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Commentary on EMS (Emergency Medical Services), medicine, and science.
Rogue Medic
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- April 19, 2012
- 12:30 PM
- 284 views
Flawed Helicopter EMS vs Ground EMS Research - Part II
by Rogue Medic in Rogue Medic
Most of the data was incomplete? Is this a surprise?
No. The authors used the NTDB® (National Trauma Data Bank®) to number crunch to find associations and then declared that association is proof. The NTDB® is very flawed data.
The scientific method does not state that we should use weak data to data mine for associations and then claim that these weak associations are proof of anything. This is a failure to use the scientific method.
The NTDB® has been used before. I hav........ Read more »
Galvagno, S., Haut, E., Zafar, S., Millin, M., Efron, D., Koenig, G., Baker, S., Bowman, S., Pronovost, P., & Haider, A. (2012) Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA: The Journal of the American Medical Association, 307(15), 1602-1610. DOI: 10.1001/jama.2012.467
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, & Chang DC. (2010) Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of surgery. PMID: 21178760
Hemmila, M., Jakubus, J., Wahl, W., Arbabi, S., Henderson, W., Khuri, S., Taheri, P., & Campbell, D. (2007) Detecting the blind spot: Complications in the trauma registry and trauma quality improvement. Surgery, 142(4), 439-449. DOI: 10.1016/j.surg.2007.07.002
- April 18, 2012
- 03:30 PM
- 219 views
Flawed Helicopter EMS vs Ground EMS Research - Part I
by Rogue Medic in Rogue Medic
The media are posting headlines that there is finally evidence that helicopters save lives.[1]
This is from JAMA, which generated a bunch of headlines with the misleading claim that a glucose-insulin-potassium cocktail saves lives just a few weeks ago. The press bought it. A lot of people accepted the news reports.
Is this research similarly exaggerated far beyond what the evidence justifies?
Is this research valid?... Read more »
Galvagno, S., Haut, E., Zafar, S., Millin, M., Efron, D., Koenig, G., Baker, S., Bowman, S., Pronovost, P., & Haider, A. (2012) Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA: The Journal of the American Medical Association, 307(15), 1602-1610. DOI: 10.1001/jama.2012.467
- April 12, 2012
- 10:45 PM
- 407 views
Most Common Cause of Death in Anaphylaxis is Failure to Give Epinephrine
by Rogue Medic in Rogue Medic
The most common cause of death in anaphylaxis is failure to give epinephrine.
That is according to Dr. Corey Slovis, presenting at the 2012 Gathering of Eagles Conference.[1]
This is shocking news. Where do we have any evidence of that?... Read more »
Sampson, H., Mendelson, L., & Rosen, J. (1992) Fatal and Near-Fatal Anaphylactic Reactions to Food in Children and Adolescents. New England Journal of Medicine, 327(6), 380-384. DOI: 10.1056/NEJM199208063270603
- April 5, 2012
- 09:30 PM
- 613 views
Naloxone in cardiac arrest with suspected opioid overdoses
by Rogue Medic in Rogue Medic
Can naloxone improve survival from cardiac arrest?
This is an interesting study that looks at some old charts to try to figure out if naloxone made any difference when it was given to cardiac arrest patients suspected of having an opioid overdose. Here is the interesting part of their hypothesis –... Read more »
Saybolt, M., Alter, S., Dos Santos, F., Calello, D., Rynn, K., Nelson, D., & Merlin, M. (2010) Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42-46. DOI: 10.1016/j.resuscitation.2009.09.016
- April 4, 2012
- 02:40 PM
- 318 views
Should We Start Using a Glucose-Insulin-Potassium Cocktail
by Rogue Medic in Rogue Medic
Those unfamiliar with research have been making the usual exaggerated claims that come from wishful thinking and not considering the possible harm from rushing to adopt a treatment based on weak evidence.
