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Commentary on EMS (Emergency Medical Services), medicine, and science.
Rogue Medic
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- May 8, 2013
- 04:30 PM
- 62 views
Does experience matter – Part II
by Rogue Medic in Rogue Medic
In spite of the evidence to the contrary and a lack of rationality in the claim, we continue to be told that increasing the number of people with a title, such as paramedic, will result in better care.
Here is more evidence that dividing the skills among more people leads to less skilled care.
The authors begin by referring to other studies that demonstrate the high failure rate of doctors performing procedures on children.
How is that relevant to EMS? We have a low frequency of use of ........ Read more »
Mittiga, M., Geis, G., Kerrey, B., & Rinderknecht, A. (2013) The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View. Annals of Emergency Medicine, 61(3), 263-270. DOI: 10.1016/j.annemergmed.2012.06.021
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
Tanz RR, & Charrow J. (1993) Black clouds. Work load, sleep, and resident reputation. American journal of diseases of children (1960), 147(5), 579-84. PMID: 8488808
Meyr, A., Gonzalez, O., & Mayer, A. (2011) Quantification and Perception of On-call Podiatric Surgical Resident Workload. The Journal of Foot and Ankle Surgery, 50(5), 535-536. DOI: 10.1053/j.jfas.2011.04.035
- May 2, 2013
- 04:30 PM
- 56 views
Will IV Oxygen Save Lives?
by Rogue Medic in Rogue Medic
Intravenous oxygen delivery that works?
Maybe temporary oxygenation, but not yet.
Will this change the approach to CICV (Can’t Intubate, Can’t Ventilate) patients?
No, but it may change the approach to CICO (Can’t Intubate, Can’t Oxygenate) patients.
The distinction is important. ... Read more »
Kheir, J., Scharp, L., Borden, M., Swanson, E., Loxley, A., Reese, J., Black, K., Velazquez, L., Thomson, L., Walsh, B.... (2012) Oxygen Gas-Filled Microparticles Provide Intravenous Oxygen Delivery. Science Translational Medicine, 4(140), 140-140. DOI: 10.1126/scitranslmed.3003679
- April 17, 2013
- 04:30 PM
- 85 views
Is Nitroglycerin Bad for Severe Sepsis?
by Rogue Medic in Rogue Medic
Yesterday at "The Paramedic's Edge," this was the topic of discussion of a possible use of NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries).
NTG is a vasodilator and sepsis is a vasodialtion problem. There are other problems with sepsis, but vasodilation may be the primary problem.... Read more »
Guglin, M., & Postler, G. (2009) High dose nitroglycerin treatment in a patient with cardiac arrest: a case report. Journal of Medical Case Reports, 3(1), 8782. DOI: 10.4076/1752-1947-3-8782
SPRONK, P., INCE, C., GARDIEN, M., MATHURA, K., & ZANDSTRA, D. (2003) Nitroglycerin for septic shock. The Lancet, 361(9360), 880-880. DOI: 10.1016/S0140-6736(03)12692-X
Spronk, P., Ince, C., Gardien, M., Mathura, K., Straaten, H., & Zandstra, D. (2002) Nitroglycerin in septic shock after intravascular volume resuscitation. The Lancet, 360(9343), 1395-1396. DOI: 10.1016/S0140-6736(02)11393-6
- March 26, 2013
- 10:30 AM
- 101 views
Does the Goal of a Pulse Lead to Bad Resuscitation Decisions
by Rogue Medic in Rogue Medic
The paper does address some interesting aspects of resuscitation.
ROSC (Return Of Spontaneous Circulation) is the goal for many people.
ROSC is a red herring.
Those of us who think ROSC is important do not seem to understand how much long-term damage we can do in our attempts to get ROSC, or to get ROSC quickly.
