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

- Rogue Medic

Ignore the Absence of Evidence – Defend the Status Quo?

Does epinephrine improve outcomes from cardiac arrest?

If an improved outcome is a pulse at the time of transfer and a huge hospital bill for the family, with the possibility of continuing huge bills to care for the minimally conscious nursing home patient until sepsis ends the punishment – then yes, epinephrine improves outcomes.

If an improved outcome is leaving the hospital with a pulse and a brain that works as well as it did before the arrest – then no, epinephrine does not improve outcomes.

Obtaining ethics board approval for a trial of such a standard medication as epinephrine will be challenging.[1]

This is why we should never make a treatment a standard of care until after there is good evidence that it improves outcomes that matter. Too many people will claim that it is unethical to find out how dangerous the treatment is. We don’t want to know that we have been killing patients.

Looking at the most recent study looking at epinephrine and lack of survival from cardiac arrest, he concludes –

The bottom line is we should remind ourselves that all interventions come with unintended consequences. We need to continue with practicing the status quo, but we also need to be careful with epinephrine and get more involved in research.[1]

We just need to clap for Tinkerbell?
 


 

Does evidence of improved survival support the status quo?

No.

We need to continue with practicing the status quo,

Why?

Bleeding patients to remove humors used to be the status quo.

Did we kill thousands, tens of thousands, hundreds of thousands, or millions of patients?

How many patients died to protect the status quo egos of the barbers?

Was there any evidence of improved survival?

No.

Did barbers base treatment on experience?

Yes.

Experience clearly supported bleeding patients.

Did barbers base treatment on logical conclusions, based on their experience?

Yes.

Our memories of our experiences allow us to deceive ourselves by remembering what supports our biases, while we conveniently ignore what does not support our biases.

Relying on evidence, that has been collected in a way to minimize the interference of bias, is what will help us to recognize our errors long before experience has a clue.

Or we can continue to celebrate our ability to ignore reality, while we make Sweeney Todd’s body count look tiny.

Footnotes:

[1] Research Study Examines Epinephrine’s Effects on Cardiac Arrest – Epinephrine has been the mainstay of cardiac arrest, but is it effective?
JEMS
David Page, MS, NREMT-P
Wednesday, June 13, 2012
Article

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Comments

  1. Rogue,

    This is why we should never make a treatment a standard of care until after there is good evidence that it improves outcomes that matter. Too many people will claim that it is unethical to find out how dangerous the treatment is. We don’t want to know that we have been killing patients.

    Yes, that is agreed. However the problem is that epi in cardiac arrest IS the standard of care, whether we like it or not; and as such is more difficult to get testing approval for than a new untested medicine.

    There WAS evidence that epi improves outcome; the problem was that the evidence was flawed. IMHO, one of the best things from Hagihara et. al. is that it fairly conclusively disproves any link between ROSC and true survival. Given that equating ROSC with survival has (finally) been disproved, and the old ROSC data on epi has (finally) been discredited, now it will be much easier to get approval for a true double-blind study of the effect of epi.

    Also, don’t forget that a significant number of people do feel that simply getting ROSC without recovery of brain function is better than dead; never forget the disastrous situation around Terry Schiavo.

    And yes, it will take a long time to change the mindset about cardiac arrest and epi. That is true in any field of science, where it is usually just egos at stake; but even more so in medicine because the much higher stakes lead to stronger emotional attachment to particular data and methods.

    Whether remarks about voodoo, Tinkerbell, and Sweeney Todd change minds faster or slower is a matter of personal opinion.

  2. I just love that an EMS blog is citing Kuhn. Not just invoking the word “paradigm” in a cheap way, but actually showing some appreciation for his larger thesis.

    Maybe I’ll go dig up my well-underlined copy of “Structure.” It’s in a box somewhere downstairs…

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