Screening in Disguise: You Can't "Unknow" that Troponin, But You Can Dismiss It After Careful Thought

During MICU rounds last month, there were a lot of troponins ordered, and most of them should not have been.  Invariably when abnormal troponin values are reported on rounds, there is no mention of whether the patient had anginal chest pain, whether there were ischemic EKG changes, or whether this information was sought at the time the troponin was drawn.  This is because troponins are being used as a screening test, rather than as a diagnostic test.  "Not so!" exclaims the resident, eager to convince me that he has not engaged in the kind of mindless testing he knows I loathe.  I am told that because the first troponin was mildly elevated in a little old lady with cirrhosis, overdose, right heart failure and urinary tract infection, that we need to follow it to see where it "peaks".

No Code, Slow Code, 45 Minute (Purgatory) Code: Responsibility and Accountability in Attempted Resuscitation from Death

Physicians can abdicate their responsibilities as reasoned guides for patients making decisions at the end of life and as gatekeepers of resuscitation practices in many ways:

• By failing to address "Code Status" at all, letting patients be "Full Code" by default (and by failing to work as a profession to reconsider or change the default)
• By asking, in a matter-of-fact manner, "if your heart stops, do you want us to do CPR to try to restart it" without discussing the probability of success and the likely outcomes, both immediate and longer term, in the (often unlikely) event of success
• By failing to probe the reasons why a code status election that is at odds with their (and/or the nurses') judgment has been made; i.e., taking for granted the legitimacy of a Full Code declaration when doing CPR will clearly or likely be futile
• By discussing the issue of code status solely from an agnostic position, as though there is no right or wrong election, when in fact the physician has a strong belief about what is appropriate and what is not (such as Full Code nonagenarians, elderly patients with hemorrhagic stroke, those on the ventilator with multisystem organ failure, those with metastatic cancer, etc.)
• By defaulting to a Slow Code as a dissimulating compromise for the conflict between the documented code order and their sense of what is medically appropriate
• And the topic of this post:  by conducting a 45 minute code without reevaluating, during that time interval, the premises upon which the Code Blue was initiated, and without integrating the new information that accrues during the resuscitation attempt

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.