Friday, November 15, 2013

In Praise of Lasix: A Utility Approach to Pharmacotherapeutics

In a prior post, I focused on reducing polypharmacy to oligopharmacy or nopharmacy because of an underlying belief that most medications are useless at best, harmful or wasteful or distracting at worst.  But I'm not a complete nihilist.  I've also done a good deal of thinking about some medications that I think we should use more of.  On the basis of Bayesian and therapeutic threshold approaches to decision making, it stands to reason that one should have a lower threshold for using high utility/efficacy agents.  The utility of a given agent is the product of the probability that a disease it treats is present and the utility of the agent for that disease (which is itself the probability of an effect in any case and the magnitude of that effect.)  Thus, if the utility of the agent is high (furosemide/Lasix), it could be useful even if the probability of disease is low (CHF in a patient with normal BNP and ECHO); indeed it could have more net utility than a low utility agent (Digoxin) in a high probability disease (EF 30%, BNP 1000). Note also that if the agent is effective at treating a common disease (as opposed to a rare one), it's general utility will be higher. It follows that the threshold for the use of these high utility agents (when I say high utility I mean net utility, thus the benefits greatly outweigh any side effects) should be low - and we should actively look for opportunities to use them.  Here are the drug utility equations (where Drug X treats Disease X):

General Utility (drug X) ~ Prevalence of Disease X * (Probability of effect in Disease X * Magnitude of Effect)

Specific Utility (drug X) == Probability of Disease X * (Probability of effect in Disease X * Magnitude of Effect)

So, in sum, drugs have higher utility when they treat common diseases, and when their effects on disease are both likely and of high magnitude.  Lasix fits this bill because fluid overload states are common, Lasix makes almost everybody pee (if given in adequate doses) and it makes them pee a lot (if given in adequate doses.)

Monday, October 28, 2013

Your Last Words for a Few More Breaths: Unspoken Trade-offs in End-of-Life Care

A man with widely metastatic cancer is admitted to the hospital for shortness of breath, deteriorates in spite of broad spectrum care, and is transferred to the ICU.  The patient is documented to be "full code" and, while the prospect of "coding" him is unsettling for his providers, they struggle to articulate exactly why.  (Correct intuitions are often difficult to dissect and describe.)  Often the discussion (amongst themselves or with the family) centers on the direct, observable, physical aspects of suffering that must be borne by the patient during the resuscitation process and/or the transition to life support.  "Breaking of ribs" and the like.

But years of quiet and thoughtful reflection identifies some second order and often unspoken nuances of the transition to life support that are perhaps more important than the first order physical aspects.  When the man dying of cancer deteriorates to the point that his oxygen saturation cannot be supported without life support or his respiratory distress is too severe, and I position myself behind that bed, propofol and an 8.0 (endotracheal tube) in hands, I know the oft unspoken truth - that this is the last time that this man will be indubitably conscious and coherent or will speak to anyone, most notably his family.  Insomuch as life consists of an interaction with one's environment, with a central focus on social interactions, the patient dies the moment I induce with propofol and insert that tube between the vocal cords.  He has traded his last words for a few more breaths.  (He has also traded away his ability to enjoy food or drink.)

Friday, August 9, 2013

The Rodeo is Over: Why I put the Bronchy Donkey Out to Pasture

Photo compliments of Jan Aberegg:  A mini donkey in Ohio.
They say that when you have a hammer, everything looks like a nail.  And when you are a pulmonologist, everything looks like a reason to "saddle up the Bronchy Donkey", my tongue-in-cheek reference to the bronchoscope, a device used to look into a patient's airways.

In the four years that I have been in the world of private practice as an intensivist and inpatient consulting pulmonologist I have performed elective bronchoscopies (outside of emergency airway management and tracheostomy placement) only two times.  Herein I will describe the reasons why this is so, and why many others continue to ride the Bronchy Donkey into the ground.

