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The past few days have included a lot of thoughtful debate/discussion about #COVID19 and #ARDS, some snark (of which I too am guilty), and a hefty dose of HOW DARE YOU CHALLENGE A MASTER, YOUR RIGIDITY IS KILLING PEOPLE. I have a few things to say. Bear with me as I ramble a bit.
The idea that #EvidenceBasedMedicine does not allow for individualization for specific patients and changes in their clinical courses is a fallacy. Certain concepts that are known to save lives can & should be adhered to in a manner that is appropriate for the individual patient.
I thought this was obvious but that clearly is not everyone’s interpretation of #EBM. Also lung-protective ventilation does not = set it and forget it. Settings needed to maintain LPV will obviously change during a patient's course, something that experienced clinicians know.
While I mentioned that my mortality so far has been much lower than that reported in recent cohorts, I am not presenting this as a reason for why you should “do as I say." While it would feel good to be self-congratulatory, there are many unanswered questions.
Perhaps it’s because we practice meticulous #EBM and have sufficient staffing ratios, or perhaps it’s because my patients are less chronically ill or the air in Los Angeles is better. Until these questions are answered, my experience is also anecdotal.
On the flip side, I am really tired of hearing “everyone at my hospital is dying so we are doing this [insert random unorthodox therapy]” with no regard for the possible consequences. Even anecdotally, I have yet to hear, “people stopped dying when I started doing X new thing"
It sounds obvious, but please consider the possibility that your random unorthodox therapy may be contributing to this mortality. New is not always better and it’s disappointing to me that people are being so cavalier.
Regardless, this is why more data from multiple institutions is needed, & there are plenty of hard-working people gathering this - @Dr_SRKashyap, @covid19registry, among others. And as @gsmartinmd said, with >100K ventilated #COVID19 patients, this is no longer a data-free zone.
While I understand the desperation to find something new that works, as we all want to save lives, we should first #DoNoHarm, and if we do find an effective novel therapy, it should build upon what was helping before, not throw those things away.
Also, while I LOVE @ChrisCarrollMD's term #eminencebasedmedicine, what I think is even more unbecoming is when people with absolutely no critical care expertise try to condescendingly “drop knowledge” on clinicians on the frontlines of #COVID19.
These also seem to be the folks who are the most adversarial and feel the most sure that they’re right. If you have not cared for an #ICU patient since your 2 week rotation as a PGY2 ten years ago, please consider the possibility that you don’t know what you’re talking about.
Ideas are needed and welcome, regardless of your level of seniority or area of expertise. Some of your ideas will not pan out and that's ok. However, presenting your ideas as facts when they are not facts is reckless and arrogant.
Finally, we are #AllInThisTogether and, even if we argue, we all want the same thing, which is to help patients and save more lives. Have a good week all and be well. I'll be back in the unit so maybe I'll have some more #COVIDDeepThoughts to share soon.
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