Biphasic should replace Monophasic Defibrillators
Debate Rounds (5)
Biphasic: having two distinct phases, as in a waveform
Monophasic: consisting of one phase in a waveform
Biphasic defibrillation has been proven to cardiovert a patient from ventricular fibrillation at higher rates at lower dosages than monophasic defibrillation. Biphasic defibrillation at 120J-200J is as efficient and effective, if not more, than monophasic defibrillation at 360J.
American Heart Association
I negate; biphasic defibrillators should NOT replace monophasic defibrillators.
For the statement "Biphasic should replace Monophasic Defibrillators" to be true, replacing monophasic defibrillators must be the best thing to do.
For example [remember, this is a hypothetical, I am not claiming this example case to be true], let's say defibrillators were not useful at all - that both monophasic and biphasic were solely harmful to use, but biphasic were less harmful. The statement "Biphasic should replace Monophasic Defibrillators" would not be true, since it would make much more sense to simply stop using them at all. Replacing the monophasic with biphasic would be unnecessary, since there would be a better alternative - not using them at all.
Further, I accept my opponents definitions.
Note that I will often shorten 'xphasic defibrillators' into 'xphasics,' where x is either mono, bi, or tri. This is for ease of reading as well as ease of typing.
With the right phase durations, triphasic defibrillators are currently optimal for both effective defibrillation and lessening the risk of damage. For largely the same reasons biphasics are superior to monophasics, triphasics are superior to biphasics. Thus, by the very logic my opponent applies in round 1, monophasics should be replaced with triphasics, as should biphasics. Replacing monophasics with biphasics would simply add another unnecessary step to the process, since the biphasics should also be replaced with triphasics.
[Journal article from the American Heart Association.]
So rather than replacing monophasics with biphasics, I am advocating replacing both monophasics and biphasics with triphasics. Thus, the resolution is negated.
One more piece of relevant information, also from the source listed above:
"Most defibrillators that can deliver a biphasic waveform already contain the switches and other hardware necessary for delivery of a triphasic waveform. Therefore, slight alteration of the software in the defibrillator to switch the waveform a second time to deliver the third phase is the main change required for delivery of a triphasic shock."
Thus, it is extremely easy to convert most biphasics into triphasics. While my opponent is suggesting replacing monophasics with biphasics despite the hardware changes necessary, a good part of my advocacy [biphasics->triphasics] does not rely on such costly hardware changes.
I will attack his points, then follow up with my own.
1- The American Heart Association's study on triphasic defibrillation was inconclusive.
My opponent claims that replacing both monophasic defibrillators as well as biphasic defibrillators is the "best thing to do", and bases this statement on a study by the American Heart Association for which he provides a link. This information is very familiar to me. The studies conducted by the AHA on triphasic defibrillation were experimental, and were not conducted with defibrillators, rather they were conducted with devices created for the purpose of the experiment, and the waveform was controlled by a "Macintosh computer". It is both impractical and illegal to employ these devices in a hospital setting, and it was these experiments which led to the development of biphasic defibrillators. Note- the development of triphasic defibrillators was not a result of the experiments, nor subsequent experiments employing
2- Some of the results listed in this 2000 article were from as early as 1983. It has been 25 years and triphasic external defibrillators have not been developed. If we are going to debate choices, and what is the best choice, the best choice should be one that is available. When referring to cardioversion, monophasic, and biphasic defibrillators, and within the context of "replacing monophasics with biphasics", it is important to note that I am referring to existing technology that is available and present within hospitals. Replacing both monophasic and biphasic defibrillators with non-existent triphasic defibs is impossible.
3- My opponent's contention that "most defibrillators that can deliver a biphasic waveform already contain the switches and other hardware necessary for delivery of a triphasic waveform" is untrue. He is citing an article published in 2000, which contains info from older studies. The various biphasic defibrillators on the market- Zoll, Philips, Physio Control, HP do not have the hardware or switches necessary for delivery of a triphasic waveform. Furthermore, they do not possess the controlling software. On top of that, alteration of an existing FDA approved medical device and making it a completely different device in which the dose and use would be severely altered is illegal. The FDA has a process for approving these devices, and triphasic external defibrillators have not been approved for use, and there is no proof that they are even in development.
4- My opponents contention, which I affirm is false, that biphasics possess the hardware to become triphasics would still require monophasics to be replaced with biphasics. "Therefore, slight alteration of the software in the defibrillator to switch the waveform a second time to deliver the third phase is the main change required for delivery of a triphasic shock". I don't believe this statement to be true, and would love to hear the electronics theory behind this, but if it IS true, and since triphasic defibrillators are not commercially available, you would still have to replace monophasics with biphasics if you wanted triphasics. It would be legally impossible, however, to alter a biphasic defibrillator to deliver a third phase. It is probably also electronically impossible, given that a biphasic operates essentially as an AC current (delivering one positive charge followed by a negative charge), to deliver a third purely positive charge that is part of the original complete waveform. My opponent cited a study without understanding the technology being cited within the study (implantable internal defibrillators). I would love to hear how an external defibrillator can be altered to deliver a third phase (electronically AND legally).
