Nature did just that: humans who are heterozygous for the sickle cell anemia trait are less likely to die from infection with malaria. Other mutations of the hemoglobin genes also confer some resistance. That's why the hemoglobinopathies like sickle cell anemia and thalassemia are distributed throughout malaria endemic areas.
but organizations don't want new EMT graduates having significant doubts about the basics of their training {CPR and rescue breathing are two of the basics of EMT training- can't do both - then you can't pass an EMT course}. A lack of confidence in what they have recently learned is often more dangerous, better to have them have with a healthy case of nerves and their basics training not quite perfect or up-to-the minute.
1) You said organizations don't want to have EMTs question what they learned, and such questioning is disadvantageous.
In the anecdote, she didn't question her training (that statement about bringing the shit really is in BEC.) I not only questioned it, but realized this was beyond lame and well into google video range (had their been GV at the time.)
2) You said its better for EMTs to be confident in what they learned rather than keep their training perfectly up to date.
The problem is that confidence in what you do, if its the wrong thing, can wreak a lot of havoc. I'd rather be treated by the person who realizes what they are doing is fallible and is going to change and keeps up with any new updates like the ones I posted to that are over a year old, but which the other physician posting doesn't seem to have read... as a reasonable demonstration of my point.
Well of course.... if there is no bruising there is no rape right?
Bowyer and Dalton "Female victims of rape and their genital injuries" BJOG: An International Journal of Obstetrics and Gynaecology 104 (5), 617-620. 1997. "Conclusion: The study shows that only a minority of women examined by specifically trained police doctors show evidence of genital injury. The absence of genital injury does not exclude rape."
Merritt "Vulvar and genital trauma in pediatric and adolescent gynecology." Current Opinion in Obstetrics & Gynecology. 16(5):371-381, October 2004. "Many recently published articles have noted that the history as given by the child or adolescent is the most important factor in determining the etiology of genital injuries as abuse or accidental. The history is more important than any documented or lack of documented findings on physical examination. Distinguishing whether the injury was accidental or caused by abuse is of significance to the family and the injured child or adolescent. Genital examinations of victims of documented abuse are often normal."
http://www.co-obgyn.com/pt/re/coobgyn/abstract.000 01703-200410000-00004.htm;jsessionid=F9lDHCpbb4hFW X0Kb2Px6RgNZh8zzlNR7gcpGP8QvpgVmz3TQ9vv!1570379021 !-949856144!8091!-1
But then c'mon, what the hell do academic Pediatricians and Gynecologists know of how to determine whether sexual abuse of children happened! We all know that you can tell if a girl is pure based on whether or not her hymen is intact, that all rape victims show physical signs (because if the bitch didn't struggle, it wasn't a rape, eh?), and that if a three year old says Daddy put his penis in my vagina that MUST have been coached by the mother who left the dad.
The AHA's current guidelines page is here. A good quick summary for recent changes is the 'Summary of Changes' document which covers the changes from community to skilled provider CPR. http://www.heart.org/presenter.jhtml?identifier=30 35517
Before I was an ER physician, I was an EMT. I didn't have as much clinical information as I do now, but I was able to think for myself. One particular event comes to mind... in the book Brady Emergency Care (the text for most EMT courses) it tells you that if possible, if the person has vomiting or diarrhea, you should try to transport the effluent to the hospital.
I was stuck working with another EMT who was (literally) a sorority girl who was a sophomore pre-med at UNC. We were up in the back woods of Orange County (20 miles and 50 years from Chapel Hill) and had a call at a house with no indoor plumbing. The teenage daughter had a bad stomach flu. Unfortunately without a toilet, the family facilities (in winter) was a 5 gallon plastic cement bucket on the back porch (filled about 2/3 full with excrement of various family members.) Ms Alpha Kappa Dumbass decides we must take the bucket of shit and piss to the ER. Arguing with her that A) their were multiple samples of people's shit in said bucket, B) the bucket would spill and smell on the 20 mile ride, and C) no ER nurse would ever let me live this down if I walked in with that bucket'o'turds.... were all quite meaningless in light of her photographic memory of Brady Emergency Care's dictum.
Ultimately I just gave up and told her I would drive, she could do what she wanted, but if that shit spilled SHE would clean it up.
The predictable thing happened, and by arrival at UNC Hospitals, we had a 1/3 full cement bucket which had been 2/3 full. Ms Alpha Kappa Dumbass (now smelling of shit to high heaven) marches in with the bucket and the stretcher. I was literally physically incapacitated and had to sit on the floor as the triage nurse had the most entertaining (yet incredibly short) conversation with this idiot.
The morals of this story are that 1) you are better off knowing why you are doing something than memorizing rote procedure and 2) someone who thinks things through rather than carrying 3 gallons of shit and piss to the ER is the one that gets to take an hour lunch break while the unit is 10-7 as the ignorant sorority chick gets to scrub shit out of the ambulance. Same thing with this argument. You are better off with a thinking EMT helping you who will be able to take basic concepts and expand them to fit the situation.
In addition teaching that a protocol that is at best evolving to be somewhat evidence based is infallible will make it a while lot harder to retrain people if they think they learned the absolute truth a decade ago.
