Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Creationism and the Politics of Ignoring Reality – Part 1

 

National Review Online has an odd apologist for Creationism claiming that without the secular left, Creationism would not be a problem.

Of course, he does not appear to think that Creationism is a problem, only that criticism of Creationism is a problem.
 


Image credit. Click on images to make them laerger.
 

No one thinks about creationism more than the secular Left.[1]

 

There is an outbreak of Ebola virus in Guinea.

While Creationists will tell us that since humans and monkeys are not related, they cannot have the same diseases. However, Ebola virus comes to humans from monkeys. Monkey DNA and human DNA are almost identical. We have small genetic differences that make a big difference in genetic expression, but these are terms that have to do with science and Creationism is about rejecting science that makes the Creationists uncomfortable about their beliefs in their Gods.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Ebola will probably not make it to the US, this time, but it is expanding its range. We cannot make Ebola go away with prayer. We need medicine, which is based on valid science. The fewer people we have who understand biology, the longer it will take to find effective treatments.
 

To be sure, a small number of Christians fiercely and zealously defend the young-earth position, but their influence is vastly overstated by secular journalists who need them more than the church does.[1]

 

Journalists are creating a push to teach Creationism religion in science classrooms?

Apparently, it is only a small number, when David French is defending something by trying to get people to ignore it.

Why is a political writer so opposed to keeping non-science out of science education?

Science is not easy to understand and he appears to be upset that this version of Cosmos seems to explain science as well as the last version. For example, the eye is commonly used as an example of irreducible complexity, the Creationist way of saying, I don’t understand, therefore it is impossible.

Neil deGrasse Tyson explains the evolution of the eye pretty well in about 8 minutes below (I apologize for the advertising) –
 


 

At every stage of its development, the evolving eye functioned well enough to provide a selective advantage for survival and among animals alive today, we find eyes at all these stages of development – and all of them function.

The complexity of the human eye poses no challenge to evolution by natural selection. In fact the eye, and all of biology, makes no sense without evolution.[2]

 

There are no gaps in the evolution of the eye. We can see the various degrees of evolution of the eye in different species, including species with much better eyesight than our eyesight. So why do we assume that the claims of evolutionary gaps, from people who do not understand evolution, are true?

Do we ask the person who has trouble with a paper airplane to explain the theory of flight?

Do we ask the person who does not understand gravity to explain relativity?

The failure of Creationism may not even be because scientists do a better job of explaining science, but because of the ethical failures of those trying to discredit science. I will explain in Part 2.

-

Footnotes:

-

[1] The Left’s Strange Obsession With Evangelical Creationism
By David French
April 1, 2014 2:19 PM
National Review Online
Article

-

[2] Some of the Things That Molecules Do
Cosmos: A Spacetime Odyssey
Season 1, Episode 2
Fox
28:48
Video at Hulu.com

.

Today in Kansas, Some Witchcraft is Melting

 

Why are more medical directors abandoning the mythology of their ancestors?

Because it has become almost impossible to ignore the absence of evidence of any improved outcomes and the abundant evidence of harm.

Today, in Kansas, Johnson County Med-Act threw a bucket of water on their Long Spine Board Witchcraft and Kansas was not hit by a tornado. Kansas is only being hit with snow.
 


Download YouTube Video | YouTube to MP3: Vixy
 

But there must be some good reason to use backboards!
 

The backboard has been a component of field spinal immobilization despite lack of efficacy evidence.[1]

 

When there is no evidence of benefit, then it is not an insult to call a treatment witchcraft, dogma, alternative medicine,
 

Other than historical dogma and institutional EMS culture we can find no evidence-based reason to continue to use the Long Spine board as it currently exists in practice today. The evidence that does exist regarding the Long Spine board is overwhelmingly negative.[2]

 

There must have been a time, in the beginning, when we could have said – no. But somehow we missed it. Well, we’ll know better next time. – Tom Stoppard
 

Will we know better next time? Our history does not give us reason to be optimistic about our ability to avoid this error.

We should have said, No.