Now, my opponent can argue that I did not specify external defibrillators, HOWEVER within the context of the study I referenced, my reference to monophasic defibrillators, etc. all make it obvious to the knowledgeable debater that I am referring to external defibrillators. Internal implantable defibrillators are commonly referred to as ICD's- implantable cardioverter defibrillators- rather than "defibrillator" which is the term used for the common external monophasic or biphasic defibrillators we see in hospitals, airports, train stations, ambulances, etc., including AED's or Automated External Defibrillators which are already almost all (if not all) biphasic. If my opponent wants to implement the best possible technology then he must restate his entire argument, nullifying his R1 argument because quadriphasic waveforms are more efficient than triphasic waveforms. Alas, we are not discussing which waveform is more efficient, rather whether or not biphasic defibrillators- an available technology, should replace monophasic defibrillators- a widely used technology.
The process is already taking place voluntarily at hospitals throughout the country. Lifepak 9, Lifepak 10, 11, and even early versions of the Lifepak 12 used monophasic technology, but even the Lifepak 12 has gone beyond it's recommended life cycle. With the recent Joint Commission Sentinel Alert warning about the use of outdated technology, it is time hospitals stop beating around the bush and replace their outdated defibrillators.
It's true that the study I linked was not quite statistically significant on the issue of showing that triphasics are more effective than biphasics. Here is a study with statistically significant findings on the issue, from 2002:
The defibrillation success rates in this study are unilaterally in favor of triphasics, as shown in these four graphs from the study:
By requiring less energy/amps/ to be put through a subject's body for effective defibrillation, triphasics are not only more effective, they can also cause less damage to a subject.
My opponent's initial case is built off the supposition that increased effectiveness is enough warrant to increase production of the superior defibrillator, even though biphasics likely cost slightly more than monophasics. If we follow this logic, we come to the conclusion that triphasics should be produced instead. If we don't accept this reasoning, then we should continue using monophasics due to their cheaper manufacturing costs. In either case, biphasics should not replace monophasics.
My opponent says that since triphasics are available within hospitals, they should not be considered as a choice. Let us follow that vein of logic for a minute.
My opponent claims that we should only consider "existing technology that is available and present within hospitals." This means that any device that is currently not in a hospital is not on the table as a choice, according to my opponent.
Note that all biphasics that are currently in hospitals are mosyt likely in use. Monophasics that are in hospitals are also in use. There is likely too much defibrillation for the biphasics to handle alone, otherwise hospitals would not ever have a reason to use a monophasic. Thus, it is impossible, if we're only considering technology that is existing and present in hospitals, to 'replace' monophasics with biphasics. It would be like a couple of working adults 'replacing' their first car with the second car - first, we wouldn't call that replacing; second, it would be impractical, since they need both cars.
"Difficulty Converting Biphasics to Triphasics"
My opponent claims that there is some problem in converting biphasics to triphasics, even though I provided a reliable source for my claim that the conversion was possible and simple. His argument against this reliable source is a mere claim that I am wrong. That doesn't wash. A claim with a good source will always trump a mere claim to the contrary. If my opponent wishes to argue that it is difficult to convert biphasics to triphasics, then he will have to back that claim up with more than just his own words and his conjecture about how he thinks it's not possible. I have a scholarly journal article claiming that conversion from biphasics to triphasics would usually require only small software changes, my opponent has only himself claiming the contrary.
"Converting to triphasics not legal"
My opponent points out that since triphasics have not been approved by the FDA, it is illegal to convert biphasics to triphasics, or to adopt triphasics at all.
I will point out that we are talking about what 'should' happen. Due to triphasics being superior, the FDA should approve them, and should approve the conversion of existing biphasics into triphasics. It shouldn't just approve them as a general rule, but sould approve the specifications the hospitals would be switching to.
Lastly, I will address this issue of existing technology once more. My opponent points out that biphasics are used almost exclusively in many places. We're not talking about those places, though. He also points out that monophasics still are widely used. Consider this:
1. Replacing these many monophasics with biphasics would require the production of many new biphasics.
2. There is little to no difference in hardware between biphasics and triphasics, so producing triphasics would be about as easy as producing biphasics. This comes not only from the fact that most biphasics can be converted to triphasics with software changes, but also from the basic design of a biphasic and triphasic defibrillator. The triphasic does not require any additional hardware - biphasics already have the hardware necessary to deliver shocks and switch phases.
3. Triphasics are more effective than biphasics.
4. Therefore, triphasics should be produced instead of biphasics to replace the monophasics that are still in use.
My opponent claims that quadriphasics are even better. He doesn't support this with evidence, but assuming it is true, perhaps it would be best to replace monophasics with quadriphasics rather than triphasics. Whether this is true or not, one thing is clear. If we are to replace monophasics with another type of defibrillator, it shouldn't be biphasics.
I will now allow my opponent to respond.
The study I cited in my R1 argument refers to external defibrillation in an emergency setting using the existing technologies of biphasic defibrillators vs. monophasic defibrillators. These are the only two types of defibrillators commercially available in hospitals, and the only ones addressed in the study as they are the only two waveform types approved for use by the FDA. Biphasic and Monophasic defibrillators are currently Class II (approved for market) type devices.
The study my opponent cites does not refer to any device approved for market by the FDA. The study was experimental, and used devices made in a lab setting and controlled by a computer that is not approved for control of cardiovertive devices (Macintosh Computer). Triphasic defibrillators exist only as Automatic Implantable Cardioverter-defibrillators (ICD's). The significance of the difference between an ICD and an external defibrillator, or simply, defibrillators is that ICD's are used on ONE patient, and the implanting of such a device would be exclusive to that patient, and would be at the cost of that patient. Understand- the studies DO NOT refer to the same devices. This is like debating semi-trucks and mentioning motorcycles based on their similarities as "vehicles". (http://en.wikipedia.org...)
