 Archive for the ‘Medical Studies’ CategoryPress Ganey ArticleFriday, September 24th, 2010Remember that survey that we did last fall about Patient SatisFICTION? Two of the editors at EP Monthly finally used some of the survey results to create an article about Press Ganey. Interesting reading … 2+2=7? Seven things you may not know about Press Ganey Statistics Urine Toxicology PearlsSaturday, August 21st, 2010Drug seekers will love this post. EMedHome.com recently published a set of pearls about urine drug testing that included several things I wasn’t aware of. Did you know that …
Links to some of the cited articles are here, here, and here. By the way … if you came across this post in a web search on how to beat drug tests and now think you’ve got it made – don’t worry. There are plenty of other ways that doctors can tell whether or not you’re using drugs. I’m not giving away all of our secrets. Attack of the SuperbugsThursday, August 19th, 2010
Some doctors prescribe antibiotics for coughs and stuffy noses because the patients want them. If you’re one of those patients who think that antibiotics make your coughs go away, or clear up your stuffy noses, or somehow make your sinus headaches vanish, or if you’re a doctor who prescribes antibiotics for these symptoms, this post is for you. You’re killing people with your dumb demands and/or your inappropriate prescriptions. MRSA stands for methicillin resistant staphylococcus aureus. There is regular staph aureus – that bug is pretty much fading into the sunset and being replaced by staph aureus on steroids. Because so many people are requesting/using antibiotics for non-bacterial infections, the bacteria in their systems learn how to beat the antibiotics – in effect, making the antibiotics useless. For example, in our area, Levaquin is frequently prescribed by many doctors for obvious viral infections. Then, when people have a urinary tract infection, almost half of the strains of E. coli – the most common urinary tract pathogen – in our town are resistant to Levaquin and Cipro and all the other drugs in that family that would normally kick E. coli‘s butt. We have had several patients who had simple UTIs turn into serious systemic infections because they were initially treated with Cipro or Levaquin for their urinary tract infection and the antibiotics didn’t help. Now there’s a super duper bug that’s coming to a town near you. According to a recent article in Lancet Infectious Diseases, bacteria are now picking up a new gene called NDM-1 that makes the bacteria resistant to almost all antibiotics. Most of the bacterial with this gene were E. coli, but the gene can apparently can be relatively easily transferred to other bacteria. The only antibiotics that bacteria with this gene were sensitive to were tigecycline and colistin. Right now most of the isolates are in India and Pakistan, but it is only a matter of time before the super duper bugs have spread worldwide. A 2007 JAMA article showed that MRSA infections were abundant (.pdf file). An editorial accompanying the JAMA article noted that “The estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000).” In addition, the editorial noted that if the predicted number of MRSA deaths was accurate, the 18,650 MRSA-related deaths in 2005 “would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States.” Currently, a study by the CDC is claiming that the incidence of MRSA is declining (I wasn’t able to find the study on the CDC’s web site) by between 17 and 27 percent in the past few years. Even if MRSA goes away – which it won’t – there are still other resistant bacteria out there that are going to become a greater part of our lives. According to this San Fransisco Chronicle article, there’s “extremely drug-resistant tuberculosis” (XXDR TB). Doctors don’t even know how to treat this disease – or if they even can treat it. Less resistant TB can cost $100,000 per year to cure. Patients with XXDR TB will probably just die. The San Fransisco Chronicle article also notes that drug-resistant infections killed more than 65,000 people last year – more than prostate and breast cancer combined. In excess of 19,000 of the patients who died from drug-resistant infections had MRSA. So how do we stop the spread of resistant bacteria? It’s actually pretty simple. 1. Patients need to stop requesting antibiotics for nasal congestion, coughs, bronchitis, and “sinus infections.” Doctors need to stop prescribing antibiotics for these diseases. Norway nearly eradicated MRSA just by restricting antibiotic use. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better.” The slogan on a packet of tissues in Norway says “Penicillin is not a cough medicine.” See another article on Norway’s approach to antibiotic resistance here. 2. Wash your hands. Patients, doctors, everybody. Wash … your … hands. One friend wrote me and asked whether or not you’ll be viewed as a “trouble patient” if you request that your doctor wash his or her hands after entering your room. My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator. If, on the other hand, you tell them “wash your hands you filthy friggin barnyard animal”, you’re asking for a loogie down your back when you’re not looking. The video below kind of sums up the whole handwashing idea. I don’t watch TV, but apparently the green on the woman’s hands ends up killing her in the next episode.
