Ep81 - Treatment of Atrial Fib with RVR
Download MP3So I hear you have this crazy idea that paramedics should be treating patients with AFib RVR in the field. That's nonsense. What makes you think this?
Christine O'Neil:Well, we were able to look at a ESO data set and determine that patients spend less time in the hospital because they get discharged from the ER more frequently instead of being admitted, and they have a lower mortality rate. So if you think that's crazy, then, yeah, I guess it is.
Jeff Jarvis:Wow. Maybe I have to reconsider this.
Ginger Locke:What is a lighthouse? It is a tower with a bright light at the top, located in an important or dangerous place. The main purpose of a lighthouse is to serve as a navigational aid and to warn of dangerous areas. Welcome to the EMS Lighthouse Project podcast. Illuminating the darkness of current EMS clinical practice with the bright light of science.
Ginger Locke:Here's your host, doctor Jeff Jarvis.
Jeff Jarvis:Howdy, y'all. I'm doctor Jeff Jarvis. Welcome back to another episode of the MS Lighthouse Project podcast where we Mikey, what do we do here? Well,
Mike Verkest:we shine the bright light of science on the darkness of EMS clinical practice too.
Jeff Jarvis:We do shine that bright light on the darkness of clinical practice, and I'll tell you what, I have not talked about where that tagline came from in a long time. So I figure I should do it. Let's do it. We just we are sitting here live in, Ashland, Oregon Indeed. At the State of Jefferson Conference.
Jeff Jarvis:Wonderful conference. If you've never been, you need to. It's an amazing conference. Wonderful people. Beautiful area.
Jeff Jarvis:Yeah. Well, we gave, we I was along for the Mike Key show and we talked about podcasting. Yeah. And, I hadn't told the story about where the name of the podcast came from in a long time, and it came from, us drinking bourbon. Cheers, my friend.
Jeff Jarvis:Cheersies. And, after a few of them, I got inspired by my favorite author, Carl Sagan. He wrote
Mike Verkest:a book
Jeff Jarvis:called The Demon Haunted World, because of that book, I and the Bourbon decided that maybe the mission of the podcast to be to shine the bright light of science on the darkness of modern clinical practice.
Mike Verkest:I love it.
Jeff Jarvis:Mikey, do you know an area of science that is really, really dark right now?
Mike Verkest:I mean, there's a lot. But if I had to guess, I would say it's probably the treatment of AFib.
Jeff Jarvis:My god. Would you really? Yeah.
Mike Verkest:I mean, it's it's pretty it's pretty controversial in the industry right now. Wow. Like, what do you do? Like, do you shock them? Do you give them medication?
Mike Verkest:Do you send them home? Do you I I don't know. It's it would be great if there were some research on that topic.
Jeff Jarvis:Wow. That is an amazing segue. It's an amazing coincidence too because I just happen to have a paper here that I wanna talk about.
Mike Verkest:It's perfect.
Jeff Jarvis:Yeah. Well, let's let's jump into it, shall we? I'm ready. You know, we started this episode off with a with a, it was kind of a fun little thing with Christy O'Neil, where she was talking about why the treatment of AFIBRVR, rapid ventricular response in the field is important. Yeah.
Jeff Jarvis:And what we said, for those of you who can't see it, I asked her in jest, why should we give a damn about patients with Afib RVR? We can just take them to the hospital, and they'll do fine. And her answer was great. You will see there. It said, well, if you don't care about ED length of stay, if you don't care about mortality, if you don't care about rate control, then sure.
Jeff Jarvis:Drive them to the hospital. Well, she was a member of a research group at a research forum, the pre hospital care research forum.
Mike Verkest:I've heard of that before.
Jeff Jarvis:PCRS, amazing group. And the, you know, PCRF. ESO teams up with PCRF. We just where I shot that video of her was at a PCRF in Salt Lake City. Gorgeous.
Jeff Jarvis:Me and Dave Wampler stayed over an extra day, went and skied.
Mike Verkest:Oh, yeah. That's right. I saw the pictures.
Jeff Jarvis:Oh my god. Hennen I'm glad you didn't break anything. It was the first time I've ever skied in Utah. There was powder. I'm a skier that skis in mostly hard packed snow.
Jeff Jarvis:I didn't know what the hell to do when I hit powder. It was, it was kind of fun. Well, Christy was there, we were at this PCRF and I remembered and I said, you know, you did a project at PCRF where y'all came up with this concept. You took the data. You worked with a statistician.
Jeff Jarvis:You answered a clinical question. And by the time that or the episode. By the time that session was over, y'all had an abstract. Well, they actually did the next step. They did the hard work to turn it into a manuscript.
Jeff Jarvis:Awesome. It got published in PEC at the end of last year, and it is a truly amazing paper. So let's talk about it a little bit. Okay. The name of the paper is if I can read it here.
Jeff Jarvis:Here we go. Prehospital intervention improves outcomes for patients presenting an atrial fibrillation with rapid ventricular response. The lead author is, Christy O'Neil was on there, Dowerker, Wanta, Lewis, and our buddy, Lawrence Brown. Lawrence Brown was the statistician who helped to them at the PCRF. And, boy, when I'm reading this paper, I can see, Lawrence droppings all over it.
Jeff Jarvis:This is a really, really well done paper. It's a well written paper. It's easy to follow, and they looked at this, and they said, what are the criticisms we're going to get? And they addressed them upfront. It was it was wonderful.
Jeff Jarvis:I love that. This was published in pre hospital emergency care, as I mentioned, 2023. It is still you know, you get these things off the press, which means that it's great you get the evidence early, but it really jacks with your citations.
Mike Verkest:So I
Jeff Jarvis:don't have the full citation. I'll drop it in on the YouTube video. Here is let's run through the the PICO question, shall we? So this was a study that used the 2021 ESO research dataset, and they use this thing called propensity matching.
Mike Verkest:I've heard that term.