If my opponent wishes to question the reliability of my Wikipedia source, I would ask that he first check the sources cited within the Wikipedia article before discrediting my source simply for being from Wikipedia. I would also note that the Wikipedia source cites sources cited by my opponent's posted study. ICD's are clearly not the devices I am referring to in this debate, and they are clearly the devices referred to by my opponent's source.
My opponent's reference to manufacturing costs is ridiculous. He cannot possibly cite a source detailing the manufacturing costs of a biphasic defibrillator vs. a monophasic defibrillator. The cost of a brand new defibrillator has remained constant- anywhere from $9,000- $15,000 depending on the options purchased with the defibrillator (monitoring capabilities, 3-lead, 5-lead, or 12-lead ECG capabilities, pacing, SPO2, etc.). A monophasic defibrillator at the time of purchase would cost the same as a biphasic defibrillator costs today. For a hospital to replace a similar device it would be a tax write off that balances their budget. It is also in the hospital's interest to meet Joint Commission Sentinel Alerts like their recent alert regarding keeping up with new technology.
2. Existing Technology
What I said were available in hospitals are triphasic ICD's- NOT external defibrillators. There is a big difference, and it would behoove my opponent to educate himself on the difference, as I pointed out there was a difference in my last round and he completely ignored my argument. My opponent does not understand the logic of why some hospitals have monophasic defibrillators as well as biphasics, and attempts to justify a similarity between adults and their vehicles. I assure you there is not a similarity in that hospital departments operate on individual budgets, yet many hospitals provide defibrillators based on an Emergency Department budget. If the hospital provides leniency of choice to the directors of the individual departments, there is not always uniformity, and that is the root of my argument. Many department heads have their own arguments as to why they will not replace monophasic defibrillators, and the argument is usually they are used to the operation of that particular defibrillator and are not comfortable with new technology. My argument stems from the fact that biphasics are more efficient, and being afraid of new technology is not a good argument because it is a Joint Commission standard to keep up with new technology- both in availability and in training. My opponent's argument makes no sense. My argument on availability of technology is based on commercial availability. In other words, using my opponent's analogy of replacing a vehicle- it would be ridiculous for a husband to want to replace his old vehicle with a flying vehicle knowing full well that vehicle is not available. If he were serious about replacing his old vehicle with newer technology, he would go to a dealership and purchase something that is available. It would be delusional for the man to request a flying Hummer that runs on solar power because they don't exist.
3. Converting Biphasics to Triphasics
My opponent claims that he has cited a source, and I accept that. The problem is I understand the technology cited in the source, and he does not. An ICD can be converted into a triphasic (at the time there were no triphasic ICD's) defibrillator using the tiny switches the small device had available, and that is what led to the development through legal means of triphasic ICD's. My opponent, however, cannot cite how the ICD's were converted, and much less can he cite how a biphasic external defibrillator can be converted into a triphasic external defibrillator. If you cite a source, it should be as reference otherwise you are committing a logical fallacy of appealing to authority. If I argue that you can convert a diesel engine into a biodiesel engine and I cite a source, it should explain how it can be done- not simply that it can be done, otherwise the statement is simply hearsay. I am not saying the statement within the article is hearsay, rather that my opponent does not understand the differences between the technology cited in the study- ICD's- and the technology I am referring to- external defibrillators.
4. Converting Biphasics to Triphasics
My opponent claims that this argument is about what "should" happen. The evaluative "should" in this debate is whether biphasic defibrillators should replace monophasic defibrillators- both technologies commercially available to hospitals. My opponent presents an evaluative "should" that is not compatible with my premise, and is not an opposition to my premise. His evaluative "should" is hypothetical- triphasic waveforms should be used because they have been proven superior. The problem is that a triphasic defibrillator has not been developed and is not commercially available to hospitals. Should this line of argument be opened up, the debate would convert entirely to quadriphasic waveforms, which are superior to mono, bi, AND triphasic waveforms, BUT there is not existing device called a quadriphasic defibrillator just as there is no triphasic defibrillators. I contend that hospitals should replace and outdated technology with an existing superior technology- monophasic vs. biphasic defibrillators.
My opponents "lastly" paragraph makes no sense. Biphasic defibrillators are already in production and being sold. The fact that hospitals would buy them to replace existing monophasic defibrillators will not require any manufacturing on the part of hospitals. He, again, claims that biphasic defibrillator possess the hardware and software necessary to operate as triphasics. I will again point out that his source does not reference biphasic defibrillators that existed at the time- in fact, it was those studies that led to the development of the first biphasic external defibrillators in 1996, and triphasic ICD's a little later. I never claimed quadriphasic defibrillators are better than triphasics- I said quadriphasic WAVEFORMS are more efficient than triphasic waveforms. The devices to deliver them do not exist as commercially available devices, just as triphasic external defibrillators do not exist. Monophasic defibrillators exist, and so do biphasic defibrillators. My opponent should either concede the debate, or educate himself on the subject if he is to continue. Thank you.
"My studies 'vs' my opponent's"
Note that our studies do not conflict in any way. My opponent showed in R1 that biphasics were superior to monophasics, a fact I've never denied. I've shown that triphasics are superior to both monophasics and biphasics, and that converting biphasics to triphasics is a simple firmware update away.
My opponent explains that only monophasics and biphasics are 'commercially available in hospitals.' First, unless there is a market set up inside of most hospitals, that is not true. The only units available in hospitals are units that are currently there.
But then, we're not talking about what the hospitals can use IMMEDIATELY. We're talking about what they _should_ use moving forward. Perhaps I haven't been as clear as I could be on my advocacy. I will list out all the points in my advocacy.
