Kelly Grayson writes about the use of evidence in EMS. Ironically, he starts by repeating the
lie dogma misconception that EBM (Evidence-Based Medicine) requires randomized controlled trials. The rest of the article explains why we harm patients when we do not base our treatments on valid evidence.
The parachute paper states –
It is a truth universally acknowledged that a medical intervention justified by observational data must be in want of verification through a randomised controlled trial.
A universal truth? No. It is satire, from the yearly issue of the BMJ that pokes fun at medicine.
The most cited article on EBM is more than 7 years older than the parachute paper and is seen by many as the definitive description of EBM. The sub-title tells a lot about what EBM is –
It’s about integrating individual clinical expertise and the best external evidence.
The article clearly exposes the myth that randomized placebo controlled trials are required by EBM.
Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.
Yet, the myth of the parachute paper continues to be dogmatically spread, even in an article criticizing dogma.
And it’s easy to do, because at the heart of dogma in medicine is our desire to help our patients. It sounds good. The theory was plausible. The motivation was admirable. The goal was reachable. The lie was easy to believe, because every good lie contains a kernel of truth.
We want to believe that experience and our memory of what we were taught in school is all that we need.
We want to believe in medicine that is a constant, unchanging benefit to our patients.
The truth is that we need to keep learning and keep improving, because some of what we do to our patients is harmful. We just do not know what part is harmful, yet.
If we do not keep learning, we choose to harm patients. If we do not keep improving, we choose to harm our patients.
Far too many fervently believe in a treatment because they’ve seen it work with their own eyes.
There’s a reason eyewitness testimony is so easily discredited; because people are fallible.
I’ve seen it work with their own eyes. is one of the lies of medicine.
Patients improve, or only seem to improve, for many different reasons.
The patient was already getting better and the last treatment we gave had nothing to do with the patient’s improvement.
The patient was not as sick as we initially thought and the last treatment we gave had nothing to do with the patient’s improvement.
The patient was getting better from one of the previous treatments and the last treatment we gave had nothing to do with the patient’s improvement.
The patient was being harmed by one of the previous treatments and the harm from the previous treatment was wearing off when we gave the last treatment, which had nothing to do with the patient’s improvement.
The patient’s vital signs are not the best indicator of the health of the patient and the last treatment we gave only made the patient’s vital signs look better.
And so on.
 Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20;327(7429):1459-61. Review.
PMID: 14684649 [PubMed – indexed for MEDLINE]