It has been truly fascinating to look at the responses to the paper on use of the glidescope for trauma patients. The post looks at the paper from R Adams Cowley shock trauma centre that shows little benefit and potential harm from the use of the glidescope. My summary conclusion would be..
For trauma patients in an international standard trauma centre the Glidescope offers no benefit over Direct Laryngoscopy and may lead to harm
This has prompted a great flurry of activity defending video laryngoscopy. This is fine, but it has got me thinking about how we consider evidence around devices differently to evidence for therapies.
Now, the post was purely and simply about the paper, not VL in general. It is interesting to see the debate run off into the distance (in much the same way as the FAST question did) and that’s great. Here at St.Emlyn’s we absolutely love to challenge how we think, and hopefully how others think as well. Journal club often acts as a spring board to a much wider debate in the same way that this paper has. We really like this and a major part of our teaching is to get people to stop and challenge everything that they do. When trainees come to us they often find it difficult as we ask them ‘why are you doing that’ a lot. In a short space of time they learn that much of what we do is anecdotal, traditional or cultural. It’s not based on evidence, a realisation that shakes the foundations of our practice. Our journal club works in the same way and to be honest we absolutely love papers like this as they challenge our assumptions. Surely VL is better, it’s more modern, you can get a better view, it’s just a CCD on a stick, you can share learning, everyone can see what’s going on etc. The danger is that the evidence for benefit comes from our belief in that it is true without actually knowing what the benefits are.
Indeed much concern has been raised about devices in the past about how doctors select, use and implement new devices and implants. In Europe the biggest recent debacle has been around the use of breast implants. Now that’s quite an extreme example but there are principles to be drawn here.
Just for fun, and this really is tongue in cheek. let’s compare thoughts on the evidence from stroke thrombolysis trials with the thoughts around VL that have popped out of the journal club review……
|There is no change to death rate||Ah, yes, but in survivors the outcome was better (though the deaths occurred earlier in the thrombolysis group)||Ah yes, but it was easier to intubate them.|
|This was a sub group of patients (exclusions or specialist centres)||Sure, but stroke is a pathological process not a geographical one||True, but intubation is intubation isn’t it?|
|I don’t need to see the evidence, I’ve seen it work!!!||You have heard of TIAs, right????||You just have to use it and you will know that it’s better|
|It feels good to do stuff||Look at me I’m doing something to my stroke patient with this drug||Look at me I’ve got a shiny new toy.|
|Get a rep down to explain the benefits||**********||**********|
|The problem was they used the wrong dose regime/wrong sort of VL||If only they had used the 45mg bolus instead of the 50mg it would clearly have shown benefit||King is better than Glidescope better than Aitraq better than AMBU(juggle order according to personal opinion)|
|The intervention was only part of the patient journey||The benefits of thrombolysis were masked by poor care in other parts of the system||Intubation is only part of the journey, you can’t isolate it as a factor.|
|The complication rate was higher than I see in my practice||They must have been doing it wrong||They must have been doing it wrong|
So, for the record I am not anti-VL. Far from it in fact, I love a bit of new kit just as much as the next Emergency Physician and if money appears from someone else’s budget I will almost certainly be quite hypocritically on the phone to Tim, Jo and Minh in a flash.
However, in a cash strapped NHS I need to be careful where I spend other peoples money. To make a good business case I want to know what the benefits will be to my patients first, and my clinicians second. As an evidence based emergency physician I aspire to apply the same tests to a new device as I would to a new drug. If data is published on patient outcomes I will certainly read it and look at what it has to offer to the debate.
Sadly we are all hopelessly biased in critical appraisal. It is very difficult to be completely neutral when reading any paper. If I was anti-VL before reading the paper I’d probably think this was a great piece of work. If I was pro-VL I can easily find a number of concerns to dismiss the findings as irrelevant. Personally, I’m pretty neutral about it all. What I’m not neutral about is that this is a pretty well conducted study that looks at patient focused outcomes. As an evidence based emergency physician you really can’t ignore that….