Should we rush to make this a standard treatment, that will become a Standard Of Care through inertia and tradition?... Read more »
Selker HP, Beshansky JR, Sheehan PR, Massaro JM, Griffith JL, D'Agostino RB, Ruthazer R, Atkins JM, Sayah AJ, Levy MK.... (2012) Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes: The IMMEDIATE Randomized Controlled Trial. JAMA : the journal of the American Medical Association. PMID: 22452807
- March 23, 2012
- 08:00 AM
- 357 views
Dr. Ken Grauer on Killing Patients Just to Get a Temporary Pulse With Epinephrine – Part II
by Rogue Medic in Rogue Medic
Dr. Ken Grauer wrote a couple of extended comments in response to "Killing Patients Just to Get a Temporary Pulse With Epinephrine."
Dr. Grauer has provided some commentary on this on his web site – KG-EKG Press.
"ISSUE #10: Should We Still Use Epinephrine for Cardiac Arrest?"
So, how bad was epinephrine in this study?... Read more »
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), 1161-1168. DOI: 10.1001/jama.2012.294
Callaway, C. (2012) Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1198-1200. DOI: 10.1001/jama.2012.313
- March 17, 2012
- 12:30 PM
- 374 views
Two Experiments Confirm the Importance of the Scientific Method
by Rogue Medic in Rogue Medic
I could try to make this suspenseful, but it is not a surprise. Attempts to confirm the experiment did not confirm faster than light neutrinos.
The other experiment is even less surprising. There was a paper that claimed that psychic powers are real and that there is proof. Several attempts have been made to reproduce the results. The psychics predicted success, but those predictions were not correct and nobody should be surprised.... Read more »
Bem DJ. (2011) Feeling the future: experimental evidence for anomalous retroactive influences on cognition and affect. Journal of personality and social psychology, 100(3), 407-25. PMID: 21280961
Ritchie, S., Wiseman, R., & French, C. (2012) Failing the Future: Three Unsuccessful Attempts to Replicate Bem's ‘Retroactive Facilitation of Recall’ Effect. PLoS ONE, 7(3). DOI: 10.1371/journal.pone.0033423
- March 15, 2012
- 04:45 PM
- 362 views
Does RSI Protect Against Aspiration of Stomach Contents
by Rogue Medic in Rogue Medic
One of the reasons we use RSI (Rapid Sequence Induction/Intubation) is to protect the airway from aspiration of stomach contents, blood, debris, and other things that might make their way into the lungs and make the patient’s already very bad day, very much worse.
Does RSI protect against aspiration?
We are presented with a patient who appears to need airway management.... Read more »
Neilipovitz DT, & Crosby ET. (2007) No evidence for decreased incidence of aspiration after rapid sequence induction. Canadian journal of anaesthesia , 54(9), 748-64. PMID: 17766743
- March 14, 2012
- 08:00 AM
- 544 views
Intramuscular Midazolam for Seizures – Part VI
by Rogue Medic in Rogue Medic
Which seizure patients should be treated with benzodiazepines?
Most patients stop seizing without any treatment and benzodiazepines can cause respiratory depression, so we need to be careful.
You can’t be too careful!
Right?... Read more »
Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494
Hirsch LJ. (2012) Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus. The New England journal of medicine, 366(7), 659-60. PMID: 22335744
- March 13, 2012
- 12:15 PM
- 426 views
Intramuscular Midazolam for Seizures – Part V
by Rogue Medic in Rogue Medic
How should this large double-blind, randomized, noninferiority trial comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) lorazepam (Ativan) affect the way we treat patients with seizures?
21.3% of patients had their seizures stop before they could be given IV lorazepam, while none of the IM midazolam patients had seizures stop before being given medication.
Does that provide a bias toward improved outcomes with IM midazolam?... Read more »
Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494
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. The New England journal of medicine, 345(9), 631-7. PMID: 11547716
- March 9, 2012
- 08:00 AM
- 362 views
Intramuscular Midazolam for Seizures – Part IV
by Rogue Medic in Rogue Medic
If an IV is already in place, on average the IV lorazepam should stop the seizure about 1.6 minutes after the lorazepam is pushed into the IV line.
The IM midazolam should stop the seizure about 3.3 minutes after the midazolam is injected into the muscle, on average.
