dr-exmedic.com

Research on the composition of ambulance crews is always fun to critique, in part because it’s generally pretty meaningless, and frequently raises more questions than it answers.  That makes it great to have come across a new study, which examined cardiac arrest survival rates in Milwaukee County, for patients treated by 2, 3, or 4 (or more) paramedics.

The authors looked at 12 years of cardiac arrest data, and were able to correlate EMS cardiac arrests to hospital patients, in order to accurately track not only ROSC but survival to hospital admission and discharge.  (From this aspect, at least, that makes this one of the higher-quality crew composition studies I’ve seen.)  The raw numbers gave roughly similar survival-to-discharge rates for crews with 2, 3, or 4+ medics (8.7, 8.7, and 8.4% respectively).  However, the percentage of each group responding to shockable rhythms was lowest in the 2-medic group (40.7%), higher in the 3-medic group (49.9%), and higher still in the 4-medic group (59.8%).  Given that the shockable patients are the most savable, the 4-or-more group should have had the highest save rates…but they didn’t.  This became very obvious when the researchers controlled for things known to make a survival difference (presenting rhythm, for example, or whether the arrest was witnessed):  patients treated by crews with 4 or more medics had 2/3 the odds of surviving to discharge of those treated by only 2.

One explanation the researchers suggest is somewhat plausible–perhaps all those medics being present and looking for something to do result in more ALS interventions being performed, resulting in less CPR (and we all now know how important quality CPR is).  Personally, I expected even the adjusted save rates to be perfectly identical, so my money is on another possibility:  that there’s some other factor that causes high mortality, but happens to be associated with having more medics on scene.

For example, survival has been shown to be lower in poorer people, who are also more likely to live in an urban area–exactly the kind of place you’d expect to get a response with more medics than you need.  This would mean that more medics don’t give worse care than fewer, but that their abundance is a marker for something about the individual, in the same way that ice cream sales and rape rates correlate almost perfectly–not because they are related but because they are related to some third thing (which, in the case of ice cream sales and rape rates, would be temperature).

Filed under: EMS Research
No Comments »

It turns out that, in addition to the national poison control center number (800-222-1222), there is a National Button Battery Ingestion Hotline.  I knew that swallowing a button battery can be bad; I didn’t think it warranted its own number.  Fun factoids:

• Nearly 25% of batteries are swallowed because they are mistaken for medicines or pills.
• Adults and older children often think of the mouth as a “third hand”, holding the battery there while working.

I guess that means that many of these ingestions are Darwinian in nature…pretty much everyone but the little kids.

Filed under: Emergency Medicine
No Comments »

The search for decent Android medical software continues, and I’ve discovered that an old favorite off my Palm has been ported to Android:  Diagnosaurus.  Although not particularly useful in the EMS setting, it’s a fun little tool I’ve come to know and love.

Then there’s something that isn’t a medical program, but could be useful as such:  Google Goggles.  If you aren’t already familiar, it’s a program that searches based on pictures you take with your phone.  While it already claims to do a decent job with logos, artwork, and other mundane objects, it seems as if recongition of unknown medications would be a perfect medical use for this.  I tried it last night, but couldn’t get a match.

If you also think this would be a great idea, I’ve suggested it to the powers that be–go ahead and vote!

Filed under: Uncategorized
No Comments »

It turns out that there is a campaign underway to sponsor the purchase of pet oxygen masks for ambulances.  Not surprisingly, it’s heavily supported by the company that makes said masks, but that doesn’t mean it isn’t a laudable goal.  Granted, if I had 65 extra bucks sitting around I’d be sending them to something that would help people survive, but there’s nothing wrong with making sure your local ambulance has some pet masks, either.

Filed under: EMS
No Comments »

There is an article about navigating to emergency calls in the latest EMS Magazine, and I found one tip in particular very funny:

Every village, town and city has a numbering system. Each one is different, but the key is that there is one.

Obviously, by the use of the word “every,” the author has never been to Pittsburgh’s suburbs, where we can’t even assure that the odd numbers will be on the same side of the street for its entire length.

Filed under: Medical Humor
No Comments »

I’m watching The Big Lebowski on Versus, and I just watched John Goodman smashing a Corvette and yelling:  ”This is what happens when you find a stranger in the Alps.”  (Original completely vulgar line here, if you didn’t already know.)

Filed under: Random Humor
No Comments »

Here’s an ad from the Sunday paper a few weeks ago that’s unintentionally hilarious and disgusting to anyone who thinks of BV as an abbreviation for bacterial vaginosis.

