From ancient Greece, where physicians believed disease resulted from gods wreaking havoc on humans in acts of vengeance, to the more body orientated approach of Hippocrates and Galen, to our modern day, one thing has remained true. Physicians have had a very long tradition of getting it so spectacularly wrong as to cause needless suffering and death while refusing to believe it. Frequently wrong, rarely in doubt, has been the mainstay of medicine for centuries. Ignoring their mistakes, an art form.
Medical historians and physicians imagine medical history as a long triumphant arc of steady progress resulting from the discoveries of genius while completely ignoring thousands of years of harm at the hands of average physicians practitioners. So complete is the propaganda, that medical students today swear to uphold the utter quackery of Hippocrates while reciting the Hippocratic oath – where insuring proper payment to teachers is number one on the list of things to do, followed by homage to the gods, and a promise never to perform abortions.
From blood-letting, to blistering, to the inhalation of noxious gases in order to sweat out the Pox (and kill people by the thousands) – physicians have had, over thousands of years, a long unwavering tradition of sureness even while being completely and utterly wrong. Relentlessly so. And whereas the rare genius is responsible for medicine’s advancements it wasn’t until modern times, when the scientific method finally forced its way into medicine around 1900, that every day clinical medicine changed in meaningful ways. Even today we frequently do not learn from past mistakes, we instead choose to rewrite history and prop up prestige – grand and glorious.
In my experience this continues today in critical care medicine. My exposure to it started in 1991 as a trainee when on a cold and rainy November night two grand papers were published in the bible of internal medicine – The New England Journal. Tight glycemic control in the ICU and early goal directed therapy (EGT) in septic shock. Both studies were small, single center studies, both poorly done – and as time would finally tell us, both were utter nonsense. But oh my, what a fuss they caused.
Entire careers were made on implementing tight glucose control only for us to learn a decade later that we were probably killing 1 in 37 patients unnecessarily with it. An entire campaign was begun in response to EGT – the Surviving Sepsis Campaign – to insure that the first six hours of treatment was adhered to according to the EGT study – despite being pretty much on your on after that. It was utter folly. We learned very early that early antibiotics and infection source control were the only interventions in sepsis found to make a difference. Despite this we had to tolerate ridiculous, non-physiologic hemodynamic ‘guidelines’ that were more like commandments from the Mount than guidelines, despite being first extracted from someone’s behind and completely made up. Central venous pressure – one size fits all. Aggressive fluid resuscitation in EVERYONE based on the unproven assumption that sepsis patients always present hypovolemic. Whereas it is true vascular permeability is increased in sepsis, experts have completely ignored the lymphatic’s ability to dramatically increase fluid return to the central veins in such circumstances. And so sepsis representing, per se, a hypovolemic state has become gospel despite being untrue, as was blood-letting for thousands of years I suppose.
But after more than a decade of physicians and physiologists pointing out how un-physiologic the SSC resuscitation recommendations were, they decided to take it out of realm of physiology and reduce recommendations to commands. You will give 30ml/kg IVF to every septic shock patient, and you will follow lactate. Don’t do that in New York and face criminal charges. No attempt was made to explain the cardiovascular physiologic effects, or reasons, just do it. And no attempt to even explain where the recommendations came from since there is no evidence, none, that this is the right amount of fluid to give to anyone for any reason, or that following lactate improves outcome. But we all know sepsis causes hypovolemia on presentation so this seems reasonable. Except we do not know that. Separate from insensible and GI losses we have no idea if early sepsis actually represents a hypovolemic state. We do know that more than 60% of patients with sepsis presenting to the ED are not fluid responsive. We do know that most do not have peripheral or pulmonary edema prior to resuscitation - begging the question where does all that extravasated fluid go? And finally and most importantly, we do know one size does not fit all – ever– in medicine, underlying the absurdity of such recommendations.
I could go on. But here is the point. Did we learn anything from our tight glycemic control experience despite probably causing excess death? No, we did not. Most centers just choose another glucose target, completely ignoring the complex metabolic and endocrine effects of insulin or the harm it may be doing, regardless of hypoglycemia. Did we learn anything from EGT? Apparently nothing except three separate studies have proven it a miserable failure. And instead of learning the lessons from that experience the SSC just made up a whole new set of guidelines and on and on we go.
Bloodletting started in ancient Greece and continued into the 20thcentury. It obviously did not work, and usually harmed. But physicians refused to learn from their mistakes for thousands of years, having refused to do so since the beginning. How many died and suffered unnecessarily as a result? A long and dangerous tradition – sureness in the face of ignorance.
A tradition very much alive today.
