Utter Rubbish: A Call for a Moratorium on the 4 AM Blood Draw

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man.  - George Bernard Shaw

Depending on the week and the driver, I am often awakened around 4 AM when one of several delivery trucks backs into the driveway of the restaurant beside my house, 15 feet from my bedroom.  Rankled, I have been known to open the window and have words with the driver, who, in my opinion, should park on the street, thus creating a distance between our house and his beeping, rattling, diesel-idling, polluting truck with its slamming ramps and gates and whatnot.  Because he mindlessly prioritizes a minute or so of his time over my and my wife's uninterrupted sleep.  Sometimes, we just get back to sleep before the next truck comes and awakens us again.

In relating this story to my father, he told me that the residents of a Northeast Ohio municipality recently passed a city ordinance banning the picking up of garbage before a certain hour, because of complaints of the noise and disturbance that the rubbish trucks cause at earlier hours.  Immediately drawing the analogy of the 4 AM phlebotomy visit in the hospital, my father wonders why, in the era of customer service, we subject the sick of society to this indignity and injustice while they're in the hospital.  And the answer is that I don't know.  A quick Google search is of little help.

There are two likely and possibly related reasons for the 4 AM blood draw.  First, in days of yore, physicians rounded very early in the hospital and then went to their office or to the operating room.  They wanted the lab results by the time they rounded so they could complete the rounding task and move on to others and not worry what Mrs. Jones' creatinine was all morning.  So, in essence, we have historically been awakening patients at 4 AM for physicians' convenience.

Helping Those Who Won't Help Themselves: The Role of Personal Responsibility in Medicine

Give a man a fish, or teach him to fish.

It is a well known secret in medicine:  many of those we care for are unconcerned with their own care, as evidenced by their revealed preferences.  "What medications are you on?" the physician asks.  "I don't know, doc," comes the reply.  "Why are you on carvedilol?"  "I don't know."  "What was your last HgbA1C?"  "What's that?"  We have encouraged physicians and other professionals in the healthcare system to take responsibility for every aspect of patient's care to the peril of patients' own interest and investment in their care.  How often do you enter a room and find a patient researching their illness and its treatment, rather than surfing the internet or watching TV?  Is your patient more concerned with the timing of the next dose of antibiotic or the next dose of dilaudid?  How often do your patients keep detailed records of their past medical history?  Why does the intern or resident or PA or NP schedule follow-up appointments for patients, rather than the patients do it themselves prior to discharge?  Why must so many patients be coaxed out of bed and working with physical therapy?  The actions of patients reveal their preferences.  Those who are invested in their own care take responsibility for it and are knowledgeable.  Those who would rather watch television than work with physical therapy reveal other priorities and preferences.

All the hubbub about healthcare and health disparities has entirely glossed over the role of personal responsibility and accountability in medicine.  Some may find it inexcusable that many patients have so little investment in their own health care, expecting instead that the government, their insurance company, and the healthcare system at large allows them to abdicate their own personal responsibility without consequences.
(I am not here referring to people who are unable to care for themselves, but rather those who are perfectly capable but who shirk the responsibilities.  If you cannot accept this and wish to accuse the author of "blaming the victim" read no further.  Yes, the victim of disease is being blamed for any lack of personal responsibility that is contributing to poor health.)

If there is a lack of personal responsibility in medicine, there are several important implications that we should be concerned about.

Mindless Medicine: The Importance of Minding Your P's and C's

I see far too much mental laziness in medical practice these days.  I will give some examples below.

To teach the residents mindfulness in diagnostics and therapeutics, I used to tell them to mind their P's and C's:

• Problem:  What is the major malfunction that we are dealing with?
• Proof:  Do we have proof of the problem or diagnosis?  Is there uncertainty, or are there other possibilities?
• Cause:  How did this problem come to be?  Why is this happening?  Is there a deeper cause?  An even deeper one?
• Cure:  What interventions should be employed to treat the problem(s) identified?

Sometimes I receive a call from the ER to admit a patient and the "presentation" if you would call it that amounts to rattling off a list of the laboratory abnormalities.  "What is the problem?" I ask.  "He's going to have to come in," is the reply.  No, my friend, moving the patient out of the ED is YOUR problem.  I'm asking what is the PATIENT'S problem.  You are here, after all, to serve the patient, right?  Some ERs appear to be evolving into glorified triage centers, with a primary focus on differentiating those who can be sent home, flown out, or admitted, rather than centers focused on making expedient and prompt provisional diagnoses so that time sensitive therapies can be administered post haste.

We Must Suffer: Moral Hazard in Modern Medicine

I was first introduced to the concept of moral hazard in Rich Rubin's book In an Uncertain World.  He describes the deliberations within the Treasury and the Executive branch during the Mexican and Asian debt crises of the 1990s about whether the US should bail out the sinking currencies of these countries to prevent larger repercussions throughout the world's economies.  Moral hazard is the risk that those bailed out economies would not "learn their lesson" and the bailout would serve as encouragement to take similar risks in the future, repeating the crises and the need for future bailouts.  The concept of moral hazard resurfaced again during the recent economic crisis in the US, brought about by large US banks and their promiscuous lending practices.

