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

- Rogue Medic

You had me at ‘Controversial post for the week’ – Part II

 
In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?
 

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]

 

Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.
 

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]

 

We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.
 


Image credit.
 

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.
 

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]

 

PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. 😳

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.
 

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.

 

We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.
 

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]

 

The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.

Footnotes:

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

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Comments

  1. A small note of perspective here, so you can understand the magnitude of this uphill battle. Many EM positions still require that the doctor have current ACLS, PALS, and ATLS cards in order to be hired. So, Ambulance Chaser’s first act as a medical director might be attending a mandatory ACLS provider class…

    (For just one example: http://www.americasjobexchange.com/job-detail/Emergency-Medicine-Physician-New-Martinsville-WV-561137240, for just one example)

    Even though, as emergency MDs and DOs, we sit on hospital resuscitation committees, re-write prehospital protocols, and, oh yeah, run codes, we still have to deal with the merit badge mentality. Not a new issue, and not yet a settled one.

    • Brooks,

      A small note of perspective here, so you can understand the magnitude of this uphill battle. Many EM positions still require that the doctor have current ACLS, PALS, and ATLS cards in order to be hired.

      Just because hospital administrators require merit badges does not make it a smart move.

      I provided a bunch of research to one of my medical directors because anesthesia would not let emergency physicians use propofol.

      An administrative decision by the people above the ED, but the wrong decision. Eventually, that was changed.

      You don’t really expect to convince me of something by telling me that someone in a position of authority says so, do you? 😉

      Not a new issue, and not yet a settled one.

      And my criticism of it is not new, either.

      Maybe we should have a bunch of doctors who are hospital administrators and a bunch of emergency physicians take a class together and humiliate them.

      Or have a bunch of doctors who are hospital administrators and a bunch of paramedics take a class together and humiliate them even more.

      Get Kelly Grayson’s daughter (she is probably a teenager now) to take a class with a bunch of doctors who are hospital administrators. She probably has been to enough of Kelly’s classes that she would do better than the doctors.

      Perspective needs to be provided. 😛

      .

  2. The”merit badge” mentality is problematic on more levels than one.

    At best, possession of said merit badge indicates that one is able to memorize and follow protocols. It says nothing about that individual’s ability to think critically and adapt to variances in the clinical situation.

    Even worse, in reality having the merit badge doesn’t even necessarily mean that one is proficient in said protocols. Why do certain people get nervous every 2 years and feel the need to “study for ACLS”? Anyone being held responsible for caring for patients in resuscitation situations should know that stuff like the back of their hand … And should know that it is a set of guidelines, and not the one and only Right Way To Do Things.