1. FDA should allow use of triphasics and/or quadriphasics immediately, since they are superior.
2. All biphasics that can be converted to triphasics or quadriphasics via firmware updates should be updated as such.
3. Manufacturers who produce biphasics should stop immediately, due to their superiority with little to no additional manufacturing cost.
4. The market should then be allowed to run its course. Newly converted or newly manufactured triphasics or quadriphasics would no doubt come to replace the outdated monophasics over time.
You see, it does not matter that the FDA has not approved tri's or quad's in the status quo, since they do so as part of my advocacy.
ICD's vs. External Defibrillators
Neither of the studies I presented state that they are talking about ICD's. In fact, the first study I gave explained that it used EXTERNAL defibrillation:
"Under fluoroscopic guidance, via right external jugular access, a 0094 Endotak lead (CPI) with a 4.7-cm-long RV electrode and a 6.9-cm-long superior vena cava electrode was positioned with the tip at the RV apex. A titanium can with a surface area of 92 cm2 was placed in the left pectoral region and made electrically common with the superior vena cava electrode."
My opponent has completely fabricated this nonsense about how my studies are talking about internal defibrillators.
Here is a statement from the other study I presented:
"The defibrillation shocks were delivered from commercially available self-adhesive monitor-defibrillator electrode pads (model M3501A, Philips Medical Systems, Andover, Massachusetts) with a conductive area of 102 cm2, placed on the shaved chest of the pig. One pad was placed anteriorly over the sternum, and the second pad was placed posteriorly over the vertebral column."
For those who don't know, the M3501A is an EXTERNAL defibrillator pad.
Both of my studies used external defibrillation. My opponent is fabricating all claims to the contrary, and I have supported my claim that they are external defibrillation.
Even so, if they were internal, it would make no difference. The studies were done to compare the effectiveness of different waveforms, not the effectiveness of internal vs. external.
"Manufacturing cost of monophasic vs. biphasic"
I never claimed to know the difference in manufacturing cost between monophasics and biphasics. I simply know that the difference in manufacturing cost between biphasics and triphasics is quite small, due to identical hardware with only software differences.
Triphasics are currently available, by way of the fact that a simple firmware update will change most biphasics into triphasics. See my first source, which I've shown was talking about external defibrillators, which claims that they can be converted quite easily, with only software updates. This also makes sense, since biphasics already have hardware capable of 1. giving a pulse for a certain amount of time, and 2. Automatically switching to a new pulse after the first pulse. There's nothing new that a triphasic would need.
Due to this small difference between biphasics and triphasics, biphasics could be converted immediately, and biphasic manufacturers could switch the default firmware immediately.
Sorry, but claiming to have expertise and asserting that I am wrong does not amount to a good argument. I have provided a credible source - a rigourous, professional study in a well-respected journal. I have also explained why there would need be no hardware changes to convert biphasics to triphasics - biphasics already have all the mechanisms necessary to operate as triphasics. All that's necessary is a simple firmware change.
But just in case someone believes my opponent's argument here makes sense, that his self-proclaimed expertise is superior to my sources, I hereby proclaim myself a super-expert, and I'm saying my opponent is wrong. Therefore he is wrong, because I said so and I claimed I'm more of an expert than he.
And once again, my opponent ignorantly claims that my studies were using ICD's and this mysterious 'Mac computer,' with nothing but the sound of his voice backing him up. And as of this round, I've shown that both my studies were in fact using EXTERNAL defirillation, contrary to my opponent's unbacked claims.
"Not in opposition"
My opponent claims that my advocacy is not in opposition to his, but it is. I detailed my advocacy quite well earlier in this round, and it does not contain the replacement of monophasics by biphasics. Thus, I am negating the resolution, I am explaining why, RATHER THAN monophasics being replaced by biphasics, they should be replaced by something better than biphasics. My opponent must simply show why his advocacy, which includes biphasics replacing monophasics, is superior to mine.
I explained last round that my opponent's advocacy requires the manufacturing of more biphasics. There are simply not enough biphasics sitting idly on merchants' shelves to replace all monophasics.
Even so, it doesn't matter. Biphasics can be converted to triphasics quite easily, with naught but a change in firmware. And perhaps even into quadriphasics, though I don't have a source backing me up on that one. In either case, either would be superior to the biphasics my opponent wishes to use, and since biphasics can be converted to triphasics rather easily, it only makes sense to do that right away.
Oh, and thanks for the study showing that quadriphasics are the best of the first four waveforms. If biphasics can be converted into them easily, that's just one more way to negate the resolution.
"My opponent should either concede the debate, or educate himself on the subject if he is to continue."
Thanks for the advice, Mang, but I'm already quite educated on this topic. If you remember, I'm a super-expert. Hopefully you don't up the ante and proclaim yourself a super-super-expert, or things might get a little crazy.
Good luck to my opponent in the following rounds.
I have posted this information simply to point out the similarities in the expertise of those listed in the study and my own. I am the Lead Biomedical Technician at St. Joseph's Hospital's Biomedical Engineering Department. I am pointing this out due to the technical level my opponent has forced me to respond in. I will put quotes from his studies in quotes, and follow up with how I have addressed these statements in my arguments, and how my opponent has ignored the expertise of his own sources.
"300-�F-capacitor defibrillator"/"140-�F-capacitor defibrillator"- Method of delivery of shocks cited in my opponent's source. Note the names of the departments above.
