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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.
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.
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.
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….
It’s only natural that I would fall in love with an online store named ThinkGeek, but they’ve really outdone themselves with this sleeping bag.
Everyone likes to complain about the National Registry exams. Sure, there’s probably some truth to the adage that the only thing they measure is how well you take NR exams–but having met some of the people who passed them (barely, and after several tries), I’m very afraid of the people who can’t.
However, analyses of those exams can be fairly interesting. I recently read an abstract of such an analysis (sorry, no direct link available, but if you can find this you can read it) comparing results from the FISDAP practice exam (formerly known as OSPE) to NR pass rates. The OSPE questions were categorized as “critical thinking” or ” knowledge” in nature. It turns out that people who did well on the critical thinking questions tended to pass the NR exam, while a person’s ability to answer the knowledge questions didn’t really make a difference. To me, this suggests that the NR exam tests critical thinking skills more heavily than memorization ones.
This is actually a good thing, and makes me very happy. After all, with the advent of portable brains (they’ve been around for years, only now they aren’t on paper), anyone can look up a fact if need be–but a good drug reference won’t do your thinking for you. In the field, it’s far more critical that a medic can put together a diagnosis and treatment plan than it is to be able to remember that pheochromocytoma is a contraindication for lidocaine; it’s absolutely wonderful that the main exam for medics*, imperfect as it may be, is at least trying to test for the one that matters.
* in most states
After buying my Palm Tungsten E2, I quickly grew to love the thing. It kept track of my schedule and had thousands of applications (we called them programs, back then) available, many for free, including many useful medical tools. Ever since the iPhone started running software (aka “apps”), I’ve been longing for something that would combine my phone, Palm, and my MP3 player into one device. Just over a month ago, I remained convinced that Palm would be the company to provide that–particularly since there is an emulator that would ease any transition by allowing me to run all of my existing Palm programs.
My mind was changed by fear that Palm Pre sales haven’t been high enough to stimulate software development, and impatience that it was only available on Sprint’s lousy network. My wife and I now own Motorola Droids.
Now I’m in a bind: no way to run my old Palm programs (without carrying the thing around), and few really good medical references available (there are a few things in Android market, and a few web pages formatted for mobile phones–but that latter is only really useful when you have internet service, isn’t it?). However, there is light at the end of the tunnel that is Android medical software:
Basically, I’m hoping that I’ll have a truly functional medical PDA again within 6 months. I’d like to have it sooner than that, but I’m not holding my breath.
Just a roundup of funny CPR-related video clips I’ve seen over the years….
Ironically, the last clip I’m about to link to is the most informative of the bunch (if not strictly detailed or accurate), but I didn’t embed it directly, probably because of the excessive cleavage involved. (Come on, what do you expect of a video produced by “French Maid TV”?) But I do recommend celebrating every successful resuscitation with a pillow fight….
I recently discovered a bathroom at work that has a list of rules posted on its walls. Each has a little phrase followed by an explanation, such as “What goes up must come down–if you are raising the toilet seat, make sure to put it back down.” (Not that this is such a great idea in a mixed-use public toilet–leaving the seat up protects it against men who don’t lift the seat–but you get the idea.) The one that struck me as odd was this one:
No more snow–if powder lands anywhere other than your body, wipe it up.
I’m trying to figure out if this employee restroom was posted with a cut-and-paste sign from the Internet (doesn’t seem to be), if there really is that much of an employee drug problem, or if someone was just poking fun.