We should have insisted on evidence.

The history of medicine is full of things that seemed like a good idea at the time.

Seemed like a good idea at the time is just the slightly more respectable form of conbining alcohol, a dangerous idea, and Watch this!
 

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool. – Richard Feynman.
 

We never seem to tire of fooling ourselves.

Why am I so critical of tPA for acute ischemic stroke, backboards for potential spinal injuries, furosemide for acute heart failure, ventilations for cardiac arrest, all drugs for cardiac arrest, . . . ?

Because all of these treatments have become standards of care, even though they have not been adequately studied.
 


Original picture image credit of tPA alternative medicine pusher Dr. Patrick Lyden.
 

We fool ourselves and harm our patients.

If you disagree, provide some evidence of any of these treatments producing improved outcomes that matter.

We should assume every treatment is harmful, until there is valid evidence that the treatment is safe and effective.
 

Just like blood-letting and every other superstition-based treatment.
 

The ambulance stretcher is in effect a padded backboard and, in combination with a cervical collar and straps to secure the patient in a supine position, provides appropriate spinal protection for patients with spinal injury.[1]

 

Why not just leave out the harmful device that cannot be demonstrated to improve outcomes and cannot even be demonstrated to be safe?

But someone will sue and everyone will lose everything!
 

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.[3]

 

It is the EMS Nuremberg Defense when we do it.
 

it may be common or customary for EMS providers to use a long spine board or collar, decisions of standard of care and negligence are not based on what is the best, reasonable care, not on what is usually done.66 [4]

 

This witch is only mostly dead, but we can’t stop now.
 


Download YouTube Video | YouTube to MP3: Vixy
 

To read more on the topic –
 

For You Disciples of Spinal Immobilization…
… Bryan Bledsoe debunks your religion in the August issue of EMS World Magazine. And in that same issue, I take a dump on your altar. Our karma ran over your dogma.
August 1, 2013
by Kelly Grayson
A Day in the Life of an Ambulance Driver
Article
 

The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World
Article
 

Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article
 

In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
December 15, 2012
Article
 

Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning
Article
 

Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World
Article
 

A Change of the Dogma – If spinal immobilization helps only one . . .
Sun, 15 Jan 2012
Rogue Medic
Article
 

C-Spine Death Knell with Rogue Medic
Tue, 22 Jan 2013
Rogue Medic
Article
 

Plastic Snake Oil – EMS Spinal Immobilization
February 24, 2014
Life Under the lights
Article
 

Some podcasts –

A Change of the Dogma: If it helps only one? Episode 36
First Few Moments
January 12th, 2012
Dr. Laurie Romig, Russell Stine, Bob Lutz, Kyle David Bates, Kelly Grayson, and me.
Podcast
 

C-Spine Death Knell with Rogue Medic.
John Broyles and me.
January 19, 2013
1-Union-801
Podcast
 

Immobilization or not that is the question – EMS Garage Episode 156
Chris Montera, Scott Keir, Dr. Dave Ross, Sam Bradley, Patrick Lickiss, and me.
Feb. 24, 2012
EMS Garage
Podcast
 

And the video that only makes sense if you work in EMS –
 


Download YouTube Video | YouTube to MP3: Vixy
 

-

Footnotes:

-

[1] EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma.
White Iv CC, Domeier RM, Millin MG; and the Standards and Clinical Practice Committee, National Association of EMS Physicians.
Prehosp Emerg Care. 2014 Feb 21. [Epub ahead of print]
PMID: 24559236 [PubMed - as supplied by publisher]
 

-

[2] Johnson County EMS System Spinal Restriction Protocol 2014
Ryan C. Jacobsen MD, EMT-P, Johnson County EMS System Medical Director
Jacob Ruthsrom MD, Deputy EMS Medical Director
Theodore Barnett MD, Chair, Johnson County Medical Society EMS Physicians Committee
Johnson County EMS System Spinal Restriction Protocol 2014 in PDF format.