Jeff Jarvis:Now, a few episodes ago, I might have been discussing a bad use of propensity matching. How it was used in the head up CPR papers. Yeah. Incidentally, the editorial that I was working on has now published. My co authors and I so I wanna give a shout out to doctor Michael Sayer, doctor Remley Crow, doctor Jim Menningazi, and doctor Henry Wang.
Jeff Jarvis:We worked on this editorial to really say why we don't think it's ready yet, and their use of propensity matching, we feel was inappropriate to answer the question. And the reason it was inappropriate is they took one data set collected at a different time in a different place for a different reason, and then tried to compare that to another data set 10 years later
Mike Verkest:I see.
Jeff Jarvis:For a whole different thing to try to control and figure out what the implications of an intervention that all patients in one dataset got no patients in another dataset got. So I don't feel like that was an appropriate use of propensity matching. So in brief, propensity matching is where you basically say, there are differences in the patients who got treated and didn't get treated. So we'll talk about it in this case, in atrial fibrillation. They took the ESO data set and they broke it into 2 groups, those who got an intervention and those who did not.
Jeff Jarvis:Yeah. Mikey, you probably see a lot of patients with AFib.
Mike Verkest:Well, back in the day, I did. For sure.
Jeff Jarvis:You did. Yeah. Did you give all of them treatment?
Mike Verkest:No. In fact No. We really I mean, unless there was, you know, the classic, you know, blood pressure issues, altered mental stat I mean, we didn't we didn't do anything.
Jeff Jarvis:Unstable. Yeah.
Mike Verkest:We had no That's all you did. Yeah. We had unstable. No stable treatment.
Jeff Jarvis:Nope. Alright. That's So but you cardioverted some patients Mhmm. And not others. Yep.
Jeff Jarvis:So you could say there was a fundamental difference in the patients who got treatment and those who didn't. Yeah. So you might have seen, say, a 65 year old female, long standing history of AFib on anticoagulation who went and she forgot her beta blockers. Yep. She's in AFib.
Jeff Jarvis:Her heart rate's 150. Her blood pressure is 50. And you're like, sorry. Ride the lightning. Yep.
Jeff Jarvis:And zapper. Yep. But you might see another patient with Afib RVR, also heart rate of 150, but their blood pressure is say 120, you don't zap them.
Mike Verkest:That's correct, sir.
Jeff Jarvis:Fundamental difference between the two groups. So propensity matching, like logistic regression, is another way of trying to control for confounding variables. That is something that impacts the outcome of a patient other than what you're trying to study. Okay. So propensity matching, in this case, took those patients with afib RVR that got treatment and let's say patient number 1 is a 62 year old female with a heart rate of such and such, no comorbid conditions.
Jeff Jarvis:The blood pressure is 120. They don't have all these other things and no other medication. And you took them to hospital x and you happen to give them diltiazem. K. Well, they will match that to another patient that's 65 years old with a long standing history of AFib, RBR, on anti whatever.
Jeff Jarvis:Everything, including the the hospital they went to is the same, except they did not get Get
Mike Verkest:the intervention.
Jeff Jarvis:So in order to do that, let's say you have 300 patients that get the intervention, you need a much bigger sample size over here to draw from. K. Fortunately, the majority of patients with Afib RBR don't get treatment. So they were able to do that. So that's that one to one matching.
Jeff Jarvis:They use the exact same data set. Therefore, it's an appropriate use of this. Still not a randomized control trial, but it's it's pretty good.
Mike Verkest:Funny enough, we actually looked at our our, afib RVRs in our system. This was probably 2013. Just because we because we were trying to figure out, do we need to add a medication to the box?
Jeff Jarvis:Yeah. Treat it. Yeah.
Mike Verkest:So what we found was there were and I'm gonna make this number up, but it'll it's it the ratios is gonna be the same, that we had 3,000 patients
Jeff Jarvis:Okay.
Mike Verkest:Over 4 years, and exactly 0 of them went code 3 to the hospital, or had an otherwise life saving intervention performed on them. There were a few that got cardioverted.
Jeff Jarvis:Okay.
Mike Verkest:But a majority of them just went to the hospital.
Jeff Jarvis:Now, that's not surprising to me since you said you did not have the ability to do anything other than cardio.
Mike Verkest:So we were looking at where they transported lights and sirens back to the hospital because they were so
Jeff Jarvis:unstable. Oh, okay. Mhmm. So Yeah. So assuming that you are not indiscriminately using lights and sirens, which is bad.
Mike Verkest:Yes. Which is why? 100% sure happens. Do you think?
Jeff Jarvis:I think this is a confounding variable. I think this is a great great concept here, but the only reason you're going to go lights and sirens to the hospital is they're really sick. And the indication for going zapped is they're really sick. So why would we be surprised that we don't go lights and sirens to the hospital very often for patients we don't go zapped on?
Mike Verkest:Well, you know, even patients that get zapped and that are doing better still end up going code 3 to the hospital because we just did this thing. Oh my god. Yeah. What if we gotta do it again? I don't you know, I mean, it was a different time.
Mike Verkest:It was 10 years ago.
Jeff Jarvis:Yeah.
Mike Verkest:At least. But, anyway, I just thought it was an interesting
Jeff Jarvis:license arms for the hospital on a patient you had already successfully intubated?
Mike Verkest:Well, of course.
Jeff Jarvis:Because they're sick. Right? Let's just overlook the fact that you've already taken care of their time critical emergency. You've managed their airway. Guess what?
Jeff Jarvis:Emergency's over. No more emergency. Yeah. Take your time. Be careful.
Mike Verkest:Yeah. We're getting off track. But, yes, same idea.
Jeff Jarvis:Oh, it's a you know I love this topic. Right?
Mike Verkest:Yeah.
Jeff Jarvis:Alright. So that's their methods. ESO 2021 research data set. Those patients who got it didn't get it. They use propensity matching.
Jeff Jarvis:Their population, let's do the PICO question. Mhmm. These are adults with an initial rhythm initial rhythm of atrial fibrillation, and they had a a heart rate of greater than or equal to 110. K. Where did they
Mike Verkest:find 110. Where did they find 110? I mean, I've sat I've I mean, I I know I've sat in these, but Oh, I'm sorry. You mean,
Jeff Jarvis:why not 109?
