Rogue Medic

TOTWTYTR - EMS 2.0, Again

2009-11-06T02:22:00.001-05:00

Too Old To Work, Too Young To Retire has a nice post on EMS 2.0, but from a slightly different perspective - EMS 2.0, Again - Or "Ten Tools that Basic EMTs Need".

Before you start reading and get all kinds of upset about these things needing ALS, stop and think. For one thing TOTWTYTR has thought about this before writing it. He is one of the clearest thinking people in EMS, even when he does disagree with me about EMS. I do not disagree with him about anything on this list. Go read his explanations, nice short explanations, and learn.

These are for Basic EMTs.

10. CPAP. 9. Epi Pens. 8. Narcan. 7. Aspirin. 6. Glucometer. 5. Albuterol nebulizers. 4. A better airway than the OPA or NPA. 3. AEDs. 2. Mad CPR skills.

1. Better assessment skills.

This is not a Letterman List. These are all serious suggestions.

The assessment skills are important before being able to implement some of the others, but why do we not demand excellence in assessment already?

I know.

I know.

The NR (National Registry of EMTs) says that they know what is good enough.

The NR pretends that the NR's incompetent very very structured assessment of an EMT's assessment of an actor is valid.

Yes, the patient is unstable. Trust me. . . . Really. I can tell from here. Yes. Even with my eyes closed. No. I'm not peeking. There is no judgment involved. Not even a little bit.

If the NR does not know how to assess EMT skills, how would the NR possibly recognize the two most important parts of a real competent assessment?

Thoroughness. You cannot assess properly, if you miss what is wrong. This is not to suggest that there is anything wrong with a focused assessment.

Flexibility. This is essential, unless you believe that all patients will present as NR scenario actors do.

The OCD (Obsessive Compulsive Disorder) at NR is at the point where they should probably be involuntarily committed. They are a danger to others.

The most important word in the English language is Why? This word is stricken from the NR vocabulary formulary. Why? Because Why? has too much potential for independent thought and that most evil of evils - Critical Judgment.

Maybe if we just put a bunch of Ativan in the drinking water at NR HQ.

Now before you go back and look at the picture at the top of the post. Do you want an assessment that meets NR standards, which are unethically low, or do you want a real assessment by a real EMT? A real EMT is someone who has been properly trained in assessment, not in performing an OCD ritual that is no different from learning the steps to a witchdoctor's medicine dance.

OK. Look at the picture.

A lack of critical judgement means that almost everyone on that plane is dead. NR does not like critical judgment. NR likes dead.

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EMS 2.0: Critical Thinking in Prehospital Training

2009-11-05T03:11:00.001-05:00

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

Even though EMS 2.0 may not be any more successful at changing EMS than previous efforts at improving patient care, it does seem to be getting more attention. One place is EMS1.com. The names do not share etymology beyond the letters EMS, although both have been wise enough to get Kelly Grayson to contribute. Kelly is also the author behind A Day In the Life of An Ambulance Driver.

Kelly wrote an article called EMS 2.0: Critical Thinking in Prehospital Training. In the article, he does make reference to my blog, but that is not the reason for this post. Although, he does summarize many of my points very nicely.

He also mentions a debate on paramedic-initiated refusals. A debate that I have not commented on, because I have not been able to sit down and read through enough comments to get caught up to the current comments. This is a debate that has also taken place many times before.

Here is an example of the commentary -

"We've got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!" they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.

This is the essence of the problem. Too many people still believe that the right technology will produce a foolproof^TM paramedic/nurse/doctor/et cetera.

Too many people still believe that the right technology will produce a foolproof^TM human.

This completely ignores the Law of Unintended Consequences.^{^TM} This law is far too important and entertaining to ignore.

In another article on EMS1.com, Stop Talking, Dan White suggests that providing continuous transmissions of all of the information we are looking at in the ambulance - ECG, SpO₂, EtCO₂, BP, et cetera - will lead to more concise communication with the ED. While he means well, I think that he is overlooking the probability that the Unintended Consequence gremlins are just waiting to pounce. As Kelly writes -

All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools.

Many places have made pulse oximetry a BLS skill. How many of them use it appropriately? Nursing homes regularly send patients to the ED because of a low sat.

The fancy equipment does not lead to better care. It often only leads to toggle switch care. Sat of X or less = emergency. Sat of more than X = no problem. There is nothing in between. Everything is either an emergency, or does not meet treatment criteria.

Less than 8 - intubate. More than 8 - procrastinate.

Or should our patients receive airway management from someone who has an understanding of airway managment that goes beyond a nursery school rhyme?

Kelly continues with -

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal.

Adding to the EMS scope of practice presumes that we are already good at what is in our scope of practice. The debate about paramedic-initiated refusals is an example of this. How many paramedic schools spend any time on education about which patients do not need to go to the ED? It is not really something we receive training to do, so it is no surprise that when we arrogantly do what we are not trained to do, we provide many examples of incompetence.

At one place where I used to work, they kept track of what happened to patients who refused or were triaged to BLS after being assessed by paramedics. Their main criterion was whether the patient ended up in the ICU. Unless something changes dramatically in the patient presentation, none of these patients should end up in the ICU. Yes, some stubborn refusals will, but the chart should reflect that the paramedic saw the potential for significant complications and did not just say, OK. Sign here.

I have seen refusals, where the full narrative is - Medical command consents to refusal. Patient signed AMA form. Available at XX:xx. Indicating a total scene time - leaving the vehicle, assessing the patient, contacting medical comand, getting a signature from the patient, and notifyinging dispatch that the medic is available - of less than 5 minutes. The medic is only surpassed by the medical director in lack of attention to the problem.

Some of you may argue that things aren't that bad. You may know of EMS educational programs that excel at turning out capable EMTs.

There are excellent programs. These excellent programs exist in spite of the National Registry's No Paramedic Left Behind dog and pony show.

The National Registry does not just share responsibility with the bad EMS programs for the pathetic state of EMS education, the National Registry pushes the envelope to the point where stupid, dangerous, and irresponsible all begin to sound like compliments.

But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it's not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.

Sad, but true.

It's when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we'll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.

There are many, who suggest that all we need to do is to require more education to improve EMS. All it takes is a degree to make EMS a respectable profession. As long as we keep doing things the same way, does it matter if we require 3 months of misinformation?

What if we require 6 months of misinformation?

What if we require 1 year of misinformation?

What if we require an Associate's degree in Misinformation?

What if we require a Bachelor's degree in Misinformation?

What if we require a Master's degree in Misinformation?

Should we just pile it higher and deeper?

Until we get rid of the misinformation in EMS education, it does not matter how much time we spend making students memorize misinformation - we are not providing a useful education. We are not protecting patients.

There are schools that do a good job. We need to find out what they are doing well. We should not be telling everyone that more of the same is the solution to bad education.

For some other perspectives on this, Unconventional Thoughts On Emergency Services by Steve Whitehead at The EMT Spot. Not really an education post, but all of his posts are education posts. Nice clear posts that get us to look at things differently.

And I’m Hangin’ Up My AHA Spurs by Buckman at Gomerville. Great writing and he tells a story as well as Kelly does, which is no small achievement.

^ ^TM Unintended Consequence
Wikipedia
Like Murphy's law, again a humorous expression rather than an actual law of nature, this law is a warning against the hubristic belief that humans can fully control the world around them.
Article

Possible causes of unintended consequences include the world's inherent complexity (parts of a system responding to changes in the environment), perverse incentives, human stupidity, self-deception, failure to account for human nature or other cognitive or emotional biases. As a sub-component of complexity (in the scientific sense), the chaotic nature of the universe – and especially its quality of having small, apparently insignificant changes with far-reaching effects (e.g., the Butterfly effect) – applies.

Robert K. Merton listed five possible causes of unanticipated consequences:^[8]
Ignorance (It is impossible to anticipate everything, thereby leading to incomplete analysis)
Error (Incorrect analysis of the problem or following habits that worked in the past but may not apply to the current situation)
Immediate interest, which may override long-term interests
Basic values may require or prohibit certain actions even if the long-term result might be unfavorable (these long-term consequences may eventually cause changes in basic values)
Self-defeating prophecy (Fear of some consequence drives people to find solutions before the problem occurs, thus the non-occurrence of the problem is unanticipated)

The Relevance paradox where decision makers think they know the areas of ignorance about an issue, and go and obtain the necessary information to fill the ignorance, but neglect certain other areas of ignorance, because, due to not having the information, its relevance is not obvious, is also cited as a cause.

Bone Marrow Donations Blocked By A Bad Law

2009-10-30T05:40:00.002-04:00

First, a little information about the process of bone marrow donation. I do not know if this is being used regularly, or anything about the outcomes of the patients it is being used on, but it looks as if it should lead to much better outcomes.

Now, the part about the bad law.

Saving Lives: Challenging the Ban on Compensating Bone Marrow Donors

I have been registered with the National Marrow Donor Program for a couple of decades. I have not yet matched any patient in need of a bone marrow transplant.

Why donate?

Bone marrow donation may be the difference between life and death for a patient. Bone marrow donation would not be a major inconvenience for me. The comparison is not even close. Too often, I put up with major inconveniences for much less of a good outcome.

There are some pretty personal questions that need to be answered, but you can review the exclusion criteria here.

I will have at least one more post on the problems with donation regulations.

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The Blame Game

2009-10-27T17:35:00.007-04:00

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

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

Then he went into respiratory arrest.

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

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

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

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

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

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

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

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

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

"That stuff isn't accurate. You are in the stomach."

Strike One!

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

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

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

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

Strike Two!

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

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

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

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

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

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

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

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

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

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

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

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

What about dopamine? The chart includes dopamine.

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

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

Strike Three!

He blames others for his incompetence.

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

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

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

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

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

Footnotes:

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

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

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

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Comment on President Obama To America - STFU!

2009-10-25T00:28:00.013-04:00

In the comments to President Obama To America - STFU!, C. Watford of My Variables Only Have 6 Letters wrote the following -

The Constitution has been put up onto such a high pedestal that both sides treat it like their Good Book(tm). Just like other Good Books, both sides cherry pick meaning from it. Nobody is reading it, rather saying what they want and pointing to the Good Book as proof. Yay!

The big difference between those Good Books(tm) and the Constitution is that the Constitution was intentionally written to protect citizens from governmental abuse. None of the Good Books(tm) were.

The British coolonists, who committed treason against their King, were aware of the many ways that governments abuse power. After winning their freedom from one abusive government - thousands of lives for those freedoms - the American people refused to agree to a Constitution without some specific protections from any new government. Other Americans objected that any specific enumeration of rights would only lead the government to usurp the power to legislate every freedom not enumerated in the Bill of Rights. That is exactly what has happened.

America was in a bit of an awkward position, with some demanding that the Constitution be approved immediately, while others wanting to hold out for a more perfect document with better protections for the citizens.

As Alexander Hamilton wrote at the very beginning of the Federalist Papers -

AFTER an unequivocal experience of the inefficacy of the subsisting federal government, you are called upon to deliberate on a new Constitution for the United States of America. The subject speaks its own importance; comprehending in its consequences nothing less than the existence of the UNION, the safety and welfare of the parts of which it is composed, the fate of an empire in many respects the most interesting in the world. It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force. If there be any truth in the remark, the crisis at which we are arrived may with propriety be regarded as the era in which that decision is to be made; and a wrong election of the part we shall act may, in this view, deserve to be considered as the general misfortune of mankind.^[1]

We have a bunch of Supreme Court Justices, who have been engaged in a continual expansion of their power to oversee and authorize/revise/expand federal regulation.