-

[3] Thank You for Smoking
Movie, based on the book by Christopher Buckley
Wikiquote
Quote page

-

[4] Board to Death – The state of prehospital spinal injury care in 2013
Rommie L. Duckworth, LP
Created: July 15, 2013
EMS World
Article

.

Child Killers Sentenced, But Not the Ringleader

 

Child sacrifice advocate Pastor Nelson Clark can continue to preach alternative medicine that kills and he can continue to blame the victims.

The secret of alternative medicine is to blame the victim.
 


Image credit. Pastor Nelson Clark of the First Century Gospel Church.
                 I preach human sacrifice!
 
 

In an interview with The Inquirer, Clark said God did not want the Schaible children to die.

Instead, he said, the children died because of some “spiritual lack” in the Schaibles’ lives – a flaw they need to correct to prevent future deaths.[1]

 

If a doctor prescribed prayer for deadly conditions, the doctor should face charges.

Pastor Nelson Clark of the First Century Gospel Church is just another alternative medicine practitioner prescribing alternative medicine for deadly conditions and blaming the victims.

We need to treat all of these medical frauds the same.

We need to stop them from killing children.

Sacrificing children to alternative medicine is wrong.

It does not matter if the alternative medicine is religious, what matters is that we protect children from killers.

The Schaibles were sentenced to 3 1/2 to 7 years in prison, but that won’t stop Pastor Nelson Clark from preaching child sacrifice at the First Century Gospel Church.

The Schaibles lost two children to this fraud, they will spend time in prison, they probably will be prevented from putting a third child in the cemetery, but Pastor Nelson Clark will preach on and he will continue to blame the Schaibles for lacking faith.
 

States that allow a religious defense to most serious crimes against children include: Idaho, Iowa, and Ohio with religious defenses to manslaughter; West Virginia with religious defenses to murder of a child and child neglect resulting in death; and Arkansas with a religious defense to capital murder, according to Children’s Healthcare, an educational charity. Approximately a dozen U.S. children die in faith healing cases each year, the AP reported.[2]

 

This human sacrifice is

not the first time that children have died with the help of Pastor Nelson Clark.

not the second time that children have died with the help of Pastor Nelson Clark.

not the third time that children have died with the help of Pastor Nelson Clark.

not the fourth time that children have died with the help of Pastor Nelson Clark.

Pastor Nelson Clark doesn’t have a good record of praying the germs away.
 

The couple has seven surviving children, while six of them are in foster care, some residing with relatives. The children are getting an education, medical, dental, and vision care now.[2]

 

Also see –

Update on – Is it OK to kill children in the name of God?

-

Footnotes:

-

[1] Pastor: ‘Spiritual lack’ killed two boys
By Mike Newall, Inquirer Staff Writer
Posted: April 29, 2013
Philly.com
Article

-

[2] Pennsylvania Couple Faces Prison After 2nd Prayer Death Of Child With Pneumonia: Should Faith Healing Be Considered Manslaughter?
By Lizette Borreli | Feb 20, 2014 12:00 PM EDT
Medical Daily
Article

.

Alternative Medicine, Wishful Thinking, and Irresponsible Drug Pushers

 

Most emergency physicians avoid using homeopathy, acupuncture, Reiki, and other alternative medicine because there is no valid evidence that these treatments work, or because of they are not considered standards of care, or because there is no recommendation to give them from ACEP (American College of Emergency Medicine).

This is good, because alternative medicine is fraud.

Is there an alternative field of aerodynamics making planes for us to fly? Where is this alternative science?

Are people using alternative electricity to power their homes? Where is this alternative science?

According to the homeopathy hypothesis, the more dilute something is, the more powerful it is. We could solve the world’s energy problems – if the alternative science of homeopathy were anything more than wishful thinking.
 

How does that relate to emergency medicine?

When it comes to emergency treatments for cardiac arrest, stroke, heart failure, possible spinal cord injury, et cetera, many emergency physicians are just as superstitious as your local witch doctor. Currently, the most prominent example of alternative emergency medicine is tPA (Alteplase) for acute ischemic stroke.
 

