I hardly EVER receive derogatory correspondence (one letter every two years, or so). And, when I respond to one, I rarely ever (in fact, NEVER before THIS) hear BACK from the nasty-gram-sender. Consequently, it's usually quick and easy to post a nasty-gram.
But, since I've been fielding SEVERAL Emails from Ms. Mohr, RN, PhD (and, because I've been terrifically busy with MUCH more important stuff), I've put-OFF writing and posting this Nasty-Gram saga.
Finally, today, I've managed to finish my "review" of (reply to) Mohr's first Nasty-Gram. And, because I highly doubt that anyone would be interested in the ENTIRE posting of ALL our Emails (AND, because I simply don't have time to FUSS with ALL four or five PAIRS of them), I'm ONLY going to post and respond to Mohr's FIRST letter. Basically, her first Email says it ALL and UNIVERSALLY represents the her "attitude" anyway!
I also really and truly wanted to AVOID having to spend time writing a point-by-point response to even her FIRST Email. But, Jeeze! Although I seriously doubt that any reader would fail to note that she has some truly unfortunate self-image problems, Mohr manages to make enough "legitimate-sounding" points in her FIRST Email, that I'm STUCK having to address them point-by-point, STUCK having to provide references to support my responses.
STILL, the MOST "UNFORTUNATE" aspect of Mohr and I sniping at each other, is that; after her THIRD Email to me, I did some more Internet research about her, and discovered that she IS an advocate for mandating safer restraint methods!!! So, although SHE certainly doesn't want to think so, we are actually on the "SAME SIDE" we have a COMMON GOAL; that of STOPPING LETHAL FORMS OF RESTRAINT.
During my more extensive Internet research about Mohr, I discovered a document-posting of the 1999 NAMI (National Alliance for the Mentally Ill) testimony she provided before a Senate Appropriations Subcommittee on Labor-HHS-Education hearing on "Deaths From Restraints At Psychiatric Facilities" and a 2002 Statement she made to the Centers For Medicare And Medicaid Services, on behalf of the Advocates Coalition For The Appropriate Use Of Restraints.
[I'll provide links to both those document sites at the end of the following
incredibly silly and unfortunate business.]
The following Email was sent to me by Wanda Mohr, RN, PhD; co-author of
Adverse Effects Associated With Physical Restraint.
As you read it, keep in mind that she sent it to me WITHIN TWO HOURS of my posting
that article (and my very few comments about it) in my Restraint Asphyxia Library!
[BTW: The ONLY "editing" I've done of Mohr's Email
is to remove some odd line-breaks, and better-format her original paragraph-breaks,
so that her letter is EASIER TO READ.
I did NOT alter Mohr's spelling, capitalization, punctuation, or Email CONTENT!]
Sent: Tuesday, January 27, 2004 4:34 PM
Subject: your "review"
Several medical colleagues have pointed out your website "review" of our article on the adverse effects associated with physical restraints recently published in the Canadian Journal of Psychiatry.
First of all, where do you who have no degrees and no advanced formal education get off "reviewing" the work of scientists (Ted Chan, ourselves, and others) who are working diligently to determine the multiple factors responsible for death proximal to restraints?
I really don't care what your experience has been, it is not a substitute for education. Moreover, the value of experience over education has been roundly debunked in the literature (see Dawes and Meehl). Although you may think that you know what you are talking about, your observations are both ill informed, rude, lacking in class and professionalism, and serve only to discredit you.
Articles submitted to peer reviewed professional journals are submitted to rigorous review by fellow scientists. You seem to believe that you are much more learned than they. The arrogance of this position is actually quite amusing. This is not to say that peer reviewers may not be wrong, it is to say that there is a reasoned way of discussing issues with which you disagree. That way is NOT to post the kinds of screeds that you do.
While I do not want to give you any more ammunition for your amusement or to feed your ego, let me take exception to your comments:
1) Re. our recommendation to have psych units equipped to deal with cardiac emergencies -- given your reasoning -- we should forget about CPR altogether. All cardiac arrest results in respiratory acidosis which then progresses to metabolic acidosis. You have no evidence to base your allegation that ACLS will not help in restraint asphyxia, as there are no studies that show this in humans and case reports are not empirical studies. Moreover, there are more reasons than positional asphyxia from which people die proximal to restraint. If you'd read the article carefully, we talk about several. Certainly you would not deny that resuscitation efforts should not be employed in the event of cardiac arrhythmia.
2) This article was not only about prone restraint death, as you make it appear.