"In the case in question, Mommy Dearest coached a three year old to say that 'Daddy put his penis in my vagina'. Those words. From a three year old. A medical examination returned an intact hymen and no signs of physical trauma."
This goes to show you don't have to know anything to have an opinion.
An intact hymen is sometimes found in sexually active women.
And lack of signs of trauma is no evidence that a sexual assault has occurred. Only about half of rape victims have visible evidence of trauma. Arguing that a lack of bruising (in an exam that may have occurred weeks after the incident) shows that he was innocent is up there with the argument that if a woman begs her rapist to use a condom that it obviously couldn't have been rape.
And its odd that if she was mommie dearest there was no evidence that he could muster against her? Plus that must be a damn smart three-year-old to be able to maintain that facade after evaluation by a trained forensic psychologist. In my experience kids aren't even good at maintaining a lie about how the bead got in their nose, much less whether daddy put his penis where.
He may say that, and you may want to believe your friend, but like I said before: every prison is filled with innocent men.
Um, that would be the perspective of a physician who apparently hasn't read a recent AHA update or the articles in Circulation that discuss this in detail. Not to mention the other studies that caused the changes in the AHA guidelines which predate this one and were the basis for the AHA change. The emphasis is less on advanced airway management and more on compressions. The difference is in the detail with which its considered. In community CPR its dumbed down a fair deal, but even for critical care physicians the rules are changing.
"I don't have the sources in front of me, but one report I read bragged at the 13% home replacement rate of CPS removals in southwest Missouri. That is, 13% of kids taken by the state eventually make it back to their home. I cannot be made to believe that their false positive rate on all accusations is only 13%,"
That is because the majority of CPS reports do not result in removal of the children from the home. The default is to leave the children in the home unless there is an immediate risk. That 13% is in the minority of extreme cases where the children were actually removed. To give you an example, I would say on average that I file 2 reports per month with CPS. In the past year I have taken emergency custody in two cases. So yes, I think in the cases where it was bad enough they immediately took the kids, 13% is a reasonable false positive rate.
"However, the idea that a state agency can arbitrarily reassign your kids without requirement of due process or other constitutional considerations is absolutely terrifying to me."
That is because the child's right to safety trumps the parents property rights to the child. The safest thing for the kid who is at immediate and high risk is to remove them to a place of certain safety until the courts figure out exactly what went on and who placed the kid in real danger. The default should not be that despite the fact that your child has obvious whip marks on his back, burns on his buttocks, malnourishment, and a festering infected wound on his foot that you should be able to take him out of my ER unless I can prove beyond the shadow of a doubt immediately in the ER that you are the one who has abused and neglected the kid. (And that was one of the cases in which I've taken immediate custody.)
If you kid arrives to my care in that condition, you'll take him home over my cold and dead body despite your concerns about being deprived your constitutional right to starve and beat the shit out of your property.
First, while this one study was not an RCT, there are RCTs that give similar results in the same direction. This one was just the study that got press (likely because it was the first big one published after the AHA changed the CPR guidelines.) The data from the King County Washington group come to mind immediately, but there are other studies that show the same thing.
Second, while airway is important in cardiac arrest, it is less emphasized according to the new AHA ACLS guidelines. For example, with the VF/pulselessVT/asystole/PEA algorithm, intubation of the trachea takes a lower priority. In the words of the mothership about treatment of pulseless arrest: "Insertion of an advanced airway may not be a high priority," from the AHA's 2005-6 update: http://www.americanheart.org/downloadable/heart/11 32621842912Winter2005.pdf
Or if you want the original article from Circulation: "Thus, during the first minutes of VF SCA the lone rescuer should attempt to limit interruptions in chest compressions for ventilation. The advanced provider must be careful to limit interruptions in chest compressions for attempts to insert an advanced airway or check the rhythm." http://circ.ahajournals.org/cgi/reprint/112/24_sup pl/IV-51
So even with in-hospital arrests, during the first few minutes which determine in large part whether a patient survives neurologically intact, being aggressive about securing the airway may be misguided. I think I am pretty facile with a laryngoscope, but it is still a good 20 seconds of interruption of compressions to intubate, more if its at all difficult. Those 20 seconds may make the difference, so intubating *after* ROSC may be a better option. If they don't have ROSC in 10 minutes, it is unlikely that intubation will help anyway.
Lastly, even if the absolute risk reduction was small, why not do the kind of CPR that gives you the slightly better outcome and exposes people to less risk of communicable disease? The couple of times I've done CPR au natural, it was just about the grossest thing I've ever had to do.
"Having actually given CPR for more than 2 minutes, it can literally cause you to pass out if you're the only one there: you have to combine forceful compressions (of breaking THROUGH the ribcage to the heart to get it going) with breathing into a person..."
Huh? I've done CPR for more than 2 minutes on numerous occasions and I am way not as fit as a swim instructor should be. I usually start needing a break at 5-7 minutes. Perhaps you are referring to the oft confused human-elephant CPR?
As an rapidly ageing ER doctor who used to be an EMT, I find your confidence in the ACLS protocols to be kind of innocently cute. I hate to break it to you... but ACLS is one of the most arcane and poorly researched areas of critical care medicine. Very gradually over the past decade or so there has been a move to do real research (even though it is one of the hardest areas to do research since getting IRB approval for trial is pretty close to impossible.) But a lot of it is still 'seemed like a good idea at the time' kind of medicine.