"Under fluoroscopic guidance, via right external jugular access"- Fluoroscopy is a process of real time x-ray through a fluoroscopic image intensifier. It is used during invasive surgeries. The right external jugular is a vein. My opponent cites this as evidence that the ICD's are external defibrillators, but it is evident that the electrodes in question in this paragraph are internal. The superior vena cava is another vein. The "rv apex"? Right ventricular- the right ventricle is a part of the heart. This is why if we cite a source we must understand the information contained therein. The 0094 Endotak Lead is a subcutaneous electrode.
"Jian Huang, MD; Bruce H. KenKnight, PhD; Dennis L. Rollins, MS; William M. Smith, PhD; Raymond E. Ideker, MD, PhD"- These are the names of the doctors conducting the study. http://www.freepatentsonline.com... This is a link to their filing of a patent for the ICD's developed during the study, and explanation of their purpose and findings, and the explanation of their use of the VENTAK™ external cardioverter defibrillator. The term "external cardioverter" in reference to an ICD refers to the position of the leads external to the veins rather than internal to them, not the defibrillator itself. http://18.104.22.168/search?q=cache:57uqV6EerAIJ:bulk.resource.org/gpo.gov/register/1995/1995_19948.pdf+VENTAK%E2%84%A2+external+cardioverter+defibrillator&hl=en&ct=clnk&cd=3&gl=us
Now, to emphasize the study addresses ICD's there is this statement "This study only tested 300-�F-capacitor triphasic waveforms; it is unknown whether the findings would also apply to triphasic waveforms delivered from other-size capacitors." My opponent bases his entire case on the following statement: "However, most defibrillators that can deliver a biphasic waveform already contain the switches and other hardware necessary for delivery of a triphasic waveform. Therefore, slight alteration of the software in the defibrillator to switch the waveform a second time to deliver the third phase is the main change required for delivery of a triphasic shock." This is obviously in reference to ICD's using 300 micro farad capacitors, and no other types of defibrillators because they were not tested.
Now, on to the other study...
It is important to note that this study was exclusive to pigs. Here is the first statement I will address.
"Defibrillating shocks were delivered from a custom-built defibrillator with a 115-�F capacitor, which was capable of delivering biphasic or triphasic truncated exponential waveform shocks with polarity, pulse duration, and selected energy, as determined by the operator"- A custom built defibrillator does not possess various protections for the patient that a commercially available defibrillator would provide. A custom built defibrillator tested on pigs also cannot be looked to as an option for replacing commercially tested and approved Class II defibrillators.
"The defibrillation shocks were delivered from commercially available self-adhesive monitor-defibrillator electrode pads"- This second study did in fact employ external defibrillation, HOWEVER this study does not claim that biphasic defibrillators can be easily converted into triphasic defibrillators, and in fact does not use a commercially available biphasic defibrillator altered to deliver triphasic shocks, rather it used a custom built defibrillator. This, besides my last contention, nullifies this line of argument from my opponent.
My opponent states that both of his studies "used external defibrillation". His claim that I have fabricated facts to the contrary has been proven false, and his argument is nullified. My opponent cannot show how an external biphasic defibrillator can be converted into a triphasic defibrillator.
"The electrode pads we used are proportionately large for 18- to 28-kg pigs compared with 70-kg humans...These species differences may explain the observation that the highest biphasic waveform success rate we observed was about 80%, whereas in humans, higher success rates have been observed"- I posted a link to a study in which higher success rates of defibrillation were observed amongst human patients using biphasic defibrillators. My opponent's own study suggests it could not reproduce this feat due to their limitations using pigs, and therefore the results of the study cannot be applied to humans, as there is no telling what the comparison would be between triphasic vs. biphasic amongst humans.
"The waveforms utilized in our custom-made defibrillator did not compensate for high impedance by automatically adjusting the duration and/or voltage of the pulses, as do some commercially available biphasic waveform defibrillators."- Another failure in this study, and more evidence that the defibrillators used in these studies are not compatible with commercially available biphasic defibrillators.
As for my opponent's contentions against commercial availability, it is obvious I meant to say "commercially available TO hospitals" as I made the statement "commercially available", excluding the "in hospitals" designation several times throughout my arguments. As for his statement on immediate availability, my opening statement makes it obvious that my premise is based on commercially available technologies. My premise refers to "biphasic defibrillators", and their efficiency compared to monophasic defibrillators, while my opponent's contention is based on waveforms- not commercially available defibrillators. Read from my R1- "My position is that biphasic defibrillators are more beneficial to the patient, are more efficient, and provide more reliable technology than do monophasic defibrillators."
An obvious Con to this statement would be "biphasic defibrillators are not more beneficial to the patient, more efficient, and a more reliable technology than monophasic defibrillators". My opponent's alternative of triphasic defibrillators cannot make the claim "triphasic defibrillators are more beneficial to the patient, more efficient, and provide more reliable technology than biphasics" because triphasic defibrillators are not commercially available, and are not a technology that has been developed. My argument is not that triphasics should not be developed, but if it takes ten years before they are commercially available I will argue (if proven more efficient) that they should replace the outdated biphasics. It is important to note that the average life cycle of medical equipment is ten years, and if they are available in such time this position would THEN be consistent with traditional replacement policies.
My opponent asserts that he is more of an expert on this subject than I am.
