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Truth, and Epinephrine, at Our Fingertips: Unveiling the Pseudoaxioms
Created: Aug 21, 2010 by
Oscar Rago
Last Update: Sep 17, 2010
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Toxicology
1872 views, 0 comments
(5 of 5)
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Newman's paper on lidocaine and epi , one of my favorites!
PAIN MANAGEMENT/EDITORIAL
Truth, and Epinephrine, at Our Fingertips: Unveiling the Pseudoaxioms
David H. Newman, MD
From the St. Luke’s/Roosevelt Hospital Center, New York, NY.
0196-0644/$-see front matter Copyright © 2007 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.06.016
SEE RELATED ARTICLE, P. 472.
[Ann Emerg Med. 2007;50:476-477.] In an effort to demonstrate epinephrine’s safety when added to anesthetic agents for regional block anesthesia, in a 1991 report 2 British hand surgeons injected their own toes with epinephrine.1 Much to the surprise (and perhaps head-shaking giggles) of their colleagues, both physicians and all of their toes survived, intact. Despite the humor, the drama of the act is telling. The anecdote conjures a famous experiment performed 7 years earlier by a similarly frustrated gentleman who drank a flask of Helicobacter pylori to test his hypothesis that peptic ulcer disease is often bacterial in origin. Within a few days, Dr. Barry Marshall had fallen ill, and within a few decades he had won the Nobel Prize in Medicine. The British surgeons Latimer and Kay, on the other hand, have remained no more recognized than the falsehood they challenged. In this issue of Annals, Waterbrook et al2 present a laudable review of the evidence pertaining to the safety of epinephrine, an effective hemostatic agent that prolongs and improves digital anesthesia. The review is important and indeed potentially groundbreaking in that it opens a largely undiscussed Pandora’s Box: the medical pseudoaxioms. Although axioms are universally accepted principles or rules, pseudoaxioms, like pseudoscience, are false principles or rules often handed down from generation to generation of medical providers and accepted without serious challenge or investigation. In 1956, a popular textbook of hand surgery published the ominous warning “epinephrine should never be injected into the finger because from this gangrene has often resulted.”3 Among the cases cited to support this and later assertions were reports of procedures during which, as often as not, no epinephrine was used. In those in which epinephrine was present the “gangrene” was frequently a circumferential burn from a misguided but apparently common home antisepsis remedy in which the still-anesthetized finger was soaked in hot, often boiling, water or boric acid.4-6 Add to these reports epinephrine’s in vivo half-life (short), vasoconstrictive impact (mild), and native propensity for inducing infection (none), and the implausibility of a digit-threatening event caused by epinephrine becomes evident.7 The danger of injectable 476 Annals of Emergency Medicine
epinephrine in the digit, wrongly invoked and then robotically repeated, is a classic pseudoaxiom. This “digital” pseudoaxiom has features common to many others. It is a warning ostensibly protecting patients and physicians from peril. It is based on case reports and anecdotes. These reports have been widely misinterpreted. An authority (in this case, a prominent textbook) propagated the misinterpretation. It has become pervasive. And it has persisted despite numerous articles in the literature, including comprehensive topic reviews that have definitively refuted it. Notably, in cases in which pseudoaxioms have emerged we have often been unaware of the data. But in some cases, many are aware and simply neglect to examine, integrate, or even seriously consider the available evidence. In the case of digital epinephrine, despite multiple previous reviews and ample evidence, how many of our colleagues are now routinely (or even occasionally) using the drug? We are not alone. Hand surgery specialists, including plastic and orthopedic surgeons, have largely upheld this pseudoaxiom, and physicians from all fields continue to fall prey to a myriad of others. Many general surgeons still cling to the dictum that narcotics may be harmful in the setting of undifferentiated abdominal pain, a pseudoaxiom repeatedly disproved and now openly disavowed by the textbook that initially asserted it.8,9 Similar pseudoaxioms abound in virtually all medical fields, and many more have found purchase in the minds of laypeople. (How many times must we tell our mothers that weather is not a causative agent in bacterial infections of the lung?) Physicians, however, are not laypeople. We are justly held to a higher standard, and the question is this: In the midst of a professional culture that increasingly invokes the “evidence-based” moniker and that calls “science” its godhead, to what can we attribute such incongruous behavior? The persistence of recognized pseudoaxioms in medicine is complex and multifactorial. When peer behaviors comprise a practice pattern, for instance, it can be difficult for physicians to break norms, even when those norms are unsound. In medicine, a field in which most decisions do not have definitive or even adequate evidentiary support, we often seek and find comfort in consensus. Given the massive knowledge base for which we are responsible and the limited time that we have for independent review, we frequently rely on the teachings and habits of our
