a 50% reduction in pain intensity 30 minutes after intravenous administration of 0.1 mg/kg of morphine.[2]

Arguments can be made that this endpoint is as valid as reduction of pain to less than 3 out of 10. Farther down, I will compare the results if 3 out of 10 had been used.

patients were eligible if they were between 21 and 65 years of age, spoke English or Spanish, or had acute pain with onset within the past 7 days. Exclusion criteria included previous use of methadone, use of other opioids or tramadol within the past 7 days, previous adverse reaction to morphine, chronic pain syndrome, altered mental status, pregnancy, use of monoamine oxidase inhibitors in the past 30 days, systolic blood pressure less than 100 mmHg, or inability to provide informed consent.[2]

Those are all reasonable exclusions.

Patients were asked by the research associates to rate their pain intensity at baseline and 30 minutes post baseline. Peak analgesia from intravenous morphine is achieved within 5 minutes of administration in most patients.9,10 Clinically, 30 minutes seemed to be a reasonable time within which adequate analgesia should be achieved in patients with severe pain. Further, it is unlikely that an analgesic effect would be missed with this interval because the elimination half-life of morphine is 2 to 4 hours.9,10 [2]

I confess. I only checked the abstracts for footnote 9[3] and footnote 10[4] cited for morphine reaching peak effect within 5 minutes. I do not feel that 5 minutes is accurate for peak effect. For peak serum levels, 5 minutes may be correct. When acute pain patients start discussing their serum morphine levels with me, then I will wonder about this, but not before then. I will address the onset of effect of morphine and the peak effect in covering other acute pain research that more directly addresses this.

I feel that an assessment of pain at 30 minutes will not miss a significant amount of the pain relief that morphine will provide.

On the side, I have provided parts of the chart from the study that shows the change in pain levels at 30 minutes. this is the caption – Figure.

Distribution of 30-minute pain score by baseline pain score.*

*Shaded area indicates number and percentage of patients whose pain scores decreased <50%.[2]

In other words, if a patient’s rating of their pain started at 10 out of 10, the shaded area extends down to the top of 5 out of 10. If a patient’s rating of their pain started at 8 out of 10, the shaded area extends down to the top of 4 out of 10. You can see how many patients remained in the less than 50% relief by the shading.

Pain is generally rated on an 11 point scale from 0 being no pain. Some people like to start at one, feeling it is more important to have the scale only have ten points, but end at ten. So 1 is nothing for them. I feel much more comfortable explaining to patients that nothing means nothing. Actually, I find that I do not have to explain the concept of zero. For somebody experiencing severe pain, I expect that zero is their desired level of pain.

10 out of 10 is the worst pain imaginable. Dr. Wesley had a very imaginative way of expressing this on the podcast.

For the patients starting with the pain level of 10 out of 10, 68.1% did not have relief of at least 50%. That number really does not tell us a lot, but it is less than one third, so that means a lot of patients with very little relief. We are not describing complete relief of pain, but only a reduction of 50%. Less than 1/3 having a 50% reduction in pain level is pathetic.
 

15.9% had no relief at all.
 

None.

15.8% had a decrease in pain to 3 out of 10 or less. The difference is just due to rounding. Both percentages represent 13 out of 82 patients. I added up the fractions, so that the numbers on the chart match my numbers. For patients with an initial pain level of 10 out of 10, a decrease of 50% is expected to be much more likely, because the target also includes patients with a decrease in pain to 4 out of 10 and patients with a decrease in pain to 5 out of 10.

For these patients, it would not have mattered if we had started at 0 mg morphine, 2 mg morphine, 4 mg morphine, or the larger dose of 0.1 mg/kg. There was no improvement. I know what you’re thinking.

At least the pain did not get worse.

How would we know? Maybe their pain did get worse, but they didn’t have any higher number to use to tell us. Maybe they just initially rated their pain higher than they should have. It happens. This is one of the problems of the pain rating scale – subjectivity.
We also have too many people who feel quite comfortable under-treating the pain of other people. I do not think they should be making pain management decisions. Well, maybe they would be more appropriate making pain management decisions if they were intentionally torturing people.

If a lack of compassion/lack of empathy is a problem for healthcare providers, perhaps this is one criterion that we can use to identify those who might be better off being seamlessly integrated into the exciting field of fast food service. These paramedics, viewing patient care with a Quantity is Job One approach, will not be missed by patients. A lot of people have been saying that we should find a way to eliminate those without empathy from the classrooms.

They feel that it is easier to teach people to be paramedics, than it is to teach empathy. I am not convinced, but this is certainly worth considering.

Now, let’s look at the patients who were slightly better off. They only rated their pain as a 9 out of 10, initially. How did they do?

74.9% had less than a 50% relief of pain. One problem here is that half of 9 is 4 1/2. There is no 4 1/2 out of 10 on the list. Patients who started with a pain level of 9 out of 10 needed to lower it to 4 out of 10for the purposes of it being considered a 50% decrease in pain for this study.

How would things have been different, if we split the 3 patients in half? Don’t worry, when we get to the overall numbers, we end up with an even number. No procrustean methodology is intended. These 3 patients make up 25% of the patients who initially rated their pain 9 out of 10. If we split that in half, we would have 62.4% with a 50% reduction in pain. If we considered all of the 4 out of 10 patients to have had a 50% reduction in pain, then the split is 50% of the 9 out of 10 patients with a 50% reduction in pain.

The 8 out of 10 patients had 16.7% with no change in pain. A 50% reduction in pain was reported by half of the 8 out of 10 patients.

