Lessons from 1950s cardiology ~ why a non-evidence-based medical practice should never be allowed to become the standard of care

by faithgibson on June 21, 2012

in Contemporary Childbirth Politics

This article was first posted on the Canadian Maternity Care Discussion Group (MCDG) by Dr. Michael Klein, professor Emeritus of Family Practice & Pediatrics (University British Columbia) and listmaster of the MCDG.

It tells the story of how total, prolonged, flat-on-your-back bed rest became the standard of care for heart attack patients without any scientific evaluation. It seemed ‘so logical’ to cardiologists that they strenuously opposed doing any research about it. Unfortunately, enforced bed rest turned out to dramatically increase the death rate for such patients. It is a prime example among many of how medical practices, from the perspective of the medical profession, many seem ‘appropriate’ but prove to be very harmful.

Confining women in labor to bed is a routine part of the medicalization of normal labor and birth.  Like bed rest in cardiac patients, the obstetrical profession also strenuously opposed research on the various practices and protocols (immobilization in bed being just one of dozens) that were imposed to supplant physiological management. These protocols all seemed so ‘logical’ to obstetricians that they were never scientifically evaluated prior to their imposition.

While immobilization and other labor-related medical interventions rarely results in death or permanent damage for laboring women and their babies, these non-physiological practices profoundly disrupt the biological process required for a normal childbirth. They make it substantially harder (sometimes impossible) to meet the physical and psychological needs of laboring women without resorting to powerful drugs and other medical and surgical interventions.

The following reposted article is a ‘case in point’ for why we should not allow medical practices to become ‘standard of care’ without appropriate scientific evaluation.

It also encourages us to keep trying to change unscientific practices, even when they are popular with the medical professional, the media and most of the lay public.  Truth does eventually come forward and win out.

faith ^O^

A Chair to the Rescue
Posted on February 3, 2011
Bernard Lown, MD

Not so long ago, doctors bled, purged, cupped, and performed all sorts of mayhem to cure diseases about which they had not a clue. With the advent of scientific medicine in the late 19th and early 20th centuries, evidence increasingly guided medical practice. This was particularly true for acute illness. Science, though, remained a porous veneer overlaying the treatment of chronic diseases , especially those afflicting the elderly. With the best of intentions, doctors over-treated their patients with unproven procedures and polypharmacy. These exacted an inordinate toll in suffering, morbidity, and death.

The advent of scientific medicine did not stop doctors from breaching the hallowed moral injunction of their profession, Primum nihil nocere (“first do no harm”). Early in my medical career I became keenly aware of how doctors — though committed to benefiting their patients — unwittingly harmed them. The insight derived from a transformative experience. It occurred sixty years ago, shortly after I began a cardiovascular fellowship under the mentorship of Dr. Samuel A. Levine at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital) in Boston. Dr. Levine was a clinician without peer — astute in diagnosis, innovative in managing intractable clinical problems — and a riveting teacher.

At the time, the major challenge in hospital-based cardiology was dealing with the steady inflow of patients with acute heart attacks. Care was largely palliative: to relieve chest pain, to prevent blood clots, to ease the breathlessness and edema provoked by a failing heart muscle. Patients were confined to strict bed rest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance. During the first week, they were fed. Moving their bowels and urinating required a bedpan. For the constipated, which included nearly every patient, precariously balancing on a bedpan was agonizing as well as embarrassing.

Because world events might provoke unease, some physicians prohibited their patients from listening to the radio or reading a newspaper. Visits by family members were limited. Since recumbency provoked much restiveness and anxiety, patients required heavy sedation, which contributed to a pervasive sense of hopelessness and depression. Around one in three patients died. Not surprisingly, many died from blood clots migrating to their lungs.

In addition to the pain [KS3] stemming from the heart attack and the accompanying fear of dying, patients had to cope with the torment of isolation, the indignity of infantilization, and the unbearable distress of excessive bed rest. Physicians convinced themselves and their patients that complete bed rest was the price of survival. Visiting Martians, witnessing this travail, might have judged the scene differently, regarding hospitals as prisons where inmates were subjected to a unique form of torture.

