Mind the Gap: Knowledge Translation in Remote Care

Knowledge translation in medicine is a sluggish process.  Research can take many years to become ‘practice changing’ and be applied at the clinical coalface.  Conversely it can take a generation shift to debunk long and strongly held medical dogma despite a lack of evidence or even evidence of harm being available.  Country hospitals in Australia are traditionally ‘behind the times’.   One might say that this is an accepted norm – that we rural clinicians are expected to be behind the curve of modern practice.  In recent years with the advent of Free Open-Access Medical Education this is changing.

There are so many wonderful examples of how the FOAM community has facilitated and accelerated knowledge translation into practice.  So I thought I would share with you a story.  It is a story about my little hospital and how we can break the traditional stereotypes of rural hospitals struggling to deliver adequate care.  In fact, I believe that we have the potential to do great things – to be at the cutting edge and provide the sort of care that we all went into this gig to deliver.

I will start by telling you about Misty – she is one of the great nurses I work alongside.  Misty is a Resus machine!  She is an ALS trainer and can run a team like anyone.  I love doing Resus with Misty  - I know that there will be continuous CPR, rapid rhythm checks and the protocol will be followed without any fuss.  This gives me time and the headspace to fart around with the other bits – looking for reversible causes, getting some context – and of course intra-arrest Ultrasound to find soluble problems.

Misty is very up to date.  So we have been discussing therapeutic hypothermia over the past few years – trying to work out a way that it could be done in our corner of Australia.  We see our share of cardiac arrests – but we area  small shop, so actually getting ROSC post-arrest happens only a few times a year.  Therapeutic hypothermia – as practiced prior to Nov 2013 – is tricky for the occasional operator.  We do not have access to fancy cooling devices – just a fridge and a fan!  And once we cooled a patient we are then faced with the logistical nightmare of transferring them at < 34 degrees for 2000 km.  This involves several planes, a few long waits in hangars and a constant ambient temperature of about 38 degrees!  However – it is on the Resus protocol and drilled in the curriculum for nurses and trainee doctors.

For the last few years I have been feeling a little frustrated about this.  I wrote one of the first Broome Docs posts on it 3 years ago.  I have been wanting to provide great care for our remote patients – but therapeutic hypothermia was just too logistically hard. Yet it seemed like an important intervention with a potent NNT of ~6.  Then last November the TTM trial came out.

Now a lot has been written by folk who do a heck of a lot of post-arrest care about how to apply this paper in practice.  However for me – there is no agonising.  Our current standard of care was essentially trying to do good ICU housekeeping and avoid fever.  I wished I could get them down to 34 degrees, but there was no way to do this consistently.  So imagine my delight at reading this paper!  Bottom line: no difference between targeting 36 and 34 degrees in post-arrest patients.  That is some knowledge I can translate.

So as luck would have it, a few weeks after the TTM papers hit the street – we resuscitated a patient in my ED.  It was a great team effort – 20 minutes of CPR, 4 DC shocks and no break in compressions with a team of 3!  That is cool.  Once we got ROSC and the dust settled the conversation turned to post-arrest care – and the bugbear of hypothermia.  But this time I was not conflicted.

The FOAM discussions I had seen and taken part in were all fresh in my mind.  Instead of being worried about doing “as good as possible” care.  I was confident that we could do excellent, up-to-date care.  This was a very empowering experience for me.  No more doubts, or lingering concerns about what we were doing – this was a moment where we could push on and do “aggressive” intensive care.  We could give our patient the best chance to recover.

So here is a list of the stuff I have learned over the past few years that I could translate into practice and do the best care in our little ED:

