Anti-vaxers lie for the same reason as other people – for personal benefit.

Many anti-vaxers claim that there is an international conspiracy of doctors and researchers, as if all of the doctors and researchers, or even the pediatric doctors and researchers, in the world could agree on much of anything. When you realize how ridiculously large this conspiracy would be, how much a doctor or researcher would gain from providing valid information to expose such a conspiracy, and how aggressively law enforcement would punish those behind such a conspiracy, you understand the use of ridiculous is appropriate as a description of the conspiracy theory.

This is just another example of some people thinking they know more than everyone else, based on a lack of understanding. This feeds the over-inflated egos of anti-vaxers.

The smallpox vaccine has saved hundreds of millions of lives. Anti-vaxers opposed the smallpox vaccine and delayed the eradication of smallpox. Anti-vaxers helped smallpox kill people..

Our children are no longer vaccinated against smallpox, because smallpox has been wiped out by vaccines. Millions of children’s lives, and adult lives, are saved every year by the smallpox vaccine, without even giving it to children, because enough people rejected the lies of anti-vaxers.

Vaccines continue to save millions of lives every year, in spite of opposition by anti-vaxers.

There is plenty of research showing that vaccines are effective and safe, but to give the single clearest example of the benefit of vaccines, look at the following paper from JAMA. The Journal of the American Medical Association is one of the most respected medical publications in the world. Use any search engine to find a list of the most respected medical journals and you will find JAMA near the top.

Look at the decrease in the rates of illness and the rates of death for each vaccine-preventable illness after the introduction of the vaccine for that illness. Click on the image for a larger, easier to read version.

This information has been simplified for those not comfortable with scientific research (I do not know the source of the image, it was not part of the paper in JAMA):

As you can see, these diseases are almost never a problem in America, where vaccination rates are still pretty high, although anti-vaxers are causing more and more outbreaks of diseases we had not seen in decades.

Some anti-vaxers will claim that the vaccines didn’t get rid of these diseases. These anti-vaxers claim that improved sanitation, improved hygiene, and improved diet got rid of these diseases. While these improvements are helpful, here is why that is just another anti-vax lie.

We have outbreaks of vaccine-preventable illnesses in America, when the rate of vaccination drops, even though sanitation, hygiene, and diet did not deteriorate. Yes, many of our diets are getting worse, but that is not what is causing outbreaks of whooping cough, measles, and other vaccine-preventable illnesses.

The rates of illness and death only have a dramatic change for each of the vaccine-preventable illnesses after the introduction of each vaccine. If sanitation, hygiene, and diet were the reasons, the illnesses would all start to go away at the same time, although not necessarily at the same rate. If that were the case, the decreases in these diseases could easily be shown to be due to improvements in sanitation, hygiene, and diet, but that is not the case.

Anti-vaxers cannot explain that, but anti-vaxers are not reasonable.

Why has the polio vaccine been so effective in India, when India has widespread problems with sanitation, hygiene, and diet?

Here is what the authors wrote:

India, a vastly diverse country with a 27 million birth cohort, undertook the largest vaccination drive against WPV (Wild Polio Virus) in the world. With high population density, poor civic infrastructure, poor sanitation, an almost nonexistent public health system, rampant malnutrition and diarrhea, difficult-to-reach locales, high population mobility, and extremely high force of WPV transmission in few states,3 the interruption of WPV transmission was extremely difficult and demanding. The interplay of these challenging factors provided a perfect milieu for the WPV to circulate, and the prospect of achieving zero-polio status seemed insurmountable.[2]

India completed a full 5 years as a “polio-free nation” on January 13, 2016.1 It was a remarkable feat considering the odds against achieving this status.[2]

Anti-vaxers will make excuses, but this clearly exposes the anti-vax lie that disease elimination being due to improved sanitation, hygiene, and diet, rather than due to vaccines.

The reason smallpox vaccine is no longer given to children, is the worldwide eradication of smallpox by vaccination.

Anti-vaers delayed the worldwide eradication of smallpox.

Anti-vaxers have prevented the worldwide eradication of polio.

Anti-vaxers continue to try to protect polio from eradication.

Children would no longer need polio vaccination, if it weren’t for anti-vaxers.

If you don’t like giving the polio vaccine to your child, blame the anti-vaxers.

You can also read the full text of the article for free at Pediatrics at the link below, if you want to understand more of the details that the anti-vaxers don’t want you to understand. Pediatrics is one of the most respected pediatric medical publications in the world. Use any search engine to find what pediatric medical journals are the most respected and you will find Pediatrics near the top.

The best half of EMS agencies are producing twice as many good outcomes as the worse half of EMS agencies.[1]

Most of us are bad at resuscitation and those of us treating the most cardiac arrests are doing the least good.

Why do so many of us refuse to improve our standards?

What is so much more important than patient outcomes?

