The "Panel"

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On Sat, 11 Oct 2008 15:17:05 -0500, "Bryan Bledsoe, DO"
<bbledsoe at earthlink.net> said:

> There is also an arrogance from many in the medical community
> who
> support widespread HEMS--not all, but some. There is a continuing mantra
> of
> "You don't understand the literature" or "That is not what the literature
> is
> saying" or "You have a selection bias" or something to that effect.
> Medical
> literature is what it is. The beauty of science is that studies can be
> evaluated and, if needed, repeated. You do not have to have a secret
> decoder
> ring to evaluate the medical literature on HEMS. 

If only it were as simple as having a decoder ring.

1. Medical literature continues to be interpreted in the frame of the
existing biases.

2. IRBs continue to approve studies that are too small to show any
statistically significant result. 

3. IRBs continue to approve studies that do a poor job of controlling
for variables that are controllable. 

4. Few seem to have a problem with the absence of good research in areas
that are very controversial.

The controversy is due to the lack of good research.


> Granted, the overall
> quality of HEMS is literature is fairly low. But, like many things in
> EMS,
> there has been a reversal of the burden of proof. That is, the HEMS
> system
> has become widespread and entrenched and instead of proponents publishing
> literature supporting their point, they say "prove it doesn't work." 
> Where
> else in health care does that occur? 

Look at resuscitation of hemorrhagic trauma patients. Where are the
studies that are designed to be large enough to be clear and convincing
in their results?

Where is the demand for these studies?

The reliance on expert opinion means that the care a patient receives
will depend on the bias of the physician writing the EMS protocols.

This is one area with the same reversal of the burden of proof. I agree
that fluids are overused, but that is my opinion based on the inadequate
literature and the lack of logic on the part of those treating the blood
pressure, rather than treating the patient.

As a paramedic, I do not have the authority to change protocols. I can
push the edges of the protocol. I can even violate the protocol. I can
also be censured/decertified for either action, if any of those with
authority to oversee EMS wish to exercise that authority. 

What would I be able to point to as a defense? 

Not a lot.

The response would be - "You're not a doctor. You don't get to make
those decisions. If you want to change things become a doctor."

They are obviously correct about the first statement. I am not a doctor.

I agree with the second statement with some reservations. I should have
to demonstrate a good reason for my violation of protocol. There should
not be carte blanche for a medic to violate protocols just because the
medic does not like them.

The third statement is idiotic. Are all of the doctors already
practicing so helpless that they will not perform good science unless I
become a doctor? Am I really that powerful?

Well, I have no desire to be a doctor.

Still, where are the good studies that show clearly the effects of HEMS?
The studies that demonstrate clearly which patients are most likely to
benefit? The studies that show which are most likely put patients at
excessive risk?

Where are the studies that are large enough and well enough controlled
to show the appropriate role of fluid in resuscitation of hemorrhagic
hypotension?

There is resistance to even studying this, because the "experts" are so
convinced that they are right, that there is opposition to subjecting
"their" patients to randomization to a treatment arm they do not approve
of. In other words, these experts are guaranteeing that there will NOT
be convincing research until someone with a decoder ring comes along.

The scientific method is the decoder ring.

We can believe anything we want, but until we can point to large, well
designed studies, all we are doing is worshiping in different temples of
ignorance.

Eventually some of these temples will be shown to have been more harmful
to patients. By favoring their particular religious sects over science,
they will all have been responsible for an awful lot of graves. 

As long as the science is poor, the patients will ALL be subjected to
experimental studies, because without real evidence, it is all
experiment.  

We need for the proponents of the various treatments to get together to
set up a study in a way that they all agree on one thing. This study is
large enough, well controlled enough, . . . , that if the results are
negative for what I believe - I will change my mind. Otherwise those who
believe differently will always be able to come up with some excuse for
why the study is being misinterpreted.

Dr. Mattox,

You believe that fluids should not be administered by EMS. Design a
study large enough, with whatever controls you feel are necessary, that
you would accept the results - results that would cause you to change
your mind about fluid administration.

Get together with the most vocal of your opponents and dare them to add
whatever conditions that would convince them that they are wrong.
Combine your criteria, which would probably require making the study
even larger, and find some way of agreeing on the oversight. 

And do the study. 

Until there is convincing evidence those favoring treating the blood
pressure, rather than treating the patient, will be able to claim that
the research is not convincing.

We need the same approach in HEMS and several other areas of medicine.
Spinal immobilization, airway management (BVM vs. intubation vs. RSI)
with aggressive physician oversight, . . . .

There are other areas where this kind of research will be impractical,
such as needle decompression of tension pneumothorax. That is not a
reason to avoid setting up the studies that are practical.

Or we continue to hide behind the claim of the FDA that a standard of
care based on expert opinion is not experimental treatment. That not
studying these untested or poorly tested opinions is somehow ethical. 

Insisting that experimental treatment be continued indefinitely, with no
hope for any evaluation of the random uncontrolled application of
opinion, is not ethical.

Now, I apologize for using Dr. Bledsoe's post as an excuse for a rant,
but there is a decoder ring. It appears to be a secret to a lot of
supposed scientists. It does not say, "Be sure to drink your Ovaltine."
It says, science means trying to disprove what you believe. 

Otherwise we are dealing with  religion, and a second rate religion, at
that. 

I do not mean any disrespect to those on this list, since I have learned
a lot from this list. 

I do not think it is disrespectful to offer constructive criticism. This
is meant as constructive criticism.

Tim Noonan.


> Drs. Mattox, McSwain and others have
> made a life's work of writing and reading the medical literature. Surely
> their read (and the read of all educated men and women) should carry the
> same weight. When other first world countries (e.g., Canada, Australia,
> Germany, United Kingdom, et al) are doing something different than those
> of
> us in the United States, it is time for pause and introspection.  Perhaps
> "the panel" will be that introspection.
> 
> 
> Bryan Bledsoe, DO, FACEP
> Clinical Professor of Emergency Medicine
> University of Nevada School of Medicine
> Department of Emergency Medicine
> University Medical Center of Southern Nevada
> Las Vegas, NV
> 
> --
> trauma-list : TRAUMA.ORG
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