Human Sacrifice: The Cost of Being Progressive in EMS?

For every EMS provider that understands what a NNT or P value is, there are ten out there that think backboards save lives and that oxygen is somehow a pain med. For every provider that knows the difference between a Randomized Controlled Trial (RCT) and an observational study, there is an army of providers that believe asystole is an indication for naloxone. Show me an EMS provider who knows about what the AHA means with their proprietary class IIb recommendation (see below if you don’t know) and I will show you a hundred providers who are convinced that oxygen is a lifesaving intervention in a normoxic myocardial infarction patient.

Mary Baker Eddy authored the book of magical Christian Science nonsense, “Science and Health with Key to the Scriptures” in 1875.  I find myself consulting a somewhat similar book with some frequency, “EMS Protocols Version 10.” Both books deal with raising the dead and treating the sick and injured and both books are far from being what one could consider science as they rest on a large foundation of anecdotal evidence and appeal from authority.

The 2015 AHA Emergency Cardiovascular Care Guidelines (AKA ACLS) which sort of forms a default standard of care* in our industry are mostly based on opinions and limited data. Shockingly, 46% of the recommendations in the guidelines are drawn from studies with limited data sets and 23% of the recommendations being based on “expert opinion.”

Much of what we do in the name of ACLS  either does not work or does not work and might be harmful. Instead of asking if a medication works we have entered some sort of weird “the emperor has no clothes” paradigm. We now have to prove things do NOT work before we stop subjecting patients to out “treatments.” Painting with a broad brush here, for the average patient some of our treatments are about as effective as Reiki.

 

Some examples of what I mean:

• Amiodarone in cardiac arrest: No better than a placebo in terms of increasing CPC scores.
• Epinephrine in cardiac arrest: Not helpful in cardiac arrest in terms of increasing CPC scores , likely harmful
• Saline in trauma: harmful in large doses
• Backboards: No benefit in terms of immobilization, possibly harmful
• C-collars: No benefit in terms of immobilization, possibly harmful
• Lasix in acute pulmonary edema: No benefit, probably harmful in acute pulmonary edema
• High flow oxygen in the normoxic patient: No benefit, harmful in some patients
• Lights and sirens: Little benefit, high risk.
• TPA ambulances: No benefit (except marketing)
• Lucas devices: No benefit over well performed CPR with adequate rescuers, may be harmful
• Surviving sepsis guidelines (30ml/kg for ALL patients): May be harmful to some (most?) patients
• Some Supraglottic airways in cardiac arrests: No benefit in most cases, may be harmful

And let’s not forget a laundry list of our greatest misses involving things like MAST, high dose epinephrine in cardiac arrests, Therapeutic hypothermia following cardiac arrest, sodium bicarbonate in cardiac arrests, stacked shocks, treating “malignant” PVCs, and whatever else lurked in the drawers of the Plano box that you would give during cardiac arrests. The issue is all of these things made sense at the time; they all seemed like good ideas at the time.

The problem is the trend continues in EMS.
We simply refuse to learn from the past.

In the name of being a “progressive” agency, EMS is yet again engaging in alternative medicine.  A small study on anesthetized pigs shows promise in performing heads up CPR and suddenly an EMS agency is being progressive and performing heads up CPR. If the science does not pan out and patients end up getting a treatment that made them worse, please accept our apologies in the name of “progress.”

But what is a bit of human sacrifice when things like marketability and JEMS articles are at stake? All those dead patients are just grist for the mill, casualties in the war against the status quo.

I fully support well done randomized controlled trials in medicine and many of our current practices need to be placed under the magnifying glass of an RCT; but an agency simply rolling out a new unproven, poorly researched treatment and touting their “results” does not equal an RCT. As providers, we have very little skin in the game here, we have all the upside if the new hotness works and we have none of the downside. If the treatment turns out to be causing harm we simply wash our hands of it and talk about it in blog posts like this a few years later. We don’t consider the countless dead we left behind when the next new shiny thing comes our way.

 

Another disturbing trend that is emerging is that of the “compounding resuscitationist” phenomenon. I agree that standard dose epinephrine either has little meaningful effects or is somewhat harmful. If I were to suffer a cardiac arrest I do not want any epinephrine given to me, and a sort of DNE form (Do Not Epi) might need to be created. I think a drug without any proven benefit and an association with harm should not be given to patients. Unfortunately many people are playing mad scientist and coming up with their own proprietary dosing regimens: adding a milligram to a liter and running it in over 20 minutes, spaced out dosing, giving some random dose of epinephrine, dosing based on etco2, giving only one or two doses, or a number of other alternative dosing regimens. This is not science, it is alternative medicine. It does not clarify anything; it only muddies the waters further.

Should we even discuss the madness that stroke ambulances are? Perhaps that is topic best left to a separate post.

There is a certain satisfaction one may get from being progressive. It feels good, it strokes the ego a bit when you have new information and do things other agencies are not doing. It may even generate some attention for you and your agency, especially if you are good at self-promotion. As long as you continue to employ the confirmation bias and only remember the few times the progressive movement was correct it is easy to continue this dangerous trend.  We owe it to the dead to proceed with caution and diligence and avoid the seductive power of progressiveness.