In response to Emergency Cardiovascular Care 2010 Update Interview – MedicCast – Part I, firetender wrote
On one hand, you say you’re practicing real medicine and on the other you’re lamenting that a lot of the stuff you use hasn’t quite been proven, and lotsa stuff being used elsewhere should be taken off the trucks because you recognize our patients are being used as guinea pigs. Still, you DO recognize you are part of an experiment..
I am critical of the treatments that are used in EMS, and in the hospital, that are not science-based.
Where is the inconsistency?
If patients are being treated with something not supported by good evidence, they should be informed of this, or the appropriate waiver of informed consent for emergency research should apply. That is not the case with the treatments I criticize.
The only thing that I’m adding is that it’s quite myopic to think that the practitioners that came before you didn’t base what they did on science. It was just the science of their times.
Show me controlled trials, not anecdotal evidence and you will convince me that they were using science.
I have not seen any well controlled experiments that demonstrate efficacy and safety for alternative medicine treatments.
The default approach is to doubt that a treatment works, not to say, What if . . . ?
The science of their times was not experimental science. Where were the controls on variables?
Only remnants of what I used are in your drug box. And most of them don’t at all get used the way I used them because they were found to be, in some cases, dangerous!
That is because they were not based on research showing improved outcomes.
We are very far away from the point of having any of our treatments set in stone. On the continuum of medical knowledge, we are still infants. You don’t seem to be willing to live with that.
The only mature way to deal with that is to use science to find out what does work, rather than adopting something based on expert recommendation or ancient wisdom or anything other than experimentation. Expert recommendation and ancient wisdom almost always lead us to things that do not work.
Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation … Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:
Science is the belief in the ignorance of experts.
– Richard Feynman.
The things that do work are able to demonstrate efficacy and safety and are adopted by medicine.
The things that do not work are not able to demonstrate efficacy and/or safety and they are often adopted by alternative medicine and promoted as the secret treatment “Big Pharma” doesn’t want you to have! Pure BS, but pure BS perfectly describes alternative medicine.
Just like it was temporary, and soon to be “proven” wrong, so too will yours be.
Are you claiming that we will find out that morphine and fentanyl are not effective for pain management?
Are you claiming that we will find out that lorazepam and midazolam are not effective for sedation?
Are you claiming that we will find out that CPAP (Continuous Positive Airway Pressure) and high-dose nitrates are not effective for hypertensive acute pulmonary edema?
Are you claiming that we will find out that high quality chest compressions and defibrillation are not effective for cardiac arrest?
Are you really that crazy?
These treatments will probably be replaced by better treatments, but that does not mean that these treatments do work any more.
If I own a car and use it for a couple hundred thousand miles, then I sell it and buy a newer and better car, does that mean that the my original car did not work? Does that mean that I did not go to any of the places I traveled to in that car?
Science shows us what does not work much more clearly than it shows us what does work. That is the nature of the scientific method. We test something against a placebo. If it does not produce better results than a placebo, then it is just another placebo.
I have written about this here, here, here, here, here, here, here, here, and here.
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The large, blind, multi city trials that you desire are wonderful, but not always practical and are never cheap. Studies done on animals are easy in comparison because you can control all of the variables. You can’t do that in the hospital, much less in the field. Often to get a suitable study population takes years and years, and as a result many studies are done on smaller than ideal study populations. Cardiac arrest studies are probably even harder because in the real world we do relatively few of them. I might do 12 a year, maybe. I don’t remember the our system wide numbers, but they aren’t terribly large and we do collect a lot of data. Still it’s hard to make
A couple of years ago impedence threshold devices were the best thing going. Well, until a large enough study determined that they weren’t the best thing going. In fact, they might even have decreased survival. Remember high dose epi? Same thing. I think that the truth is that some part of ACLS is always going to be by trial and error. I don’t much like that fact, but I’m not sure there is a way around it.
That’s without the politics. Try explaining to a patient’s family, let alone a grand standing politician, that their loved one or constituent is going to get the placebo when you have a potentially life saving drug in your drug box. Let me know how that works for you.
Too Old To Work,
These studies are cheap to perform, but they generally do not provide much in the way of valuable information. We continually find treatments that provide spectacular success in animals. When tested in humans, they do not work. Most of the cardiac arrest drugs do a great job in lab animals, but none have been shown to improve outcomes in humans.
The cardiac arrest drugs we have are based on animal studies and on small human studies. They were not placed in the guidelines based on studies that showed improved outcomes. We still do not have any good survival to discharge studies. Rather than require evidence of benefit, we approved these based almost entirely on Wishful Thinking.
They should not know they are getting the placebo. If the patient, the family, the medics, the doctor, or anyone else knows who is getting the placebo, the trial is not properly blinded.
If we want a chance at getting the experimental treatment, we need to accept that we might only end up receiving the placebo.
We need to be told that there is no good evidence that the experimental drug works any better than placebo. That is the reason for the research.
Or we can choose not to participate in the research (there are opt out provisions even for cardiac arrest research). If we do refuse to participate, it should mean that we do not receive the experimental treatment(s) or the placebo, but that we only receive treatments that have been shown to improve outcomes that matter.
Currently, we do not do that. Currently, the default treatments are not well tested.
Currently, the
standard of caredefault treatment is best described as, Wouldn’t it be wonderful if . . . ?This is not medicine.
…and then!
Well, Rogue, to be honest with you, I might very well be, but I’ll embrace it based on your Feynman quote!
It’s quite possible a lot of the therapies and drugs you mention will be shown to do what they were advertised to do. But when the next set of experts determines that what they did really didn’t help that much in the long-term, and, in fact interfered in some way with progress that they now have shown essential to recovery, then where does that put you?
You are practicing the medicine of today. If we’re doing what we’re supposed to be doing, according to Feynman, then you’re sure to be proven wrong!
Let’s put it this way, Rogue, today, you really are Feynman’s expert!
firetender,
I converted your attempts at html to real html. I did not change any of your words.
You confuse experts with science. I will explain in more detail.
Later today (10-28-10) at 06:30 – The Difference Between Doubt and Post Modernist Insanity – Part I.
Next week – The Difference Between Doubt and Post Modernist Insanity – Part II.
The week after – The Difference Between Doubt and Post Modernist Insanity – Part III.
You provide plenty of opportunities for me to explain about the different logical fallacies that you rely on.