Moral hazard and the decisions that it may influence have an inherent omission bias:  while I cannot force an alcoholic to take disulfuram (without a court order), the alcoholic cannot force me to provide him with alcohol.  The status quo is the moral reference frame.

Moral hazard stems from a fundamental underpinning of human behavior:  we learn appropriate avoidant behaviors through pain.  Children with a mutation that prevents them from feeling pain have short lifespans because they do not learn appropriate avoidant behaviors, as detailed in this poignant NYT article.  It is a striking article, and I don't think a person could have a full appreciation of moral hazard until they read it, so please do.

If there is moral hazard in general, it certainly exists in medicine as well.  I will illustrate this through several examples.

Should DNR be the Default Resuscitation Order After a Certain Age? The Case of Arnold Relman

"Oh lente, lente, currite noctis equi."  - Christopher Marlowe, The Damnation of Doctor Faustus

In at poignant and pithy piece in the New York Review of Books this year, the late Arnold Relman, former editor of the NEJM, described his experience breaking his neck and having cardiac arrest three times in the trauma resuscitation bay.  Because Relman was a visionary and outspoken pioneer in the movement to recognize and reduce medical waste and runaway spending (according to his recent obituary in the NYT) I thought it would be timely rather than disrespectful to evaluate the last year of his life after his accident as a case study on the utility of resuscitation in advanced age (I will not here attempt to define advanced age - only to posit that it exists at some cutoff that could be defined statically or dynamically).

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

Underperforming the Market: Why Researchers are Worse than Professional Stock Pickers and A Way Out

Here's an occasional cross post from the Medical Evidence Blog.  It's a bit more technical than what is usually posted on Status Iatrogenicus, but it gives a summary description of a pervasive problem with "evidence based medicine" that is so widely applicable to practice that I think it deserves some recognition here.

Underperforming the Market: Why Researchers are Worse than Professional Stock Pickers and A Way Out

Dated but Not Outdated: Why the Pager Endures as a Means of Physician Communication

In this post on the Huffington Post yesterday, Sachin Jain, a physician and presumably a technophile, bemoans the enduring use of pagers among physicians, labeling pager carriers as outdated and failing to leverage available technology to make communication more efficient.  As a devoted pager carrier, I will enumerate the many reasons why the pager is a preferred communication modality for many physicians, and the ways in which Dr. Jain is missing the point.

1. Patient Safety.  I work in the ICU.  If there is something that the RN needs to inform me, s/he needs to know that I have received the message.  If said RN (or intern or resident or other physician) pages me and I respond, they know I know.  If instead they send a text message or leave a voice mail, they do not know that I received the message.  They assume I did, and move on to other tasks.  If I did not receive the message, time sensitive things can get missed or delayed and that's a big safety issue.

Antifragile but Exposed: A Framework for Understanding Disease that Can Improve Diagnostic Decision Making

Ruination IPA by Stone

It is said that the history reveals the diagnosis 90% of the time, but it is not stated why this is so.  Herein I will explain the logic behind this aphorism.

I used to tell residents that most of the time, the diagnosis is something common, or something related to something we already know the patient has.  In addition, when teaching history taking, I told the medical students to view history taking as an exercise in determining what the patient is exposed to in his or her environment, for these exposures weigh on the probabilities of potential diagnoses.  These principles explain the basis of the history aphorism.

Nassem Nicholas Taleb was right in his book Antifragile - evolution has made our species beyond robust - antifragile, a term which he coined.  We resist disease, we repair injury, we get stronger when exposed to stress (the antifragile principle).  But there are ailments that humans suffer for which evolution has not worked out a defense or a solution, or those which result because evolution is helping the same organisms which attack us become antifragile just as it selects us for antifragility.  This is why infectious maladies are at the top of the list for adult (and I suspect pediatric) internal medicine admissions.  Pneumonia, UTI, URI, etc.

The Hits are Recorded, the Misses are Not: How the Culture of Medicine and the Third Party Payer System Foment Waste and Inefficiency

It doesn't make sense, but that's how we do it.  Usually, if you want to judge the calibration of a decision maker, you tally hits and misses both, not just the hits.  If you fail to record misses, a high hit rate might just signify a lot of swings.  But in medicine, we are taught to ignore misses.  It's only hits that count.  This doesn't make sense because it encourages overtesting and waste.  If surgeons practiced this way, all heck would break loose, everybody would be cut open and organs wantonly plucked from them.

There is a physician at a Midwestern institution who is known to come on service and order an echo bubble study on several (all?) patients the first day he is on service.  He has doubtless impressed a generation of medical students when the occasional PFO (patent foramen ovale) is found and he gets to wax prolific about shunts and other mechanisms of hypoxemia for a few minutes as they listen with fawning and rapt attention.  What they do not know is that he finds PFOs about 10% of the time he orders his echos, and this is just above the rate of PFOs in the general population.  He's basically finding PFOs at random.