Let’s start with Figure 2 C How is survival to the emergency department distributed among EMS agencies?

ROSC to the ED (Emergency Department) looks great. The results are skewed to the right, which is what we want to see in outcomes. Unfortunately, this is not an outcome that is important. Yes, you do need to have ROSC (Return Of Spontaneous Circulation) to survive, but it is important that we not cause irreversible harm in order to get very reversible ROSC.

How reversible is ROSC?

Those distributions are similar, although they are decreased by more than half. If leaving the hospital with a pulse were the outcome that mattered, it might not be so bad.

But these are not on the same scale. The ROSC to the ED figure continues to 46%, with a greater than symbol to indicate that some will do better, while the survival to discharge figure stops at 20%, with the same greater than symbol to indicate that there are some beyond that number. How many beyond the end of the figure? The authors decided that it was not enough to waste space on, because they cut it off there.

Where would the survival to discharge percentages be on the ROSC to the ED figure?

The arrow on the right is where the 46>% bar from the ROSC to the ED figure.

It is important to put these percentages in perspective, which means looking at the differences in the numbers at the bottom.

Now we need to look at the percentage surviving with enough brain function to be able to take care of themselves – those probably not going to a nursing home. This is the group everyone wants to be in. Figure 2 B.

The percentages of patients able to care from themselves looks a lot different from the previous figures. The results are skewed to the left, which is not what we want to see. Skewed to the left means that the outcomes are mostly on the lower end of the scale – the bad end.

The percentages on the bottom of the figure have not been changed (from those used for survival to discharge), but the results have worsened (been skewed to the left).

Compared with the first image, this is a very different outcome. We should admit that ROSC to the ED and survival with the ability to take care of ourselves are very poorly correlated.

We need to stop focusing on the harmful distraction that is ROSC.

Most people consider healthy brain function to be important. There are people who insist that we give too much attention to the chemistry of brain function, as if changing a person’s brain does not change a person’s behavior. When our brain chemistry changes, we change. Similarly, when our brains are damaged, as often happens during resuscitation, the part of us that makes us the people that we are is damaged. We do not think with our hearts, nor with our guts, no matter what metaphors some of us like to use.

We are not good at resuscitating the part of the patient that matters the most to the patient.

We are not good at producing the outcome that matters the most to the patient.

We appear to be best at focusing on what matters the least.

If we could get the half of the EMS agencies that are not effective at producing survival with good neurological function to improve their patient care, that would result in a big increase in outcomes that matter to patients.

It is important that we not cause irreversible harm in order to get very reversible ROSC.

Many excuses center around the need for local people to be able to claim that they know something that the evidence does not show, although they consistently fail to provide valid evidence for these claims. This local knowledge appears to be intuitive – they just know it, but cannot provide anything to support their feelings.

The latest research can be interpreted in many different ways, but it definitely does not support the claims of the advocates of parochialism.

MOR = Median Odds Ratio – how many times more likely is something to happen.

What is most commonly measured is what matters the least – ROSC (Return Of Spontaneous Circulation). Did we get a pulse back, for even the briefest period of time, regardless of outcomes that matter.

What matters? Does the person wake up and have the ability to function as they did before the cardiac arrest.

Those who justify focusing on ROSC claim that, If we don’t get a pulse back, nothing else matters, but that is the kind of excuse used by frauds. How we get a pulse back does matter. The evidence makes that conclusion irrefutable, but there will always be those who do not accept that they are causing harm. They will make excuses for the harm they are causing. Getting ROSC helps them to feel that they are not causing harm. ROSC encourages us to give drugs like epinephrine, which have been demonstrated to not improve any survival that matters.

The means of obtaining ROSC can be compared to the means of doing anything that requires finesse. Sure, it feels good to try to force something. Sure, you can claim that forcing something is the most direct way to accomplish the goal.

Can the advocates of focusing on ROSC produce any valid evidence that their approach leads to improvements in outcomes that matter? No. The evidence contradicts their claims. The evidence has caused us to eliminate many of their treatments – treatments they claimed had to work because of physiology. As it turns out, they were wrong. They were wrong about their treatments and wrong about their understanding of physiology.

If you want to win money, bet that any new treatment will not improve outcomes that matter.

Is presence of a pulse upon arrival at the emergency department an important outcome? Only for billing purposes. The presence of a pulse justifies providing more, and more expensive, treatments. Is the presence of a pulse upon arrival at the emergency department a goal worth trying for? As with ROSC, only if it does not cause us to harm patients to obtain this goal, which is just something that is documented, because it is a point of transfer of patient care.

After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]).[1]

There is a lot of variability.

What did they find?

Most of the people in EMS, who claim to be doing what is best for their patients, are making things worse.

69% means that there are two EMS agencies producing bad outcomes for every EMS agency producing good outcomes.