The government has demonstrated a willingness to use any excuse to restrict these few essential rights. It is considered acceptable to become more and more like the Taliban in an attempt to fight the Taliban. That was a big win for bin-Laden and psychiatrists everywhere. Not that we have not been heading for a less and less free America for a long time.

The term Nanny State is not wrong. We are drowning in laws that are sold to voters as a way to protect us from ourselves. We have legions of bureaucracies telling us what risks we may take. We have had many prohibitions including an infamous Constitutional Amendment to restrict the rights of citizens. All of these prohibitions have been abysmal failures.

We have attempted to protect our children from the possibility of making bad decisions. Such attempts are much worse decisions. The result of the prohibition of alcohol was just an increase in the power of organized crime, the power of the bureaucracies that were created to enforce the law, and the number of Americans willing to break the law. Americans punished by laws that we pretend are to protect the people most harmed by these laws - Americans. The punishment continues with the DEA (Drug Enforcement Administration), organized, crime, and terrorists - all profiting off of these laws, at the expense of Americans.

We have become so insane, in the enforcement of these laws, that we have even started convicting property of crimes.

We have the DEA determining what is appropriate medical care. We punish the most vulnerable people in the country, just so we can pretend that we are protecting people. Police telling doctors what is acceptable medical care. Of course, there is no evidence to support these restrictions on medical care.

If you have a family member with untreated/undertreated pain, thank Congress and our Presidents and the Supreme Court. They consider it more important to keep Americans in their place, than to allow patients to receive ethical treatment.

At least we have protected dying Americans from demon rum - Oops, I was singing the wrong party line - demon morphine.

As a nation, we have been pampered and pandered to so much that we are willing to agree to pretty much anything if only some ~~politicians~~ liars will tell us that this will make us safe.

Imagine if somebody had told the American colonists that they would be safe - if only the would stay as part of Britain. Imagine that.

But you do not have to imagine that, because that is exactly what those treasonous rebels rejected by opposing King George. The ~~Founding Fathers~~ treasonous rebels risked everything. Their property. Their freedom. Their lives. And the lives of their family members.

For freedom.

Not for safety.

They were not worried about protecting some whining victims' feelings.

We can have politically correct rules. We can silence those, who express ~~dangerous~~ uncomfortable ideas. We cannot have safety.

The closest we can come to safety is by abandoning freedom. All personal freedom includes risks. Of course, abandoning our freedoms to the government, is no different from urinating and defecating on the graves of all of those who have died to defend America. America, the Land of the Free and the Home of the Brave. Not the land of the empowered victim.

I know. I know. The world is much different today. Freedom is not as important as safety. I should just STFU! Americans should just STFU!

We should respect others, but respect is earned. There is no reason to respect someone willing to restrict our rights. Respect is not earned by the color of our skin, or our sexual orientation, or our job titles, . . . . Respect is earned by people with the freedom to take responsibility for their own actions. Without freedom, we are just following orders. Many people feel that we should just follow orders and STFU!

Not me.

PS - This should not apply just to Americans, but I write it from an American perspective. This is not because other countries are unimportant, but because I am not familiar with their laws. There is the occasional exception, such as the libel suit by the BCA (British Chiropractic Association), just because Simon Singh used the word bogus in a description of the dangerous fraud that the BCA promotes.

^ ¹ Federalist No. 1
General Introduction
For the Independent Journal.
Saturday, October 27, 1787
Alexander Hamilton
Gutenberg.org
Federalist No. 1

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Second comment from Anonymous on Teaching Airway - Part I

2009-10-23T15:05:00.002-04:00

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

There is also a thoughtful analysis of airway management and intubation in Airways and ET tubes... at 9-Echo-1.

In the comments to Teaching Airway - Part I - comment from Anonymous, Anonymous writes -

Hi, me again...Nothing brings out a good post from you better than BS. Your best posts come from you when you're challenged.

Thank you.

So I get to respond to your post...

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.

Yes, but studies can't be started and performed without anecdotal evidence to steer research. We have to do a few things wrong to figure out what's right.

I agree. Although there may be some research that is begun without some anecdotal evidence to support it, that is probably rare.

We do have to do a few things wrong to figure out what's right. We spend too much time on punishing mistakes, rather than looking for ways to avoid those mistakes. We are taking the wrong approach to figuring out what is right.

I see this as a reflection of insecurity and ignorance by those in charge. Those in charge are insecure because of their ignorance. Maybe they just do not know how to do things well, but they do not seem to be doing the right things to learn how to do things well. One easy way to learn how to do things well. Find somebody doing it well, and ask them for some ideas. In Too Many Medics? comment from Anonymous, I included the abstracts from 2 systems that demonstrate excellence at intubation.

One of our big problems is that we do not look at bad outcomes as opportunities to learn how not to keep making the same mistake. We look at bad outcomes as an excuse to punish somebody. Why learn from our mistakes, when we can deny that we made a mistake, and punish someone else for our mistake? Win - Win? Right?

That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.

I know and I really don't expect anything less from you. I'm not doing this for the check.

I need the paycheck, but I could probably make more in a different line of work. If I had gone into a different line of work, I would have less debt at the end of the month.

There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.

I agree 100%, but how do you sort them out, in a city wide system, with poor medical command, that sometimes barely has a budget to even staff trucks.

That is probably the thing that is going to have the greatest effect on who should intubate. A system, like the one you describe, will have a lot of horrible medics, but do nothing to get rid of them. Or just a little more than nothing.

A system that gets rid of maybe one bad medic a year, but has a couple dozen bad medics, and has them training new medics, is not likely to stop getting worse. That is a system that is not getting better, but getting much worse. Everybody sees that the bad medics are tolerated. Sure they sacrifice one every year, or maybe every other year, just so they can say that they do something about bad quality. They make it seem as if they are doing something significant, but what they really are doing is telling everyone that they are not serious, or that they really are too stupid to understand.

Who are they?

They are the medical director, the chief, the CEO, the City Manager, the QA/QI/CYA department, the union, and all of their accomplices.

Anyone, who has one of those jobs is responsible for eliminating bad patient care. All of them have that responsibility, but few seem to do anything significant to eliminate bad patient care.

The same medics that keep the CPAP (Continuous Positive Airway Pressure) stuffed under the seat because "we're right down the street from the hospital, we'll just use meds" attitude. I've seen it and it's scary.

I'm NOT supporting these systems, but how do you change it?

That is a good question. There needs to be somebody who just insists that patient care be the priority. That needs to come from the top. When the bosses get on camera and defend horrible care, there is no reason to expect things to change until that boss is gone, and probably some others, too.

I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.

Yes, again I agree, in fact I use CPAP, NTG (NiTroGlycerine), and Ace inhibitors on a regular basis and I don't drop a tube, in fact most, are turned around at the hospital. The CHF I described carried down on the Reeves was unresponsive and wasn't going to fit in a stairchair, so yes, my partner bagged, I put in a line, NTG paste w/3 sprays in a foamy mouth (no IV NTG), Lasix (which I rarely give because CPAP works so well), and Captopril 125. Then I suctioned the pt and tubed while waiting for fire to help carry out my pt. The pt waited to long. Indicated for intubation. I saw that pt again, alive, and good for them. You've had that pt before, most medics have.

Was that pt saved by the tube? No idea, yep, no idea. Would CPAP work, no. Would a KingLT which we carry work, maybe, no idea, didn't use it. I saw need for a tube and did it because it was indicated, could I have just bagged that pt, sure, would have been a bitch, but it could be done. I have even used the ramp on the KingLT to place a successful tube, it's was pretty cool actually. The problem is these patients are still presenting while science and training catch up or figure out what's best for the patient and when you FINALLY get people comfortable the rules change. Little and large systems seems to continue to fail, and most likely to "follow the dollar" where other systems seem to always be on top of things.

There are patients like that. Sometimes they do not have time to call, because the onset is so rapid. The train wrecks will not necessarily be any better, regardless of what we do. Positive pressure ventilation (CPAP) is probably the most important treatment for this patient. Next most important is high dose NTG. 10, 20, 50, 100 NTG sprays - whatever it takes. As long as the blood pressure does not dramatically drop. I have given over 50 NTG sprays and still not had the systolic pressure drop to even 200, in some patients. We are unnecessarily afraid of NTG. Hypertensive CHF patients tend to be ~~resistant~~ very resistant to the effects of NTG. The only reason not to be giving 3 to 5 sprays/tabs at a time to hypertensive CHF patients is having a bad protocol.

The NTG paste makes no sense. You are applying it to the skin to be absorbed by the circulation to the skin, but the patients skin signs indicate that the circulation to the skin is just not there.

Pale - due to a lack of hemoglobin reaching the skin.

Cool - due to a lack of the warmth from blood reaching the skin.

~~Diaphoretic~~ Sweaty - due to the large amounts of adrenaline being released by a body in hypoxic panic. The adrenaline shunts the circulation away from the skin.

The circulation needs to pick up the NTG from the paste on the skin to take it to where it is needed in the pulmonary circulation. It is not needed on the outside of the skin, unless we are looking for ways to accidentally expose our coworkers to NTG.

A great example of this is when someone is suturing a laceration and injects lidocaine with epinephrine (epinephrine is adrenaline). The skin around the injection site becomes more pale, as you are watching. This is what is going on to all of the skin on the pale, cool, sweaty patient. This is one reason that it does not make sense to use NTG paste. The other reason is that the low dose of the NTG paste is like trying to make the tide rise by urinating in the ocean. With precise enough tools, we may be able to measure a minuscule difference, but it does not make any noticeable difference. The epinephrine is shunting the blood away from the skin, not the lidocaine. The lidocaine is for pain relief. The epinephrine is to minimize bleeding during suturing.

As far as educating residents and stopping them from pulling my KingLT, the second you find an answer to that then post it immediately, I'm up for anything with that.

The best way to educate the residents is to educate the attendings. Maybe I have been spoiled, but I have found that the attendings are willing to look at different ways of doing things, if you present it to them in a way that makes sense. You may find that it takes several years to get them to actually change things, but I have found that they are willing to listen. Then it becomes a matter of politics. How do you identify the attending most likely to do something about it? Doctors are more likely to listen to other doctors. Good reasons coming from a medic are less likely to persuade a bunch of doctors, than the same reasons coming from another doctor.

If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them.

I get that secret smile when I turned the pt prior to arrival also.

You lost me on that one.

As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating.

I really do know that, and I agree. I have family that I really wouldn't want some of these medics even touching them.

I kind of figured that.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills.

True, but I have seen a few attendings reach for a LMA because they couldn't get an ETT placed. What is their standard for maintaining skills? Are they are judge? I've taken many ACLS classes over the years and every ED doc shows up but shows no initiative and participates. Here's your card doc, oh and did I mention your codes, run like 1998.

