Rogue Medic

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

Rogue Medic
182 posts

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  • June 29, 2011
  • 07:30 AM
  • 1,890 views

Definitely Certain

by Rogue Medic in Rogue Medic

Too often we will look at just the rare, but well publicized error. We ignore all of the otherwise overwhelming accuracy. We are frequently far less accurate at assessment than those we condemn.

If we do not measure what we are doing, we probably will be wildly inaccurate in our estimation of our performance.
... Read more »

  • June 16, 2011
  • 07:30 AM
  • 1,528 views

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department – Part I

by Rogue Medic in Rogue Medic

What the emergency department needs to treat, EMS also needs to treat.

We can pretend otherwise.

We can pretend that just driving fast while wrestling with a patient is in some way safe.

These are delusions just as much as what is going on in the head of the patient with acute behavioural disturbance.
... Read more »

  • June 14, 2011
  • 07:30 AM
  • 3,016 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  

  • June 9, 2011
  • 07:30 AM
  • 1,353 views

Allow Me To Manipulate.. I Mean Immobilize Your Spine – Part I

by Rogue Medic in Rogue Medic

We aren't immobilizing patients to protect them from injury. We are immobilizing patients to protect ourselves, our bosses, our medical directors, and our organizations from the people we are supposed to be protecting - our patients.

We claim that it is unethical to do otherwise.

Could we come up with a better way of demonstrating that we do not have a clue about ethics?... Read more »

Hauswald M, Ong G, Tandberg D, & Omar Z. (1998) Out-of-hospital spinal immobilization: its effect on neurologic injury. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 5(3), 214-9. PMID: 9523928  

  • May 27, 2011
  • 07:30 AM
  • 2,005 views

Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia

by Rogue Medic in Rogue Medic

We do not have enough information to determine what effect fentanyl has on blood pressure in these patients, but we no longer have a good reason for expecting that fentanyl will produce hypotension.

There are many possible side effects of fentanyl, but even in hypotensive patients we should not expect any sudden deterioration in blood pressure with judicious administration of fentanyl by competent EMS personnel.

The real surprise was in the rate of hypoxemia.... Read more »

Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, & Vanbuskirk K. (2006) Safety and effectiveness of fentanyl administration for prehospital pain management. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 10(1), 1-7. PMID: 16418084  

  • May 23, 2011
  • 07:30 AM
  • 1,862 views

Utilization of warning lights and siren based on hospital time-critical interventions

by Rogue Medic in Rogue Medic

We have too many treatments/procedures that are based on nothing more than superstition, tradition, and/or wishful thinking. We need to evaluate what we do in as unbiased a way as possible to find out if there is any benefit to any patient, rather than just blindly continue with each myth-based intervention.... Read more »

Marques-Baptista A, Ohman-Strickland P, Baldino KT, Prasto M, & Merlin MA. (2010) Utilization of warning lights and siren based on hospital time-critical interventions. 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(4), 335-9. PMID: 20845321  

  • May 13, 2011
  • 07:30 AM
  • 2,112 views

Is Friday the 13th bad for your health

by Rogue Medic in Rogue Medic

This is reminiscent of some of the old medics' tales in EMS that are cited as the basis for otherwise baseless nonsense, such as - "If you don't give anti-nausea medication with morphine, then the patient will vomit." A small percentage of patients receiving morphine will develop nausea. Only some of that small percentage of patients will end up vomiting. ... Read more »

Scanlon TJ, Luben RN, Scanlon FL, & Singleton N. (1993) Is Friday the 13th bad for your health?. BMJ (Clinical research ed.), 307(6919), 1584-6. PMID: 8292946  

  • May 4, 2011
  • 07:30 AM
  • 2,502 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 »

  • April 5, 2011
  • 07:30 AM
  • 2,178 views

Motor Vehicle Intrusion – EMS Research Episode 7

by Rogue Medic in Rogue Medic

Why let reality get in the way of a protocol for trauma triage?

After all, we have never let reality interfere with trauma treatment before.

What about cardiology has led us to focus exclusively on specificity, but ignore sensitivity?

What about trauma has led us to focus exclusively on sensitivity, but ignore specificity?
... Read more »

Isenberg D, Cone DC, & Vaca FE. (2011) Motor vehicle intrusion alone does not predict trauma center admission or use of trauma center resources. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 15(2), 203-7. PMID: 21226551  

  • March 24, 2011
  • 07:30 AM
  • 2,015 views

Killing Poison Control Centers to Pretend to Save Money

by Rogue Medic in Rogue Medic

So, to celebrate "National Poison Prevention Week" (March 20 - March 26), politicians decided to kill the Poison Control Centers.

No, they're just cutting the funding a little bit.

From $29.3 million down to $2 million.

Assume that you make $29.3 thousand dollars per year. Now assume that your pay is cut to $2 thousand per year. How is that going to work?... Read more »

LoVecchio, F., Curry, S., Waszolek, K., Klemens, J., Hovseth, K., & Glogan, D. (2008) Poison control centers decrease emergency healthcare utilization costs. Journal of Medical Toxicology, 4(4), 221-224. DOI: 10.1007/BF03161204  

  • March 15, 2011
  • 07:30 AM
  • 2,054 views

Correction to Spine Immobilization in Penetrating Trauma: More Harm Than Good

by Rogue Medic in Rogue Medic

I let my biases get the better of me when I wrote about this in "Spine Immobilization in Penetrating Trauma: More Harm Than Good?"

While I spent a significant portion of that review explaining why evidence of benefit was not present in this study, I ignored the problems with the data when the authors concluded that there was harm.

That was a mistake on my part. While I do believe that harm is likely, this study does not provide evidence to support that belief. ... Read more »

Haut, E., Kalish, B., Efron, D., Haider, A., Stevens, K., Kieninger, A., Cornwell, E., & Chang, D. (2010) Spine Immobilization in Penetrating Trauma: More Harm Than Good?. The Journal of Trauma: Injury, Infection, and Critical Care, 68(1), 115-121. DOI: 10.1097/TA.0b013e3181c9ee58  

  • March 8, 2011
  • 07:30 AM
  • 1,968 views

Misplaced endotracheal tubes by paramedics in an urban emergency medical service system

by Rogue Medic in Rogue Medic

Here is a study that sets out to determine if one part of my statement is correct. Were we correctly placing endotracheal tubes before we even had the fancy technology of waveform capnography?... Read more »

  • March 1, 2011
  • 07:30 AM
  • 2,040 views

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

by Rogue Medic in Rogue Medic

In Part II, I explained the problems with the NTDB claiming that only 49.3% of trauma patients had IV starts documented. While that is a problem, looking at the data on the rest of the "top 5 procedures" makes the documentation failure even more obvious.... Read more »

  • February 22, 2011
  • 07:30 AM
  • 8,071 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 »

  • February 20, 2011
  • 07:30 AM
  • 1,998 views

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

by Rogue Medic in Rogue Medic

We expect the PubMed abstract to provide the important information.

In this case, we would be wrong.

This study does not look at Prehospital Intravenous Fluid Administration.... Read more »

  • February 14, 2011
  • 02:30 PM
  • 2,361 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  

  • January 28, 2011
  • 07:30 AM
  • 5,923 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  

  • January 12, 2011
  • 07:30 AM
  • 3,553 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  

  • December 31, 2010
  • 07:30 AM
  • 4,971 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 »

  • December 6, 2010
  • 07:30 AM
  • 2,604 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  

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