Correction – The text crossed out is not accurate. I should have thought that through a bit better before I posted it. My caption for Table 1 is accurate. However, what I should have written afterward is –

The worse half of EMS agencies are only producing half as many good outcomes as the better half of EMS agencies.

We are bad at resuscitation and those doing the most resuscitating are doing the least good.

Why do so many of us refuse to improve our standards?

What is more important than the outcomes for our patients?

Why are we so overwhelmingly bad at resuscitation?

What are the authors’ conclusions?

This study has implications for improvement of OHCA management. First, the analysis indicates that the highest-performing EMS agencies had more layperson interventions and more EMS personnel on scene.[1]

They do not conclude that we need more doctors, more nurses, or more paramedics responding to cardiac arrest.

Second, our findings justify further efforts to identify potentially modifiable factors that may explain this residual variation in outcomes and could be targets of public health interventions.[1]

We need to figure out what we are doing, because the people telling us that they know that we need intubation are lying.

We need to figure out what we are doing, because the people telling us that they know that we need epinephrine are lying.

We need to figure out what we are doing, because the people telling us that they know that we need amiodarone are lying.

We need to figure out what we are doing, because the people telling us that they know that we need ________ are lying.

How dare I call them liars?

Let them produce valid evidence that the interventions they claim are necessary actually do improve outcomes that matter.

Have them stop making excuses and start producing results.

I dare them.

The only time we have made significant improvements in outcomes have been when we emphasized chest compressions, especially bystander chest compressions, and when we emphasized bystander defibrillation.

It is time to start requiring evidence of benefit for everything we do to patients.

Our patients are too important to be subjected to witchcraft, based on opinions and an absence of research.

There is plenty of valid evidence that using only chest compressions improves outcomes.

The results are in from two studies comparing intubation with laryngeal airways. There continues to be no good reason to intubate cardiac arrest patients. There is no apparent benefit and the focus on this rarely used, and almost never practiced, procedure seems to be more for the feelings of the people providing treatment, than for the patients.

Patients with a short duration of cardiac arrest and who receive bystander resuscitation, defibrillation, or both, are considerably more likely to survive and are also less likely to require advanced airway management.22 This problem of confounding by indication is an important limitation of many large observational studies that show an association between advanced airway management and poor outcome in out-of-hospital cardiac arrest.23 This study found that 21.1% (360/1704) of patients who did not receive advanced airway management achieved a good outcome compared with 3.3% (251/7576) of patients who received advanced airway management.[1]

In other words, we are the least skilled, are the least experienced, and we have the least amount of practice, but we are attempting to perform a difficult airway skill under the least favorable conditions. Ironically, we claim to be doing what is best for the patient. We are corrupt, incompetent, or both.

We also do not have good evidence that any kind of active ventilation is indicated for cardiac arrest, unless the cardiac arrest is due to respiratory conditions. Passive ventilation, which is the result of high quality chest compressions, appears to produce better outcomes (several studies are listed at the end).

We need to stop considering our harmful interventions to be the standard and withholding harmful treatments to be the intervention. We are using interventions that have well known and serious adverse effects. This attempt to defend the status quo, at the expense of honesty, has not been beneficial to patients.

The ETI success rate of 51% observed in this trial is lower than the 90% success rate reported in a meta-analysis.29 The reasons for this discordance are unclear. Prior reports of higher success rates may be susceptible to publication bias.[2]

Is that intubation success rate lower than you claim for your organization? Prove it.

Another possibility is that some medical directors encourage early rescue SGA use to avoid multiple unsuccessful intubation attempts and to minimize chest compression interruptions.5 Few of the study EMS agencies had protocols limiting the number of allowed intubation attempts, so the ETI success rate was not the result of practice constraints.[2]

Is there any reason to interrupt chest compressions, which do improve outcomes that matter, to make it easier to intubate, which does not improve any outcomes that matter? No.

While the ETI proficiency of study clinicians might be questioned, the trial included a diverse range of EMS agencies and likely reflects current practice.[2]

This is the state of the art of intubation in the real world of American EMS. Making excuses shows that we are corrupt, incompetent, or both.

I no longer have the link, but I think that this image came from Rescue Digest a decade ago.

These results contrast with prior studies of OHCA airway management. Observational studies have reported higher survival with ETI than SGA, but they were nonrandomized, included a range of SGA types, and did not adjust for the timing of the airway intervention.9,10,31-34[2]

We should start doing what is best for our patients.

We should not continue to defend resuscitation theater – putting on a harmful show to make ourselves feel good.

What would a competent anesthesiologist use in the prehospital setting? Something that offers a benefit to the patient.

Do we have to stop using epinephrine (adrenaline in Commonwealth countries) for cardiac arrest?