He claims to have pretty much the same qualifications as the people conducting the studies I linked. That's great, if it' indeed true. However, my opponent's claims are completely irrelevant. No matter his qualifications, he is still required, like anyone else, to back up his assertions. Not only that, but this is the internet. No one knows whether my opponent is really the Lead Biomedical Technician at St. Joseph's Hospital's Biomedical Engineering Department, or if he is just lying to us to make himself seem more credible. Like a suspect on the witness stand, we have to take his claims with a grain of salt.
"First study used ICD's"
I concede this point. It's irrelevant anyway, since the first study I linked was inconclusive.
RE: ""However, most defibrillators that can deliver a biphasic waveform already contain the switches and other hardware necessary for delivery of a triphasic waveform. Therefore, slight alteration of the software in the defibrillator to switch the waveform a second time to deliver the third phase is the main change required for delivery of a triphasic shock." This is obviously in reference to ICD's using 300 micro farad capacitors, and no other types of defibrillators because they were not tested."
My opponent is mistaken here. While the study used 300-�f triphasics, the quote was not talking specifically about the defibrillaters they used. In fact, the writers specify they are talking about "Most defibrillators." Most defibrillators were not part of their study, but the possible conversion of biphasics to triphasics was not a conclusion of the study, it was a simply a relevant fact stated in the study. The only logical conclusion is that it was truly referring to 'most defibrillators,' without the imaginary 300-�f qualifier my opponent wishes they used.
The only point of the second study was for me to show that triphasics were indeed statistically significantly better than biphasics, something the first study failed to show. My opponent is not arguing against this fact, so it seems he agrees that triphasics are indeed superior.
My opponent had, in round 3, claimed that this study used internal defibrillation, but he has abandoned that claim.
Of course, he is now claiming that the results, while valid, might not be the same in humans. He claims that 'there is no telling what the comparison between triphasic and biphasic would be for humans.' Nonsense. The reason the study used pigs in the first place is that they are similar enough that we could at least get a good idea of the differences between triphasic and biphasic for humans. While the results might not be exactly the same for humans, there is nothing suggesting triphasics are inferior to biphasics, and there are studies indicating a superiority of triphasics to biphasics. The only logical conclusion is that triphasics would be superior in humans as well, just as they are when used in ICD's, as my opponent has pointed out.
If biphasics can be converted to triphasics easily, then triphasics are available to hospitals, so this enitre point of commercial availability is really just a restatement of my opponent's assertion that conversion of defibrillators is not very easy. No need to address the same point twice - I've already argued earlier this round that most biphasics can be converted to triphasics easily.
"My opponent's position"
No matter what my opponent claims, we are NOT debating whether biphasics are superior to monophasics. We're debating whether or not "Biphasic should replace Monophasic Defibrillators." My opponent, as PRO, is claiming that they should, I am claiming that they should not. Let us look at two different statements.
1. "Biphasics should replace monophasics."
2. "Triphasics should replace monophasics."
These are mutually exclusive. The answers to these questions will tell us which is true, assuming one or the other is indeed true.
Which are better, biphasics or triphasics?
Would it be difficult for either of these to replace monophasics, and is the extra trouble worth it?
The answer to the first question is that triphasics are superior. Triphasic waveforms have been shown to be superior in various applications, whereas biphasics have never shown themselves to be superior to triphasics.
The answer to the second question is that it would be a little bit more difficult for triphasics to replace monophasics. The additional difficulty comes from the need to flash the firmware in biphasics to convert them to triphasics. However, this is a very small difficulty, and the benefits of triphasics outweigh this small level of difficulty.
Of course, it could be true that neither of the statements is true. This would be true if there was some other alternative, like quadriphasics, that was even more worth it. This is only a problem for my opponent. My only obligation in this debate is to show that my opponent is wrong. Due to the nature of his claim, I simply have to provide one or more superior alternatives to biphasics replacing monophasics. Piling on more alternatives only helps me, and only hurts my opponent.
One last thing
My opponent did not address my explanation of why firmware changes would be enough to convert biphasics to triphasics. I claimed last round that biphasics had all the necessary hardware to be converted into triphasics- a pulse generator, and a mechanism to automatically switch pulses, among other things. My opponent had demanded that I do more than just cite a source, but that I provide reasoning for why my source is correct; I did just that, and now he has failed to address my reasoning. By dropping this part of my argument, he is conceding that biphasics contain all the necessary hardware to be converted to triphasics, and that firmware changes should be all that's required for the conversion.
I look forward to these concluding statements.
R1: In his non-resolutional advocacy, my opponent claims that "for the same reasons biphasics are superior to monophasics, triphasics are superior to biphasics". This statement is simply not true. My opponent has failed to provide a conclusive study with the various available biphasic waveforms, compared with equal triphasic waveforms at the same energy levels that would back up this statement. There are currently two commercially available external defibrillators, and two commercially available ICD's- monophasics and biphasics, though patents for triphasic ICD's have been submitted. My opponent's conclusion to this paragraph is "I am advocating replacing both monophasics and biphasics with triphasics, thus, the resolution is negated". My opponent's position is impossible, as there are no commercially available triphasic defibrillators. Because there is no way I can provide a source for what does not exist, I would urge all who question the validity of this statement to diligently search Google for any mention of triphasic defibrillators. You will find patents for triphasic ICD's, but none commercially available, and tests for triphasic waveforms. Conduct a similar search for biphasic defibrillators and you will come up instantly with at least 4 manufacturer's and various models- HP, Philips (which acquired HP's medical unit), Zoll, Medtronic/Physio Control. Medtronic/Physio Control is the market leader in defibrillation technology, and has not submitted a triphasic defibrillator to the FDA for consideration for Class II (commercially available devices) as it has with it's biphasic defibrillators.
