Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

I’ve Seen It Work and Other Lies

 

One of the problems with getting people to pay attention to evidence in EMS is our belief that we have seen something work.

What does that mean?

I did something and based on my limited assessment I decided that what I did made the patient better.

For example, I measure the blood pressure before I treat the patient with magic® and the blood pressure is very low. I measure the blood pressure after I treat the patient with magic® and the blood pressure is also very low, but at least one of the numbers is higher.

Since all of my interventions are intended to be good, I conclude that my treatment with magic® is a good thing. The patient got better because I used magic®. I will now use magic® every time my patient’s blood pressure is low.

On the other hand, suppose I measure the blood pressure before I treat the patient with magic® and the blood pressure is very low. Then I measure the blood pressure after I treat the patient with magic® and the blood pressure is also very low, but this time both of the numbers are lower.

This is not a failure of the magic®. No. The patient was too sick to respond to magic®. Or I give some other excuse. It certainly could not be that I am using an ineffective magic®. No. I only use magic® that works.

Based on my hours of sitting in an EMS classroom, asking Is this going to be on the test? – I know what works. I’ve seen it work.

Never mind that doctors have said the same thing about every treatment that was at one time the standard of care –

Bleeding patients to get rid of the bad humors will make patients better.

I’ve seen it work!

Kayexalate lowers potassium in hyperkalemia.

I’ve seen it work!

Trendelenburg position improves outcome for hypotension due to hemorrhage.

I’ve seen it work!

Atropine improves outcomes in asystolic cardiac arrest.

I’ve seen it work!

Feeding kids sugar makes them hyperactive.

I’ve seen it work!

We know what works!

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Comments

  1. My good friend Dave once told me he brought a patient out of asystolic arrest with Narcan. I asked him whether or not it was a confirmed narcotics overdose. He said he didn’t know. So I asked him how he knew it was the Narcan that took the patient out of asystole. He said, “because he converted right after I gave him Narcan!” (Post hoc ergo propter hoc fallacy.) So I asked, “If you were to do a rain dance and then it rained, would it be the rain dance that made it rain?” He said, “Yes.”

    • Tom,

      My good friend Dave once told me he brought a patient out of asystolic arrest with Narcan. I asked him whether or not it was a confirmed narcotics overdose. He said he didn’t know. So I asked him how he knew it was the Narcan that took the patient out of asystole. He said, “because he converted right after I gave him Narcan!” (Post hoc ergo propter hoc fallacy.)

      I know a lot of people who assume that because they gave Narcan, then there was an improved level of consciousness, the patient must have taken heroin (or some other opioid). I wrote a bit about this in Narcan Solves Riddle – Part I, Part II, Part III, and Part IV.

      Post hoc ergo propter hoc fallacy.

      This is just one of the reasons it is so difficult to get people to understand why evidence is important. We are constantly looking for reasons to believe. We are constantly looking for reasons to be deceived. We aren’t deceived by others as much as we are by ourselves and our desire to find solutions.

      Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong.

      H.L. Mencken.

      So I asked, “If you were to do a rain dance and then it rained, would it be the rain dance that made it rain?” He said, “Yes.”

      Were there adult beverages involved?

      OTOH, I have not seen Dave’s rain dance, but I have witnessed his sarcasm. This may have been another example.

      .

  2. cupping for pneumonia…I’ve seen that bad boy work!
    Using EXTERNAL HONEY and HEAT for: 1) “pancreatic pain” 2) “liver detoxification” 3) “Gallbladder stasis”…we have all seen those work!

    • Simon G,

      cupping for pneumonia…I’ve seen that bad boy work!
      Using EXTERNAL HONEY and HEAT for: 1) “pancreatic pain” 2) “liver detoxification” 3) “Gallbladder stasis”…we have all seen those work!

      If we think about it, we have all seen patients improve after treatments that make no sense. So we don’t usually claim that the bizarre treatment works, but when we don’t consider the treatment to be bizarre, we react the opposite way. We insist that the treatment caused the improvement.

      .

  3. As someone who’s currently in magical [osteopathic] doctoring school, part of the problem is that every so often what’s considered magic might actually help. However, part of the problem with those who practice magic is that it’s an all of nothing aspect. Sure, some manipulative therapy works well, others is no better than pointing jazz hands towards the patient. However too many who do practice magic think that all of it (both the evidence based, evidence null, and evidence against magic) is a cure all for everything while the vast majority of those who don’t practice medicine use the evidence negative aspects to argue against the evidence based practices and ignore the evidence null (lack of evidence isn’t the same as evidence against) aspects.

    • Joe Paczkowski,

      As someone who’s currently in magical [osteopathic] doctoring school,

      Some of the most prominent evidence-based medicine, or science-based medicine, proponents are osteopaths.

      part of the problem is that every so often what’s considered magic might actually help.

      We spend a quarter of a billion dollars a year testing alternative medicine treatments. Have any of them been able to show that they are predictably reproducible?

      If something cannot be predictably reproduced, why should we expect it to work for us?

      If we feel that we are special and the rules don’t apply to us, we expect things to work. But if the rules don’t apply, then why don’t we just wish ourselves better? Because, after actually trying to wish ourselves better, we often are not better, so we look for something to give it that extra bit of mojo oomph.

      We don’t understand medicine, so we don’t go to a real doctor. We go to a witchdoctor.

      And if it really does help However, part of the problem with those who practice magic is that it’s an all of nothing aspect.

      We need to do a much better job of teaching probability in school.

      Sure, some manipulative therapy works well, others is no better than pointing jazz hands towards the patient.

      And we would do a much better job of getting people to understand if we could get them to understand probability.

      However too many who do practice magic think that all of it (both the evidence based, evidence null, and evidence against magic) is a cure all for everything

      And they often blame the patient for failures. the patient did not want it enough. Hardly a kinder, gentler, more holistic response to illness.

      while the vast majority of those who don’t practice medicine use the evidence negative aspects to argue against the evidence based practices and ignore the evidence null (lack of evidence isn’t the same as evidence against) aspects.

      There are plenty of doctors who do not understand evidence-based medicine any better than those who use magic.

      Evidence is supposed to be obtained in a way that is as free of bias and variables as possible.

      If we study the use of an alternative medicine treatment delivered exactly the way that the experts at this treatment say it should be delivered, and it is delivered by experts in this treatment, the result should be clear.

      If the study is large enough and the results are no better than a placebo version of the treatment, then the treatment is a placebo, even if a very elaborate placebo.

      Likewise –

      If we study the use of a conventional medicine treatment delivered exactly the way that the experts at this treatment say it should be delivered, and it is delivered by experts in this treatment, the result should be clear.

      If the study is large enough and the results are no better than a placebo version of the treatment, then the treatment is a placebo, even if a very elaborate placebo.

      Internal mammary artery ligation, antiarrhythmics for post MI PVCs, high-flow oxygen for MI, . . .

      None of these conventional medicine treatments can be predictably reproduced as more effective than placebo.

      All of these treatments are placebos.

      It doesn’t matter if a magic treatment is provided by a witchdoctor or a conventional doctor, by a witchparamedic or a conventional paramedic, they are still just placebos.

      How do we ethically obtain informed consent if we are telling the patient a lie?

      If we are able to ignore that the treatment does not really work, aren’t we also ignoring the side effects?

      .

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