So all that stuff in the neato little flow chart you have is only slightly more evidence based as the belief that ERs are busier on full moons or that uttering the Q-word will cause an influx of calls to 911.
And you think its bad now? Well I remember having to give Bretylium Tosylate for refractory VFib... and we *liked* it that way... we loved it... we couldn't get enough if it!
Nope. Even trained paramedics, ER physicians and ER nurses do a shitty job of doing an adequate number of compressions if they interrupt to do ventilation.
I was an EMT before I became an ER physician so I have seen a lot of shitty CPR done by people who know better. Just being someone who does it frequently does not mean you do it well.
If my partner dropped dead in front of me now, I would give him the biggest MF prechordial thump I could muster (in hopes that he went into VF) call 911, then wail on his chest like a crazed weasel on crack. Hard and fast is the only thing that will save him. I would aim for at least two deep compressions per second. If he survives to have issues with a hemothorax or pulmonary contusion then I did good CPR.
If it got to 3-5 minutes and EMS had not arrived I would probably give a couple of breaths and probably once a minute thereafter. If it got to fifteen minutes and they had not arrived, I would let him go.
"He's complied with ever detail of the law, and even though no evidence exists against him, he'll still probably not see his kids again"
And prisons are filled with innocent men. And every kid that has the most obvious kind of patterned injuries 'came home like that'. And every pre-ambulatory infant with a bucket handle fracture 'fell'.
I strongly doubt that there was no evidence against him that he would lose all visitation rights. That evidence might have not been a videotape of him abusing his kids, but you are not going to get a custody settlement that does not even allow supervised visits without a shred of evidence against one parent. Even in proven cases of abuse, supervised visits are almost always provided.
Of course that is the same kind of argument as "My cousin has this friend who was in this car accident and the cops told him that if he'd have been wearing his seatbelt and hadn't been thrown out of the car, he'd have died. So I don't wear no damn seatbelt." Its a convenient story to justify something that we'd like to be justified despite evidence to the contrary.
First you make the incorrect assumption that if there were not mandated reporting laws that abusers would somehow feel safe going to the ER for care. Even if there were no such laws I would *still* report abuse and take emergency custody of children exactly as I do now. What mandated reporting laws do is say that EVERY health care provider must do the same. So lack of mandated reporting laws only makes it haphazard whether you will get busted. Plus such laws ensure providers that as long as they act in good faith they will be legally protected if they take the appropriate action.
Second, the police cannot arrest or even charge your example's boyfriend unless she is willing to bring charges. Mandatory reporting of DV in states that have it (not all do if the victim is not a child or other vulnerable person like dependent elders) simply means that the police come to the ER to see if the victim will press charges. If she loves that shitstain and he hasn't killed her yet or placed her in a coma, she can still keep him out of trouble.
However, if the victim is a child or dependent adult then the state (and in this case mandated reporters at their direction) must assume that if the victim were capable of making their own decisions they would choose to not remain in an abusive situation. For example, a 5 year old whose parents beat him with an electric cord is not able to make the decision whether or not he should stay with his abusers. His parents, by their treatment of the boy demonstrate they do not make decisions in the child's best interest. Therefore the state *should* step in to protect the child. Mandated reporting of abuse of minors and dependent adults allows the state to fulfill that responsibility.
And if the reason that your kid got a broken arm or an intracerebral hemorrhage is that you beat the shit out of him, he should be able to get care. And I should be able to piss in a cup and force you to drink it after I and a couple of nurses take you in the back and beat the living crap out of you. But instead we just call CPS and take your kid into custody. In comparison, I think that's pretty benign.
Though the evidence suggests that most kids (and adult domestic violence victims) who are ultimately killed due to abuse have had an encounter with a medical professional in the past month.
Its not that abusers don't bring in their victims, its that no one makes the connection between injuries and the cause. Hence MR laws.
Well, I'm going to double-reverse-counter-counter-sue you.
And besides, I read a counterfeit Esperanto version of her book that I* downloaded from whacknut-manifesto.com. I never click through that kind of stuff.
-Nick
*By 'I' I mean, me Jeff Douchebag, the guy who stole NickGorton's laptop and is posting this before I surreptitiously return it without him ever noticing.
I can see why she wouldn't want to get indexed. She's basically providing information for people trying to resist intervention from child protective services. She suggests taking your children and hiding them out of state if CPS tries to contact you. She also suggests (and sells an ebook about) teaching your children to never talk to a social worker or answer questions... you know like 'does anyone ever hit you?' and 'what did you have to eat yesterday?' and 'do you have a doctor to go to when you are sick?'
Of course CPS and child abuse reporting in general is imperfect. I'm an ER physician which makes me a mandated reporter. This means if I simply suspect abuse or neglect, I am required by law to report it. The system is set up to favor false positives over false negatives. That means that CPS investigates many cases for every real abusive situation they find.
This is NOT a bad thing. There are 1500-2000 reported deaths from child abuse every year in the US. One in twenty kids in the US is physically abused in any given year and most of those victims are under age 6. Most of these cases of abuse never come to the attention of authorities because child abuse is woefully under-reported (which is why we have mandated reporter laws.)