The 7 out of 10 patients had the most interesting changes. None of the patients had the same pain level as initially. 40% of the 5 patients with7 out of 10 pain (2 patients) had an increase in level of pain. This is the kind of thing that is supposed to be impossible. Apparently, impossible is a bit over-rated.

How could a patient receive such a large dose, at least compared with what has been considered the normal dosing, and not only not improve, but have an increase in pain? Not just one patient, but 2 patients.

There is always the possibility of drug diversion, but during a study, with more people paying attention to what is going on, that is even less likely than under normal circumstances.

The 7 out of 10 patients had the worst improvement of all. Some had their pain increase, but none of them had a more than 50% improvement in their pain. Zero.

If you were to use the same approach as with the 9 out of 10 patients and count a change to 4 out of 10 as a 50% improvement, since there is no 3 1/2 out of 10, you would still have 80% with less than 50% improvement.

Finally, there are the 6 out of 10 patients. Both improved to 4 out of 10, which means none of them had more than 50% improvement in their pain.

Overall, more than 2/3 of severe pain patients had a less than 50% improvement in pain. Even if you added in the patients who improved to 5 out of 10 from 9 out of 10 and the patient who improved to 4 out of 10 from 7 out of 10, you only end up with 63.9% improving by less than 50%. Just under 2/3.

The primary measure of adequate analgesic response to morphine is percentage of reduction in pain intensity dichotomized into less than 50% versus greater than 50%. Although there are other measures, we chose a 50% or greater reduction in pain because this threshold has been used frequently in pain meta-analyses and has the appeal of quantitative simplicity and easy clinical interpretation. Patients’ age, sex, and pain location were obtained from the medical record or the patient. Ethnicity was self-reported. Additional administration of analgesics was ascertained from the records and consultation with the ED staff. Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff and thus were under constant supervision. The research associates monitored the patients carefully as well. Vital signs were routinely measured by the nursing staff at 0, 15, and 30 minutes. For the purposes of the study, the research associates monitored the oxygen saturation, blood pressure, pulse rate, and respiratory rate at 0 and 30 minutes. Patients were reassessed by the clinical staff if systolic blood pressure was less than 100 mm Hg, pulse rate was less than 60 beats/min, or respiratory rate was less than 12 breaths/min to determine whether an opioid antagonist was needed. If oxygen saturation dropped by more than 5%, the patient was reassessed, and oxygen was administered at a fraction of inspired oxygen that returned the oxygen saturation to its baseline level. Patients whose presenting oxygen saturation was 95% or less were given oxygen on presentation.[2]

How many patients ran into problems from this larger than normal dose of morphine?

One patient was reassessed by the medical staff because the respiratory rate was 12 breaths/min, 1 patient’s oxygen saturation dropped more than 5%, 2 patients had a systolic blood pressure less than 100 mg Hg, and 8 patients had a pulse rate less than 60 beats/min (range 52 to 60 beats/min). None of the patients required administration of an opioid antagonist at any time during the 30-minute study period or for 2 hours thereafter.[2]

Not any problems that required any kind of intervention that could not be handled by a basic EMT, never mind a medic with all sorts of advanced implements of destruction. Essentially, with 10 minutes of training and authorization to add oxygen, people from registration and housekeeping could have manged these patients safely.

The protocol specified a dose of 0.1 mg/kg morphine to be given intravenously during 1 to 2 minutes. Because of rounding up or down, some patients received weight-based doses that varied slightly from the specified dose. Before data analysis, we decided to accept weight-based doses ranging from 0.09 to 0.11 mg/kg as meeting the protocol criterion for a 0.1 mg/kg standardized dose.[2]

Earlier, I mentioned that a decrease in pain to a level of 3 out of 10 is commonly used. In this study of severe acute pain, there was a less than 50% decrease in the pain level for 67% of patients.

What if the goal had been a reduction of pain to 3 out of 10, rather than the easier to reach reduction of 50%?

82% of patients did not reach the 3 out of 10 pain level.

An 82% failure rate when the goal is a pain level of 3 out of 10, or better.

A 67% failure rate when the goal is a 50% decrease in pain, or better.

People continue to tell me that this is not a problem. However, these people are not the patients with severe pain. These people are the administrators, the medical directors, the nurses, and other paramedics. In other words, the people denying the problem are the ones supposed to be making sure that this problem does not happen.

Things are improving, but it would be difficult for things not to improve. A lot of this improvement is due to research. This dismal starting point I attribute to the paranoia of the What if . . . ? crowd. They would rather restrict something they do not understand, than learn how to use it properly. They are very dangerous. Fortunately, abundant research is pointing out the ridiculous nature of their restrictions on pain management.

LIMITATIONS
Our sample is almost entirely composed of poor, inner-city Hispanic and black patients. Given the many cultural influences perception and expression of pain, it is quite possible that prevalence of poor response to morphine in other settings and other populations may differ from what we have reported. Because a convenience sample was recruited when trained research associates were present, the findings might have differed if consecutive patients had been enrolled. The patients in this study had heterogeneous locations of pain, having in common only high pain intensity and need for opioid analgesics. However, this reflects the true variety of clinical emergency practice. Some of the pain, though severe, was episodic and fluctuating. Thus, assessment of it at 30 minutes using a single numeric rating scale reading may not provide an accurate overall reflection of the degree of pain relief experienced during the preceding half hour. There is no a priori reason, however, to postulate that this methodology of sampling produces bias because pain that is changing over time seems about as likely to worsen as it does to improve throughout a constant interval.
[2]

Pain of 3 out of 10 is often used, because this is a decrease to mild pain, rather than severe or moderate pain. There is much more that can be said about the ways of measuring pain, but I am not going to do that, today.

