Level of evidence should have been assessed

EDITOR—Heames et al assessed the performance of doctors in placing defibrillation paddles in the correct positions on the chest of a training manikin.1 They forgot to assess the level of evidence that allows for the determination of correct placement. Volume 46 of Resuscitation presents only two references about paddle placement: one is the original work by Lown in 1967, the other a 1981 study by Kerber et al.2–4 The text in Resuscitation is almost word for word that of the American Heart Association's guidelines published in 1992 in the journal of the American Medical Association, which offered the same paucity of references.5

I conclude that the evidence on which Heames et al base their assessment is the original work done in 1967 and the comparison made by Kerber et al. The work in 1967 was done with quite different equipment, timings between shocks, and wave forms. The comparison by Kerber et al was between anterolateral and anteroposterior placement, with only one version of either except for the pad's diameter, and exclusively addressed the cardioversion of atrial fibrillation.

So far as the references quoted go, there is no evidence that the variation detected by the study is of any clinical importance.

Other factors have not been assessed

EDITOR—Heames et al report a study of 101 doctors who were asked …