Over the past 3 weeks I’ve had the honor, the privilege and the … to hang out with the „big boys” in the lion’s den (a.k.a. the echocardiography lab). It’s been a lot of fun and quite a learning experience. I’ve discovered a fair number of their „dirty secrets” while playing the „eyeballing game” with the guys. Here are the rules:
It is obviously not my goal to ridicule the art and the skill of an experienced cardiologist. Nevertheless the interaction prompted some questions which are likely to remain unanswered. To be honest I was fairly surprised by the level of subjectiveness governing the echocardiographic interpretation. A little more or a little less is just a matter of a slightly different caliper placement. Hence I am asking… Why do we care about the absolute numbers if they’re a product of an estimation? Why do we allow those digits to guide important clinical decisions (e.g. AICD placement) if they’re a matter of comparative assessments and relative impressions? Furthermore, why would one argue against the value of a bedside echocardiographic evaluation by a trained non-cardiologist if that is enhanced with real-time clinical clues and patient’s historical data?
I am not sure if it’s money, pride, ego or all of the above, that drive hostility towards point-of-care echo evaluations by emergency physicians or critical care providers, as an example. There are no logical arguments in this debate and statements such as recent JASE gate (a.k.a. Focused Cardiac Ultrasound recommendations from the American Society of Echocardiography) are inconsistent with patient advocacy. Countless lives have been saved and even more outcomes have been improved thanks to bedside echocardiography. Let’s quit the dispute and focus on mutual education. Beyond any shadow of doubt we can learn a lot from our cardiology colleagues, while we can certainly teach them a trick or two…
Speaking of echo education. Below a few of the million interesting echo resources:
- Newest first! My most recent discovery is a fantastic article from January 2014 issue of Critical Care Clinics. Drs. Perera, Lobo, Willims and Gharahbaghian provide you with an exhaustive point-of-care echo review.
- Introduction to Bedside Ultrasound by Matt & Mike in 2 digital volumes.
- Intro to Bedside Echo by Joe Minardi – part 1 and part 2. Created for medical students – great for anyone!
- Yale Echo Atlas
- Nice iASE app for the big boys/girls. Advanced echo recommendations, summaries and calculators from the ASE (American Society of Echocardiography).
I am just going through my PILE OF GUILT (read: stack of EM literature) that tends to accumulate over time… At the very least I try to browse through the journals and magazines as they trickle or pour in, but sadly enough I end up playing a catch-up game.
The August 2013 issue of the Annals of Emergency Medicine ended up waiting for its review until December. Such a 4-month delay is nothing to be proud of :-(. Especially because of this excellent editorial by Dr. Steven Green on clinical decision rules. He describes common pitfalls and important caveats concerning these clinical tools. They are omnipresent in our daily practice and we tend to apply them as a sort of bandaid or anti-lawsuit remedy. The problem is that quite a few of the rules add little or nothing to our sound judgement (read: GESTALT). They are far from being the Holy Grail of emergency medicine, so before you choose a given rule and potentially cause more harm than benefit to your patients, consider the following factors (after Dr. Green):
- Relevance of clinical question – simply don’t bother with rules that answer trivial or unimportant questions.
- Derivation – best rules meet rigorous derivation standards.
- External validation – crappy decision rules perform great in the derivation sample but fail if applied to a new patient sample.
- 1-way versus 2-way application – most rules are designed as 1-way tools, and lead to negative consequences if applied in a 2-way fashion. Let’s take PERC (Pulmonary Embolism Rule-out Criteria) as an example. You are supposed to forego further testing if the patient is „PERC negative”. It is not meant to indicate the need for a PE evaluation if patient is „PERC positive”. If applied in 2-way fashion this rule would lead to increased testing and potential harm.
- Implication for current practice – ask yourself if the rule improves your clinical gestalt. In a multitude of medical conditions gut feeling seems to perform better, e.g. pulmonary embolism.
- Applicability to your patient population – certain rules do not factor in modern practice patterns such as use of bedside ultrasonography, which honestly makes them redundant and obsolete to begin with.
- Ease of use – who on earth has the capacity to remember all those multi-step rules? Availability of automated calculators and/or drop-down charting add-ons certainly increases applicability.
The bottom line is – majority of the rules are more of a double-edge sword than a protective shield. It is unwise to apply them in an automated fashion. Once you’ve built your clinical judgement it is often superior to any rules. Nevertheless, these tools probably help to unwrap your gestalt from its immature cocoon.
If you asked 100 ED docs around the world what „patient satisfaction” means to them and their daily practice, you would likely get 100 different answers… Pose the same question to 100 emergency physicians in the U.S. and you’ll certainly get 200 angry eyeballs looking at you with disgust!
There is obviously nothing wrong with keeping your patients happy. It is quite important indeed. Nevertheless, when someone „incredibly brilliant” decides to make money by convincing an employer to cut your wages based on their crappy metrics, it turns into a caricature of a noble concept.
Chained by the patient satisfaction surveys docs in the American healthcare system tend to do the strangest things first. Why would one care about the Hippocratic oath if the hypocrisy of satisfaction scores (SS) governs our practice? Sadly enough it becomes nearly impossible to treat patients and „first do no harm” when at times you are dealing with demanding customers instead. Empowered by Dr. Google and their right to „100% satisfaction or money back” they insist on unncessary or even harmful tests and treatments. We, as physicians, are at loss both financially and morally when creating a vicious circle of over-testing, over-diagnosing and over-treating. We end up bankrupting the system and harming our patients when attempting to meet the absurd SS demands. (Oh yes – I deliberately chose the „SS” acronym as it is a deadly weapon).