To a medical novice like me, the justification for enforced bed rest was persuasive. It was based on a sacrosanct therapeutic principle, the need to rest a diseased body part, be it a fractured limb or a tuberculosis-afflicted lung. Unlike a broken bone, which could be immobilized in a cast, or a lung lobe, which could be collapsed by inflating the chest cavity with air, the heart could not be cradled into quietude. The only approximation for a diseased heart was to diminish its workload. It was long known that during recumbency the heart rate slows and blood pressure drops, both indices of less oxygen usage and therefore of decreased cardiac work. Heart rest was therefore equated with bed rest.

But was this the case with those who had sustained a heart attack? In perusing medical journals I could find no reports on the subject, which was surprising, because the literature was dense with articles for managing patients with heart attacks. Being involved with the daily care of these patients, I became rapidly aware of the harm wrought by enforced bed rest.

Dr. Levine frequently discussed the adverse effects of prolonged bed rest. Among the possible complications were atelectasis, or a collapse of the lung lobes, predisposing the patient to pneumonia; peripheral vein phlebitis that could lead to fatal pulmonary emboli; lung congestion; prostatism; urinary retention; the thinning of bones; bed sores; frozen shoulders; and constipation. Yet so strong was the weight of tradition that Dr. Levine dared not move to reverse it, even though the harm exacted was evident. This was another illustration of medical tradition derailing healthy skepticism and impeding commonsense measures. Lacking was a categorical moral urgency among physicians, without which tradition is rarely altered.

Experience with two patients compelled me to rebel against the entrenched practice of bed rest. The first involved a man in his early fifties. Mr. J. had been a robust, hustling, successful salesman. He bragged about not having had a sick day in his life until felled by the heart attack. Though not a patient on our service, Mr. J. would call me over during morning rounds and relate his tale of woe. He conveyed a sense of itching restiveness, seemed prone to ready tears, and was markedly depressed. He beseeched me to speak to his doctor to get him out of bed. “This bed is killing me,” he moaned.

One morning, after he had been in bed continuously for about a week, we were having the same forlorn conversation. It was two weeks before Thanksgiving. By happenstance his doctor appeared. More as a plea than question, Mr. J. asked, “Will I soon be out of bed to go home for Thanksgiving?” After all these years I still recall the doctor’s abrupt and peremptory answer: “With your massive heart attack, you’ll be lucky to be home for Christmas.” Mr. J. shuddered, closed his eyes, convulsed, and died. At the time we knew nothing about cardiopulmonary resuscitation or defibrillation. The doctor mumbled as he walked away, “I was right about his prognosis.”

At about the same time, a patient of Dr. Levine’s who had had a heart attack developed intractable congestive heart failure. The usual measures — digitalis, diuretics, and oxygen — did not alleviate the breathlessness. Dr. Levine ordered the patient into a chair for two hours daily. He reasoned that gravity would shift the excess fluid from lungs to extremities. In the lungs fluid starves the body of oxygen; in the ankles it is cosmetically unattractive but harmless. Within two days after this new regimen, the patient improved remarkably and went on to recover.

Dr. Levine felt his theory confirmed, though I was not persuaded. In the first place, it was unlikely that gravity could have been effective when the patient spent the majority of time in bed. Other factors must have operated, since his improvement was almost immediate after he sat up in a chair. Most decisively, he did not develop pitting edema in the ankles. When the patient was pressed for an explanation for his turnabout, he answered, “For the first time, I knew I would survive.” The remarkable change in his demeanor confirmed a renewed hold on life. His voice stopped wavering, dropping off at midsentence; his conversation was no longer self-pitying; and his despondent facial expression was replaced by a ready smile.

These two experiences undermined my belief in bed rest as an appropriate treatment for heart attack victims. In fact, I agreed with the proverbial Martian visitor. We were torturing patients. In the words of the American theologian Reinhold Niebuhr, “We mean well and do ill, and justify our ill-doing by our well-meaning.” Such justification inhibits a recognition and an acknowledgment of misdeeds. Observing a sudden unnecessary death as well as a seemingly miraculous recovery clinched my resolve to undertake a study that would clarify the merits, if any, of enforced bed rest.

I suggested to Dr. Levine that we investigate whether treating heart attack patients in a chair altered their prognosis. Each of his newly admitted patients with an acute heart attack would be given the option to spend increasing amounts of time in a chair daily. This was to be carried out on all newly hospitalized patients on his service. Dr. Levine agreed with this protocol.