Most of the instances of 'think of the children' posturing are conservative unthinking crap. However advocating outdated ideas of parental property rights over the rights of children to not be abused goes beyond simple whack-job well into the realm of pure evil.
...Avoid all drugs that are currently advertised on TV unless absolutely necessary.
They don't advertise drugs that are old and off patent; they advertise drugs from which they can make a boat-load of dough. So in general the new purple pill for whatever has only been on the market for a few years and thus has only had a few years of post-marketing surveillance which makes them inherently more dangerous.
When a drug comes to market it has usually been tested on only up to 10,000 people through phase 3 trials. After it gets to market, we do what is essentially a 'phase 4 trial' where a drug we think is safe (based on about 10K subjects) now gets tested on a million subjects. So if there is a rare but serious complication that occurs with the drug, often this will only become apparent after the drug is marketed. This is the reason that every so often we hear of new drug X being withdrawn from the market. (For example: Baycol, Vioxx, etc.)
Now, admittedly the hype over such post-marketing withdrawals is generally way overdone. The FDA is a bunch of hacks, the drug companies are poisoning us, and our doctors are part of a communist plot. Whatever.
What really happens is that a drug only tested on 10,000 people may very well kill 1:5,000 people who use it and we may not know that based on statistical vagaries of limited studies.
However, the point is that the newfangled drug that you saw on TV may have a cheaper, safer, and just as effective 20 year old cousin who has withstood 'phase 4 trials' and demonstrated its safety. Being new, fancy, flashy, advertised on TV, or even easier to use, doesn't make a drug better or safer any more than it does an OS.
When that happens, the particular doctor in question gets his ass sued into oblivion because of that behavior.
The problem is (almost never) nefarious intent or a willingness to sell out a patient's best interests for a plastic pancreas. The problem is more that drug detailing *works very well*. The drug company knows that if you see a plastic pancreas bearing the name XOLOCXA you will be more likely to think of XOLOCXA and prescribe it to your patients. They also know that the detail rep will be able to glom onto a little of your time because the social pressures inherent in accepting the pancreas of doom. Someone gives you a lunch, a plastic pancreas, and a USB drive that looks like a XOLOCXA tablet and well... you hafta talk to the (usually a sexy looking) woman for a little while. Duh. Of course during that 15 minutes you are subjected to a detailed description of the utility of XOLOCXA and get copies of the pharma-sponsored research that (shock and horror!) showed a positive outcome. (I actually read an article a while back that pharma recruits their drug reps from college cheerleading squads. Pretty sick.)
And that is the exact reason that the only thing I ever accept from a drug detail rep is drug samples. I don't even particularly like accepting that, but its a necessary evil for some of my patients. Even the availability of samples makes me more familiar with a certain set of drugs... so it is easier for me to rx because I know more about it.
Dude, you are high on something that you must share with the rest of us. I'm an ER physician and I also volunteer at a clinic 2 days a week seeing those who are 'low income and freeloader types' as you so eloquently put it. However the vast majority of my patients at clinic are not qualified for any public medical assistance. You generally have to be either disabled or have dependent children (in some states) to have medicaid benefits. The big losers in the US are the working poor... they may make $20-30k/year working but have no insurance because their jobs do not offer it and they make too little to afford it themselves.
Nick
That is the whole point of disability accommodation. You need to actually go to a certain amount of cost and inconvenience to make society accessible for everyone.
Does it cost a lot to make buildings accessible to people in wheelchairs? Yes. Could you get around it by just having the wheelchair-ambulating person ask for a lift up when he got to a place with stairs? Yes. Would it be wrong to expect this person to be limited in this way despite the fact that it otherwise causes a significantly greater cost to fit public buildings with ramps? Also yes.
Part of the reason that we as a society accept that more must be done to make those with disabilities more fully able to independently act is precisely because of the effects that dependence produces. And that goal of greater independence is valuable enough that it merits our effort and cost.
Moreover, I for one am sick of being the country that is always last to adopt international standards. The lack of metric standard units in the US is embarrassing enough. Can we PLEASE not drag our knuckles on this one too? Someday I'd eventually like to travel to the EU without having to wear a tasteful maple leaf ensemble.
You could do this before the internet. It simply had to be done with print rather than with a blog entry. Unidentified sources have been around since there were clay tablets and journalists have been protecting them for just as long. Of course when its the Pentagon Papers that's different...
I ask and BF says 'no detergent! what are you crazy?' That he can say that with a straight face while advocating putting a toaster in a dishwasher really amazes me.
Probably. My boyfriend taught me this trick: nasty, disgusting appliance or electronics? Wash it in the dishwasher, let dry a week, then re-use spanking clean item.
I thought he was trying to kill me when I found our toaster in the diswasher. But that was 7 years ago, and I'm not dead.
Yet.
Unfortunately its not only Lamo, but any close relatives who will be influenced by his inclusion in the DNA database. As was published this month in the journal Science, it is possible to identify the DNA of 'close matches' to crime scene DNA if a criminal's relatives' DNA was in the database. With this evidence in hand it is pretty simple to then get a warrant for a suspect's DNA.