Tuesday, August 6, 2013

If It's Not Good Information, It's Bad Information: Improving the Signal to Noise Ratio in ICU Communication

I learned over a decade ago a lesson that can be condensed into the following adage:  If the patient's family knows the creatinine level and the white blood cell (WBC) count, somebody is letting the intern do the talking.  And, (sorry, interns everywhere) that's not a good thing.

You see, interns don't know very much, just enough to be dangerous.  This derives from the fact that they have little to no meaningful experience.  They know what they read in Med I and Med II, and they can parrot their handful of attendings from key rotations during Med III and Med IV, but after that, silence.

What they mostly lack is experience which allows them to see the big picture and to know what the general course of a patient is likely to be.  When a patient such as the one in a previous post comes in, they can wax prolific about the FENA (fractional excretion of sodium) and pre-renal, intrinsic renal, post-renal, Bartlett's, Gittleman's, etc., but they probably don't know that renal failure requiring dialysis carries a mortality in the ICU of 60% and they certainly don't understand the contribution of poor functional status to prognosis in critical illness.  Because they don't teach those big picture things in medical school.  They teach biochemistry and physiology.  (Medical Educators everywhere, take note.)

An analogy would be:  you take your 1982 Honda Civic to the mechanic and the apprentice comes out and tells you that they're going to torque the head bolts to 80 Newton-Meters and fill the transmission with 750cc of whatever weight synthetic oil.  Who cares?  We want to know if you can fix it, how it's going to run afterwards, and how much it will cost.

Monday, August 5, 2013

An Opportunity Lost is an Opportunity Cost: Doubling Down with Your Final Days

Experience and study teach that decision making in and about life is more akin to chess than it is to checkers.  A good decision maker will think several steps into the future and will consider multiple alternatives, not just the obvious first order choices.

 In medicine, we are often perilously mired in first order choices, to the detriment of patients.  We act as though there are just simple binary choices to make, such as treatment and life versus no treatment and death.  Would that it were so simple.

Someone I knew, a decade ago, made a courageous choice.  Faced with the grim prognosis of an aggressive metastatic cancer, he elected to forego any treatment and take his chances.  He left the hospital and got one month of relative freedom from medical burdens.  He got his affairs in order.  He selected his own grave site.  He visited with friends and family and doubtless did countless other things that he could not have done had he elected to receive chemotherapy and or radiation or debulking surgery or basically any medical intervention given the desperate nature of his case.  His last month could have been characterized by painful procedures and  repeated scans, nausea, vomiting, and anorexia induced by chemotherapy, cumbersome trips to radiotherapy - you get the picture.  In another parallel universe his doppelganger, selecting "treatment" for this runaway cancer, would have traded away the last month of his life - and probably would not have benefited from the trade.  An opportunity lost is an opportunity cost.

Let's look at another case.  An 82 year old frail man on dialysis for several months presents with increasing fluid in the chest around the lungs   Initial (non-invasive) testing suggests malignancy/cancer.  The patient can be steered in several directions ranging from hospice (given age, functional status, and co-morbidities, the prognosis is poor), to straightforward diagnosis via needle biopsy sampling (of fluid or superficial lymph nodes) followed by consideration of treatment options, or to aggressive video assisted thoracic surgery under general anesthesia to take control of the fluid, scar down the lung to prevent recurrence, and get a definitive diagnosis by surgical biopsy.

Note that as the aggressiveness of the diagnostic and treatment approach increases, so does the likelihood of never leaving the hospital as a result of complications.  An opportunity lost is an opportunity cost.  And the patient who selects or is steered towards the most aggressive treatment option may well pay with their final days for the marginal chance of improving their outcome - measured, of course, in the number of days that they can live unencumbered at the end of their lives.  In this case, regretfully, an aggressive approach was taken, and the patient died in the hospital, on life support.

We have to be very cognizant of these costly lost opportunities when we present options to patients, lest they double down with their final days.