Although I knew that the project would be a chore, I didn’t expect it to be an act of martyrdom. Little did I realize that violating firmly held traditions can raise a tsunami of opposition. The idea of moving critically ill patients into a chair was regarded as off‑the‑wall. Initially the house staff refused to cooperate and strenuously resisted getting patients out of bed. They accused me of planning to commit crimes not unlike those of the heinous Nazi experimentations in concentration camps. Arriving on the medical ward one morning I was greeted by interns and residents lined up with hands stretched out in a Nazi salute and a “Heil Hitler!” shouted in unison.

The study involved getting patients into a comfortable chair for increasing durations on succeeding days. Compared with recumbent patients, ours required fewer narcotics for chest pain, less sedation for anxiety, and fewer sleeping medications. Nurses commented that the patients’ demeanor changed from anxious and depressed to an eagerness to resume normal living. Witnessing even one patient in a chair rapidly won converts from the house staff, who soon became enthusiastic adherents. Patients in chairs promptly began to harangue their doctors to let them walk and pressed for an early discharge.

Despite dire predictions by senior medical attendants that these patients would experience fatal arrhythmias, heart rupture, or congestive heart failure from an overstressed heart muscle, none of those complications were encountered. Comments by patients experiencing their second or third coronary artery occlusion confirmed that we were on the right track. Invariably they indicated that the current episode was the easiest to bear.

Our first publication to reach a wide medical audience involved 81 consecutive patients, 61 males and 13 females.(1) Only 8 patients, or 9.9 percent, died during the month of hospitalization. This outcome was impressive, since half the patients on admission were in congestive heart failure, and a quarter had life-threatening disturbances of heart rhythm, findings associated with a high mortality. It was striking that not a single patient experienced thrombophlebitis or pulmonary embolism. At the time this was a dreaded complication, accounting for a quarter of the fatalities among heart attack patients.

Our sample size was small, the data was largely anecdotal, and there was no simultaneous matched control population, but the findings were so impressive that no other study was ever conducted on the chair treatment. There were grumblings from some senior physicians. I overheard one leading academic joke that the proper name for this new radical management should be the “Boston electric chair treatment for heart attacks.”

Practicing physicians rapidly abandoned the use of strict bed rest. Until our work, patients were kept in the hospital for a month or longer. Within a few years after our publication, the period of hospitalization was reduced by half. The range of activities permitted to patients was extended, and self‑care became the norm. The hateful and dangerous bedpan was abandoned; walking was allowed earlier; hospital mortality was reduced by about a third. Rehabilitation was hastened, and the return to work was accelerated. The time required for full recovery was reduced from three months to one month. Considering the fact that in the United States about one million people suffer heart attacks annually, perhaps as many as one hundred thousand lives were salvaged each year by this simple strategy.

One might ask, why didn’t the victims of the earlier treatment protest? As soon as I posed this question I realized its absurdity. After all, power is tilted largely in favor of doctors. When one entrusts one’s well-being and life to another, scant space is left for questioning the other’s knowledge or behavior. This is especially true for victims of a heart attack. They are well one minute and at death’s door the next. The bed-bound victims, paralyzed in a cocoon of dread, are led to believe that total inactivity and a hibernation-like state is the sole ticket for survival. The prohibition of any movement or exertion reinforces their helplessness and unquestioning submission. Patients are abruptly thrust upon the mercy of forces over which they have no control. The daily visits of their doctors are anticipated with impatience and unease. Moses descending from Mount Sinai could not have been greeted with more reverence. Every syllable is regarded as divine revelation. Bed rest is therefore accepted as mandated from on high.

The passage of these many years has not lessened my disquiet about the adherence to a form of care not only without merit but draconian to boot. [KS4] Why subject patients afflicted with a life‑threatening condition to a treatment that could only increase their misery and lead to major complications? This was not just a small error; it was a colossal misjudgment. Why were the deleterious consequences of strict bed rest not detected sooner? Why had this aspect of patient management never been investigated? Why had doctors not sought the opinions of patients and nurses who were intimate witnesses to the harm being inflicted? Until our publication, no systematic investigations of bed rest for heart attack patients had been reported in the medical literature.

