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?