3) You took issue at our being "on the fence." Nothing can be further from the truth. This was the first major article to review death resulting from restraints in a psychiatric journal. I am sorry to inform you Mr. Miller, psychiatrists do not read your website for their information and education. I challenge you to find ONE article that synthesizes the available literature on the possible and actual reasons for adverse outcomes proximal to restraint use as comprehensively as our team did. Why did you think we wrote it? Because there was nothing there and people were continuing to put their heads in the sand about the issue, and they continued to act in the same unsafe way.
4) We were as strong as the traffic would bear. Medical journals are not People magazine. Scientists are cautious and not given to editorializing and ranting, but rather to making reasoned arguments. Would you rather have NOT have had this piece out in the professional literature due to provocative, argumentative language?
5) When you publish this on your website, please do not answer by calling me by my first name, as you did with one of my colleagues. I have given you the courtesy of addressing you as Mr. Miller please give me the same.
Wanda K. Mohr PhD, RN, FAAN
Psychiatric Mental Health Nursing
AAAND ... HERE are my responses to the very FEW
legitimate-sounding points contained within Mohr's Email.
Clearly, her mistaking me for a "Mr" simply reflects her failure to learn more about me and my website before striking-out at same.
And, thankfully, the First Amendment to the United States Constitution alleviates me from having to address Mohr's incredibly defensive and hostile ("where do you ... get off") denial of the RIGHT of someone without Big-Fat-Letters behind their name to gasp! criticize her.
RE: "I really don't care what your experience has been, it is not a substitute for education. Moreover, the value of experience over education has been roundly debunked in the literature (see Dawes and Meehl)."
Considering that statement, I found it terrifically interesting that Mohr BEGAN her April 13, 1999 testimony before a Senate Appropriations Subcommittee with the following statement [MY italics & boldface];
"As a nurse I am here today to tell you that restraint and seclusion are the most draconian methods of patient control in mental health settings. I've seen them used, and I've broken up situations that could have turned into potential tragedies."
Furthermore, Mohr BEGAN her October 29, 2002 address to the Centers For Medicare And Medicaid Services as follows [MY italics, boldface, & ALL-CAPS];
"Good morning. My name is Wanda Mohr and I am a professor of psychiatric mental health nursing at Rutgers University College of Nursing in New Jersey. I have extensive clinical experience in the care of psychiatric patients and have conducted research and published widely on the use of restraints in psychiatric settings. I teach advanced practice psychiatric nurses and direct the program that graduates advanced practice nurses with prescriptive privileges. MORE IMPORTANTLY I have the experience of living with a mother who had a chronic and persistent mental illness and I have seen first hand how restraints are used and misused."
Oh! It is absolutely AWFUL that Mohr's MOM was (apparently) subjected to inappropriate forms of restraint. But, that does not at all "excuse" Mohr's unsupported ABUSE of ME!
Apparently Mohr feels that having "experience" is a perfectly legitimate and "valuable" thing to argue in support of HER OWN "qualification" or right to offer an opinion. Yet, she quite emphatically (and emotionally) disclaims "experience" as being a legitimate or "valuable" argument in support of MY "qualification" or right to offer an opinion. Can we say, "Double Standards"? I think we can.
Additionally, Mohr blatantly states that she doesn't "CARE" what my experience has been, and offers a grand total of ONE (entirely inadequately-cited) reference to support the legitimacy of her statement alleging that this single mystery-citation effectively "debunks" the value of experience. Especially since Mohr could only cite ONE reference to support her ridiculous statement (and, given her "EXPERIENCE" co-authoring published articles), why did Mohr fail to cite her reference in a manner that readily allowed readers to find it, so that they might determine its LEGITIMACY?
Interestingly enough, Medline and Medscape searches for ANY articles written by a "Dawes" or by a "Meehl" between 1980 and 2004 yielded absolutely NO HITS. Yet, a search for "the value of experience over education" yielded all sorts of articles touting the seriously valuable benefit of experience!
In fact, the majority of those hits reminded me of the "internship" requirement for ANY practitioner, prior to being allowed to practice without supervision. Think about it. Why would internships (the obtaining of actual "experience") be a standard requirement for EVERY manner of care-provider, if "education" was the ONLY thing important to care provision, the ONLY thing important to gaining Big-Fat-Letters after someone's name?
BTW: My favorite find during that search was this article: Gutierrez MC, Soto RG: Alligator attack: an illustration of the impact of early clinical exposure. Med Educ (England), Dec 2002, 36(12) p1182-4.
CONCLUSION: The [experience gained from] clinical exposure of medical students is central to their development as clinicians.
Hmmmm. "CENTRAL" to their development as clinicians. Go figure.