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.[1]

The results showed that 1 mg of epinephrine every 3 – 5 minutes is even worse than I expected, but a lot of the more literate doctors have not been using epinephrine that way. What does this research tell us about their various methods? The podcast REBEL Cast (Rational Evidence Based Evaluation of Literature in Emergency Medicine) has a discussion of this question in REBEL Cast Ep56 – PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?.[2]

The current ACLS/ILCOR (Advanced Cardiac Life Support/International Liaison Committee on Resuscitation) advice on epinephrine does not state that epinephrine is a good idea, or even require that you give epinephrine to follow their protocol –

The major changes in the 2015 ACLS guidelines include recommendations about prognostication during CPR based on exhaled CO2 measurements, timing of epinephrine administration stratified by shockable or nonshockable rhythms, and the possibility of bundling treatment of steroids, vasopressin, and epinephrine for treatment of in-hospital arrests. In addition, the administration of vasopressin as the sole vasoactive drug during CPR has been removed from the algorithm.[3]

What was the ACLS/ILCOR advice in the 2010 guidelines?

The 2010 Guidelines stated that it is reasonable to consider administering a 1-mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest.[4]

This is in a paragraph that links to the PICO (Population-Intervention-Comparator-Outcomes) question that has been an open question for over half a century – In cardiac arrest, is giving epinephrine better than not giving epinephrine?[5]

Again, ACLS/ILCOR only considered a dose of epinephrine to be reasonable. Again, this was based on low quality evidence. I am not criticizing the efforts of those who worked on the Jacobs study of adrenaline vs. placebo, because they were stopped by the willfully ignorant opponents of science.[7]

What about the method of attempting to titrate an infusion to the hemodynamic response, which Dr. Swaminathan and Dr. Rezaie alluded to?

There is a lot of anecdotal enthusiasm from doctors who use this method, but I do not know of any research that has been published comparing outcomes using this method with anything else. How do we know that the positive reports from doctors are anything other than confirmation bias? We don’t.

This year is the 200th anniversary of the publication of the very first horror novel – Frankenstein; or, The Modern Prometheus. The doctor in the novel used electricity to raise the dead (and the subjects were very dead). There were no chest compressions in the novel, but it is interesting that we have barely made progress from the fiction imagined by an 18 year old with no medical training, although she did have the opportunity to listen to many of the smartest people in England discuss science. Mary Godwin (later Mary Wollstonecraft Shelley by marriage) was 16 when she started writing the novel.[8]

We have barely made more progress at resuscitation than a teenager did 200 years ago in a novel. Most of our progress has been in finally admitting that the treatments we have been using have been producing more harm than benefit. Many of us are not even that honest about the harm we continue to cause.

We dramatically improved resuscitation in one giant leap – when we focused on high quality chest compressions and ignoring the medical theater of advanced life support.

There are two treatments that work during cardiac arrest – high quality chest compressions and rapid defibrillation.

Why haven’t we made more progress?

We have been too busty making excuses for remaining ignorant.

We need to stop being so proud of our ignorance.

We now know that amiodarone doesn’t work for cardiac arrest (and is more dangerous than beneficial for ventricular tachycardia – even adenosine appears to be better for VTach), atropine doesn’t work for cardiac arrest, calcium chloride doesn’t work for cardiac arrest (unless it is due to hyperkalemia/rhabdomyolysis), vasopressin doesn’t work for cardiac arrest, high dose epinephrine doesn’t work for cardiac arrest, standard dose epinephrine doesn’t work for cardiac arrest – in other words, we have tried all sorts of drugs, based on hunches and the weakest of evidence, but we still haven’t learned that there isn’t a magic resuscitation drug.

Should anyone be using any epinephrine to treat cardiac arrest outside of a well controlled study?

Among adults who are in cardiac arrest in any setting (P), does does the use of epinephrine (I), compared with compared with placebo or not using epinephrine (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

The results are in from the only completed Adrenaline (Epinephrine in non-Commonwealth countries) vs. Placebo for Cardiac Arrest study.

Even I overestimated the possibility of benefit of epinephrine.

I had hoped that there would be some evidence to help identify patients who might benefit from epinephrine, but that is not the case.

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.

More people survived for at least 30 days with epinephrine, which is entirely expected. There has not been any controversy about whether giving epinephrine produces pulses more often than not giving epinephrine. As with amiodarone (Nexterone and Pacerone), the question has been whether we are just filling the ICUs and nursing home beds with comatose patients.

There was no statistical evidence of a modification in treatment effect by such factors as the patient’s age, whether the cardiac arrest was witnessed, whether CPR was performed by a bystander, initial cardiac rhythm, or response time or time to trial-agent administration (Fig. S7 in the Supplementary Appendix).[1]

The secondary outcome is what everyone has been much more interested in – what are the neurological outcomes with adrenaline vs. without adrenaline?

The best outcome was no detectable neurological impairment.

the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment.

Our work with patients and the public before starting the trial (as summarized in the Supplementary Appendix) identified survival with a favorable neurologic outcome to be a higher priority than survival alone.[1]

Click on the image to make it larger.