Tuesday, July 30, 2013

Rage, rage against the dying of the light: The Fighter and the Pyrrhic Victory

It's only been two days since my last post on prognosis and end-of-life care in the ICU, and I'm anxious to blog about today's NEJM article on low tidal volume in the operating room on the Medical Evidence Blog, but the happenings around me already today mandate another post about realistic prognostication and it's effective communication.

When I make an assessment of a patient in the ICU, my list of summary conditions and conclusions often looks something like this:


  1. Advanced age
  2. Poor Functional Status
  3. Malnutrition/Cachexia
  4. Swallowing dysfunction
  5. S/P fall and hip fracture
  6. Aspiration pneumonia
  7. Congestive Heart Failure
  8. Respiratory failure
  9. Renal failure
  10. Poor Prognosis for both survival and return to independent livinng
This is not the norm.  The norm is to methodically list all of the acute and chronic medicalized and pathophysiologically interesting diagnoses.  In that vein, obvious things that can't be traced to a medically interesting and well delineated disease cascade are left out (such as advanced age and poor functional status.)

Sunday, July 28, 2013

Use Your Own Judgment: The Feckless Physician, the Tyranny of Autonomy, and the Courage of Convictions

All too often as an intensivist I am called upon to evaluate/treat a patient who is "Full Code" but who is utterly moribund.  My moral fiber is shredded by  the thought of instituting critical care measures in a poor, frail,weak, malnourished and cachexic, demented and derlirious nonagenarian (or octogenarian, or septuagenarian) with incurable disease.  So, it would be morally corrupt to acquiesce to the "Full Code" order and proceed as an  insentient automaton and put such a patient on life support, knowing that nothing good, and a good deal bad will come of it.  "A cog in the wheel" as it were.

Something strange and tragic is going on here:  While my physician colleagues are most often in consensus about the likely outcomes and the perceived futility (or net harm) of medical care in these cases (as are other informed medical personnel), they often do acquiesce to the "Full Code" order, and initiate the self-perpetuating sequence of futile treatments, disappointments, and indignities inflicted upon dying patients.  This disconnect has two possible explanations:
  1. Patients' values and preferences are vastly divergent from those of their physicians and other informed healthcare providers; or
  2. Patients and their families have not been properly informed about the prognosis, likely outcomes, and burdens of care.  (If denial is involved, this still counts as improper information - as with alcoholism and addiction, physicians have a duty to break down denial.)
So, does my moral repugnance at the thought of taking the moribund nonagenarian, giving him propofol to ablate his consciousness for (probably) the remainder of his natural life; inserting a tube through his vocal cords and thus making it impossible for him to speak; knowing that he's delirious/demented and has little hope of knowing what's going on and is probably in fear or distress; physically tying down his hands to the bed so that when he reacts instinctively to pull out the tube that is gagging and choking him, he cannot; inserting various other tubes and medical devices into his nose, urethra, anus, mouth, and through skin incisions into various other bodily structures; performing CPR and having my fellow healthcare workers feel and hear the breaking of his ribs and sternum; knowing that this poor patient will never leave a healthcare institution and return home - does this moral abhorrence derive from a set of values that I have about life and humanity that are divergent from those of the patient and his family?  Or does it result because I have different information about what these procedures entail and what their effect is likely to be?  (That effect candidly amounts to torture.  I am being asked to torture the poor fellow.)

The answer is obvious because people are more alike than they are different.  I have an abhorrence to these acts because I (and other informed healthcare workers) understand them better than the patients/families - there is "asymmetrical information" as economists would say.  Why would this be?

This results because of the "feckless physician" - the squeamish nebbish who believes that guarding the family (and himself - especially himself) from a vivid description of futile (and harmful) care at the end of life and the emotional reactions consequent to this discussion are more important than avoiding the horrors of actually delivering that "care" and inflicting that suffering on the inexorably dying.  And here I will state it:  the feckless physician, in making this choice, is morally corrupt.