No MOC for Me: Why I'm Not Signing Up For Maintenance of Certification

By the end of this month, holders of ABIM (American Board of Internal Medicine) and ABMS (American Board of Medical Specialties) board certifications are supposed to sign up for "Maintenance of Certification" a requirement that costs a bunch of fees and poses a bunch of busywork problems for physicians.  In general all I have heard in terms of reactions from colleagues are frustrated groans and begrudging acquiescence.  But I refuse to sign up for MOC.  Here are the reasons why.

Firstly, I am not required, for my employment, to have a board certification.  Nor am I for any other reason.  The only institution which can "force" you to have board certification is your employer or a hospital credentialing committee.  So, if somebody's gonna be the guinea pig, it may as well be me.

Jahi McMath: Poster Child for Medical Futility, or Scapegoat?

I periodically check for news updates on Jahi McMath, and today I found this news report that suggests that Jahi McMath is still alive, or at least that her heart is still beating, more than two months after she was declared dead on the basis of "brain death."

Based on the commentary on previous posts here and on PCCMcentral.org debating this issue, I can say the following:

1. Jahi McMath is legally dead on the basis of an incontrovertible and unequivocal diagnosis of brain death.  I have no doubts in this regard.
2. Jahi McMath has a beating heart and thus is not considered to be dead on the basis of the intuitions and opinions of her family and some others.

You may choose #1 or #2 above.  I personally don't care how you choose.  But I'm interested in the differences in reasoning and opinions among those who choose #1 and those who choose #2.

"No! Not NARCAN!" Exclaimed the Woman Not Breathing and Being Bagged

I will begin this post with a little anecdote.  It was about ten years ago at Johns Hopkins Hospital and I responded to a "Code Blue" on the step-down unit.  There was a woman, about 30 or 40 years old with several chronic medical problems who had stopped or nearly stopped breathing.  I was at the head of the bed delivering bag-mask ventilation (bagging; using the Ambu-bag, the first responder kinda thing).  We were preparing to intubate (insert a breathing tube into the trachea) the patient when an astute co-fellow, L.R., came on the scene and inquired as to whether the patient might be overdosed on narcotics.  He said aloud "should we try some Narcan?"  (Narcan counteracts the effects of narcotics and can cause arousal of a patient overdosed on them.)  This patient who was comatose, not breathing, and unresponsive in spite of being bagged and poked and prodded by the numerous staff who responded to the emergency, suddenly awakened and exclaimed, vehemently and audibly through the bag-mask ventilation:  "Nooooo!  Not NARCAN!"  Apparently, even a near-death experience is not as fearsome or worthy of arousal as reversal of the effects of narcotic medications.

Healthcare workers will find this amusing for its irony, and I could use it as a segue to a soapbox soliloquy about the dangers of narcotics, but I've already blogged that rant.  Here,  I'm simply using it as a segue to a discussion about the use of Narcan drips in the treatment of overdosed patients.  I was taught during a toxicology rotation in my residency a clinical saw that can be summed up as "If there's an antidote, give it."  Years of experience and reflection have borne out the wisdom of this adage.  Narcan and other antidotes are often benign and as I have discussed in other posts, their benefits even in uncertain cases often outweigh their potential harms enough that they should be given.  Narcan is especially useful when available to heroin addicts, when used by first responders in the field, or when used as a "test" of whether depressed consciousness is due to the effects of narcotics (as part of the "coma cocktail").  But when the decision has been made to admit a patient for observation after an overdose with prolonged effects, the question arises:  should we start a Narcan drip?

You Are the Hunted: Eat What You Kill Versus the Salary Model (Let Others Do the Killing, My Eats Are Free)

"It's hard to get a man to understand something when his salary depends upon his not understanding it."  - Upton Sinclair

This week, a popular NYT article describes how physicians are flocking to salaried positions in hospitals and healthcare systems in order to preserve their incomes amid reimbursement cuts, and to protect themselves against the vagaries and uncertainties of the healthcare landscape in the age of Obamacare.  For those not used to thinking about physician remuneration, I will give a brief synopsis.  There are basically two models of physician earning, and hybrids of the two.

The "Eat What You Kill" Model
Yes, this is the colloquialism commonly used to describe physician reimbursement in a pure private practice model.  An analogy to hunting for survival, you get to bill for, and keep the collections from, patient encounters that you pursue.  The harder and the more often you hunt, the greater your bounty.  Here are the problems with this model:

Behind Closed Doors Lurk Proxy Wars: Is Visitation Really About Visitation?

I decided to rewrite this today, on January 30th, 2016, after thinking about it for almost two years.

