Conrad Theodore Seitz

Here’s a study of advanced life support (ALS) versus basic life support(BLS) that appears to show ALS is less effective, that is, has poorer survival.  It was published in JAMA Internal Medicine and reviewed in the New York Times yesterday.

The study was an observational cohort, with 31 292 ALS cases and 1643 BLS cases.  That seems like a lot of advanced life support vs only a few basic cases; the difference is due to the availability of ALS in most instances.  When ALS is available, it is applied, regardless of circumstances.  This study corroborates earlier studies that showed, first, when a cardiac arrest is witnessed, survival is greater; and second, that bystander CPR (by definition BLS) improves outcomes.  Rapid external defibrillation helped outcomes, which confirms its use as a first option in witnessed cardiac arrests.  Another study showed that the use of epinephrine or vasopressin led to worse outcomes.  The use of tracheal intubation rather than continuing basic bag and mask ventilation did not help either.

The result was that, after 90 days, 8% of BLS cases survived and were discharged from the hospital.  Only 5% of ALS cases did as well.  Early on, after 30 days, 13% of BLS cases and 9% of ALS cases survived.  44% of ALS survivors had poor neurological function, while only 21% of BLS cases had poor neurological function.  All patients were Medicare eligible and the study was “nationally representative.”

The only caveat to these findings would be if patients who were doing poorly at onset were more likely to receive ALS.  This is a potential that could be evaluated if the cases were reviewed to see if ALS was not attempted because the patient responded immediately to BLS.  I wasn’t able to review to full JAMA study to see if this type of review was done, since access to the full article requires a paid subscription to JAMA.

Nevertheless, the point seems clear: some of the interventions used in ALS are pernicious.  Whether these involve intubation, administration of epinephrine or other drugs, or other procedures is not clear.

The New York Times article tries to make the point that sometimes, less is more.  This is certainly true of treatments for cancer.  Lumpectomy and limited radiation are superior to mastectomy in localized breast cancer, partly because some very early types of breast cancer never develop into clinically apparent disease.  Ductal carcinoma in situ (DCIS) is a case in point; studies show that many of these lesions never progress.

When a breast cancer is detected by screening, even DCIS, treatment is counted as success because there is no alternative; no one would allow a DCIS lesion to remain in place to see whether or not it progressed.  Therafter, minimal treatment is more successful than aggressive treatment because all the side effects of aggressive treatment count against it, whereas the untreated lesion never progresses and has no side effects.

There is a significant amount of overtreatment built into modern medicine.  Patients with sore throat visit the doctor and demand antibiotics, even though there is no evidence that antibiotics make any difference to the course of the average sore throat in the adult.  Even children usually don’t benefit from antibiotics, and even proven cases of streptococcal pharyngitis only do marginally better under treatment.  This is not to imply that a patient with a sore throat and a fever doesn’t need to take penicillin; in many cases, the penicillin brings about relief in less than 24 hours.  Studies of symptom relief don’t always have the ability to distinguish improvement in 48 hours from that in 8 hours.

Many other examples of overly aggressive treatment can be adduced, but by the same token, there are many examples of undertreatment due to lax standards and inadequate attention (brought on by overemphasis on trivial, ineffective treatments to the point where adequate long term treatments are not brought up because of lack of time.)

The NYT article is at: http://www.nytimes.com/2015/01/13/upshot/doing-more-for-patients-often-does-no-good-.html and the JAMA abstract is at: http://archinte.jamanetwork.com/article.aspx?articleid=1939373&utm_campaign=social_112514&utm_medium=twitter&utm_source=@jamainternalmed

Here’s another deeply sentient comment from the New York Times, on the article announcing the Governor McDonnell was sentenced to two years in prison for corruption in his office.  The corruption amounted to $177,000 worth of perks such as a free Rolex, rides in the corruptor’s Ferrari, and low interest loans, all in exchange for promoting the corruptor’s phony vitamin business.

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Possibly the following from Wikipedia regarding Judge Spencer will either clear things up or further baffle us on his poorly chosen comment about being broken hearted:

James R. Spencer was nominated by President Ronald Reagan on September 9, 1986 to the a seat on the United States District Court for the Eastern District of Virginia, Richmond Division. He was confirmed by the United States Senate on October 8, 1986 and received his commission on October 14, 1986. He was the first African American to be nominated to this position in this district. In 1985, Judge Spencer earned a master of divinity degree from Howard University.

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Since when does a master of divinity qualify a person to be a Federal District Court judge?  Since the grantee is “African-American” (like other paragons of his race such as Clarence Thomas.)  That’s what made him so “broken hearted” at having to sentence a fellow Republican to prison at all, much less for more than a year.

The New York Times published an editorial on December 30 2014 with some information that was news to me.  To sum it up in one quote, here it is:

“India has the highest number of suicides in the world. According to the World Health Organization, of 804,000 suicides recorded worldwide in 2012, 258,000 were in India. Indian youths between 15 and 29 years old kill themselves at a rate of 35.5 deaths per 100,000 — the highest in the world — and suicide has surpassed maternal mortality as the leading cause of death of young Indian women. ”

The government has announced an ambitious mental health program that looks to be impossible to fulfill.  The first obstacle is the budget, and the national health budget has been reduced by 20 percent, from  $5 billion to $4 billion.  There is only one psychiatrist for every 343,000 people.

It appears that the government will be unable to deliver on its promise of mental health care for all the people.  Young people in particular are under a great deal of stress.  For example, young women have to choose between traditional, arranged marriages and modern style dating or a career, of which many are available now.  Young men have to deal with the stress of competition for the best grades, then the best job, or any job at all for that matter.

The conditions at India’s mental hospitals are dismal, and electroshock therapy is widely used, probably for its sedating effects.  Patients are exposed to physical and sexual abuse at times, far more often than in Western hospitals.  There simply is not enough mental health care, which causes excessive anxiety, frustration, and depression.  The suicide rate is a clear signal that stress and lack of care are overwhelming, especially for the younger population.

This problem is one that requires a force majeure to solve.  Some event like the French Revolution, something really big.  Something so big that many parts of it are simply accepted without question.  For example, the metric system of kilograms and kilometers originates with the French Revolution.

We’ll think of something that really works at the same time we discover the solution to so many of our societal ills, because all the ills stem from a common cause and can be cured by the application of a common remedy.  For example, many of our problems stem from the fact that we allow free rein to people who wish to obtain a fortune at the expense of a majority of gullible or powerless people.  We could solve so many troubles if we used reason to provide for everyone, especially those who don’t understand reason, and prevent them from being exploited, even with their consent.