Medical dogmatism is sustained by a multiplicity of factors. Foremost is the fact that doctors traverse an uncertain terrain. Nearly every diagnosis is an act of discovery. Faced with a myriad of variables, a doctor can never be certain which measures will heal. Some remedies that work for one patient are not only ineffective for another but may be injurious or even lethal. In fact, an experienced physician appreciates that outcomes are never predictable except statistically in a large population. Yet the doctor has to treat a particular and distinctive individual. And when confronting pain, infection, hemorrhage, diabetic crisis, life‑threatening arrhythmias, and other serious conditions, doctors cannot delay action until indubitable evidence is available. One might as well be waiting for Godot. Paradoxically, human beings, when compelled to act, learn to justify a chosen course with an assurance unwarranted by the evidence for the course chosen.

In pondering other reasons for the practice of strict bed rest, I believe they reflected the sad truth that doctors sixty years ago had little to offer heart attack victims. When good answers are unavailable, bad answers may replace them. Bed rest seemed a logical treatment to reduce the burden on the ever-beating heart. Don’t we go to bed when we are tired? Doesn’t sleep rejuvenate? Don’t doctors plaster‑cast a broken limb to protect it from physical activity? Yet such simplistic reasoning has been responsible for blood letting, stomach freezing, using X-rays for peptic ulcers, impaling catheters in the heart to gauge its function, dispensing hormone therapy to menopausal women, administering lobotomies to the mentally ill. The list seems unending.

There was another reason that the detrimental effects of prolonged bed rest were not discovered earlier: the anti-psychology mind-set of medical practitioners. Doctors inadequately appreciate that churning emotions affect every bodily organ. Emotions alter our chemistry, our immune system, our neural traffic; they predispose us to all sorts of illnesses and may even precipitate sudden cardiac death. Even now, when cardiologists list the risk factors for heart disease, the key role of psychosocial and behavioral stress is left unmentioned. No wonder the adverse consequences of enforced bed rest, predominantly emotional, were misperceived and largely ignored.

When a new paradigm takes hold in medicine, its acceptance is extraordinarily rapid. Few acknowledge that they once adhered to a discarded method. This was succinctly captured by the German philosopher Schopenhauer. He maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as having always been self‑evident. When recently searching the medical literature, I could find no references to bed rest as a treatment option for those with heart attacks. Perhaps this embarrassment for the medical profession was deemed best forgotten.

*This subject is discussed in “The Lost Art of Healing” (Ballantine Books 1999) as well as in the Lown Forum, Winter 2011.

1. Levine SA, Lown B: “Armchair” treatment of acute coronary thrombosis. JAMA 148: 1365‑1369, 1952.

This entry was posted in Healthcare and tagged Bed rest, Heart attack treatment. Bookmark the permalink.

Nigel Paneth | February 4, 2011 at 5:47 pm |
Dear Dr. Lown:
As a former student of yours (one week of rounds at the Brigham in 1971) I want to tell you how much I enjoyed your piece on the perils of bed rest in myocardial infarction. I am a collector of examples of low cost-high benefit medical and public health interventions (at an epidemiology meeting presentation, I once called them “cheap thrills”) that contrast very favorably with the latest billion-dollar-a-year pharmacologic innovation.
My favorite examples (I am a pediatrician) have been folic acid for neural tube defects (less than a penny a day); keeping prematures warm (analagously to heart attack bed rest, it replaced the disaster of keeping them cold) and putting babies to sleep on their backs (halving the sudden infant death rate at no cost at all!). I am very pleased to add your “chair for heart attacks” to this list.

Barbara Roberts, MD | February 7, 2011 at 10:44 am |
Dear Bernard: Thank you for this trip down memory lane. Thank you for pointing out our profession’s frequent hubris. I have to wonder how many of the current “dogmas” in vogue today are harming our patients.

Barbara Roberts, MD

Sarah Burke (@smrburke) | May 3, 2012 at 10:55 am |
Dear Dr. Lown,

Thank you for sharing your experience! I am a public health student with interest in childbirth practices, some might say a bit alternative, and I see this type of ‘protective care’ much too often. From routine episiotomies (much less frequent now than in the 80s-90s, but then again c-sections have risen tremendously), to laboring in bed without continuous support, and directed pushing in supine positions. Most of these practices have no benefits and even harms, according to the literature, yet are routinely used in North American hospitals. Women who arrive in hospital with a birth plan and doula can even be ridiculed for wanting to ‘do what their body does naturally’.

I admire your courage to change the system of care from the inside, especially in facing the challenges, ridicule, and perhaps even insults from colleagues.

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