The previous post took on the heretical task of making the case against wide open visitation in the ICU without restrictions.  I took that stance for several reasons.  First, I'm a heretic and an iconoclast, and I believe that free thinking, rationality, and good judgment and decision making require all angles of a debate to receive their due - my goal is to keep the dialogue fire stoked.  Related to this, I sensed (and still sense) an agenda - open visitation is being pushed for ideological or financial reasons (yes, the almighty dollar - patient satisfaction scores are tied to Medicare reimbursement), professional associations such as the AACN are pushing the issue, and substandard data are being touted to support this agenda.  Next, it was and is my belief that because of the agenda, nurses' (and physicians') dissenting voices are being shamed into a collective hush by The Man, as it were, and that this censorship needed redress on this blog (it got redressed in 60,000 views and over 100 comments to the original post, still visible below.)  Furthermore, this institutionalized censorship may cause pervasive Hawthorne effects in any nursing survey that is done on the topic.  Finally, it was and is my view that if open visitation is the stated goal, there may be subgoals that are driving the desire for open visitation, and satisfaction of these subgoals through other means may be superior to open visitation for making everybody happy.  That is, desire for unrestricted visitation may be the symptom of an underlying disease and treating the underlying cause (such as poor communication) may cure both the disease and its symptoms.

Even if these considerations are cogent, reasonable and rational (which does not mean that they lead to the correct conclusions), there was a significant omission from my train of thought, small hints of which were peeking through from the text.  If some physicians and nurses don't want open visitation, maybe that too is the symptom of a deeper underlying disease that likewise could be addressed in other specific ways - and it thus follows that restricted visitation is not necessarily the solution that their symptoms demand either.

Doctorin' with Double Effect: The Ethics of Withdrawal of Life Support and Oxygen in Dying Patients

There has been a lot of discussion about the ethical nuances of withdrawal of life support and provision of medications that relieve suffering but accelerate death, but precious little about an important aspect of end of life care that comes up all the time - what are our obligations regarding provision of oxygen to dying patients?

The withdrawal of life support is an activity (a commission) that is ethically protected because patients' autonomy and right to refuse treatments overrides the harm (death) that comes about when physicians act to withdraw life support.  This in itself is interesting because most states prohibit euthanasia (or the provision of prescriptions that enable patients to take their own lives), which is in essence a commission (as opposed to an omission) that accelerates death.  I'm struggling to understand the distinction, except that the withdrawal of life support restores the patient to a "natural state" and allows nature to take its course, whereas the provision of a prescription to allow a patient to overdose is a commission that seems to interfere with nature.  (Jonathan Baron has written extensively about our preference for "natural states" which often leads to worse outcomes.)  That takes care of the natural versus human distinction (which of course ignores that humans are part of nature), but I still struggle to understand why the patient in Oregon has to administer his own overdose, unassisted by a healthcare professional - what's the difference between a healthcare professional assisting with the administration of an overdose and accelerating death, and his removing life support and thus accelerating death, if both acts are in deference to patient autonomy, and both are commissions, and indeed both are direct actions, as opposed to indirect ones?  Maybe it's because you can act directly and cause harm in respect of autonomy as long as you restore a natural state (withdrawal of life support), but you cannot act directly to cause harm in respect of autonomy by causing an unnatural state (medication overdose).  I think this stream of consciousness has led me to the distinction.  Maybe.  The devil is in the details.

The Girl is Brain Dead but the Emperor Has No Clothes

Oh, my, what a predicament.  Jahi McMath has been released from Oakland Hospital to the custody of the coroner and her family.  She has been issued a death certificate.  And she's being transferred to an undisclosed care center, where it is hoped she will begin receiving artificial nutrition.  This is the height of both irony and tragedy.

The comments by physicians and bioethicists in the CNN articles all harken to the idea that there appears to be no error, she meets criteria for brain death and thus she's "legally dead."  This misses the point.  Her parents don't care if she's "legally dead."  The legal definition does not comport with their own intuitions about death and her mother says as much.  She will accept that her daughter is dead only when her heart stops beating.  I can understand why a person may take this stance.

Real (Cardiac) Death and Invented (Brain) Death: The Oakland Case

This article in the January 4th, 2014 New York Times reports on the tragic case (the "Oakland Case") of a 13-year-old girl who suffered complications from elective surgery in early December 2013, whose condition deteriorated and who has been declared brain dead.  While it is not articulated directly in the article, her parents appear to object to the medico-legal conceptualization of brain death and they wish to force the hospital to continue to provide care for her.  A judge has placed an injunction against the hospital, prohibiting them from removing her from life support (in this case, this most likely means mechanical ventilation) until Tuesday January 8th, 2014. The medical establishment at the hospital where she is/was a patient has clearly taken the path of defending the concept of brain death and their rights and responsibilities under the laws concerning brain death -they have refused to insert a tracheostomy or a permanent feeding tube into the girl - and they may have, and we may be tempted to, ascribe her parents' behavior to anger, grief, bereavement, etc.  But I think this case illuminates some broader issues about bioethics, brain death, and organ procurement.

