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
"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
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."