Furthermore, when doing a really quick, generic INTERNET search regarding the issue of "experience versus education," the hits I found reminded me of another really interesting FACT: In United States courts of law, I've been legally "qualified" as an "Expert" in prehospital emergency medicine practices, by virtue of my education and experience. I've ALSO been legally "qualified" as an "Expert" in RESTRAINT ASPHYXIA issues, SOLELY by virtue of my EXPERIENCE, and my years of performing personal research.
Thus, despite Mohr's inadequately-cited "see Dawes and Meehl" argument, EXPERIENCE alone is legally-recognized as a legitimate and valuable basis upon which to consider someone an "Expert Witness" regarding ANY subject.
See: Underwager R, Wakefield H: A paradigm shift for expert witnesses. Issues In Child Abuse Accusations (the official journal for the Institute for Psychological Therapies), Volume 5, Number 3, Summer 1993 [Available HERE on the Internet]
If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise. (William Daubert, et ux., etc., et al., Petitioners v Merrell Dow Pharmaceutical, Inc., Supreme Court of the United States, No. 92-102, decided on 6/28/93, p. 8.)
Note the ORDER in which "experience" and "education" are listed in the above quote, as they relate to the basis upon which someone may be legally-qualified as an "Expert." Note also the "or" qualification within the above quote! Essentially, in a court of law, consideration of someone's "experience" carries an EQUAL WEIGHT when compared to consideration of someone's "education."
Consequently, Mohr's inadequately-cited "argument" against the VALIDITY of EXPERIENCE (and SELF-EDUCATION) is entirely without merit. Even if the parent/relative of a wrongfully-restrained child/adult is a "high-school dropout," if that parent/relative devotes a significant amount of time to extensively studying and researching the medical, psychiatric, and forensic literature related to the subject of restraint practices, that "HIGH-SCHOOL-DROPOUT" parent/relative CAN become an "EXPERT" on the subject. Furthermore, COMMON SENSE recognizes that, if such a person managed to gain PERSONAL EXPERIENCE in the application of (and subjection to) different forms of restraint, she/he would be even BETTER ABLE to come to a reasoned, logical, and MORE REALISTIC understanding of the effects of restraint even though "self-educated" than the majority of "clinical researchers" who (although they have Big-Fat-Letters behind their names) too often have little-to-NO personal experience in dealing with the real-life crises that lead to restraint application, little-to-NO personal experience in having been subjected to any methods of emergency restraint!
RE: "1) Re. our recommendation to have psych units equipped to deal with cardiac emergencies...
Well ... First of all: ANY care facility that bandies DRUGS about (especially "psychotropic" drugs!) should ALREADY be required to train and equip their employees to perform CPR (Basic Life Support), and Advanced Cardiac Life Support (ACLS), in the event of a "cardiac emergency." In fact, back in the '70's , when I spent seven years working as ward-staff at a State Psychiatric facility, that kind of requirement WAS already established. I cannot imagine that such a reasonable and VITAL requirement would have been DIMINISHED or NEGATED since then.
Additionally, ANY care facility (especially a PSYCHIATRIC care facility) should ALREADY be required to have employees trained and equipped to perform ALL FORMS of Basic and Advanced Emergency Care Provision ("FIRST AID"), in the event that ANYONE in their care experienced ANY kind of medically- or traumatically-induced emergency be it "cardiac" in nature, or not.
SO! As a suggested response to issues raised within an article entitled "Adverse Effects Associated With Physical Restraint," Mohr et al's "recommendation" that "psych units [should be] equipped to deal with cardiac emergencies" is demonstrably redundant, entirely superfluous, and cannot possibly be reasonably expected to have ANY EFFECT upon reducing the occurrence of "Adverse Effects Associated With Physical Restraint."
RE: "1) ... Certainly you would not deny that resuscitation efforts should not be employed in the event of cardiac arrhythmia.
Well, JEEZE. "Double-negatives" are always difficult to address. But, I'll do my best to answer this question, precisely as Mohr posed it:
YES, I WOULD "deny that resuscitation efforts should not be employed in the event of cardiac arrhythmia"!!!
I adamantly believe that resuscitation efforts should ALWAYS be employed when someone is noticed to be DEAD! UNLESS someone's head has been completely lopped-off; or the entire contents of someone's TORSO have been carved out and completely separated from their body; or someone's death has gone UNNOTICED for so long that their body had become RIGID due to rigor mortis ... or the like! [Get the picture? I thought you would!]
DO I THINK THAT MOHR REALLY MEANT TO WRITE THAT STATEMENT AS SHE DID? NO!!!
