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Commentary on EMS (Emergency Medical Services), medicine, and science.

Rogue Medic
174 posts

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  • February 3, 2016
  • 11:30 AM
  • 110 views

The RAD-57 – Still Unsafe?

by Rogue Medic in Rogue Medic

I decided to look for something I wrote that I have been wrong about. I thought about Masimo and their RAD-57. I had been very critical of Dr. Michael O’Reilly (then Executive Vice President of Masimo Corporation) for being an advocate of bad science, but he has been hired away by Apple.[1] He should be less dangerous with a telephone than he was with the RAD-57. At the time, he wrote –... Read more »

  • December 8, 2015
  • 01:50 PM
  • 195 views

Why is progress so slow in resuscitation research?

by Rogue Medic in Rogue Medic

Why is progress so slow in resuscitation research? A lot of money and time went in to finding out which type of blood-letting ventilation works best – ignoring the absence of valid evidence that ventilation is better than no ventilation. Why not gamble with our patients?

In response to The Fatal Flaw in Trial of Continuous or Interrupted Chest Compressions during CPR,[1],[2] Kenny commented that –

there are many things in your blog that are not correct.[1]... Read more »

Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., Weisfeldt, M., Stiell, I., Morrison, L., Aufderheide, T., Cheskes, S.... (2015) Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 2147483647. DOI: 10.1056/NEJMoa1509139  

  • November 25, 2015
  • 10:15 AM
  • 286 views

The Fatal Flaw in Trial of Continuous or Interrupted Chest Compressions during CPR

by Rogue Medic in Rogue Medic

This is not a study that has a valid control group to determine if there is any benefit from ventilation. There is no group that does not receive ventilations, so it is like a study of one type of blood-letting vs. another type of blood-letting with the researchers taking for granted that blood-letting does improve outcomes. That is not a problem if blood-letting actually improves outcomes.

Should we take it for granted that blood-letting improves outcomes and that the only hypothesis worth s........ Read more »

Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., Weisfeldt, M., Stiell, I., Morrison, L., Aufderheide, T., Cheskes, S.... (2015) Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 2147483647. DOI: 10.1056/NEJMoa1509139  

Alldredge BK,, Gelb AM,, Isaacs SM,, Corry MD,, Allen F,, Ulrich S,, Gottwald MD,, O’Neil N,, Neuhaus JM,, Segal MR,.... (2001) A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus. New England Journal of Medicine, 345(25), 1860-1860. DOI: 10.1056/NEJM200112203452521  

  • October 20, 2015
  • 09:45 PM
  • 204 views

How Bad is the Evidence for the New 2015 ACLS Guidelines?

by Rogue Medic in Rogue Medic

The new ACLS guidelines are out. How bad is the evidence?
The short answer – The Advanced Cardiac Life Support guidelines could be worse.
How does the American Heart Association determine that a recommendation is not beneficial?... Read more »

  • September 10, 2014
  • 06:00 PM
  • 67,274 views

Anecdotes and the Appearance of Improvement

by Rogue Medic in Rogue Medic

We like to give treatments that produce results that we can see and logically attribute to the treatments we gave.

We like to give IV (IntaVenous) furosemide (Lasix – frusemide in Commonwealth countries) for CHF (Congestive Heart Failure).

1. The patient had CHF.
2. I gave IV furosemide.
3. The patient produced urine.... Read more »

  • August 19, 2014
  • 10:15 PM
  • 933 views

Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

by Rogue Medic in Rogue Medic

Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?

If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?