He rationalizes this away by invoking the misguided principle of autonomy - the notion that people should be able to make choices for themselves.  But this ethical principle has certain premises and preconditions, and it is easy to pretend that they have been met - namely that the preconditions of information and understanding have been met.

So, when the patient (or, often his surrogates) is/are making choices such as "Full Code" that seem at odds with his moral intuitions and common sense, the feckless physician deludes himself into believing that he has imparted the requisite information about the procedures and likely outcomes in an adequate manner, and he acquiesces.  He is satisfied to invoke the foundationally precarious principle of autonomy to justify the indignities that are about to befall the poor, dying, nonagenarian.

And he calls the intensivist.

Thursday, July 11, 2013

Oligopharmacy and Nopharmacy: "He is the best physician who knows the worthlessness of the most medicines."

Refrigerator Magnets of Heavily Promoted Drugs
When I was an intern, I read in a pocketbook (my coat pockets were overflowing with guides and manuals in those halcyon days) called Drug Prescribing in Renal Failure that in elderly patients, 65% of hospital admissions are caused by or contributed to by an adverse drug reaction.  At first blush, this seems like a gross overestimation (like the 100,000 deaths per year from medical errors which probably IS a gross overestimation), but experience bears out this wisdom.  As the number of drugs increases, so does the potential for interactions and side effects - multiplicatively.  There are two related practical implications of this observation.

First, it is my practice when admitting a patient to the ICU or hospital to stop all nonessential medications.  This includes outpatient medications and many medications begun by other physicians during the admission.  It would include medications such as:

Thursday, July 4, 2013

Parsimonious Practice: How to Treat DKA with 5 Lines of Orders in Half a Day

Few processes in medicine are as simple as the treatment of DKA (diabetic ketoacidosis) or have been as gratuitously complicated by anal retentive micromanagers of physiology.  Here is a departure from that custom that I have refined iteratively during the past four years.  It is guided by the goal of reversing ketoacidosis (and associated dehydration) and getting patients eating and back on subcutaneous insulin as expeditiously as possible, while reducing waste and burdens of care and without compromising safety.  It does not have as a goal to rigidly govern lab values or usurp control of physiology during the process.  The caveat to be aware of is that I have refined it in young(ish), adult, non-compliant Type I diabetics without insulin resistance who have moderate to severe acidosis and hyperglycemia.  (I do not treat "DKA" with a serum HCO3- greater than or equal to 14 with an insulin infusion - I treat it with fluids and reinstitution of subcutaneous insulin.)  It also presumes that there was no trigger other than non-compliance, or that the trigger (e.g. UTI) has been investigated and addressed.  I will briefly discuss the 5 orders, their benefits and potential drawbacks.  First, the orders:

1.)  Bolus with 5 liters of Lactated Ringers Solution
2.)  Begin insulin infusion at 5 units per hour (FIXED DOSE, NO BOLUS, NO TITRATION).
3.)  Check blood sugar every 2 hours; When blood sugar less than 200 mg/dL, reduce insulin drip to 1 unit per hour.
4.)  If blood sugar is less than 100 mg/dL (on any insulin dose) or greater than 300 mg/dL on 1 unit per hour, call MD.
5.)  Check serum K+ and HCO3- 12 hours after the start of treatment.

Tuesday, July 2, 2013

The Obesity Odyssey: Tie Me to The Mast, Wire My Jaw Shut, Rewire My Guts Into a Roux-en-Y

In the last post, I was titillated by the JAMA authors' observation that, as prescription opioid overdose deaths have quadrupled, people and their physiology have not changed - their exposure to opioid drugs has changed.  Is there any more apt an explanation for why obesity and overweight rates and associated complications have swelled like 10 pounds of sugar in a 5 pound sack?

