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MODERN MEDICINE: YOU CAN NEVER HAVE IT.

Notes from an emergency room doctor: its "new," "the latest thing," the "most modern." That's what I want. Isn't that what we all want, whether we're shopping for cars, computers, or medical care? Unfortunately, we now live in an age where you can never get "new." "New" is ephemeral. Buy a new car and it's used as soon as you drive it off the lot. A new computer - well, just as soon as you buy one, they'll announce some newer and better technology, so what you own will seem as "modern" as a manual typewriter.

"Modern" that's the kind of medicine that most physicians like to think they practice. But unfortunately, technology is moving so fast and there are so many vagaries to research, that "new" knowledge is often "old" not long after you learn it.

In emergency medicine, many of the standard drugs we used in cardiac arrest situations a decade ago are contraindicated today. The MAST suit, "military antishock trousers," those pneumatic garments inflated around trauma victims in shock and used on tens of thousands of patients since Vietnam are now dismissed as useless or detrimental. And now, new research on the resuscitation of trauma victims seems to indicate that we've been doing that wrong all these years too.

Today there's lots of drama in an emergency call. "We've got a victim down," a paramedic will report over the radio, "gunshot wounds to the chest and abdomen, b.p. sixty over zip."

"Put in two large bore i.v.'s," the emergency room responds, "run in lactated Ringers wide open, and transport code three."

That was the universal practice. Give lots of intravenous fluids to bleeding trauma patients to raise their blood pressure, to better perfuse their organs, and prevent death. But physicians at Baylor University and the University of Oklahoma tested that common practice, publishing their results in this October's New England Journal of Medicine. When a paramedic call came in with someone in shock due to penetrating trauma to the torso, like a gunshot or stab wound, they would order i.v. fluids given in the field to trauma patients on even numbered days, but no i.v. fluids given to those who arrived on odd numbered days. Those patients had fluids withheld until they arrived at the hospital and underwent surgery to repair their wounds. Surprisingly, those that were given "no fluids" in the field had a greater survival rate, shorter hospital stays, and fewer complications than those that had prompt fluid resuscitation.

The researchers theorized that intravenous fluids increased blood pressure in trauma victims but that this higher blood pressure dislodged the clots that formed naturally to plug bleeding vessels. The "fluid resuscitated" patients therefore lost more blood volume then those who received no fluids until their wounds were repaired in surgery.

Certainly further research needs to be done but, if these findings are confirmed, every paramedic and emergency medical system in the country will change their "modern methods" of practice. The radio dialogue with the medics will be simplified to, "pack 'em up and come on over." All those exciting television scenes showing medics starting i.v.'s and hanging bags of saline will be as outdated as depression era shoot-em-ups.

"Modern medicine" is as fleeting a concept as a "new car" because somebody is out there somewhere working on a premise that will prove we've been doing it wrong all these years. What was "good" will be found to be "bad" and what was "new" will be "old."