Rogue Medic

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

Rogue Medic
182 posts

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  • September 10, 2014
  • 07:00 PM
  • 113,355 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 »

  • September 12, 2011
  • 02:20 PM
  • 16,013 views

Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure – Part IV

by Rogue Medic in Rogue Medic

We seem to most insist on stripping information of its meaning when we create multiple choice tests. Correct answers become a simple matter of memorization separated from understanding. This is one way to create the protocol monkey - the automaton, whom we claim is rendered harmless by being prevented from thinking. This desire to prevent the use of judgment may be the ultimate irrational decision.... Read more »

Wears RL. (2011) Risk, radiation, and rationality. Annals of emergency medicine, 58(1), 9-11. PMID: 21459481  

  • July 8, 2013
  • 02:45 AM
  • 13,793 views

Do Paralytics Improve Outcomes Following Resuscitation?

by Rogue Medic in Rogue Medic

This study will get some people excited because of an impressive p value for an odds ratio of improved cardiac arrest outcomes - 7.23 (1.56–33.38) p = 0.01.

NMBs (NeuroMuscular Blockers/Blockade) are paralytic drugs that are used to prevent movement by the patient. Does this study truly show that immediate use of NMBs improves neurologically intact survival from cardiac arrest?... Read more »

Salciccioli JD, Cocchi MN, Rittenberger JC, Peberdy MA, Ornato JP, Abella BS, Gaieski DF, Clore J, Gautam S, Giberson T.... (2013) Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients. Resuscitation. PMID: 23796602  

  • September 11, 2012
  • 10:00 PM
  • 10,866 views

Prove it – Ventilation improves survival from cardiac arrest

by Rogue Medic in Rogue Medic

Is a dead person going to be resuscitated sooner if we decrease the return of blood to the heart?

Ventilations decrease the return of blood to the heart.

Is a dead person going to be resuscitated sooner if we decrease whatever blood pressure we are creating with continuous chest compressions?

Ventilations decrease blood pressure, too.

Is a dead person short of breath?

Not unless resuscitated.

Is a person in cardiac arrest from an arrhythmia going to be hypoxic?

Probably not,........ Read more »

Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, Shellenberger J, Clark L, & Bobrow B. (2010) Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17(3), 269-75. PMID: 20370759  

  • February 22, 2011
  • 07:30 AM
  • 8,001 views

Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part II

by Rogue Medic in Rogue Medic

Even the "no fluids group" in that study did have "two 14 gauge IVs started." If we evaluated that study according to the criteria of the current study, both groups received IV fluids, since both had IVs started.

We know that is not true.

In the Bickell study, we know which of the patients who had IVs started received fluids and we know how much fluid patients received.... Read more »

  • November 17, 2010
  • 07:30 AM
  • 7,707 views

The RAD-57 Pulse Co-Oximeter – Does It Work – Part II

by Rogue Medic in Rogue Medic

Should anyone ever use a low RAD-57 reading to justify returning a fire fighter to a fire?

No.

Sending a fire fighter, with a not-yet-detected elevated COHb, back into the fire is probably only sending that fire fighter back into the same environment that produced the not-yet-detected elevated COHb.

This is not the way to make good things happen.... Read more »

  • September 11, 2011
  • 07:30 AM
  • 6,182 views

Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure – Part III

by Rogue Medic in Rogue Medic

Bringing up the imagery of Hiroshima radiation exposure in a study is one way to get us to by-pass the purpose of an objective study, while retaining the appearance of objectivity. Was this the intent of the authors? Probably not, since they got this question from an earlier study. However, they may have appreciated the emotional appeal.... Read more »

  • January 28, 2011
  • 07:30 AM
  • 5,846 views

Etomidate in procedural sedation

by Rogue Medic in Rogue Medic

"Some patients, even with significant doses of medication, still continued to verbalize significant amounts of pain."

Just giving more is not always an option. Maybe there are restrictions in the protocol. Maybe the patient's vital signs change in a way that suggests that more medication is not the best idea at that time.
... Read more »

Levins T. (2011) Etomidate in procedural sedation. Air medical journal, 30(1), 45-8. PMID: 21211712  

  • December 12, 2011
  • 01:00 PM
  • 5,299 views

Does Epinephrine Improve Survival from Cardiac Arrest

by Rogue Medic in Rogue Medic

Even though epinephrine (adrenaline) is used automatically in cardiac arrest, and there is evidence that epinephrine helps to produce a pulse (ROSC – Return Of Spontaneous Circulation), there is no evidence that epinephrine improves the only survival statistic that matters – discharge from the hospital with a brain that still works. There were so many deviations from assignment protocol in their 2009 study,[1] that the authors decided to examine the results based on what treatment pa........ Read more »

  • December 31, 2010
  • 07:30 AM
  • 4,905 views

Asymptomatic Sustained Ventricular Fibrillation in a Patient With Left Ventricular Assist Device

by Rogue Medic in Rogue Medic

This patient is pulseless. Pulseless patients are not rare. A 911 call for a pulseless patient is usually because the pulseless patient is dead.

Contrariwise, a patient talking to me has a pulse. I have had several patients who were awake and talking, but without any palpable pulses. The absence of palpable pulses is different from the absence of pulses. All of these patients, with no palpable pulses, were significantly symptomatic.... Read more »

  • November 26, 2010
  • 07:30 AM
  • 4,774 views

How Not to Respond to Negative Research

by Rogue Medic in Rogue Medic

That advice from Dr. O'Reilly may encourage us to return fire fighters to an environment that has already made them toxic, but with the mistaken belief that they have carboxyhemoglobin levels of zero, when their carboxyhemoglobin is really very high.