Volume , . : October
Newman mentors and peers. In addition, medicolegal jeopardy looms. We are subject to the whims of an idiosyncratic system in which even spurious claims can alter lives and careers. But there is another, arguably more important, reason that pseudoaxioms persist. The simple and unflattering truth is that in many cases, we won’t unlearn. We are a culture of educational achievers whose competitive intellects have allowed us to succeed through hard-fought layers of academic paring and years of professional rigor, and our expertise and knowledge define and sustain us. We are therefore tenacious with our knowledge, and it is a difficult and complicated matter for us to demur or confess that years of practice may have been wrong, or believe that our mentors and teaching may have misled us. Sidney Burwell, the former dean of Harvard Medical School, in a now-famous statement told his students that half of what they learned would prove to be wrong within 10 years,10 a statement later corroborated by research estimating the half-life of medical “facts.”11 But how can facts have a half-life? They can’t, of course. Burwell’s statement is, at its core, recognition that in medical education we have historically confused fact with opinion. And although we have seen impressive advances in the half-century since Dr. Burwell’s assurance that medicine will constantly change, it is a powerful irony that his own lesson remains unchanged: much of the opinion that we learn is wrong, and we must be prepared to unlearn it. It is easier said than done. Leaders in the influential field of evidence-based medicine and those in the developing field of knowledge translation are finding major barriers to education that emphasizes evidence and to implementing evidence in clinical practice.12 Evidence-based clinical practice guidelines and continuing medical education, 2 of our most embedded staples for maintaining competence, updating knowledge, and affecting practice behaviors, are often unheeded or ineffective.13,14 The Waterbrook et al2 review is an important step in the right direction. Peer-reviewed journals should seek out research and reviews that unveil the pseudoaxioms because their publication and dissemination will protect and support those who correctly challenge or deviate from unsound norms. Leaders in the field of medical education must concentrate efforts on developing methods to routinely separate opinion from fact at the moment of knowledge integration. And perhaps most important, as individual physicians we must learn to unlearn. Learning and unlearning are mental processes and as such cannot be mandated. It will therefore take a shift at the individual level in the way we view our science and our place in it for us to overcome the pseudoaxioms and all that they represent. Waterbrook et al2 have joined a noble line. They have shown us again that not only can we comfortably and routinely put
Truth and Epinephrine epinephrine into the hands of our patients but also, like Latimer and Kay before us, we can put truth into our own hands.
Supervising editor: Judd E. Hollander, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Reprints not available from the author. Address for correspondence: David H. Newman, MD, St. Luke’s/Roosevelt Hospital Center, Department of Emergency Medicine, 1111 Amsterdam Ave, New York, NY 10025; 212-749-5159; E-mail dnewman@chpnet.org. REFERENCES
1. Latimer J, Kay P. Outpatient carpal tunnel decompression without tourniquet: a simple local anaesthetic technique. Ann R Coll Surg. 1991;76:398. 2. Waterbrook AL, Germann CA, Southall JC. Is epinephrine harmful when used with anesthetics for digital nerve blocks? Ann Emerg Med. 2007;50:472-475. 3. Bunnell S. Surgery of the Hand. 3rd ed. Philadelphia, PA: JB Lippincott; 1956. 4. Kaufman PA. Gangrene following digital nerve block anesthesia. Arch Surg. 1941;42:929-938. 5. McLaughlin CW. Postoperative gangrene of the finger following digital nerve block anesthesia. Report of a case. Am J Surg. 1942;55:588-589. 6. O’Neil EE, Byrne JJ. Gangrene of the finger following digital nerve block. A report of eight cases with discussion of the gangrene pathogenesis. Am J Surg. 1944;64:80-87. 7. Sylaidis P, Logan A. Digital blocks with adrenalin: an old dogma refuted. J Hand Surg [Br]. 1998;1:17-19. 8. Ranji SR, Goldman E, Simel DL, et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296:1764-1774. 9. Cope Z. Early Diagnosis of the Acute Abdomen. 19th ed. New York, NY: Oxford University Press; 1996. 10. Pickering GW. The purpose of medical education. BMJ. 1956;2: 113-111. 11. Poynard T, Munteanu M, Ratziu V, et al. Truth survival in clinical research: an evidence-based requiem? Ann Intern Med. 2002; 136:888-895. 12. Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence-to-practice gap. Ann Emerg Med. 2007;49:355-363. 13. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282:1458-1465. 14. Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of Continuing Medical Education. Evidence Report/ Technology Assessment Number 149. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ publication number 07-E006.
Volume , . : October
Annals of Emergency Medicine 477
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