But tPA, approved for strokes in 1996, only works if given within 4.5 hours of a stroke.[1]

 

That is an optimistic interpretation of the research –
 

The recent release of the American College of Emergency Physicians guideline recommending the use of tPA for ischemic stroke is remarkable. While it is unsurprising that a professional guideline flouts science, the publication is striking for its casual tone and its methodologically inexplicable review of evidence. Scientific thinking is absent.[2]

 

The evidence is horribly flawed, but the advocates respond just as we expect alternative medicine pushers to respond – with logical fallacies.

Ad hominem attacks on those who criticize the bad research.
 

These few persistent myths about thrombolytic therapy were first promulgated by self-appointed ‘expert critics’ who are unabashedly anti-intellectual in their opposition to this therapy. They decline to either read or attempt to understand data and rigorous analysis of that data.[3]


Alternative medicine pusher Dr. Patrick Lyden.
 

What is the appropriate time period for giving tPA?
 


IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[4]
 

Patients get better if tPA is begun within 3 hours, get worse if tPA is begun between 3 hours and 4 1/2 hours, but get better when tPA is begun after more than 4 1/2 hours.

Clearly, there is some strong evil magic that is working against tPA in that 3 to 4 1/2 hour time period, but it is all unicorns and rainbows the rest of the time.

Does that make sense?

No.

That suggests that the evidence we have does not adequately assess the effects of tPA for acute ischemic stroke.

Reasonable people can disagree, but Dr. Lyden appears to be calling those who disagree biased just because they disagree. This is bad science and bad medicine.

We need research that is well controlled, not research that requires a lot of excuses.
 

MedPage Today is providing a good forum for discussion of this actual medical controversy and not just promoting the ad hominem criticisms of Dr. Lyden. There are links to plenty of other sites discuissing the problems with the evidence.[5]

I most recently wrote about this here – The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

I am not an emergency physician, so this is not something that affects my care of patients. I do not have to worry about being sued for not giving tPA and being accused of allowing a bad outcome. I do not have to worry about being sued for giving tPA and being accused of producing a bad outcome.

If you are an ACEP member, tell ACEP what you think of the evidence, or the flaws in the evidence.

-

Footnotes:

-

[1] Few stroke patients get clot-busting drug
Liz Szabo,
USA TODAY
10 a.m. EST February 13, 2014
Article

-

[2] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

-

[3] ER Briefs: tPA ‘Works’, ACEP on Target
Published: Feb 10, 2014
By Elbert Chu
Interview with Patrick D. Lyden, MD
Article

-

[4] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

-

[5] ER Briefs: Open Season on ACEP tPA Guidelines
Published: Jan 29, 2014 | Updated: Jan 30, 2014
By Elbert Chu
Article
.

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.
 


Download YouTube Video | YouTube to MP3: Vixy
 

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]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com

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.

.

Is it Ethical to Treat a ‘Bad’ Person?

 


Image credit. If you are not upset by this image, you are much better at compartmentalizing than I am.
 

A question was posted on Facebook a while ago.

Suppose that you are dispatched for burns. Your patient is reported to have burned some children and burned herself while setting the children on fire.

Some of the children have died, but others are alive and are in severe pain.

The surviving children are already being treated appropriately. There are more than enough people and pain medicine to treat the children. There is only your patient for you to deal with.

Your patient even states, I did it.

Do you withhold treatment?

Do you provide any pain management?

Do you treat the person who admits to burning these children?

Why?

or

Why not?

.

JAMA Opinion Article in Support of Anecdote-Based Medicine

 
There is a horrible defense of ABM (Anecdote-Based Medicine) in the current issue of JAMA (Journal of the American Medical Association).

Apparently, because there is no evidence to support some things the author believes in, the problem is with the evidence.

For example –
 

There is no evidence to suggest that hospitalizing compared with not hospitalizing patients with acute shortness of breath reduces mortality.[1]

 

While R. Scott Braithwaite, MD, MS does appear to realize that it is therefore reasonable to conclude that we do not know if this improves outcomes, he advocates that ignorance intuition is bliss.

