I was enjoying this week’s EMS Garage. They added some people I know through the wonders of the internet. Nick Nudell, who does a lot with the EKG club.com. The eponymous Sam the EMT, who with EpiJunky, used to moderate an EMS version of Grand Rounds – Normal Sinus Rhythm.
At about 28 1/2 minutes, there was a bit of discussion of an article by Dr. Wesley[2] reviewing a study of Trendelenburg position from 2004.[3] I was expecting Skip Kirkwood to be somewhat consistent in his approach to research. At least consistent to the other 2 episodes I had listened to. I was disappointed.
Let me explain about the way we should apply research to medical treatments, especially medical treatments in the far less stable environment of EMS. Without evidence of a significant benefit from the treatment, there is absolutely no reason to use the treatment. This does not just apply to EMS treatments, but the limitation is much more important in EMS, because it is so easy to make things much worse.
Worse?
As in, She’s not only merely dead, she’s really most sincerely dead.
Here are the points that were made in defense of this indefensible treatment:
- 1. Does it hurt anybody?
- 2. To argue this is kind of like arguing against gravity.
- 3. They (the authors of the research calling Trendelenburg a myth) never said it was a bad idea
- 4. With orthostatic hypotension, people will get dizzy when they sit up, obviously gravity is working that way.
- 5. I’ve seen pedal edema much relieved by putting the feet up, which means fluid does follow gravity in some way or another.
- 6. Even the study itself . . . said that venous return is increased. Starlings Law comes into effect here. If venous return is increased, why isn’t that helping?
- 7. A lot of the people that I put in Trendelenburg, or sit on their head, are going to die anyway. These are people that are bad off. Maybe it doesn’t really turn the tide on that particular patient, but it doesn’t necessarily mean that it isn’t a good idea and we shouldn’t be trying it. Until there’s something that shows that it’s bad for people. . . .
- 8. Since the research has been done on healthy volunteers – Why would you do that to somebody who wasn’t sick?[1]
Now, these might be impromptu responses to somebody bringing up a study, except that they mentioned that Dr. Wesley was supposed to be on the show to discuss his review of this article. In his comments, he mentions reading the article. The original article and Dr. Wesley’s review of it are available for free at the links at the end of this post.
They never said it was a bad idea.[1]
There are only 2 pages of, This is a bad idea. Maybe they should have written in big letters – Danger! I could copy all of the problems described, such as impaired respirations due to the abdominal contents pushing down on the diaphragm, but it is better if you read the short paper. I will add one, that appears not to have come up. Reflux, the migration of stomach contents to the oropharynx in a supine person, seems much more common, now. How does reflux change when the stomach gets some help from gravity? Does that kind of fluid following gravity not count?
Misstatement that the lungs were pushing down on the diaphragm corrected due to the vigilance of Vince. 4/28/09 @ 12:00
There’s a lot of studies trying to reinvent the wheel, or go back and look at these obvious things, and say, Well, is this good or not?[1]
While these are all valid questions, they are not valid reasons for using the treatment.
Why not?
These are valid reasons for setting up a study to determine the safety of a treatment. This is something generally done with healthy volunteers. This is to get an idea of what is happening to the body before inflicting it on sick people.
If the treatment is found to be safe, it may progress to a study of effectiveness.
Since there do not appear to be any good effectiveness studies, this is not reinventing the wheel. Would he even know a wheel if it rolled over him?
If the treatment is so obviously effective, set up a study to demonstrate that it is effective. If this is Skip Kirkwood speaking, he seems to understand science, when dealing with cardiac arrest. Is this an example of Dissociative Identity Disorder (DID)? DID is the new name for Multiple Personality Disorder – maybe more personalities identify with this identity.
First, do no harm?
Dr. Wesley finishes his review succinctly:
Perhaps we can begin to treat our patients based more on science than on 150-year-old ritualized procedures.[2]
Will Dunn seems to understand it. Dr. Wesley pretty clearly understands it.
Late addition 5/05/09 at 21:12 – Another person, who clearly gets it and has written about it, is ParaCynic.[4]
Updated formatting and fixed broken links 9/14/2012 at 00:45.
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Footnotes:
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[1] EMS Garage Episode 31: Reckless Abandon
EMS Garage
Apr.24, 2009
Link to Broadcast
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[2] The Myth of the Trendelenburg Position
Keith Wesley, MD, FACEP
JEMS.com
Street Science
Article
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[3] Myth: the Trendelenburg position improves circulation in cases of shock.
Johnson S, Henderson SO.
CJEM. 2004 Jan;6(1):48-9. No abstract available.
PMID: 17433146 [PubMed – in process]
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[4] Tourniquets, Trendelenburg, Tampons, Toilet Paper.
ParaCynic
Article
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