Are there some patients who will do better with epinephrine than without?

Maybe (I would have written probably, before these results), but we still do not know how to identify those patients.

Is titrating tiny amounts of epinephrine, to observe for response, reasonable? What response would we be looking for? Wat do we do if we observe that response? We have been using epinephrine for over half a century and we still don’t know when to use it, how much to use, or how to identify the patients who might benefit.

I will write more about these results later

We now have evidence that, as with amiodarone, we should only be using epinephrine as part of well controlled trials.

This is a nice study, which unfortunately ran into problems with enrollment and funding. There are some things that I think should have been done differently.

The doses of chilled IV (IntraVenous) fluid were not weight-based, while the fluid in the human body is weight-based. If midazolam (Versed) was given, the dose was just a single dose of 5 mg, or 2 doses of 5 mg each. The effects of midazolam are much less weight-based, than fluid, but the appropriate way to administer midazolam is to titrate to effect. Even if administering 10 mg of midazolam produces the desired effect in 80%, or 90%, of patients, that can still leave a significant portion inadequately sedated. The goal of TTM (Targeted Temperature Management) may be defeated by the movement of an even mildly agitated patient.

Would another drug, such as ketamine, be more appropriate? How much does use of midazolam affect the use of pressors to counter the vasodilatory effects of midazolam? Unlike other sedatives, ketamine does not seem to produce vasodilation and/or depress cardiac activity. The midazolam was only mentioned in the description of the study interventions and only described as being given to prevent shivering, so the dose may be adequate, but there is only the one mention in the entire paper.

The fluid administration was shown to be different with a p value of <0.0001. The difference is only 170 ml (5 3/4 oz), so it is a distinction described as significant by p value, but it does not appear to be a significant difference in any way that would affect patients. The SD (Standard Deviation - how much variability exists in about 2/3 of patients) is the same as the amount of fluid given to the control group and 2 3/4 times the amount of the difference. In other words, there was a lot of overlap in the volumes administered to the patients in the two groups.
While the p value of <0.0001 suggests confidence in the results being due to change only one time in 10,000, that is misleading.

Total fluid infused was not documented for 98 (35%) patients who received Prehospital Cooling and 121 (40%) control patients.[1]

The raw data on the volumes is not included, nor is the shape of the graph of distribution of the volumes, but it looks as if 20%, or 30%, of the control group may have received more fluid that the intervention group – and then there are the more than 35% of patients without documentation of fluid volumes.

Since the amount of difference is small, it does not seem to matter, but the intervention group was forcing the chilled fluid into the patients with pressure bags, so why so little difference between the groups?

How long does it take to administer 170 ml of chilled IV fluid by pressure infusion? Does it take longer than it takes to get from the ambulance to the hospital stretcher?

That is just a statistical oddity that is not going to affect outcomes.

The next may be the true the significant finding of the study.

Patients in the prehospital cooling group were more likely to (ever) receive TTM in hospital [190 (68%) vs 170 (56%); RR 1.21, p = 0.003] than patients in the control group.[1]

TTM (Targeted Temperature Management) is the new term for therapeutic hypothermia, which has been shown to be effective.

If not, why not?

Across all studies that used conventional cooling methods rather than no cooling (three studies; 383 participants), we found a 30% survival benefit (RR 1.32, 95% CI 1.10 to 1.65). The quality of the evidence was moderate.[2]

With no difference in the rhythms of the control group and the intervention group, why the difference in the rate of TTM in the hospital?

Will this be similar to the case of waveform capnography? EMS ended up pressuring many/some EDs to begin to use EtCO2 on all intubated patients. This was a change from the previous, much too common, ED practice of complaining about and pulling at the EtCO2 tubing, because it was an unknown item that was in the way.

EMS should not need to encourage the ED to provide better care, especially about treatments/assessments that originated as in-hospital treatments/assessments. It should be the reverse.

There is an excellent review of TTM research at Life In The Fast Lane.[3]

Continuing from Part II, which looked at the way the satirical parachute paper misrepresents EBM (Evidence-Based Medicine), but that is expected from satire. You could also provide a great defense of blood-letting as the best medicine using satire.

After claiming to know what he is writing about, Kevin finishes with this –

As a reminder, there is not level 1 evidence that oxygen works during an acute heart attack either. That is because we do not withhold it from anyone to study it in randomized fashion due to ethical concerns and assumptions made from non-level 1 evidence.

What does Kevin mean by level 1?

There have been some studies of oxygen. It is unethical to not study the drug oxygen.

For example, there was a study of One hundred percent oxygen in the treatment of acute myocardial infarction and severe angina pectoris in JAMA (Journal of the American Medical Association) way back in 1950.