We had thousands of years of blood-letting that was based on Dr. Braithwaite’s flawed reasoning.[2]

We had thousands of patients killed by assuming, based on Dr. Braithwaite’s flawed reasoning that getting rid of ectopic heart beats would improve survival of patients who had already had a heart attack.[3]

Almost every proposed medical treatment does not make it through the FDA’s (Food and Drug Administration) evaluation of safety and efficacy.

Why?

When we require evidence, we find that most treatments fall into three categories.

1. Not effective.

2. Not safe.

3. Not safe and not effective.

What evidence satisfies Dr. Braithwaite’s flawed reasoning?
 

In each case, these hypotheses have been untested and therefore there is no evidence to suggest otherwise, presuming a definition of “evidence” that requires formal hypothesis testing in an adequately powered study.1 [1]

 

What is reference #1?

The satirical piece about parachutes that was published a decade ago.[4]

Does EBM (Evidence-Based Medicine) really work the way presented in a satire piece?
 

Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.[5]

 

Is it intellectually honest to base criticism of anyone, or anything, on an exaggeration?

If we accept Dr. Braithwaite’s flawed reasoning, yes.

But Dr. Braithwaite’s flawed reasoning is dangerous.
 

However, deciding to intervene when “there is no evidence to suggest” also may make sense, particularly if the intervention does not involve harm or large resource commitments, and especially if benefit is suggested by subjective experience (eg, the qualitative analogue of the Bayesian prior probability).6 [1]

 

Dr. Braithwaite’s wishful thinking is encouraging him to experiment on people with no ethical approval and no acceptable documentation for research purposes.

You are Dr. Braithwaite’s guinea pig and he says that it is unethical to withhold a treatment that is based on logical fallacies, such as cherry picking[6] and basing decisions on sample sizes too small to produce any valid information.[7]
 

I want to know the real risks and benefits of this treatment.


 
 

Beyond its ambiguity, “there is no evidence to suggest” creates an artificial frame for the subsequent decision. It may signal to patients, physicians, and other stakeholders that they need to ignore intuition in favor of expertise, and to suppress their cumulative body of conscious experience and unconscious heuristics in favor of objective certainty.[1]

 

Ignore intuition, rather than choose a treatment based on intuition?

Dr. Braithwaite does not go that far, but he does claim that a lack of evidence of harm justifies abuse treatment by intuition.

-

Footnotes:

-

[1] A piece of my mind. EBM’s six dangerous words.
Braithwaite RS.
JAMA. 2013 Nov 27;310(20):2149-50. doi: 10.1001/jama.2013.281996. No abstract available.
PMID: 24281458 [PubMed - in process]

-

[2] Answer to What is this Dangerous Treatment and How Long Did it Take to Stop Using it
Wed, 01 Feb 2012
Rogue Medic
Article

-

[3] C A S T and Narrative Fallacy
Mon, 20 Jul 2009
Rogue Medic
Article

-

[4] 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.

-

[5] Evidence based medicine: what it is and what it isn’t.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
BMJ. 1996 Jan 13;312(7023):71-2.
PMID: 8555924 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

-

[6] Cherry picking (fallacy)
Wikipedia
Article
 

Cherry picking, suppressing evidence, or the fallacy of incomplete evidence is the act of pointing to individual cases or data that seem to confirm a particular position, while ignoring a significant portion of related cases or data that may contradict that position. It is a kind of fallacy of selective attention, the most common example of which is the confirmation bias. [1] Cherry picking may be committed intentionally or unintentionally.

 

-

[7] Hasty generalization
From Wikipedia
Article
 

A person travels through a town for the first time. He sees 10 people, all of them children. The person then concludes that there are no adult residents in the town.

 

.

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part II

ResearchBlogging.org
 

Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.

What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?
 

