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.