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

- Rogue Medic

Why US EMS will never get to sit at the adult table – The Appeal to Authority

 

Do you like articles that inveigh against EMTs/paramedics and EBM (Evidence-Based Medicine)?

Here are some samples from a rant by my friend Mike.
 

Here is the bottom line, at the top of the page, they have too little education, do not understand science, and are too simple minded.[1]

 

Apparently, an EMT irritated him. I have occasionally been a source of irritation for Mike.

EMS does have too little education, but the problem is less about the quantity, than it is about the quality. If EMS education were more evidence-based that would improve the quality, but it would not make Mike happy.

People do not understand science. Things appear to be improving in both EMS and medicine. This article is an ironic example of the problems with medicine, with understanding science, and with the use of evidence.

There is really only one example of the use of valid evidence –
 

Maybe you were even one of those services that “forced” your local hospital to institute the now questionable practice of hypothermia based on “science?” More sad news, you were duped.[1]

 

I have written about the research which shows that prehospital therapeutic hypothermia with IV (IntraVenous) fluid does not work.[2],[3],[4],[5]

Mike does not explain how he came to the conclusion that the science pathophysiology was wrong. Was it a lucky guess?
 

You should do yourself a favor and go read some of the many websites on science based medicine compared to “evidence based medicine.”[1]

 

Mike follows this recommendation with a list of some of the potential problems with research. We do need to better understand research, but a lack of perfection affects everything, so imperfection is not a reasonable criticism of EBM or SBM (Science-Based Medicine).
 

I have yet to see an EMS provider pick up a study they like and try to reproduce it.[1]

 

How would having each individual reproduce each study, be relevant to anything? If I do not study something myself, I cannot use the research?

Later he exaggerates the problems with EMS research. Was he mocking himself here? Is he mocking himself there? Both? 😳

What is important in interpreting medical research, is that we are able to read a study in a way that we can identify flaws in the study, see if the researchers found ways to control for as many variables as possible, recognize possible biases, et cetera.

It is not necessary for each person reading/citing a study to reproduce that study. What matters is that the therapeutic hypothermia research has been replicated.[6],[7],[8],[9]

I did not set up any studies to reproduce the therapeutic hypothermia studies, because the information is in the paper. When the information is not there, that is a flaw. I did explain that prehospital therapeutic hypothermia with IV fluid is an example of why it is wrong to extrapolate from pathophysiology about untested treatments.
 

If it was possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation, why would we need healthcare providers at all?[1]

 

There is a website that creates quotes like this for the wisdom of Deepak Chopra. It generates random fictional quotes that sound like what Chopra would say (e.g. – “Interdependence belongs to the flow of bliss”). See what you get. Maybe I should create a quote generator for Mike.[10]

Would any reasonable person suggest that it is possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation?

Why does Mike?
 

That’s right, no double blind random placebo controlled studies on the validity of CPR. No prospective treatment studies on unconscious people who cannot be advised on and consent to the risks. No deviating from “the standards” or “commonly accepted” modalities of care. Sometimes you can get a waiver, but it is easier to walk on water and part seas.[1]

 

The therapeutic hypothermia patients were conscious and gave consent to participate in the study?

Think about that and how much Mike understands what he is writing about.

Consciousness was a reason for exclusion from these studies. Why doesn’t Mike know this?

Pick up any study with human patients. It will explain how the ethical consent was handled for the patients in that study.
 

Nazi Germany is the closest anyone has come to unbiased human experimentation.[1]

 

The Nazis were obtaining consent?
 

This is followed by some brave attacks on straw men, then praise for the parachute study – a satire paper that is based on a logical fallacy.[11],[12]

There is nothing wrong with using logical fallacies for satire. Did Mike intend his manifesto as satire or as spectacular irony? 😳
 


Volunteers eager to participate in unbiased Nazi experiments?
 

Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff. They read a study, and assume this evidence has been met.[1]

 

That may apply to most doctors, too. It isn’t the right way to approach research, but it is a criticism of the reader, not the evidence.

Then Mike valiantly lashes out at some more straw men.
 

What can EMS, and doctors, do to better understand research?

Read some of the many analyses of evidence that are available for free on the internet. I frequently write about the problems with research, but I do not make the mistake of claiming that EMS research is useless.