Don't be silly! She's not stupid. She's just very defensive, hostile, and ... disturbed.
I think Mohr was so entirely overwhelmed by self-doubt and reactionary-defensiveness in response to someone criticizing her co-authored article, that she entirely missed the POINT of my VERY FEW criticisms AND entirely missed that fact that I had even COMMENDED parts of her article!
[BTW: Since the onset of her vitriolic Email barrage, I have NOT changed ANY of the comments I included when I FIRST posted it. And, if I ever DO alter or amend my comments, I'll be sure to retain the original comments, and clearly identify any new ones provided! Consequently, what you STILL see there is the entirety of what prompted Mohr's first Email.]Additionally, I think Mohr was so entirely overwhelmed by self-doubt and reactionary-defensiveness, that she was desperate to find a way to negate the validity of ALL my opinions desperate to "belittle" ME so that she might gain an artificial sense of improved self-worth, AND avoid having to answer to her "peers" in regards to my criticisms. Clearly, when Mohr wrote, "Certainly you would not deny that resuscitation efforts should not be employed in the event of cardiac arrhythmia," she was acutely ... discombobulated.
RE: "1) ... All cardiac arrest results in respiratory acidosis which then progresses to metabolic acidosis.
Apparently, Mohr is entirely unacquainted with the extensive amount of research that has documented the SIGNIFICANT DIFFERENCE between levels of acidosis consistently associated with "common" cardiac arrests, and levels of acidosis consistently associated with restraint-asphyxia-related deaths. Clearly, Mohr needs to better research this particular pathophysiologic aspect of restraint-asphyxia-related deaths. To assist her research, I happily provide Mohr with the following references:
- Hick JL, Smith SW, Lynch MR: Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med March 1999; 6:239-243.
- Katz LM, Wang Y, Rockoff S, et al. Low-dose Carbicarb improves cerebral outcome after asphyxial cardiac arrest in rats. Ann Emerg Med (United States), Apr 2002, 39(4) p359-365.
- Dybvik T, Strand T, Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation (Ireland), Apr 1995, 29(2) p89-95.
- Fillmore SJ, Shapiro M, Killip T. Serial blood gas studies during cardiopulmonary resuscitation. Ann Intern Med 1970; 72:465-9.
- Chazan JA, Stenson R, Kurland GS. The acidosis of cardiac arrest. N Engl J Med 1968; 278:360-4.
- Gazmuri RJ, Weil MH, von Planta M. Cardiopulmonary resuscitation: acid-base alterations and alkalizing therapy. Rev Med Chil (Chile), Mar 1989,117(3)p322-9.
- American Heart Association; Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1974;227:833-868.
- American Heart Association; Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1986;255:2843-2989.
- Textbook of Advanced Cardiac Life Support, Second Edition (c) 1987 by The American Heart Association.
- 1997-99 Emergency Cardiovascular Care Programs, Advanced Cardiac Life Support (c) 1997 by The American Heart Association.
- 2000 Handbook of Emergency Cardiovascular Care for Healthcare Providers (c) 2000 by The American Heart Association.
- Von Planta M, Bar-Joseph G, Wiklund L, et al. Pathophysiologic and therapeutic implications of acid-base changes during CPR. Ann Emerg Med (United States), Feb 1993, 22(2 Pt 2) p404-10.
But, what MOST disturbs me about Mohr's entirely erroneous statement that, "All cardiac arrest results in respiratory acidosis which then progresses to metabolic acidosis," is THIS:
IF Mohr had been ACLS (Advanced Cardiac Life Support) educated and certified during ANY of the years wherein her Resume/CV cites her having received her "BSN" or "PhD" nursing education if Mohr had ever WORKED as an ACLS-certified nurse Mohr WOULD KNOW that "common" cardiac arrests are NOT accompanied by significant levels of respiratory OR metabolic acidosis. She would know this because, ACLS treatment protocols for "common" cardiac arrest since 1986 have CONTRAINDICATED the "automatic" or "first line" administration of SODIUM BICARB (the acidosis-"antidote")!
Admittedly, I apparently have been an ACTUAL patient-care-provider longer than Mohr has. In fact, when I was FIRST EDUCATED in ACLS emergency care provision, we DID "automatically" administer sodium bicarb to ALL cardiac arrest victims, as part of the FIRST-LINE DRUGS delivered in our effort to resuscitate them. And, I was an ACTUAL patient-care-provider when, in 1986, the American Heart Association first issued its CONTRAINDICATION of the "automatic" or "first line" administration of sodium bicarb.