This study assessed an initial dose of morphine that is consistent with starting doses recommended in standard texts.6-8 [2]

This dose clearly provides inadequate analgesia, and it may well be higher than what is routinely administered in many EDs.[2]

To summarize. 0.1 mg/kg should only be viewed as a starting dose.

Some of you may be wondering why I am using a study of morphine administered by doctors in an ED as a surrogate for morphine/fentanyl administered by paramedics before arriving at the hospital. The paramedic is as close to the patient as you are to the computer screen. How does a competent paramedic miss significant changes in patient presentation under those circumstances? There are incompetent paramedics. They should be remediated, but if they are not capable of providing competent care, they need to explore areas of employment where their lack of competence is less dangerous. There is no obligation by any employer to endanger patients by protecting the jobs of less than competent paramedics.

In the hospital, the doctors and nurses are assessing and treating other patients, documenting patient care, restocking, dealing with other patients, et cetera. If anyone believes that there is closer observation in the ED, than in a competently staffed ambulance, please provide some evidence to support this extraordinary claim.

Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff and thus were under constant supervision.[2]

That may seem reasonable to someone who has never set foot in the Montefiore Medical Center’s ED. This is not meant as a sleight to anyone working there. There are times when all sorts of craziness is going on and the claim that, without some staff member directly assigned to their care, any patients thus were under constant supervision, is not believable. In EMS, we almost always have more providers than patients. In the ED, the reverse is true. This is unavoidable.

The quote actually states, Patients in this study were placed near the physicians’ and nurses’ station, directly in the line of sight of the staff. That leads up to a conclusion that is inappropriately drawn from the first part of the sentence. The conclusion should be that because patients were directly in the line of sight of the staff, if the staff actually did look up and did focus their eyes on the patients directly in their line of sight and did decide to assess the appearance of those patients, then the patients could be said to be thus under occasional intermittent supervision at a distance. To claim that these patients thus were under constant supervision, is an unreasonably optimistic exaggeration.

Footnotes:

[1] Public Perception of Pain Management
Rogue Medic
Article

[2] Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients.
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
PMID: 16187470 [PubMed – indexed for MEDLINE]

[3] The diposition of morphine in surgical patients.
Berkowitz BA, Ngai SH, Yang JC, Hempstead J, Spector S.
Clin Pharmacol Ther. 1975 Jun;17(6):629-35.
PMID: 1139854 [PubMed – indexed for MEDLINE]

The disposition of serum morphine following administration of 10 mg/70 kg was determined by a sensitive and specific radioimmunoassay in 31 anethetized surgical patients ranging in age from 23 to 75 yr. Following iv injection, 93 per cent of the morphine disappeared from the serum within 5 min. The early serum levels of the drug (2 min) correlated directly with the patients’ ages (r equal to 0.63, p smaller than 0.01). Patient 23 to 50 yr of age averaged 0.29 mug/ml, whereas patients 51 to 75 ur of age averaged 70 percent higher, 0.49 mug/ml. The serum half-life between 10 and 240 min was independent of age and averaged about 2 hr after either iv or im administration. Following im admininstration, morphine was rapidly absorbed, with peak levels occurring within 10 to 20 min. The decline in morphine serum levels paralleled the decline in morphine analgesia and was coincident with the apperance of morphine glucuronide in the serum. These studies demonstrate the applicability and specificity of the radioimmunoassay for morphine and suggest that serum levels of morphine may be a useful and objective indicator of its pharmacologic activity.

[4] Kinetics of intravenous and intramuscular morphine.
Stanski DR, Greenblatt DJ, Lowenstein E.
Clin Pharmacol Ther. 1978 Jul;24(1):52-9.
PMID: 657720 [PubMed – indexed for MEDLINE]

The disposition of parenteral morphine was assessed in two pharmacokinetic studies. In Study 1, 10 mg of morphine sulfate was administered by intravenous (IV) infusion, intramuscular (IM) injection, or both, to 8 healthy young adult male volunteers. Plasma morphine concentrations were determined by radioimmunoassay in multiple blood samples drawn after each dose. Mean (+/-SE) kinetic parameters following IV morphine were: volume of distribution (Vd), 3.2 (+/- 0.3) L/kg; elimination half-life (t1/2beta), 2.9 (+/- 0.5) hr; clearance, 14.7 (+/- 0.9) ml/min/kg; extraction ratio, 0.70 (+/- 0.04). After IM morphine, peak plasma levels ranged from 51 to 62 ng/ml and were reached within 20 min of injection. The absorption half-life averaged 7.7 (+/- 1.6) min. Systemic availability was 100% complete. In study 2, 4 elderly male patients (61 to 80 yr of age) received 45 to 80 mg of morphine sulfate IV prior to operative repair of an abdominal aortic aneurysm. Morphine pharmacokinetics were determined as described above. Kinetic variables were Vd, 4.7 (+/- 0.2) L/kg; t1/2beta, 4.5 (+/- 0.3) hr; clearance, 12.4 (+/- 1.2) ml/min/kg; extraction ratio, 0.59 (+/- 0.05). Both studies demonstrate that morphine distribution is rapid and extensive and its t1/2beta relatively short. IM morphine is rapidly and completely absorbed.

