It was a late afternoon in the spring of 2011, and my pager went off once again. The ED was calling – another ICU admission, a critically ill middle-aged man who needed to be brought up to the unit after a cardiac arrest. Oh, how I wished I could be surfing at La Jolla Shores, or eating tacos and mangos down on the beach at Playas de Tijuana.
We put in our lines, ordered the cooling protocol, and called the CT surgeon to start ECMO, just like we had been taught. We met with the family, wrote our notes, and moved on to the next patient. And then the next. Always rounding.
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Yesterday, I flipped through a JAMA which had recently arrived in my mailbox and spotted a randomized controlled trial of 334 patients from France. The study looked at moderate hypothermia in cardiogenic shock (33-34 degrees) versus normothermia. The researchers found that it was ineffective to cool people, although the study was probably underpowered.
Much of what we do in medicine is not based on randomized controlled trials and meta-analyses, and may therefore be dangerous. I don’t think most people really understand how far we are from “primum non, nocere,” first do no harm. It wasn’t just our patient in California back in 2011 – many patients are affected by this.
It’s not just critical care medicine and hypothermia in cardiogenic shock. Psychiatry, surgery, infectious diseases, general internal medicine, and primary care are full of interventions which might not benefit the patient. More randomized trials are needed to figure out what works and what doesn’t. Importantly, we must rethink standards for a medical intervention and recognize the difference between the science and the art of medicine.
If a treatment lacks sufficient scientific evidence then shared decision making between the patient or family member and the clinician is required. We all want the same thing – the highest quality of care for every patient – and shared decision making is the way to get there.
Practically speaking, however, there’s a lack of time for this. If America could obtain single payer/ Medicare-for-all, that would free up time to have these important conversations.
Philip A. Lederer 
Important. My doctor has me on a medicine and I don’t think it works and it might be hurting me.
Thanks
On Thu, Feb 3, 2022 at 6:06 AM Health and Healing wrote:
> Philip Lederer MD posted: ” It was a late afternoon in the spring of 2011, > and my pager went off once again. The ED was calling – another ICU > admission, a critically ill middle-aged man who needed to be brought up to > the unit after a cardiac arrest. Oh, how I wished I could be surf” >