For those unfamiliar with the medico-legal definitions, brain death is a diagnosis that is made after severe brain damage from a variety of insults.  It is a very specific diagnosis that is based on a host of physical examination techniques and sometimes corroborating diagnostic studies, and it means that there is evidence of irreversible cessation of ALL brain function that has been caused by total lack of blood flow to the brain.  A patient who is declared brain dead is legally dead.  I have diagnosed brain death dozens of times.  The medical mantra is that, properly diagnosed brain death always means that there is NO brain function and that "real death" (that is, cessation of heartbeat) will inevitably ensue in coming weeks or months as the body cannot continue to  function without brain function.  But isn't this interesting!  That we need to reassure people that "real death" will inevitably ensue seems to reveal that we recognize that brain death is not real death, but that it will, after time lead to real death!  (Of course, all paths lead to real death, eventually.). Clearly this landscape is fertile ground for cognitive dissonance.  Let's explore why.

In Praise of Lasix: A Utility Approach to Pharmacotherapeutics

In a prior post, I focused on reducing polypharmacy to oligopharmacy or nopharmacy because of an underlying belief that most medications are useless at best, harmful or wasteful or distracting at worst.  But I'm not a complete nihilist.  I've also done a good deal of thinking about some medications that I think we should use more of.  On the basis of Bayesian and therapeutic threshold approaches to decision making, it stands to reason that one should have a lower threshold for using high utility/efficacy agents.  The utility of a given agent is the product of the probability that a disease it treats is present and the utility of the agent for that disease (which is itself the probability of an effect in any case and the magnitude of that effect.)  Thus, if the utility of the agent is high (furosemide/Lasix), it could be useful even if the probability of disease is low (CHF in a patient with normal BNP and ECHO); indeed it could have more net utility than a low utility agent (Digoxin) in a high probability disease (EF 30%, BNP 1000). Note also that if the agent is effective at treating a common disease (as opposed to a rare one), it's general utility will be higher. It follows that the threshold for the use of these high utility agents (when I say high utility I mean net utility, thus the benefits greatly outweigh any side effects) should be low - and we should actively look for opportunities to use them.  Here are the drug utility equations (where Drug X treats Disease X):

General Utility (drug X) ~ Prevalence of Disease X * (Probability of effect in Disease X * Magnitude of Effect)

Specific Utility (drug X) == Probability of Disease X * (Probability of effect in Disease X * Magnitude of Effect)

So, in sum, drugs have higher utility when they treat common diseases, and when their effects on disease are both likely and of high magnitude.  Lasix fits this bill because fluid overload states are common, Lasix makes almost everybody pee (if given in adequate doses) and it makes them pee a lot (if given in adequate doses.)

Your Last Words for a Few More Breaths: Unspoken Trade-offs in End-of-Life Care

A man with widely metastatic cancer is admitted to the hospital for shortness of breath, deteriorates in spite of broad spectrum care, and is transferred to the ICU.  The patient is documented to be "full code" and, while the prospect of "coding" him is unsettling for his providers, they struggle to articulate exactly why.  (Correct intuitions are often difficult to dissect and describe.)  Often the discussion (amongst themselves or with the family) centers on the direct, observable, physical aspects of suffering that must be borne by the patient during the resuscitation process and/or the transition to life support.  "Breaking of ribs" and the like.

But years of quiet and thoughtful reflection identifies some second order and often unspoken nuances of the transition to life support that are perhaps more important than the first order physical aspects.  When the man dying of cancer deteriorates to the point that his oxygen saturation cannot be supported without life support or his respiratory distress is too severe, and I position myself behind that bed, propofol and an 8.0 (endotracheal tube) in hands, I know the oft unspoken truth - that this is the last time that this man will be indubitably conscious and coherent or will speak to anyone, most notably his family.  Insomuch as life consists of an interaction with one's environment, with a central focus on social interactions, the patient dies the moment I induce with propofol and insert that tube between the vocal cords.  He has traded his last words for a few more breaths.  (He has also traded away his ability to enjoy food or drink.)

The Rodeo is Over: Why I put the Bronchy Donkey Out to Pasture

Photo compliments of Jan Aberegg:  A mini donkey in Ohio.

They say that when you have a hammer, everything looks like a nail.  And when you are a pulmonologist, everything looks like a reason to "saddle up the Bronchy Donkey", my tongue-in-cheek reference to the bronchoscope, a device used to look into a patient's airways.

In the four years that I have been in the world of private practice as an intensivist and inpatient consulting pulmonologist I have performed elective bronchoscopies (outside of emergency airway management and tracheostomy placement) only two times.  Herein I will describe the reasons why this is so, and why many others continue to ride the Bronchy Donkey into the ground.

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.

An Opportunity Lost is an Opportunity Cost: Doubling Down with Your Final Days

Experience and study teach that decision making in and about life is more akin to chess than it is to checkers.  A good decision maker will think several steps into the future and will consider multiple alternatives, not just the obvious first order choices.