  • Continuous CPR is key.  Minimising breaks for rhythm checks to a few seconds.
  • Watch this space for the automated devices. {LUCAS} has great potential in small EDs with a skeleton staff who struggle to maintain CPR for long periods.
  • NO intubation prior to ROSC – this is a hard habit to break for those of us with Anaesthesia background – but it makes a lot of sense in Resus care
  • Using ET CO2 to guide resus, quantify CPRs effectiveness and detect ROSC – this patient maintained a pretty good ETCO2 – and it gave our team great motivation to continue despite a longish downtime
  • Post ROSC assessment: taking time to do a basic neuro exam after ROSC in order to assess function.  In the past I would have been to hasty to get the patient paralysed and sedated and lost the window to assess disability.  Another benefit of using the LMA during the Resus – no need to rush in with ETT securing agents.
  • Positioning for ventilation – supine is not cool – all our patients should be head up where possible.
  • Lung-protective vent strategies – dialling up 6 – 7 ml/kg IBW on the vent is easy,
  • Maintaining a sensible set of parameters – not aiming for EUBOXIA, but just enough to keep the physiology in a happy place.
  • Temperature control:  my interpretation  of the TTM paper and discussion is that we (i.e. rural resus teams) should aim for 36 degrees.  We should avoid fever as that seems to be the true culprit.  In my experience this can be done with a few wet towels and a bedside fan.
  • Good housekeeping – e.g FAST HUGS IN  BED
  • Family in the Resus Room.  Lets be honest – this is a bad scenario.  Despite our high-riving at achieving ROSC – this is a disaster for the family.  Fewer than 10% are going to make a full recovery and many will die in the coming days.  So the post-arrest period is also the only window many family will have to say “Goodbye” before their loved-one is shipped across the country.  We need to respect this and give as much access as is possible, answer questions and explain the process ahead for the relatives.

Now – back to Misty.  We did a debrief the next day – and the TTM trial was news to all in the room.

Misty is now in the absurd position of having to teach “therapeutic hypothermia” in a hospital which cannot in reality provide it!  This was just absurd prior to the TTM trail – now it becomes just silly really.  The protocols which our Health Service employ have taken many years to get hypothermia onto the algorithms – and now I think we should try and undo this in a blink.  The reality is that we have not been able to achieve the old standard – so we should embrace the new data and focus our attention on excellent TTM and careful ICU care.  However, I suspect it could be another few years before the official local protocols are amended – so what to do?

I believe that at the end of the day we as individual clinicians working in our teams have to keep up to date and try to close the knowledge translation gap.  Relying on protocols which are often well out of date or not really applicable to our immediate patient is problematic.  So this is where FOAM becomes so important to me – rapid translation of knowledge to the bedside.

My final thoughts come from my Manchester mate – Prof. Simon Carley [@EMManchester].  He gave a smashing talk at SMACC GOLD about changing our practice based on new data – summarised nicely below.   The trick is to make sure the data is applicable to your context and that it is of appropriate quality.  We have a responsibility to narrow the knowledge translation gap – but also to ensure we are moving to higher ground when we bridge the gap!

Evidence

Taking the BS out of Medical Evidence

HI all

It has been a bit quiet on the blog over the festive season and with the lead up to SMACC making us all busy beavers.

I have a quick recommendation for you – I have started listening to a new podcast – actually it has been going for a few hundred episodes but I just discovered it!

Best Science in Medicine podcast and blog is run by a couple of Canadian docs.  It is really well suited to the Australian GP / general Med practice with a heavy emphasis on evidence based therapeutics.  They are also pretty funny with some great videos / muscio-medical satire.

There is a cool section entitled “Tools for Practice” with a great number of evidence summaries on common GP topics.  This really is a gold mine of great peer-reviewed summaries of evidence.

Here is their latest music video – Bohemian Polypharmacy, education and entertainment all  in one !

Check it out

Casey

Clinical Case 100: Back to the Future

Whooo hooo! Here we go – Broome Docs is bringing up the century of Clinical Cases.

I thought that for the big 100 we would go back to the beginning – back to Case 001.  It was the first post on the blog – it was a multi trauma case – a lady hit by a 4WD with lots of injuries.

So we are heading back to the future – and I am taking a mate along for the road – none other than the KI Doc – Tim Leeuwenburg (@Kangaroobeach).

TIML

 

team leader

Tim is a man obsessed with remote trauma, prehospital and all the kit that goes long with it.  He is a deep thinker, a true pioneer of excellence in Rural critical care…  So I thought I would make it tougher for him.

