30 Mar, 14 | by scarley
A guest blog this week from a wise and reflective soul in California. Dr Charles Murphy reflects on change, belief and progress in medicine following the publication of the ProCESS trial in the New England Journal of Medicine. The trial itself is open access and well worth a read. You can find it here, then read on and reflect with Charles.
The ProCESS study  brings to mind the observation by Sir William Osler that (to paraphrase) one should use a new therapy as often a s possible while it still works. I have used Swan Ganz catheters, aminophylline, bretyllium, MAST trousers, nasal intubation, ipecac and neonatal suction bulbs while they worked and abandoned them when they no longer worked. I told parents to put children on their stomachs so they wouldn’t aspirate and later to put them on their backs so they wouldn’t suffocate. I breathed for patients during basic CPR and now wouldn’t because they do better without respiratory support. In asthma, I have used magnesium because it worked. I stopped using it because it no longer worked and now occasionally use it because it now sometimes works. I still use sorbitol even though it never has worked because too many people believe it works. I smile benignly at all those who regard orthostatic vital signs as highly useful and, with apologies to Robert Knopp who demonstrated their frequent misuse , say nothing because there are too many “true believers.” I complied with the 4-hour pneumonia guidelines while they worked. I am complying with the sepsis guidelines while they still work? The biggest improvement in patient care in the ED in my 32 years on the UCSF emergency medicine faculty has been the low-tech addition of the Discharge Coordinator in our ED to help patients arrange follow-up. The Lancet chose the development of the oral rehydrating solution for children as the single most important medical therapy of the 20 century with an estimated 40 million lives saved.  In Medicine, skepticism and humility will always work.
1. The ProCESS investigators. A randomized trial of protocol-based care for early septic shock. 2014, New Eng J Med, March 18.
2. Knopp R, Claypool R, Leonardi D. Use of the Tilt Test in Measuring Acute Blood Loss. Ann Emerg Med 9:72-75.
3. Editorial. “Water with sugar and salt”. Lancet 2, August 5, 1978, pp. 300–301.