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

- Rogue Medic

EMS Dinosaurs and the Slow Gazelles – EMS Office Hours


 

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and Dave Brenner discussed a couple of topics kind of related to dinosaurs before I got on the show. We ended up discussing what a dinosaur is (all of us) and what a problem dinosaur is (someone who refuses to learn).
 

EMS Dinosaurs and the Slow Gazelles
 

I stated that dinosaurs, the problem people – those who refuse to learn, make excuses for the failure of their beliefs to be confirmed by reality (valid evidence of improved outcomes).

Here are some of the treatments that are routine in EMS, but are not supported by valid evidence of improved outcomes.

Backboards, a lot of saline for uncontrolled hemorrhage, ventilations for cardiac arrest, airways for cardiac arrest, drug for cardiac arrest, furosemide (Lasix, frusemide in Commonwealth countries) for acute CHF (Congestive Heart Failure), sodium bicarbonate is a good treatment for acidosis, high-flow oxygen in the absence of hypoxia, 50% dextrose for hypoglycemia, steroids for spinal injuries, et cetera.

All of these are based on an absence of evidence or on inadequate evidence. Most of them have evidence of more harm than benefit.

Why do we continue to add treatments to guidelines before there is evidence of benefit?

Because we believe that the treatments work because we are dangerous optimists. We refuse to learn that we harm patients by rushing treatments in to guidelines.

In the absence of evidence of benefit, we should assume that every treatment is harmful.

If reality does not agree with what we believe, then the problem is not reality, but our refusal to accept reality.
 

There was a discussion of prehospital therapeutic hypothermia with IV (IntraVenous) chilled saline, which has been clearly demonstrated to be not beneficial and possibly harmful. In-hospital therapeutic hypothermia does work, but having EMS start this was a bad idea and now needs to be removed from protocols.

There have been three studies of the effect of prehospital chilled saline for post-resuscitation therapeutic hypothermia. Dr. Bernard’s study showed no benefit and was stopped early because the results made it clear that there was no benefit.[1] Dr. Bernard talks with Dr. Scott Weingart on two EMCrit podcasts about the more recent studies.[2]
 


Click on images to make them larger. “Normal” temperature is 37°C and varies throughout the day, including when almost dead. The drop in the graph is not a temperature drop. It is the drop in survival for both groups.
 

After publication of the seminal trials of therapeutic hypothermia after cardiac arrest,2,3 this approach was recommended in international guidelines,4 despite arguments by some investigators that the evidence was weak, owing to the risk of bias and small samples.6,25 [3]

 

We are doing a lot to the patient that can cause complications with no expectation of any benefit.

This is a bad idea.

 


 

The intervention reduced core body temperature by hospital arrival, and patients reached the goal temperature about 1 hour sooner than in the control group. The intervention was associated with significantly increased incidence of rearrest during transport, time in the prehospital setting, pulmonary edema, and early diuretic use in the ED. Mortality in the out-of-hospital setting or ED and hospital length of stay did not differ significantly between the treatment groups.[4]

 

We need to wait for evidence of improved outcomes.

If we cannot provide evidence of improved outcomes, all we have is wishful thinking.

Wishful thinking kills.
 

Go listen to the podcast.
 

PS The story from Welcome to the Monkey House by Kurt Vonnegut is called Harrison Bergeron. It is only a couple of pages and beautifully written. The full text is on line for free here.
 

THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way. Nobody was smarter than anybody else. Nobody was better looking than anybody else. Nobody was stronger or quicker than anybody else. All this equality was due to the 211th, 212th, and 213 th Amendments to the Constitution, and to the unceasing vigilance of agents of the United States Handicapper General.

. . . . .

 

Go read Harrison Bergeron.

Footnotes:

[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

[2] Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I
EMCrit
Podcast page with links to research mentioned in the podcast.

Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II
EMCrit
Podcast page with links to research mentioned in the podcast.

[3] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

[4] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed – as supplied by publisher]

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Comments

  1. We all know what really drives all this stupidity. See there are medics etc out there that are true believers in this hocus pocus, but often it isn’t just them. It’s the “powers that be” whether that’s a medical director, manager, owner, board, chief, or grand poobah. Until the ones in power accept science and reality we will keep doing this. What I’d ask is why aren’t any and all of these people purporting to be rational scientists going to see the light and realize that they are little better than snake oil salesman and televangelists? To paraphrase/bastardize from a Kevin Smith movie. When can I ditch these little chuckleheads whose folly we are a constant victim of preventing us from treating our patients? When, Lord, when? When’s gonna be my time?

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