Instead of one critically injured patient – I am going to throw 3 at him…

  1. The original Case 0001 victim – she has been clipped by a 4WD doing about 70 kph.  She has extensive (R) sided injuries – femur, pelvis, blunt abdo
  2. The driver of the 4WD swerved to avoid her and rolled his vehicle – he has been ejected from the vehicle (no seatbelt) and has a large open head injury – brain on view.
  3. The child (also unrestrained) of the driver, he has a near complete amputation of the lower leg but is alert and trapped in the vehicle.

Oh, and in true country style – time is not our friend.  It is now more than an hour since the collision – bleeding has happened and our patients are not in a good way.  And we are in the middle of nowhere, a long way from help.

Tim joined me for a chat about the practicalities, the strategy and the bigger picture.  We cover quite a bit of the stuff we have both learned over the past few years from our FOAMies.  So sit back, grab a brew and enjoy.

DIRECT DOWNLOAD the podcast.

Pelvic binder images from Tim – yep, best to leave them on if in any doubt. Avoid rehandling and trouble!

NicePelvic Binder ON
    then…  
AhhhhhPelvic Binder OFF
  then…  
Pheww!Whoops, binder BACK ON

Thanks for reading, listening and commenting – looking forward to the next 100!

 

Casey

The 7 Laws of Diagnostics

March 6th 2014 is Change Day in Australia.  Change Day  is a movement promoted by individuals working within the health system. It is all about each of us Making a Pledge to do one thing (or many things) to improve the health and wellbeing of others. What pledge can you make to improve patient, client and consumer health outcomes?

I think this is an important project – it is not about hospitals, health services or government – it is all about the little things that individuals can do to make a small difference to their own ‘sphere of influence’ and do better for those with whom they come into contact.

Here is mine: “I’m pledging to promote and teach a rational approach to diagnostic testing in order to prevent over diagnosis, unnecessary and costly interventions and patient harm.”

So here is how I am hoping to do so.  Plagiarism.

I am a huge fan of Dr David Newman (Smart EM) of the Mt Sinai School of  Medicine New York City.  I was lucky enough to cross paths with David on the FOAM circuit last year and he is truly an inspirational speaker and a gentleman of profound knowledge.   So I am happy to stand upon his shoulders in order to honour my pledge.

Dr Newman has developed his own “4 Axioms of Diagnostic testing” – if you want to hear it from him check out the Smart Testing podcast.  Time well spent.

However, if you want to be slack and want it in a quick & easy format here is my “adaptation”, perversion and expansion of the Laws.  Also a hat tip to my friend Dr Anand Senthi for some of the concepts.  You should be aware that by “test” I am using a very broad definition – it includes most of the questions and clinical examinations that you perform – not just the bloods and imaging that you use every day.

Click to get examples of each Law.

This law seems self-evident. However, in our very human minds we often equate a “negative” result with “normal” with “safe” or “Fine, you’re fine! Get outta here, go home!” This is a myth. There is no such thing as zero risk. Only baseline risk. You know this – but your patient does not. They may believe that the negative ECG and troponin means they are free of any atheroma

Once again – you know this. Every question you ask, every blood on that biochem panel comes with a bell curve, a normal range and some doubt. For some we are familiar with the sensitivity, specificity, NPV, PPV, +LR, – LR blah, blah, blah…. What I see though in practice is binary thinking – if the WCC is up – I will act, if normal – I will wonder what I missed… Be aware that each piece of information is just a clue – there are few absolutes in our daily practice.

David Newman tells a funny anecdote about the man who accidentally got a bHCG test which came up “positive”. The point being – if a test is applied in the wrong context it is meaningless. This is an extreme example. But there are many subtle examples in daily practice. For example, a patient with 3 days of mild arthralgia. If you run a complete “rheumatic screen” over this patient: (ANA, ds DNA, Rheum factor, anti-CCP, uric acid, ESR, arbovirus serology, HLA B27 typing…..), then you will often come up with one or two ‘hits’. They are of course meaningless without a more specific clinical context – some sort of symptom that puts the patient in a context where a result would prompt further investigation.