One hundred years ago, there was precious little obesity.  We have not changed physiologically since then.  Two things have changed:
  1. How much fuel (food) we're putting in our tanks (bellies) (and it's "octane level" - how many calories it has per unit volume); and
  2. How hard/far/long we're running the engine (i.e., the manual work our bodies perform daily)
It's utterly amusing that the obesity epidemic is viewed in any other terms.  It's quite simple - 100 years ago, we did not have processed, ready-to-eat, high caloric density, cheap, easy, convenient foods that required little or no preparation time.  And we did not have leaf blowers, washing machines, elevators, 3 cars per family, power mowers, pressure washers, desk jobs, televisions - you get the picture.  In short, we ate fewer calories and we burned far more calories performing just the basic tasks of life, let alone actual manual labor performed as members of the workforce.  We are exposed to much more food, and much less physical work.  It's a dose-response issue.

Wednesday, June 26, 2013

Pain Is The Fifth Vital Sign - And If You Don't Have Any, You Might Be Almost Dead

"The cure is worse than the disease", it has been said about some supposed remedies.  We might be at that point in the treatment of acute and especially chronic pain with opioid (narcotic) analgesics.  In this article in the May 9th issue of JAMA Dowell et al make the astute observation that as opioid related deaths have quadrupled in the last decade or so, people have not become more susceptible to the drugs - it's just that their exposure has increased.  Exposure increased because several alleged patient advocacy groups (American Pain Society, Veteran's Health Administration, the Joint Commission) campaigned to convince physicians that they were not adequately recognizing and treating pain, callously leaving countless patients unnecessarily writhing in abject misery.  Led by these and other coalitions of busybodies, we went from possible undertreatment of pain (with narcotics) straight to guaranteed bona fide undeniable overtreatment (with a brief pass through [but not a stop at] optimal treatment).  Part of this overzealous campaign was the coining (original source unknown) of the contagious catchphrase "pain as the fifth vital sign."  

This is interesting because pain is a SYMPTOM, something reported by a patient (part of the HISTORY), whereas a [vital] SIGN is an observation or measurement (part of the PHYSICAL EXAMINATION) made by a practitioner such as blood pressure, heart rate, a bruise on the skin, a pulsatile uvula (Muller's sign), or some other finding.  (The more rare, uncontemporaneous, and useless a sign is, the more likely its name is an eponym.)  But the pain coalition (PC) successfully circumvented this convention by cooking up pain scales and cutesy numbered diagrams bounded by smiley faces and sad faces, adding a cloak of objective legitimacy to the subjective experience of pain.

Thursday, June 20, 2013

Logic Based Medicine: The Case of Activated Charcoal

Like all good things, Evidence Based Medicine (EBM), when taken to far, runs the risk of making us overwrought and becoming cliche.  I think we are reaching this point.  Given Ioannidis' meta-research findings that most published research findings are false (does he consider the irony that that may apply to his findings too?) the corrupting and corrosive influence of industry on research programs and guideline construction, the biases of academic researchers intent on grants, prestige and promotions (as well as honoraria to supplement paltry academic salaries - I was there once, and I did it too), and the zealousness of "experts" who wish to interpret the evidence in the form of an edict for all to follow (euphemistically called "guidelines"), and several other disturbing trends, it becomes apparent that in the end we must rely upon our own judgment and logic to discern the proper path to follow.  And so it is with Activated Charcoal (AC) administration, an agent used in overdoses and toxic ingestions that has a remarkable capacity to adsorb ingested substances and theoretically limit their toxicity.  (It is not barbecue charcoal, the photo is tongue-in-cheek.)