50% dextrose has problems.... Read more »

Kiefer MV, Gene Hern H, Alter HJ, & Barger JB. (2014) Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29(2), 190-4. PMID: 24735872  

  • August 13, 2014
  • 11:35 PM
  • 681 views

The Controversy of Admitting 'We Do Not Know What Works'

by Rogue Medic in Rogue Medic

There are several news articles today criticizing a study because the patients might be deprived of a drug that has not been adequately studied in humans. This criticism is coming from journalists – the people who publicized the fraudulent vaccines research by Andrew Wakefield, who was trying to sell his competing vaccine and was being paid to produce negative research by lawyers suing the vaccine companies.[1]

The real controversy is that this untested drug became the standard of care ........ Read more »

Larabee TM, Liu KY, Campbell JA, & Little CM. (2012) Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83(8), 932-9. PMID: 22425731  

Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, & Holmberg S. (1995) Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?. Resuscitation, 29(3), 195-201. PMID: 7667549  

Olasveengen, T., Sunde, K., Brunborg, C., Thowsen, J., Steen, P., & Wik, L. (2009) Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial. JAMA: The Journal of the American Medical Association, 302(20), 2222-2229. DOI: 10.1001/jama.2009.1729  

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S. (2012) Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307(11), 1161-8. PMID: 22436956  

Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T. (2012) Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76(7), 1639-45. PMID: 22481099  

Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P.... (2012) Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium. Resuscitation. PMID: 22858552  

Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, & Dickinson GE. (1992) High-dose epinephrine in adult cardiac arrest. The New England journal of medicine, 327(15), 1045-50. PMID: 1522840  

Callaway, C. (2012) Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1198. DOI: 10.1001/jama.2012.313  

  • August 5, 2014
  • 11:00 PM
  • 698 views

What is the Best Way to Manage Cardiac Arrest According to the Evidence?

by Rogue Medic in Rogue Medic

There is an excellent review article by Dr. Bentley Bobrow and Dr. Gordon Ewy on the best management of sudden cardiac arrest from the bystander to the ICU (Intensive Care Unit).

They point out something that we tend to resist learning. Cardiac arrest that is not due to respiratory causes does not need respiratory treatment. A person who is unresponsive and gasping is exhibiting signs of cardiac arrest, not signs of respiratory problems.... Read more »

  • August 3, 2014
  • 05:00 PM
  • 785 views

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

by Rogue Medic in Rogue Medic

This study is interesting for several reasons.

In a system that claims excellence, the most consistent way to identify the study group is by documentation of a protocol violation - but it is not intended as a study of protocol violations.

This may hint at some benefit from epinephrine (Adrenaline in Commonwealth countries), but that would require some study and we just don't study epinephrine. We only make excuses for not studying epinephrine.

The atropine results suggest that the ........ Read more »

  • July 31, 2014
  • 11:35 PM
  • 756 views

Fall With Dementia and No Change from Baseline Mental Status

by Rogue Medic in Rogue Medic

This happens many times every day. A patient falls and may have hit her head, but there is no change from her normal mental status. To complicate matter, she takes an anticoagulant.

There are no clear signs of serious trauma. so should we automatically go to the trauma center?

What can help us decide?... Read more »

  • July 11, 2014
  • 12:15 AM
  • 676 views

Remote CPR Skills Testing Online - A Crazy Idea?

by Rogue Medic in Rogue Medic

On the MedicCast, Jamie Davis interviews Roy Shaw of SUMO about a method of remote CPR certification for health care providers.

"The Single Use Manikin Option, or SUMO™, is an AHA-compliant way of getting certified in CPR completely online.[1]"

What different ways of dealing with certification/recertification problems should we use?... Read more »

Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. (2011) Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-Hospital Pediatric Providers. PEDIATRICS, 128(1). DOI: 10.1542/peds.2010-2105d  

  • June 29, 2014
  • 11:55 PM
  • 712 views

Safety of Intranasal Fentanyl in the Out-of-Hospital Setting - A Prospective Observational Study

by Rogue Medic in Rogue Medic

I have been very critical of plans to have first responders treat people they suspect of having a heroin (or other) opioid overdose with naloxone.

Would first responders be safer with fentanyl?

