The Police State We Call Health Care

I have some news for you. We are living in a police state! I am sorry, as I know it hurts to hear that we choose to live in bondage. Don’t be fooled by shiny title of being a health care professional, the pennies on the dollar we get paid from the ridiculous pool of money we generate, and the lifestyle that we were promised but rarely experience. We are watched 24/7 because of the title we carry. We are judged for every word we say, whether at work or outside work. We are evaluated by students, patients, residents, co-workers and supervisors. I have not seen any evaluation for a patient, many of whom should be charged with some extra payment for abusing the system or the team. And the residents we can evaluate are protected by a system called ACGME, who might retaliate by giving a bad score for the training program if that program did not crucify us. We became hostages by our own doing. Your life outside work is not yours to control. Your Facebook and Twitter accounts are watched. You will be judged for the opinions you express. And sure enough you might even be disregarded for some promotion because of your beliefs, practices or orientation. The stigma of being from this race, a graduate of this institution, having this sexual orientation, being from this background or finishing at a foreign school is alive and thriving behind closed doors. Let’s be honest about it. I have seen it around me happening in the past. You have to join a crowd, but which crowd? The oppressors? The oppressed? It cannot be both. The academics of medicine also is infected with this disease. You have to be from a certain closed circle to rise. You have to compromise your righteous path in order to gain. You cannot call in sick. You must sacrifice your personal life. You need to go “above and beyond,” simply because that is expected. We are the victims and the criminals at the same time. Heaven forbid you give feedback to a resident who felt it was harsh (despite his or her limited knowledge). We avoid consulting services daily, because we do not want to deal with the frustrations. I have seen how residents from surgery or orthopedics can be dismissive of your concerns, how they can delay care for hours, and how they can request unnecessary studies before even seeing the patient. And if you become forceful about timely evaluation or treatment, trust me – you will hear about it later. Who is suffering here? I think patients and the emergency team equally. We spend a significant amount of our time addressing nonsense scenarios. We are fostering this culture, because we accept it. I see myself drifting every day into accepting this wrongdoing by people around me. I cannot blame a patient or the family if our own team members are not functioning as they are supposed to. Recently, I had a very nice chat about this culture with a brilliant pediatric surgeon who recognized how it limits our ability to provide excellent and efficient care. We reached a realization that our culture need to be changed. This change will be a long road filled with many hardships. We have to stop judging others. We have to quit the hierarchy. We have to eliminate the unnecessary hoops that we have to jump through. We need a system that cares about patients more than the bottom line.  We have to create a system that holds health care professionals and patients equally accountable. And most … Continue reading The Police State We Call Health Care

Medical Assistance in Dying (MAID)

Very soon, the law against assisted suicide in Canada will cease to exist, but exactly what happens next remains to be seen. On April 14th, the federal government tabled Bill C-14 in an attempt to legalize the process of medical assistance in dying (MAID). The bill is currently making its way through Parliament, but may not be ready in time for the June 6th deadline [1]. The legalization of MAID has been called a ‘sea ...

Author information

Francis Bakewell

Francis Bakewell

Dr. Francis Bakewell is an 4th year Emergency Medicine resident at the University of Ottawa and an MHSC Candidate in Bioethics through the Joint Centre for Bioethics at the University of Toronto. He is interested in how we talk to patients, and how we might provide more ethical care in the ED.

The post Medical Assistance in Dying (MAID) appeared first on CanadiEM and was written by Francis Bakewell.

Everything You Always Wanted To Know About: REBOA!

REBOA has become one of the hot topics that everyone seems to be talking about (and writing about). As with any hot new trend, it’s important to understand the facts, as much as they’ve been worked out. The enthusiasts are, by definition, always very enthusiastic, and sometimes the hype overshadows the reality.

During the next week, I’m going to methodically make my way through the basics, like what it is, how we came up with the idea, and what it entails. Then I’ll look through the literature as we know it. Finally, I’ll try to put it all together and make some recommendations about what you should be doing with it.

Tune in, starting Tomorrow!