Monday, June 3, 2013

I Know it When I See it: Antibiotic Resistance, the Chronically Dying, and Futile Medical Care

Today's issue of the New York Times features (yet another) article sounding alarms about antibiotic resistance and the supposed need for new antimicrobial agents.  There are several common hackneyed reasons why we have the current predicament of drug resistant organisms such as:

  • Use of antibiotics in livestock, which accounts for 80% of use in the United States.  This should be the prime target for efforts to reduce resistance, not use in humans.  
  • Inappropriate use of antibiotics in outpatients who have mild/minor illness and who have viral illness (not responsive to antibiotics) 75% of the time.
  • Inappropriate drug, dose, duration of therapy, etc., in both outpatients and inpatients.
The article calls for reducing the hurdles needed to develop and test new agents.  Well and good.  But I have another idea:  fund testing of antibiotic dosing duration for several common infections such as pneumonia, cellulitis, urinary tract infection, etc.  Right now, it's all over the board, with some patients getting two weeks for pneumonia, some getting five days (my patients).  Moreover it is my suggestion that such trials stratify patients on the basis of the prior probability of the infection being treated.  I would posit that the lower the probability of infection, the more likely it is that a shorter course will suffice.  Clinical improvement criteria could also be built into these studies so that courses could be truncated when patients improve.  If we could cut the duration of exposure from 10 days to 5 days, we would remove selective pressure for development of resistant organisms and opportunistic infections (fungemia; C. diff; ESBL).  I'm not sure we need new toys so much as we need to play properly with the toys we already have.  (And no, I'm not a fan of biomarkers like procalcitonin to guide duration of administration.)

Monday, March 18, 2013

Worshiping Relics of the Past: The Physical Examination

It seems like every year or so, an article such as this one is published in just about every medical journal either lamenting the withering importance of the physical examination (PE), bemoaning contemporary physicians' indifference to it, inventing creative perspectives to enshrine and hallow it, or just harkening back to the "good 'ol days" when that was "all we had."

The whole state of affairs is ironic and silly, for several reasons.  I would be shocked if the same doctors who hanker after the good 'ol days of Valsalva and Mueller maneuvers, Austin-Flint murmurs and Cannon A-waves don't carry around iPhones, iPads, Up-to-Date Apps, and every other manner of advanced electronic device, aid, and tool.  (They are probably also vocal proponents of EMRs.)  They don't dust off an old EKG machine from the 1960s once a week and teach medical students how to use it just in case they find themselves on a medical mission in Cuba one day.   They use computers and statistical programs to perform calculations for their epidemiological studies, not slide rules and Z-score tables.  If they have a mortar and pestle, or an old microscope, it is on a shelf under various diplomas, testaments to the past and nothing more.  So why all the fuss over the slow but inexorable obsolescence of the PE?

Monday, March 4, 2013

Ventilating Corpses and Resurrecting the Dead: The State of Modern Critical Care Medicine

