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The BMJ has decided to weigh in on a subject I’ve written about a couple of times this year, namely, the fact oxygen may be more harmful to the body than once thought.  The latest word is actually a randomized trial done in lovely Australia, considering whether oxygen benefits or harms COPD patients.  More specifically, they randomized patients with COPD, and patients at risk for COPD, into groups which then received either high-flow O2 (and nebulizer treatments delivered using O2) or nasal cannula O2 to maintain an SpO2 of 88-92% (with nebulizer treatments delivered at room air).

It’s actually a pretty well-thought-out study, and it came to a striking conclusion:  mortality was 9% for high-flow O2 and only 4% for titrated.  When you take out the patients who didn’t have tests consistent with COPD, the numbers are 9% and 2% respectively–even more striking.  (All these numbers are statistically significant.)  Put another way, as the authors so eloquently do, “for every 14 patients who are given high flow oxygen, one will die.”

What’s interesting is that the effect persists when all the protocol violations are taken out of the analysis:  9%/5% for all comers, 10%/2% for those with confirmed COPD.  Unfortunately, these numbers didn’t achieve statistical significance, because more than half of those who were supposed to get titrated O2 got at least a bit of high-flow.  Strangely, even though this should pull the numbers closer together, it doesn’t change them one bit–which suggests either statistical error (unlikely), or that there is a huge effect, much larger than I would have ever expected it to be.

So how much longer will we continue to hear the phrase, “A little O2 never hurt anybody” when there’s absolutely no proof that it’s true?

I’m not 100% sure that this needed to exist.  But it does.  God Bless the Free Market.  :)

Any shift which involves CPR performed with 2 thumbs can safely be classified as a bad shift.

For the second year in a row, I’ll be speaking at the regional EMS conference.  This year’s topic:  Zombies! and other CNS Derangements.

So EMS is officially a subspecialty of emergency medicine, recognized by the American Board of Medical Specialties.  What will change?

Not much, particularly since the first exam for certification isn’t expected to happen until 2013.

This recognition isn’t important for its practical effects.  There aren’t going to be enough EMS-certified docs for any but the largest paramedicine systems to make subspecialty certification a job requirement.

What is important is the recognition: the admission that leadership of, and research about, paramedicine constitutes its own field.  This is notable in its own right:  the edifice of medicine conceding that a field only a few decades old is worthy of training in.  This really reflects years of preparation on the part of those working towards this certification, but also reflects the growing importance of paramedicine to medicine itself.  After all, ambulance services are a way to get people to higher levels of care, as well as the way that a good chunk of your hospital admissions enter the door.

Bottom line:  this is good for all involved, but you won’t see a difference for years.

This just in: EMS is now an officially-approved subspecialty of Emergency Medicine. More on this when I’m not taking care of sick kids here….

Every so often, an attending physician in the hospital will admit of something he or she has done for a patient that it’s based as much on “voodoo” as it is on any real science.  In a way, much of medicine is pretty much the same way, because there are so many practices that don’t have a real research base, particularly for uncommon conditions.  (Toxicology is one such area–except for the most common drugs, it’s hard to find enough cases to do a double-blind, randomized, controlled trial.)

Paramedicine is no different, with its Golden Hour and its spinal immobilization.  The latest practice to come into the spotlight (and this is both a hospital practice and a pre-hospital one):  oxygen administration in cardiac patients.

This recent article isn’t new research, but a review of existing research.  For years, the AHA Emergency Cardiac Care committee–ostensibly a research-oriented body–has recommended oxygen be given to most cardiac patients.  (Specifically, it “should” be given to patients with low pulse oximetry, and is “reasonable” to give in STEMI over the first 6 hours.)  Yet there are increasingly frequent hints that too much oxygen may indeed be bad for some patients, and the news is just as bad for non-cardiac-arrest victims:  a single high-quality trial (admittedly small) showed no benefit for oxygen and actually a trend towards increased mortality with oxygen.  The rest of the evidence is hampered by its low quality:  non-blinded, non-randomized trials, one in dogs, and one with non-standardized measurement and oxygen administration times.

