Thursday, November 26, 2015

Jugular Venous Pulsations Video - How to Examine it Properly and not Mistake it for the Carotid Pulsations

In the video below, watch the jugular venous pulsations to know what you ought to be looking for.  In my experience, most of the time, physicians at all levels cannot identify confidently and accurately the pulsations that are clearly identified in the video.  Indeed, in many videos purporting to show the JVP on youtube, the pulsations are being shown in the external jugular veins, or carotid arterial pulsations are seen and are being mistaken for jugular venous pulsations.

In two other positions with this particular "jugular model" (keep OJ away from her!), the pulsations were not visible enough to make a compelling video image, emphasizing the finicky nature of the pulsations, the need to position the patient correctly to see them, and the general difficulty of confidently and accurately identifying the pulsations during a cardiac examination which is all too often cursory and unreliable in its findings.

The key feature of the JVP, to differentiate it from the carotid arterial pulsations is to watch to see if the most prominent feature of the "waves" is a rapid descent or a rapid ascent.  In the former case, as in the video, it is the venous X and Y descents of the venous A and V waves which are most obviously seen.  All too often, the rapid ascending waves of the carotid arterial pulses are mistaken for the JVP.  Look for rapid descents - when you find them you know you have found what you're looking for.

Tuesday, November 17, 2015

Beliefs That Dictate Evidence: Open Visitation in the ICU (Again)

The cart belongs behind the horse.
I recently blogged on idealogues who haven't any interest in the truth, rather their interest is in defending their beliefs.  For these true believers, evidence is sought selectively and strength of belief is not apportioned to strength of evidence.  Beliefs reign supreme, and evidence serves the beliefs.  The cart leads the horse.

And so let it be with open visitation in the ICU.  I'm interested in this because it is an issue of practical concern for me, and my interest was recently piqued because in nursing school, my wife was taught that open visitation is better for everyone and that ample evidence supported this contention.  Today, I came across a tweet about ICU visitation policies, a statement from the American Association of Critical Care Nurses.  So I decided to investigate a bit further the evidence upon which their policy proposals are predicated.

The very first statement in the "Supporting Evidence" section of this document is "In practice, 78% of ICU nurses in adult critical care units prefer unrestricted policies."  This statement is at odds with my personal experience working with ICU nurses for the better part of the past 20 years.  While they are patient and family advocates generally, they also recognize that the exigencies of the ICU environment require some limitation of visitation, and so does their own psychological well-being.  So I began by investigating references 7-13 which are proffered in support of this statement which for some (many?) lacks face validity.  Here are those seven references, a description, and a synopsis taken from the abstract of each:

Tuesday, November 10, 2015

Messed Up Seven Ways To Sunday: Communication About Course and Prognosis

I was reminded the other day about the importance of narrative storytelling and theory of mind in communicating with patients' families.  A good storyteller, say Stephen King, has theory of mind - he can see into the minds of his readers and anticipate how they are going to react to what he writes, to the story he's narrating to them.  He knows full well that if he uses a vocabulary that they don't understand that they can't possibly engage with his story.

So if you EVER use the word "intubation" while talking to a family, or "mesenteric ischemia" or "lumbar puncture" or similar technical jargon, you are not going to engage them with your story, and you are going to confuse and frustrate them.  You must use your theory of mind to infer what parts of your medical vocabulary that laypeople do not understand (most of them).

Next, you cannot enter the room of a patient who, say, crumped from flash pulmonary edema and was intubated, and start talking about "mitral stenosis" and "wedge pressures" and "diuresis".  They have NO IDEA what those things mean.  A better narrative would be:
"She had rheumatic fever when she was a child, right?  Well rheumatic fever injures and inflames the heart valves and over the years they can stiffen from that inflammation and injury.  It's just like a guy who injures his knee playing football in high school and then years later has arthritis in the area of that injury.  Same thing, basically.  Anyway, the heart compensates for that stiff or constricted valve over the years by building up pressure behind the valve, just like pressure builds up behind the kink in a garden hose.  You can live like that for a long time because the heart and body are good at compensating, but there comes a point where the pressure behind the kink in the hose or the stiff valve causes fluid to leak into the lungs and then it's hard to breathe with the lungs wet and heavy.  This is essentially what's happened to her - she came in with low oxygen and trouble breathing from fluid in the lungs caused by a stiff valve in the heart.  So we have to remove fluid with water pills to get her breathing without the assistance of the breathing machine, and then she's going to need surgery to replace that valve at some point, which will be determined by the surgeon."