Dr. O'Reilly's advice is bad for Masimo investors.

Dr. O'Reilly's advice is bad for patients.

Dr. O'Reilly's advice misrepresents the research.... Read more »

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 : the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation, 25(3), 253-6. PMID: 20586019  

  • January 12, 2011
  • 07:30 AM
  • 3,500 views

Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma

by Rogue Medic in Rogue Medic

What this study does examine is the policy of having police transport patients with penetrating injuries to the head, neck, torso, upper arm, or thigh, rather than wait for EMS. Since the staffing problems seem to have continued to deteriorate after the completion of the study, the policy probably leads to a significantly higher percentage of police transports now, than when the original study was done.... Read more »

Band RA, Pryor JP, Gaieski DF, Dickinson ET, Cummings D, & Carr BG. (2010) Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. PMID: 21166730  

  • June 14, 2011
  • 07:30 AM
  • 2,966 views

ED procedural sedation of elderly patients: is it safe

by Rogue Medic in Rogue Medic

Compared with the patients receiving propofol alone, patients receiving propofol with an opioid had a much more dramatic drop in the dose of propofol given as their age increased.

Were there differences between the rates of hypotension among those only receiving propofol and those receiving propofol with an opioid? Among all patients? More among elderly patients? Less among elderly patients?... Read more »

Weaver CS, Terrell KM, Bassett R, Swiler W, Sandford B, Avery S, & Perkins AJ. (2011) ED procedural sedation of elderly patients: is it safe?. The American journal of emergency medicine, 29(5), 541-4. PMID: 20825829  

  • September 7, 2010
  • 06:22 PM
  • 2,955 views

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract

by Rogue Medic in Rogue Medic

This is only based on the limited information in an abstract, but it does raise some important questions about when and why we needle decompress someone with a suspected tension pneumotorax.... Read more »

Blaivas M. (2010) Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29(9), 1285-9. PMID: 20733183  

  • October 9, 2011
  • 06:00 PM
  • 2,854 views

Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy – Part 1

by Rogue Medic in Rogue Medic

Yesterday I wrote about the law being signed to allow teachers to give rectal diazepam (Valium) to student (for seizures, not to keep the class quiet).[1] Today I look at some of the reasons to question the use of RD (Rectal Diazepam) Diastat from Valeant Pharmaceuticals North America.... Read more »

  • December 15, 2011
  • 07:30 AM
  • 2,780 views

Intraosseous Versus Intravenous Vascular Access During Out-of- Hospital Cardiac Arrest – A Randomized Controlled Trial

by Rogue Medic in Rogue Medic

For treatment of medical cardiac arrest patients, which is better – IO (IntraOsseous) or IV (IntraVenous) access for medication administration?

Since no medications have ever been demonstrated to improve survival from cardiac arrest (only chest compressions and defibrillation have), the most important consideration will be what method results in the least interruption of compressions and the least interference with defibrillation.... Read more »

  • December 6, 2010
  • 07:30 AM
  • 2,552 views

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part III

by Rogue Medic in Rogue Medic

The research only demonstrates improved survival to admission, as if that does anything more than provide false hope and huge hospital bills. Why do we base the standard of care on such limited research?

Since there is no new amiodarone research, let's look at the old surrogate endpoint research that compares amiodarone with placebo. Keep in mind that this surrogate endpoint study is the basis for over a decade of still unproven treatment.... Read more »

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  

  • May 4, 2011
  • 07:30 AM
  • 2,448 views

Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.

by Rogue Medic in Rogue Medic

"This randomised controlled trial aimed to compare the efficacy and safety of 5 g aliquots of 10% and 50% dextrose in the out of hospital treatment of adult hypoglycaemic patients."

An important point is that the participating EMS agencies realize that supplementing the patient's dietary dextrose with intravenous dextrose means we are giving a drug and that drug should be titrated to effect.[2] The same is true of supplemental oxygen. We need to recognize that these are drugs t........ Read more »

  • February 14, 2011
  • 02:30 PM
  • 2,308 views

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper

by Rogue Medic in Rogue Medic

Should we assume that a tension pneumothorax is subtle?

I don't think so.

Why do we teach about tension pneumothorax as if it is the same as an easily missed simple pneumothorax?

I think it is because we don't realize just how unsubtle a tension pneumothorax is.
Absolutely.
... Read more »

Blaivas M. (2010) Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29(9), 1285-9. PMID: 20733183  

  • August 26, 2010
  • 09:18 PM
  • 2,155 views

Drug Shortages Affect Those Still in the Dark Ages – Furosemide

by Rogue Medic in Rogue Medic

Part 2 - Furosemide.

This drug shortage could be a good thing.

EMS may be forced to do without drugs that cause more harm than benefit.

Maybe we will be smart enough to realize that we are not helping our patients with these drugs.

Maybe.... Read more »

Mosesso VN Jr, Dunford J, Blackwell T, & Griswell JK. (2003) Prehospital therapy for acute congestive heart failure: state of the art. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 7(1), 13-23. PMID: 12540139  

Mattu A, Martinez JP, & Kelly BS. (2005) Modern management of cardiogenic pulmonary edema. Emergency medicine clinics of North America, 23(4), 1105-25. PMID: 16199340  

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