Thanks to SeaSpray and to GrumpyRN for the ideas for this post. Wash … your … hands Sending Home the LOL who DFOThursday, July 29th, 2010
Anyway, the study looked at what factors were likely to be present in patients who passed out and who had a “serious outcome” or death in the following month. Serious outcomes or death occurred in 7% of all patients who passed out in this study. They found that positive fecal occult blood, low hemoglobin levels, low oxygen saturation, and Q waves on the EKG were all predictive of worse prognosis for patients with syncope. In addition, a BNP (brain natriuretic peptide) level greater than 300 was present in 36% of syncopal patients who later suffered serious cardiovascular events and in 89% of syncopal patients who later died. More than 98% of patients who had none of these risk factors also had no serious outcome or death in the subsequent month after their syncopal event. So check the BNP on syncope patients and get out those rubber gloves, ladies and gents. Add syncope to the list of patient complaints for which rectal exams may be indicated. After all this, if you’re still wondering what “LOL who DFO” means, then you have to read this religious post. Regulating RadiationMonday, June 28th, 2010
The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bells Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan. She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians. It appears that the case cited may be this one. More information here. The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80. The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%. The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation? Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it. In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism? Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get as much radiation” be a sufficient defense in a medical malpractice trial? The suggestions are good, but they don’t apply to clinical practice. In addition, while the FDA does regulate “radiation-emitting electronic products” including diagnostic x-ray equipment, telling patients how many diagnostic radiographic studies they may “safely” obtain is likely an area of mission creep for the agency – akin to regulating how many hours of television people may watch in a day (yes, television receivers emit radiation) or how many hours George Hamilton may spend under his radiation-emitting sunlamp. I’m not so sure that having the FDA limit the number of scans a patient can receive is a good thing. I also take issue with Dr. Smith-Bindman’s statistics that demonstrate greater than a 1% incidence of developing cancer from a single CT scan. If 1 in 80 patients can get cancer from a single CT scan and almost 80 million CT scans are performed every year, each year we are causing close to 1 million cases of cancer in US citizens. According to the American Cancer Society, it is estimated that 1.5 million total cases of cancer will be diagnosed in the US in 2010. Is our use of CT scans really causing more than half the cases of cancer in the US each year? Even if we cut the incidence in half, causing 500,000 new cases of cancer each year is a hard allegation to substantiate. Dr. Bruce Hillman wrote an accompanying article citing how “an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.” As some causes of the unnecessary use of diagnostic imaging he cites patients who “pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.” He also cites defensive medicine, self-referral, medical training programs that ingrain “shotgun” diagnostic testing to confirm diagnoses with the “greatest possible certainty.” He also acknoledges that radiologists also share in the blame for fueling the explosion in diagnostic imaging. We don’t need to change the physician’s mindset. We need to change the public’s mindset. If less testing is performed, more people will have diseases that won’t be diagnosed … or that won’t be diagnosed early enough. That is an inevitable result of reducing the use of diagnostic radiologic testing. Will the public and the juries sitting in medical malpractice trials accept this fact? Can we say that a 95% possibility you don’t have a deadly disease or severe injury is “good enough” and non-actionable? Until society makes the commitment to lower the bars over which clinical physicians must jump, the incidence of diagnostic imaging – and all the radiation that accompanies it – will go up and not down. There were many news articles published about this study, including USA Today and Forbes.com. I didn’t see any clinical physicians interviewed in these articles – only radiologists. That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs. How confident would we be if USA Today encouraged readers to pick up the paper next week when USA Today will have chemical engineers commenting on how mechanical engineers should stress test products more thoroughly? Hey – they’re both engineers, right? The money quote from Dr. Hillman in a Reuters article really irked me, though: If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk. How about this: When the dumb ER doc orders the next total body scan, walk over to the emergency department, examine the patient, and come up with your own diagnosis without using your deadly CT scanner. Get rid of your hindsight bias and make a prospective diagnosis without having the benefit of a “normal” diagnostic test sitting on the computer screen in front of you. Isn’t as easy as your little news sound bites make it seem, is it? Want to regulate