Willie Sutton was a bank robber. When caught he was asked: “Why rob banks?” His answer – “That is where the money is!” When it comes to testing I believe you should start your workup with the tests that are most likely to yield a useful result. This can be tough for junior Docs – they often feel obliged to do the ‘lesser’ tests first, before going for the one that might actually make a diagnosis. As a rough rule – imaging is more useful that blood work for a lot of our common presentations. I do a lot of bedside US in lieu of bloods that will not change the situation. It is about bang for buck – but balanced against risk of radiation, potential harms etc

Thresholds come in two flavours – upper and lower. Intuitively you know this. You have all heard the mantra: only do the test if it will change your management. Rarely is this practiced! Thresholds are set by the disease: – incidence – seriousness of morbidity, mortality – characteristics of available therapies Definitions: Upper threshold – probability at which treatment is required. When will you pull the trigger on therapy. Lower threshold – the probability below which treatment would be futile or more harmful than beneficial.

A lot of the diseases that we are trying to diagnose occur in old, frail or unwell patients. In a way this is an expansion of the Lower threshold rule above. If the prognosis of the patient will not be changed – for the better or worse by your investigation – then don’t do it. Classic example would be chasing a ?DVT on a patient with terminal malignancy who has already had a few major GI bleeds.

Few thing really annoy me. One is hearing the medical students present a case and when asked: “What tests would you do?” They reply: “Routine bloods…. then …” I am not sure if there is a formal, agreed batch of “routine bloods” – let me know if I missed that lecture in Med School. Routine tests break a lot of the above rules. My guess is that there is a presumption that we will catch anything we missed on history and exam if we do the ‘routine bloods’. If you are in my ED and you utter this phrase you will be asked to justify every one of them. If you do it a second time I may spifflicate you with your stethoscope. Sure, some may be completely appropriate – and there is a valid reason for doing a lipase in the guy with bad pain radiating to his back with vomiting++. However, you should have formed this ‘pretest probability’ AKA ‘the context’ from your clinical examination and history.

OK, those are my 7 Laws of Diagnsotics. Would love to hear your additions, subtractions or examples.  As always – I am frequently wrong, so please let me know why on the comments below.

Casey

 

Medical Media Management

This is a completely non-clinical piece.

Over the last 3 years I have been doing a weekly radio “spot” on ABC radio in WA.  10 minutes, once a week with a mix of medical and health topics including some live talkback Q&A.  It has been a really interesting experience and I have learned a lot – both about Medicine, but also about communication and how the media works.   There is truly nothing more challenging and terrifying than to do “live medicine”.

Last week I hung up the microphone for the last time – so I thought I would take a moment to reflect and share my thoughts with you all.

I think that this is a good topic to discuss as most of you will at some time have cause to be interviewed or make some sort of statement to some sort of public media – radio, TV or maybe an online journal.  It can be daunting and most doctors I know have a visceral aversion to discussing anything to do with their work in a public forum – we are perfectionistic types and it is a high-stakes environment – what you say might be broadcast to thousands of people… somebody is sure to disagree!

So here are my insights, tips and Lessons Learned:

