Clashing concepts

One thing I meet (fairly often) is the clash between the RCT and the patient ‘preference’. (I have to use ‘quotes’ because I know it’s the wrong phrase but I can’t find the right one.)

Take an example – topical anaesthesia for accessing implanted central lines in children & young people with cancer. For those who don’t know, nearly every child who needs chemo in Western Europe, North America and Australasia will have a surgically placed central line to enable venous access for blood taking and drug delivery. For some, it will be a ‘wiggly’ one, like a Hickman or Broviac. For some it will be an implanted one, like a Port-a-Cath or Pass-port.

For venous access, we are aware from RCTs that topical anaesthesia is effective at making stabby things less painful. It’s magic. There’s a some comparative evidence to show that EMLA may be a bit less good than Ametop creams. And there’s some data which suggests vapocoolants may be effective despite how the authors interpret that data (pain is probably reduced but it’s unpleasant putting it on).

The RCT-only approach would demand that Ametop be used, EMLA if you couldn’t get hold of it, and stop the order for cold spray. (Actually, an extremist may argue that as the populations under study in the trials didn’t have implanted CVCs then we can’t use any of that information & should declare complete ignorance.) It’s an observed phenomenon that some patients will ask, or their proxy will ask, for spray, nothing, cream, bubbles, the iPad, all of them … For some people cream ‘doesn’t work’ and spray does .. But the ‘working’ might be expectation, placebo, one-off bad experiences …

When it’s a choice of magic for Port access, we’ll let it go.

What if it was a choice of antibiotic prescription for otitis media? Do the same rules apply?

– Archi


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