 In medicine, we are often perilously mired in first order choices, to the detriment of patients.  We act as though there are just simple binary choices to make, such as treatment and life versus no treatment and death.  Would that it were so simple.

Someone I knew, a decade ago, made a courageous choice.  Faced with the grim prognosis of an aggressive metastatic cancer, he elected to forego any treatment and take his chances.  He left the hospital and got one month of relative freedom from medical burdens.  He got his affairs in order.  He selected his own grave site.  He visited with friends and family and doubtless did countless other things that he could not have done had he elected to receive chemotherapy and or radiation or debulking surgery or basically any medical intervention given the desperate nature of his case.  His last month could have been characterized by painful procedures and  repeated scans, nausea, vomiting, and anorexia induced by chemotherapy, cumbersome trips to radiotherapy - you get the picture.  In another parallel universe his doppelganger, selecting "treatment" for this runaway cancer, would have traded away the last month of his life - and probably would not have benefited from the trade.  An opportunity lost is an opportunity cost.

Let's look at another case.  An 82 year old frail man on dialysis for several months presents with increasing fluid in the chest around the lungs   Initial (non-invasive) testing suggests malignancy/cancer.  The patient can be steered in several directions ranging from hospice (given age, functional status, and co-morbidities, the prognosis is poor), to straightforward diagnosis via needle biopsy sampling (of fluid or superficial lymph nodes) followed by consideration of treatment options, or to aggressive video assisted thoracic surgery under general anesthesia to take control of the fluid, scar down the lung to prevent recurrence, and get a definitive diagnosis by surgical biopsy.

Note that as the aggressiveness of the diagnostic and treatment approach increases, so does the likelihood of never leaving the hospital as a result of complications.  An opportunity lost is an opportunity cost.  And the patient who selects or is steered towards the most aggressive treatment option may well pay with their final days for the marginal chance of improving their outcome - measured, of course, in the number of days that they can live unencumbered at the end of their lives.  In this case, regretfully, an aggressive approach was taken, and the patient died in the hospital, on life support.

We have to be very cognizant of these costly lost opportunities when we present options to patients, lest they double down with their final days.

Rage, rage against the dying of the light: The Fighter and the Pyrrhic Victory

It's only been two days since my last post on prognosis and end-of-life care in the ICU, and I'm anxious to blog about today's NEJM article on low tidal volume in the operating room on the Medical Evidence Blog, but the happenings around me already today mandate another post about realistic prognostication and it's effective communication.

When I make an assessment of a patient in the ICU, my list of summary conditions and conclusions often looks something like this:




ASSESSMENT:

1. Advanced age
2. Poor Functional Status
3. Malnutrition/Cachexia
4. Swallowing dysfunction
5. S/P fall and hip fracture
6. Aspiration pneumonia
7. Congestive Heart Failure
8. Respiratory failure
9. Renal failure
10. Poor Prognosis for both survival and return to independent livinng
    

This is not the norm.  The norm is to methodically list all of the acute and chronic medicalized and pathophysiologically interesting diagnoses.  In that vein, obvious things that can't be traced to a medically interesting and well delineated disease cascade are left out (such as advanced age and poor functional status.)

Use Your Own Judgment: The Feckless Physician, the Tyranny of Autonomy, and the Courage of Convictions

All too often as an intensivist I am called upon to evaluate/treat a patient who is "Full Code" but who is utterly moribund.  My moral fiber is shredded by  the thought of instituting critical care measures in a poor, frail,weak, malnourished and cachexic, demented and derlirious nonagenarian (or octogenarian, or septuagenarian) with incurable disease.  So, it would be morally corrupt to acquiesce to the "Full Code" order and proceed as an  insentient automaton and put such a patient on life support, knowing that nothing good, and a good deal bad will come of it.  "A cog in the wheel" as it were.

Something strange and tragic is going on here:  While my physician colleagues are most often in consensus about the likely outcomes and the perceived futility (or net harm) of medical care in these cases (as are other informed medical personnel), they often do acquiesce to the "Full Code" order, and initiate the self-perpetuating sequence of futile treatments, disappointments, and indignities inflicted upon dying patients.  This disconnect has two possible explanations:

1. Patients' values and preferences are vastly divergent from those of their physicians and other informed healthcare providers; or
2. Patients and their families have not been properly informed about the prognosis, likely outcomes, and burdens of care.  (If denial is involved, this still counts as improper information - as with alcoholism and addiction, physicians have a duty to break down denial.)

