April 9, 2014

"Don't Be an Idiot"


This is exactly one of the best lessons I learned in med school was from a young attending neurologist (who also used to cite studies in her patients' charts). I forget exactly which precise neurologic phenomena she was referring to, basically the lesson is to not use jargon when you don't need to.

For example, if you say "dysphagia" and you really mean "odynophagia" (which people do all the time), you are flat out wrong. The person you're talking to will a) think you're an idiot or b) get the wrong message from you. And even if you are right, they might c) misinterpret what you say, because jargon.

But if you say "it hurts when he swallows" then everyone knows what you're talking about.

Similarly, in actual clinical ED care*, I was taught to not use GCS numbers. Instead, give a narrative: "he's intubated, not opening his eyes, and extending from stimuli." Avoids misremembering the scale, miscounting, miscalculating, and miscommunication. And in most cases when we're talking about GCS, people on both side of the conversation are under some level of stress, so it's 15 fewer things to worry about.


*but not on exams

March 26, 2014

Real Genius.

The Effect.
Dunning-Kruger has long been a favorite effect of mine, but I never saw the original paper (why would I read an "old" psychology paper when there's wikipedia?). Today I pointed it out to Mark Reid & Chris Wright, there was some banter, some laughs, and Mark linked to the original Dunning-Kruger paper.

The acknowledgments caught my eye:


No, not the NIH R01 grant that supported this research. Look at the acknowledgments.

Some googling "confirmed" -- that's emergency physician Boris Veysman* back when he was an undergrad psych major at Cornell. He writes a lot of "narrative" pieces -- I particularly like this one.

I guess the lesson is to read the paper, or: "Always... no, no... never... forget to check your references."

I'll end with the epitaph from Dunning & Kruger:
It is one of the essential features of such incompetence that the person so afflicted is incapable of knowing that he is incompetent. To have such knowledge would already be to remedy a good portion of the offense. 
(Miller WI. Humiliation. Ithaca, NY: Cornell University Press)

Great discussion of Dunning-Kruger by Lauren Westafer.

March 18, 2014

Trust the ProCESS

ProCESS covered in MedPage Today by Elbert Chu. Also covered by Nick JohnsonSalim Rezaie, Simon Carley, ProCESS author Don Yealy, and of course EMCrit.

It turns out that we're getting pretty good at this. ProCESS is a 3-arm RCT comparing EGDT classic, protocolized "standard care," and usual care, and it showed essentially equal outcomes. The main difference from earlier EGDT studies is that they started collecting in 2008.

I think the main lesson from ProCESS will be that we all took the lessons of the original Rivers study (and the great follow up studies, like the 2010 Jones trial they mention) to heart: we now aggressively look for severe and occult sepsis, and work hard to resuscitate septic patients. Standard therapy before 2001 was not very aggressive, i.e. hang a liter or 2 of fluid and some ceftriaxone, then forget about the patient in the corner.

The main lessons of Rivers were that we should look hard for sepsis, pay close attention to the septic patients, and aggressively resuscitate them. The good news here is that by 2008, we were doing that much better. The study arms not only had similar mortality, they received similar volumes of fluid (much closer than in Rivers) and similar rates of other advanced interventions.

Much like our evolution of trauma care, step 1 was learning how to take these patients seriously and get aggressive protocols in place, and step 2 is to judiciously apply the appropriate interventions to the appropriate patients. That ProCESS was all academic centers might hurt its usefulness in other settings, which don't always have teams of residents and fellows to focus on these patients. Many community hospitals have gotten around this in a number of other creative ways, such as by making a "Code Sepsis" where the MICU team comes to the ED -- treating sepsis like a STEMI or a stroke, which makes a lot of sense, as it's as (or more) serious, and Rivers showed us how much early, aggressive treatment matters.

I still think there is a place for protocols: particularly when we have very sick patients, or we're swamped on a busy shift or exhausted at the end of a shift, it is helpful to have protocols handy to both standardize care and serve as gentle reminders when we need it. I don't think we're completely done innovating in sepsis care, but again and again we're showing the answer is good attention to the basics -- early identification, antibiotics and fluid -- and not technology or wonder-drugs.

...and that vital signs are insufficiently sensitive to identify sepsis, or as markers of adequate resuscitation.