The hospital decides what their rules are. Some restrict some skills to only certain doctors, while others may not have any restrictions for any doctor, as long as the doctor maintains a state license and malpractice insurance. Most are probably somewhere in between these extremes. It has been my experience that some ED attendings, board certified in EM, are scary at intubation and airway management in general. Others are great. I have sat in the parking lot to intubate some patients, because they were not responding to medical treatment, I knew that they would be intubated soon, and I knew who was the on duty attending. Why subject the patient to that doctors obligatory 2 or 3 failed intubation attempts, followed by a call to anesthesia and a waltz-by intubation, when they could come in with a tube in place and have less iatrogenic harm?

Some doctors just do not seem to get airway management. We all have our blind spots. I keep trying to minimize mine.

As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.

I'm not that old, and would NEVER disagree with that statement.

:-)

Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?

I've got none, and I'm not going to claim it, they are really new prehospital, around here anyway. LMA's have been around for awhile but as far as I know no squad, at least in my area ever carried them. However I'm sure your reply will have a stat.

I will have to follow up with some posts on prehospital LMAs. There are services using them. There has been research on prehospital LMA use, but it is going to take a while to go through it and come up with something thorough.

Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.

Agreed

After all, anesthesia seems to be leading the way in airway management, and they are increasing their use of LMAs. That may be where the rest of in-hospital airway management is headed.

You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.

I've suctioned enough of them, I am aware for long term, in my head I was focusing on pt's that should have turned around and are only on a vent for a few days to a week. The patient that I knew would probably turn around if we were all aggressive on in the beginning, the CHF pt who was just to weak, but after being medicated, tubed, and cleared out, would allow the tube to be pulled assuming all the ABG values looked good.

Even that may change. VAP (Ventilator Associated Pneumonia) is a big concern in hospitals. It seems to fall into the never event category. As Ambulance Driver mentioned, hospitals are paying attention to the cost of care. They are going to try to cut down on costs, so I expect that we will see a lot more use of LMAs in the hospital, even if they don't improve outcomes or expenses, but because they might and hospitals are all about saving money.

No waveform, then the tube is pulled, PERIOD.

Yeah, even I slapped myself for that statement, I got out of control. Let me explain what I was thinking. If I place a blind tube and don't see a good waveform then the tube is pulled. This is on a patient that should show an ETCO2 reading. I could expand on it more but I think you get the jist.

Please send video of you slapping yourself. I am not above cheap sensationalist publicity. ;-)

As I understand it, unless there are conflicting assessments, if there is no good wave form, the tube should be pulled. At least, that is the way I approach confirmation, and I get the impression that we agree.

Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating.

Again, how do we fix it?

I think the first thing is that we need agreement on what should be minimum standards, but that has to come mostly from the medical directors.

We need research to show what the differences are between places that intubate well and those that, even though the service may have some people who are great at intubation, the service overall does a horrible job of intubating patients. To do that we need well done research, which you get into below.

We need very well done research in places that intubate well, that are large enough to show what conditions are likely to benefit from intubation. There will always be good reasons for deviating from the typical treatment, but we do not even have research to clearly show that intubation does not cause harm.

We probably need a separate designation for medics permitted to intubate. I don't know if it should be like the EMT-D add on for defibrillation, or whether it should be something like the critical care paramedic certification, with an broader scope of practice than whatever the regular paramedic would be. There are many ways of handling this.

I think this would be an important part of what Ckemtp is trying to do with EMS 2.0 over at Life Under the lights. My initial impression was that this is just going to be another passing fad, but I think he might be on to something. We need to transform EMS from a trade to a profession. Airway management is one of the areas, where EMS really needs to push the doctors to improve. We do not have the authority to change the rules, but I don't see any reason to let that stop me. EMS 2.0 is also covered in Ckemtp, EMS 2.0 – Momentum Building, Happy Medic, Medic999, Too Old To Work, Too Young To Retire, Ambulance Driver, and even The Fire Critic and Firegeezer.

Waveform capnography?

EMS - Yes, usually. In Pennsylvania, it is mandatory for ALS.

ED - No. Some places have it, but most do not seem to use it.

One-on-one observation of patients for heavy sedation/aggressive pain management?

EMS - Yes, what are we going to do, leave?

ED - No, this requires rearranging staffing and will be done, if necessary, but is certainly not the baseline level of care. Generally, each ED nurse has 3 patients, or more.

These are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty - Now - Part I.

cont still...damn restrictions...

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 (PreHospital Intubation)

Scary stats, but failed why? Attempted but unable to place or, attempted and misplaced. That's a big difference. If I miss a tube and I can't get it, if I'm still able to oxygenate the pt to keep the stats up then it's still successful, I just may not be able to move on to additional treatments. It sucks but it happens. If I misplace a tube then I'm killing my patient and think I'm helping. If I stick a blade in the patients mouth, it's an attempt if I try to tube or not, even if it's to suction to even clear an airway. If I have to do this on 5 of 10 patients then I'm at a 75% success/failure attempt rate. Data can be manipulated to favor for or against. It all looks bad on a pie chart, something we all learned in statistics at college.

I think there are plenty of problems with the data from Miami, but nobody has come out and provided documentation of these flaws. There is one very interesting rumor that I have heard. I do not like dealing in rumors, but I am hoping that somebody reading this will be able to document this, or get the medical director(s) involved to set the record straight, at least if the rumor is true.

The rumor is that in at least one of the services studied, the medical director strongly encouraged the use of alternative airways as true alternatives to intubation, rather than as back up airways, for airway management. However, the way the success/failure of intubation was determined was based on just two things. Was there any kind of airway intervention - BVM, CombiTube, LMA, crichothyrotomy, endotracheal tube, unrecognized esophageal tube. If any of those methods of airway management were being used, but there was not a properly placed endotracheal tube, this was considered a failed intubation.

After two ETI attempts, placement of a Combitube is considered as a rescue airway measure.

For this study, members of the Department of Anesthesiology assessed the airways of patients at their admission to the trauma bay. We defined prehospital airway management as paramedics having had an active role in managing the patient’s airway through a variety of approaches, including ETI, laryngeal mask airway (LMA), and Combitube and/or cricothyroidotomy.We defined a failed PHI as the improper localization of an endotracheal tube (ETT) on arrival at the trauma center or the need to use alternative rescue devices for airway management after intubation attempts.

Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

If the CombiTube is used as an initial airway measure, it is definitely not a rescue airway measure. If the doctors assessing the intubations were not familiar the way that airway management was being performed, then their determination of all CombiTubes as failed intubation attempts would be wrong.

From the way I read the study, if a CombiTube, or LMA, salesperson happened to stop at an accident scene and placed an airway, but the patient was transported by a BLS ambulance (no endotracheal tubes anywhere on the ambulance), this might have been classified as a failed endotracheal tube attempt. They might have presumed that paramedics were involved in the management of the airway, since they consider the ConbiTube to be only a rescue airway, rather than an alternative airway. I don't think they would have done the same for a BLS crew transporting with just BVM airway managment if no ALS was available. From the system design, it is possible that all 911 ambulances have a medic on board. Still, there is no good reason why a BLS interfacility transport ambulance could not arrive on scene, deliver excellent care, realize that the closest ALS is at the hospital, and transport. BVM only. No possibility of endotracheal tube. According to the study, it might be classified as a failed intubation attempt.

Well, that is the thing that bothers me the most. Is the rumor true?

If the rumor is true, how many patients classified as having missed endotracheal tube attempts, never had any endotracheal tube attempts?

If the rumor is true, how can the researchers publish this without disclosing that variable? A variable that should have been controlled for, but if the rumor is true, a variable that was not controlled for.

You claim that you know that it is necessary. How do you know?

Only by experience, discussions with our command doc, and in my training and education I've receive to date that I'm acting in the best interest of my pt.

This is one of the reasons we need to have good research. It is unfortunate, but apparently medical school does not do a good job of preparing doctors to interpret research. If they cannot even interpret the research correctly, what is the research they design going to look like? We need to start doing a much better job of educating people about research and the scientific method.

You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.

Again, results can be biased.

Yes.

The difference between good research and bad research is that the good research goes to extremes to exclude the influence of bias. Bad research may not recognize bias, or may come up with pathetic excuses for using the biased methodology. Not that there aren't other ways of creating bad research.

Some of the reasons I started this blog are:

To educate people about research.

To get people to discuss research.

To get people to look critically at research, rather than just say, That is too complicated for me.

To get people to seek out research to persuade doctors of better ways to provide patient care.

For your last regarding how medics should be trained and certified I agree, but is it possible and should MD's/Residents be held to the same standards.

I think that doctors should be held to higher standards than medics. This is one of the reasons for having EMS as a separate medical specialty. Sort of a way of saying, If you want to make contributions to EMS, this is the background you need to have. If you do not meet the criteria for board certification as an EMS physician, then go away. We still have too many non-emergency medicine physicians in the EDs, but this would be a start.

We are facing a lot of misunderstanding/obstacles from doctors, who think they understand EMS, even though they do not. That is one thing holding EMS back. Our patients deserve better.

Should we add a new cert level?

EMT-Pi

Forget about EMS 2.0, we're going straight to EMS 3.14159 . . . . Well Vince may enjoy the math humor, even if not many others do. :-)

I think that we need to be continually assessing the appropriateness of the different levels. Just because this is the way things have been done, does not mean that it is the way things should be done. There will be a lot of change in EMS. We should be doing things to try to make the changes good for the patients. Maybe a different certification. Maybe just more widespread use/recognition of the EMP-CC (critical care) level. Maybe much fewer medics and a lot more medical directors growing a set (metaphorically only, since some are women). We need to have an organization with the authority and the understanding to keep us moving in the right direction. I do not see the DOT (Department of Transportation) as that organization. Anything that combines EMS with firefighting, police, homeland security, or any other Wouldn't it be cool if we could be used as an excuse for them to syphon off money for their pet projects? agency.

Love your posts, I've read them all. You too AD.

Thank you. As you have noticed, I enjoy a good debate. I think that we will not change things until we have identified all of the problems. I certainly do not have all of the answers. I don't even have all of the questions. You contribute a lot to the discussion.

I'm on your side I promise. You really could take my blade away, I really do only tube as a last resort and I like Mystery Medic's idea. Glidescopes are nice.

You point out one of the problems. The ones in need of having intubation taken away are the ones who will fight to the death (the patient's) to keep intubation, but will resist any refresher/retraining/minimum requirements. They do not get that this is about the patients, not about making medics feel good, briefly, before going back to the routine calls that we do not feel challenged by.

I have not used the Glidescope. I have read good things about it. I think that it has the same potential for leading to bad outcomes as anything else - too much focus on the airway, as if the airway is not connected to a patient. A patient, who might not even have primarilly an airway problem. How many patients suffer anoxic brain damage because of intubation attempts? This is something that we should be able to avoid with excellent oversight, but we do need that oversight.

What do you feel about walking a pt to the bathroom around a corner in the house after getting diltiazem for rapid Afib that reduces and refuses to go with you to the hospital unless she can pee, assuming she is is on O2 and the monitor. Had a partner almost have her own stroke on my decision.

I have probably induced a few TIAs in partners, nurses, doctors, et cetera. If the patient has the capacity to make informed decisions about her own care, she may do pretty much anything that we think is unwise/dangerous.

We can pretend that we know that allowing a patient to do something, that we think is a bad idea, will kill them or make them much worse, but we do not know that. We can present them with all of the information about why we think it is a bad idea, but unless we are abducting the patient, or been given power of attorney, or have involuntarily committed them, . . . we do not have the authority to force the patient not to do what we think is unwise, nor do we have the authority to force patients to do something that we think is essential.