Mike Verkest:Yeah. Why not 117 or 26 or 170 or whatever.
Jeff Jarvis:Interestingly, they referenced some AFib guidelines, which I didn't know about. I will tell you, if I see a patient in the ER with a heart rate above 110, I'm gonna treat it. Now I'm assuming that they came to the ER for a reason. In other words, they're symptomatic. If you're at home with AFib, you always have AFib and your heart rate jumps up to 1 to I don't know.
Jeff Jarvis:You just get up and Yeah. Move around. Mhmm. Watch it for a little bit. If it goes down, leave it alone.
Mike Verkest:Yeah.
Jeff Jarvis:But apparently, that's in guidelines. Okay. Well, I
Mike Verkest:was just curious.
Jeff Jarvis:It it is interesting because if you're gonna write a protocol for the treatment of RBR, maybe you would use a a higher number. Right? Yeah. So maybe if they used 150 instead of 110, the results might have been different.
Mike Verkest:A 100%.
Jeff Jarvis:They did a sensitivity analysis using 150 just to be clear because, you know, doctor Brown, smart guy. These are all smart folks. This is one of the reasons I really like this paper, a lot of, different analyses. So, you had to be an adult greater than 18, you had to have your first ECG was afib. Okay.
Jeff Jarvis:Not a first ECG of sinus and then Afib, because that clouds the picture. Really? Was it really Afib then? Yeah. Yeah.
Jeff Jarvis:Heart rate greater than 110, Transport unit only. So the reason they did that is we don't wanna double dip.
Mike Verkest:Oh, okay.
Jeff Jarvis:So it was a Sure. Per encounter data set just like nemesis. So you could have multiple records. Didn't wanna do that. Now they also addressed one of the big problems.
Jeff Jarvis:When I took over the system in Fort Worth, what I learned is my predecessor had removed diltiazem for the treatment of afibr br and I asked why. And they said, well, you know, we were misdiagnosing patients. We were treating an awful lot of sepsis that really had sinus tachy and they just needed fluids. Yeah. Or they had AFib RVR, but their underlying problem was sepsis, and you gave them dilt and started a monodil drip.
Jeff Jarvis:And then
Mike Verkest:they crashed, and they died. Right. Whatever. Yeah.
Jeff Jarvis:In this paper, they excluded trauma, hyperthermia, so fever, hypothermia. I'm not entirely sure why, but they did. I mean, I'm not questioning it. I just don't associate AFIBRVR with hypothermia, but maybe they had a reason. They also excluded sepsis.
Jeff Jarvis:And then if there was an out of hospital cardiac arrest prior to arrival. So if AFib was your posterosced rhythm, that is just give that shit time and it'll probably settle out. So different thing. So that's the population. Their intervention was you did rate control.
Jeff Jarvis:Their control is you did not do rate control. K. Easy. And here are your outcomes. Number one outcome is ED disposition was home.
Jeff Jarvis:So did you get admitted or did you get sent home? Okay. And for the purposes of dispo home, if you came if your home was a nursing home Oh. So if you came from a SNF and went back to the SNF, they counted that as discharge
Mike Verkest:home, which
Jeff Jarvis:is Fair enough. Probably reasonable. Mhmm. Secondary outcomes were EMS rate control. You were above 110.
Jeff Jarvis:Did you get a low? I hear you. I think they used 110. I'm trying to remember. They measured length of stay for those patients that had HDE outcomes.
Jeff Jarvis:Remember, we're dealing with the ESO dataset, something you're very familiar with. Indeed. ESO has, I think, probably the largest health data exchange. We have more outcomes with ESO. I think we're up to like 20%.
Mike Verkest:Yeah. It's it's a lot.
Jeff Jarvis:Great data set. So you can get ED dispo, you can get rate control, you can get adverse events, but you need the HDE. Actually, you do need the HDE for dispo home, as well as length of stay. And then check this shit out, Mikey. They looked at hospital mortality.
Jeff Jarvis:But did you die? Yeah. Great question. They looked at that. And then, you know, the big reason not to treat is you're worried about creating a bunch of hypertension.
Jeff Jarvis:Right? I think you were just asking me. Somebody was asking me earlier, hey, what about these new heart association guidelines? Oh, it's Peter Hasse.
Mike Verkest:Yeah. Because you
Jeff Jarvis:know, we are in Oregon. Indeed. Peter and Amber are here.
Mike Verkest:Yep.
Jeff Jarvis:Howdy, Peter and Amber. So, they said the these guidelines say, don't treat with diltiazem in the field because you don't know if they could have a low EF. Cardiologist really, really, really worry about this. And I think they're, I I don't know. I need to bring one on and talk about it.
Jeff Jarvis:Yeah. But I think they're extrapolating the experience of don't put patients with a low EF on oral calcium channel blockers, put them on a beta blocker instead. And I think they're extrapolating to don't try to achieve rate control with an IV medication.
Mike Verkest:Okay.
Jeff Jarvis:That that's my guess. I I'm not a cardiologist. I should probably ask one before I say something. Fair enough. So that's what they looked at.
Jeff Jarvis:Now, as I get into the results of this, what they found, I wanna go a little bit over, some parts of the paper. I wanna start with their consort. They have this beautiful consort diagram, and, they talk about a consort diagram is just a flow of patients. They started off total ESO data set of 911 calls with a ground transporting unit, 5,100,000
Mike Verkest:I was gonna say it was gonna be in the 1,000,000.
Jeff Jarvis:Big ass data set. Right? Now the majority of patients don't have AFib in this case, 5,000,000 didn't. Okay. Get rid of those.
Jeff Jarvis:Now we're dealing with documented AFib, 156,000. K. Now we're going to exclude 21,000 either because of age. They excluded age of the trauma. Yep.
Jeff Jarvis:Couple reasons to exclude over 100. One is that there aren't many patients that are older than a 100, and because of that, if you give their age and you include them, it becomes identifiable.