If oxygen is so much better than room air for heart attack patients, the patients receiving 100% oxygen should have dramatically better outcomes than patients receiving room air by mask in this double-blinded study. The results were not statistically significant, but patients receiving 100% oxygen did not do as well as the patients receiving room air by mask.[1]

Hypoxic patients were treated with oxygen, rather than enrolled in the study, because the study looked at treating heart attack, rather than treating hypoxia. Whether we should treat hypoxia without symptoms is also a different question.

Kevin’s comment was written in September, which is ironically when the paper Oxygen Therapy in Suspected Acute Myocardial Infarction was published. We have stopped using blood-letting to treat patients, even though withholding blood-letting used to be considered just as unethical.

CONCLUSIONS: Routine use of supplemental oxygen in patients with suspected myocardial infarction who did not have hypoxemia was not found to reduce 1-year all-cause mortality.[2]

The evil scientists did not uphold dogma? Burn the heretics.

The acronym for the study reflects the addiction to continuing questionable treatments, which must not be questioned. DETO2X.

Have competent people condemned this research as unethical?

I have not looked at any of the other medical research blogs, but you should go ahead and read them (listen to the podcasts, watch the videos) and see what they write. Tell me if anyone condemns the research. Don’t quote Gwyneth Paltrow or Dr. Oz, but competent science bloggers.

The actual dogma was to give oxygen to heart attack patients, so is routine oxygen for heart attack just another case of harming patients with tradition?

What does Cochrane tell us?

Authors’ conclusions There is no evidence from randomised controlled trials to support the routine use of inhaled oxygen in people with AMI, and we cannot rule out a harmful effect. Given the uncertainty surrounding the effect of oxygen therapy on all-cause mortality and on other outcomes critical for clinical decision, well-conducted, high quality randomised controlled trials are urgently required to inform guidelines in order to give definitive recommendations about the routine use of oxygen in AMI.[3]

Ignorance is preferable to error; and he is less remote from the truth who believes nothing, than he who believes what is wrong.

- Thomas Jefferson

Notes on the State of Virginia (1781-1783)

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Bigotry and science can have no communication with each other, for science begins where bigotry and absolute certainty end. The scientist believes in proof without certainty, the bigot in certainty without proof. Let us never forget that tyranny most often springs from a fanatical faith in the absoluteness of one’s beliefs.

Ashley Montagu.

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Today we rely less on superstition and tradition than people did in the past, not because we are more rational, but because our understanding of risk enables us to make decisions in a rational mode.

- Peter L. Bernstein

Against the Gods: the remarkable story of risk (1996)

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Mark my word, if and when these preachers get control of the [Republican] party, and they're sure trying to do so, it's going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can't and won't compromise. I know, I've tried to deal with them.

Barry Goldwater.

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I think every good Christian ought to kick Falwell right in the ass.

Barry Goldwater

Said in July 1981 in response to Moral Majority founder Jerry Falwell's opposition to the nomination of Sandra Day O'Connor to the Supreme Court, of which Falwell had said, "Every good Christian should be concerned." as quoted in Ed Magnuson, "The Brethren's First Sister," Time Magazine, (20 July, 1981)

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What do you think science is? There's nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?

Dr. Steven Novella.

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What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books.

Sigmund Freud (1933)

Today the samizdat is digital and burning a copy has the opposite meaning. A little later, persecution of the Jews was once again the law - Freud's four sisters all died in concentration camps, although not by burning.

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"Can you prove that it’s impossible?” “No”, I said, “I can’t prove it’s impossible. It’s just very unlikely”. At that he said, “You are very unscientific. If you can’t prove it impossible then how can you say that it’s unlikely?” But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible. To define what I mean, I might have said to him, "Listen, I mean that from my knowledge of the world that I see around me, I think that it is much more likely that the reports of flying saucers are the results of the known irrational characteristics of terrestrial intelligence than of the unknown rational efforts of extra-terrestrial intelligence." It is just more likely. That is all.

Richard Feynman.

The Character of Physical Law (1965)
chapter 7, “Seeking New Laws,” p. 165-166:

It has been over half century since Feynman explained this. The reports of flying saucers have continued, but there is still no valid evidence to support belief in flying saucers. Feynman's explanation is a good definition of unlikely.

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An ignorant mind is precisely not a spotless, empty vessel, but one that’s filled with the clutter of irrelevant or misleading life experiences, theories, facts, intuitions, strategies, algorithms, heuristics, metaphors, and hunches that regrettably have the look and feel of useful and accurate knowledge.

David Dunning - explaining the Dunning-Kruger effect.

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Treat beliefs not as sacred possessions to be guarded but rather as testable hypotheses to be discarded when the evidence mounts against them.

Philip Tetlock.

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Squatting in between those on the side of reason and evidence and those worshipping superstition and myth is not a better place. It just means you’re halfway to crazy town.

PZ Myers

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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Imagine a world in which we are all enlightened by objective truths rather than offended by them.

Neil deGrasse Tyson

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Education is a progressive discovery of our own ignorance.

Will Durant.