So, does my moral repugnance at the thought of taking the moribund nonagenarian, giving him propofol to ablate his consciousness for (probably) the remainder of his natural life; inserting a tube through his vocal cords and thus making it impossible for him to speak; knowing that he's delirious/demented and has little hope of knowing what's going on and is probably in fear or distress; physically tying down his hands to the bed so that when he reacts instinctively to pull out the tube that is gagging and choking him, he cannot; inserting various other tubes and medical devices into his nose, urethra, anus, mouth, and through skin incisions into various other bodily structures; performing CPR and having my fellow healthcare workers feel and hear the breaking of his ribs and sternum; knowing that this poor patient will never leave a healthcare institution and return home - does this moral abhorrence derive from a set of values that I have about life and humanity that are divergent from those of the patient and his family?  Or does it result because I have different information about what these procedures entail and what their effect is likely to be?  (That effect candidly amounts to torture.  I am being asked to torture the poor fellow.)

The answer is obvious because people are more alike than they are different.  I have an abhorrence to these acts because I (and other informed healthcare workers) understand them better than the patients/families - there is "asymmetrical information" as economists would say.  Why would this be?

This results because of the "feckless physician" - the squeamish nebbish who believes that guarding the family (and himself - especially himself) from a vivid description of futile (and harmful) care at the end of life and the emotional reactions consequent to this discussion are more important than avoiding the horrors of actually delivering that "care" and inflicting that suffering on the inexorably dying.  And here I will state it:  the feckless physician, in making this choice, is morally corrupt.

He rationalizes this away by invoking the misguided principle of autonomy - the notion that people should be able to make choices for themselves.  But this ethical principle has certain premises and preconditions, and it is easy to pretend that they have been met - namely that the preconditions of information and understanding have been met.

So, when the patient (or, often his surrogates) is/are making choices such as "Full Code" that seem at odds with his moral intuitions and common sense, the feckless physician deludes himself into believing that he has imparted the requisite information about the procedures and likely outcomes in an adequate manner, and he acquiesces.  He is satisfied to invoke the foundationally precarious principle of autonomy to justify the indignities that are about to befall the poor, dying, nonagenarian.

And he calls the intensivist.

Oligopharmacy and Nopharmacy: "He is the best physician who knows the worthlessness of the most medicines."

Refrigerator Magnets of Heavily Promoted Drugs

When I was an intern, I read in a pocketbook (my coat pockets were overflowing with guides and manuals in those halcyon days) called Drug Prescribing in Renal Failure that in elderly patients, 65% of hospital admissions are caused by or contributed to by an adverse drug reaction.  At first blush, this seems like a gross overestimation (like the 100,000 deaths per year from medical errors which probably IS a gross overestimation), but experience bears out this wisdom.  As the number of drugs increases, so does the potential for interactions and side effects - multiplicatively.  There are two related practical implications of this observation.

First, it is my practice when admitting a patient to the ICU or hospital to stop all nonessential medications.  This includes outpatient medications and many medications begun by other physicians during the admission.  It would include medications such as:

Parsimonious Practice: How to Treat DKA with 5 Lines of Orders in Half a Day

Few processes in medicine are as simple as the treatment of DKA (diabetic ketoacidosis) or have been as gratuitously complicated by anal retentive micromanagers of physiology.  Here is a departure from that custom that I have refined iteratively during the past four years.  It is guided by the goal of reversing ketoacidosis (and associated dehydration) and getting patients eating and back on subcutaneous insulin as expeditiously as possible, while reducing waste and burdens of care and without compromising safety.  It does not have as a goal to rigidly govern lab values or usurp control of physiology during the process.  The caveat to be aware of is that I have refined it in young(ish), adult, non-compliant Type I diabetics without insulin resistance who have moderate to severe acidosis and hyperglycemia.  (I do not treat "DKA" with a serum HCO3- greater than or equal to 14 with an insulin infusion - I treat it with fluids and reinstitution of subcutaneous insulin.)  It also presumes that there was no trigger other than non-compliance, or that the trigger (e.g. UTI) has been investigated and addressed.  I will briefly discuss the 5 orders, their benefits and potential drawbacks.  First, the orders:

1.)  Bolus with 5 liters of Lactated Ringers Solution

2.)  Begin insulin infusion at 5 units per hour (FIXED DOSE, NO BOLUS, NO TITRATION).

3.)  Check blood sugar every 2 hours; When blood sugar less than 200 mg/dL, reduce insulin drip to 1 unit per hour.

4.)  If blood sugar is less than 100 mg/dL (on any insulin dose) or greater than 300 mg/dL on 1 unit per hour, call MD.

5.)  Check serum K+ and HCO3- 12 hours after the start of treatment.

The Obesity Odyssey: Tie Me to The Mast, Wire My Jaw Shut, Rewire My Guts Into a Roux-en-Y

In the last post, I was titillated by the JAMA authors' observation that, as prescription opioid overdose deaths have quadrupled, people and their physiology have not changed - their exposure to opioid drugs has changed.  Is there any more apt an explanation for why obesity and overweight rates and associated complications have swelled like 10 pounds of sugar in a 5 pound sack?