Mike Verkest:Oh, okay.
Jeff Jarvis:Also, it's if they're a 150, I think the oldest patient I've seen in the data set was, like, 280 years old.
Mike Verkest:Oh, yeah.
Jeff Jarvis:It That name was not Lazarus. Yeah. It was fat fingers.
Mike Verkest:Yep. Fat fingers.
Jeff Jarvis:So they excluded those. Young ones, they excluded. Cardiac arrest, they excluded. So you can kind of see where they got those. They ended up with a 135,000.
Jeff Jarvis:K. And then they said, well, ultimately, you had a couple more. You had to exclude another 96,000 because, well, they weren't an RVR. They ended up with 39,000, and those were broken up. 33,000 of those had no intervention.
Jeff Jarvis:49100 did. K. Well, that's alright. Yeah. That sounds like a good Yeah.
Jeff Jarvis:That's a pretty good propensity match. For sure. So they ran through these. I'd like to read I'm just gonna read verbatim. Alright.
Jeff Jarvis:I'm gonna put it up on the screen here. I very rarely read something, but I wanna read this because I think this section and I'll skip ahead a little bit because my slides are out of order. Note to self, I should change that. This just talks about why you should treat afib. Let's just say that the results of the study were positive.
Jeff Jarvis:Okay? This gives the most concise reason for propensity matching that I've come up with. I think they said it much better, and boy do I smell Lawrence here, than I did in all of my whining about head of CPR. Administration of prehospital AFIBRVR interventions is not random. The decision to provide an intervention may be driven by both nonclinical and clinical factors.
Jeff Jarvis:Whether and which AFib RVR interventions are available varies by EMS system. Further intervention will not be indicated and may specifically be contraindicated in some patients with Afib RBR. Thus, therefore, one concern is that untreated patients may be systematically different. Systematically different, Mikey. Systematically different, either more seriously ill or maybe less seriously ill than the patients that were treated.
Jeff Jarvis:We therefore use propensity score matching to minimize confounding due to such differences. Propensity score matching minimizes bias by selecting only untreated patients who are demographically and clinically similar to corresponding treated patients. Thus approximating the conditions of random allocation.
Mike Verkest:I love that.
Jeff Jarvis:They said that very very well. Yeah. First off, they said approximating random allocation. They didn't say we don't ever need to do a randomized control trial again. Just to to point that out.
Jeff Jarvis:Alright. You wanna you wanna maybe talk about some results?
Mike Verkest:Let's find out what they found out.
Jeff Jarvis:Let's get into it. They actually use something called an average treatment effect among the treated in ATET.
Mike Verkest:Oh my gosh.
Jeff Jarvis:That's different than the big gangly thing in Star Wars.
Mike Verkest:Yeah. We have ATAT.
Jeff Jarvis:Yeah. ATAT. T. I'm a Star Trek guy, so I don't know if it's is it a t or.
Mike Verkest:It is. It is. Well, either way. Okay.
Jeff Jarvis:Yeah. I think people will say at at Yeah. Because it's kinda weird. Yeah. Alright.
Jeff Jarvis:So they used that. Now, in a this type of allocation, and I'm not a statistically significantly large enough nerd to tell you which populations the ATET does this in. Thank goodness. But in this one, it approximates a risk difference. So we're just gonna talk about a risk difference.
Jeff Jarvis:The risk difference here is the difference in risk between treated and treated controlled for all of the things, and they controlled for lots and lots of stuff. Alright. Let's start off with EMS rate control. Among those who are not treated, only 18% had rate control. Well, not shocking.
Jeff Jarvis:Right? It just happened to happen. 41% of those who treated were treated got rate control. That is a statistically significant, adjusted risk difference or a t e t 23% difference. The other thing they did is they gave a number needed to treat.
Mike Verkest:Okay. Good.
Jeff Jarvis:Love me some number needed to treat. Number needed to treat means how many patients with AFib RBR do you need to give the treatment to to get one additional outcome? And in this case, it's right control. That number is 5. That's pretty good.
Jeff Jarvis:That's damn good.
Mike Verkest:Like, that's good. I think AEDs, we talked about this before, is like 1 or 2?
Jeff Jarvis:AEDs or 4.
Mike Verkest:Okay.
Jeff Jarvis:I mean,
Mike Verkest:that's Yeah. So 5,
Jeff Jarvis:that's that's pretty good. Mikey, do you give aspirin? You'll you'll hopped on a truck tomorrow. Yeah. You have a patient with a stimmy, you're gonna give him aspirin?
Mike Verkest:You bet you.
Jeff Jarvis:Do you know you have to treat 46 patients? Oh, 47 patients, I'm sorry, with aspirin to prevent one additional death among patients having a STEMI.
Mike Verkest:That seems kind of odd.
Jeff Jarvis:At 47, that seems pretty high. Number needed to treat. However, we give the shit out of that. Yeah. Yeah.
Jeff Jarvis:Because the number of 47 is actually pretty good. 5 is just way better. Yeah. Alright. Discharged home from the emergency department, 34% versus 38%, significant.
Jeff Jarvis:Mhmm. Number needed to treat, 26. K.
Mike Verkest:Still looking good.
Jeff Jarvis:I'm liking it. Yeah. Length of stay, not significant. Length of stay in the ED and the emergency depart, the ED and hospital. Excuse me.
Jeff Jarvis:I'll get that right. Not clinically seeing a bit. K?
Mike Verkest:How about hospital mortality? Curious about that one.
Jeff Jarvis:I mean, we're just treating the symptoms. Right? We're making them feel better. It's not really gonna save lives. Oh, my God.
Jeff Jarvis:Hospital mortality in the untreated 6.7%. In the treated is 4.3. Wow. Adjusted risk difference, 2 and a half percent lower. That is statistically significant.
Jeff Jarvis:Confidence interval range goes from 4.2% less to 0.8% less. Number needed to treat a 40.40. Wow. Which is less than 47 with aspirin. Yeah.