This study helps to point out some of the inconsistencies with our ROSC fetish.... Read more »
Koscik, C., Pinawin, A., McGovern, H., Allen, D., Media, D., Ferguson, T., Hopkins, W., Sawyer, K., Boura, J., & Swor, R. (2013) Rapid Epinephrine Administration Improves Early Outcomes in Out-of-Hospital Cardiac Arrest. Resuscitation. DOI: 10.1016/j.resuscitation.2013.03.023
- March 22, 2013
- 10:00 AM
- 207 views
Equipoise and Ethics and IRBs, Oh My!
by Rogue Medic in Rogue Medic
In the comments to what I wrote yesterday about seizures and a study comparing lorazepam (Ativan), diazepam (Valium), and placebo,[1] Brooks Walsh had the following comment –
"Although I’ve read the study before, I am only wondering now how the IRB for Alldredge 2001 thought there was 'equipoise' between placebo and benzos."... Read more »
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH. (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
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
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. DOI: 10.1001/jama.2012.294
- March 14, 2013
- 09:30 PM
- 149 views
Should We Use Immobilization For Penetrating Injuries To The Neck - Comments at Paramedic's Edge
by Rogue Medic in Rogue Medic
Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting? [1]
That is the entire question that was asked at The Paramedic’s Edge.
There are really several questions being asked.... Read more »
Stuke, L., Pons, P., Guy, J., Chapleau, W., Butler, F., & McSwain, N. (2011) Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee. The Journal of Trauma: Injury, Infection, and Critical Care, 71(3), 763-770. DOI: 10.1097/TA.0b013e3182255cb9
. (2001) The cause of neurologic deterioration after acute cervical spinal cord injury. Journal of Neurosurgical Anesthesiology, 13(3), 280-281. DOI: 10.1097/00008506-200107000-00022
- March 10, 2013
- 10:00 PM
- 155 views
Japanese man dies after 25 hospitals reject him
by Rogue Medic in Rogue Medic
In January, in Japan, 25 hospitals refused to permit an ambulance to transport a man who was pronounced dead when he finally arrived at a hospital.
Were the patients already in the ED (Emergency Department) less stable than this patient?
Was this patient going to be the straw that breaks the camel’s back and result in the deaths of other patients already in the ED?
What kind of evidence do we have to justify diversion?
... Read more »
Khaleghi, M., Loh, A., Vroman, D., Chan, T., & Vilke, G. (2007) The Effects of Minimizing Ambulance Diversion Hours on Emergency Departments. The Journal of Emergency Medicine, 33(2), 155-159. DOI: 10.1016/j.jemermed.2007.02.014
Vilke, G., Castillo, E., Metz, M., Upledger Ray, L., Murrin, P., Lev, R., & Chan, T. (2004) Community trial to decrease ambulance diversion hours: The San Diego county patient destination trial. Annals of Emergency Medicine, 44(4), 295-303. DOI: 10.1016/j.annemergmed.2004.05.002
Burke, L., Joyce, N., Baker, W., Biddinger, P., Dyer, K., Friedman, F., Imperato, J., King, A., Maciejko, T., Pearlmutter, M.... (2013) The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time. Annals of Emergency Medicine, 61(3), 303-3110. DOI: 10.1016/j.annemergmed.2012.09.009
- March 5, 2013
- 04:30 PM
- 178 views
Bougies and ALS Airways
by Rogue Medic in Rogue Medic
The last paper we were working on for the EMS Research Podcast was this paper on the use of a bougie in the intubation of a simulated patient with spinal immobilization.
Is BAI (Bougie-Assisted Intubation) an improvement over traditional intubation (ETI or EndoTracheal Intubation)?... Read more »
Messa, M., Kupas, D., & Dunham, D. (2011) Comparison of Bougie-Assisted Intubation with Traditional Endotracheal Intubation in a Simulated Difficult Airway. Prehospital Emergency Care, 15(1), 30-33. DOI: 10.3109/10903127.2010.519821
- February 27, 2013
- 11:55 PM
- 181 views
Does Intubation Prevent Aspiration of Stomach Contents?
by Rogue Medic in Rogue Medic
This is a study that looked at the rate of aspiration among patients intubated in the PH (PreHospital or EMS) setting and compared them to patients intubated in the ED = (Emergency Department) setting.
There is one huge difference between these settings – EMS was not authorized to use any form of chemically assisted intubation or RSI (Rapid Sequence Induction/Intubation). At the time of this study, the only drugs available to snow the patient would have been morphine, midazolam (Versed)........ Read more »
Ufberg, J., Bushra, J., Karras, D., Satz, W., & Kueppers, F. (2005) Aspiration of gastric contents: association with prehospital intubation. The American Journal of Emergency Medicine, 23(3), 379-382. DOI: 10.1016/j.ajem.2005.02.005
- February 10, 2013
- 11:00 AM
- 217 views
Advanced Airway vs. BVM During CPR – Which is Worse?
by Rogue Medic in Rogue Medic
The authors wanted to find out what method is (worst) best for ventilating patients during out-of-hospital treatment of cardiac arrest.
