The Struggles of tPA Consent

Providing informed consent for any therapeutic intervention can be challenging.  And, then there’s stroke.  Acute stroke spans the gamut from mildly limiting to profoundly disabling – with a non-linear relationship between the NIHSS and disability.  There are folks with NIHSS score of 4 who can walk into the Emergency Department, and there are folks with the same score or lower who are functionally incapacitated.  All this means it’s a struggle to provide an individualized estimate of the benefits, risks and alternatives in consent for tPA.

This is a lovely, short, qualitative survey of a handful of (mostly) neurology consultants in the United Kingdom, asking a few questions regarding the diagnostic process, shared decision-making, and consent for thrombolysis.  Not all consultants surveyed seemed to appreciate the challenges, but others recognized limitations in the data, as well as how difficult it made informed consent:
“I think there needs to be em, err a minimum standard, standardised information available based on what you believe is the right interpretation of the trial. We have to remember that this is based on em, err limited number of randomised trials ..... This is a particularly heterogeneous disease it cannot be applied to a single patient, I think the predictions em in model could be designed but again I don’t think it can be predicted for an individual group of pa-, individual patients so we believe these are the kind of risks and benefits but you know it cannot be predicted to the individual patient.”
Other physicians commented upon the challenges of making a rapid, certain diagnosis, and the inadequate demands made upon patients and families to choose in a time-compressed setting.  Overall, it’s an interesting little read.

“Risk communication in the hyperacute setting of stroke thrombolysis: an interview study of clinicians”

The International Research HUMANIZING INTENSIVE CARE: The IC-HU Project

Hello everybody, my dear friends.

Today I would like to make an statement and announcement:

First of all, I want to inform you that I have submitted an application to European Society of Intensive Care (ESICM) Research Awards 2014.

With the Application: The International Research HUMANIZING INTENSIVE CARE: The IC-HU Project', we would aim to spread the message around the world through an awesome research project. Of course, if we would get the Award, it would be an enormous boost international recognition. 
So I hope that all of you have "fingers crossed" the last week of June/first of July. 

And the announcement: The IC-HU Project is looking for editors.

If you have thought to collaborate with a post or you have something that you want to share, now your thoughts will accommodate on the blog. 

I am searching 5 editors between health professionals (nurses, physicians, psychologists, occupational therapists, physiotherapists, social workers, etc) patients and families.

My idea is to be fixed collaborators (one day per week) and if we manage to win the grant, I would value the possibility that your post were paid.

To make the selection, send me a post to my email: I only have 2 requirements: short post and with an image. Free humanizing topic, of course.
The deadline is 31 May.

Good luck, and thank you! Let´s go on!!

Happy Tuesday

Posted in Uncategorized |

What is possible, what is reasonable, what is best?

If there was one session at smaccGOLD that blew everyone away it was this (OK, SonoWars was mind-blowingly awesome as well…). On day 2 of the conference, Victoria Brazil (@SocraticEM) facilitated a discussion of some of the most difficult intangibles in critical care. What happens at the end of life? What is possible, what is reasonable, what is best?

The panel involved a fantastic line up including intensivists, emergency physicians, palliative care specialists, paediatricians, trainees, and — last but definitely not least — a social worker:

  • Ray Raper
  • Steve Philpot
  • John Hinds
  • Rachael Pery-Johnston
  • Bill Lukin
  • David Anderson
  • Greg Kelly
  • Liz Crowe

Make sure everyone you know listens to this!

The audio (mp3 download here):

The video:

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes.

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The Interplay of Emotions & Learning

Our goal should be to create a student who moves up the knowledge axis, along an “excelsior spiral that climbs the tree of knowledge” – Barry Kort

Rob & Chris’ debate about whether learning styles exist (or not)  touches upon a subtle, but important point. Forcing a student to come out of their comfort zone is important in the educational journey, in fact, there is likely a strong interplay between emotions & learning.  Many have attempted to identify the healthy amount of discomfort that’s necessary in the learning process, but I thought this paper by a group from M.I.T. highlighted some very important concepts.

In an attempt to engineer a computer application that could identify a student’s emotions, Kort highlights some theoretical concepts that are highly adaptable to medical education & other STEM courses.  The underlying principle of this paper is that there is a necessary cycle in learning that requires making mistakes, evaluating/reflecting about what went wrong, deconstructing false beliefs, discovering a potential solution, and ultimately repeating the cycle until the problem is solved.

Dr. Kort begins with the establishment of a static model that plots Positive/Negative emotions on the horizontal axis against Learning/Unlearning on the vertical axis. (below).

Emotions & Learning Model 1

Let’s briefly review this model and how it applies to medical trainees:

Students will often begin in the upper quadrants (I or II) – with a clinical question, interest, or endeavor.  This could be the result of an interesting patient, failed resuscitation, missed questions during a “pimping session” or whatever – but something that sparked an interest.   Quadrant III often is reached during a period of research or self-reflection.  During this time, the learner will likely identify knowledge gaps or misconceptions that currently exist.  The reflection, deconstruction, & unlearning process that ensues is likely the most critical.

After a period of failure, the learner will eventually progress to Quadrant IV where a new potential answer is identified, or a true solution is realized or understood.  Ultimately, the idea is that the student should traverse a series of both positive and negative emotions on their path to truly understanding the answer to their question.

So where does the educator exist within this process?

The authors contend that the instructors role is to help the student continue their path around the loop, as well as teaching them how to propel themselves especially after a setback.

Fluid Emotions & Learning Model

The last variable to consider is time, which can be added as a third axis (z-axis).  By incorporating time, the authors define the educator’s  role as that of a mentor, where the student progresses in an orbital fashion along an, “excelsior spiral that climbs the tree of knowledge.”  Essentially, building their knowledge base as they travel through this cycle of failure and success.


Some key pearls to take away from this paper include:

  • Learning is an active process that incorporates some degree of struggle.
  • Expert teachers are very adept at recognizing and addressing the emotional state of learners, and even more importantly – are able to effectively guide them through this learning cycle again and again.
  • Much of this theory focuses on the individual learner, however it is possible to incorporate these concepts into a lecture if necessary – see, “Make Your Audience the Hero”

Teachers who incorporate the cycle of learning and unlearning into the educational constructs of their classroom are (in my opinion) more effective educators.

Finally, there is something important about what this journey teaches students outside of the intended lesson plan, something that we’ll address next time – the value of GRIT.

Some parting questions to the educators out there:

      • Do you think some form of negative emotion is important to the learning process?
      • Is there actually value in allowing students to struggle?

Leave your thoughts below!


References [Free full text]

  1. Massachusetts Institute of Technology Affective Computing Lab
  2. Kort B, Reilly R, Picard RW.  An Affective Model of the Interplay Between Emotions and Learning.
    Download Paper Here.

    Contact me on Twitter @JohnGreenwoodMD

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