Monday, July 29, 2019

"I'm Not Comfortable With"....Analyzing Decisions Involving Risk

A woman with upper gastrointestinal bleeding is admitted to the ICU with significant hemoglobin drop from baseline several months before.  The INR was >10 on admission, presumably reflecting sphlanchnic hypoperfusion during the bleeding episode (decreasing clearance or increasing effect of warfarin) in addition to consumption of clotting factors during bleeding.  The INR is reversed with vitamin K, and an EGD is performed showing a nonbleeding vessel which was clipped.  The following day, the patient is up and walking around and eating a full liquid diet with no further evidence of bleeding.  MAPs are in the mid to low 60s, and she is "called out" for a transfer to the regular medical ward.  The resident is reportedly "not comfortable with" having the patient on the floor with the low mean arterial pressures.  How best to analyze the situation?

(I will only briefly note that the expression of discomfort describes an emotional reaction that may or may not be concordant with a logical and factual analysis of the situation at hand.  In this case I suspect it has something to do with the availability heuristic, where dramatic events [gushing blood] are estimated to have higher probabilities than they warrant.)

The discomfort seems to stem from a concern that the patient will deteriorate on the regular medical ward and require interventions that are not available there, prompting readmission to the ICU and incurring the risk of a missed opportunity to provide necessary care during any delays in executing the transfer.  Factors that may raise that concern are marginal hemoglobin values (7-8) especially considering a baseline of almost twice that several months before, the size of the GIB and the resulting hemodynamic instability, the marginal MAPs at the time of transfer.  Mitigating factors are the absence of ongoing bleeding, the inference that any marginal MAPs must be from a residual volume deficit (she does not have coincident sepsis), that the vessel was successfully clipped, and the patient is up and walking about in spite of the measured MAPs.  But how are we to integrate this into an estimate of the risk that may be incurred from transfer?

Monday, July 22, 2019

The Bermuda Triangle of Guidewires: Do They Just Fly Away Never to Be Seen Again?

In last week's NEJM, author Matt Bivens reports an extraordinary experience: while inserting a venous catheter, he let go of the guidewire and moments later looked and saw it migrating into the patient's jugular vein, on its own.  He grabbed it as it was running away, just before it escaped from him.  While I can imagine, as he did, how it may have happened, it is an exceptional claim.  Some aspect of the venous circulation or respiratory motion must have been pulling the wire downstream into the patient, if this story is true.  I say "if" because it is truly extraordinary.  Not only must the venous circulatory flow have been "grabbing" the wire, carrying it downstream, it had to do so with enough force to overcome the friction of the wire as it traversed the tissues of the neck.  (Not mentioned is the size of the patient's neck or whether this happened pre- or post-dilation, or whether the patient was in Trendelenberg - if so the catheter had to be pulled up hill!)

I have never seen or felt a guidewire move in such a way, over 20 years and thousands of lines.  However, I did turn my back on an intern circa 2000 and that intern pushed and/or flushed the guidewire into the patient.  So I was interested in the 4 references in the article purporting to show that guidewires have wings or feet or that the venous circulation can pull them and overcome the tissue resistance and mass of the wire.  Here is a summary:

Friday, July 5, 2019

The Truth Doesn't Always Need A Test: Thresholds for Medical Decisions

Jason Carr, MD didn't need a test to know what this is
Kassirer (and Pauker) got the idea for the Threshold Approach to Medical Decisions in part (as he tells it in his memoir Unanticipated Outcomes) because he had observed a pattern of irrational behavior among nephrologists (he was one) in the 1960s.  Evaluating a patient with nephrotic syndrome and knowing the diagnosis was very likely to be membranous glomerulonephritis, most nephrologists still insisted on a biopsy prior to starting corticosteroids.  Pauker and Kassirer realized that we never get to 100% certainty in medicine and that tests only modify the pre-test probability of disease.  They reasoned that there ought to be a threshold of pre-test probability of disease that is high enough to justify treatment without testing.  That is, sometimes, the pre-test probability of disease is so high as that it obviates testing, and we can just skip to treatment and avoid risky and invasive testing like a kidney biopsy.  Only if the disease fails to respond to therapy (thereby reducing the clinical pre-test probability below the treatment threshold) should we resort to the biopsy.

Almost 40 years after the publication of their article, we still are not consistently following the axioms of the threshold approach.  Here are several recent examples:
A 20-something black woman presents with cough, weight loss, massive hilar and mediastinal lymphadenopathy and interstitial parenchymal changes.  She is scheduled for a bronchoscopy and EBUS to confirm the diagnosis of sarcoidosis prior to initiating corticosteroids.