I will write more about this, because it is important and we seem to be very poorly prepared to deal with patients who do not agree with us. I just graduated EMT/medic/nurse/doctor school and I know everything. Usually the person making such an assertion is demonstrating that they actually are the most ignorant person in the room, but they often get their way, because they are the most insistent/intimidating/arrogant person in the room. Except when I am there. ;-)

Then the follow up to Ambulance Driver's comment.

Yeah I gotta fess up. I worked very hard on that first post to A) piss you off a little because I enjoy your follow up to BS and trolls and B) because I think if shows what many medics still really think.

Nothing to apologize for. We need to have good debates about what is best for patients. We currently have to rely mostly on expert opinion, because the research is too often inadequate to answer the question of what is best for the patient or what are the right requirements for intubation.

I still believe current research is biased and I would love to see a wide scale study in direct favor of the patient with all aspects of the pros/cons of intubation.

Research will always have problems, but it is still the best method we have of answering the questions of what is best for the patient. I would like to see that research, too.

I see turmoil in our future. We as medics are expected to learn more every year and that makes it harder to be proficient in the skills we already perform. We do this all without getting a pay raise, my cost of living increase alone was frozen for another year.

That is a problem. We do need to have medics dedicated to EMS. Not cross-trained as anything else. There is too much that we need to do to maintain proficiency to have paramedic be something done in addition to another job that people think is interchangeable, or related, or a way of saving money. These are generally not people you would want providing care for any real patient, yet they make decisions about how that care is delivered. Politicians are the enemies of EMS.

Tom Peters writes about this problem, but not as an EMS topic. He asks the question, Do you suffer from too much talent?

In EMS, we seem to act as if we have such talented medics, that cross-training in another field is not going to interfere with their ability to provide excellent care.

Maybe we just don't care about excellent care - until we are the patients (or our families). Isn't a 52% intubation success rate, even if partially inaccurate (12% esophageal intubations is also ridiculous) worse than bad patient care?

Do we suffer from too much talent?

Hope no hard feelings, RM, great follow-up :)

I do not take criticism personally, so there would be no reason for hard feelings. I like it when you make me think.

Thank you.

Other blog posts commenting on this, by others and by me, in order of posting, have been -

The Airway Continuum at EMS1.com by Kelly Grayson, AKA Ambulance Driver. 11/06/07

Teaching Airway: EMS Educast Episode 33 at EMS EduCast. 10/02/09

Teaching Airway - Part I at Rogue Medic. 10/10/09

Teaching Airway - Part I at Paramedicine 101. 10/10/09

Teaching Airway - Part I - comment from Anonymous at Rogue Medic. 10/11/09

Teaching Airway - Part I - comment from Anonymous at Paramedicine 101. 10/11/09

Rogue Medic's Comment Section… at A Day In The Life Of An Ambulance Driver. 10/11/09

Paramedics and intubation at 9-Echo-1. 10/12/09

Attention all Companies at The Happy Medic. 10/12/09

Snapshot from the Paramedic Battlefield at Firegeezer. 10/12/09

Have You Seen This? at The Fire Critic. 10/12/09

Comment On A Comment at Too Old To Work, Too Young To Retire. 10/13/09

Airways and ET tubes... at 9-Echo-1. 10/14/09

EMS as a Profession? at The Fire Critic. 10/20/09

Airway comments by Rachel at Rogue Medic. 10/21/09

Airway comments by Rachel at Paramedicine 101. 10/21/09

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Blogger Migration and Leadership

2009-10-22T20:40:00.005-04:00

All sorts of blogs are getting up and moving around. I have changed the sidebar links. I think I got all of them. Unlike coconuts, blogs do appear to be migratory.

First, the one not moving to FireEMSBlogs.com. The author of Brick City Blues and Pocono Paramedic is now at -

Paramedic Herbie.

The blogs moving to FireEMSBlogs.com are -

A Day In The Life Of An Ambulance Driver

Life Under the lights

Happy Medic

Medic999

STATter911

And I am adding one from that site.

The Fire Critic.

I'm probably not the only one feeling that I aam being told, Silence! I kill you, when seeing Fire Critic's avatar. Maybe, then I'm Walter.

Fire Critic has a great post about leadership. Something that would be good for the EMS Leadership podcast.

Top Ten Qualities of a Great Fire Officer

There is a lot of good stuff about leadership that applies to any leader.

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President Obama To America - STFU!

2009-10-22T18:32:00.004-04:00

This week, at Temple University in Philadelphia, an intolerant mob gathered to give us an example of the Groupthink that we will be expected to participate in. The only thing missing was Adolph Hitler urging the mob on. It is all the fault of the ~~Jews~~ people who don't accept the politically correct party line.

While Mr. Wilders' ideas may be offensive, silencing him does nothing to change his ideas. If he is correct, even if only partially, then silencing him is silencing truth. He does not appear to be advocating violence, but criticizing those advocating violence in the name of Mohammed. Unless we dismantle ~~Freedom of Speech~~ . . . ~~Establishment/Free Exercise of Religion~~ . . . ~~the Right to Assemble Peacably~~ . . . the whole First Amendment in a futile attempt to avoid unpleasantness.

We need to accept that reality is not always pleasant.

And yet, pretending that blasphemy laws and the First Amendment can coexist, is exactly what President Obama's representative has agreed to at the UN (United Nations). I guess that we can always replace the First Amendment with one that endows some people with the right to force others to provide medical treatment for them. Golly, it's just as if ~~Karl Marx~~ Thomas Jefferson were reincarnated and back in the White House rewriting the Constitution the right way.

It is all about living in the make pretend world of President Obama. Make pretend that President Obama will be less destructive to the Constitution than President Bush was. It's a coin toss, but only time will tell.

If I remember correctly, President Jefferson had a slightly different way of dealing with Islamic jihadist demands.

There is a great article on this by Jonathan Turley. Just say no to blasphemy laws -

Thinly disguised blasphemy laws are often defended as necessary to protect the ideals of tolerance and pluralism. They ignore the fact that the laws achieve tolerance through the ultimate act of intolerance: criminalizing the ability of some individuals to denounce sacred or sensitive values. We do not need free speech to protect popular thoughts or popular people. It is designed to protect those who challenge the majority and its institutions. Criticism of religion is the very measure of the guarantee of free speech — the literal sacred institution of society.

True diversity makes it impossible to be politically correct.

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

At least we still have the right to petition the Government for a redress of grievances.

Good luck with that. This was a unilateral surrender. The battle is over. President Obama is taking it doggy style from Mohammed, but at least he got a Nobel Prize reach around out of it. His punk prize. I haven't seen any pictures of him sitting down since then.

Silencing speech is more hateful than any hate speech.

When the symbol is more important than what it represents, we have done more desecration than any of its enemies ever could.

True diversity makes it impossible to be politically correct.

The more we hope for change, the more things stay the same.

If you do not like what somebody is saying, you just need to be the one who appears to be the greater victim. It's all about the victimhood. Weakness is Power. War is peace, Freedom is slavery, Ignorance is strength.

In America, if we had a healthy respect for authority, we would still be British. Too much of the world is demanding safety. Safety from all risk. This is impossible, but if you really want to set yourself up for failure, demand to be safe from being offended.

True diversity makes it impossible to be politically correct.

Preaching that some ideas are too dangerous to be heard - that is hate speech.

President Obama is guilty of hate speech, but there is not any ethical reason to outlaw hate speech.

Why does President Obama make hateful statements about the US Constitution - the same Constitution that he took an oath to preserve, protect and defend?

I do solemnly swear (or affirm) that I will faithfully execute the Office of President of the United States, and will to the best of my ability, preserve, protect and defend the Constitution of the United States.

President Obama, we need to encourage the rest of the world to be free. Abandoning essential freedoms in America sets a very bad example.

Nothing is more American than freedom of speech. We need to defend freedom of speech against the easily offended. The easily offended of the left and the easily offended of the right. Both are enemies of the Constitution.

Oh well, I hear the Gulag is nice this time of year. The sunny Siberian setting. Free housing. Personal attention that borders on concierge level service. Fresh air. Exercise. Ah, freedom. Sisyphus would understand. Prometheus, too.

Maybe the slogan should have been Hate and Change. The Intolerance President. I can hear President Obama now - All right Mr. De Mille, I'm ready for my close-up, and I am big. It's the Constitution that got small!

Science is not politically correct. How can the Science President make policy that is so anti-science? Perhaps libel will also be a problem, not just in the UK, but in the US.

If ideas are criminalized, where does it end?

Next stop, the Dark Ages. All must join in, or be declared witches.

If there is anybody I have not offended, I apologize. Don't get frustrated. There's always next time.

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Tin Foil Hat, Inc. and Vaccination

2009-10-21T18:53:00.006-04:00

Also possibly posted as part of the Skeptics' Circle over at Young Australian Skeptics. Go check out the rest of what is there. I am again late with a submission. Since Australia is half a day ahead of us, Wednesday evening here is already tomorrow, there. Or something like that. ;-)

Over at The Gotham Skeptic, there is a post with the title, The New Plague, about the fanaticism of those who are anti-science, anti-vaccine, and anti-child.

To start out, here is the first paragraph -

A new epidemic is creeping across parts of the US. It primarily affects infants and children of higher socio-economic status, and it has the potential to cause horrible illness and death. It has already begun to cause outbreaks in scattered communities throughout the country. If it is not contained quickly, more carnage will result. The epidemic I am describing is not Swine Flu. It is not a newly mutated animal virus imported from some far-flung corner of the globe. It is the epidemic of parental vaccine fear, and it is a major threat to the safety of children everywhere.

And a part of the last paragraph -

An often-used saying by those who fight against the irrationality of anti-vaccinationism, is that “vaccines are the victim of their own success.” Certainly, one could not point to a more successful public health measure than vaccination. Vaccines have saved more lives and prevented more disease and disability than all other public health measures combined. They have been so successful, that most parents (and most physicians) have no first-hand knowledge of the diseases against which children are vaccinated.

In the comments, there is some defense of scaremongering from E.S. Hamblin -

Moreover, I feel the safety testing has been far less rigorous in recent years than previously, and that the incentive to downplay adverse events and “spin” results of trials. As a scientist and a writer, I’m fully aware of how easy it is to nuance statistics and facts–you can’t change the numbers themselves, but you CAN pick and choose which numbers you make public.

Please provide some evidence that the FDA (the Food and Drug Administration) is not receiving accurate data.

The FDA is not the public. The FDA actually has a bunch of scientists, who are accustomed to dealing with statistical data, reviewing these data.

E.S. Hamblin, you act as if the FDA has no understanding of research. Why?

E.S. Hamblin, you act as if the FDA has no role in drug approval. Why?

If anything, VAERS (the Vaccine Adverse Event Reporting System) leads to an over-reporting of adverse events. There is no requirement for evidence of any link between a vaccination and an adverse event. This method is good for quality control, since it discourages exactly what E.S. Hamblin alleges. I do not need to be a doctor, nurse, or any kind of health professional to make a report to VAERS. I do not even have to have any idea of what I am doing. VAERS would rather look at hundreds of false reports, and they do, than miss some actual adverse events that are related to vaccination. Yet, E.S. Hamblin mistakenly believes that there is less being done to make vaccines even safer. At least, less than in the good old days. Vaccines are possibly the safest medicines available, but when we choose fear over logic, we will make bad decisions.