BIJUR, P., KENNY, M., & GALLAGHER, E. (2005). Intravenous Morphine at 0.1 mg/kg Is Not Effective for Controlling Severe Acute Pain In the Majority of Patients Annals of Emergency Medicine, 46 (4), 362-367 DOI: 10.1016/j.annemergmed.2005.03.010

.

Ignorance

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

This morning I wrote about ignorance in Double Edged Swords.

What do I do about my own ignorance?

I try not to ignore it. Although I could have fun with the concept of ignoring ignorance. My ignorance is infinite and growing.

The stuff that I do not know is growing more quickly than I can possibly learn new things. Then, there are all of the things I forget. Clearly, this is a losing battle.

I should just give up, right?

No.

Much more important than knowing any particular facts, is the ability to understand how to determine if something is true. For example –

Is this going to be on the test?

This is not a question that will help me to learn what is true. While the answer does fall into the category of true/false, what is really being asked is, How much ignorance can I maintain, while obtaining a passing score on the test?

This question is likely to come from someone satisfied with a response of, Because I said so, as long as it means that he/she does not have to do more work. If that answer does mean more work, it is likely that there will be complaints about the answer.

This response is likely to come from someone who can be described as blissfully ignorant. Someone who would argue vehemently about being called ignorant, but would not do anything to avoid actually being ignorant.

There is a limited amount of information that I can learn in any day. I can read, talk with people, learn by doing (for example, patient care situations can teach me about different responses to illnesses/injuries and to treatments), I can think about something that is complicated and hope to develop a better understanding of the subject, I can ask questions about things that I do not understand or I can ask questions to improve my understanding of something (this may convince me that I really do not understand something that I thought I did understand), et cetera. There are many things I can do. Sometimes, the best thing I can do is to take a break and just relax.

One thing that I should not do is accept an answer that does not make sense. If the answer does not appear to make sense, then that may be an indication that I do not understand what I am trying to understand. Because that is the way it works, is not understanding and is not even close to a good explanation.

There are plenty of things that I do not understand. That is OK. The important thing is to keep learning, keep evaluating what I am learning, and to keep trying to improve my understanding.

This is why I question so much of what we do in EMS. If I do not ask questions, I do not learn. If the answers do not make sense, I need to figure out if it is because I do not yet understand, or because the answer does not make sense, or something else.

At the top of this blog (and along the side), I have some quotes that relate to understanding. One of my favorite quotes is –

It is better to not understand something true,
than to understand something false.

Neils Bohr

This is one of the biggest problems we have in EMS. So much of what we claim to know/understand is completely ridiculous just not true. Rather than eliminate treatments that are based on ignorance – treatments that are based on understanding something false – we come up with excuses.

There is no good excuse for defending willful ignorance.

Willful ignorance harms our patients. We need to stop justifying this abuse of patients.

We need to keep asking the questions about patient care that make people uncomfortable.

We need to keep improving assessment, treatment, and judgment.

Most of what I learned in paramedic school is wrong.

I can deny that statement, I can defend that statement, or I can admit that I have a lot of ignorance to correct.

How can I justify how I treat patients, if I do not keep trying to learn what is best for patients? Learning is constant change.

Most of what I learned in paramedic school depends on understanding something false.

We are better than that.

Our patients deserve better than that.

.

Double Edged Swords

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

A post at Paramedicine 101, by Medic999, raises some important questions. Chronicles of EMS – A double edged sword? This is what I think addresses the most important part of the way we do things and why we do them differently in different places.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do.

That is the human thing to do, to assume that our leaders are making the right choices.

I take the opposite approach. I want our leaders to prove that what they are doing is good for patients. Not that their way is the best way, but that their way can be demonstrated to be good for patients.

Most of what we do in EMS fails that test.

Why should we continue to use these experimental treatments?

Why should we continue to we continue to be guided by ignorance?

Medic999 points out that he was unaware of some possible improvements to patient care. Now he wonders why his protocols do not include treatments like therapeutic hypothermia.

We often will dismiss something because it is a foreign idea. If you want to have a political idea ridiculed, one of the quickest ways is to suggest that it came from France, except if you are in France. As if the origin of an idea has anything to do with the quality of the idea.

There is nobody so perfect that he/she never produces a bad idea. Conversely, we should not assume that there is such a perfect fool, that he/she never produces a good idea. To assume that the origin of an idea is more important than the idea, is itself a bad idea.

Unfortunately, Not originated here means not used here is EMS dogma in many places.

We come up with excuses to avoid changing things.

We act as if our patients will be better served by avoiding improvements in EMS care.

If we are not here to provide the best care to our patients, shouldn’t our patients be protected from us?

One objection that I repeatedly hear from EMS traditionalists is that, We have to be able to say that we did everything we could for the patient.

The parts they leave out are –

As long as the idea originated here!

As long as we don’t have to change the way we do things!

As long as we don’t have to sit in a classroom, or read, or do anything else that would be considered learning!

As long as the patient does not expect us to provide excellent patient care!

As long as we get to spend more time stroking our egos than we spend on improving patient care!

Chronicles of EMS is a double edged sword. Through Chronicles of EMS, Medic999 has more knowledge about what EMS does in other places. Now he is less satisfied with the way things are done where he works. His satisfaction level has decreased because his knowledge level has increased. This is where the term ignorance is bliss comes from. The more we know, the less satisfied we are with traditional solutions.

But this is not about satisfaction. The decrease in satisfaction is only due to looking at things the wrong way. With more knowledge we have the ability to make improvements that make things better for patients.