  1. Relax & be yourself.  Most media interviews are conversational in nature – so you need to imagine that you are chatting one-on-one with the journalist.  Trying to talk  in a more formal fashion tend to make you sound awkward and artificial.
  2. Slow down.  Anxiety and time pressures tend to make us talk faster than usual.  This is bad on radio / TV – it makes it hard to listen and tends to confuse the message.  I have found that one needs to deliberately slow the tempo of one’s speech in order to sound like a real human!  Also try to avoid prolonged sentences / speeches.  There is an impulse to say everything that you know in one giant monologue.  This is not good radio!  Keep it chatty!
  3. Less is more.  Depending on the media you could get as little as 10 seconds air time.  It might be a few minutes, but generally TV and radio tend to go with short sharp interviews….  so that means  that you have an extremely small window to get your message across. You need to have a premeditated “sound byte” ready on the tip of your tongue.  A single sentence or phrase that you want to use to communicate the core message or statement that you are trying to make.
  4. Reasearch is a double-edged sword.  Knowing a lot about a topic is good, however it can make for a dull conversation.  So doing research is sometimes a waste of time and may confuse the message.  In my experience 95% of my research was unnecessary  - it was superfluous to the requirements.  Sure – you need to know the facts, a few hard numbers are useful – as you will be asked for them.  However, remember that the audience are regular folk – not a room full of Medical Students or colleagues.  They want to know the big picture, no jargon, no subtleties of evidence.  It is your job to interpret the evidence, science or research that you are being asked about – and make it digestible for the audience.  Qualitative answers are usually superior to quantitative ones for most topics and audiences.
  5. What is the angle?  Journalists are in the trade of selling stories.  They love a new angle, a fresh idea, a gritty story – or even better some controversy and drama.  We, doctors, tend to shy away from all that.   However, this is the reality of the media.  My advice is to take the bull by the horns!  Come up with your own angle, a new way to look at the topic, make it interesting or fun.   Otherwise one of two things might happen. Either you end up sounding really dull, or you will be put in a situation where you are part of the drama – they will push you to make it edgy – and this may not be where you wanted to go!
  6. Be hard on the problem, soft on the person.  I have had a few occasions where I have been asked for an opinion where I know it will be contradictory to another public opinion.  In this situation there is a real risk of offending a colleague, or at least sounding adversarial in a public forum.  My advice is to “play the ball, not the man!”. [Sorry - an Aussie Rules footy expression.]  Argue about the problem, explain the difficulty and why there are differing opinions.  But avoid any ad hominem attacks.  Journos can sense a conflict – so ensure it remains gentlemanly.
  7. Choose your words carefully.  You may give a 10 minute interview that ends up as a 30 second “bit” in the news.  So remember point 3 above.  But, you need to be careful.  Sentences can be taken out of context and sound really terrible.  So watch exactly what you say, and let the journalist know if you feel you said something that might be misconstrued.  Usually a quick correction or clarification can resolve any slips.
  8. Avoid absolutes.  There are few thing in medicine that are absolutely true, false, wrong or right.  But the public like a clear answer – an expert opinion one way or the other.  There is a risk of being misinterpreted if you give too hard an opinion – so you need to have words like ‘usually’, ‘commonly’, ‘in most cases’ in your vocabulary.  Otherwise you know that your words will be interpreted as Gospel truth by somebody out there.  I make exceptions for subjects such as smoking and vaccinations etc – if you have an opportunity to spread a good Public Health message – then do it loud and clear!
  9. Empathy is key.  If you are talking to a “patient” – somebody who has a problem then you need to be really compassionate.  Clearly it would be foolhardy to give specific advice or consult “on air” – but there is no reason one cannot empathise with a caller’s suffering.  I have and plenty of occasions where callers have wanted to discuss their personal medical problems on the radio – this is a treacherous ethical area – however being empathic and showing basic human understanding is vital and completely acceptable in my view.
  10. It is all about Education.  The reason that I gave up my time ver the last few years was simple – it was a great opportunity to spread good health messages in a time when our media is saturated with mistruths and quackery.  Recall every time you have tried to talk a patient out of oral ABs for a runny nose – for me this was a chance to have those types of conversations with thousands of people at once.  If your goal is to promote health and prevent injury then it is all worthwhile I think.

Anyway, that is all we have time for today. ;-)

If you have any questions about this type of thing, experiences about being on the media that you want to share – hit me on the comments below.  Hope you find this useful once day!

Casey

Bedside Ultrasound Evidence Echoes

As you might know – I am an Ultrasound tragic.  You may not know that I will also confess to being a little obsessed with biostatistics.  So in the lead up to SMACC GOLD I have been doing some research and come up with a few interesting info graphics that I thought I would share with you all.

The concept is what I call the “Sonospectrum” – everything we do in diagnostic medicine is imperfect.  Clinical examination is a relatively blunt tool, bedside ultrasound has its great moments and other times when it just cannot give us a robust answer, even the CT scan – the ionising oracle has its own short fallings (mainly due to overcalling diagnoses).  Each modality of ultrasound sits somewhere on the spectrum – for example ED US is great for detecting intrauterine pregnancy but not so powerful when it comes to excluding a PE (based on ECHO).  For some clinical questions ultrasound is more potent than other forms of examination and imaging – it is the “gold standard”.  So how do you know when to use it as a ‘diagnostic test’, when is it a ‘useful tool’, when is it an ‘extension of the clinical examination’ or when is it just a guy ‘fiddling with knobs at the bedside’????