The question then arises, who is most likely to have relatives in any criminal database? Well, the poor and disenfranchised for one. Racial minorities for another. About one in six black men is in the US criminal justice system in his lifetime. That compares with about 1/35 in the overall US population. So if you are a black person who commits a crime, it would be statistically more likely that a close relative would be included in a DNA database than it would be for a white person.
So while it seems like there is nothing wrong with establishing a database if it is only used to find 'the bad guys', that view ignores the fact that this would result in disproportionately detecting people based on race as well as other socioeconomic determinants of kinship that are pertinent but not as easy to use in my example.;) In a moral system, justice should be meted out equally at all stages of the game - which is why we have laws against racial profiling.
Nick
Slashdot Mirror
Nature did just that: humans who are heterozygous for the sickle cell anemia trait are less likely to die from infection with malaria. Other mutations of the hemoglobin genes also confer some resistance. That's why the hemoglobinopathies like sickle cell anemia and thalassemia are distributed throughout malaria endemic areas.
-Nick
Because malaria infection is not a survival disadvantage to the mosquito as it is in humans.
-Nick
1) You said organizations don't want to have EMTs question what they learned, and such questioning is disadvantageous.
In the anecdote, she didn't question her training (that statement about bringing the shit really is in BEC.) I not only questioned it, but realized this was beyond lame and well into google video range (had their been GV at the time.)
2) You said its better for EMTs to be confident in what they learned rather than keep their training perfectly up to date.
The problem is that confidence in what you do, if its the wrong thing, can wreak a lot of havoc. I'd rather be treated by the person who realizes what they are doing is fallible and is going to change and keeps up with any new updates like the ones I posted to that are over a year old, but which the other physician posting doesn't seem to have read... as a reasonable demonstration of my point.
Nick
Well of course.... if there is no bruising there is no rape right?
/ full/116/2/506
0 01703-200410000-00004.htm;jsessionid=F9lDHCpbb4hFW X0Kb2Px6RgNZh8zzlNR7gcpGP8QvpgVmz3TQ9vv!1570379021 !-949856144!8091!-1
Bowyer and Dalton "Female victims of rape and their genital injuries" BJOG: An International Journal of Obstetrics and Gynaecology 104 (5), 617-620. 1997. "Conclusion: The study shows that only a minority of women examined by specifically trained police doctors show evidence of genital injury. The absence of genital injury does not exclude rape."
And look, the American Academy of Pediatrics agrees with me that the hymen is an innapropriate indicator or abuse in girls: http://pediatrics.aappublications.org/cgi/content
Merritt "Vulvar and genital trauma in pediatric and adolescent gynecology." Current Opinion in Obstetrics & Gynecology. 16(5):371-381, October 2004. "Many recently published articles have noted that the history as given by the child or adolescent is the most important factor in determining the etiology of genital injuries as abuse or accidental. The history is more important than any documented or lack of documented findings on physical examination. Distinguishing whether the injury was accidental or caused by abuse is of significance to the family and the injured child or adolescent. Genital examinations of victims of documented abuse are often normal." http://www.co-obgyn.com/pt/re/coobgyn/abstract.00
But then c'mon, what the hell do academic Pediatricians and Gynecologists know of how to determine whether sexual abuse of children happened! We all know that you can tell if a girl is pure based on whether or not her hymen is intact, that all rape victims show physical signs (because if the bitch didn't struggle, it wasn't a rape, eh?), and that if a three year old says Daddy put his penis in my vagina that MUST have been coached by the mother who left the dad.
Mmmm-kay. That all sounds reasonable.
-Nick
The AHA's current guidelines page is here. A good quick summary for recent changes is the 'Summary of Changes' document which covers the changes from community to skilled provider CPR. http://www.heart.org/presenter.jhtml?identifier=30 35517
p l/
When big changes in the AHA guidelines happen, they are usually published in a special edition of Circulation. That has the details ad nauseum. http://circ.ahajournals.org/content/vol112/24_sup
Before I was an ER physician, I was an EMT. I didn't have as much clinical information as I do now, but I was able to think for myself. One particular event comes to mind... in the book Brady Emergency Care (the text for most EMT courses) it tells you that if possible, if the person has vomiting or diarrhea, you should try to transport the effluent to the hospital.
I was stuck working with another EMT who was (literally) a sorority girl who was a sophomore pre-med at UNC. We were up in the back woods of Orange County (20 miles and 50 years from Chapel Hill) and had a call at a house with no indoor plumbing. The teenage daughter had a bad stomach flu. Unfortunately without a toilet, the family facilities (in winter) was a 5 gallon plastic cement bucket on the back porch (filled about 2/3 full with excrement of various family members.) Ms Alpha Kappa Dumbass decides we must take the bucket of shit and piss to the ER. Arguing with her that A) their were multiple samples of people's shit in said bucket, B) the bucket would spill and smell on the 20 mile ride, and C) no ER nurse would ever let me live this down if I walked in with that bucket'o'turds.... were all quite meaningless in light of her photographic memory of Brady Emergency Care's dictum.
Ultimately I just gave up and told her I would drive, she could do what she wanted, but if that shit spilled SHE would clean it up.