My opponent also made the following claim: "Thus, it is extremely easy to convert most biphasics into triphasics." He has failed to show how it would be "extremely easy" to convert biphasics into triphasics, and has referenced his first study to back this statement up. When I asked for elaboration, he said he didn't need to elaborate because he was citing a credible source. Indeed his source is credible, but his source did not make the same claim. Furthermore, I have demonstrated that his source was referring to ICD's for which the authors submitted a patent for the triphasic ICD they converted from a commercially available biphasic ICD.
R2: In this round he sources another study, and claims it is statistically significant. I demonstrated how the authors of the study themselves claimed their study was inconclusive as there were other studies that showed biphasic cardioversion at higher levels amongst humans, and their study was porcine. My opponent denied this claim, which came directly from his source.
My opponent makes this claim as well: "By requiring less energy/amps/ to be put through a subject's body for effective defibrillation, triphasics are not only more effective, they can also cause less damage to a subject". This is a false claim, as it refers to energy delivered at 50J and 100J regardless of phase, delivered at 6.8A, 8A, and 10A. Joules is a measurement of energy, and amperes is a measurement of current. The formula for joules is a little complicated, but in this case the current is constant, and it is the time applied that changes: triphasic (4.8/4.8/4.8 ms) and biphasic (7.2/7.2 ms).
My opponent then makes the following false claim: "If we don't accept this reasoning, then we should continue using monophasics due to their cheaper manufacturing costs." He implies that manufacturing costs would somehow negatively affect the manufacturer and the consumer (the hospital), but he later claims to not know the manufacturing costs, and ignores my statements regarding the cost for the hospital. He ignores that triphasic defibrillators are not commercially available, and have not even been submitted to the FDA for consideration. This would mean there is a window of at least ten years before they would become commercially available and trusted within the industry (biphasics were invented in 1996 and took over the market around 2006).
And the following: "There is likely too much defibrillation for the biphasics to handle alone, otherwise hospitals would not ever have a reason to use a monophasic", ignoring the fact that monophasics were around before biphasics, hence my recommendation that they finally be replaced once and for all as an obsolete technology.
He repeats the following: "I provided a reliable source for my claim that the conversion was possible and simple" which is simply nonsense. Biphasic external defibrillators cannot be converted into triphasics, and biphasic defibrillators that CAN be have NOT been because all the studies are inconclusive, even though there is a manufacturing model already patented.
And makes the following claim: "Due to triphasics being superior, the FDA should approve them". The FDA has not received any triphasics for approval. Studies are still being conducted, but none have yet been done on humans.
And this statement makes no sense: "It shouldn't just approve them as a general rule, but sould approve the specifications the hospitals would be switching to." The FDA cannot simply approve a "conversion" procedure, or whatever it is he is referring to. This would violate patents, copyrights, trademarks, would violate NFPA 99 recommendations which is law in some states, Joint Commission guidelines on equipment alterations, etc.
Due to limited space, I will jump to his false claims in Round 4.
"He claims to have pretty much the same qualifications as the people conducting the studies I linked"- Not true. I claimed we had similar backgrounds and specifically pointed out that I work for the Biomedical Engineering Department at St. Joseph's Hospital. Some of the participants in his studies work at Biomedical Engineering Departments, and it is this department that would validate these claims when considered by a hospital during capital purchases.
"No matter his qualifications, he is still required, like anyone else, to back up his assertions"- I've left no assertions un-referenced. I pointed out my background simply to make it clear that I understand what the sources are referring to, while my opponent ignores facts within the sources themselves.
"I concede this point. It's irrelevant anyway, since the first study I linked was inconclusive."- Yet he later asserts the biphasic/triphasic conversion referred to was not specific to ICD's, though the authors submitted for a patent for their converted ICD.
"The only logical conclusion is that it was truly referring to 'most defibrillators,"- Other statements made within the study refer to ICD's as "defibrillators". The authors never referenced any external defibrillator, nor any external application. The only logical conclusion is they were referring to the biphasic ICD they converted into a triphasic for the study, and similar ICD's which contain very similar hardware.
"My opponent is not arguing against this fact, so it seems he agrees that triphasics are indeed superior."- All you have to do is read the study and see it states various times that the study was inconclusive, and limited for various reasons.
"the results, while valid, might not be the same in humans"- I quoted the study itself. My opponent claims the study came to conclusions the authors themselves do not claim.
"If biphasics can be converted to triphasics easily"- I am dying for elaboration. I challenge you to show me how a Lifepak 12 Adaptiv Biphasic Defibrillator can be converted into a triphasic. My opponent claims to have given an explanation of how a biphasic defibrillator can be converted into a triphasic. He has seriously underestimated the number of internal components of a Lifepak 12, Lifepak 20, Hearstart XL, Zoll M series, or any biphasic defibrillator. My opponent's claims are simply not true. He has failed to show why biphasics should not replace monophasic defibrillators.
My opponent claims that I have not substantiated the claimthat triphasic waveforms are better than biphasic waveforms at defibrillation. However, the second study I referenced did just that. While it was a study done on pigs, and the numbers might be a bit different for humans, the consistent statistical superiority of triphasics in the study means we can at least take from the study that triphasic waveforms are more effective than biphasics at defibrillating mammals.
Further, my opponent complains that there are no commercially available triphasics, something he has said many times. However, that does not matter; biphasics can be easily converted to triphasics with a mere firmware upgrade. Since triphasics are superior, biphasics should be converted immediately, which leads to the impossibility of my opponent's resolution.