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You don't use science to show that you're right,

you use science to become right.

Randall Munroe

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Just because science doesn't know everything doesn't mean you can fill in the gaps with whatever fairy tale most appeals to you.

There appears to be in mankind an unacceptable prejudice in favor of ancient customs and habitudes which allows practices to continue long after the circumstances, which formerly made them useful, cease to exist

Benjamin Franklin.

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If science proves some belief of Buddhism wrong,

then Buddhism will have to change.

Tenzin Gyatso, 14th Dalai Lama.

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Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them;

Thomas Jefferson.

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Science doesn't make it impossible to believe in God.

It just makes it possible to not believe in God.

Stephen Weinberg.

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There are no forbidden questions in science,

no matters too sensitive or delicate to be probed,

no sacred truths.

Carl Sagan.

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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It is better to not understand something true,
than to understand something false.

Neils Bohr.

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God does not play dice with the universe.

Albert Einstein

Stop telling God what to do with his dice.

response by Neils Bohr.

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All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

Paracelsus.

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What is not true, as everyone knows, is always immensely more fascinating and satisfying to the vast majority of men than what is true.

H.L. Mencken.

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Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are.

Niels Bohr.

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How wonderful that we have met with a paradox. Now we have some hope of making progress.

Niels Bohr.

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An expert is a man who has made all the mistakes which can be made in a very narrow field.

Niels Bohr.

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Every sentence I utter must be understood not as an affirmation, but as a question.

Niels Bohr.

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Some subjects are so serious that one can only joke about them.

Niels Bohr.

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I have no special talents. I am only passionately curious.

Albert Einstein.

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Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions.

Albert Einstein.

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Never memorize what you can look up in books.

Albert Einstein.

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The prestige of government has undoubtedly been lowered considerably by the prohibition law. For nothing is more destructive of respect for the government and the law of the land than passing laws which cannot be enforced. It is an open secret that the dangerous increase of crime in the United States is closely connected with this.

Albert Einstein.

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the chance is high that the truth lies in the fashionable direction. But, on the off-chance that it is in another direction - a direction obvious from an unfashionable view of field theory - who will find it? Only someone who has sacrificed himself by teaching himself quantum electrodynamics from a peculiar and unusual point of view; one that he may have to invent for himself. I say sacrificed himself because he most likely will get nothing from it, because the truth may lie in another direction, perhaps even the fashionable one.

If you've made up your mind to test a theory, or you want to explain some idea, you should always decide to publish it whichever way it comes out. If we only publish results of a certain kind, we can make the argument look good. We must publish both kinds of results.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.

Richard Feynman.

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Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

Richard Feynman.

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The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty.

Richard Feynman.

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Some people say, "How can you live without knowing?" I do not know what they mean. I always live without knowing. That is easy. How you get to know is what I want to know.

Richard Feynman.

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I don't know anything, but I do know that everything is interesting if you go into it deeply enough.

Richard Feynman.

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So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies . . . publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.

William Osler.

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The greater the ignorance the greater the dogmatism.

William Osler.

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The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.

William Osler.

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One of the first duties of the physician is to educate the masses not to take medicine.

William Osler.

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In the fields of observation chance favors only the prepared mind.

Louis Pasteur.

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Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.

Louis Pasteur.

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Not far from the invention of fire must rank the invention of doubt.

Thomas Henry Huxley.

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The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.

Thomas Henry Huxley.

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The foundation of morality is to have done, once and for all, with lying; to give up pretending to believe that for which there is no evidence, and repeating unintelligible propositions about things beyond the possibilities of knowledge.

Thomas Henry Huxley.

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My business is to teach my aspirations to conform themselves to fact, not to try and make facts harmonise with my aspirations.

Thomas Henry Huxley.

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There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.

Tom Stoppard

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All men can be criminals, if tempted; all men can be heroes, if inspired.

G. K. Chesterton

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There is no such thing on earth as an uninteresting subject; the only thing that can exist is an uninterested person.

G. K. Chesterton

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Good taste, the last and vilest of human superstitions, has succeeded in silencing us where all the rest have failed.

G. K. Chesterton

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Men become superstitious, not because they have too much imagination, but because they are not aware that they have any.

George Santayana

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If we are uncritical we shall always find what we want: we shall look for, and find, confirmations, and we shall look away from, and not see, whatever might be dangerous to our pet theories. In this way it is only too easy to obtain what appears to be overwhelming evidence in favor of a theory which, if approached critically, would have been refuted.

Karl Popper

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It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

Upton Sinclair

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Freedom is what you do with what's been done to you.

Jean-Paul Sartre

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Where goods do not cross frontiers, armies will.

Frédéric Bastiat

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The ultimate result of shielding men from the effects of folly is to ﬁll the world with fools.

Herbert Spencer

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Political language — and with variations this is true of all political parties, from Conservatives to Anarchists — is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

George Orwell

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Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.