Tin Foil Hat, Inc. has no budget for research. They only have to point out coincidences, raise suspicions, and mislead people in order to satisfy their business plan. Their business plan is to sell things to the gullible.

Research costs? Nothing.

Printing costs? They appear to try to save money by shunning punctuation, capitalization, grammar, and spelling.

Does Tin Foil Hat, Inc. need to provide any kind of scientific evidence? No. Of course not. They never met a well done study they didn't hate. Well done research has continually failed to support their claims. Research is the enemy for Tin Foil Hat, Inc. Research has the goal of objectivity, while Tin Foil Hat, Inc. Corporate Communication Officer Chicken Little realizes that drama, not objectivity, is what sells.

Misdirection, fear, uncertainty, coincidence, confusion, . . . are the tools of Tin Foil Hat, Inc.

E.S. Hamblin points out that the drug companies have a profit incentive, while ignoring the same bias from the anti-science critics of the drug companies. This profit incentive is worth considering. The drug companies have the oversight of the FDA.

Tin Foil Hat, Inc. has no oversight. They only have to generate a profit. There is no accountability.

If your child dies, because you took the advice of Tin Foil Hat, Inc., expect nothing.

Don't expect an apology. Don't expect to sue them for malpractice, since they will claim that they are not giving medical advice. Their job is to start the riot, get out of town, then criticize the way the riot was handled. If we want an example of corrupt and irresponsible behavior, this is where we will find it.

Back to E.S. Hamblin's comment -

there’s also such a thing as caveat emptor, and when the people offering the data to us have a financial incentive to convince us to use the product, that raises red flags as to the data’s veracity.

The drug companies do have a financial incentive. The FDA has the role of oversight to protect the public from harm that might result from a too zealous pursuit of their financial incentive.

Tin Foil Hat, Inc. also has a financial incentive. Tin Foil Hat, Inc. has no oversight to protect the public from the harm that might result from a too zealous pursuit of their financial incentive.

On the one side, we have scientific zealots. Doctors, who do the research. Doctors, who publish the research. Doctors, who review the research. Doctors, who criticize the research. The result is that science corrects its mistakes.

On the other side, we have pure zealotry. No scientific understanding. No research or review. They attempt to hide any criticism of their faulty, purely ideological methods. The result is that they try to cover up their mistakes.

Scientists point out mistakes. They do not try to cover up mistakes.

What is a scientific zealot?

A scientific zealot is one who is searching for the truth, regardless of what the truth is. A scientific zealot has the goal of objectivity.

The pure zealot has no interest in the truth. They take a post-modernist approach. I will never know everything, therefore I cannot know anything. My feelings are all there is. I feel that vaccines are bad. I feel that I should oppose vaccines. Hmmm. I need to sell things to allow me to spread the word. I'll write books. I'll sell supplements. I'll provide treatments. I don't need a license, just my agenda and a bank account for deposits.

This isn't even a bad business plan, since there is always free advertising - The sky is falling! News at 11.

Caveat emptor suggests that we should be wary of quacks selling nonsense. On the one side, we have drug companies with so much regulation, that it costs millions of dollars to get a drug approved by the FDA. Many of these drugs are abandoned in early research, because they are dangerous or ineffective. On the other side, we have a bunch of scientific illiterates claiming the sky is falling.

If I walk off a cliff, because I am so busy watching for the sky to fall, it isn't because I have been paying too much attention to science. It is because I have been paying too much attention to nonsense.

For another view on this debate, that has science on one side and science is scary on the other side, there is an excellent article in Wired Magazine - An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All.

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Airway comments by Rachel

2009-10-21T02:49:00.001-04:00

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

So there I am sitting at home, still not finished with my response to the most recent comments from Anonymous - 3 parts, due to Blogger's character limit (4,095 characters if I remember correctly - not as limiting as Twitter's 140, but . . . ), when I receive a comment from Rachel of Rachel's Rants. Well, it made me smile like the Grinch on Christmas Day.

Why

This has been a debate among a bunch of crazy old men. I am assuming about Anonymous, but I do not think I am wrong about age or gender. Working in EMS pretty much guarantees the crazy part. As for Ambulance Driver, while he is creeping up on AARPville more slowly than I am, he did just put another candle on the cake.

The comment from Rachel is a bit different. She is a young woman and a relatively new paramedic. 3 years worth of new. Well, here is the comment to Teaching Airway - Part I. I do not need to add much to show you why it puts a spring in my step and whatever other optimistic metaphors might apply.

I have come across your blog from 9-Echo-1's site and I have to say as a 3 year medic, I'm all for more training on intubation or even just taking that skill out of the scope of practice altogether.

Of course, my Y chromosome translates that to A man's got to know his limitations. With the squint and everything. This may be the most important thing to understand in EMS, although it might be better to translate it to - A paramedic's got to know his limitations. Or her limitations.

During my 3 years I've only had 2 chances to intubate. I'm glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice.

And it is not just the opportunity to intubate, but the quality of education, the refresher training, and the quality of oversight.

I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill.

Exactly.

I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years.

Another excellent point.

The next two parts I switched to bold text. They deserve extra attention.

I've said this before sometimes the best intervention is a BASIC one.

Right there, you boiled AD's Airway Continuum down to one sentence.

I know hard concept for some to understand. Too often I see medics treat very aggressively and while sometimes that is indicated it should not be standard operating procedure.

I agree. Although I do not think that aggressive is the right word. I consider myself to be very aggressive in not using treatments that are not indicated. I often receive criticism from some other people in EMS, from some nurses, and from some doctors. Rarely from my medical directors. While I may be forgetting something, I don't think that I ever received much criticism from a medical director for under-treating a patient.

We need to figure out which patients are surviving to the hospital because of us, which are surviving to the hospital in spite of us, and how to tell the difference. This is where assessment combined with good research will make a big difference in what we do - and maybe a big difference in patient outcomes.

Anyway, go read Rachel's blog. She only posts about a once a month, but they are worth reading.

PS. Ambulance Driver has a new address for his blog A Day In The Life Of An Ambulance Driver, with a new banner that has more pictures of KatyBeth, Yay! Maybe there will be a blog from her, something like A Day In The Life Of An Ambulance Daughter.

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Dopamine - Nice Packaging

2009-10-16T03:00:00.005-04:00

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

Dopamine is one of those drugs that seems to have been designed by a plaintiff's lawyer, at least as far as the dosing is concerned. The dose range is 2 to 20 mcg/kg/min (micrograms per kilogram per minute). Some complicated math to be performing, especially since the main indication for treating a patient with dopamine is that the patient is trying to die before arriving at the hospital. If you do not have this concern about the survival of the patient, perhaps the dopamine is not indicated. It isn't enough that our patient is seeking out the stability of the grave, we seem to find ways to make it as difficult as possible to safely treat these unstable patients.

But on critical care transports dopamine is often used at a renal dose.

That is a whole different post. This is about the packaging of dopamine.

200 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

400 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

800 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

Maybe even some other concentration. Those are the only concentrations I have seen, but that does not mean that others do not exist. Some places carry the dopamine that needs to be mixed by the medic prior to use. That means that there are practically endless possibilities for concentrations, based on the actions of the medic.

Here are some charts for calculating the drip rates for different concentrations. The different concentrations are in different colors near the top. You can open these in their own tab, or window, and print them out. I used to do this and tape them to the dopamine bags, so that every bag had a copy of the correct chart taped to it. When you need, or think you need, dopamine is not the time to be messing around with math. Your attention should be on patient assessment. It isn't as if we do not already have enough distractions from patient assessment.

200 mg in 250 ml (which also works for 400 mg in 500 ml and 800 mg in 1 liter):

400 mg in 250 ml (which also works for 800 mg in 500 ml and 1,600 mg in 1 liter):

And then there is the highly concentrated 3.2 mg/ml dopamine. At one place, where I used to work, this was the concentration they carried, but the punchline was that they only used 10 drop/ml tubing (trauma tubing). Look at this chart of drip rates and divide everything by 6 to get the right drip rate. Most patients were in the 1 or 2 drops per minute range. The pot holes had more of an effect on the drip rate than I did. A 100 kg patient (220 pounds - no lightweight) at 10mcg/kg/min would be getting all of 3 drops per minute. Of course, when you have a basic EMT as the ALS coordinator and he is more concerned about keeping the costs down by ordering only one type of tubing, or whatever brainstorm might have been going on in his head, well then patient care is definitely not the priority.

Of course, it does not help that we are still in the dark ages, using ounces and pounds, and miles, and all sorts of other bizarre measurements. The metric system is much easier to work with, but when we are using entirely different measurements outside of patient care, we need to be able to convert from that Imperial System to the metric system.

We in the US almost switched, back in the 1970s. If we had, most of you reading this would have grown up with the metric system. You would not have to do all of these conversions. You can thank your parents for that piece of stupidity. They were not thinking of you.

Of all of the iatrogenic deaths in the US, how many are due to conversion errors? Thousands each year? Tens of thousands each year? Nobody knows. If we admit that this is a problem, then we might feel obligated to do something about it. Better to ignore the problem. Just be glad that we switched to a decimal monetary system long ago.

We package dopamine in 200/400/800/1,600/3,200 concentrations. Why? Do we need to make it complicated for people to calculate? We could use nice simple numbers, as we do with dobutamine, which comes in 250 mcg/ml, 500 mcg/ml, 1 mg/ml, 2 mg/ml, and 4 mg/ml concentrations. Nice simple math. Not dopamine with 800 mcg/ml, 1.6 mg/ml, and 3.2 mg/ml concentrations. It is as if ATLA (the American Trial Lawyers Association) designed the packaging to assure a steady supply of cases.

We can change the labels to DOPamine and DOBUTamine, so that the drugs are not confused, because reading is not one of our strong points, but how many people are better at math than they are at reading?

Risk management is not among our strong points.

Maybe it is all a part of a fiendishly clever plan to free up beds, so that hospitals are not on divert all of the time? Yeah! That's the ticket. It's a conspiracy.

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Well, Nobody's Perfect

2009-10-13T18:15:00.003-04:00

Mule Breath and I have disagreed on the use of TASERs. I feel that, just as any other tool, it is not the tool that is the problem, it is the person behind the tool. While Mule Breath agrees with that, he thinks that there are too many problems with police abuse of force to allow police to use TASERs.

Here is a case of a police officer, who seems to be going out of his way to make Mule Breath's case.

This is from The Agitator. Further information, about the same cop, includes -

When the video first emerged last week, the Dolton police department refused to release Lloyd’s name. With good reason. Lloyd is in jail in Indiana.

I thought he was a police officer.

I think the word was is going to be the important one for him.

Christopher Lloyd, not to be confused with the actor, was fired from another job as a police officer. It seems he killed his ex-wife's husband. He claimed it was self-defense, but for some reason he needed to shoot the guy 24 times in order to protect himself. That was just the number of times the coroner said the man had been shot. We do not know how many times he missed.

