Cliff Reid has just written a MUST READ post on cricoid pressure in response to a long discussion on the FOAMcc Google Plus Community featuring the usual logical fallacies, circular arguments and dogmatic claims of negligence against enlightened practitioners who have discarded this unproven technique.
In one of the concluding paragraphs he advocates the renaming of this procedure as manual Routine Esophageal Transposition with Airway Restriction and Distortion (aka manual RETARD). I invite you to use this new terminology when describing this procedure.
Also note the comment that Cliff left below the post:
Please note I have had some feedback that this post has caused offence to person(s) I have the utmost respect for, for which I sincerely and publicly apologise. I am grateful for their honest feedback which has resulted in some subtle rewording to avoid the impression of ad hominem attack.
I consider cricoid pressure to be potentially harmful to patients, and feel duty bound to challenge it most assertively. Through social media we have immense influence and here I have attempted to offset its continued promotion by other influential figures who add credence to those who wield the power to punish a provider legally or professionally for not following a non-evidence based guideline.
I respect these colleagues immensely, and I respect ABSOLUTELY their right to hold and express different views to myself, but I do NOT respect all of their views, and I do not believe any view held by a ‘public figure’ (including me) should be protected from critique, criticism or even ridicule if the latter promotes detailed consideration and skepticism of the topic in question. I promise it is NEVER personal.
Please read the post in the spirit it is intended – as a cheeky poke in the ribs to those who actively put themselves in a position of influence, forfeiting any entitlement to protection from criticism. If you think this is ‘anti-anaesthetist’, read the paragraph beginning ‘An unsurprising but at the same time very reassuring observation…‘. I am continually in awe of the anaesthetists I work with who are so much smarter than me and who have taught me so much.
Finally to the individual practitioner torn over this issue. Please follow your institutional policy, and always do what you think is best for the patient in the moment. If the guideline doesn’t fit with what you think is right, work on changing the guideline.
Keep lysing the dogma
This is the comment I left on Cliff’s post:
Fantastic post Cliff
It is clear that manualRETARD is:
“..an example of an intervention introduced with little evidence, handed down from teacher to student over the years as a pseudoaxiom. Pseudoaxioms need to be criticised, studied and discarded where appropriate.”
To me it is clear that:
(1) there is little to no evidence for it’s benefit
(2) there is low level evidence that it can cause harm
(3) the weight of evidence is for harm over benefit, especially in the critically ill due to distraction, unnecessary added complexity, and delay to first pass intubation.
It is obscene to think that there are health professionals who would claim that those who do not perform this worthless procedure are negligent. We need to eradicate this procedure being deemed mandatory from any guideline or recommendations (such as NAP4) on RSI. We also need to name and shame the logical fallacies used by proponents of this technique to justify its use.
I have amended the LITFL CCC entry on cricoid pressure appropriately:
Cheers and thanks
Look out for John Hinds’ destruction of cricoid pressure when released on the smaccGOLD podcast.
Finally, I agree with Cliff – it is up to the individual to make up his or her own mind, and importantly to follow local policy. But I am adamant that no claims can be made about cricoid pressure, or not performing cricoid pressure, being a standard of care. Any guidelines or protocols that suggest otherwise should be challenged. No one should be able to call a doctor negligent for performing or not performing cricoid pressure given the (lack of) evidence.
Down with dogma!