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In the featured article at Emergency Physicians Monthly, Dr. David Newman describes the differences between some treatments that we use, even though there is no good evidence that they work and a treatment that we do not use enough, even though there is good evidence that it works.
Do we want to be giving patients the treatments that do not work, but that are approved by the merit badge organization?
Do we want to give the treatment that really improves outcomes for patients?
{Noninvasive ventilation}
Q: Does noninvasive positive pressure ventilation for CHF save lives?
a: Yes!
by Ashley E. Shreves, MDNNT=8
For every eight CHF patients you treat with NIPPV, one death is prevented
NNH=18
Side effects were minor, and the most common was gastric distension, then skin damage (20) and mask discomfort (30) [1]
Absolutely not.
As long as someone is with the patient and knows how to remove the mask (simple), use suction, and call for help, things are OK. In EMS, we should always have someone at least that competent with the patient.
NNH = 18 – The Number Needed to Harm is 18, but the harm is minor.
NNT = 8 The Number Needed to Treat is 8, but that treatment is life saving.[2]
For every 8 times we appropriately use NIPPV (CPAP – Continuous Positive Airway Pressure or BiPAP – Bilevel Positive Airway Pressure) we should expect to save one life that would not otherwise have been saved.
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What about ACLS treatments?
Q: Do intravenous drugs, as recommended by ACLS algorithms, improve survival?
a: Excellent studies say NO
by David H. Newman, MD
NNT
For neurologically intact survival, there is NO BENEFIT.
NNH
No medical harms were identified[1]
It is not correct to say that there are no harms, but that the research does not provide enough information to identify those harms.
There probably are some benefits, but we are insane to keep giving epinephrine to patients who had cardiac arrest because of a heart attack and expect that there will be no harm, or even to expect that the benefit will be greater than the harm.
We need to identify if there are any patients who do benefit from epinephrine, or any of the other drugs, and limit their use to those specific indications – if any benefits exist.
We need to stop treating these drugs like magic.
With ACLS (Advanced Cardiac Life Support), we follow the Chain of Magic, rather than any valid chain of survival.
Maybe the next revision of the guidelines will be based more on science, than on witchcraft.
We need to get rid of the reckless and irresponsible people who make the following statement –
Prove that it is harmful before we remove it!
First, do no harm.
vs.
Until you can prove that it is harmful, the harm is only theoretical.
Tell that to the babies treated with thalidomide.
Tell that to all of the people, or the families of the dead, who were treated not based on evidence, but on If you can’t prove it is harmful, it is safe.
Why are there so many of us who defend this nonsense?
The burden of proof is on those proposing the treatment, even if the treatment is traditional.
The burden of proof is not on those asking for evidence.
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Footnotes:
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[1] NIPPV for CHF Works, ACLS Algorithms Do Not
by David Newman, MD
September 26, 2012
Emergency Physicians Monthly
Article
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[2] Non-Invasive Positive Pressure Ventilation for Acute Pulmonary Edema
August 22, 2010
The NNT
Article
Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis.
Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA.
JAMA. 2005 Dec 28;294(24):3124-30. Review.
PMID: 16380593 [PubMed – indexed for MEDLINE]
CONCLUSIONS: Noninvasive ventilation reduces the need for intubation and mortality in patients with acute cardiogenic pulmonary edema. Although the level of evidence is higher for CPAP, there are no significant differences in clinical outcomes when comparing CPAP vs NIPSV (bilevel noninvasive pressure support ventilation).
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