I vividly remember being chided by the ICU Director in my residency during ICU rounds one morning, circa 2000:
Director:  "Scott, why did you intubate this man?"
Me: "Well, Dr......he couldn't breathe and the family...."
Director:  "Scott.  This man has metastatic anaplastic thyroid carcinoma.  He's dying.  We're not in the business of ventilating corpses."
But ventilating corpses is indeed the business of modern critical care medicine.  I'll leave it to you to decide whether that's a good or a bad thing.  But in so doing, you should grapple with the data and the larger issues.
An article the February 20, 2013 JAMA describes ventilation weaning practices in an LTACH (Long Term Acute Care Hospital).  It is a very well done study that confirms what I already thought I knew:  that tracheostomy mask weaning is superior to playing around with pressure support levels.  Well and good.  But there's an elephant sitting on the article:  two thirds of the randomized patients were dead by 12 months, regardless of whether they were weaned or not.  Two of three patients were dead.  Despite undergoing prolonged intensive care, receiving a tracheostomy, being sent to a veritable nursing home, and probably being artificially fed, and despite all the suffering, physical and mental, emotional and spiritual that this entails, two of three of them were dead at one year.  And this is not a new finding:  the data on 1-year mortality for tracheostomy patients in an LTAC in this article comport with those of other studies such as this one by Kahn in JAMA in 2010.
We need to begin, as a society, to seriously question if this is a good thing to be doing to/with the dying, which will one day include us.  Namely, should we PEG, Trach (verbs), and send the dying to a nursing home for a prolonged trial of weaning from which only one of three of them will survive?
The authors introduce the subject by describing the expansion of LTACHs in the US over the last decade (from 192 in 1997 to 408 in 2006), and their associated costs ($1.3 Billion in 2006).  They also note that because of the aging population, there is an anticipated 38% increase in demand for intensive care physicians in the next decade.  But they make no mention as to whether these increases are desirable and appropriate.  One possibility is that these increases reflect a misguided way of dealing with death and the dying.
But being alive at 12 months does not mean being well and it most certainly does not mean back at home as though the index illness never happened.  The probability of being alive and breathing without assistance after one year for a patient who goes to an LTACH with a tracheostomy is on the order of 25%.  The probability of being alive, breathing on your own, walking and eating and urinating normally?  I don't know, but it's less than 25%, I suspect a good deal less.  The probability of living independently?  Less than 10%.
And I can tell you from vast experience that the majority of patients and their families, when in possession of these statistics, do not want a tracheostomy and an LTACH and all the associated encumbrances and miseries.  Then why are so many patients receiving tracheostomies and going to LTACHs?  Because their physicians are not arming them with these statistics - or they think they are, but they are victims of wishful thinking and patients and their families are not receiving the message that physicians think they are delivering.  And why is THAT happening?  Probably a lot of reasons, but I think the general notion can be summed up by an analogy I introduced at a Division of Pulmonary and Critical Care Medicine conference about 6 years ago at Les Wexner's Ohio State University Medical Center.  I was dumbfounded by how little critical thought was given to the accepted wisdom that a PEG and a tracheostomy and a discharge to an LTACH was considered a success by those practicing critical care medicine.  Here's the analogy I challenged them with:
Suppose I give you a superpower.  With this superpower, you can resurrect the already dead, and restore them to life, but it is a life dependent on a PEG and a Trach and an eternal existence in an LTACH.  How many deceased (and in peace) people would you resurrect with this superpower?  A hundred?  A million?  A billion?
(Obvious corollary questions are:  how many people, as a society, can we afford to support in LTACHs?  How many people would want to be thusly resurrected?  A philosophical discussion about status quo bias could also ensue.)
Silence filled the room.  Nobody responded.  I think they assumed I was being absurd, and this absolved them of responsibility for giving serious consideration to the issue I was raising.  And this failed responsibility is how we got here in the first place.  Because nobody is questioning the current status quo.  Rather we congratulate ourselves for "saving lives" and celebrate the anticipated rising demand for our kind.  Hooray, our disservice is in demand!

Monday, February 11, 2013

Reconsidering the Premises of Care: The Patient Perspective and the Relief of Minimalist Medicine

This post is about some half-baked ideas that result from inferences I have made after noticing some patterns in my dealings with patients, inspired by one such interaction today.

Every now and again I have noted that some patients seem pleased by something I say, some perspective I present, and their pleasure I infer from their asking for my name and contact information so that they may pass it on to their other treating physicians.  This is somewhat unusual since I make clear that I am a dedicated inpatient doctor who only briefly contributes to their care in the most acute of settings.  And I have noticed that it is most likely to happen when I offer to them a perspective that gives permission, as it were, to pursue a less aggressive course of care even in patients who are not really at the very end of their lives.