Don't worry. Nobody else could possibly have been in danger, since he recreated the climax of Bonnie and Clyde in front of their kids (the story states their kids, but does not specify if the father is Lloyd or the dead guy). Apparently, Chicago PD accepted his story of self defense. It is not known if any donuts were exchanged in consideration of this determination. I'm surprised they didn't go with suicide.

Now, being the curious character that I am, I'm wondering.

Was it a 6 shot revolver, reload and fire 6 more shots, reload and fire 6 more shots, reload and fire 6 more shots? And that is if all of the shots hit the target.

Was it something with a 14 round clip? He still would have needed to reload.

Was it a 50 caliber machine gun fired Rambo style?

Maybe he cloned himself and they all shot the guy.

Don't be silly. Bonnie and Clyde were shot many more than 24 times.

Bonnie was shot 23 times and Clyde was shot 25 times.

Maybe somebody should send him a tub of that Kentucky Jelly, because his boyfriends in prison may be even rougher than he is.

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On Some Days a Health Czar Just Shouldn't Get Out of Bed

2009-10-13T15:44:00.001-04:00

I needed a break from the intubation posting. I do not have a strong position on this and have not even paid attention to the debate. However, yes you knew that was going to lead to a However, there are a couple of things that I have read in the past day that point out some problems for the advocates of the government run, but less bureaucratic system. Yes, that is likely to be an oxymoron, but that is the way it is being sold.

Over at Musings of a Dinosaur, Dr. Dino writes Just Saying "No" to Colonoscopy, which is a criticism of an insurance company that deserves a lot of criticism. At the end is the comment -

Aside from Medicare paying for kidney transplants, but discontinuing coverage for anti-rejection drugs after three years.

According to Stanford -

The averagelife expectancy of a kidney from a deceased donor is approximately 10 years. The average life expectancy of a kidney from a living donor is longer, about 18 years.

Even somebody educated according to the bureaucratic child abuse/educational vacuum that is No Child Left Behind, should be able to recognize that 10 years is longer than 3 years, and 18 years is 6 times as long.

Dr. Wes comments on the inadequacies of the government solution in Model Health Care System Drops Medicaid Patients.

Yep, the Mayo clinic is refusing Medicaid patients from two states, citing poor payment rates.

I guess, if the goal is How to get the hospital out of patient care, the non-bureaucratic system that is also known as Medicare, is claiming success. Speaking of success, I wonder how they are at intubation.

There certainly are problems with insurance companies, as Dr. Dino points out in the rest of her post. So, why does the government seem to be trying so hard to make the insurance companies look not so bad?

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Teaching Airway - Part I - comment from Anonymous

2009-10-11T22:14:00.006-04:00

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

In the comments to Teaching Airway - Part I, Anonymous writes -

We get it,

No. You do not get it. You misrepresent what I wrote. Maybe others get it and maybe not, but all I can tell from your comment is that you do not get it.

This reminds me of debating other anti-science zealots. You attribute things to me that I never stated, then you argue against those statements - statements I did not make. The argument that you are making is called a straw man. You misrepresent my statements. You point out flaws in the statements that I never made. You then claim that my statements are false.

My position is simple. This is the second to last paragraph from the post you disagree with.

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

Can you provide any evidence - real evidence, not some stories of one time at band camp - controlled studes, retrospective studies, observational studies, anything? Where is your evidence of improved outcomes due to prehospital intubation?

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.

you don't want a medic putting in a tube

That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.

The specific part of patient care being debated is airway management. Airway management includes intubation as only one of the possible methods. The right method for the patient in the prehospital setting is what matters.

We have presumed that intubation is the right method, because of expert opinion - not because of evidence of benefit.

There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.

I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.

and you're burnt out from the field and want to stop being a medic.

I guess, when you can read minds, you might lose interest in things like science - since there is no science to support mind reading.

Whether I am burnt out is irrelevant. If I am extra crispy, it is irrelevant. If I am just a little toasty around the edges, it is irrelevant. If I am bright and cheery and always eager to have an opportunity to brighten someone's day, it is irrelevant.

So how about for the next 6 months I stop tubing my patients.

A better option would be to do a study with a lot of medics, but only those proficient at intubation. Have the medics intubating only every other day to compare outcomes. Otherwise, we can only speculate about outcomes for many of these patients.

The CHF patient that waited a little to long to call now frothing at the mouth, I'll just have my BLS partner bag while I try to get a line in to start the 4 drugs I need to help them.

CPAP (Continuous Positive Airway Pressure) would be much more appropriate. You should try to get your medical director to write a protocol for it, because research shows that CPAP decreases the need for intubation in CHF (Congestive Heart Failure).

High dose NTG (Nitroglycerine), preferably IV (IntraVenous), but SL (SubLingual) is OK until high dose IV NTG is available. Again, research shows that high dose NTG decreases the need for intubation in CHF.

ACE inhibitors (Angiotensin Converting Enzyme inhibitors, e.g. enalapril or captopril) given SL or IV also has research showing ACE inhibitors decrease the need for intubation.

You may notice that one of the goals of treatment is to reduce the need for intubation, not to intubate. Of course, there are some doctors, who do not keep up with the research. These doctors tend to continue to focus on intubation and furosemide (Lasix). The research shows that these doctors are not encouraging good patient care. I will write a post addressing the treatment of CHF.

Then I'll try to carry them down 3 flights of stairs on a reeves with a king tube shoved in their throat.

One of the most important things to do with respiratory patients is to sit them upright, unless the patient's blood pressure is low. Using a Reeves is a bad idea, unless the patient is hypotensive.

When I finally get to transport I dump them in an ER where the resident pulls the Kingtube and gets to try a few times to put in the ETT before the attending finally steps in. Well that sounds a lot better for my patient.

If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them. Treat the patient with the treatments that decrease the need for intubation. Persuade your medical director to write protocols that permit this. By treating the patient to prevent intubation, and preventing intubation just happens to be good patient care, you get to frustrate that resident.

The resident would probably prefer not to pull the King airway and intubate. The resident would probably prefer to never have a reason to intubate the patient. The resident's lack of understanding of the appropriate use of a King airway is an education problem. The doctors need to realize that they may not need to replace these airways.

Doctors also used to immediately deflate MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment). The ignorance of the resident does not justify bad patient care by EMS.

Oh, how about the anaphylactic patient that's not responding to meds. We'll just wait until we have to cric their neck, because we do that so often and that's so much easier to practice.

Why do you believe that intubation would make that difference?

How about the asthma patient or the old COPD'er that doesn't respond to meds. BLS bagging and alternative airways are so much better for transport.

As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating. There are too many studies showing horrible rates of intubation. I have written about some of these studies here, here, here, here, here, here, here, here, here, here, and here.

You know why they are called alternative airways? They are used as a last ditch effort to get any air into the body.

Please provide some documentation to support your claim about the origin of the term.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills. The research demonstrates that the lack if intubation skill is widespread.

The name alternative airway is not evidence of anything.

Calling them alternative airways has nothing to do with their ability to provide an adequate airway. It has to do with the preconceptions of those naming the device. If they had been named superlative airways, would you demand to use them because the name says superlative?

As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.

Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?

The actions of ill-informed emergency physicians and nurses do not determine the value of prehospital treatments. We need to be able to understand what is best for the patient. We need to base what is best for patients on outcomes research, as much as possible.

Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.

We should attempt to have the terminology help us to understand the use of equipment. The research may significantly change the role of alternative airways. The terminology does not determine the outcome of research. The terminology should not limit appropriate care, either.

If they were truly adequate then you could admit the patient to ICU and never move it.

Maybe that is where the research is headed. Maybe some of the ICU patients will be better off with alternative airways, rather than endotracheal tubes.

They are temporary. My ETT can stay in until the patient needs it to be pulled.

You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.

Another thing to consider is that the alternative airways may be less likely to result in trauma to the airway, infection of the airway, or other complications.

At least we use capnography to confirm placement though most ED's RN's don't even know what a proper waveform is.

Which is it? Do you base your treatment on what may be done in the ED, or do you congratulate yourself on using better equipment that the ED?

You claim that it is wrong to use an alternative airway, because the ED will not use your airway. I disagree with your conclusion, here.

You claim that it is right to use waveform capnography, in spite of the ED not using your capnography. I agree with your conclusion, here.

No waveform, then the tube is pulled, PERIOD.

No!

Although waveform capnography is probably the single best form of tube confirmation, it is not perfect. Even waveform capnography results in false positives and false negatives. Since it is not perfect, having it overrule all contrary assessment is wrong and dangerous. I wrote about that particular mistake of airway management in Zero Tolerance V - Autopilot Oversight - Sparrowmict comment.

Learning to tube on a dummy or in the OR is fine but the last 4 tubes I had were made on people in real world situations.

The real world is where EMS works. Using dogma to guide treatment, rather than evidence is not good for real patients.

Vomitus, blood from a GSW pooling in the throat, a patient half under a bed, and one apneic in the grass behind an apartment build at midnight. No pretube waveform, no flicking of eyelashes, no controlled situation, no nothing. Just me and a F'd up patient that needed air.

Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating. As I have already mentioned, there are plenty of studies showing much less than adequate intubation success rates by paramedics in some systems.

If you want people to have 10 tubes before graduation and 2 a year in the field then fine but YOU are on a mission to stop a skill that has been used to save more people then will ever have showed up on any research report.

I am trying to limit intubation to people who might actually not be dangerous with a tube.

I am trying to limit intubation to patients for whom there is likely to actually be a benefit in their medical outcome.

The seatbelt of a car has saved many more then it's harmed and it has harmed but do you think we should stop wearing them because of the 3% of the cases where someone couldn't get out of the vehicle to safety.

I never made any such claim.

You are suggesting that the harm of prehospital intubation is less than the benefit. Not just a little less, but a lot less.

Before you start making claims about Mom, Apple Pie, and how wonderful prehospital intubation is, maybe you should show that the benefit is real. Please, just provide some evidence that there is as much benefit from prehospital intubation as there is harm.

When you can show me data that say medics are missing 25% I might start to agree that something might need to be done but every medic knows this skill.

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 (PreHospital Intubation)

Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

You claim that there are no studies that show worse than 3/4 prehospital intubation success rate. That is an unacceptable success rate, but the reality is that I have written a bit about this study that only shows 1/2 success. It appears that you like to make dramatic, but completely wrong statements.

I do everything I can to avoid a tube and when I do it, it's necessary.

I generally agree with this approach, but it seems to contradict your claim that intubation is so good for patients.

You claim that you know that it is necessary. How do you know?

You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.

If I haven't done one in 6 months so what, as a proficient medic I recognized the need, and I have been trained to perform, if I failed then most likely no alternative airway would substitute.

Maybe you would be good after 6 months of not intubating. Would you have had any practice with a mannequin, or with a cadaver, or anything else?

Even if you were still good at intubation after 6 months of not intubating, what about others? The research definitely does not support the belief that going 6 months without intubating is tolerable.

if I failed then most likely no alternative airway would substitute.

Another bold statement. Based on what?

The intubation research, that documents success rates of prehospital intubation, shows a pretty good success rate for alternative airways after the failure of intubation. This is exactly the opposite of what you claim about alternative airways not being able to substitute.

After all my rant answer me one yes or no question. Assuming the way medics are currently trained, do you think medics should intubate? Yes or No?

Which way that medics are currently trained?

If you mean the way that medics are trained as described in this study demonstrating intubation excellence?

