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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

April 29, 2012

Just Like Spiderman

A recent twitter conversation went very quickly from placement of IOs to appropriate critical usage of evidence based medicine. Below, see a nice series of 4 (short) essays on EBM -- a debate between Gordon Guyatt, described as the "founding father of EBM" and Marty Tobin, the great intensivist (whose son may or may not have been in my anatomy group as an M1), "all taking place in the pages of the journal Chest." The 2 quoted phrases as well as this debate and the articles were referred to me by the great Canadian EM/CC/US Dr. Rob Arntfield.

My impression of the debate: EBM is wonderful, but of course has its limitations. It's not as simple as RCT=great, no RCT=terrible; but some questions we can better answer with better evidence. And like Spiderman (and everything) we have to be responsible and critically apply evidence. Some questions aren't amenable to RCTs* so do the best with what you can. That is why most PEM docs still fluid resuscitate sepsis kiddies, and I still place LMAs in cardiac arrests even though it might lower measured carotid flow in 9 pigs.

The debate (all articles are free):
Point: evidence-based medicine has a sound scientific base.
Karanicolas PJ, Kunz R, Guyatt GH.
Chest. 2008 May;133(5):1067-71

Counterpoint: evidence-based medicine lacks a sound scientific base.Tobin MJ.
Chest. 2008 May;133(5):1071-4

Rebuttal From Dr. Guyatt et al
Gordon H. Guyatt, MD, MSc, FCCP, Paul J. Karanicolas, MD, and Regina Kunz, MD, PhD
Chest. 2008 May; 133 (5):1074-1075

Rebuttal From Dr. Tobin
Martin J. Tobin
Chest. 2008 May;133 (5):1076-1077

*for these, you can randomize poor dying African children to standard therapy vs placebo

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