Many others write about EMS and emergency medicine research. I described some of the best sites a year ago.[13]
 

Read some of these –

Life in the Fast Lane Research Review

The EMSB Digital Research Library

Skeptical Medicine

Mill Hill Ave Command

EMS Patient Perspective

Street Watch: Notes of a Paramedic

A Day in the Life of an Ambulance Driver

EMS 12 Lead

SMART EM

EM Crit

Emergency Medicine Literature of Note

Canadian Prehospital Evidence Based Protocols

SOCMOB Blog – Standing on the corner, minding my own business in the ER

prehospitalresearch.eu

The Poison Review

PHARM – PreHospital And Retrieval Medicine

EM Lyceum

Emergency Medicine Ireland

Skeptics’ Guide to Emergency Medicine

Dr. Bryan Bledsoe
 

For an accurate description of SBM, read the site that originated the concept –
 

Science-Based Medicine

Footnotes:

[1] Why US EMS will never get to sit at the adult table
The5Conflicts
April 26, 2014
Article

[2] The Relentless Optimism of a Stalker Applied to Medicine
Wed, 23 Apr 2014
Rogue Medic
Article

[3] EMS Dinosaurs and the Slow Gazelles – EMS Office Hours
Wed, 12 Feb 2014
Rogue Medic
Article

[4] What Can EMS Expect From 2014? #2 Prehospital Therapeutic Hypothermia
Tue, 31 Dec 2013
Rogue Medic
Article

[5] Is Earlier Better for Therapeutic Hypothermia? Part I
Wed, 20 Nov 2013
Rogue Medic
Article

[6] 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]

[7] 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]

[8] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed – indexed for MEDLINE]

[9] 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.

[10] The enigmatic wisdom of Deepak Chopra
random fictional Deepak Chopra quotes
Quote generator
 

It has been said by some that the thoughts and tweets of Deepak Chopra are indistinguishable from a set of profound sounding words put together in a random order, particularly the tweets tagged with “#cosmisconciousness”. This site aims to test that claim! Each “quote” is generated from a list of words that can be found in Deepak Chopra’s Twitter stream randomly stuck together in a sentence.

 

[11] 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]

Free Full Text from PubMed Central.

[12] Does the parachute study prove that research doesn’t matter? Part I
Wed, 22 Aug 2012
Rogue Medic
Article

[13] Some Excellent New Medical-Research Sites
Fri, 24 May 2013
Rogue Medic
Article

.

Comments

  1. Rogue, the quotes out of context and arguments are fascinating. Especially since you are making up arguments which were not part of my post. You should probably provide a link so people can read it themselves.

    • Mike,

      I did provide a link. I just checked it and it still works.

      Perhaps footnotes confuse you.

      I also provided links to the other sources of my information.

      People should read your contradictory rant and read a bit about how EBM and SBM work.

      Readers should be able to realize that you are not making valid arguments, no matter how many contradictory argumnts you provide.

      🙂

  2. I tried the link, I just got a ping-back to here, so I figured it didn’t work. I am still rather new to the whole blogging thing and regrettably do not have your skill or cult or personality.

    I kindly ask you remind your readers that I have no problem with dissenting opinions or even insults, but I do expect them to have the courage to sign their own name to what they write.

    • Mike,

      I kindly ask you remind your readers that I have no problem with dissenting opinions or even insults,

      When did that change occur?

      but I do expect them to have the courage to sign their own name to what they write.

      I don’t care if you think I lack courage.

      Anyone who wants to know who I am can find out easily.

      I choose to keep the blog anonymous because anonymity is important to some bloggers.

      Attempting to silence people is something I continue to oppose.

      Attempting to change the subject from your use of logical fallacies is not a valid defense.

      .

    • Mike,

      I tried the link, I just got a ping-back to here, so I figured it didn’t work.

      Below is a copy of the footnote. The [1] in the footnotes is an active footnote. If you click on the one in the article, it will take you to the one in the footnotes. If you click on the one in the footnotes, it will take you to the one in the article.

      The link to your article is in the word Article. For the PubMed citations, the link is in the PubMed ID. For the full text articles, the link is in the part that begins, Free Full Text . . .

      [1] Why US EMS will never get to sit at the adult table
      The5Conflicts
      April 26, 2014
      Article

      In the sidebar is information on how to create these footnotes, if you want to provide sources for your information.

      I recommend citing relevant sources appropriately – it is much more important than anyone’s identity.

      🙂

Speak Your Mind