Intuitively, devices such as the indirect video laryngoscope should improve intubation performance. As such, this study tested the hypothesis that achieving better visualization during the intubation with the GlideScope Video Laryngoscope would result in a better airway management performance as measured by shorter intubation times.[1]

 

The authors also intuitively assume that shorter intubation times mean better airway management. This suggests that speed is the most important factor in airway management.
 


Image credit.
 

They are probably still preaching the myth of the Golden Hour at Shock Trauma.

Is speed more important than quality?
 

There is an excellent assessment of intubation attempt in this paper.
 

Confirmation of intubation attempt duration and success was identified using closed-circuit video.[1]

 

We should not be relying on self-reported intubation success, unless we aren’t interested in a study of fiction. We do not accurately report intubation success, so an objective measurement of success is essential. This should be applied to EMS, as well.
 

The failed intubation rate was less than 0.5%, but the participants had already excluded over a quarter of the patients, so how impressive is a half a percent failure on 3/4 of patients?

What is the success rate for all patients?
 

For all of the statistics regarding study measures, a p < 0.05 was chosen as the threshold for determining significance.[1]

 

Secondary outcome measures are free shots at finding something “significant,” so they should be required to achieve a higher standard than the 1 in 20 p value of < 0.05.[2]

 

To account for any potential bias from patients not enrolled owing to attending discretion, comparison analysis was performed between the eligible, enrolled patients and the eligible, nonenrolled patients. The data demonstrates that all groups were proportionally similar in their demographics, injury mechanism, ISS, and arrival vital signs (data not shown).[1]

 

And, according to Dr. Newman in the SMART EM podcast, the Mallampati scores of the excluded patients were similar to those of the included patients.
 

Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.[3]

 

We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.[4]

 

Do the demographics, injury mechanism, ISS, and arrival vital signs increase the ability of the Mallapati to predicting difficult intubation?
 


Image credit.
 

How do we know that the difficulty was similar between included patients and excluded patients?

Similar Mallampati scores.

How useful are Mallampati scores at predicting difficulty of intubation?
 

The pooled estimates demonstrated that only 35% of the patients, who underwent tracheal intubation with difficulties, were correctly identified with a modified Mallampati test.[4]

 

Does the Mallampati score work well for predicting difficulty of intubation with a video laryngoscope?
 

The clinical use of videolaryngoscopes may change the accuracy of predictors of difficult tracheal intubation and require a different definition of difficult tracheal intubation.[4]

 

The Mallampati score does not appear to be of much use in comparing the excluded patients from the included patients, but that is what the authors use to assure us that the patients are similar.

Mallampati scores compare one aspect of visibility, but how important is visibility for intubation?

To be continued in Part III.

-

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] Do multiple outcome measures require p-value adjustment?
Feise RJ.
BMC Med Res Methodol. 2002 Jun 17;2:8. Review.
PMID: 12069695 [PubMed - indexed for MEDLINE]

Free Full Text from BioMed Central.
 

Standard scientific practice, which is entirely arbitrary, commonly establishes a cutoff point to distinguish statistical significance from non-significance at 0.05. By definition, this means that one test in 20 will appear to be significant when it is really coincidental. When more than one test is used, the chance of finding at least one test statistically significant due to chance and incorrectly declaring a difference increases. When 10 statistically independent tests are performed, the chance of at least one test being significant is no longer 0.05, but 0.40.

 

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[3] A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway.
Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.
Anesth Analg. 2006 Jun;102(6):1867-78.
PMID: 16717341 [PubMed - indexed for MEDLINE]

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[4] Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients.
Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J; Danish Anaesthesia Database.
Br J Anaesth. 2011 Nov;107(5):659-67. doi: 10.1093/bja/aer292. Epub 2011 Sep 26.
PMID: 21948956 [PubMed - indexed for MEDLINE]

Free Full Text from Oxford Journals.

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Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

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Lee A, Fan LT, Gin T, Karmakar MK, & Ngan Kee WD (2006). A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesthesia and analgesia, 102 (6), 1867-78 PMID: 16717341

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Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J, & Danish Anaesthesia Database (2011). Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107 (5), 659-67 PMID: 21948956

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