One of the SS vampire companies promotes their business by insinuating they improve healthcare through enhanced patient experience. This particular business and alike have been on the market for over 30 years. Unfortunately it doesn’t look like they’ve accomplished much positive. According to the 2013 Commonwealth Fund International Health Policy Survey U.S. adults are the least happy patients compared to 10 other industrialized countries:
To further blacken the picture the above survey of 20000 (twenty thousand) patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., and the U.S., has shown that „U.S. adults are significantly more likely than their counterparts to forgo health care because of the cost, to have difficulty paying for care even when they have insurance, and to deal with time-consuming insurance issues”.
Isn’t it tragic? Heaviest healthcare spending among the industrialized countries and the American patients struggle more than elsewhere to stay happy and healthy?
While my annotations above might seem cynical and sarcastic to some, a ground-shaking study by Fenton et al. has shown that patient satisfaction links to higher health-care spending and INCREASED MORTALITY. They surveyed 50000 (fifty thousand) U.S. adults which is a nationally representative sample. „The study found that patients who were most satisfied had greater chances of being admitted to the hospital and had about 9 percent higher total health-care costs as well as 9 percent higher prescription drug expenditures. Most strikingly, death rates also were higher […]. More satisfied patients had better average physical and mental health status at baseline than less satisfied patients. The association between high patient satisfaction and an increased risk of dying was also stronger among healthier patients„. No matter how you look at it, rating doctors is bad for patients’ health and it’s quite unhealthy for the national budget.
In the end it’s time everyone admits that being able to sue doctors and give them crappy satisfaction scores doesn’t make patients truly happier nor healthier. Not a single honest soul benefits from tying physician wages and hospital reimbursements to the SS metrics. Instead of Affordable Care Acts the American patients need a reenactment of affordable care that first does no harm. Some could also use a gentle reminder that public yelling is barely acceptable for angry toddlers and feet stomping might get them plantar fasciitis… But that’s a different story…
I would imagine that every pancreas with a history of -itis remembers the ole good days of bumming around until the pain was over… Lipase 3 times the upper limit of normal was good enough for the pancreas to rest and „self-digest” ;-).
Just refer to any major textbook and it will tell you to starve that poor -itisized pancreas. However, if you look at the most recent guidelines on Management of Acute Pancreatitis (AP) published by the American College of Gastroenterology, it does not seem like such a good idea anymore.
Here, just for you the newest nutritional recs to de-bum the pancreas care:
- In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and the abdominal pain has resolved (conditional recommendation, moderate quality of evidence).
- In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet (conditional recommen- dations, moderate quality of evidence).
- In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided, unless the enteral route is not available, not tolerated, or not meeting caloric requirements (strong recommendation, high quality of evidence)
- Nasogastric delivery and naso-jejunal delivery of enteral feeding appear comparable in efficacy and safety (strong recommendation, moderate quality of evidence).
Have you seen this revelation? ENTERAL FEEDING is recommended to PREVENT INFECTIOUS COMPLICATIONS? Clinical and experimental studies have shown that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Patients provided with oral feeding early in the course of AP have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Total parenteral nutrition should be avoided in patients with mild and severe AP.
So don’t let the pancreas bum around, at least not too much. Feed enterally as early as you can! And by the way, while we are on it, you can also stop that clear liquid or naso-jejunal nonsense.
Nov 19th, 2013: Now that was a crushing publication… On Nov 17th, 2013 NEJM published the results of an international trial (TTM trial) with 950 patient’s which assassinated the concept of therapeutic hypothermia? The study group concluded that „in unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C„.
Therapeutic hypothermia industry must be shivering in fear… Who is going to buy any thermo-suits and likewise devices if all you need is 36 degrees Celsius?
Not a single conscious person likes to shiver… That „brain freeze ache” you get when eating your ice-cream too fast doesn’t feel good at all… Why would those benefit the unconscious? Well, it doesn’t seem like they do! Not that fever does them any good either – golden middle way works best! Who would have thought?
Dec 2nd, 2013: On the website of University of Pennsylvania, Perelman School of Medicine, Dr. Benjamin Abella from Center for Resuscitation Science posted a video as commentary to the Targeted Temperature Trial TTM trial. Nice try at rescuing the therapeutic hypothermia industry – so it seems His ties to this business are quite overwhelming! Still referred to as „potential” conflict of interest – interesting concept, isn’t it?
Aside from my major industrial reservations, in response to Dr. Abella, I’d say:
- Nowhere does TTM trial suggest that temeprature management after cardiac arrest is irrelevant – it just shows there is no need to brain freeze the patients after ROSC.
- As mentioned above, common sense is enough to conclude that hyperthermia is not a good option – maintain your patients at low normal 36 degrees Celsius.
- In 2002 the HACA trial and Bernard et al. only compared hypothermia with relative hyperthermia. TTM trial filled in the gap and showed that low normothermia is just as good.
- Dr. Abella raised a concern that in TTM trial 73% of patients received bystander CPR – as opposed to Philly? – I guess if you are doomed to have a cardiac arrest make sure it’s not in Philly – probably best on your European vacation?