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Editor's Notes |
jules-rothstein@attbi.com
One of the unsung heroes of American engineering, James Buchanan Eads, had a great deal to be proud of, including the invention of the ironclad warship in time for the Union to deploy it along the Mississippi River during the Civil War. His ironclads turned the tide in the battle for the Mississippi, and they saw action in all of the major battles on that river, including those at Vicksburg and Memphis. Perhaps his most notable achievement was the steel bridge that spans the Mississippi River in St Louis, a bridge that now bears his name.
Like many other historical figures, however, Eads must also bear responsibility for a moment of narrow vision and a sin of omission that cost countless lives.
In building his magnificent bridge, Eads faced the common curse of many engineers in the mid-1860s: what was then called caisson disease and is now called ‘the bends,’ or decompression disease. From 1867 (when construction began) through 1870, despite attempts to pressurize the areas where workers were digging foundations for the supporting piers, 14 men died as a result of caisson disease. Eads, who cared deeply for his workers, eventually found that, by using a slow-moving elevator car, workers could be raised from the depths without suffering the disabling and often fatal effects of the bends. By discovering the benefits of a slow, controlled ascent, he brilliantly solved a problem—but he failed to tell others about his solution! He did not keep it a secret on purpose, nor did he willfully withhold the information. He just never got around to publicizing it.
The bends continued to take lives. In 1872, during construction of New York's Brooklyn Bridge, as many as 20 men may have died from caisson disease, and many more would be disabled, including Washington Augustus Roebling, the chief engineer. The problems with caisson disease were so severe that they almost led to the abandonment of efforts to build the Brooklyn Bridge.
As an editor, I see in the story of these 2 great engineers a missed opportunity—an opportunity missed because of a failure to communicate. The results were tragic. There are no villains in this story, just one man so fixated on saving his own workers that he forgot his wider responsibility. Sound familiar? I often hear physical therapists proclaim the benefits of their approaches and techniques and their extraordinary outcomes, but rarely do I hear them offer to write about what they do so that it can be shared with a wider audience. In my view, this too is a sin of omission, a missed opportunity, with potentially harmful (if not tragic) results.
As with 19th century engineering, sins of omission occur in health care not because people are evil or selfish but because practitioners—especially, I would add, physical therapists—tend to fixate on the patient before them and the next scheduled patient rather than acting on a more global responsibility to all patients and all physical therapists. We don't realize that sharing our knowledge and publishing in peer-reviewed journals are the obligations of all physical therapy professionals. The publication of information is not optional, especially if we claim to care about our patients and our profession.
Information withheld from colleagues cannot be applied, and its very existence can be doubted. During the height of the Cold War, for instance, there were periodic reports of all sorts of miracles achieved by biomedical researchers in the Soviet Union and other countries behind the Iron Curtain. This information was seldom if ever shared in a peer-reviewed arena, and, as a result, the remainder of the scientific world could not examine the research critically.
Much of what was claimed to exist behind the Iron Curtain ended up being the product of propaganda machines. A notable exception was the report of a new and apparently more tolerable form of electrical stimulation, often referred to (not surprisingly) as ‘Russian electrical stimulation.’ Despite the popularity of this form of stimulation, and despite the frequent mention of references, much of the foundational work never appeared in the English–language literature. This month in Physical Therapy, Ward and Shkuratova (pages 1019–1030) provide information from the original Russian-language papers. (An introduction by Editorial Board member Anthony Delitto, PT, PhD, FAPTA, appears on pages 1017–1018.) Now users of Russian electrical stimulation can see for themselves the conceptual and biological basis that was used when this form of stimulation initially was developed. The material is dated but relevant.
The information in this unique paper is unlikely to provide solutions as critical as those that could have been offered by Eads for the bends. But our Journal is committed to the principle that scientific information needs to be codified in peer-reviewed publications for the benefit of current practitioners and future generations.
With that in mind, I note Donachy and Christian's case report (pages 1009–1016) about a person with carpal tunnel syndrome following postmastectomy lymphedema. In our March installment of ‘Evidence in Practice,’ Dr Charles Ciccone examined the clinical question: Can a comprehensive lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema? The purpose of ‘Evidence in Practice’ is to demonstrate the process by which we seek information and not to provide practice guidelines or illustrate best practice; however, we received several letters from people who claim expertise in lymphedema management and who were critical of the management used in the case example. The letters (published last month and in the upcoming November issue) focused on how to manage lymphedema. The point of the letters was always the same—‘This is how you should treat patients with lymphedema"—and their arguments were based on opinion, anecdotes, or poorly referenced articles that are for the most part in non–peer-reviewed publications or journals not available in English.
This brings us to the difference between commission and omission; between opinion and facts about real patients. In their case report, Donachy and Christian illustrate what they did, and, even though case reports cannot claim causality, they can provide readers with insight into how colleagues managed a clinical problem. Had Roebling been able to read such a report about Eads' techniques, many men might have lived to see the fruits of their labor, and Roebling might not have spent so much of his own life in pain.
Make no mistake: Like all journals and magazines, Physical Therapy appreciates—and actively seeks—letters and the discussions they can stimulate. But we also recognize the need for practitioners as well as other members of the physical therapy community to add to our knowledge through publication of well-developed and detailed accounts. The Journal welcomes case reports illustrating all forms of patient management, and, when the peer-review process finds that they contain the type and level of detail that allows clinicians to replicate what was done, we are delighted to publish them.
Can details help? On pages 1000–1008, Segers and colleagues provide evidence and ample warning about excessive pressures in cuffs used for sequential compression therapy. These authors could have collected these data to guide only their practice, but they did more. They generated an article, and they worked through the peer-review process so that the profession would be richer for knowing what they know. They offer suggestions that can be useful to anyone using compression therapy.
All of the authors whose work appears in the Journal go through the trials and tribulations of peer review. I thank all of them for their inspiration and persistence. As a result of their efforts, our profession and our patients benefit. For those of you who have not yet taken on the challenge, I hold up the example of James Buchanan Eads: an admirable person who cared for his fellow humans, but who could have done even better by sharing what he knew.
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