Research and Reviews in the Fastlane 137

Research and Reviews in the Fastlane

Welcome to the 137th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine
R&R Hall of Famer - You simply MUST READ this!Goyal M et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016. PMID 26898852

  • This is a meta-analysis of patient level data taken from the 5 recent endovascular stroke treatment trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND IA) and the authors taut an NNT of 2.6 for improvement. However, the data here is presented in a loaded fashion. This incredible NNT is for the endpoint of an ordinal shift or improvement of 1 point on the modified Rankin Scale. This measure has long been thought useless for stroke since going from a 6 (dead) to a 5 (severe disability) or from a 1 (no significant disability) to a 0 (no symptoms) is irrelevant and aren’t equal outcomes. The more relevant endpoint (mRS 0-2 at 90 days) still yields an impressive NNT = 5. Unfortunately, the authors bury incredibly relevant information like the strict imaging criteria used in these studies and the fact that only a tiny number of stroke patients meet criteria based on these studies. Finally, the COI list is long and convoluted as always. Is this intervention useful in a small minority of patients? Probably. Should we all be changing our stroke care systems to meet this need? Probably not.

The Best of the Rest

Quirky, weird and wonderful

Sieweke N et al. Cardiac Troponin I elevation after epileptic seizure. BMC Neurol 2012. PMID 22804867

  • Apparently seizures can elevate troponin-I (but not trop-T). Who knew? Possibly secondary to vascular disease so maybe it’s a type-2 MI of some sort? Very strange.
  • Recommended by Seth Trueger

Research and Critical Appraisal
R&R Landmark paper that will make a difference
Wasserstein RL et al. The ASA’s statement on p-values: context, process, and purpose. The American Statistician. 2016. DOI 10.1080/00031305.2016.1154108

  • Statistical significance and p values are widely touted, proudly displayed, and increasingly reported. Yet p values are problematic, so much so the American Statistical Association created a statement essentially calling the literature out for misuse. P values indicate how incompatible the data are with a specific statistical model. They NEITHER reflect the probability that the null hypothesis is true (they are calculated assuming the null hypothesis is true) NOR the probability that the data were produced by chance alone. P values also do not measure effect size or significance. We see a great deal of research overturned and it appears that misused statistics may be to blame. Handle p values cautiously.
  • Recommended by Lauren Westafer

Airway
R&R Landmark paper that will make a difference
Long B et al. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016 Mar 23. PMID 27073134

  • Patients with tracheostomies often invoke some fear and commotion in the ED. This well written to-the-point paper on management of the patient with tracheostomy provides the basic need-to-know stuff and an algorithm for handling the most common emergencies.
  • Recommended by Søren Rudolph

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this
Morris JR et al Comparative Trends and Downstream Outcomes of Coronary CT Angiography and Cardiac Stress Testing in Emergency Department Patients with Chest Pain: An Administrative Claims Analysis. Acad Emerg Med. 2016 PMID 27155236

  • This is an analysis of a large administrative claim data (OPTUM labs, a type of “big data” warehouse). The authors look at the rate of CT Coronariogram use in the last several years and subsequent healthcare utilization. Interestingly, the use has increased 4-5 fold, and problematically, the downstream use of resources in those patients has increased. In practicality, the use of CTca is associated with increase of further stress testing, invasive procedures and re-admissions. Looks like CTca is not beneficial in people with moderate to high risk chest pain, and is only helpful in people with low risk who arguable don’t need any sort of advanced testing.
  • Recommended by Daniel Cabrera

Pediatrics
R&R Hot Stuff - Everyone’s going to be talking about this
R&R Landmark paper that will make a difference

Freedman SB et al. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA 2016. PMID 27131100

  • Kids just want to drink juice, but I’ve been told forever that if I let kids with gastro drink juice they would die (or something like that). This is a randomized, controlled non-inferiority trial out of the Hospital for Sick Children that compared electrolyte solution to a combination of half strength apple juice in the ED and the child’s preferred fluid (juice or milk) at home. Put simple, the apple juice group had fewer treatment failures. There were a few weakness in the study, including the fact that is was a single centre study, included only children with mild (or no) dehydration, and used a composite outcome that might not have been entirely clinically relevant to me. However, this is a game changer for me. I am switching to juice for kids with gastro, and I know they will be happier for it.
  • Recommended by Justin Morgenstern

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Jun 1, 2016 @ 9:34 pm

The post Research and Reviews in the Fastlane 137 appeared first on LITFL: Life in the Fast Lane Medical Blog.