Jeff Jarvis:We're giving aspirin to all of our patients who might might be having a STEMI. This gives you a pretty good rationale for why to do it. I was not expecting this. I did not expect to see a mortality difference.
Mike Verkest:How about how about things like, hypotension and things like that? I I I would be curious about that. What's the incidence of that? Would you be curious? I am curious.
Mike Verkest:Curious. Mhmm.
Jeff Jarvis:Curious. Let me help your curiosity, Mike. Thank you. Our our our cardiologist say don't use diltiazem, and the and if they happen to have low EF, you can't give them dilt because why? Well, because you can drop their blood pressure.
Jeff Jarvis:Okay. Guess what? Those patients who got an intervention, remember this is not just diltiazem.
Mike Verkest:Yep. It's any intervention. Rate control. Rate control.
Jeff Jarvis:Yep. Or or rhythm control. Rhythm. Yep. Yep.
Jeff Jarvis:Hopefully, convert them. There was statistically significantly more hypertension in the treated group. Untreated was 7.2. In the treated, it was 9.8. 2.6 percent difference.
Jeff Jarvis:Okay. Here's the interesting thing. They then went in and said how much of that hypotension was transient and how much was not So
Mike Verkest:what was the duration?
Jeff Jarvis:None of it was non transient. And they define that by where they saw hypotensive at ED arrival, they were not.
Mike Verkest:Wow. Okay.
Jeff Jarvis:They gave them the thing, whatever the thing was, had a little bit of hypotension, a little bit more, 3% more, but it went away. Bradycardia, you gotta worry about bradycardia. Sure. No significant difference. Okay.
Jeff Jarvis:Why do we care about hypotension or bradycardia? Well, because they can combine and lead to badness. Yeah. And what's the ultimate badness? The cardiac arrest.
Jeff Jarvis:Cardiac arrest, no difference. Wild. That's that's impressive stuff. Now, I mentioned that they did some sensitivity analysis. So one was, well, maybe we only ought to be treating patients with a heart rate above 150.
Jeff Jarvis:And I'll I'll tell you, when I write my protocols Yeah. It ain't 110. Yeah. I I require it to be a little bit different. They ran it again at 150.
Jeff Jarvis:That improved rate control and compute better mortality still there. And that's what we like in a sensitivity analysis. You do the analysis in multiple different ways and you get the same result. That's good. They had the same result.
Jeff Jarvis:Now, in this case, they did see no difference in ED discharge. Still rate control and mortality. Now the other thing, Mikey, the other thing is that maybe they're just treating sinus tachycardia with diltiazem, with labetalol. Yeah. Low pressure.
Jeff Jarvis:Yeah. Whatever it is. And of course, there's no difference because they weren't in the damn rhythm to begin with. So which was the problem with my system. That's what we were really worried about.
Jeff Jarvis:Yeah. So they said, well, let's now look only at those patients that had HDE outcomes and had confirmed AFib, either in the ER or the hospital. Now we know they have AFib. Yeah. Now let's rerun it, same results.
Jeff Jarvis:No difference. No difference in adverse events, still lower mortality. So I'm liking this. Yeah. Heike, I'm thinking this is pretty good.
Jeff Jarvis:Sounds good. What's my bottom line here, buddy? I think if you treat AFib with anything compared to not treating, you have better rate control. Patients like that, that's good. You have fewer admissions.
Jeff Jarvis:You have better mortality. We don't like dead people. No. Fewer patients die, better mortality, no difference in meaningful adverse events. Yep.
Mike Verkest:I like that part. I
Jeff Jarvis:think that's a big thing, man.
Mike Verkest:Yeah. Yeah. Especially the adverse events part. I mean, that seems to be the, and we're down to about 2,000 people in here, by the way. Mhmm.
Mike Verkest:It's wild.
Jeff Jarvis:But I'll tell you, these 2,000 really care.
Mike Verkest:I I appreciate The 2 that are still here, they're just like hanging
Jeff Jarvis:in there. 1,000, you mean? Yeah. Yeah. Right.
Jeff Jarvis:Yeah. Yeah.
Mike Verkest:That's what I meant. Yeah.
Maia Dorsett:By the
Mike Verkest:way, you should go check out pocus stuff on YouTube. You know, you should.
Jeff Jarvis:Yeah. I hear that's a really good channel.
Mike Verkest:Up and
Jeff Jarvis:coming. Check it out, man.
Mike Verkest:Yep. It's good. Yeah. No. I mean, this it's clear that we should be doing something.
Mike Verkest:Right? And,
Jeff Jarvis:well, it's more clear now. It's it's absolutely more clear. Yeah. It it really is. It was it I moved up to Fort Worth Mhmm.
Jeff Jarvis:And it's always interesting to go from one place to another because the assumptions are different. I had a lot of assumptions in Wilco. Why do we do it? Well, because we've always done it.
Mike Verkest:Yeah. Why the
Jeff Jarvis:hell wouldn't you do it?
Mike Verkest:Mhmm.
Jeff Jarvis:And sometimes, it's really good to challenge those assumptions because maybe I've been doing things for a reason that just makes no damn sense whatsoever. Yeah. I don't know. Maybe giving epinephrine and cardiac arrest. Maybe it's the right thing.
Jeff Jarvis:Maybe it's not. I don't know. And you're not gonna know until you study it. Yep. They studied it.
Jeff Jarvis:This is a great question. Really, I would recommend you read this paper. Very well written. They go in and they really address all of the potential challenges. Now, again, this is a retrospective cohort study, it's not a randomized controlled trial.
Jeff Jarvis:Yeah. We really need to I would love to see this confirmed in a randomized controlled trial. Now again, their groups, any treatment versus no treatment. So you could say, well of course you're gonna see a benefit because the only treatment was electricity. And the only reason we give electricity is they're sick as snot And if they don't get it, they're not sick as snot.
Jeff Jarvis:There's no snot. Yeah. There's no sick. So of course, you're gonna see a benefit. 2% of these patients that got treatment got electricity.
