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Sun Oct 12 07:42:25 BST 2008

On Sat, 11 Oct 2008 22:13:00 -0700, "Wilson, Matthew, M.D."
<Matthew.Wilson at cshs.org> said:
> Were do you want me to pik you and anser with ful sent or you won't be
> able to go to another party

Something tells me that you are capable of even full words. 

If what I have written is unclear, using full words and sentences might
help to clarify that.

If you need someone to party with, perhaps a different list would be the
place to look.

Tim Noonan.

> Matthew Wilson, MD, FACS
> Assistant Director of Trauma Services
> Cedars-Sinai Medical Center
> Department of Surgery
> 8700 Beverly Blvd, Ste 8215NT
> Los Angeles, CA 90048
> Ph/Fax: (310) 423-6444 / (310) 423-0139
> Email: Matthew.Wilson at cshs.org 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
> To: Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>
> Sent: Sat Oct 11 22:09:39 2008
> Subject: Re: The "Panel"
> 
> On Sat, Oct 11, 2008 at 11:43 PM, <htaed_rd at 123mail.org> wrote:
> 
> 
> > 2. IRBs continue to approve studies that are too small to show any
> > statistically significant result.
> >
> 
> There job is not to assure the validity of the study, just to protect the
> rights of study subjects and to keep the university/hospital/etc from
> getting sued into oblivion.   The issues of assuring statistical
> significance and controlling for variables is the responsibility of the
> researchers and, to a lesser degree, the peer reviewers of the journal(s)
> the research is submitted to.  If there is a problem with significance or
> confounding variables, then the paper should be sent back to have the
> issues
> addressed.
> 
> 
> > 3. IRBs continue to approve studies that do a poor job of controlling for
> > variables that are controllable.
> >
> 
> See above.
> 
> 
> > 4. Few seem to have a problem with the absence of good research in areas
> > that are very controversial.
> >
> 
> Personally, I think some of the people who ignore the evidence on
> subjects
> such as this do it, at least in part, simply because they enjoy heated
> debates.
> 
> The controversy is due to the lack of good research.
> >
> 
> Well, not entirely, but the research could certainly be more extensive.
> 
> 
> >  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?
> >
> 
> I don't know of any in health care, but it reminds me sadly of the
> responses
> of people who believe in aliens when asked to provide evidence of their
> stance.
> 
> 
> > 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.
> >
> 
> I miss my old service- the medical director allowed us to have input on
> the
> protocols.  If we could provide a legitimate reason why our option was
> more
> viable or beneficial, he was all for it.  This is one of the best
> arguments
> for requiring EMS medical directors to have actually worked as EMTs or
> paramedics.  It helps counter the "edict from the ivory tower" feeling
> that
> one often encounters in protocol development.
> 
> 
> >
> > 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 service I worked for the longest actually had a *protocol for
> violating
> protocols*.  The stance was basically that if you had a valid reason for
> not
> doing something that was implicitly required in the protocols or skipping
> steps in the protocol (for example: airway management and not even trying
> to
> intubate before going to a surgical airway in a patient with their face
> taken most of the way off by a shotgun, etc) or frankly doing something
> that
> was not in our skill set (example: sticking my fingers into a trauma
> patient's thigh to get control of a femoral bleed that we could not
> control
> otherwise), you could do so.  The one stipulation was that it had to be
> defensible and it had to be done in the best interest of the patient and
> not
> for the convenience or ego of the medic.
> 
> Still, where are the good studies that show clearly the effects of HEMS?
> 
> 
> What about the studies that show most patients are discharged soon after
> arrival?  What about the studies that show minimal survival benefit in
> most
> settings?  What about that study from the NTSB about the hazards of the
> current manner in which aeromedical operations are conducted?
> 
> 
> > The studies that demonstrate clearly which patients are most likely to
> > benefit?
> 
> 
> The answer to this boils down more to the distance (or more accurately,
> the
> trasnport time) to definitive care than the care delivered because of the
> few differences in care delivered and the increased difficulty in
> delivering
> care in a helicopter.   Therefore, the benefit is going to occur in
> remote
> or rugged areas where evacuation by other means is going to result in a
> dramatic delay.   Most of the time, the patient is going to benefit most
> by
> being taken to the closest hospital and then be referred up the echelon
> of
> care (to use the military medical vernacular) as the treating physician
> dictates.
> 
> The studies that show which are most likely put patients at excessive
> risk?
> >
> 
> The NTSB has a searchable database of these. ;)
> 
> 
> > 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.
> >
> 
>  That is the problem.  I wish more people were just interested in doing
>  what
> is correct based on evidence than trying to advance their own agenda. 
> The
> truth is likely in the middle somewhere between the two camps and we
> really
> need to find a middle ground on who gets flown, but we can not compromise
> on
> the "when" of flying people because of the safety ramifications.
> 
> 
> 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.
> >
> 
> Well said.  I am happy to work with anyone (regardless of which side of
> the
> issue they are on, so long as the study gets published not matter which
> side
> of the argument it supports) who is willing to open their records to
> settle
> this.   One of you all out there has to have the data and if you can get
> the
> funding for a study, let's run with it.
> 
> 
> 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.
> 
> 
> See my above comment.
> 
> 
> 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.
> >
> 
> One more reason to dislike the FDA.
> 
> 
> > 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.
> 
> 
> I've disproven more of my previous beliefs about aircraft crashes in the
> course of my research than I have reinforced.
> 
> I do not think it is disrespectful to offer constructive criticism. This
> > is meant as constructive criticism.
> >
> 
> It is some of the best worded criticism I have seen in a long time.   You
> have my respect (whatever that is worth to you).
> 
> 
> 
> -- 
> Stephen L. Richey, CRT
> Aviation Injury Research Project Leader
> Saginaw Valley State University
> Work E-mail: slrichey at svsu.edu
> Home Office Phone: 248-366-4452
> 
> "It is the characteristic excellence of the strong man that he can bring
> momentous issues to the fore and make a decision about them. The weak are
> always forced to decide between alternatives they have not chosen
> themselves."- Dietrich Bonhoeffer
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