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

- Rogue Medic

A Comment on Is There a Placebo Effect – Part II

There are some interesting comments in response to Is There a Placebo Effect – Part II.
 

pyroknight writes –
 

Our job is to provide objective AND subjective relief. It is not an either or proposition.

 

I agree. Perhaps I should have stated that more clearly.

I write a lot about subjective treatments, such as pain management and sedation. I stress that these are important, but I do think that objective improvement is more important.

If I have a patient with severe pain and life/limb threatening injuries, I will defer the pain management, if it will interfere with the apparent life/limb threat. On the other hand, I do not see hypotension as a contraindication for pain management.[1] I will prioritize transport over pain management, if I think that the delay increases the threat to the patient’s life/limb. If there is no life/limb threat, then I will spend as much time on scene as necessary to mange the patient’s pain prior to transport. I do not see any reason for the patient’s subjective discomfort to be anything less than a priority in the absence of a life/limb threat.

I also dispute the assertion that providing subjective relief is not beneficial to patient status. Anxiety increases oxygen demand and causes the release of all kinds of nasty intrinsic chemicals which are not conducive with good-health. For years I have treated dyspnea patients under both the “difficulty breathing” protocol and the “anxiety” protocol. Whether they are having a panic attack (I think most prehospital providers would agree that a large number of patients have some degree of psychiatric issue, diagnosed or not) or are merely anxious BECAUSE THEY CAN’T BREATHE, they are still anxious. I believe it is ethical and medically proper to treat the bronchoconstriction AND the anxiety. Why wouldn’t we want to improve the patient’s physical and emotional simultaneously if we have the capacity.

 

I agree with this as well.

Respiratory disorders were thought of as entirely hysterical by many only a century ago. While we know that is not the case, we should not ignore the subjective aspects of difficulty breathing. If anyone thinks this is unimportant, I suggest testing out the sensation of suffocation – not autoerotic asphyxia, but breathing into a bag and rebreathing your own CO2 (Carbon diOxide). It seems that the increase in CO2 has much more to do with the subjective respiratory distress, than the lack of oxygen does.

This is important for all of the reasons given by pyroknight. Our protocols tend to be far behind our ethics, when it comes to considering any patient’s feelings. We are more concerned about respiratory depression in tachypneic patients than is appropriate. With a medic sitting right next to the patient, it should be impossible to go from SOB (Short Of Breath) to apneic, due to reasonably titrated sedation without passing through a state of dramatic improvement.

The point I was making is that focusing exclusively on the subjective benefits of placebos, would lead us to see no difference between albuterol and placebo albuterol, or acupuncture, or sham acupuncture.

That would be a mistake.

That is where I think Daniel Moerman, PhD’s editorial leads us.

Teeks writes –
 

“If Daniel Moerman, PhD is correct and the subjective improvement is what is important,…”

Sorry, but any improvement in subjective scores must translate into objective, functional, real world gains. Improving scores on subjective measures, without an accompanying objective improvement, is meaningless manipulation of test taking behaviour.

 

I am not clear on what you mean by a manipulation of test taking behavior, but there is value to improving subjective conditions. For example, I have often had calls for hysterical hyperventilation, which should not be assumed based on superficial appearances. I calm the patient down, teach the patient to control his breathing, and only get a refusal after their vital signs and subjective assessment are back to normal. While a benzodiazepine might get me there sooner, it might also mask assessment findings of a more serious medical cause of the hyperventilation, many of which are life threatening.

I have repeatedly stated that –

My most important job as a medic is to calm everyone on scene down.

Everything after that is a bonus.

I think that the biggest mistake we make in EMS, and all of medicine, is exaggerating the seriousness of the threat to the patient of just about everything, except when we want to talk the patient into a refusal.

The best way to avoid that is to try to balance the objective and the subjective, but the objective is not to be ignored.

pyroknoght responded to Teeks with –
 

Teeks, I think you may have missed the sarcasm coming from Rogue. I am pretty sure the implication was not to abandon procedures and medications that provide measurable, physical relief to the patient. I believe the intent was to mock the fact that someone would waste time and energy measuring and reporting subjective relief in the first place.

 

I don’t think that paying attention to the subjective is a waste of time.

I do think that paying attention to the subjective at the expense of the objective, can be dangerous.
 

I stand by my post that if we can provide subjective relief WITH objective relief, then we are caring for the whole patient and not just attacking the signs and symptoms. Compassionate caregivers consider the patient’s emotional well-being in the course of care and do not merely treat the patient’s physical ailments.

 

I agree.

While I tend to be much more aggressive with fentanyl and midazolam than most of the other medics I know, I do find that calming the patient and making the patient comfortable with the care they will receive helps to avoid using even higher doses.

I think that one of the biggest problems in EMS, and all of medicine, is that we have mistaken subjective assessments of what good patient care is.

Also, since these were treatment studies, I am not sure how you would end up with manipulation of test-taking behavior. The “test” in this case was relief of symptoms. I doubt someone with dyspnea cares much how their behavior affects a study. They just want relief! The smart ones would probably tell you they expect objective relief, but they would settle for the subjective relief because THAT is what makes them feel better. It’s sort of like making cough syrup taste good. The nasty tasting stuff may give you objective relief, but if you can add a little sweetener and some flavoring, you can achieve the objective while sparing the patient the awful aftertaste of the just as beneficial but heinous medicine that tastes like, well, medicine.

 

On the other hand, having something taste more mediciney may produce more of a placebo effect.

And Brandon Oto of EMS Basics writes –
 

Thought #1: How many of our patients call us for relief of objective complaints? Certainly part of our job is to catch and provide a path to the treatment of dangerous “objective” problems, but strictly speaking, that’s not usually why they called us. Note we call it a “chief complaint,” not a “chief pathology,” even if many of us have started conflating the two. My arm hurts. I feel bad. I’m dizzy.

 

Just because we use a certain terminology does not dictate what is most important. Protocols are moving more to ACS (Acute Coronary Syndromes), rather than Chest Pain protocols. We are recognizing that the chief complaint may not fit into our protocols so easily. Also there is the big problem of ignoring the true medical condition by focusing on pigeonholing the chief complaint.[2]

Thought #2: If we grant that it’s important to correct things that can lead to additional morbidity and mortality, surely you do not OPPOSE making people feel better.

 

I want patients to feel better.

What I oppose is the suggestion that –

In this group of mild/moderate asthmatics, since the subjective improvement was almost as good with the placebos as with the albuterol, that the placebos are as good as the albuterol.

This is a very dangerous attitude and appears to be what Daniel Moerman, PhD is suggesting.

Footnotes:

[1] Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Rogue Medic
Article

[2] Influence of Sex on the Out-of-hospital Management of Chest Pain – Part I
Rogue Medic
Article

I have not written Part II, but I probably will at some point.

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Comments

  1. No quibbles. I just feel that relieving suffering is one of the most powerful and important things we can do in medicine (even or maybe especially in prehospital medicine); I’m glad we’re on the same page there.

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