When we learn that most patients flown to trauma centers did not benefit from being flown, we realize that we are contributing to the excessive death rate among flight crews when we call for more flights, which leads to more helicopters, which also leads to a greater dilution of experience for flight crews. Tradition tells us to fly patients based on mechanism of injury. This allows the blissfully ignorant EMS personnel to think that they snatched the patient from the jaws of death.

When we learn that by rushing to perform ALS procedures during CPR, we have been neglecting the quality of chest compressions. When we improve the quality of chest compressions, we triple the survival rate – the real survival rate, not the misleading and short term return of a drug induced pulse. This is the first improvement in survival to discharge. This only came by discarding the traditional way of doing things.

When we learn that intubation is performed horribly in many places, some of us work to improve our intubation skill, some move to alternative airways much more quickly, some do both, while traditionalists just claim that it is more important for them to intubate, than to provide competent airway management.

Ignorance can be bliss. Tradition can be bliss. Both can also be deadly for our patients.

Knowledge is a double edged sword, but it is much better to provide excellent patient care than to hide behind That’s the way we’ve always done things!

Medic999 is not suggesting that blissful ignorance is better. He is pointing out that the more he knows, the more problems he becomes aware of. This is not a bad thing.

If we are not aware of the problems, we will not correct the problems.

If we do not correct the problems, our patients suffer.

The more we know, the less satisfied we are with traditional solutions.

Our goal should be the protection of our patients by the destruction of our traditions.

Over at Medic999, there is a vigorous discussion in the comments to CoEMS – A Double Edged Sword.

.

The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival


ResearchBlogging.org
Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

A recent study looks at The association between emergency medical services staffing patterns (the number of paramedics dispatched on an ambulance) and out-of-hospital cardiac arrest survival. They make some interesting observations.

We tested the hypothesis that two or more paramedics at the scene of OHCA would be correlated with a higher rate of survival to hospital discharge.[1]

Since there were at least 2 paramedics on scene, they really compared the presence of 2 medics with the presence of 3 medics and with the presence of more than 3 medics. OHCA is Out-of-Hospital Cardiac Arrest.

Paramedic treatment of cardiac arrest is provided by protocol and direct medical oversight.[1]

An interesting interpretation of the word direct. A medical command physician is available by phone or radio for consultation/orders. This is historically the way direct medical oversight has been interpreted, but it requires some flexibility in the interpretation of the meaning of direct. The word oversight requires similar flexibility, since the physician depends entirely on what the medic says, except for the medical command physicians who perversely just say no to everything.

Cardiac arrests resulting from a drug overdose, suicide, drowning, hypoxia, exsanguination, stroke, or trauma were excluded from the study. Also excluded were cases in which no crew configuration or responding unit information was available, cases in which no resuscitation effort was attempted, and cases in which no time data were available.[1]

It is reasonable to exclude some of these causes, since they are not standard medical cardiac arrests and do not contribute significantly to resuscitation statistics. The intent of the study seems to be the effect of the number of medics on standard cardiac arrest. Trauma is reasonable to exclude, since resuscitation from traumatic arrest is, for all practical purposes, zero percent. Movies and TV suggest otherwise, but there is nothing about chest compressions that reverses blood loss, TBI (Traumatic Brain Injury), pneumothorax, cardiac tamponade, or other traumatic causes of sudden death. On the other hand, there are some causes of cardiac arrest that do respond to chest compressions, such as commotio cordis[2], [3] or lightning strike,[4] that might appear to fall into the trauma category. Cardiac arrest due to stroke may have resuscitation outcomes as dismal as trauma.

Why exclude cardiac arrest due to hypoxia? Are they looking only at airway obstruction as a cause of hypoxia? Does this include anaphylaxis or asthma? What about CHF (Congestive Heart Failure), which could be categorized as hypoxic or as cardiac? These are questions that were not addressed.

There is no explanation for any of these exclusions anywhere in the paper. Are these excluded because the authors consider resuscitation to be so unlikely that they would only contribute a more zeros to the data?

If a paramedic responded as part of the first response unit’s crew, the paramedic was not counted as being part of the crew configuration. The independent variable was categorized solely on the number of paramedics present in the responding ALS unit crew. Milwaukee County EMS operates with a minimum of two paramedics on ALS ambulances. During the study period, there were no cases treated by one paramedic.[1]

In other words, although we are looking at whether more medics lead to better outcomes, we will set aside cases where the medics are first responders, unless those first responders are responding on an ambulance. Interesting, but it is difficult to tell if this would have any influence, since no numbers are reported. If medic first responders are rare, it probably will not have any effect on outcomes. Not having data, we do not know if it is rare. If medic first responders are common, this should not be ignored as a variable.

It might be nice to evaluate the effect of paramedic first responders. Even though there does not appear to be any benefit from having paramedics treating cardiac arrests, as first responders or otherwise, some systems are adopting the practice of having every responder be a paramedic. These systems seem to encourage the belief that, even though paramedic treatments do not improve outcomes, the sight a lot of paramedics on scene is more important than anything that might actually improve outcomes. There is no need to address things that matter, when we can put on an impressive show, unless survival is important.

Neurologic status at discharge was not available.[1]

Too bad. That could be useful information to have.

There were sufficient data to analyze 10,057 (98%)cases.[1]

That is very good.

FIGURE 2. Frequencies of cardiac arrest outcome by year in Milwaukee County.
ROSC = Return Of Spontaneous Circulation.
I added the red circles and green squares to make it easier to identify the lines. Nothing else was changed about this chart.

The most interesting thing that I notice is that increases in one of the surrogate end points (ROSC) seems to indicate drops in the end point that matters – survival to discharge. While they did not have access to the neurological status at discharge, this information seems to contradict what everyone claims is important about resuscitation – If we don’t have ROSC, we cannot improve survival to discharge.