Endotracheal tube?
Supraglottic airway (laryngeal mask airway, laryngeal tube, and esophageal-tracheal twin-lumen airway device)?
BVM (Bag Valve Mask)?
This assumes that ventilations provide some sort of benefit to the patient. There is no evidence to support this myth.... Read more »
Hasegawa K, Hiraide A, Chang Y, & Brown DF. (2013) Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 309(3), 257-66. PMID: 23321764
Segal, N., Yannopoulos, D., Mahoney, B., Frascone, R., Matsuura, T., Cowles, C., McKnite, S., & Chase, D. (2012) Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest. Resuscitation, 83(8), 1025-1030. DOI: 10.1016/j.resuscitation.2012.03.025
- February 3, 2013
- 09:00 PM
- 122 views
Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I
by Rogue Medic in Rogue Medic
MV observed the following the lack of distinction in scene time for penetrating trauma mortality, which I did not give the proper attention in "EMS Time and Survival from Blunt and Penetrating Trauma." I will try to correct my mistake here.... Read more »
Lerner EB, & Moscati RM. (2001) The golden hour: scientific fact or medical "urban legend"?. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 8(7), 758-60. PMID: 11435197
McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C. (2013) Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61(2), 167-74. PMID: 23142007
- January 31, 2013
- 10:00 PM
- 135 views
EMS Time and Survival from Blunt and Penetrating Trauma
by Rogue Medic in Rogue Medic
People will tell you that they just know the we need to load and go. Some even claim that the mythological Golden Hour is real. Maybe there will be an episode of Ancient Aliens about R Adams Cowley identifying the meaning of trauma and writing it on a cocktail napkin in a bar.
... Read more »
McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C. (2013) Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61(2), 167-74. PMID: 23142007
- December 27, 2012
- 09:00 PM
- 219 views
If the patient is asleep, does that mean that the pain is gone?
by Rogue Medic in Rogue Medic
Is it appropriate to stop giving pain medicine just because the patient is asleep?
My little burned patient was probably not expressing relief from pain with her periods of unresponsiveness – especially since she had not received anything for her severe pain. Each time that she woke up screaming, that was also a clue. the medical command doctor’s orders were to give no pain medicine.[1]
Is propofol effective at putting patients to sleep without relieving their pain?
Sleep do........ Read more »
Paqueron X, Lumbroso A, Mergoni P, Aubrun F, Langeron O, Coriat P, & Riou B. (2002) Is morphine-induced sedation synonymous with analgesia during intravenous morphine titration?. British journal of anaesthesia, 89(5), 697-701. PMID: 12393765
- December 19, 2012
- 04:15 PM
- 233 views
More evidence that antibiotics are over-prescribed - How should that change?
by Rogue Medic in Rogue Medic
Today Lancet Infectious Diseases posted an early release of an article that shows that the antibiotic amoxicillin still does not work on viruses.
Many doctors still routinely prescribe antibiotics for viral infections.
Bias, perhaps the biggest confounder in medical research, is controlled for very well.
What does the study show?... Read more »
Little, P., Stuart, B., Moore, M., Coenen, S., Butler, C., Godycki-Cwirko, M., Mierzecki, A., Chlabicz, S., Torres, A., Almirall, J.... (2012) Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. The Lancet Infectious Diseases. DOI: 10.1016/S1473-3099(12)70300-6
Butler CC, Hood K, Kelly MJ, Goossens H, Verheij T, Little P, Melbye H, Torres A, Mölstad S, Godycki-Cwirko M.... (2010) Treatment of acute cough/lower respiratory tract infection by antibiotic class and associated outcomes: a 13 European country observational study in primary care. The Journal of antimicrobial chemotherapy, 65(11), 2472-8. PMID: 20852271
- December 13, 2012
- 11:45 PM
- 214 views
How do we measure the QT segment when there are prominent U waves?
by Rogue Medic in Rogue Medic
This ECG has large T waves, U waves, and P waves, but where does one end and the other begin?
