Greenhalgh Trisha
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
J Eval Clin Pract. 2018 Oct;24(5):1132-1138. doi: 10.1111/jep.12925. Epub 2018 Apr 15.
Evidence-based medicine is the application of research findings to inform individual clinical decisions. There is a tension-both philosophical and practical-between the average result from a population study and the circumstances and needs of an individual patient. This personal account of "evidence-based" trauma care illustrates and explores this tension.
The author, a keen athlete, describes her experience of a high-impact cycle accident that led to limb fractures (which were diagnosed and treated according to evidence-based guidelines) and also an occult injury to the cervical spine (which was not diagnosed at the time). Some evidence-based guidelines are reviewed and applied to the case. The clinical record described the cycle accident as a "fall." Initial assessment directed the clinicians' gaze to the obvious injuries, whose treatment was straightforward. On admission, the patient (aged 55 years at the time) was offered "falls prevention" via a guideline-based checklist. Several months later, neurological sequelae indicated possible damage to the cervical spine. But the NICE Guideline recommending cervical spine imaging in cases of high-impact trauma had not been considered-perhaps because the clinical narrative had been prematurely assigned to the script of "older person with fall." Furthermore, the author, who was (appropriately) treated with neurosurgery, was surprised at the response of clinical colleagues, based on application of an irrelevant section of a guideline, that her cervical discectomy was "nonevidence based." Nonsteroidal anti-inflammatory drugs for postoperative pain were indicated in this patient even though they were not recommended for the average patient.
As Sir John Grimley Evans' warned, we should avoid using evidence-based guidelines in the manner of the fabled drunkard who searched under the lamp post for his key because that was where the light was, even though he knew he had lost his key somewhere else.
循证医学是将研究结果应用于指导个体临床决策。在人群研究的平均结果与个体患者的情况和需求之间，存在着哲学和实践层面的矛盾。这篇关于“循证”创伤护理的个人记述阐述并探讨了这种矛盾。
作者是一名热衷于运动的人，描述了自己遭遇的一起高冲击力自行车事故，事故导致肢体骨折（按照循证指南进行了诊断和治疗），同时还存在颈椎隐匿性损伤（当时未被诊断出来）。文中回顾了一些循证指南并将其应用于该病例。临床记录将此次自行车事故描述为“摔倒”。初步评估使临床医生将目光聚焦于明显的损伤，其治疗较为直接。入院时，通过基于指南的检查表为患者（当时55岁）提供了“预防跌倒”措施。几个月后，神经后遗症表明颈椎可能受损。但英国国家卫生与临床优化研究所（NICE）关于在高冲击力创伤病例中推荐颈椎成像的指南并未得到考虑——可能是因为临床描述过早地被归入了“摔倒的老年人”这一模式。此外，接受了（恰当的）神经外科治疗的作者，对临床同事基于应用指南中不相关部分而做出的反应感到惊讶，即她的颈椎间盘切除术是“无循证依据的”。尽管非甾体类抗炎药不被推荐用于一般患者，但该患者术后疼痛却使用了这类药物。
正如约翰·格里姆利·埃文斯爵士所警告的，我们应避免像寓言中那个醉汉那样使用循证指南，醉汉在路灯下寻找钥匙，仅仅因为那里有光，尽管他知道钥匙丢在别的地方。