In the above chart, as ROSC increases, survival to discharge decreases. Is this statistically significant? I don’t know, but it appears to be pretty consistent. The numbers are not provided by years, but the trend can be determined from the chart. Below, I list the the changes from year to year in ROSC (Return Of Spontaneous Circulation) and in Survival (survival to discharge from the hospital).
= year to year decrease. = increase. = no change. More arrows = more change.

1993 to 1994         ROSC               Survival

1994 to 1995         ROSC               Survival          

1995 to 1996         ROSC ⇑⇑⇑⇑     Survival              

1996 to 1997         ROSC ⇑⇑            Survival            

1997 to 1998         ROSC ⇑⇑            Survival          

1998 to 1999         ROSC ⇓⇓⇓        Survival

1999 to 2000         ROSC ⇑⇑            Survival

2000 to 2001         ROSC ⇓⇓⇓        Survival            

2001 to 2002         ROSC ⇑⇑            Survival ⇓⇓        

2002 to 2003         ROSC ⇑⇑            Survival ⇑⇑

2003 to 2004         ROSC               Survival

2004 to 2005         ROSC               Survival ⇑⇑        

I need to point out that this study was not designed to examine any connection between ROSC and survival to discharge. The yearly data are not included, so I am only looking at the direction of change of the bars connecting one year to the next. Out of 12 years, the change in percentage of ROSC is the same as the change in percentage of survival only 5 times. Sometimes these divergences are dramatic. Almost every big change in ROSC had an opposite change in survival.

As percentage of ROSC improves, percentage of survival seems to decrease. Maybe we need to stop obsessing about improving ROSC and just work on the more complicated problem of improving long term survival, which is all that really matters.

it appears that even though there was a medication change in the treatment protocol, changes to the American Heart Association guidelines, advances in abilities, training, equipment, CPR performance, and variation in hospital care, survival to hospital discharge remained stable during the study period. This may indicate that we have not yet identified the factors that are crucial to improving survival and that more research is needed to find the ideal treatment for cardiac arrest.[1]

Contrariwise, it may indicate that we have already found the most effective paramedic/ALS (Advanced Life Support) treatment. We are just unwilling to accept it, because we cannot believe it is that simple. Excellent continuous compression CPR interrupted only by rapid defibrillation.

We do not need paramedics for this. Therefore the number of paramedics on scene may only lead to interference with effective treatment.

It is important to note that, as is shown in Table 1, crews with two paramedics treated fewer cardiac arrest cases with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia than crews with three or more paramedics. Yet the unadjusted and adjusted odds ratios demonstrated that two paramedics conferred a survival advantage. This seems counterintuitive and may indicate an even stronger association between crew size and survival.[1]

If there is a bias in the data, it is likely one that hides the magnitude of the harm to patients from more paramedics.

The Milwaukee County EMS system operates with a minimum of two paramedics on ALS ambulances. During the study period, no cases were treated by one paramedic. A single paramedic’s influence on outcome was not able to be evaluated.[1]

The data do appear to be stating that the more paramedics on scene, the less likelihood that the cardiac arrest patient will leave the hospital alive.

When adjusted for variables previously correlated with cardiac arrest survival and referenced against crews with two paramedics, patients treated by crews with three paramedics (0.83, 95% confidence interval [CI] 0.70 to 0.97, p = 0.02) and crews with four or more paramedics (0.66, 95% CI0.52 to 0.83, p < 0.01) were associated with reduced survival to hospital discharge.[1]

The number of paramedics does not appear to interfere with ROSC, only with long term meaningful outcome.

The studies of ALS interventions keep pointing out the increased ROSC with ALS interventions. Unfortunately, the surrogate endpoint of ROSC does not appear to lead to improved survival to discharge.

Standard cardiac arrest treatment has led to more of an emphasis on continuous compressions and defibrillation. Standard cardiac arrest treatment still includes epinephrine, amiodarone, atropine, intubation, and intravenous access – treatments that have repeatedly failed to show improved survival to discharge.

During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.[5]

By supported by strong evidence, they mean that there is not any evidence of improved survival to discharge with drugs, IVs, endotracheal tubes – anything other than good continuous compressions and defibrillation.

Maybe this study means that the more people capable of performing less-than-helpful treatments, the more likely that less-than-helpful treatments will be given.

Perhaps, with the next revision of the cardiac arrest guidelines, we will make the ethical decision to limit treatments to those that have been shown to improve survival, rather than subjecting everyone to these treatments that have not been shown to improve survival.

Footnotes:

[1] The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival.
Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB.
Prehosp Emerg Care. 2010 Jan-Mar;14(1):71-7.
PMID: 19947870 [PubMed – indexed for MEDLINE]

[2] An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis)
Link MS, Wang PJ, Pandian NG, Bharati S, Udelson JE, Lee MY, Vecchiotti MA, VanderBrink BA, Mirra G, Maron BJ, Estes NA 3rd.
N Engl J Med. 1998 Jun 18;338(25):1805-11.
PMID: 9632447 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM         Free PDF from NEJM

[3] Protecting our children from the consequences of chest blows on the playing field: a time for science over marketing.
Link MS, Bir C, Dau N, Madias C, Estes NA 3rd, Maron BJ.
Pediatrics. 2008 Aug;122(2):437-9. No abstract available.
PMID: 18676560 [PubMed – indexed for MEDLINE]

Free Full Text from Pediatrics         Free PDF from Pediatrics

[4] Electric Shock and Lightning Strikes
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 10.9: Electric Shock and Lightning Strikes
Free Full Text         Free PDF

[5] Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Access for Medications: Correct Priorities
Free Full Text         Free PDF

Eschmann, N., Pirrallo, R., Aufderheide, T., & Lerner, E. (2010). The Association between Emergency Medical Services Staffing Patterns and Out-of-Hospital Cardiac Arrest Survival Prehospital Emergency Care, 14 (1), 71-77 DOI: 10.3109/10903120903349820

.