something to really stop the flow of radiation into patients? How about making the American College of Radiology start regulating the number of diagnostic radiology reports from their members that contain phrases such as “cannot rule out underlying lesion, recommend CT scan for comparison”, and then “CT scan non-diagnostic, recommend bone scan for further clarification”. We could cut down on costs if radiologists would stop recommending “MRI for clinical correlation”, also. I’m betting that we won’t see too many sound bites about the implications from this radiology report lingo hitting the headlines any time soon. Will Insurance Deny Payment if You Leave AMA?Tuesday, May 11th, 2010Fifty seven percent of all health care providers (and probably just as many patients) believe that if you leave the hospital or the emergency department against medical advice, insurance companies will not pay for the visit. Half of doctors surveyed have told or would tell patients that insurance would not pay the bill if they left AMA. With 1 in 70 of all discharges in the US being against medical advice, such a policy would have a significant effect on finances for both patients and hospitals (if patients are unable to pay for denied coverage). Enter a study in last month’s Annals of Emergency Medicine titled “Insurance Companies Refusing Payment for Patients Who Leave the Emergency Department Against Medical Advice is a Myth” Several researchers reviewed 104 AMA discharges in a suburban hospital emergency department and queried 19 insurance companies including HMOs, PPOs, Medicare, Medicaid, and worker’s compensation. Out of 104 AMA discharges, each and every visit was fully reimbursed by the insurance companies. Now that the cat is out of the bag, will insurers change their tunes? May not be a bad idea to find out what your policy covers before you have to make a decision to leave AMA. Add Another Thing to the ListTuesday, March 16th, 2010
The American College of Radiology published this study that purported to analyze the “appropriateness” of outpatient CT and MRI scans ordered from primary care clinics at an academic medical center. In the study, researchers at the University of Washington used “appropriateness criteria from a radiology benefit management company” to determine whether CT scans and MRIs ordered by the lowly primary care physicians met “criteria for approval.” Then researchers compared studies that did meet “criteria for approval” with those that did not meet “criteria for approval” and found that 26% of the studies ordered were considered “inappropriate.” The authors listed several examples of “inappropriate” studies such as obtaining a brain CT for chronic headache, obtaining a lumbar spine MR for acute back pain, ordering knee or shoulder MRI in patients with osteoarthritis, and ordering a CT for hematuria during a urinary tract infection. Here’s the thing, though. The study states that “only” 24% of the “inappropriate studies” had positive results and affected patient management. In other words, if the researchers had not performed the “inappropriate studies”, they would have missed clinically significant findings in a quarter of patients. The conclusion of the “study” is that because the sensitivity of appropriate studies is higher than that of inappropriate studies, primary care physicians need help to “improve the quality of their imaging decision requests.” Want some help? Here’s some help for you: Stop the Monday morning quarterbacking and create a policy at your academic institutions so that none of the lowly primary care physicians can obtain a diagnostic radiology test without the esteemed radiologist’s approval. Lowly family practitioners can order the tests and you researchers just veto them when they cross your desk. Think of all the money and wasted testing you’ll save. Oh yeah … then you can be legally liable for the bad patient outcomes when you don’t allow the test. Why doesn’t one of you suggest that as an official ACR policy at your annual meeting in April? Those tests don’t look quite so “inappropriate” when you don’t have the benefit of a retrospectoscope, do they? P.S. Have family practitioners ever done a study to determine how many of the additional radiographic tests recommended in a radiologist report (i.e. “hip fracture present, cannot rule out pathologic fracture, recommend MRI and bone scan”) were retrospectively “appropriate”? Reducing Bloodstream InfectionsMonday, February 22nd, 2010
You’re probably wondering what a traffic light has to do with bloodstream infections. I’ll get to that later. This month, Consumer Reports published a well-written article about reducing hospital infections, and a lot of the take-home messages are good ones. The Consumer Reports article focuses on blood stream infections – also known as “septicemia“. Consumer Reports compared central line infection data for intensive care units at 926 hospitals in 43 states. Hospitals voluntarily submit such information to the Leapfrog Group, a nonprofit organization based in Washington, D.C. and Consumer Reports obtained the data from Leapfrog. As many people realize, septicemia and sepsis can lead to significant mortality in patients. Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Anything that we can do to prevent bloodstream infections will be a net positive for patient care. So it was interesting to read the data Consumer Reports collected regarding central line-related bloodstream infections. In every state, hospitals significantly decreased the number of central line infections that occurred. In fact, many hospitals – several with more than 6,000 central line days – reported ZERO central line-related blood infections. You read that right. ZERO. Zilch. Nada. Absolutely no incidents of central line-related bloodstream infections. The prevention in central line-related infections is credited to a simple five step checklist that was developed by Peter Pronovost, a Johns Hopkins critical care specialist. He felt that public disclosure of infection rates was a powerful motivator for hospitals to reduce the incidence of infections. I agree, to a point, but there is a bigger motivator out there, though. Cold hard cash. Under Section 5001(c) of the Deficit Reduction Act, the Centers for Medicare and Medicaid Services was required to select diagnosis codes that “have a high cost or high volume”, results in higher payment, and “could reasonably be prevented using evidence-based guidelines.” Bloodstream infections related to catheters was chosen as one of these codes and eventually became known as a “never event” – at least alluding to the notion that such infections should “never” happen and making a firm statement that the government would “never” pay for care related to such infections. In law, the concept of incurring liability for the occurrence of an event, regardless of whether that event is within one’s control is called strict liability. Here are come comments I previously made about strict liability in medicine. So first I’d like to start by congratulating the hospitals in Pennsylvania that made the Consumer Reports list for ZERO central line-related bloodstream infections. Congratulations to these hospitals on jobs well done. You’re probably wondering why I chose to look at the hospitals in Pennsylvania, aren’t you? As part of the public shame er, um, disclosure efforts required under Pennsylvania law, Pennsylvania created a web site to compare various costs of treatment and efficiency of health care for multiple different medical problems. Pennsylvania collects information on more than 4.5 million patient visits each year and then summarizes that information on its Health Care Cost Containment Council web site (which it calls “PHC4″). Now if all four hospitals dropped their cathether-related blood infections to ZERO, then the incidence of blood infections should also decrease at least a little, right? Let’s look at UPMC Shadyside. Even though the number of catheter-related blood infections was ZERO, the cases of septicemia increased each year between 2002 and 2008, and they increased a lot. As in 145 cases in 2002 up to 881 cases in 2008. The costs to treat those cases also increased – from $30,000 to more than $69,000 per event. AND their “outlier” numbers for prolonged length of hospital stay in patients with sepsis were worse than expected between 2006 and 2008. UPMC St. Margaret’s data also showed an upward trend, from 152 cases of septicemia in 2002 to 250 cases of septicemia in 2006 and then down to 209 cases by 2008. Costs also more than doubled during that time period, reaching $37,228 per case by 2008. Southwest Regional was the only hospital that had a downward trend of septicemia cases, but even that data was haphazard. 32 cases of septicemia in 2002, 40 cases in 2004, 14 cases in 2006, and 23 cases in 2008. The costs for treating septicemia at Southwest Regional also doubled, but in 2008, its charges were $16,253 – less than one quarter of UPMC Shadyside charges for treatment of the same medical problem. Magee-Women’s Hospital also had strange data. The number of septicemia cases it reported remained between 5 and 9 per year from 2002 to 2005. Suddenly in 2006, the number of cases at Magee-Women’s jumped to 28 and remained between 23 and 28 per year from 2006 to 2008. Its costs increased by almost double from 2004 to 2008, reaching $41,288. You’re probably thinking that other variables can affect this data, and I’d agree with you. Perhaps more people in Pennsylvania just happened to develop non-catheter related bloodstream infections during those years. Maybe all the other hospitals except for those above are getting contaminated central line kits delivered to them. Maybe some hospitals focus so much on preventing catheter associated bloodstream infections that they drop the ball in other areas. Who knows what other facts may explain the precipitous fall in catheter related bloodstream infections despite a significant increase in bloodstream infections as a whole. It just puts a question in my mind. Are things really getting better or are hospitals all over the country just telling us … and CMS … what we want to hear? Think about it. For the sake of example, I’m going to use UPMC Shadyside because of their high volume of patients. Assume in 2008, that 10% of the patients with septicemia at UPMC Shadyside were Medicare patients with catheter-related bloodstream infections (this article from Great Britain cites catheter related bloodstream infections as 10%-20% of all hospital acquired infections in the UK, so I’m staying on the low side of the cited statistics). If all those infections were considered “never events,” Shadyside would have lost more than $6 million dollars in 2008 on the care of those patients. Every patient with a catheter-related bloodstream infection at Shadyside can translate into more than $69,000 in lost revenue for the hospital. With reimbursements being cut and many hospitals bleeding red ink, you think that every hospital out there doesn’t have an incentive to selectively interpret bloodstream infection data? Here are some