The BV in the ad, incidentally, is actually a vineyard.

Bonus link:  irony, defined.

Filed under: Sunday Silliness
No Comments »

It’s been a long time since I’ve seen a study suggesting that virtually any part of ACLS really helps cardiac arrest victims, and a recent study in JAMA is no exception.  Pretty soon, all we’ll be doing is CPR and defibrillation.

This study is fairly unusual:  it’s a randomized, controlled trial of full IV access and meds in cardiac arrest versus no IV access at all.  (Patients who had a pulse return could get an IV and any indicated meds.)  Previous trials of meds in cardiac arrest have been primarily either RCTs comparing one med to another, or retrospective data on a particular med.  Furthermore, this trial looked at survival to discharge as its primary outcome, and neurologically intact survival as a secondary outcome, something that’s been missing in many previous medication trials.  (Even the infamous trial that got many people using amiodarone used admission to ICU as its primary outcome, and didn’t look at neurological status at all.)  They also reported effects of IV access on CPR quality.

The good news:  the study was fairly high quality.  IV access didn’t seem to change CPR quality in the group of patients that got it.

The bad news:  IV meds don’t seem to do much for the patients.  Patients who got them were more likely to have ROSC (particularly in the group of patients with non-shockable rhythms), but were statistically no more likely to be discharged from the hospital (with or without a good neurologic outcome).

Here’s where things get sticky.  No medication trial I know of has ever shown any medication to improve survival to good outcome.  However, I also don’t know of any that have been able to show harm from medications, either.  This study is exactly the same, despite its relatively high quality–it shows no difference between the groups.  The problem is that both pro-medication and anti-medication camps will be able to use this study for their arguments.

The anti-medication side will point out the obvious finding:  there was no increase in survival with the meds.  The pro-medication side will point to several trends that did not reach statistical significance (there was a slight trend towards better survival in the IV group) and claim that a big enough study would make a that difference statistically significant–and that unless we can show a harm from the meds, we should keep using them in case they do have a small helpful effect.

That gets to the heart of the matter:  it’s tough to do cardiac arrest research.  These researchers picked their study size to show a statistically significant difference only if IV meds doubled survival.  That took 851 patients, and getting that number of patients took five years to accumulate.  There just isn’t enough research money floating around to have the efforts like some of the cardiology trials that enroll 10,000 patients to show a 1% difference in mortality.

Filed under: EMS Research
No Comments »

Just about everyone who works in paramedicine long enough eventually ends up with a story of someone trying to ventilate a patient in cardiac arrest using the bag on a nonrebreather.  The two medics whose stories I remember best happen to involve nursing home staff in one case, and a cop in the other.  Lately, however, I’m wondering if those folks were on to something.

There’s been a big push lately to improve the quality and number of compressions during CPR, and one way to do so is to use passive ventilations rather than a BVM–that is, to throw a nonrebreather on the patient and allow the chest compressions to move a little air.

However, even though this idea is a few years old, it’s still a big change from the old way of doing things.  When such a protocol was instituted in Arizona in January 2005, medics were allowed to bag the patient at their discretion.  Now, an analysis of the first few years of data is showing us what happened to both groups of patients.  Counterintuitively, some patients who got a nonrebreather did significantly better:  among witnessed shockable arrests, no-BVM patients had 38.2% neurologically intact survival compared to 25.8%.  However, patients in nonshockable rhythms or who had an unwitnessed VF/VT arrest were no better off–in fact, the survival for those patients was lower in the no-BVM group, although the numbers didn’t reach statistical significance.

Unfortunately, this article isn’t the kind of practice-changing data that would put everybody on track to start using minimally-interrupted compressions:  it was retrospective data, and the patients weren’t randomly put into treatment groups–there could be some hidden bias among providers in deciding who gets BVM or not.  By the same token, it’s strong enough to stimulate more trials, and possibly even help affect what happens at next year’s ILCOR meeting.  I know I’m certainly looking forward to what the 2010 CPR guidelines look like.

Filed under: EMS Research
No Comments »

Some time ago, I submitted paperwork to get state continuing education credits approved for a class I’d like to give.  It’s a one-hour lecture (perfect for conferences) on how to use a 60-second exam of the cranial nerves to detect more strokes.  When the approval came through, I noted that two different resources conflicted on how the credit was given.

It turns out that BLS providers who take the course cannot get con-ed credit because assessment of the cranial nerves isn’t part of their National Standard Curriculum.  In other words, BLS providers cannot get credit for trying to reach much beyond the limited education they’re given.  So much for going above and beyond….

Filed under: EMS Education
No Comments »