Jeff Jarvis:Yeah. That's not what they were doing. The vast majority, 98% were with medications. The biggest class by far, wasn't even a class. It was just diltiazem.
Jeff Jarvis:That was the only calcium channel blocker. Beta blockers were another 5, 4%, whatever the difference between 2 and 87 is. So, 87.5 percent got diltiazem. Really, this is a study about diltiazem.
Mike Verkest:Yeah. Yeah.
Jeff Jarvis:And I think that is the key thing here. I think it's still open. They did any diltiazem. Doesn't matter how you gave it, they included it. I mean, you could have esmolol in here.
Jeff Jarvis:Sure. But I think this is really a study about diltiazem. How they gave it, I don't know. The system I took over in Fort Worth, they gave 0.25 milligrams per kilogram and then started an infusion. That's not the way I did it at Wilco.
Jeff Jarvis:I gave a little test or done, a little whiff of diltiazem at 10 milligrams, not because I thought that was gonna get rate control.
Mike Verkest:Was it a hypotension?
Jeff Jarvis:It was I wanted to see if it was gonna drop their blood pressure. If it didn't, then I would give them the real dose Yeah. At 0.25 milligrams per kilogram. If that didn't do it, well, that's alright. Go on to the hospital.
Jeff Jarvis:Yeah. I think we have evidence here that treatment of afib with RBR is something we need to be doing. I don't think we need to be afraid of hypertension, bradycardia, or cardiac arrest, because we just don't see anything other than transient, which just didn't I don't think something I care about clinically.
Mike Verkest:I mean, I think this is a great this is a great opportunity for the for the paramedics that are watching, and this is something we just talked about on the EMS show that we recorded a few minutes ago. So check out episode 30 2. 32. Yep. Which was doctor Jarvis
Jeff Jarvis:and I.
Mike Verkest:But, you know, this is a great
Jeff Jarvis:Just to be clear, episode 32 of what, Mike? The EMS show. Yep. Like anybody who listens to The Lighthouse would not know.
Mike Verkest:I know. Okay. But I just wanna make sure that gets here. But, I mean, this is a, this is one of those papers that you should read, take the notes from a podcast, and if you don't currently have something like this in your treatment protocols, this is a great opportunity to go and talk to your medical directors. Hey, you know, I mean, it's just it makes too much sense.
Mike Verkest:I mean, this is a great study. Yeah, it's just good.
Jeff Jarvis:So I'll tell you what, I see doctor Maya Dorsett here. Maya, we are at the State of Jefferson Conference. I need you to come over here.
Maia Dorsett:I said, I I
Jeff Jarvis:I I don't know what you said before I have here. Oh, that's even better. She's saying she doesn't know what we said, which makes this perfect. Maya, come come here. We are.
Jeff Jarvis:Yeah. Maia, you're you're Here. I'll let her
Mike Verkest:slide this in microphone. My spot right here.
Jeff Jarvis:Because she has a line she has to say.
Mike Verkest:Oh, that's right. You're up.
Maia Dorsett:Oh, you know
Jeff Jarvis:In honor Of course, you can. Yes, ma'am. Come come on. They they can hear you.
Maia Dorsett:Oh, no. There's video? Yes.
Jeff Jarvis:You look beautiful. Sit down.
Maia Dorsett:Yeah.
Jeff Jarvis:The 2,000 people, now 3,000 in the audience here are saying get your ass in the screen and get up to the mic.
Maia Dorsett:You look tall when I sit next to you.
Jeff Jarvis:Well, that's the first time anybody has ever told me I look tall. So, doctor Dorsett, first off, you were here
Maia Dorsett:doctor Sani?
Jeff Jarvis:I did not, but that's coming. So we recorded this video. It this is it's in a large room. It's much less creepy than the last one we did in my hotel room. Yeah.
Jeff Jarvis:That was weird. There is that. So we were recording an episode, and I think my favorite outtake of any EMS Lighthouse project was you. And Ritu was doing what Ritu does, which is bloviate. And what did you tell him?
Jeff Jarvis:What was what was your line? Come on. I want I want to get this again.
Maia Dorsett:Let him fucking talk for 2.
Jeff Jarvis:It was. It was it was act yes. Amazing clip. You gotta go watch that.
Maia Dorsett:Just like a fucking talk or 2.
Jeff Jarvis:Oh my god. But welcome back to the the EMS Lighthouse Project. So you are a medical director. You're a medical director in New York, which is not what it's one of the 49 lesser states, and y'all don't have delegated practice. You do have certain regulatory things that you have to deal with.
Jeff Jarvis:But do y'all treat afib RVR in the field, stable afib RVR?
Maia Dorsett:Yes.
Jeff Jarvis:What do you treat it with?
Maia Dorsett:We have two options. We have either metoprolol or diltiazem.
Jeff Jarvis:Interesting. Metoprol I IV?
Maia Dorsett:IV, metoprolol, or diltiazem. And, actually, under med control order, you can get amiodarone.
Jeff Jarvis:Let's say you did not give your protocols didn't allow for a fibr br, and you have a paramedic who comes in and says, listen doc, I think we need to treat this. So in general, when you have a medic that comes to you and says, we need to do x intervention, what's your response to them? How do you deal with that?
Maia Dorsett:So my response is, so I think it's one thing to say I have an individual medic and I wanna do x intervention. I'm interested in the evidence and on a system level, I'm gonna overall improve care for patients.
Jeff Jarvis:Okay.
Maia Dorsett:I think this is one's Right. So this is one site. So I Right. We definitely have metoprolol. We have diltiazem.
Maia Dorsett:But that's, I think, in a system that you have to be really careful how you roll this out. And if you say, okay. We have AFib with RBR. We treat this. Because in the same time, this is coming in when there's an entire body of evidence, right, that when you have afib with RBR, the first question you shouldn't ask is, you know, are they, like, symptomatic from the rate?
Maia Dorsett:You have to ask why. Afib with RBR has a differential diagnosis. And when it was studied in emergency medicine patients, about 15% of them were septic.
Jeff Jarvis:Yeah.
