Rogue Medic

182 posts · 423,831 views

Rogue Medic
182 posts

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  • July 17, 2012
  • 09:00 AM
  • 1,118 views

What is the effect of clopidogrel on head injuries? Part IV

by Rogue Medic in Rogue Medic

All of these patients were ground-level falls, so from standing, or sitting, or lying on bed. All of these patients had a GCS (Glasgow Coma Score) of 15, which is normal. There does not appear to have been anything alarming about any of these patients, but two of them died - and the information does not provide any clues to identify them while they might have been treated successfully. ... Read more »

  • July 10, 2012
  • 09:00 PM
  • 927 views

What is the effect of clopidogrel on head injuries? Part III

by Rogue Medic in Rogue Medic

Continuing from Part I and Part II about the comparative effects of warfarin (Coumadin) and clopidogrel (Plavix) on tICH (traumatic IntraCranial Hemorrhage).

Total patients – 1,064.

Total seen at a trauma center – 364 (34.2%).

Total seen at a community hospital – 700 (65.8%).... Read more »

  • June 25, 2012
  • 09:00 AM
  • 1,620 views

Laryngospasm, hypoxia, excited delirium, and ketamine – Part II

by Rogue Medic in Rogue Medic

Continuing from Part I, where our excited delirium patient was sedated quickly with IM (IntraMuscular) ketamine, but developed laryngospasm and cyanosis later at the hospital.

Do we have a good drug to prevent muscular spasm of the smooth muscles?

Can we ventilate him again? Yes, but there is a bit of a pattern developing. It would not be good to ignore the possibility that this will not be the last episode of laryngospasm for this patient today.... Read more »

Burnett AM, Watters BJ, Barringer KW, Griffith KR, & Frascone RJ. (2012) Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 16(3), 412-4. PMID: 22250698  

  • June 21, 2012
  • 04:00 PM
  • 1,137 views

Laryngospasm, hypoxia, excited delirium, and ketamine - Part I

by Rogue Medic in Rogue Medic

One of the concerns with ketamine is the rare occurrence of laryngospasm.

Can EMS manage the airway without paralytics?

If we can find just one bad outcome,should we prohibit EMS ketamine use and thus prevent all of the good outcomes, just to be safe?

Let’s look at an actual example, rather than waxing philosophical.... Read more »

Burnett AM, Watters BJ, Barringer KW, Griffith KR, & Frascone RJ. (2012) Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 16(3), 412-4. PMID: 22250698  

  • June 19, 2012
  • 09:00 AM
  • 1,231 views

One hundred percent oxygen in the treatment of acute myocardial infarction and severe angina pectoris

by Rogue Medic in Rogue Medic

In the absence of hypoxia, is supplemental oxygen good for a patient with cardiac chest pain, but no hypoxia or shortness of breath?

We take it for granted that giving oxygen is good, and more oxygen is better, even if the patient is not hypoxic or short of breath, but what does the research show for cardiac patients?

This double-blinded study, released only 62 years ago – in 1950, strongly suggests that supplemental oxygen is not good for patients with chest pain and/or ECG changes......... Read more »

  • June 15, 2012
  • 09:00 AM
  • 995 views

Is this what an IRB is supposed to do?

by Rogue Medic in Rogue Medic

These researchers appear to have started off with an obstacle that they never could completely overcome. What do we do when the IRB (Institutional Review Board) is opposed to studying treatment in a way that will actually test the hypothesis in question?... Read more »

  • June 13, 2012
  • 09:00 AM
  • 1,006 views

What is the effect of clopidogrel on head injuries? Part II

by Rogue Medic in Rogue Medic

A part of this study that should received more attention is the rate of immediate tICH (traumatic IntraCranial Hemorrhage) among patients taking clopidogrel or warfarin.

5.1% of warfarin (Coumadin) patients had immediate traumatic intracranial hemorrhage.

12.0% of clopidogrel (Plavix) patients had immediate traumatic intracranial hemorrhage.

The sample was from all patients with any kind of head trauma who presented to the participating trauma centers or to the participating community h........ Read more »

  • June 7, 2012
  • 09:00 AM
  • 1,178 views

What is the effect of clopidogrel on head injuries? Part I

by Rogue Medic in Rogue Medic

This is the final paper on head trauma and anticoagulants from the current Annals of Emergency Medicine. I wrote about the pair of editorials and the other article earlier.[1],[2] There is a lot to write about in this paper, so I am glad that this is a very well done paper. It is a pleasure to read research on an important topic and not be disappointed.... Read more »

  • June 4, 2012
  • 09:00 AM
  • 1,134 views

Will spontaneous pneumothorax progress to tension pneumothorax?

by Rogue Medic in Rogue Medic

If the conventional teaching were true, then why do so few spontaneous pneumothoraces progress to tension pneumothoraces?

Why is tension pneumothorax is rare.

Treatment of presumed tension pneumothorax appears to be much more common than tension pneumothorax.[2]... Read more »

  • May 25, 2012
  • 09:00 AM
  • 1,181 views

Cochrane and a Significantly Biased Review of Steroids for acute spinal cord injury

by Rogue Medic in Rogue Medic

An interesting relic of trauma care is the use of steroids for the treatment of acute spinal cord injury. As with The Golden Hour, there are people still promoting this idea. In the words of Monty Python, it’s not quite dead, yet.