If an IV is already in place, IV lorazepam should be significantly faster.
An IV is usually not already in place when EMS shows up. so what should we do?... Read more »
Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494
- March 7, 2012
- 08:00 AM
- 538 views
Nontraumatic out-of-hospital hypotension predicts inhospital mortality
by Rogue Medic in Rogue Medic
An interesting examination of something that we take for granted. Does any instance of hypotension increase the risk of death for patients with life-threatening or potentially life-threatening conditions? Hypotension is categorized as SBP (Systolic Blood Pressure) less than 100 mm Hg, rather than SBP less than 90.
They assessed patients with respiratory distress, syncope, chest pain, dizziness, altered mental status, anxiety, thirst, weakness, fatigue, or the sensation of impending doom.... Read more »
Jones, A., Stiell, I., Nesbitt, L., Spaite, D., Hasan, N., Watts, B., & Kline, J. (2004) Nontraumatic out-of-hospital hypotension predicts inhospital mortality☆. Annals of Emergency Medicine, 43(1), 106-113. DOI: 10.1016/j.annemergmed.2003.08.008
- February 26, 2012
- 11:59 PM
- 454 views
Trauma Criteria – preventative medicine – Part I
by Rogue Medic in Rogue Medic
There are a lot of interesting things about this study, but Table 3 shows that there is some ability to improve the accuracy of triage criteria by combining criteria. This should be a no brainer, but here are some data to support this. 2.8% 4.7% 8.0% = 50%. That is a tremendous improvement over the 15.5% that they add up to individually.... Read more »
Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL.... (2009) Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control, 58(RR-1), 1-35. PMID: 19165138
Cox, S., Smith, K., Currell, A., Harriss, L., Barger, B., & Cameron, P. (2011) Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria. Injury, 42(9), 889-895. DOI: 10.1016/j.injury.2010.03.035
- February 22, 2012
- 08:00 AM
- 358 views
Mass sociogenic illness initially reported as carbon monoxide poisoning
by Rogue Medic in Rogue Medic
Here is a report of a mass delusion that seems to have been compounded by the use of the Masimo RAD-57 non-invasive CO monitor. CO (Carbon monOxide) is a significant cause of poisoning in the US, but not relevant in this case. The RAD-57 incorrectly identified CO poisoning in half a dozen people who do not appear to have had any exposure to CO.... Read more »
Nordt, S., Minns, A., Carstairs, S., Kreshak, A., Campbell, C., Tomaszweski, C., Hayden, S., Clark, R., Joshua, A., & Ly, B. (2012) Mass Sociogenic Illness Initially Reported as Carbon Monoxide Poisoning. The Journal of Emergency Medicine, 42(2), 159-161. DOI: 10.1016/j.jemermed.2011.01.028
- February 21, 2012
- 06:10 PM
- 628 views
Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients
by Rogue Medic in Rogue Medic
The Masimo RAD-57 non-invasive CO monitor is promoted as an accurate way to identify patients at risk of life-threatening complications of CO poisoning. CO (Carbon monOxide) is a significant cause of poisoning in the US, with hundreds of fatalities each year.
