Placebo paradox: Descartes dilemma

Your intern in ED has just seen a 25 yo. woman who has presented with 30 minute history of SOB, tachycardia and feeling like she is going to faint.  Her obs at triage are normal other than tachypnea @ 30/min.  To examine her chest is clear.  She is sating at 100% on 6 l/m HM.  The super keen intern has stabbed her in the radial artery and come up with the following gas:  pH = 7.45, pO2 = 350,  pCO2 = 26,  HCO3- = 16  SpO2 = 100%.  You go to the bedside and ask the usual questions:  She tells you she also has asthma, but has not really had an “attack” since she was a kid,  today she felt SOB and ‘weird’ after an argument with her supervisor at work….she is demanding a “neb” for her asthma attack….  but you know she is suffering “acute hyperventilation syndrome”.

OK, this is bread and butter to all of us.  I would like to use this case to discuss a recent New England Journal study by Wechsler et al  which compared albuterol, placebo “albuterol”, sham acupuncture and “no treatment / watchful waiting”.  They then measured FEV1 change and also subjective patient symptom improvement.  You can read the study, but here are the two telling graphs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For a great dissection of this study, discussion of the Placebo Effect and a lambasting of the author’s conclusions check out David Newman of Smart EM’s podcast on this paper.

To me this is a fascinating study as it illustrates perfectly the folly of mind-body dualism (Descartes’ dilemma) – the doctrine that separates the human mind and body.  In modern medicine this is pervasive, however I find it absurd.   The reason so many sham therapies have proven so popular is the direct result of modern medicine’s inability to deal with the ‘whole patient’.  For many patients – this is paramount – they don’t see the divide, they just know that they feel unwell.  The “placebo effect” is real and the alternative-medicine practitioners have been utilising / exploiting it with great success.

So, now back to our 25 yo in the ED.  We know she has hyperventilation syndrome.   She is currently feeling pretty anxious, subjectively dyspnoeic and might be at risk of unpleasant symptoms such as carpo-pedal spasm etc.   She is however very unlikely to have any serious complications.  She as a history of asthma, but giving her a dose of salbutamol is unlikely to help, and will very likely make her panic / anxiety worse.  Doing nothing is an option, I think most of us try a bit of acute cognitive therapy in this scenario with mixed results.

So what to do?  Is it ethical to use a “placebo neb” – this would violate her autonomy, but if effective would relieve her symptoms?  Like it or not – we do this every day, we delude ourselves into believing we are using effective treatments, when the evidence shows no benefit – but the patient’s get the benefit of the placebo effect and symptoms are relieved.

This goes to the core of our oath.  Is our job to relieve symptoms and suffering or to follow the book and treat disease, are we treating the tumour or the patient, the FEV1 or the dyspnoea?

What would you do?  Love to hear your comments

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