Who is promoting this idea? The Cochrane Collaboration.

Here is a list of the papers evaluated in this 2012 update of the 2009 Cochrane Review, which was an update of the 2002 Cochrane Review. There has been no change in the references, since the most recen........ Read more »

Bracken MB. (2012) Steroids for acute spinal cord injury. Cochrane database of systematic reviews (Online). PMID: 22258943  

  • May 24, 2012
  • 03:35 PM
  • 823 views

Validation of the Dime

by Rogue Medic in Rogue Medic

The current Annals of Emergency Medicine has a pair of editorials on the article I wrote about[1] in This is the Way to Bad Medicine back in January. Dr. Radecki also was critical of this paper.[2] There is another study that refers to the same question published in this issue, but I will write about that paper later.

"These data raise the real question, Do such findings matter? By admitting more patients and ordering more CTs, do we improve outcomes? Or do we simply find more things tha........ Read more »

  • May 22, 2012
  • 02:00 PM
  • 1,137 views

How Diagnostic is Narcan?

by Rogue Medic in Rogue Medic

At Resus.ME,[1] Dr. Reid suggests that one benefit of nebulized naloxone[2] is its diagnostic value. He asks –

"Do you ever use naloxone diagnostically, and if so, do you think it’s worth knowing that the nebulised route is an option?"

This has been studied.... Read more »

  • May 15, 2012
  • 09:00 AM
  • 1,003 views

Influence of Sex on the Out-of-hospital Management of Chest Pain - Part II

by Rogue Medic in Rogue Medic

Part I was written in 2010, so I am a bit late in continuing to ridicule this example of bad research.

How do we determine what is good care for our patients?

By having our treatment follow the category that dispatch dispatch assigned the call? I used to work in a county, where this did appear to be the case. The medics would become very upset with dispatch if they did not receive a lot of information about the patient prior to arriving on scene.

Dispatchers would express surprise when ........ Read more »

Meisel, Z., Armstrong, K., Crawford Mechem, C., Shofer, F., Peacock, N., Facenda, K., & Pollack, C. (2010) Influence of Sex on the Out-of-hospital Management of Chest Pain. Academic Emergency Medicine, 17(1), 80-87. DOI: 10.1111/j.1553-2712.2009.00618.x  

  • May 10, 2012
  • 04:00 PM
  • 834 views

Doesn’t that study prove Lasix works?

by Rogue Medic in Rogue Medic

You ask an excellent question.

The study does give the impression that furosemide improved outcomes, but it was never designed as a study of whether furosemide is helpful, or even just not harmful. Other than oxygen, morphine, and furosemide (apparently in that order) we do not know much about the treatment of this small group of patients. Even pulmonary suction is listed as a treatment, but there are no suggestions that treatments are even limited to those listed.... Read more »

  • May 8, 2012
  • 09:15 PM
  • 1,373 views

Blood volume prior to and following treatment of acute cardiogenic pulmonary edema

by Rogue Medic in Rogue Medic

One of the myths of treatment for CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure) is that the patients are fluid overloaded. We MUST make the patient pee.

If you want to live, you have to pee!... Read more »

  • May 3, 2012
  • 08:00 PM
  • 938 views

Safety of prehospital intravenous fentanyl for adult trauma patients

by Rogue Medic in Rogue Medic

What prevents us from treating pain appropriately?

Actual adverse effects of pain medicine or unwarranted anxiety, due to exaggerated fears of potential adverse effects of pain medicine?

Pain management is important. Unfortunately, EMS and emergency medicine have been better at coming up with excuses for not treating pain, than we have been at coming up with good protocols that encourage treating pain.... Read more »

Soriya GC, McVaney KE, Liao MM, Haukoos JS, Byyny RL, Gravitz C, & Colwell CB. (2012) Safety of prehospital intravenous fentanyl for adult trauma patients. The journal of trauma and acute care surgery, 72(3), 755-759. PMID: 22491566  

  • April 26, 2012
  • 11:00 AM
  • 978 views

Lessons for management of anaphylaxis from a study of fatal reactions – Part I

by Rogue Medic in Rogue Medic

What can help us to learn more about what leads up to a bad outcome from anaphylaxis?

"it seemed that study of a large number of fatal reactions might give insight into why prevention and treatment had failed."... Read more »

Pumphrey RS. (2000) Lessons for management of anaphylaxis from a study of fatal reactions. Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology, 30(8), 1144-50. PMID: 10931122  

  • April 24, 2012
  • 07:30 PM
  • 1,095 views

Glucose before Thiamine for Wernicke Encephalopathy – A Literature Review

by Rogue Medic in Rogue Medic

Maybe that explains how the requirement for thiamine before glucose came about – confabulation.

Many of our traditional treatments are better explained by confabulation, based on a persuasive hypothesis, than by any evidence of benefit to the patient.... Read more »

  • April 19, 2012
  • 01:30 PM
  • 926 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  

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
  • 04:30 PM
  • 682 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  

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