Masimo claims that their RAD-57 is able to accurately measure blood levels of CO without any complicated lab equipment. If it works, the RAD-57 might save some lives. Unfortunately, the research that has not been funded by Masimo does no........ Read more »
Touger, M., Birnbaum, A., Wang, J., Chou, K., Pearson, D., & Bijur, P. (2010) Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement. Annals of Emergency Medicine, 56(4), 382-388. DOI: 10.1016/j.annemergmed.2010.03.041
O'Reilly, M. (2010) Performance of the Rad-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement. Annals of Emergency Medicine, 56(4), 442-444. DOI: 10.1016/j.annemergmed.2010.08.016
Nilson D, Partridge R, Suner S, & Jay G. (2010) Non-invasive carboxyhemoglobin monitoring: screening emergency medical services patients for carbon monoxide exposure. Prehospital and disaster medicine, 25(3), 253-6. PMID: 20586019
Roth, D., Herkner, H., Schreiber, W., Hubmann, N., Gamper, G., Laggner, A., & Havel, C. (2011) Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients. Annals of Emergency Medicine, 58(1), 74-79. DOI: 10.1016/j.annemergmed.2010.12.024
- February 20, 2012
- 08:50 AM
- 578 views
Intramuscular Midazolam for Seizures – Part III
by Rogue Medic in Rogue Medic
This presents an interesting conundrum. Doses of benzodiazepines (midazolam, lorazepam, diazepam, . . .) are often limited, due to a fear of causing respiratory complications. When treating seizures, higher doses of benzodiazepines may protect patients from respiratory complications.... Read more »
Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494
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. The New England journal of medicine, 345(9), 631-7. PMID: 11547716
Hirsch LJ. (2012) Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus. The New England journal of medicine, 366(7), 659-60. PMID: 22335744
- February 19, 2012
- 06:30 AM
- 470 views
Intramuscular Midazolam for Seizures – Part II
by Rogue Medic in Rogue Medic
While there have been studies comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) anti-epileptic medications, this is a large study that compares IM midazolam with the best IV anti-epileptic medication in a double-blind, randomized, noninferiority trial.
For the study, there were two different doses for the auto-injector (the same as an EpiPen). The doses were not small.
Midazolam for seizures is an off-label use both when given IM and when given IV.[2]
The lorazepa........ Read more »
Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494
Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, & Waisman Y. (1997) A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Pediatric emergency care, 13(2), 92-4. PMID: 9127414
- February 2, 2012
- 06:30 AM
- 581 views
This is the Way to Bad Medicine - II
by Rogue Medic in Rogue Medic
Their categorization of only 3 (out of 32) serious adverse events as "Probably related to treatment" and none as "Definitely related to treatment" suggests that they are not being objective. How do they explain this in the discussion? They don’t. Maybe they aren’t referring to the serious adverse events, but are referring to deaths. I don’t know and since they do not explain, I can only speculate.... Read more »
Barreto, A., Alexandrov, A., Lyden, P., Lee, J., Martin-Schild, S., Shen, L., Wu, T., Sisson, A., Pandurengan, R., Chen, Z.... (2012) The Argatroban and Tissue-Type Plasminogen Activator Stroke Study: Final Results of a Pilot Safety Study. Stroke. DOI: 10.1161/STROKEAHA.111.625574
- January 24, 2012
- 04:30 PM
- 457 views
This is the Way to Bad Medicine
by Rogue Medic in Rogue Medic
Dr. Radecki at EM Literature of Note has a nice analysis of a study that promises to try to change medicine for the worse. Of course, that is not the intent of the study’s authors, but they have too much confidence in their results. The study is only looking at patients with minor head injury and minor symptoms, but taking warfarin (Coumadin).... Read more »
Menditto, V., Lucci, M., Polonara, S., Pomponio, G., & Gabrielli, A. (2012) Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol. Annals of Emergency Medicine. DOI: 10.1016/j.annemergmed.2011.12.003
- January 4, 2012
- 02:20 PM
- 635 views
Nifekalant versus lidocaine for in-hospital shock-resistant ventricular fibrillation or tachycardia
by Rogue Medic in Rogue Medic
Why compare nikefelant with lidocaine? Why not compare nikefelant with amiodarone? Why not compare nikefelant with an antiarrhythmic that is more effective than amiodarone – procainamide, sotalol, or ajmaline?
Lidocaine is probably used because the IRB (Institutional Review Board) would consider it unethical to have a placebo group. Lidocaine is the placebo, but with less safety than the placebo.... Read more »
Shiga, T., Tanaka, K., Kato, R., Amino, M., Matsudo, Y., Honda, T., Sagara, K., Takahashi, A., Katoh, T., Urashima, M.... (2010) Nifekalant versus lidocaine for in-hospital shock-resistant ventricular fibrillation or tachycardia. Resuscitation, 81(1), 47-52. DOI: 10.1016/j.resuscitation.2009.09.027
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, & Thompson PL. (2011) Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation, 82(9), 1138-43. PMID: 21745533
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