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

- Rogue Medic

Comment on If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I

 

In the comments to If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I, TexasMedicJMB writes the following –
 

I look at the approach of what works for the person performing the intubation is best.

 

No.

What is best for the patient is what is best.

Research to find out what is best for the patient is important.
 

The goal isn’t to satisfy keeping a low-tech approach, the goal is to maximize patient care.

 

That is why we need research.

We can’t just assume that we know what is best without valid evidence. If we are honest about doing what is best for our patients and if we are to behave ethically, we need to find out what is best for our patients.
 

If a difficult airway is encountered and the decision to use a Bougie (flex-tube introducer) is made does this qualify as witchcraft?

 

That depends.

What do I mean by witchcraft?

By witchcraft, I mean treatments that are based on superstition, wishful thinking, and/or anecdote, rather than valid evidence.

Is the decision to use a bougie based on valid evidence?

If not, then the decision may qualify as witchcraft, as I use the term.
 


 

However, you entirely missed the point of my criticism of the opposition to learning by these anesthesiologists.

These witches anesthesiologists refused to participate in research designed to answer a question that has not yet been answered and may affect patient survival.
 

If an anesthesiologist opts to use a Mac 0 on a pediatric pt rather than a text-book suggested Miller 0 is this witchcraft?

 

The textbook recommendation appears to be witchcraft, but feel free to provide valid evidence to support either opinion.
 

If the doctor opts to use VGL because the pt is perceived difficult due to morbid obesity, known CA tumor, etc. why is this witchcraft?
I call it prudent judgement.

 

Is there valid evidence that the GVL (GlideScope Video Laryngoscope) improves outcomes?

If not, then what you describe is not prudent judgement, but mere wishful thinking and therefore witchcraft, as I use the term.
 

From the article at http://www.ncbi.nlm.nih.gov/pubmed/22042705: Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airway.

 

That is great for someone selling video laryngoscopes

These are only surrogate endpoints, which do not matter.

Surrogate endpoints are just hypothesis generators for studies that will determine if the video laryngoscope actually improves outcomes that matter.

Surrogate endpoints are excellent for self-deception.

Where is the evidence of improved outcomes that matter?
 

From http://ccforum.com/content/17/5/R237: In the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

 

Where is the evidence of improved outcomes that matter?

According to the paper I am writing about,[1] video laryngoscopy resulted in longer intubation attempts and dramatically more hypoxia.

Are we curing the disease, but killing the patient?

Blood-letting also improved surrogate endpoints, while it increased the likelihood of death for patients treated with blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[2]

 

I am sorry that your child died, but we consider surrogate endpoints to be more important than the lives of our patients.
 

This paper could have helped to answer that question, but a bunch of anesthesiologists witches decided that they just know and they don’t care about reality or outcomes. In other words, surrogate endpoints are more important than the lives of their patients.
 

As you point out, the article you linked just leaves the sub-group in question at “discretion, unspecified”.

 


 

As Dr. David Newman stated in the podcast,[3] he contacted the corresponding author and was told that all of the attending physician discretion, unspecified patients were because there are some anesthesiologists who refuse to use anything other than a video laryngoscope.

In other words, their patient care depends on prejudice – as does witchcraft.
 

Is the discretion the witchcraft and psychics? Maybe. Is it likely these pt’s were indeed difficult airways the physician felt more comfortable using VGL?

 

Again, according to Dr. Newman, some anesthesiologists insisted on intubating all of their patients with video laryngoscopes, regardless of difficulty. They consider themselves too smart to learn, so they refused to participate.
 

Is the physician truly practicing witchcraft because he chose to perform a procedure known to lower time to intubation, improve first-pass success, etc?

 

Does lowering intubation time improve outcomes?

If video laryngoscopes shorten intubation time, then why did it take longer to intubate patients with the video laryngoscopes?

Valid research could help answer that.
 

Would it have been better if he’d have ignored the VGL device and made several attempts at DL to pass the ETT?

 

Why do you assume that would be the outcome?

Do you have any valid evidence?

One thing this paper does make clear is that there is no good reason to assume that use of video laryngoscopes improve outcomes.
 

The usage of VGL doesn’t appear to be a tool of witchcraft. This is evolution of medicine.

 

You appear to be defending the preventable deaths of patients in order to promote the continuing expansion of witchcraft in medicine.

We do not know what is best, but the anesthesiologists are defending their opinions and protecting their opinions from evidence that may contradict those opinions.

That is witchcraft superstitious nonsense.

Footnotes:

[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed – in process]

[2] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

[3] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

.

Speak Your Mind