For years, paramedicine has treated oxygen as an essentially benign drug, with no overdose potential (except in COPD patients, where there has always been a concern about the “hypoxic drive,” which many physicians argue does not kill patients).  As the science gets better and better, perhaps we can understand our treatments better–even if it means going against lore existing since the foundations of paramedical history, to understand that oxygen–like a cookie–is a “sometime” drug.

As if the news that 1 in 4 UK lap dancers has a college degree isn’t funny enough by itself, the more specific details of the finding are absolutely howl-worthy (emphasis all mine):

The researchers found arts degree graduates were most likely to report that they had turned to dancing after being unable to find other work.

and:

The main attraction of the work was the flexibility it offered

You don’t say?  Here, I thought the flexibility was a job requirement….

Here’s a study on something I never would have even thought to study:  implementing national guidelines.  More specifically, how long does it take to change over from old practices (in this case, the 2000 AHA guidelines) to new ones (the 2005 recommendations).  As with most things in medicine, the answer comes down to:  it depends.

The study looked at the time between the publication of the guidelines (12/13/05) to the end of the training period when all personnel began using them.  The first hint of any problems begins even before the results section:  2 agencies were excluded from data analysis because they had not yet begun using the 2005 guidelines when the agencies were surveyed…in March 2008.  Keep in mind that surveys were sent strictly to members of the Resuscitation Outcomes Consortium, who (in theory at least) should be a bit ahead of the trend.

Of the remaining agencies, there was a huge amount of variation:  agencies crossed over as quickly as 49 days (wow!) and as slowly as 750 days, with an average of 416.  With a median of 415 days, there were just as many agencies below the average as above it.

Interestingly, larger agencies seemed to implement the guidelines faster:  agencies with more than 10 vehicles made the switch more than 50 days earlier, on average, which probably reflects more personnel dedicated to training.  BLS-only agencies took longer than their ALS-offering counterparts (about 65 days difference), and non-transporting agencies took longer than their transporting counterparts (by almost 80 days).  The only difference looked for that didn’t reach statistical significance:  agency type, with fire, non-fire governmental, and private agencies performing statistically similar.

This is just another way of pointing out that “once you’ve seen one EMS agency, you’ve seen one EMS agency.”  With uptake times of 2 months to 2 years or more, and every number in between, it’s pretty obvious that the care you receive is determined more by where you call 911 than any other factor.

(Not to be confused with Golden Shower, incidentally–that’s something quite different.)

The concept of the “Golden Hour” has been so heavily ingrained in trauma care for so long that it’s proving nearly impossible to get rid of it–and EMS isn’t the only offender, though certainly a prominent one.  Its creation is generally credited to the father of modern trauma care, R. Adams Cowley, but claims of where he got the concept are hard to verify.  (One source suggests French WWI data, but my reading of the data shows that there is a golden three hours–where the mortality jumps from 12% to 33%.)  We’re constantly told to get patients to a trauma center within that magical hour–but does it actually matter?

While there’s no doubt that earlier is better than later when it comes to caring for severely injured people, the notion of some cutoff is silly.  (For a ruptured aorta, there’s a “golden 30 seconds,” for a small subdural, a “golden week.”)  That’s why it’s not surprising that a fairly large study of the relationship between prehospital time and survival came up with nothing.  It was actually a prospective study looking at almost 3700 patients with abnormal vital signs or altered mental status, and no matter how many ways they sliced the times (minute by minute, in 10-minute blocks, by quarters of the group, or by less/more than an hour), the results were still the same:  no association between prehospital time and death.

Perhaps someday this notion of a Golden Hour (and its cousin, the Platinum Ten Minutes) will be something that’s merely worthy of mocking.  In fact, that gives me a great idea for an EMS Drinking Game….