Intubation as a Right – No Practice required

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

I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done… and Do we make a difference?

As if I don’t already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters

Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. 🙂

9-ECHO-1’s description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don’t believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking – not stirring – the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.

Isn’t this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.

9-ECHO-1 wrote –

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.

In the comments, I responded –

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.

9-ECHO-1’s response included –

I have read all of the studies about intubation and its ‘failings’. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can’t hit the right hole, and then don’t recognize when it comes out or we missed completely.

I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren’t starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn’t know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.

If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient’s airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again – even in some all medic systems.

That isn’t airway management.

Also, less than 8 – intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.

I didn’t even get to comments on Do we make a difference? That will be another post.

The Airway Continuum is essential reading for anyone interested in intubation and airway management.

.

Journal Club 3: Episode 53


ResearchBlogging.org
Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

Of the two podcasts I had the opportunity to be on this week, this one is more to my liking, due to my desire to increase the use of research-based treatments. Having the lead author of one of the studies on the show was another positive. Greg Friese hosts Journal Club 3: Episode 53.

There is a much more thorough discussion of these papers on the podcast.

The papers covered are:

Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama.
Harris D, Willoughby H.
Resuscitation. 2009 Nov;80(11):1275-9. Epub 2009 Aug 20.
PMID: 19699021 [PubMed – indexed for MEDLINE].
Presented by Rob Theriault.

This study raises a lot of interesting questions about the way that people learn about making end of life decisions, what they anticipate the outcome of resuscitation will be, and even how medical professionals may respond to skills presented in TV medical dramas.[1]

Dismissing TV dramas as trivial ignores the effect that they may have on members of the audience, up to and including doctors.

The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care.
Jensen JL, Petrie DA, Travers AH; PEP Project Team.
Acad Emerg Med. 2009 Jul;16(7):668-73.
PMID: 19691810 [PubMed – indexed for MEDLINE].
Presented by Joe Clark.

This is a study that deserves several posts to cover, so I will not even start here. As with the other studies, this paper is discussed on the podcast.

My impression is that this resource is wonderful. If you know of a relevant paper that they do not cover on the site, send them a link to it. As with all of science, this will always be a work in progress, but that is certainly not a bad thing.

Canadian Prehospital Evidence Based Protocols.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.
Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, Snooks H, Perrin J, Nicholl J.
BMJ. 2007 Nov 3;335(7626):919. Epub 2007 Oct 4.
PMID: 17916813 [PubMed – indexed for MEDLINE].
Presented by Bill Toon.

In the US, we have studies that show an inability of the medics (at least the medics in US studies) to be able to safely direct patients to alternative destinations, such as an appointment with a general practitioner. Is the basic EMS education difference, between the US and the UK, the reason?

This study does show that specially trained experienced paramedics can identify stable patients and safely direct these patients to more appropriate resources than the Emergency Department (Accident & Emergency in the UK).

This is an education program that appears to focus on critical judgment, rather than protocol adherence. If done the right way, this should be good for patients, and therefore good for EMS and hospitals.

The full text PDFs of the three papers discussed on the podcast are available for free (until the next EMS EduCast Journal Club) at the Journal Club page of the EMS Educast.

Special guests on the show are Joseph F. Clark, PhD of JosephFClark.com and Jan Jensen of the Canadian Prehospital Evidence Based Protocols.

Footnotes:

^ 1 Positioning prior to endotracheal intubation on a television medical drama: perhaps life mimics art.
Brindley PG, Needham C.
Resuscitation. 2009 May;80(5):604. Epub 2009 Mar 18. No abstract available.
PMID: 19297069 [PubMed – indexed for MEDLINE]

Inadequate positioning of the head and neck was especially prevalent prior to intubation attempts, and improving this was seen as a simple but important first step.

As part of ongoing nationwide efforts to ensure basic resuscitation skills5 we explored all potential causes for the inadequate positioning, and this included trainees’ prior experiences. Many trainees reported limited supervision or hands-on training. Remarkably, however, when asked how they had therefore learned, after “trial and error”, a surprising number answered that television medical dramas had been an important influence.

Of the remaining 22, none (0/22) achieved more than one, let alone all three, components of optimal airway positioning. In terms of individual components, the lower cervical-spine was flexed in 0/22, the atlanto-occipital joint extended in 1/22, and the ears level with the sternum in only 3/22 cases.

While few would suggest that medical dramas can be held responsible for physician performance, it has been previously suggested that they can significantly influence beliefs.6, 7

This does show that ignoring the effect of medical dramas has the potential to be harmful to patients.