Maia Dorsett:And the other thing I tell my paramedic students is if I have AFib, I don't do sinus tach anymore. So, right, like so that is a tachycardic response to an underlying pathology. So I give people the tool in the tool box, but I don't want them to use it. I want them to be thoughtful about what is the differential diagnosis of why this patient is an afib with RVR. Is this hypovolemia?
Maia Dorsett:Is this sepsis? Is this APE? Is this Sure.
Mike Verkest:Like, a
Maia Dorsett:big paracart fusion? And once you've actually taken a good clinical history to say, I think the rhythm or the rate is the primary problem, not a response to an underlying problem, then I can go and treat it. Very rarely, when I have these patients in the ED is the first thing I give a rate control agent. Right? Like, I think about it.
Maia Dorsett:Sometimes they get some fluids because often it's sepsis. And then what I wish we would just add is they all carry magnesium. And actually, the data for magnesium and making these other medications is much more effective.
Jeff Jarvis:It might be that we finally found a use for magnesium.
Maia Dorsett:Oh, there's good There's data for magnesium in reactive airway disease.
Jeff Jarvis:It's not as good as I would have hoped.
Maia Dorsett:And eclampsia.
Jeff Jarvis:No doubt. No doubt. There is some.
Maia Dorsett:That would be the So if I had to say what would be the first med
Jeff Jarvis:Yeah.
Maia Dorsett:I'd want given because there is a reasonable data that the other medications is more effective. And if you think about the continuum of care, I'd actually add magnesium to the formula.
Jeff Jarvis:So your your thing here, what we're we have devolved now into not whether we treat Afib or not, but what to treat it with. So I would argue that there are probably this is a great concept on medical decision making. I would argue as an experienced emergency physician, you will walk into a room with a patient that shows up with palpitations. And by the time you walk out of that room, you're like, give them dilt or we're going to treat it. You don't necessarily wait for a lot of lab tests to prove it, but your history taking, your differential diagnosis pops up, and I was always treat, taught with Afib RBR that there's an eye in there somewhere.
Jeff Jarvis:You need to look for the eyes. So infection, infarction, infection, infarction, injury, insemination, oh, even intoxication. Yeah. We had to get pregnancy in there somewhere. It doesn't start with an eye, so insemination is close as we could get.
Jeff Jarvis:Yeah. Never heard of that.
Mike Verkest:Have you not
Jeff Jarvis:heard the infection, infarction, and
Maia Dorsett:I did not hear insemination with AFib with RVR. Never on my differential.
Jeff Jarvis:I will tell you I've never seen a patient who shows up with AFib RBR because they're pregnant. Just not happened to me, but, presumably, it happened.
Maia Dorsett:I have, but they had a massive PE.
Jeff Jarvis:Okay. Well, then I would god. There was another was it ischemia? It's a ischemia. How would you get an I for PE?
Jeff Jarvis:Inclaudication? That's like a Red Hot Chili Pepper song. That's not a a impasse. Impasse sounds pretty good to me. Like it can't impasse the clot.
Jeff Jarvis:So anyway, so your basic question here, to get back to the paper, when a medic comes to you and says, hey doc, I want to do this thing, your question is, well, what's the evidence? So, let's say you don't treat afib RVR with anything, regardless of how you treat it, and they bring you a paper that says, hey, this is an ESO study, we're dealing with 30,000 patients. Actually, I think the number is 4000, 5000. And it shows lower mortality in hospital with treatment. It shows that there is
Maia Dorsett:So, I'm gonna say what's the selection bias.
Jeff Jarvis:Well, what do you mean?
Maia Dorsett:So, in general, so if I Great.
Jeff Jarvis:So you're gonna question the study.
Maia Dorsett:Right. So Okay. Is there a selection bias? So, for example, I have
Jeff Jarvis:And to be fair, you know nothing about this study. So you are reading this study to begin with and you're asking these questions. These are the questions that you should ask.
Maia Dorsett:Yes. So, right, is there a difference? Just like when we talk about indication bias for airway management and cardiac arrest and retrospective data, I'm also interested in it's retrospective. This isn't randomized. So if a patient is presenting in severe sepsis with AFib with RBR, and I have a medic who's taken a good history and said, I'm not treating this with metoprolol.
Maia Dorsett:This is Those
Jeff Jarvis:were excluded. So they excluded I'll I'll click back to my things here.
Maia Dorsett:That's a question I'm gonna ask.
Jeff Jarvis:Absolutely. What's a good question? Alright. So they specifically excluded I am I am work with me or my it's a podcast. So trauma, fever, hypothermia, sepsis, and out of hospital cardiac arrest prior to arrival, Those were all things they excluded.
Maia Dorsett:Okay. So that is actually an important exclusion criteria.
Mike Verkest:Yeah. It
Maia Dorsett:is. Because this is retrospective data. So when I release some medication to say we're gonna treat this medication, right, into the wild, patients don't present with, I have palpitations and, by the way, I also have sepsis. Or I feel light headed and I have Afib with RBR and this is sepsis. I have to trust that somebody takes a good clinical history, considers that this is sepsis.
Maia Dorsett:So I think what what you're saying is
Jeff Jarvis:Is that any different than any other patient population?
Maia Dorsett:No. But this is one of the issues with saying I'm gonna take data from a retrospective study Okay. And change my protocols and release it.
Jeff Jarvis:Sure.
Maia Dorsett:Right? Because to me, like, the rub is not whether or not if a patient is symptomatic with Afib with RBR where that is the underline that is the issue. Right?
Jeff Jarvis:Right.
Maia Dorsett:The problem is due to the arrhythmia. Yeah. The the issue with the
Jeff Jarvis:Etobic tropic foci, not sepsis.
Maia Dorsett:Yes. Okay. But the the reality is, when you're taking care of undifferentiated patients, when I think about I think about the harm of potentially treating patients with the wrong treatment.
Jeff Jarvis:So let me say you are worried That's
Maia Dorsett:the diagnostic error of the why.