It is not really the same question, but it does highlight the differences and why I think fentanyl is safer. The patient will be seen by someone more likely to recognize when the treatment is inappropriate. This study looked at IN (IntraNasal) fentanyl given by basic EMTs prior to transport to the E........ Read more »

  • May 25, 2014
  • 06:00 PM
  • 670 views

Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?

by Rogue Medic in Rogue Medic

If we are going to give epinephrine to patients with rhythms that are not shockable (PEA [Pulseless Electrical Activity] or Asystole), it appears that patients receiving epinephrine earlier have better outcomes than patients who receive epinephrine later in the hospital in the less acute care settings.

Does this mean that patients who receive epinephrine have better outcomes than patients who do not receive epinephrine?

We remain willfully ignorant of the answer to that question.
... Read more »

Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A.... (2010) Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14(3), 355-60. PMID: 20388032  

  • April 3, 2014
  • 06:30 PM
  • 679 views

In Defense of No Improvement by Medic Madness – Part IV

by Rogue Medic in Rogue Medic

Continuing from Part I, Part II, and Part III in response to what I wrote about the failure of the LUCAS,[1] Sean continues with -

"Another issue I have with this data, is that it doesn’t address the following variables:
Down time
Whether or not bystander CPR was performed
Medications used
Whether or not an advanced airway was placed
Length of resuscitation"... Read more »

  • March 27, 2014
  • 10:15 AM
  • 1,011 views

In Defense of No Improvement by Medic Madness - Part III

by Rogue Medic in Rogue Medic

Sean continues to explain how the machine that does not improve outcomes allows him to provide other 'treatments' that do not improve outcomes.

I continue to point out the problems with his excuses.

.... Read more »

Larabee TM, Liu KY, Campbell JA, & Little CM. (2012) Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83(8), 932-9. PMID: 22425731  

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S. (2012) Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307(11), 1161-8. PMID: 22436956  

Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T. (2012) Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76(7), 1639-45. PMID: 22481099  

Allegra J, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, & Yablonski M. (2001) Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting. Resuscitation, 49(3), 245-9. PMID: 11719117  

Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, & Walsh T. (1999) Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. The New England journal of medicine, 341(12), 871-8. PMID: 10486418  

  • March 11, 2014
  • 11:55 PM
  • 776 views

Who Needs a 12 Lead ECG?

by Rogue Medic in Rogue Medic

Do we do too many 12 lead ECGs on patients who do not have chest pain?

This is something that some people worry about.

Save the electrodes!

Those poor little electrodes are being abused!

Are electrodes being abused?... Read more »

  • March 5, 2014
  • 03:00 PM
  • 821 views

The Failure of LUCAS to Improve Outcomes in the LINC Trial

by Rogue Medic in Rogue Medic

We love gadgets in EMS.

Dr. Bryan Bledsoe tells us that if we paint it orange and put a star of life on it, we can sell any product for a lot more money.

How much would you pay to not improve outcomes?

$10,000.00?

$20,000.00?

$30,000.00?

$40,000.00?

$50,000.00?... Read more »

  • November 26, 2013
  • 05:30 PM
  • 1,322 views

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So - Part II

by Rogue Medic in Rogue Medic

Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.

What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?... Read more »

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM. (2013) Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75(2), 212-9. PMID: 23823612  

Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L'hermite J, Wetterslev J, & Danish Anaesthesia Database. (2011) Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107(5), 659-67. PMID: 21948956  

  • November 20, 2013
  • 06:00 PM
  • 927 views

Is Earlier Better for Therapeutic Hypothermia? Part I

by Rogue Medic in Rogue Medic

When is the right time to begin TH (Therapeutic Hypothermia) to produce the best outcomes?

In the ICU (Intensive Care Unit)?

In the ED (Emergency Department)?

In the ambulance?

While the patient is still pulseless?

This question was asked in 2010.... Read more »

  • November 7, 2013
  • 12:00 PM
  • 921 views

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So - Part I

by Rogue Medic in Rogue Medic

This study starts out looking good, but there is a huge problem with the design.

If the person intubating felt that he needed to use the video laryngoscope to get the tube, then the patient was not randomized into the study.

How was this paper accepted for publication with such an obviously violation of research methodology?
... Read more »

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM. (2013) Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75(2), 212-9. PMID: 23823612  

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