This training includes didactic education in endotracheal intubation, alternative airway techniques, and skill simulation. Extensive education is provided in the pharmacology, indications, contraindications, and complications of the paralytic agent used, succinylcholine. 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.

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]

Is that the way medics are currently trained? Yes, but only in some very limited places. Maybe prehospital intubation needs to be limited to places that maintain these standards.

Maybe we just need to stop making excuses for having such low standards.

Maybe we need to stop making excuses for harming patients.

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Nobel Peace Prize and President Obama

2009-10-10T22:17:00.014-04:00

My first thought, on seeing the news that President Obama had won the Nobel Peace Prize, was that SNL (Saturday Night Live) had decided to turn the parody level up to 11. If CNN is going to take SNL seriously, then SNL will make it practically impossible for CNN. There will always be room for CNN to demonstrate greater incompetence, but not much.

I wrote about the commotion about a SNL parody of the ineffectiveness of the President thus far in his rookie year Does CNN have Any Credibility Left? The awarding of the Nobel Peace Prize appears to have been based on the CNN investigative analysis of SNL.

I went to the news source. It seemed legitimate. I checked others. This story is true.

He is the titular head of a country that is involved in 2 declared wars. There is probably more potential for this number of wars to increase, rather than to decrease. Although President Obama did not start these wars, he does not appear to be ending them.

There was the suggestion that the award was rushed to throw support behind the potential for President Obama to produce change. After all, it isn't as if they could have waited a year, or two, or three, to see if this politician actually accomplishes something more than a world tour. That might give some justification for this award. Should we change the name to the Rookie of the Year Peace Prize - Any novice leader, who has not started a war in the first couple of weeks of office can win.

If he is so inclined, he may nuke Iran. I'll bet that would make the prize committee proud.

This makes you wonder who else was being considered? The North Korean Elvis impersonator, Kim Jong-il?

Martin Luther King did not just talk about having a dream. Apparently, these days just having the dream is good enough.

President Obama's number one accomplishment. He became the borrower on the largest sub-prime loan in the history of like forever.

Should we rename this the Sally Field Prize? This is just Europe saying, . . . you've wanted more than anything to have our respect. The first time we didn't feel it, but this time we feel it, and we can't deny the fact that we like you, right now, we like you! this is like Europe telling President Obama that he has been favorited on Facebook.

A lot of marriages start, because the woman sees potential in the man. A lot of these marriages end in divorce, because the man does not use the potential the way the woman thinks it should be used. Maybe Europe should have asked for a pre-nup.

Maybe it is as some have suggested, the Not George Bush Prize. A prize awarded in the first year of every presidency that immediately follows the second term of a second George Bush. If you think that you have ever won something that had high standards, try winning this one.

President Obama has a lot of potential, but so does Sarah Palin. She might even be able to do something interesting for the talent part of the competition. Maybe it was the beer he shared to help make peace between Henry Louis Gates and James Crowley. That might be foreshadowing the way to peace with the Islamic terrorists. Hey guys. Let's sit down like a bunch of adults and discuss this over some beer and hot dogs. Yeah. That's the ticket. A Beer and Hot Dogs Summit.

Maybe the Nobel Peace Prize should have its name changed to the John Winger Prize.

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Teaching Airway - Part I

2009-10-10T18:11:00.009-04:00

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

On Teaching Airway: EMS Educast Episode 33, they have Kelly Grayson as their guest. The first of many times they will have Kelly Grayson as a guest. Hint! Hint!

Kelly says (50 minutes into the 1 hour show, so I am starting at the beginning) -

If you are going to allow paramedics to intubate, and I happen to agree with Bryan Bledsoe on this, . . . unless things change in the way we educate and regulate our EMS providers, within 10 years you are going to see intubation disappear from the paramedic skill set, except for a relatively few very well trained providers.

Since I have made similar comments, I want to point out the way that a lot of paramedics seem to interpret this sentence.

They are going to take our tubes away!

That ignores the really important part of the sentence. The part of the sentence that comes before and after the part I highlighted. That important part is this - unless things change in the way we educate and regulate our EMS providers, . . . except for a relatively few very well trained providers.

The way to prevent having the tubes taken away? If we really want to have intubation in our scope of practice, we need to continually prove that we can intubate well. We need to continually practice and work on learning more, if we expect to be able to prove that we can intubate well.

Many paramedics do not want to be told that. They want to be able to intubate, just because they think wanting to is enough. They want their Nobel Intubation Prize. Well, this isn't politics, you actually need to do something.

What do we need to do?

Kelly's immediately follows that with -

If we would pull the trigger and do what is necessary to make every paramedic like those well trained providers we envision intubating in the future. That's what needs to be done. We need to have far more stringent requirements for intubation in the initial clinical experience. It needs to be far more than 6, or 8, or 10 tubes. If it takes an extra 6 months to get those tubes, then so be it. That's the price we're going to have to pay to be taken seriously. And once on the street, if you are not getting say X number of tubes - a tube a month, call it 12 a year - if you don't get 12 successful intubations, or at least 12 attempts, in a 12 month period, there should be a clinical re-education requirement.

This was followed by Buck Feris saying, Agreed.

Can any of us disagree? Unfortunately, for many a medic/medic wanna be, that is asking too much.

Why should we have to be competent? Isn't sitting through the classes, getting food for the preceptors as a bribe, and following all of the rules that I agree with - isn't that enough?

Sure. That is good enough, but only if you work in a really unimportant job, not one where incompetence can kill patients.

We cannot demonstrate that prehospital intubation improves outcomes, but we insist on intubating.

Except for a few, we cannot demonstrate competence (pick almost any EMS intubation study), but we insist on intubating.

Why do we insist on harming our patients?

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

We do have to want it. We have to want to work at competence - not whine about being victims and whine about not being given what we want.

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The Harm of Rituals in EMS

2009-10-09T06:15:00.012-04:00

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

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

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

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

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

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

Well, what do people do wrong?

Everything.

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

Also -

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

This is just world class stupid.

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

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

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

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

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

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

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

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

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

Competent people do not need excuses.

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

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

Prove me wrong. I double dog dare you.

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

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

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

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

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EMS Needs to Be a Separate Medical Specialty - Now - Part I

2009-10-08T21:59:00.021-04:00

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following ~~the protocol~~ orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic's place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can't imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this - from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts - here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8^th Law - Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur - 10 Laws I've Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 - 1541, so this is not exactly new) wrote -

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population - a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.

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CBS Neck and Neck with CNN for Most Incompetent Network

2009-10-08T07:23:00.009-04:00

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

Then:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reduce the schedule? Based on what?

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

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

These questions are nothing but a scare tactic.

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

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

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

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

2007: Jenny McCarthy Begins Promoting Anti-Vaccination Rhetoric

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

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

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

Am I being unfair?

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

Then there is the big question.

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

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

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

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

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

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

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

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

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Trooper Daniel Martin In Trouble, Again

2009-10-06T17:05:00.006-04:00

It will be interesting to see if this is just a case of some people, who recognized Daniel Martin, and decided to claim that he was the problem. Or whether this is evidence that Daniel Martin saw the handling of his earlier 15 minutes of fame as support from OHP (Oklahoma Highway Patrol).

One good thing. OHP has stated that they will release the dashboard cam, once their investigation is complete. Both troopers are on paid administrative leave. These are both good moves. OHP appears to have improved their understanding of supervision.

Thanks to PJ Geraghty for sending me a link to the video.

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

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Does CNN have Any Credibility Left?

2009-10-06T01:39:00.014-04:00

Apparently, Jon Stewart is now writing material for CNN. The network that I have criticized for their incompetent reporting of medical topics, has decided to branch out into comedy.

Wolf Blitzer, who either has a great poker face, or really believes what he is saying, claims that SNL (Saturday Night Live) has not been completely accurate in their portayal of President Obama. Wait! Let me check my calendar. Maybe I had a Rip van Winkle episode, here. No, I did not sleep until April Fool's Day, nor is it mischief night. This is just CNN demonstrating that the future of journalism is definitely not on their network.

Next, CNN investigates professional wrestling to see if WWE is as scripted as reality TV.

Jon Stewart did a great job of reporting on the way CNBC covered financial news during the financial crash of a year ago. Jon Stewart had me laughing and had me impressed with his understanding of finance. CNN? Not so much.

This just in - CNN has unearthed an incredible story. Amos 'n' Andy were white. They were wearing makeup. Stop the presses!

I should send in a resume. Their hiring standards are incredibly low. I, Hildy Johnson, have experience covering executions. Nah, too obvious.

Just kidding. This is CNN. Nothing is obvious to them.

In the video, there is a guy assessing the accuracy of the facts presented in the comedy skit. He makes a big deal of claiming, that even though everything else is accurate, you can't tell the difference between Afghanistan and Maybery. I guess, I just misunderstood why George Will was writing that it is Time to Get Out of Afghanistan. I thought that George Will was saying that things are really bad - that we do not have any more chance of winning than the Soviets did a couple of decades ago, or the British over a century ago. Silly me - I was reading. CNN does not appear to be competing for an audience that reads.

Maybe we should ship CNN over to Afghanistan. The jihadists will be laughing so hard at these journalists that they won't be able to shoot straight.

I wrote about CNN's medical coverage of a brain dead baby. This was a year and a half ago. They still have not changed the video. I wrote to the station and I wrote to Dr. Sanjay Gupta. You know Ask Dr. Gupta, their medical expert. He is somebody who should be able to look at this and say, That is completely wrong. Change it. After all, Dr. Gupta is a neurosurgeon. For those of you who get your medical information from CNN and might not understand the big word, a neurosurgeon is a brain surgeon.

I am still waiting. The video is still there with the same completely wrong information. Maybe Dr. Gupta is still looking for his medical dictionary.

I almost feel guilty for picking on such obvious idiots. Then I rememeber that they are getting paid for their incompetence. I guess Wolf Blitzer got into journalism, because the basket weaving class was too difficult. If Dr. Gupta is your surgeon, don't bother writing, Other Side on the part of your head he is not supposed to operate on. That may be too complex. Maybe draw a skull and crossbones. Better yet just run away.

Maybe he did his residency with Mitchell and Webb.

CNN is Selling Snake Oil - All You Have to Do is Believe.

Atomic Nerds take some shots at CNN, as well. LOOK OUT, MR. PRESIDENT! MOCKERY! H/T The Smallest Minority - CNN Fact-Checks SNL.

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Correlation vs. Causation in a couple of videos for the hard of reading:-)

2009-10-04T15:47:00.004-04:00

At Respectful Insolence is this pair of videos on correlation, causation, and the Hollywood ignorantists, who cannot tell the difference. Not that ignorance would stop Honest Jenny Killer McCarthy from telling everyone else to endanger their children. Generation Rescue, Jenny McCarthy, and the anti-vaccine movement: Confusing correlation with causation.

To get the most information out of these, watch them in full screen mode, so that you can read the print on the charts that are shown.

Part I:

Part II:

Here is the sidebar information posted at YouTube.

C0nc0rdance
October 01, 2009

When we make risky decisions about our health, it's always good to be in possession of all the facts, to let our brains, and not our hearts, make the decision. Your child is thousands of times more likely to die from a preventable disease you didn't vaccinate them against than to develop autism from a vaccine you did give them. The case for autism and vaccines is solely based on weak correlations and emotional responses.