Why did the AHA contraindicate "automatic" or "first line" sodium bicarb administration in 1986? Because CASE STUDY research revealed that "common" cardiac arrests were NOT accompanied by levels of acidosis that required anything more than HYPERVENTILATION to correct; and, that "automatic" or "first-line" administration of sodium bicarb caused patients to suffer the LETHAL adverse effects of "ALKALOSIS" the opposite of ACIDOSIS, and something that CANNOT be reversed or corrected by ANY drug.
Consequently, my more-extensive patient care EXPERIENCE has given me a FAR BETTER understanding of this subject, than that of the incredibly "EDUCATED" Ms. Mohr, RN, PhD.
HOWEVER!!! Ms. Mohr, RN, PhD is purportedly a NURSING INSTRUCTOR! (Plus, HEY! She's got all those Big Fat Letters behind her name.) CLEARLY, even if she hasn't actually practiced ACLS patient care, as a Nurse-Instructor, Mohr SHOULD KNOW about this stuff! But, apparently (as demonstrated by her acidosis-related statement), she DOESN'T know about it. That is terrifically concerning!
RE: "1) ... You have no evidence to base your allegation that ACLS will not help in restraint asphyxia, as there are no studies that show this in humans and case reports are not empirical studies.
Let's begin by addressing Mohr's inference that "case reports" are INVALID for legitimate consideration, because they are "not empirical studies" shall we?
First of all ... the term, "empirical," is defined as "derived from or guided by experience or experiment." Therefore, I believe that Mohr intended to state that "case reports are not 'legitimate' studies" upon which to base "scientific" allegations. But, as with the majority of her statements, Mohr was ... discombobulated ... disturbed ... when she wrote them.
AS IT HAPPENS, in order to "refute" Mohr's unsupported argument that case reports are not "legitimate" studies upon which to base "scientific" allegations, I cite HER OWN ARTICLE the one generating all this brew-ha-ha! in support of MY argument that case studies and case reports are well-established, long-recognized, and entirely "legitimate" sources of support for "scientific" allegations!
There are 94 REFERENCES cited at the end of Mohr's co-authored "Adverse Effects Associated With Physical Restraint" article. (WOW. That's a LOT of references! That must mean that the article is "well-supported" by research don't cha think?!) But, of these 94 REFERENCES;
LASTLY, the truly compelling, factual argument, that entirely "DEBUNKS" Mohr's ill-advised attempt to promote "scientific clinical research" as somehow being more important than "case studies" when investigating restraint practices and restraint asphyxia dangers, is this:
"Scientific Clinical Studies" of humans being subjected to restraint practices or techniques that MIGHT BE dangerous CANNOT be performed! If clinical research scientists were to actually simulate ALL of the "real-life" conditions associated with ANY forms of restraint-related human deaths, the danger of causing the DEATH of one or more human-study-participants is so CLEARLY PROBABLE, that NO research scientist is willing (or ALLOWED) to DO IT!
"4) WE WERE AS STRONG AS THE TRAFFIC WOULD BEAR."
Well, there you have it! Clearly, fear of upsetting the "STATUS QUO" is Mohr's ultimate excuse for failing to suggest REALISTIC and EFFECTIVE means of avoiding "Adverse Effects Associated With Physical Restraint." (Such as taking a stand and suggesting something as REASONABLE as the DISCONTINUANCE of ANY forms of forceful-prone-restraint!)
Hey! Mohr is not the first nor the last author to succumb to this fear. Mohr is not the first nor the last "researcher" to fail to GET OFF THE FENCE and take a REAL STAND against inappropriate forms of restraint.
But, given the many arguments AGAINST inappropriate forms of restraint (such as forceful-prone-restraint) presented within HER OWN co-authored article, and given her apparent history of being an advocate of SAFER forms of restraint, it is terrifically SAD that Mohr is reduced to such an entirely inadequate excuse for failing to do her duty to humanity.
BOTH the following links will take you OUTSIDE this website.
If you have trouble accessing them, and want me to send you my DOCUMENT
form of either statement, EMAIL ME and ask for it/them !
The 1999 National Alliance for the Mentally Ill Webpage
Containing the testimony Mohr provided before a Senate Appropriations Subcommittee
on Labor-HHS-Education hearing on "Deaths From Restraints At Psychiatric Facilities."
Statement Of Wanda K. Mohr, Ph.D., RN, Faan,
Regarding The "One Hour" Rule; Presented On Behalf Of The
Advocates Coalition For The Appropriate Use Of Restraints.
To The Centers For Medicare And Medicaid Services.