Bad Luck

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One of my favorite quotes is from Robert Heinlein’s “Lazarus Long” character,

Throughout history, poverty is the normal condition of man. Advances which permit this norm to be exceeded — here and there, now and then — are the work of an extremely small minority, frequently despised, often condemned, and almost always opposed by all right-thinking people. Whenever this tiny minority is kept from creating, or (as sometimes happens) is driven out of a society, the people then slip back into abject poverty.

This is known as “bad luck.”

I thought of that quote when I read this article,

Oxfordshire ambulance services accused of “playing god” and “putting lives at risk” in new drug trial

AMBULANCE authorities have been accused of ‘playing god’ and putting lives at risk by taking part in a trial which gives cardiac arrest victims a placebo instead of adrenaline.

The study by five ambulance trusts including South Central Ambulance Service (SCAS), called PARAMEDIC-2, will eventually be rolled out to every ambulance in the county.

Current guidelines recommend routinely giving adrenaline during the resuscitation of patients who have suffered cardiac arrest.

However researchers say a clinical trial has never been done and believe it could cause more deaths than it saves.

That’s the science part, as anyone who reads Rogue Medic even casually knows. As a matter of fact, he posted on this exact topic just the other day. I don’t always agree with him, but he does make one think.

The truth is that Epinephrine has been given based on the principle of “this should work” for as long as ACLS has existed. Sure, logically, it should, but there is no science to tell us it does work or how it works if it does indeed work.

The American Heart Association, for almost 10 years now has been telling us that good chest compressions and rapid defibrillation are the only things that we know that will work if a patient is in cardiac arrest and has a survivable rhythm.

What they are now trying to do in England is figure out if Epinephrine (called Adrenaline in England) is actually of any benefit to patients in cardiac arrest. There is good reason to test this in the pre hospital environment because pre hospital providers see more cardiac arrests and see them earlier in the process than anyone else.

Of course some people don’t understand the science. Not that this little fact stops them from rendering an opinion,

Chairwoman of Oxford health group Patient Voice Jacquie Pearce-Gervis, said: “What they are doing is basically playing god by enrolling people into this trial.”

Some concerns have been raised about the trial, in which patients could be given a salt solution instead, because patients will not be able to consent to take part, only opt out of it.

This would be true if, and only if, we knew that Epinephrine was beneficial. Which we don’t. In fact, it’s possible that Epinephrine is not only not helpful, but might even cause harm and prevent resuscitation. I don’t know about you folks, but I’d like to know if the most common drug given for cardiac arrest is of the least bit of help. I’d even more like to know if it’s harmful or reduces the chances of resuscitation.

But the ambulance service said the ethics had been approved, based on European law, and that funding had been given by the National Institute for Health Research (NICE).

It’s not as if someone woke up one morning and said “Let’s give this no Epinephrine thing a go and see what happens.” There is actually some thought and science behind this.

Some people who should know better have bought into the “playing God” notion,

The trial has been designed to test this belief but Abingdon GP Dr Prit Buttar said it could lead to deaths that might have been prevented.

He said: “If a small number of people survived after being given adrenaline, and fewer survived when given the placebo, you could argue that several people who had died may have not died if they were given adrenaline.

“If you asked members of the public whether they wanted adrenaline or whether they wanted salt water after suffering a cardiac arrest, I’m sure most would say adrenaline.

“You could be causing preventable deaths with this trial.”

Sounds pretty scary, but the patients who are going to be involved in this study are by definition already dead. His argument is convoluted, to say the least. The problem is that we don’t know if it works or if it’s harmful. Does a doctor, who is supposed to be a scientist, really believe that we should continue to use a therapy that we don’t even know works?

I’m sure if you asked members of the public if they wanted adrenaline or salt water they’d say “Adrenaline.” That’s not the question being investigated in this study. If you asked the general public if they wanted an untested drug (Adrenaline), that might help them, might do nothing, or might harm them or a fluid that won’t change things either way, they’d opt for the latter.

In a joint statement, the trust and the University of Warwick said they will be publicising the trial through the local press and community noticeboards in the coming months.

They added recent studies suggested although adrenaline does restart the heart, it could possibly worsen survival rates in cardiac arrest patients.

The statement said: “The real risk would be to continue to give treatments that may have been used for decades, but have not been properly tested to modern scientific standards.”

And that’s the key. While short term success might seem good to the public, what they should be concerned about is patients surviving to discharge neurologically intact. That is the gold standard, anything else is just raising false hope.

Hopefully science, and not “advocates” who don’t seem to know much medicine or about the scientific method will prevail here.

Otherwise I see a period of “bad luck” for cardiac arrest patients in England.

2 COMMENTS

  1. They did the same kind of trial in Seattle and Toronto comparing lidocaine and amiodarone. Interesting ethical arguments at the investigators’ meeting. Also I’m not aware of any study comparing chest compressions at 100/min to 60/min which was a change in the ACLS protocol a few years ago. The change was promoted to us as “people will compress too fast anyway, so why not teach it that way”!! I do know from a personal experience doing compressions in the cath lab with a line measuring pressures in the aorta, the doctor who started out going fast was getting 40-50 mm of pressure, and when he pooped out and the first adrenaline surge was over (for me, not the patient) I was getting 90-100 mm at 60/min or so. One case doesn’t prove much, but I have not found any research proving one way or the other. There are a lot of treatments, especially in surgery, that don’t have much to back them up.

    • It’s rather scary how much of medical science isn’t very scientific at all. EMS is constantly being hounded to follow the data like the rest of medicine does. As it turns out, a lot of the science isn’t. Not very long ago, three hours was the “window” for treating strokes with thrombolytics. Now, it’s 4.5 hours in most places and their is some discussion of a longer window. All which means that the science is constantly evolving and never settled. There is now serious discussion of bringing Levophed back to ACLS.

      Who knows what the next version of ACLS will include?

      Does Epi work? Maybe it does, but not under all of the circumstances that we currently think it does.

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