My opponent also claims that I failed to back up my statement that biphasics could easily be converted to triphasics. I did this in one of my rounds - I explained that biphasics already contain all the hardware available to create triphasic waveforms - the necessary mechanisms to apply pulses, and the necessary mechanisms to automatically switch to a different pulse.
My opponent also claims that my source was talking about ICD's when it said converting a biphasic unit to a triphasic unit was easy. My source did NOT specify ICD's for that statement, it simply said that MOST BIPHASIC DEFIBRILLATORS could be converted to triphasics without only software[firmware] changes.
My opponent brings up here the 'problem' with my second study using pigs as subjects. Like I said, though, if triphasics are consistently superior to biphasics using pigs, they are probably superior for all mammals. I never claimed that the success rates would all be exactly the same for every single animal, I simply explained that a consistent trend like that is very unlikely to be different between humans and pigs. Indeed, that is why the study used pigs - because they are biologically similar enough to us that such trends would translate to humans [note that a proper controlled experiment using humans for this study would be illegal and unethical, so my opponent is asking for a bit much in wanting us to use the same species].
I did state that triphasics could be both less damaging and more effective. This is a function of their increased effectiveness. Since at the same energy levels, they are more effective, the energy levels could be lowered slightly to maintain superior effectiveness while also reducing damage. Also, my first source did have some reasoning for why triphasics would be less damaging than biphasics, but it would be a bit abusive for me to bring that up now, since it's the final round and all.
My opponent once again brings up the nonsense a bout commercial availability and FDA approval. The FDA could approve them tomorrow, and biphasics could be converted to triphasics extremely quickly, since they would only need new firmware. I explained several times how I was dealing with these two problems, yet even in the last round my opponent cannot help but bring up his exact same arguments - the same arguments I have responded to every round.
MY opponent also brings up this new argument in the final round, which is a bit abusive to do, but I will address it nonetheless:
On converting biphasics to triphasics: "This would violate patents, copyrights, trademarks, would violate NFPA 99 recommendations which is law in some states, Joint Commission guidelines on equipment alterations, etc."
> It would not violate patents. Patents assure that other companies cannot produce a specific design. This has nothing to do with flashing a new firmware on the device to allow it to operate as a triphasic. In fact, the design remains exactly the same, so a converted device could not violate a patent unless the unconverted device did as well!
> Copyrights and trademarks have even less to do with this. Copyrights would apply perhaps to the firmware on the device. However, since that firmware would no longer be in use, that has nothing to do with anything. Trademark can't be applied to anything, except maybe the name of the device, which would or wouldn't be changed to be in accordance with whatever trademarks.
> "Would violate NFPA 99 recommendations which is law in some states" - my opponent doesn't explain what that is, why it's a law, or why it can't just be appealed immediately.
> "Joint Commission guidelines on equipment alterations" - my opponent once again does not explain what these are, but IF the conversion I am advocating violates these guidelines, then a> the guidelines can be altered or appealed. and b> They are probably only guidelines, according to the name.
My opponent once again claims to have credentials in the field, but that is unprovable, and my opponent has done nothing but blankly assert it. Remember, in an earlier round, I even claimed to have even more expertise on the subject than him, a fact he didn't even deny. Thus, if we're going to place any value on self-proclaimed credentials [which we shouldn't], then we shold be listening much more to what I say.
My opponent said...> "If biphasics can be converted to triphasics easily"- I am dying for elaboration. I challenge you to show me how a Lifepak 12 Adaptiv Biphasic Defibrillator can be converted into a triphasic.
I say... > Once again, my opponent is asking a bit much. I already explained that triphasics do not require any additional components compared to biphasics, and my opponent did nothing to argue against this. He did not give an example of a component a triphasic would need that a biphasic lacks. He did not effectively argue at all against my reasoning behind easy conversion.
On many of my points, my opponent's only argument was that I am ignorant and incorrect. Rather than explaining WHY my claims are supposedly false [i.e. WHY can't a biphasic be converted into a triphasic?] he has simply asserted that I am wrong.
Also, keep in mind that my opponent started this debate for an easy win. Biphasics already have been replacing monphasics, biphasics have been shown time and time again to be superior to monophasics. The stance my opponent wanted CON to take was completely ridiculous and invalid. Luckily, I was able to create an argument against his resolution based on other, more valid lines of reasoning.
Note that besides his own assertions, my opponent has provided two sources - at the beginning, a source that showed the superiority of biphasics to monophasics, and then a source that didn't really even have to do with this debate. It was a study showing the superiority of quadriphasics to triphasics. That supports the trend my claim is based off of, that more phases = better defibrillation. Further, I gave sources for all my major claims - a source that backs up the ease of converting most biphasics to triphasics, and a source backing up the superiority of triphasics to biphasics.
My opponent made many claims - "The FDA doesn't approve that!", "It's not easy to convert biphasics to triphasics!", "I am a lead biomedical technician, so my assertions mean more than my opponent's assertions!" - were any of these claims backed up by sources? No. Each of these were ONLY assertions - no evidence, no third party testimony, and no reasoning to back these up. Just claims.
But I have wasted enough of your time. I thank any of you who successfully read this entire debate, and I implore you to vote wisely. I also thank my opponent for this discourse. Fare well.
3 votes have been placed for this debate. Showing 1 through 3 records.
Vote Placed by jjmd280 8 years ago
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Vote Placed by Supernova 8 years ago
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Vote Placed by Mangani 8 years ago
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