The predictable thing happened, and by arrival at UNC Hospitals, we had a 1/3 full cement bucket which had been 2/3 full. Ms Alpha Kappa Dumbass (now smelling of shit to high heaven) marches in with the bucket and the stretcher. I was literally physically incapacitated and had to sit on the floor as the triage nurse had the most entertaining (yet incredibly short) conversation with this idiot.
The morals of this story are that 1) you are better off knowing why you are doing something than memorizing rote procedure and 2) someone who thinks things through rather than carrying 3 gallons of shit and piss to the ER is the one that gets to take an hour lunch break while the unit is 10-7 as the ignorant sorority chick gets to scrub shit out of the ambulance. Same thing with this argument. You are better off with a thinking EMT helping you who will be able to take basic concepts and expand them to fit the situation.
In addition teaching that a protocol that is at best evolving to be somewhat evidence based is infallible will make it a while lot harder to retrain people if they think they learned the absolute truth a decade ago.
-Nick
An intact hymen is sometimes found in sexually active women.
And lack of signs of trauma is no evidence that a sexual assault has occurred. Only about half of rape victims have visible evidence of trauma. Arguing that a lack of bruising (in an exam that may have occurred weeks after the incident) shows that he was innocent is up there with the argument that if a woman begs her rapist to use a condom that it obviously couldn't have been rape.
And its odd that if she was mommie dearest there was no evidence that he could muster against her? Plus that must be a damn smart three-year-old to be able to maintain that facade after evaluation by a trained forensic psychologist. In my experience kids aren't even good at maintaining a lie about how the bead got in their nose, much less whether daddy put his penis where.
He may say that, and you may want to believe your friend, but like I said before: every prison is filled with innocent men.
-Nick
Um, that would be the perspective of a physician who apparently hasn't read a recent AHA update or the articles in Circulation that discuss this in detail. Not to mention the other studies that caused the changes in the AHA guidelines which predate this one and were the basis for the AHA change. The emphasis is less on advanced airway management and more on compressions. The difference is in the detail with which its considered. In community CPR its dumbed down a fair deal, but even for critical care physicians the rules are changing.
-Nick
That is because the child's right to safety trumps the parents property rights to the child. The safest thing for the kid who is at immediate and high risk is to remove them to a place of certain safety until the courts figure out exactly what went on and who placed the kid in real danger. The default should not be that despite the fact that your child has obvious whip marks on his back, burns on his buttocks, malnourishment, and a festering infected wound on his foot that you should be able to take him out of my ER unless I can prove beyond the shadow of a doubt immediately in the ER that you are the one who has abused and neglected the kid. (And that was one of the cases in which I've taken immediate custody.)
If you kid arrives to my care in that condition, you'll take him home over my cold and dead body despite your concerns about being deprived your constitutional right to starve and beat the shit out of your property.
-Nick
First, while this one study was not an RCT, there are RCTs that give similar results in the same direction. This one was just the study that got press (likely because it was the first big one published after the AHA changed the CPR guidelines.) The data from the King County Washington group come to mind immediately, but there are other studies that show the same thing.
1 32621842912Winter2005.pdf
p pl/IV-51
Second, while airway is important in cardiac arrest, it is less emphasized according to the new AHA ACLS guidelines. For example, with the VF/pulselessVT/asystole/PEA algorithm, intubation of the trachea takes a lower priority. In the words of the mothership about treatment of pulseless arrest: "Insertion of an advanced airway may not be a high priority," from the AHA's 2005-6 update: http://www.americanheart.org/downloadable/heart/1
Or if you want the original article from Circulation: "Thus, during the first minutes of VF SCA the lone rescuer should attempt to limit interruptions in chest compressions for ventilation. The advanced provider must be careful to limit interruptions in chest compressions for attempts to insert an advanced airway or check the rhythm." http://circ.ahajournals.org/cgi/reprint/112/24_su
So even with in-hospital arrests, during the first few minutes which determine in large part whether a patient survives neurologically intact, being aggressive about securing the airway may be misguided. I think I am pretty facile with a laryngoscope, but it is still a good 20 seconds of interruption of compressions to intubate, more if its at all difficult. Those 20 seconds may make the difference, so intubating *after* ROSC may be a better option. If they don't have ROSC in 10 minutes, it is unlikely that intubation will help anyway.
Lastly, even if the absolute risk reduction was small, why not do the kind of CPR that gives you the slightly better outcome and exposes people to less risk of communicable disease? The couple of times I've done CPR au natural, it was just about the grossest thing I've ever had to do.
Nick
-Nick
As an rapidly ageing ER doctor who used to be an EMT, I find your confidence in the ACLS protocols to be kind of innocently cute. I hate to break it to you... but ACLS is one of the most arcane and poorly researched areas of critical care medicine. Very gradually over the past decade or so there has been a move to do real research (even though it is one of the hardest areas to do research since getting IRB approval for trial is pretty close to impossible.) But a lot of it is still 'seemed like a good idea at the time' kind of medicine.
So all that stuff in the neato little flow chart you have is only slightly more evidence based as the belief that ERs are busier on full moons or that uttering the Q-word will cause an influx of calls to 911.
And you think its bad now? Well I remember having to give Bretylium Tosylate for refractory VFib... and we *liked* it that way... we loved it... we couldn't get enough if it!
