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?

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!

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.

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?

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?

Status Diabetic Ketoiatrogenicus (DKIA)

Sometimes the ill effects of status iatrogenicus go largely unnoticed except by those that directly bear the burdens of care and ultimately pay the bills.

Imagine a 29 year old type I diabetic and who's still using 70/30 insulin in the post-Ultralente Lantus era because he can't afford the latter.  So, when WalMarts runs out of 70/30, he tries to get by with regular insulin, and lo and behold a week later he's in the ER in DKA (diabetic ketoacidosis).

If you're a perspicacious doctor familiar with the treatment of low income diabetics, this case is not a great mystery.  Insulin non-compliance eventuating in DKA.  Easily treated with fluids and reinstitution of insulin.  The case may be slightly more difficult if it were a female with pyelonephritis, slightly more with shock and MSOF, and maybe totally different if it were a 59 year old male with a stroke or an MI and MOSF and DKA in an inscrutible and tangled causal web.

"It'll break her ribs": Checking boxes on the Code Blue Sushi Menu

For more reasons than I wish to enumerate here, the discussions of death and dying that physicians are having with patients at the end of life are so simplistic, myopic, confused, and lacking in nuance that they resemble a theater of the absurd.

The implications for individual patient care and health care in general are weighty indeed, but I will defer their statement to other commentators or other posts.  Herein, I review some of the absurd elements of the approaches I often see used to broach the topic of decision making at the end of life, and offer some (admittedly vague) suggestions about how this sorry state of affairs can be improved upon.

Let us begin with what has been called the "Chinese Menu" for "Code Status".  I prefer to call it a Sushi Menu.  I should pause to explain terminology.  When a patient dies in the hospital (we have various euphemisms for death in the hospital - "passing", "coding", "full arrest" [curiously, there is no "partial arrest"], etc. - but the key point which we must confront directly - not tangentially - is that people do eventually die) a "Code Blue" is called overhead.  Code blue called overhead on the hospital PA system activates a team of various hospital employees of sundry disciplines, who respond and attempt to resuscitate him.  A patient's "Code Status" is medical jargon that signals to that team what the patient wants them to do in the event that they die in the hospital. In the simplest of its various forms Code Status is dichotomized to either "Full Code" meaning the patient has directed the team to "do everything" that is reasonable to resuscitate him; or to "DNR/DNI" which means Do Not Resuscitate/Do Not Intubate - that is, do not intervene and allow the patient to die naturally in the event that they stop breathing or their heart stops.  Why would a patient choose to die naturally rather than be resuscitated?  Because often being resuscitated forestalls death only for a short time during which the patient cannot communicate or get his affairs in order - time that has little value and may increase the net burden of suffering, all of it in the hospital in a state of questionable consciousness, connected to machines and being poked and prodded and "run through the ringer" until death inevitably intervenes.  As a sage friend once said "Death is not the enemy."  Indeed it is not.  Suffering is.

Miffed at the Myth of MIVF and nonplussed by nil per os (NPO)

I will have to consult with physicians from a former generation to determine from whence came the concept of "maintenance intravenous fluids" or MIVF.  Early in medical school, especially during the pediatrics and surgery rotations, medical students are taught how to calculate fluid deficits and ongoing losses with the goal of selecting the optimal electrolyte solution and rate with which to replace them.  (Internists generally just select some base-10 friendly number such as 100 or 150 cc/hour and call it a day.)  This is a worthy enough goal, because dehydration is indeed one of the easiest and most worthwhile things to correct in the acutely ill patient.  (If you've ever puked your guts out for a day and then gotten a liter of intravenous fluid, you know what I mean.)

But the whole practice begs the question:  If there is a fluid deficit, why not just correct it once and be done with it?  If the average deficit in diabetic ketoacidosis (DKA) is 5 liters, why not just give 5 liters and stop?  I used to chide the residents during their ICU rotation:  "Bolus is for resus, rates are to maintain" to reinforce the notion that deficits should be repleted quickly.  But now I have come to question the second clause in that aphorism - do we need rates to maintain?

Specious Ideas: CO2 is bad for you and acidosis is a killer too



Here's some bad acid and CO2

Certain biases in the way we think in medicine are so pervasive and so misleading that I'm going to make a special section on this blog for them:  The Specious Ideas Series.  We'll begin with my favorite, the approach to hypercarbia (high CO2) and acidosis (low pH) both in and out of the ICU.

Patients with serious illness often have derangements in PaCO2 (arterial partial pressure of CO2; hereinafter abberviated CO2) and pH.  But it does not necessarily follow that patients are experiencing physiological stress because of CO2 and pH, and it likewise does not follow that actions to normalize these values will make patients better.  Indeed, such actions are often not only a distraction and a waste of time, but they can also be harmful.

When the elderly need a protection order against warfarin-wielding physicians

This is a tree.  If you want to see the forest, back up.

(Added 1/11/12 - This post was prescient:  See this article in today's NYT: Interactive Tools to Assess the Likelihood of Death which reviews this JAMA article: Prognostic Indices for Older Adults; here is the Prognosis Website - In my opinion, it's too complicated to be useful, but it's a start.)