examples of how that selective interpretation might occur. All of the data that I could find relates to catheter associated bloodstream infections in the Intensive Care Unit. If a patient develops signs of an infection and is then moved out of the ICU before official culture results come back, does that patient get dropped as a data source? Don’t know. I couldn’t find any guidelines on what to do in that situation. How is a “catheter associated bloodstream infection” even defined? There’s no universal definition. Even the CDC admits that “the rate of all catheter-related infections (including local infections and systemic infections) is difficult to determine. Although CRBSI ["catheter related blood stream infections"] is an ideal parameter because it represents the most serious form of catheter-related infection, the rate of such infection depends on how CRBSI is defined.” We can use the definition from the National Nosocomial Infections Surveillance System requiring “presence of recognized pathogen” in blood cultures not “related to” infection at another site. What if the pathogen was not specified? Perhaps only gram positive cocci but subtyping not performed. Does that data get thrown out? What if the patient has a pimple at another site? Is that “related to” the blood stream infection? Does that data get thrown out? What if there is a bedsore anywhere on the patient’s body? No longer a catheter-related bloodstream infection? Appendix A of this MMWR report (.pdf download) has other definitions. One definition requires that the same organism be cultured from the blood and the tip of the catheter that has been removed. What if the catheter tip wasn’t cultured? Another definition requires that two blood cultures at different times show the same organism. What if only one blood culture was done? The definitions don’t say anything about antibiotics, either. If a patient receives antibiotics prior to blood cultures being drawn, it is likely that the antibiotics in the bloodstream will inhibit bacterial growth and will falsely decrease the numbers of positive blood cultures. If the patients get antibiotics through their central lines, how do you think that will affect the results of the cultures of the tips of the central lines? Is that reportable? Leapfrog Group and the federal government make a big deal about paying for performance. “Tie payment to outcomes” the Leapfrog Group advocates. When you start tying payments to outcomes without a well-thought out plan on how to reliably measure the outcomes, you’re going to get exactly what you pay for. Garbage in, garbage out. Just like drivers trying to avoid waiting five minutes to turn a corner when they’re late for work, hospitals have an incentive to avoid undesirable situations by taking advantage of loopholes in the rules and definitions. The thing that bothers me most about data like this is that it tends to make people both complacent and angry. Does this mean that hospitals shouldn’t follow the Dr. Pronovost’s five step checklist? Absolutely not. But if those checklists work sooooo well, then why doesn’t the government just say “we’re not going to pay you if you don’t use the checklist”? Focus on the process, not the outcome. You’ll get everyone following the checklist overnight. Then you’ll see how effective it really is. Nah. There’s more political capital in making the agencies look good and making the hospitals look bad. What’s the point of this protracted post? There are a few. Now, what’s all this about CMS representatives marching in some parade … with an Emperor? P.S. Did anyone see any government run hospitals in Consumer Reports’ list? I didn’t. Contrast Allergy and ShellfishWednesday, January 27th, 2010
The pearl noted that iodine is found throughout our bodies and is added to most kinds of table salt used in the United States. Our thyroid glands need iodine to function properly. While seafood contains iodine, the allergies to seafood are due to muscle proteins, not to the iodine. One recently-published study used to create the pearl dispels this “medical myth” quite nicely. |
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In addition to 
There’s this light on my way to work that is just a royal pain. It’s set up so that you have to wait for the arrow to make a left hand turn. The intersection is busy, especially in the mornings, and the arrow only stays lit for about 13 seconds. So you end up waiting five minutes or more – through several light cycles – to make the turn.
A recent 
Stay Away From That Oxygen Stuff – It’ll Kill Ya
Monday, August 2nd, 2010Researchers found that patients who were admitted to the intensive care unit after suffering a cardiac arrest were almost twice as likely to die if they had “hyperoxia” – which was defined as a PaO2 of 300 mmHg or more.
Hyperoxia patients died 63% of the time, hypoxia patients (PaO2 < 60 mmHg) died 57% of the time, and normoxia patients (PaO2 between 60 and 300) died 45% of the time.
Common thinking with the docs I know is that more oxygen is better – except with COPD patients.
Don’t have full access to the JAMA article, so am not sure what percentage of each group ended up actually walking out of the hospital. It is entirely possible that the patients who survived ended up in chronic vegetative states.
Nevertheless, this study plus the work of Gordon Ewy in advocating “chest compression only” CPR (no mouth-to-mouth) really bring the current “standard of care” for resuscitation of cardiac arrest into question.
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