-Nick
Nope. Even trained paramedics, ER physicians and ER nurses do a shitty job of doing an adequate number of compressions if they interrupt to do ventilation.
I was an EMT before I became an ER physician so I have seen a lot of shitty CPR done by people who know better. Just being someone who does it frequently does not mean you do it well.
If my partner dropped dead in front of me now, I would give him the biggest MF prechordial thump I could muster (in hopes that he went into VF) call 911, then wail on his chest like a crazed weasel on crack. Hard and fast is the only thing that will save him. I would aim for at least two deep compressions per second. If he survives to have issues with a hemothorax or pulmonary contusion then I did good CPR.
If it got to 3-5 minutes and EMS had not arrived I would probably give a couple of breaths and probably once a minute thereafter. If it got to fifteen minutes and they had not arrived, I would let him go.
-Nick
I strongly doubt that there was no evidence against him that he would lose all visitation rights. That evidence might have not been a videotape of him abusing his kids, but you are not going to get a custody settlement that does not even allow supervised visits without a shred of evidence against one parent. Even in proven cases of abuse, supervised visits are almost always provided.
Of course that is the same kind of argument as "My cousin has this friend who was in this car accident and the cops told him that if he'd have been wearing his seatbelt and hadn't been thrown out of the car, he'd have died. So I don't wear no damn seatbelt." Its a convenient story to justify something that we'd like to be justified despite evidence to the contrary.
-Nick
First you make the incorrect assumption that if there were not mandated reporting laws that abusers would somehow feel safe going to the ER for care. Even if there were no such laws I would *still* report abuse and take emergency custody of children exactly as I do now. What mandated reporting laws do is say that EVERY health care provider must do the same. So lack of mandated reporting laws only makes it haphazard whether you will get busted. Plus such laws ensure providers that as long as they act in good faith they will be legally protected if they take the appropriate action.
Second, the police cannot arrest or even charge your example's boyfriend unless she is willing to bring charges. Mandatory reporting of DV in states that have it (not all do if the victim is not a child or other vulnerable person like dependent elders) simply means that the police come to the ER to see if the victim will press charges. If she loves that shitstain and he hasn't killed her yet or placed her in a coma, she can still keep him out of trouble.
However, if the victim is a child or dependent adult then the state (and in this case mandated reporters at their direction) must assume that if the victim were capable of making their own decisions they would choose to not remain in an abusive situation. For example, a 5 year old whose parents beat him with an electric cord is not able to make the decision whether or not he should stay with his abusers. His parents, by their treatment of the boy demonstrate they do not make decisions in the child's best interest. Therefore the state *should* step in to protect the child. Mandated reporting of abuse of minors and dependent adults allows the state to fulfill that responsibility.
-Nick
And if the reason that your kid got a broken arm or an intracerebral hemorrhage is that you beat the shit out of him, he should be able to get care. And I should be able to piss in a cup and force you to drink it after I and a couple of nurses take you in the back and beat the living crap out of you. But instead we just call CPS and take your kid into custody. In comparison, I think that's pretty benign.
Though the evidence suggests that most kids (and adult domestic violence victims) who are ultimately killed due to abuse have had an encounter with a medical professional in the past month.
Its not that abusers don't bring in their victims, its that no one makes the connection between injuries and the cause. Hence MR laws.
-Nick
Well, I'm going to double-reverse-counter-counter-sue you.
And besides, I read a counterfeit Esperanto version of her book that I* downloaded from whacknut-manifesto.com. I never click through that kind of stuff.
-Nick
*By 'I' I mean, me Jeff Douchebag, the guy who stole NickGorton's laptop and is posting this before I surreptitiously return it without him ever noticing.
-Jeff
I can see why she wouldn't want to get indexed. She's basically providing information for people trying to resist intervention from child protective services. She suggests taking your children and hiding them out of state if CPS tries to contact you. She also suggests (and sells an ebook about) teaching your children to never talk to a social worker or answer questions... you know like 'does anyone ever hit you?' and 'what did you have to eat yesterday?' and 'do you have a doctor to go to when you are sick?'
Of course CPS and child abuse reporting in general is imperfect. I'm an ER physician which makes me a mandated reporter. This means if I simply suspect abuse or neglect, I am required by law to report it. The system is set up to favor false positives over false negatives. That means that CPS investigates many cases for every real abusive situation they find.
This is NOT a bad thing. There are 1500-2000 reported deaths from child abuse every year in the US. One in twenty kids in the US is physically abused in any given year and most of those victims are under age 6. Most of these cases of abuse never come to the attention of authorities because child abuse is woefully under-reported (which is why we have mandated reporter laws.)
Most of the instances of 'think of the children' posturing are conservative unthinking crap. However advocating outdated ideas of parental property rights over the rights of children to not be abused goes beyond simple whack-job well into the realm of pure evil.
Nick
...Avoid all drugs that are currently advertised on TV unless absolutely necessary.
They don't advertise drugs that are old and off patent; they advertise drugs from which they can make a boat-load of dough. So in general the new purple pill for whatever has only been on the market for a few years and thus has only had a few years of post-marketing surveillance which makes them inherently more dangerous.