Ever since I was in medical school, I have been hearing the tired old refrain about how warfarin for stroke prevention in atrial fibrillation is underutilized in just about everybody, especially the elderly.  Well, if you want to see uber-high rates of warfarin underutilization, you need look no further than trials of stroke prevention such as the original SPAF trial (Ezekowitz, NEJM, 1992), where more than 93% of screened patients were excluded from the trial and not given warfarin!  There's an interesting contradiction.  Moreover, it is likely that warfarin is not as underutilized as has been stated because of inadequate data on appropriate exclusion criteria (see Srivastava, Thrombosis Journal, 2008).

H. pylori, Peptic Ulcer Disease, Bayes' Theorem, and treatment thresholds

I was slightly surprised today to read the authors' discussion in the Clinical Crossroads in JAMA (December 7th issue; original case November 1st issue - when the reader responses are published, there may be even more to say about this topic).  I was more thoroughly surprised when I cross-referenced UpToDate and the references that both used to defend the suspect practice.  Apparently Bayes' Theorem does not apply to H. pylori (HP), and neither does the concept of treatment thresholds.  Time to apply some uncommon sense.

At issue is whether a patient with peptic ulcer disease (PUD) should receive empiric treatment for HP, or whether "confirmatory" testing is indicated.  Early estimates suggested that 95% of patients with PUD will have HP (I recall that figure from the 13th edition of Harrison's Principles of Internal Medicine, now in it's 18th edition), but three epidemiological studies in the 1990s challenged this estimate as too high, with new estimates of 73% (study n=2394), 61% (study n=144), and 36% (studied n=95).  The binomial confidence intervals (CIs) for those numbers are 71-75%, 53-69%, and 26-45%.  The first study, with an estimate of 73% and n=2394 is actually a summary statistic derived from a combination of six other studies.  So, which estimate do we choose?  We could do a meta-analysis and combine all of these studies, but we already know what the result will be becasue the first study will trounce the others when weights are assigned.  So I'm going to just conclude that while the prevalence of HP in PUD might not be 95%, it is likely close to 73%.

This is important because you have to decide what threshold of probability you will use to trigger treatment of HP.  If that threshold is 75%, well then you might as well just treat everybody with PUD because the prior probability is so close to your treatment threshold.  One of four of the patients you treat will have been treated "unnecessarily", on average.  If that threshold is too low, then you need to raise it with testing.  But, testing is not without its own set of pitfalls, and the gains in reducing  false positives may be much less than you think.

When Care is NOT Worth it Even if the End is Life

Oh dear.  I'm a fan of Dr. Peter Bach.  We trained under some of the same mentors.  But....

In this article When Care Is Worth It, Even if End Is Death, he makes so many logical errors in thinking that I just can't let it pass tightlipped.

He describes the case of a middle aged man whom he cared for some 20 years ago who presented to the ER in extremis (about to die) from what turned out to be mesenteric ischemia (some of the bowel is dying for lack of blood flow.)  His supervisor mused that the man was hours from death.  After surgical treatment and a two week ICU stay, the patient walked out of the hospital alive, and Dr. Bach uses the case to attempt to illustrate the point that treating patients near death is not a waste of time, effort, and money.  Allow me to summarize the many errors in his logic.

Protection via Violation: A Sheriff Joe Arpaio approach to the Airway

Left: Posterior arytenoid web developed after a 40 minute intubation
Right: After endoscopic laser therapy

The subject of overdoses segues me to another topic of interest to the skeptical observer in the emergency department (ED) and intensive care unit (ICU).  Patients with alcohol intoxication, drug overdose, and various other maladies that cause decreased level of consciousness (LOC) are often intubated (a breathing tube inserted through the vocal cords and into the trachea [airway]) so as to "protect the airway".  Under normal conditions, there are powerful reflexes in the oropharynx, larynx, and trachea that cause you to gag and cough to keep everything but air out of the airway to prevent the development of an obstruction or pneumonia.  Because of this, powerful sedatives and often paralytic medications have to be given to a person to enable the insertion of the tube - otherwise it will be violently rejected by these reflexes.  Various conditions, chief among them drug and medication effects but including even normal sleep, can cause a depression of the intensity of these reflexes, which often arouses concern that patients with decreased LOC will aspirate (get liquid or solid material in the form of saliva, mucous, food, etc. into the airway).  By intubating such patients with a tube that effectively seals off the airway (by means of a balloon that is inflated at the end of the tube), it is thought that the airway is thusly "protected".

Why the Rumack-Matthew nomogram is a dangerous distraction

When a known or suspected overdose (OD) comes to the emergency department (ED), levels of several commonly ingested agents such as aspirin and tylenol are checked.  If the history or laboratory results suggest acetaminophen (APAP) overdose, the "standard of care" (if there is one - see:  Heard APAP OD review in NEJM, 2008) is to investigate the time of the ingestion and refer to the Rumack-Matthew nomogram (RMN) to determine whether toxicity is likely and to initiate a course of n-acetylcysteine (NAC) if the level is above the line on the nomogram.

Now there are several problems with the RMN that I will not fully delve into here. Suffice it to say that the RMN came from a review of a (striking!) 30 cases in a 1975 paper in Pediatrics.  The nomogram was extrapolated from this case review.  And while I'm no pediatrician, I suspect that pediatric poisionings are quite different from adult ones.  In any case, when the timing of ingestion is accurate the RMN has been a useful guide for ED physicians to determine who could be safely sent home and who would need to be admitted for treatment for APAP poisioning.