The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Why Do We Have So Little Respect For Our Patients?


 

Informed consent should require that we provide our patients with honest information about the treatment we are pushing.

Even implied consent assumes that an informed patient would make the decision to take the treatment if the patient had the capacity to make an informed decision and had honest information about the treatment.

What medical treatment do we use during cardiac arrest?

We use chest compressions and defibrillation.

Nothing else qualifies as medicine.
 


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Ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, and procainamide, are witchcraft.

There is no evidence that ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, or procainamide improve survival from cardiac arrest.

None.
 

 
Why don’t we limit treatments to what actually works, rather than what makes us feel like we are helping?

We are only exposing our patients to adverse effects for no benefit to the patient.

Nature has demonstrated a strong bias in favor of reality.

Our bias in favor of superstition is unnatural and unhealthy.
 

All treatments should be limited to high-quality controlled trials until there is valid evidence of improved outcomes with the treatment.

Surrogate endpoints do not count.

If we wish to develop an understanding of what we are doing, we need to study what we use.

If a treatment does not work under controlled conditions, why believe that it works in uncontrolled conditions?

Research gives the best opportunity to see the difference in outcome that is due to the just the treatment being studied.

If we think the treatment works, we should be insisting on showing off.

We are all talk.

We run away when challenged.

If we accept excuses for not finding out what we are doing, we end up with epinephrine for cardiac arrest – 50+ years of use, but we still do not know if it is beneficial, if it is beneficial in some patient populations and harmful in other patient populations, or if the effect is neutral.

There is no outcomes research that has shown improved outcomes, but epinephrine is the standard of care and research has been discouraged because it would be unethical to deprive patients of this witchcraft.

Any treatment that is used outside of controlled trials, without evidence of improved outcomes, is witchcraft. Why can’t we be honest about that?

I was a baby, when we started using epinephrine for cardiac arrest. I am a cantankerous old coot, now. There has been only one placebo controlled trial of epinephrine for cardiac arrest,[1] but that was crippled by political pressure because it would be unethical to deprive patients of the eye of newt.

Someday, medicine will grow up and start treating patients with something that actually works.

Footnotes:

[1] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

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This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

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Comments

  1. Why rage on about cardiac arrest when it is such a low occurrence call? Why not spinal “immobilization” or prophylactic IV starts? Why not take out the things that will make a bigger difference than just going after the low hanging fruit of cardiac arrest?

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