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

- Rogue Medic

The Relentless Optimism of a Stalker Applied to Medicine


She really does love me, she just has trouble showing it (even though she probably does not even know I exist).

This is the way stalkers think.

Insert any woman you consider to be extremely attractive. For me, the choice is more Diane Lane, than Miley Cyrus (and Kelly Grayson seems to have Christina Hendricks locked up all to himself).

Image credit.

This is the way believers in alternative medicine think.

This is the way believers in anecdote-based medicine think.

Anecdote-based medicine is the intuitive, I’ve seen it work approach to medicine that is not different from alternative medicine in any important way.

Almost always, these anecdote-based treatments are found to be harmful. Not beneficial is the same as harmful, because a treatment that provides no benefit, but exposes the patient to the risks of an unnecessary treatment is dangerous.

Clearly, Diane Lane and Josh Brolin are getting divorced because she wants to be with me, right?

I just need to believe and it will work.

I just need to ignore all objective evidence and it will work.

I just need to trust my inner stalker.


As much as I would like to think that there is something about me that appeals to beautiful women who do not even know I exist, I should not ignore reality.

Does this also apply to EMS treatments?

Prehospital IV therapeutic hypothermia has not demonstrated any benefit when begun by EMS and has demonstrated harm. The outcomes all trend toward harm, so a meta-analysis may show a statistically significant decrease in survival.[1],[2],[3],[4]

We just need to believe and it will work.

We just need to ignore all objective evidence and it will work.

We just need to trust our inner stalkers.


Should we maintain unreasonable optimism?

What if there really is a benefit?

It is much more likely that there really is harm.

Even though harm is more likely, it is more difficult to recognize.


The intervention reduced core body temperature by hospital arrival, and patients reached the goal temperature about 1 hour sooner than in the control group. The intervention was associated with significantly increased incidence of rearrest during transport, time in the prehospital setting, pulmonary edema, and early diuretic use in the ED. Mortality in the out-of-hospital setting or ED and hospital length of stay did not differ significantly between the treatment groups.[4]


If we cannot provide evidence of improved outcomes, all we have is wishful thinking.

Wishful thinking kills.

Diane Lane may really want me, but there is no rational reason to believe this.

Prehospital IV therapeutic hypothermia may really work, but there is no rational reason to believe this.

The same is true for every other treatment that is not supported by evidence of improved outcomes that matter.

We should expect harm, not benefit.

It is irrational to expect benefit, but many of us do expect benefit because we are irrational optimists and we do not pay for our mistakes. Our patients are the ones who pay for our mistakes.


[1] 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.

[2] Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I
Podcast page with links to research mentioned in the podcast.

Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II
Podcast page with links to research mentioned in the podcast.

[3] 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]

[4] 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]



  1. You laugh, but as soon as this restraining order expires, Christina will be mine.

    Oh yes, she WILL be mine.

  2. And she shall open herself to me, as the furrow to the plough.