Today, as is often the case, I suggested that a patient may wish to simplify his medication regimen, eliminating medications that, while constituents of an "optimal" regimen, are adding very marginally to his longevity while posing some very real burdens.  This patient has some longstanding chronic conditions but his medical regimen increased dramatically in complexity after a recent cardiac illness, such that he now takes two antiplatelet agents, an anticoagulant, and several medications for blood pressure and heart failure in addition to several medications he has been taking for years.  Since his most recent hospitalization six weeks ago, he has felt terrible.  This is either related to the setback he had with his recent cardiac event, or from the post-hospitalization syndrome detailed in the post about Death by 1000 Needlesticks, or, and this is not to be taken lightly, the cumulative side effects of his now complex medication regimen.  Indeed, the current hospitalization has occurred as a result of bleeding complications triggered by medications from his last hospitalization.

Wednesday, February 6, 2013

Reflexes are for Knees! Geez! Why do you need so many ABGs? (An introduction to Bayesian Clinical Decision Making.)

I wasn't always like this.  Ask co-interns and they will tell you I was the most notorious minutiae-obsessed physiology manipulator west of the Mississippi. 

What changed?  Well, I grew up and realized that micromanaging physiology is most often a fool's errand.  Evolution was indeed a brilliant chemist (Max Perutz), and I recognize my impotence in one-upping him.  I can order zero ABGs or a dozen ABGs in a week and little changes but the volume of blood that is flushed down the drain.

So, using an example from earlier in the day, I'll lead you through a stream of consciousness explanation of why I can most often do without an ABG.

A man in his 30s is admitted for alcohol withdrawal (WD) for the sixth time in 12 months.  About half of these times, his WD has been severe and he has required ICU admission.  Overnight, during the administration of benzodiazepines for his WD symptoms, he has become progressively tachycardic and tachypneic and his oxygen needs have been steadily increasing.  His saturation on the monitor displays a good tracing at 95%.  BIPAP is applied.  I can hear his respiratory rate at about 25, and based on the flow I hear from the BIPAP machine, I can guess that his minute ventilation is about 15 liters per minute (these guesses could be confirmed with RT).   Knowing nothing else about his case, I am asked if an ABG should be ordered to assess his respiratory status.  Should it?

Sunday, January 13, 2013

Death by 1000 Needlesticks: The Nocebo effects of Hospitalization

When I read an excellent article by Krumholz in this week's NEJM, a paradigm that has been evolving in my mind and my practice patterns for several years congealed:  hospitals and hospitalizations are, to some extent, bad for you.  In this post, I will extend Krumholz's ideas to conjecture about several modifiable aspects of hospitalization that I think do more harm than good.  Many interventions employed by physicians are thought to be benign or beneficial, but there are at least three ways that they could be subversively harmful:  1.) because they prolong hospitalization which is harmful in the way described by Krumholz as the "post-hospital syndrome"; 2.) because there are unrecognized direct untoward effects of the interventions and the environment in which they are administered; and 3.) because patients have adverse psychological reactions to otherwise benign interventions - that is, nocebo effects of hospitalization.  (See also this recent NYT article on nocebos.)

One of the most notorious bugbears of hospitalized patients is the blood draw.  As my colleagues and I mused in this review of laboratory testing in the ICU, much laboratory testing is unnecessary or wasteful, and may even be harmful. Nonetheless, patients admitted for a whole spectrum of maladies have laboratory studies pre-ordered on admission at distinct intervals:  daily labs in the wee hours of the morning (don't get me started on that one - why on Earth we awaken patients at 4AM to draw blood, and how do we justify it?), interval labs throughout the day to "monitor" things (e.g., hemoglobin in gastrointestinal hemorrhage), labs ordered for that Sisyphean task of electrolyte replacement, and so on.  Beyond the oft discussed topics of wasted resources and the anemia-inducing effects of phlebotomy, what if the act of drawing blood has a nocebo effect on patients?  That is, what if they perceive psychologically or unconsciously that many blood draws implies a greater degree of sickness or a stalled, stuttering, or laggard recovery?  What if the pain of phlebotomy induces neurohumoral responses that impair recovery?  What if being awakened at 4AM every day for a painful nuisance not only disturbs sleep, but impedes response to specific therapy through a nocebo effect?