One hundred years ago, there was precious little obesity.  We have not changed physiologically since then.  Two things have changed:

1. How much fuel (food) we're putting in our tanks (bellies) (and it's "octane level" - how many calories it has per unit volume); and
2. How hard/far/long we're running the engine (i.e., the manual work our bodies perform daily)

It's utterly amusing that the obesity epidemic is viewed in any other terms.  It's quite simple - 100 years ago, we did not have processed, ready-to-eat, high caloric density, cheap, easy, convenient foods that required little or no preparation time.  And we did not have leaf blowers, washing machines, elevators, 3 cars per family, power mowers, pressure washers, desk jobs, televisions - you get the picture.  In short, we ate fewer calories and we burned far more calories performing just the basic tasks of life, let alone actual manual labor performed as members of the workforce.  We are exposed to much more food, and much less physical work.  It's a dose-response issue.

Pain Is The Fifth Vital Sign - And If You Don't Have Any, You Might Be Almost Dead

"The cure is worse than the disease", it has been said about some supposed remedies.  We might be at that point in the treatment of acute and especially chronic pain with opioid (narcotic) analgesics.  In this article in the May 9th issue of JAMA Dowell et al make the astute observation that as opioid related deaths have quadrupled in the last decade or so, people have not become more susceptible to the drugs - it's just that their exposure has increased.  Exposure increased because several alleged patient advocacy groups (American Pain Society, Veteran's Health Administration, the Joint Commission) campaigned to convince physicians that they were not adequately recognizing and treating pain, callously leaving countless patients unnecessarily writhing in abject misery.  Led by these and other coalitions of busybodies, we went from possible undertreatment of pain (with narcotics) straight to guaranteed bona fide undeniable overtreatment (with a brief pass through [but not a stop at] optimal treatment).  Part of this overzealous campaign was the coining (original source unknown) of the contagious catchphrase "pain as the fifth vital sign."  

This is interesting because pain is a SYMPTOM, something reported by a patient (part of the HISTORY), whereas a [vital] SIGN is an observation or measurement (part of the PHYSICAL EXAMINATION) made by a practitioner such as blood pressure, heart rate, a bruise on the skin, a pulsatile uvula (Muller's sign), or some other finding.  (The more rare, uncontemporaneous, and useless a sign is, the more likely its name is an eponym.)  But the pain coalition (PC) successfully circumvented this convention by cooking up pain scales and cutesy numbered diagrams bounded by smiley faces and sad faces, adding a cloak of objective legitimacy to the subjective experience of pain.

Logic Based Medicine: The Case of Activated Charcoal

Like all good things, Evidence Based Medicine (EBM), when taken to far, runs the risk of making us overwrought and becoming cliche.  I think we are reaching this point.  Given Ioannidis' meta-research findings that most published research findings are false (does he consider the irony that that may apply to his findings too?) the corrupting and corrosive influence of industry on research programs and guideline construction, the biases of academic researchers intent on grants, prestige and promotions (as well as honoraria to supplement paltry academic salaries - I was there once, and I did it too), and the zealousness of "experts" who wish to interpret the evidence in the form of an edict for all to follow (euphemistically called "guidelines"), and several other disturbing trends, it becomes apparent that in the end we must rely upon our own judgment and logic to discern the proper path to follow.  And so it is with Activated Charcoal (AC) administration, an agent used in overdoses and toxic ingestions that has a remarkable capacity to adsorb ingested substances and theoretically limit their toxicity.  (It is not barbecue charcoal, the photo is tongue-in-cheek.)

I Know it When I See it: Antibiotic Resistance, the Chronically Dying, and Futile Medical Care

Today's issue of the New York Times features (yet another) article sounding alarms about antibiotic resistance and the supposed need for new antimicrobial agents.  There are several common hackneyed reasons why we have the current predicament of drug resistant organisms such as:

• Use of antibiotics in livestock, which accounts for 80% of use in the United States.  This should be the prime target for efforts to reduce resistance, not use in humans.  
• Inappropriate use of antibiotics in outpatients who have mild/minor illness and who have viral illness (not responsive to antibiotics) 75% of the time.
• Inappropriate drug, dose, duration of therapy, etc., in both outpatients and inpatients.

The article calls for reducing the hurdles needed to develop and test new agents.  Well and good.  But I have another idea:  fund testing of antibiotic dosing duration for several common infections such as pneumonia, cellulitis, urinary tract infection, etc.  Right now, it's all over the board, with some patients getting two weeks for pneumonia, some getting five days (my patients).  Moreover it is my suggestion that such trials stratify patients on the basis of the prior probability of the infection being treated.  I would posit that the lower the probability of infection, the more likely it is that a shorter course will suffice.  Clinical improvement criteria could also be built into these studies so that courses could be truncated when patients improve.  If we could cut the duration of exposure from 10 days to 5 days, we would remove selective pressure for development of resistant organisms and opportunistic infections (fungemia; C. diff; ESBL).  I'm not sure we need new toys so much as we need to play properly with the toys we already have.  (And no, I'm not a fan of biomarkers like procalcitonin to guide duration of administration.)

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.