John Adams

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We're not presuming the answers before we ask the questions.

Lawrence Krauss explaining how science works

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Malo Periculosam Libertatem Quam Quietum Servitium.

Better freedom with danger than peace with slavery.

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Whatever inspiration is, it's born from a continuous "I don't know."

Wislawa Szymborska

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All sorts of torturers, dictators, fanatics, and demagogues struggling for power by way of a few loudly shouted slogans also enjoy their jobs, and they too perform their duties with inventive fervor.

Well, yes, but they "know." They know, and whatever they know is enough for them once and for all.

They don't want to find out about anything else, since that might diminish their arguments' force.

Wislawa Szymborska.

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Theory helps us to bear our ignorance of fact.

George Santayana

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Miracles are propitious accidents, the natural causes of which are too complicated to be readily understood.

George Santayana.

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Fanaticism consists in redoubling your efforts when you have forgotten your aim.

George Santayana

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There is a fundamental difference between religion,

which is based on authority,

and science,

which is based on observation and reason.

Science will win because it works.

Stephen Hawking.

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The truth, indeed, is something that mankind, for some mysterious reason, instinctively dislikes. Every man who tries to tell it is unpopular, and even when, by the sheer strength of his case, he prevails, he is put down as a scoundrel.

H.L. Mencken.

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It is the natural tendency of the ignorant to believe what is not true. In order to overcome that tendency it is not sufficient to exhibit the true; it is also necessary to expose and denounce the false.

I am attempting to make it easier, when I use footnotes, to navigate to the information in a footnote, look at the information, and return to where you were before you clicked on the footnote. If you click on the number of a footnote in the text[1] <- click on the bracketed and underlined number - in this case [1], it will bring the footnote to the top of the screen.

[1] If you click on the bracketed and underlined number of a footnote in footnote section, the [1] at the beginning of this paragraph, it will take you to where you clicked on the footnote in the text, with the footnote along the top of the screen. [To top of footnotes]

If you wish to modify the size of the text, you can press the CTRL key and roll the mouse wheel forward or back, or you can press the CTRL key and the + or - keys to make text larger or smaller. Another way is to adjust the font in your browser controls.

This is a mostly medical blog, so here is the HIPAA incantation to ward off evil whiny HIPAA-obsessed spirits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is generally misrepresented by those in health care, but there are no violations of HIPAA here. There are some patients I could not discuss without changing details, so details may be omitted, or changed. That may decrease the dramatic effect of some of what I write, but patients are entitled to their privacy and have been since before HIPAA became the ignorant administrators' justification for imitating a two year old yelling NO!

I am not dispensing medical advice. If you get your medical advice off of a blog, instead of consulting a physician (such as your medical director), you probably should not be treating anyone, not even yourself. I could include your dog, but that would suggest that veterinarians do not provide excellent care. The veterinarians I know take pride in the care they deliver and deliver excellent care, more so than many people I know in EMS.

I do point you to research to support what I write, but you still need to make sure that you have the authorization of your medical director before changing any of your treatments. If your medical director does not agree, you can point to the research I write about. Most doctors do understand research, they just have trouble keeping up with the amount of research that is produced.

What I write does not change your protocols. If you do not like a protocol, take it up with the medical director. I have several inadequate protocols, too. I call medical command and attempt to persuade the physician that what I am requesting is in the best interest of the patient. It is rare that I am turned down, but the dose is often inadequate. I call back before I need more, so the patient does not have to put up with the On Line Medical Command delay in treatment. Health care providers should be anticipating where the care of the patient is headed - both for good and for bad.

I do not have any connection to the products I mention, other than using them and being satisfied, dissatisfied, or some combination of the two. If I have any potential conflict of interest, I will mention it clearly.

If I write about a book by an author I know, I will encourage you to buy the book from the author's web site. This means that any money goes to the author (or to where the author wants the money to go, such as a charity) and you have an opportunity to sample the author's writing for free on the author's blog before buying the book.

I may be blunt, but I do not intend it personally. There are few mistakes that can be made that I have not made. I continue to try not to be stupid; you may conclude that I fail.

I welcome any relevant comments and much that is not relevant. I reserve the right to delete any inappropriate comments. I decide what is appropriate based on my own nebulous standards. Criticism of ideas is expected. Criticism of writing style is appreciated.

I avoid obscenity because I believe that the English language provides enough opportunities for creativity that resorting to the words that may not be said on TV (and a growing group of words that may) is unnecessary. I may quote something that contains some of these words, or I may link to something that does, but that is as bad as I expect to be with these words.

On the other hand, you may feel that the ideas I present are offensive. My aim is to encourage thought, dialogue, and creativity - not to tell you everything is OK. You may leave this blog at any time and bury your mind in comfortable, familiar ideas.

If you feel that the ideas I present are not challenging, please encourage me to address whatever you feel I do not adequately address.