Generation Rescue:
http://www.generationrescue.org/evidence-science/05-autism-and-vaccines.htm

CDC statement on the safety of vaccines:
http://www.cdc.gov/vaccinesafety/

Locate a flu vaccination center near you:
http://info.findaflushot.com/blog/tag/vaccination

Get vaccinated. Do it for the people who matter to you.

Very well done.

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Changing Standards in Education - from other things amanzi

2009-10-03T15:57:00.002-04:00

I am often critical of the way EMS keeps trying to make it easier to keep up a steady flow of brand spanking new paramedics. Not because we produce a high quality product (new medics), but because the public is too ignorant to notice.

The main tool is the National Registry of EMTs exam, but other exams aren't noticeably better. Dr. Bongi, from other things amanzi, has a post up at Better Health by the name of When Incompetence Kills.

Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea.

It becomes difficult to have half a dozen, or more, medics show up for every emergency call, when we have standards. Do we decide that one competent medic is enough, or do we hit them with a double dose of barber shop quartets - in the hope that all the patient really needs is a lot of company, and maybe a song?

Of course, we choose the high quantity, low quality route.

The image is from the Wikipedia Project Triangle article.

Now not all that long ago, to miss free air on an X-ray even as a student was a mistake that would fail you. These days you can easily get through medical school without worrying about trivialities like free air on X-rays. Also, to have perforated bowel causes intense almost unbearable pain. Even a street sweeper would be able to pick this up in the patient.

Seems as if EMS is not alone in the just push them out the door with a card kind of standards.

Yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days.

About 9 years ago, I stopped teaching paramedic school, because I could not continue to contribute to this farce. I was forbidden from doing anything outside of the limited classroom time. There were 2 people in the class holding everyone else back, but nothing was to be done about them, because they have not failed the ridiculously low criteria to remain in the course. It's up to their preceptors to pass, or fail, them. According to the program director. I was forbidden from getting rid of the dangerous ~~students~~ future paramedics.

So not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do, because they didn’t know how to do it properly, caused further damage to the poor man.

One student was considered a troublemaker. One reason was that he would ask questions about things that would not be on the test. It was OK to have to essentailly repeat a lecture, because 2 people want to have paramedic cards, but don't let on that they haven't grasped the most basic points, the points from the first 5 minutes of the class. Everyone knows that the real evil is to ask a question about something that will not be on the test.

I cast my mind back to when I was still in academic circles. I remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared.

I guess I was just imagining things, because that would never happen in paramedic school. Dr. Bongi's description is of medical school.

I myself was asked to examine a student in a practical exam. I failed her because she was simply a danger to any person unlucky enough to become her patient. And yet the powers that be had so changed the system from when I was a pregrad that she could not be failed and was released into the community.

When you cannot change the system from within, the only choice left is to leave or to force them to throw you out. I have taken advantage of both exit strategies.

We are killing them with kindness.

Killing the patients with kindness to the students. But the NR validates everything they do, and they are the experts. And you can't go wrong buying a house when everyone else is, too. We'll give you one mortgage on the house and another on the downpayment.

Don't worry about the interest rate.

Debts like these never come due . . .

except in the real world.

The mortgage sellers and the NR don't have to deal with their mistakes. They are making money selling their sub-prime product. The patients pay.

Dr. Bongi, you have my sympathies. It is too bad that more people do not understand.

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Read A Banned Book To Celebrate Banned Books Week - 2009

2009-09-30T23:53:00.001-04:00

This is Banned Books Week.

Also known as Hypocrite Awareness Week. This is about people, who claim to care about education, but wish to ban books because of their fear that students might read. Even worse, students might understand.

Another name for Banned Books Week could be First Amendment Week. Not just because this highlights the threats to the free speech part of the First Amendment. The people trying to prevent children from reading are often pushing the beliefs of their religious sect on those not in their sect. This is also about protecting us from those trying to establish their religious beliefs in law, using the public school system as their weapon.

This appears to be the goal of the book banning mob:

One of my favorite books on education would probably be banned - if it weren't aimed at the teachers, rather than the students. Teaching as a Subversive Activity^[1] is about teaching the students to ask the right questions, rather than teaching them to answer questions. Education is something that continues throughout one's life. The best way to keep learning is to ask the right questions.

Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are. Niels Bohr.

Every sentence I utter must be understood not as an affirmation, but as a question. Niels Bohr.

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts. Richard Feynman.

Here is an example of the way that pressure is brought to prevent students from being exposed to any discussion of a topic, because just mentioning it could make it happen - knock on wood. The parents signed permission slips for their children to read the book. Others were not required to read it. The fanatical parents still opposed the ability of the other parents to allow their children to read this book. Book bans have nothing to do with being reasonable.

Mule Breath points out that today is International Blasphemy Day.

This is the fourth anniversary of the publishing of some cartoons in Denmark in the newspaper Jyllands-Posten^[2]

Muslims wanted to kill these cartoonists for depicting Mohammed, the newspaper employees for publishing these cartoons, and anyone who might happen to get in the way of their desire to just Kill! Kill! Kill!. Many of the same people, who might read and/or produce the newspaper below.

They can print the same cartoons. I guess, they use the phrase, It's not blasphemy, when we do it.

We even had some home grown commentary on terrorists.^[3]

Book burners, promoters of censorship, issuers of fatwas, . . . ; Muslim, Christian, Jewish . . . silencers of opposition; You are all the same.

Μολὼν λαβέ

Footnotes:

^ ¹ Teaching as a Subversive Activity
by Neil Postman and Charles Weingartner.
1969
Open library link

Wikipedia article about Inquiry Education

^ ² Jyllands-Posten Muhammad cartoons controversy
Wikipedia
Article

^ ³ I Was a Tool of Satan...
Doug Marlette describing the religious outreach from his Muslim brothers, when he printed that comic.
Article

I have outraged Christians by skewering Jerry Falwell, Catholics by needling the pope, and Jews by criticizing Israel. Those who rise up against the expression of ideas are strikingly similar. No one is less tolerant than those demanding tolerance. Despite differences of culture and creed, they all seem to share the notion that there is only one way of looking at things, their way. What I have learned from years of this is one of the great lessons of all the world's religions: we are all one in our humanness.In my response, I reminded readers that my "What Would Mohammed Drive?" drawing was an assault not upon Islam but on the distortion of the Muslim religion by murderous fanatics -

Then I gave my Journalism 101 lecture on the First Amendment, explaining that in this country we do not apologize for our opinions. Free speech is the linchpin of our republic. All other freedoms flow from it. After all, we don't need a First Amendment to allow us to run boring, inoffensive cartoons. We need constitutional protection for our right to express unpopular views. If we can't discuss the great issues of the day on the pages of our newspapers fearlessly, and without apology, where can we discuss them? In the streets with guns? In cafés with strapped-on bombs?...

Correlation vs. Causation - Girl Dies After Receiving Vaccination

2009-09-30T07:14:00.003-04:00

Natalie Morton, a 14 year old school girl received the HPV vaccine (Human PapillomaVirus), then she died.

Are the two related?

Obviously, the series of events would not be the other way around, since there would be no reason to administer the vaccine to a dead person.

Cause and effect?

Coincidence?

Let's look at the worst case. What if the vaccine did kill her? Should others avoid the vaccine?

One death out of 1.4 million vaccinations. That would put the risk at 0.71 deaths per million vaccinations. To compare that with working in the US for a year. The fatality rate averaged over all jobs, per year is 36 deaths per million employees, per year. About 50 times higher. Assuming 2 weeks of vacation, per year, the fatality rate would be about the same as working for a week at an average job in the US. Would anyone suggest that a teenager not get a job, because the risk of death is too high? No.

Of course, this is ignoring that the employee gets a benefit out of working. A paycheck.

What does the person get out of vaccination?

According to the statistics reported in the BBC article, about 1,000 girls die from cervical cancer, per year in the UK. The vaccine can prevent %70 of those cases. The math on that is easy. The vaccine should prevent 700 deaths, per year in the UK.

Minus 1; Plus 700; Net benefit - Plus 699 lives. The 700 lives are per year, but the one death probably is not per year. This extrapolation of death statistics, based on this one possible case, is all guess work and all based on the worst case scenario - that the vaccine did cause the death of the girl. With one death, trying to compute a fatality rate is an abstraction. The number of fatalities need to be averaged over a much longer time period, so that there is some idea of how frequently people die after receiving the vaccine. And we still do not have a reason to believe that the vaccine caused the death. The fatality rate may be zero.

What about the other side effects?

Picture credit.

Those are a lot of side effects.

Yes, but the rate of side effects is still low. Sticking a patient with an intramuscular needle, but without the vaccine, might produce a large number of the same side effects. These side effects do not suggest that there were patients, who almost died. We might expect to see more very sick, but not dead, people than dead people, if the vaccine is the cause of death. These side effects do not suggest that.

What does this have to do with correlation and causation?

Suppose somebody borrowed my car. While the person was driving, another person ran a red light and killed the person driving my car. The accident is investigated and no mechanical malfunctions are found with my car. Did I kill the person?

The person borrowed the car from me. The person was in the car, when killed. The person has never been killed doing anything else. The person has never been killed while driving his/her own car. The person has never been killed while flying on a plane. Et cetera. Did I kill the person?

Clearly, the death followed the loan of the car to the now dead person. Borrowed my car. In my car. Dead. Did I kill the person?

So, did the vaccine kill the girl?

The same relationship exists, except that the cause of death has not been determined for the girl. Is this a horrible and tragic death? Yes. Does that mean that we have to blame somebody? No. Horrible and tragic deaths are a part of everyday life. In EMS, we see more of that than most people do. An apparently healthy young person suddenly drops dead. Horrible? Yes. Tragic? Yes.

Do we start assigning blame before we have evidence?

Usually.

In this case, it appears that is what the newspapers have done. Big headlines with scare story wording.

Should we depend on the newspapers for medical information?

Only if we want to increase our chance of death.

Assuming one death, per year vs. 700 lives saved per year in the UK, is this bad?

699 lives saved per year, even if we assume that this girl was killed by the vaccine.

Where do I sign up?

What do you mean, I don't have a cervix? Then can we get some kind of prostate cancer vaccine? Please.

For more information:

Cervarix: MMR the Sequel? (Update 2) from The Lay Scientist, who does a great job of delving into this from a different perspective.

Cancer jab 'unlikely' death cause from BBC News.

Dr Caron Grainger, joint director of public health for NHS Coventry and Coventry City Council, said the results of a preliminary post-mortem examination had "revealed a serious underlying medical condition which was likely to have caused death".

"We are awaiting further test results which will take some time," she said. "However indications are that it was most unlikely that the HPV vaccination was the cause of death."

From the US CDC (Centers for Disease Control and Prevention) Reports of Health Concerns Following HPV Vaccination:

Deaths

As of June 1, 2009, there have been 43 U.S. reports of death among females who have received the vaccine. Twenty six of these reports have been confirmed, 9 are still under investigation, and 8 remain unconfirmed due to no identifiable patient information in the report such as a name and contact information to confirm the report. Confirmed reports are those that scientists have followed up on and have verified the claim. In the 26 reports confirmed, there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine.

More information is available at:

http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct08/12-3-hpv.pdf