In medical school we all learn about the Sensitivity and Specificity of these tests – the “test characteristics”.  However, lately I have started teaching and using “likelihood ratios” as the numbers I carry around in my head to aide my practice.  Likelihood ratios are more useful than Sens and Spec – as they can be applied to individual patients in their particular context.  Here is how it basically works:

  1. Define a clinical question, e.g.  ”Is there a drainable abscess under that cellulitis?” OR “IS there a pneumothorax?”
  2. Decide on your pre-test probability (either by using clinical acumen, or an existing tool – e.g.. Well’s score for DVT, or just use a basic know prevalence of the disease)
  3. Know the +LR and -LRs.  Are they going to be able to change your management? That is – will doing this test move your post-test probability into a range where it will either allow you to treat / intervene OR stop the process with comfort that you have in practical terms “excluded” disease?  Will you push the probability past an upper or lower test threshold.
  4. Do the test.  Get an answer [sometimes the answer remains elusive.  e.g.. Why did I think I could scan the 240 kg man with RIF pain...? Doh!]
  5. Carry on.  Integrate this information into the clinical picture and do the needful.

Bedside ultrasound is a newish field – and the evidence basis of what we use it for is young, but rapidly expanding.  In the last 5 years there has been an explosion of published papers looking at the test characteristics of bedside US done in EDs by point-of-care providers… i.e. you, or me… not the crew in the Radiology department.  A lot of the evidence comes in the form of relatively small, underpowered studies.  There are a few meta-analyses of these data sets.  So a quick disclaimer to the data presented below – I completely accept that a lot of it is based on relatively weak numbers.  However, we have to start somewhere.

Often my colleagues will say: “What did the scan show?”  However, in my head the question ought to be: “Does the result of my scan mean that I can change this patient’s management?”  These are two very different questions!   In order to be a rational practitioner at the bedside with a probe in one hand – we need to know these numbers.  Ok, you don’t need to know exactly the LRs for every exam – but you need to have a ballpark idea about what you can actually achieve with your scan.  I sometimes kick myself for missing things with the bedside US, and yet I know that for a lot of what we do – it is an insensitive tool, the specificity is often stronger.  And that is the point – we need to know what questions we can answer and not get too carried away with ourselves.  Being realistic requires discipline.  

So – enough foreplay.  Here are a couple of tables.  They rank a pile of “tests” by the relative potency of their likelihood ratios.  An LR is basically the ratio of true answers to false answers that you might expect to get from any given test.  Remember when it comes to likelihood ratios the basic rules are as follows:

For POSITIVE LIKELIHOODS – that is “If the test is positive then it is a true positive…”

  • +LR > 20 is very potent (hang your hat on it!)
  • 10  -  20 is strong (considered diagnostic in most settings)
  • 5  - 10 is good (few clinical exam findings are better than 5)
  • 2  - 5  is just barely useful, (common for a lot of the basic blood work ordered in ED)
  • < 2 is unhelpful, probably will not change your post-test significantly, unless you were already very close to a threshold
  • LR = 1  means that the test does nothing for the diagnostic process in either direction

For NEGATIVE LIKELIHOODS

  • A negative likelihood ratio tells us “if the test is negative, how likely is it that the disease is absent?”
  • It is just the same in the reverse order  really just divide 1 by the negative (fractional) value and you have an equivalent.
  • So a – LR of 0.100 carries the same weight as a +LR of 10,  -LR of 0.25 is as useful as + LR of 4.  If you see a heap of zeroes it is strong!

CLICK on these to open the info graphics.  Have a read down the list of “tests” – there are a few surprises.  Of course, the gold standards used to generate the data are crucial – so you will need to read some papers to find that out – too hard to put into a table sorry.  However I think this is useful in ordering / ranking your bedside US tests, so you know what question to ask and what you can answer in the ED.

+LR US ED

Neg LR ED US

So let me know if you think this is useful.  Or if you have a paper to analyse, a clinical question about the diagnostic characteristics of an US modality – hit me on the comments or the email.  I am expanding this project constantly.  And if you are going to be at the SMACC US Workshop – then this is good stuff to digest before the day of awesomeness that is in store for you!

Casey