When a drug comes to market it has usually been tested on only up to 10,000 people through phase 3 trials. After it gets to market, we do what is essentially a 'phase 4 trial' where a drug we think is safe (based on about 10K subjects) now gets tested on a million subjects. So if there is a rare but serious complication that occurs with the drug, often this will only become apparent after the drug is marketed. This is the reason that every so often we hear of new drug X being withdrawn from the market. (For example: Baycol, Vioxx, etc.)
Now, admittedly the hype over such post-marketing withdrawals is generally way overdone. The FDA is a bunch of hacks, the drug companies are poisoning us, and our doctors are part of a communist plot. Whatever.
What really happens is that a drug only tested on 10,000 people may very well kill 1:5,000 people who use it and we may not know that based on statistical vagaries of limited studies.
However, the point is that the newfangled drug that you saw on TV may have a cheaper, safer, and just as effective 20 year old cousin who has withstood 'phase 4 trials' and demonstrated its safety. Being new, fancy, flashy, advertised on TV, or even easier to use, doesn't make a drug better or safer any more than it does an OS.
Nick
When that happens, the particular doctor in question gets his ass sued into oblivion because of that behavior.
The problem is (almost never) nefarious intent or a willingness to sell out a patient's best interests for a plastic pancreas. The problem is more that drug detailing *works very well*. The drug company knows that if you see a plastic pancreas bearing the name XOLOCXA you will be more likely to think of XOLOCXA and prescribe it to your patients. They also know that the detail rep will be able to glom onto a little of your time because the social pressures inherent in accepting the pancreas of doom. Someone gives you a lunch, a plastic pancreas, and a USB drive that looks like a XOLOCXA tablet and well... you hafta talk to the (usually a sexy looking) woman for a little while. Duh. Of course during that 15 minutes you are subjected to a detailed description of the utility of XOLOCXA and get copies of the pharma-sponsored research that (shock and horror!) showed a positive outcome. (I actually read an article a while back that pharma recruits their drug reps from college cheerleading squads. Pretty sick.)
And that is the exact reason that the only thing I ever accept from a drug detail rep is drug samples. I don't even particularly like accepting that, but its a necessary evil for some of my patients. Even the availability of samples makes me more familiar with a certain set of drugs... so it is easier for me to rx because I know more about it.
Nick
Dude, you are high on something that you must share with the rest of us. I'm an ER physician and I also volunteer at a clinic 2 days a week seeing those who are 'low income and freeloader types' as you so eloquently put it. However the vast majority of my patients at clinic are not qualified for any public medical assistance. You generally have to be either disabled or have dependent children (in some states) to have medicaid benefits. The big losers in the US are the working poor... they may make $20-30k/year working but have no insurance because their jobs do not offer it and they make too little to afford it themselves. Nick
That is the whole point of disability accommodation. You need to actually go to a certain amount of cost and inconvenience to make society accessible for everyone.
Does it cost a lot to make buildings accessible to people in wheelchairs? Yes. Could you get around it by just having the wheelchair-ambulating person ask for a lift up when he got to a place with stairs? Yes. Would it be wrong to expect this person to be limited in this way despite the fact that it otherwise causes a significantly greater cost to fit public buildings with ramps? Also yes.
Part of the reason that we as a society accept that more must be done to make those with disabilities more fully able to independently act is precisely because of the effects that dependence produces. And that goal of greater independence is valuable enough that it merits our effort and cost.
Moreover, I for one am sick of being the country that is always last to adopt international standards. The lack of metric standard units in the US is embarrassing enough. Can we PLEASE not drag our knuckles on this one too? Someday I'd eventually like to travel to the EU without having to wear a tasteful maple leaf ensemble.
You could do this before the internet. It simply had to be done with print rather than with a blog entry. Unidentified sources have been around since there were clay tablets and journalists have been protecting them for just as long. Of course when its the Pentagon Papers that's different...
I ask and BF says 'no detergent! what are you crazy?' That he can say that with a straight face while advocating putting a toaster in a dishwasher really amazes me.
Probably. My boyfriend taught me this trick: nasty, disgusting appliance or electronics? Wash it in the dishwasher, let dry a week, then re-use spanking clean item. I thought he was trying to kill me when I found our toaster in the diswasher. But that was 7 years ago, and I'm not dead. Yet.
Unfortunately its not only Lamo, but any close relatives who will be influenced by his inclusion in the DNA database. As was published this month in the journal Science, it is possible to identify the DNA of 'close matches' to crime scene DNA if a criminal's relatives' DNA was in the database. With this evidence in hand it is pretty simple to then get a warrant for a suspect's DNA. The question then arises, who is most likely to have relatives in any criminal database? Well, the poor and disenfranchised for one. Racial minorities for another. About one in six black men is in the US criminal justice system in his lifetime. That compares with about 1/35 in the overall US population. So if you are a black person who commits a crime, it would be statistically more likely that a close relative would be included in a DNA database than it would be for a white person. So while it seems like there is nothing wrong with establishing a database if it is only used to find 'the bad guys', that view ignores the fact that this would result in disproportionately detecting people based on race as well as other socioeconomic determinants of kinship that are pertinent but not as easy to use in my example. ;) In a moral system, justice should be meted out equally at all stages of the game - which is why we have laws against racial profiling.
Nick