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

- Rogue Medic

If We Pretend that Anecdotes are Not Anecdotes, Do We Change Reality?

 

The following comment was written by Duke Powell in response to Where is the Evidence for Traction Splints?
 

I’ve been an urban paramedic for 34 years and, prior to that, a volunteer EMT for 9 years. For those who can’t add, ….that’s a long time.

How many times have I used a traction splint? …… I dunno, let’s guess 10 times.

 

That works out to an average of over four years between uses of the traction splint. That is plenty of time to have the memory of each use reconstructed many times, so that the memory and the reality may not have much in common. Each time we remember something, we recreate and modify the memory.
 

Several years ago, after several years of not even thinking about traction splinting, I found myself using it 3 times in 2 weeks.

Did it help? Yep, clinically, in my opinion, it helped.

 

Maybe it helped the patients. Maybe it harmed the patients. Maybe it helped some patients and harmed other patients. Maybe it helped the pain, but caused longer term harm. We do not know.

Without valid evidence, especially evidence of something more than the superficial appearance of improvement, we have no idea. We can use our imaginations and generate opinions, but we are merely discussing opinions.
 

Will Rogue Medic call my experience “anecdotal” and not worthy of consideration? Yes, he will.

Don’t care what the Rogue Medic thinks.

I care about what my patients and my Medical Director thinks.

 


Image credit.
 

Does calling an anecdote by a different name make it not an anecdote? It does not matter what you call it. A story is an anecdote. More than one story is just more than one anecdote.

What kind of follow up was there on the patients? What kind of comparison of the other variables was there?

Blood-letting looks like an excellent treatment – if we stick to anecdotes about 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.[1]

 

How many patients did we kill with blood-letting? Thousands? Tens of thousands? Hundreds of thousands?

The opinions of medical directors have been in favor of many harmful treatments. Do you remember nifedipine?

Anecdotes do not become evidence of good patient care by telling the stories with style. Reality does not work that way, no matter how much we want to change reality. EMS shows us people who are having reality ignore their opinions about how the world should work. If reality is not going to change for a parent who wants their dead child back, how little is reality going to change for a paramedic who wants to put a positive spin on a treatment that he likes?

Reality does not care about our opinions.

Reality does not even care about the opinions of medical directors.

Science is the way we learn the difference between what is real and what is just a pleasing mirage.
 

What do you think science is? There is nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. So which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic? – Dr. Steven Novella.

Anecdotes are not thorough observations. Anecdotes do not use consistent logic. Anecdotes do not have anything to do with systematic evaluation.

Footnotes:

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

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Comments

  1. I think Rogue is a little harsh on “anecdotes”. Anecdotes are a very good starting point for a hypothesis. What tends to be forgotten is that hypotheses must be tested before they are accepted as true.

    • mpatk,

      Anecdotes are a very good starting point for a hypothesis.

      I agree.

      I am not suggesting that we do call anecdotes something other than anecdotes.

      I am not suggesting that we claim that anecdotes are evidence.

      I think that we should put anecdotes in the proper perspective and not suggest that they are anything more than stories that can be used to create hypotheses. That is the way science works.

      I am not claiming that these hypotheses should not be tested.

      I do not think that I am being too hard on anecdotes by putting them in perspective.

      I do not think that you are being too hard on anecdotes by putting them in perspective.

      .

  2. [This started out as a note to say “If you want to find early studies of traction splint use in the BMJ look up ‘Thomas splint’ but it seems to have ‘sproutted legs, sorry about that!
    But it might explain why there is one on every truck.]

    The Thomas splint as it is known over this side of the pond has been around for a very long time, I had a 1923 training manual that detailed how to use it. (looked it up elsewhere, introduced 1857).

    Designed by Hugh Owen Thomas (1834-1891) and was originally conceived as an alternative to surgery for use in hospital under medical supervision.

    Had a huge boost in popularity as a result of WWI, not surprising given the amount of GSW that it was used to treat. There is a quote:

    ” Thanks to the use of the ‘Thomas splint’ the mortality of compound fractures of the femur fell from 80% in 1916 to less than 8% in 1918.”

    But I have to ‘fess up that I’ve not been able to track down a source for that, which is annoying as there is no indication of the context it was being used in ie. in the field or in hospital. (And it does read a bit like advertising copy.)

    There are lots of letters in the BMJ at the time hailing it as some sort of marvel.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2355339/?page=1

    It probably became standard kit on an ambulance, (over here), with the organisation of county ambulance services in 1930. This is just conjecture, but it is not inconceivable that the Doctors charged with drawing up the list of equipment to be carried were all veterans of WWI enamoured with this wonder appliance.

    Doctors in the ’50s were still in love with the thing:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1961801/?page=1

    Now to compound my sin, I’m going to add a bit more speculation. It probably clung on here for years and years due to the perception of affording some pain relief for patients, (as discussed by the other folks on a previous post), and pain relief was not carried on Ambulances, (Entonox did not arrive until 1970).

  3. Not only is it too long, it’s also in the wrong place!

    *sigh*

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