Best Bets: A call for scrutiny

Best BETS are based on specific clinical scenarios and aim to provide a clinical bottom line which should indicate, in the light of the evidence, what the clinician would do if faced with the same scenario again.¹ The article by Sen and Nechani² serves to remind us that unless Best BETS are rigorously conducted their conclusions may be inappropriate.

Sen and Nechani wonder if prehospital intubation was of benefit to the major trauma patient they describe. They conclude that prehospital intubation is associated with increased mortality and imply that this intervention should not be undertaken.

There are two main problems with this. Firstly, evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.³ Accumulating bad evidence does not make it good. Good evidence answers a highly specific question and the results are similarly specific to the circumstances. Sen and Nechani ask a poorly focused question and do not define the circumstances surrounding pre‐hospital intubation in the studies they review – especially whether anaesthetic drugs were used. Even a cursory glance at these studies reveals major differences in quality, study design, patient populations, the experience and training of the operator, the use of anaesthetic drugs and the operational environment. The brief conclusion is therefore completely inappropriate.

Secondly, good doctors use individual clinical expertise together with the best available evidence: neither alone is enough.³ Sen and Nechani question whether prehospital emergency anaesthesia is indicated in their patient. Such a question suggests that they do not appreciate the reality of prehospital critical care practice. The decision to anaesthetise and intubate an unconscious trauma patient is not controversial.⁴ The controversy relates to whether this critical care intervention can be undertaken competently and safely. Are they really suggesting that their potentially combative and physiologically compromised patient should preferentially undergo bag‐valve‐mask ventilation with an unsecured airway for a prolonged period (often greater than half an hour) with no reliable measure of end tidal CO2? Would this be acceptable in the hospital critical care environment?

The EMJ has a responsibility to ensure that Best BETS are properly conducted and reviewed. This is not the first time that clinical bottom lines with major implications have been questionable – perhaps it is time to review the process again?