When measuring the QT segment, where do we measure the end of the QT segment and why?... Read more »
Omar, H. (2012) Amiodarone-induced T-U fusion. The American Journal of Emergency Medicine, 30(9), 20810-208100. DOI: 10.1016/j.ajem.2011.10.024
- November 29, 2012
- 08:30 PM
- 314 views
Is Digoxin a Killer?
by Rogue Medic in Rogue Medic
Digoxin (Lanoxin) is an antiarrhythmic drug, which means that it is also a proarrhythmic drug. Any drug that affects the heart’s conduction system can produced changes that are bad, good, or a combination of the two. Digoxin has been associated with a higher death rate, but is that because it is prescribed to sicker patients?... Read more »
Whitbeck, M., Charnigo, R., Khairy, P., Ziada, K., Bailey, A., Zegarra, M., Shah, J., Morales, G., Macaulay, T., Sorrell, V.... (2012) Increased mortality among patients taking digoxin-analysis from the AFFIRM study. European Heart Journal. DOI: 10.1093/eurheartj/ehs348
- November 15, 2012
- 04:30 PM
- 236 views
Extreme Spinal Injury With Preservation of Neurologic Function
by Rogue Medic in Rogue Medic
How bad can spinal injuries be without causing paralysis?
The spine is supposed to be continuous.
The spine should not zig, zig, or take any other detours.
The red line over the spine should be drawn as a roughly straight line, with slight curvature, which can be extreme with kyphosis, scoliosis, or other diseases affecting the spine.... Read more »
Evans, L. (2012) Thoracolumbar Fracture with Preservation of Neurologic Function. New England Journal of Medicine, 367(20), 1939-1939. DOI: 10.1056/NEJMicm1101495
- November 14, 2012
- 08:00 PM
- 243 views
Is a clot-busting drug safe for 6 hours after stroke symptom onset – or only for an hour and a half? – Part II
by Rogue Medic in Rogue Medic
It has been a couple of months since I wrote Part I and I have not been that motivated to write this part, but Dr. Jerome R Hoffman and Dr. Richelle J Cooper have been busy with the topic. Their paper appears in the current Emergency Medicine Australasia.
"Just before the release of the results of the third inter-national stroke trial (IST-3),1 the largest trial of thrombolysis in acute ischaemic stroke (AIS), the journal Stroke published a remarkable pre-emptive strike – a comm........ Read more »
Hoffman, J., & Cooper, R. (2012) How is more negative evidence being used to support claims of benefit: The curious case of the third international stroke trial (IST-3). Emergency Medicine Australasia, 24(5), 473-476. DOI: 10.1111/j.1742-6723.2012.01604.x
Lyden PD. (2012) In anticipation of International Stroke Trial-3 (IST-3). Stroke; a journal of cerebral circulation, 43(6), 1691-4. PMID: 22556196
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A.... (2012) The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet, 379(9834), 2352-63. PMID: 22632908
- October 30, 2012
- 12:00 AM
- 307 views
Fluid Replacement in the vomiting child - IV, IO, or NG?
by Rogue Medic in Rogue Medic
Annals of Emergency Medicine has some Systematic Review Snapshots that are free and useful for getting a quick look at the evidence on various topics. In the current issue, there is a review of the evidence on fluid replacement for the child unable to take fluids orally, or unable to keep those fluids down.
Which is the best route to give fluids?
IV?
IO?
NG?
... Read more »
Barker, L. (2012) In the Child With Gastroenteritis Who Is Unable to Tolerate Oral Fluids, Are There Effective Alternatives to Intravenous Hydration?. Annals of Emergency Medicine, 60(5), 607-608. DOI: 10.1016/j.annemergmed.2012.04.003
Rouhani S, Meloney L, Ahn R, Nelson BD, & Burke TF. (2011) Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics, 127(3). PMID: 21321023
- October 25, 2012
- 05:30 PM
- 304 views
Uneventful prolonged misdiagnosis of esophageal intubation
by Rogue Medic in Rogue Medic
The ability of the patient to remain alive, and even stable, in spite of medical mismanagement, does not mean that the endotracheal tube has been placed endotracheally.
We have an infinite capacity for self-deception. This case is just one example of what is probably the most common mistake in medicine.
... Read more »
Batra AK, & Cohn MA. (1983) Uneventful prolonged misdiagnosis of esophageal intubation. Critical care medicine, 11(9), 763-4. PMID: 6884056
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