Jeff Jarvis:Okay. Fair point. So you're not worried about the patients they know have sepsis. You're worried about the patients that they don't know have sepsis. If they knew they had sepsis and sepsis is a contraindication to treatment, you're not worried about that.
Jeff Jarvis:You're worried about the unknowns. Right? Yes. Okay. Fair point.
Maia Dorsett:And I'm thinking about consideration of whether or not this is sepsis and the differential diagnosis and wanting like, there's so many things where people want to make the number normal. And it's not about making the number normal. It's about recognizing and treating the underlying pathology.
Jeff Jarvis:Fair fair point. So if you knew it was sepsis, they've excluded you from this trial. So you're not in there.
Maia Dorsett:Yes. But patients don't say I have sepsis.
Jeff Jarvis:You're right. But let's say, maybe you would see a difference in fever. Well, they excluded fever.
Maia Dorsett:What I'm actually interested in is what percentage of patients with Afib with RBR this include?
Jeff Jarvis:So say that quick let me pull the paper up. So
Maia Dorsett:who present with Afib with RBR, what percentage of them were included in this study?
Jeff Jarvis:100%. So in the ESR dataset so we're filtering it. Right?
Maia Dorsett:Yes.
Jeff Jarvis:And the way they filter this is they used the 2021 data set and they said well, Rimmley was not on this paper. Oh. Lawrence Brown was.
Maia Dorsett:Okay.
Jeff Jarvis:So what they did is they said in order here's the consort diagram. We already threw this up, and we already discussed it. So you had AFIB RBR. You're a transport unit. They said, well, we're going to exclude you if you're really old, not very old.
Jeff Jarvis:If you had cardiac arrest, trauma, fever, hypothermia, we're going to exclude those. They also excluded But prehospital
Maia Dorsett:data or ED diagnosis data?
Jeff Jarvis:Oh, you're asking about ED diagnosis. Hold that thought. This is all pre hospital. Okay. They ended up with a 135,000 that had afib, and then they a fib, and then they excluded those who didn't have RVR, and they used 110 as their cutoff.
Jeff Jarvis:Maybe 150 would have been better. They did a sensitivity analysis of 150. So they ended up with 39,000 patients with afib, broke those into those who had an intervention, 38,000, 5000, who I'm sorry, who did not have an intervention 5000
Maia Dorsett:So this doesn't actually answer my question. Because my answer is what proportion of patients with AFib with RBR. So everybody with AFib is a 156,000.
Jeff Jarvis:That's how many people had AFib RBR, which is the 30 8,000.
Maia Dorsett:But I wanna know what percentage of the excluded patients were actually
Jeff Jarvis:Well, you can see that. There are 20
Maia Dorsett:But those are not they don't necessarily have RBR. The ones they they excluded them before you determined if it's AFib with RBR. So the denominator
Jeff Jarvis:Yeah.
Maia Dorsett:Is the ones you're tempted to treat, which is you have Afib with RBR, and then what percentage, right? Because if the 20,000 who were excluded, right, it's very different proportions. Sure. If the 20,000 were excluded
Jeff Jarvis:It's not that different a proportion but
Maia Dorsett:it's But if 80%
Jeff Jarvis:of them were
Maia Dorsett:actually in RVR.
Jeff Jarvis:Okay. Well, you're right. We don't know because they excluded them. Fair point. Yeah.
Jeff Jarvis:Fair point. You sometimes you have to do your own damn study. When you read a paper, you're you're that person that stands up at the abstract and says, excuse me. I have a comment.
Maia Dorsett:No. Like, I right? Like, this is clearly this is a clearly well done study. But I think the question is, does the study answer Not
Jeff Jarvis:their question.
Maia Dorsett:Your question. Answer the question I want answered as a medical director when I say I'm gonna add something to the protocol.
Jeff Jarvis:Fair fair point. So This
Maia Dorsett:is like LASIK. Right? Like, the problem with LASIK is not is LASIK good for congestive heart failure? The problem with LASIK is we take care of undifferentiated respiratory distress.
Jeff Jarvis:Well, I can't just say we gotta go because, you know, she's kinda kicking my ass, and I I have to
Maia Dorsett:I know. Alright. I told your wife we're gonna have dinner at 7.
Jeff Jarvis:Which was 10 minutes ago. Very important. So, we're going to have to wrap it up. I was saved by Mikey. I appreciate that.
Jeff Jarvis:I think so is this sufficient evidence to say if you really hate Afib treating Afib RVR that this should change your mind? You might be like Doctor. Sarah, we talked about this earlier and he doesn't think dose VF is sufficient evidence to adopt and I don't want to jump into that debate, but he doesn't think one prematurely closed RCT is enough evidence. I respect that. We're all gonna have a different threshold.
Jeff Jarvis:For me, this helps us along the way. I don't think this is conclusive. It is clearly hypothesis generating, which is all you can do from a cohort study. I think they tried to address the limitations as best they could, an appropriate use of propensity matching as opposed to, say, 2 completely different data sets. And they showed a mortality benefit, something I was not expecting.
Maia Dorsett:And didn't expect that either. Yeah. And
Jeff Jarvis:no difference in they showed a difference in transient hypertension only. No difference in prolonged hypertension that they defined as were they hypertensive echo's to find out the and you won't be surprised to know they weren't doing echos to find out the EF.
Maia Dorsett:And they were still getting it. Yeah, they were still getting it.
Jeff Jarvis:87% of the interventions were diltiazem. 2% were cardioversions, the rest were beta blockers. I like the paper. I think it's a great paper. I think it adds to the data set much like all of the people saying, Jeff would you please shut up your ignorant slut.
Jeff Jarvis:So with that guys, thank you all very much for tuning in. Great paper. Christy, thank you for reminding me about this paper and I will see you all next time. Thanks so much. Take care y'all.
Jeff Jarvis:Doctor Doucette, thank you.
Ginger Locke:Alright. You've been listening to the EMS Lighthouse Project podcast, a proud member of the Flightbridge Ed podcast family and a FireDog production. Visitflightbridgeed.com for more information.