Harris, D., & Willoughby, H. (2009). Resuscitation on television: Realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama☆ Resuscitation, 80 (11), 1275-1279 DOI: 10.1016/j.resuscitation.2009.07.008

Jensen, J., Petrie, D., Travers, A., & , . (2009). The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care Academic Emergency Medicine, 16 (7), 668-673 DOI: 10.1111/j.1553-2712.2009.00440.x

Mason, S., Knowles, E., Colwell, B., Dixon, S., Wardrope, J., Gorringe, R., Snooks, H., Perrin, J., & Nicholl, J. (2007). Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial BMJ, 335 (7626), 919-919 DOI: 10.1136/bmj.39343.649097.55

Brindley, P., & Needham, C. (2009). Positioning prior to endotracheal intubation on a television medical drama: Perhaps life mimics art Resuscitation, 80 (5), 604-604 DOI: 10.1016/j.resuscitation.2009.02.007

.

Correction on Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.

ResearchBlogging.org

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

In Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial,[1], [2] I missed some important information. I think I expected more detail to be in the text, than in the charts and figures, so I did not read Figure 2 carefully enough. Regardless of the reason, I did miss some important information.

In response, Anonymous left this comment –

RM: I was doing some reading on this article and came across your commentary. I am unsure if you will even see this since your blog was posted a few months ago, but I just thought I would clear something up for you and anyone else who reads your commentary. You seem to have done an inadequate job of reading and understanding this article.

Yes, I did.

Specifically, you state that a major shortcoming of the study is that 10% of the no-IV group received IV medications. You actually go on make a joke about “falling on a IV” as being an unacceptable excuse.

Sometimes I think I am funnier than I actually am.

If you had read the article closely you would have noticed a perfectly adequate explanation for this, as well as the 18% of the IV med group who did not receive meds.

Yes. It is not hidden. It should not have required a close reading, but I did miss both of these.

The reason the no-IV did receive drugs was because of ROSC (Return Of Spontaneous Circulation) then subsequent new cardiac arrest (27), hospital admission (13), breach of protocol (5)…45/433=10%. I would argue that 5/433 (1%), is pretty good for a study of this magnitude.

I agree. However, if the breach of protocol had been 10%, that would have been ten times higher and reason for comment. Clearly the breach of protocol was not that high and my criticism was inappropriate.

Paramedics often make mistakes. Arrests are stressful. It seems unreasonable for you to criticize this study for 5 episodes. It would be difficult if not impossible for the researchers to have controlled that any better short of being in every ambulance. I hope this sheds a little light on the topic for you.

I agree. I was wrong. Thank you for correcting me.

On the other hand, I think that cardiac arrests should not be stressful. We spend so much time on teaching the use of medications, advanced airways, and IVs. We have no evidence that any of these lead to better survival. These unproven interventions are just more to distract EMS from what has been shown to work by good evidence. We create unnecessary stress.

What you pointed out only lends more support to conclusion of the study – that IV medications do not improve outcomes from cardiac arrest. There still is no evidence that routine use of IV medication does anything to improve survival from cardiac arrest. Without evidence to show improved survival, these treatments should only be considered experimental.

In the bizarre world of medical research in the US, these experimental treatments have become the standard of care. The lack of research cannot be overturned with anything less than the highest quality research. That research is more likely to be done outside of the US, because it is considered unethical to deprive US study participants of a standard of care, even though there is absolutely no evidence of improved survival with the standard IV medications in cardiac arrest.

Anyway, back to my errors. I made the same mistake with the protocol deviations in the IV arm of the study.

442 Randomized to intravenous administration group

418 (95% of 442) Included in primary analysis

24 (5% of 442) Excluded due to predefined exclusion criteria

17 (4% or 442) Cardiac arrest witnessed by ambulance crew

6 (1% or 442) Resuscitation not attempted

1 (<1% or 442) Traumatic etiology

344 (82% of the 418 Included in primary analysis) Intravenous drug administration established and administered as randomized

74 (18% of 418) Intravenous drug administration not established prior to end of resuscitation

42 (10% of 418) Restoration of spontaneous circulation before intravenous administration

12 (3% of 418) Inability to establish intravenous access

12 (3% of 418) Intravenous administration considered futile

8 (2% of 418) No explanation given

For the information already mentioned by Anonymous –

474 Randomized to no intravenous administration group

433 (91% of 474) Included in primary analysis

41 (9% of 474) Excluded due to predefined exclusion criteria

17 (4% of 474) Bystander physician ordered treatment

14 (3% of 474) Cardiac arrest witnessed by ambulance crew

5 (1% of 474) Resuscitation not attempted

4 (1% of 474) Traumatic etiology

1 Asthma-induced cardiac arrest

388 (90% of 433 Included in primary analysis) No intravenous drug administration established or administered as randomized

45 (10% of 433) Intravenous drug administration occurred

27 (6% of 433) Restoration of spontaneous circulation and new cardiac arrest

13 (3% of 433) Hospital admission

5 (1% of 433) Breach of protocol

I am a bit confused by the meaning of Hospital admission. Were these EMS responses to treat patients in hospitals? Elsewhere Hospital admission is used as a measurement of short term outcome – whether the patient survived to the hospital. Survival to the hospital is just a short term outcome that has led to the adoption of treatments which have later been shown to increase long term harm. therefore, these short term outcomes probably should be ignored, rather than highlighted.

For the IV group, there were 2% listed as no explanation given, but nothing specifically listed as protocol violations.

Rather than an IV/No IV approach, blinded randomization to use of a placebo syringe/active drug syringe should not be that much more difficult.

And we need to stop the ethicists from forcing experimental treatments on unsuspecting uninformed patients in the name of ethics.

Footnotes:

^ 1 Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Rogue Medic
Article

^ 2 Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed – indexed for MEDLINE]

If you want to read the entire study, this link opens it in PDF.

Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, & Wik L (2009). Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA : the journal of the American Medical Association, 302 (20), 2222-9 PMID: 19934423

.