Addendum: A few more thoughts: 
  • A number of people have pointed out that the mortality rate was much higher in the Rivers trial. Rivers had a sicker population, and (I think) we got better at treating severe sepsis. Additionally, lower mortality across the board makes it harder to find a difference between groups.
  • The one potential difference I see in the groups is that the EGDT arm had a somewhat higher rate of intraabdominal infection, and those patients are generally a bit sicker. I doubt this is enough to taint the results.
  • The rates of cardiac and respiratory failure during treatment seemed a little higher in the EGDT and protocolized standard care group, roughly in proportion to the amount of fluid they received. Not statistically significant, but intriguing, and seems to be in line with the MAP study below.


Two other new sepsis studies:

Albumin:
Another nail in the coffin for albumin and other non-crystalloid fluids in sepsis.

BP goals: MAP 65-70 as good as 80-85
No surprise that lower MAP targets as as good or better than higher BPs. Sick patients aren't like healthy people -- our goal should be to resuscitate them just as much as they need and no more, not to make them look like a normal, healthy patients. Over-resuscitation will just expose patients to the potential harms of therapy.


January 30, 2014

The Invincible Athlete: Why You Should Sign Up for Health Insurance Now

GUEST POST: This post was written by Avi Giladi, a plastic and reconstructive surgery resident training in health outcomes research, and an avid CrossFitter. 
Avi

Last week Kevin Ogar, a competitive athlete, coach, and certified CrossFit trainer, had an awful accident resulting in severe spinal cord injury. This occurred while he was performing a complex Olympic lifting movement, but it was something he – like many other athletes – had done thousands of times before. I assume he thought it would go fine, just like it had all the other times.

As the nature of Kevin’s injury became widespread news, headlines were also reporting on under-enrollment of young healthy Americans in new health care plans supported by the Affordable Care Act. The message in these dueling headlines was unmistakable: even the most fit of athletes, who seem invincible, are just one accident away from major health challenges.  

Get health insurance so you can protect yourself, which also helps protect your loved ones and the community around you. New health plans and subsidies available in all 50 states make coverage possible for millions who could not access affordable plans just a few months ago. I have a unique perspective on this for the “young invincibles” – people in their 20s who figure that health care nightmares won’t happen to them – because I know them. Across my many years of playing rugby, and now as an avid “crossfitter” logging training hours 5-7 days a week with similar friends, many of my teammates and training partners are without health insurance.

I’m fortunate to now have health care coverage through my job as a resident in plastic and reconstructive surgery; however, that wasn’t always the case. While in medical school I needed insurance, but the University plans were more expensive than I could afford. I spent hours looking for alternatives, eventually settling on the minimal coverage I could have and still meet requirements of my school – and protect myself while playing rugby. This experience helped me understand some of the tough financial and coverage decisions that many are forced to make when it comes to affording health care and health insurance. Whether we call healthcare reform the Affordable Care Act, or “Obamacare”, some of these tough decisions should now be easier thanks to this law. Plans with varying levels of coverage and affordable pricing are available.

What we can learn from Kevin Ogar, and many other unfortunate athletes who have been injured doing something they love, is that not being covered is too dangerous – and far too costly. I’m not advocating that anyone still uninsured enrolls in the most expensive plan with the highest levels of coverage; however, whether you’re involved in rugby, CrossFit, biking, rock climbing, swimming, challenge races, skiing, running, or anything else athletic, you are putting yourself at risk. Considering how much time and money we spend on gear, supplements, clean eating, and training, as post-collegiate athletes we must also prioritize protecting ourselves, both physically and financially. I highly doubt any of us will stop weight training or Olympic lifting after knowing about Kevin Ogar’s unfortunate accident, and I doubt he would advocate that we quit. However, I hope that this event will motivate those who remain uninsured to tap available resources and get health insurance as you continue in your athletic pursuits.

The deadline to enroll via the online exchanges is March 31, but there is no reason to wait. The benefits of health insurance go beyond just having coverage. Even if you seek medical attention that isn’t covered by your health plan, your expenses will still be far lower than those of the uninsured because your insurance company negotiates the pricing for you. And should something very unexpected happen, having insurance will make a big difference in your financial burden (and resultant family/network stress). Even treatment for more common and often less severe injuries, like fractures, ligament injuries, and others, can become costly – especially if surgery is required. 

Yes, the rollout of healthcare.gov in October 2013 was a letdown, but many of the web problems have been fixed. Inexpensive plans are available, through healthcare.gov or your own state’s health exchanges, and I encourage anyone still unsure about their health care coverage to research these options. You might even be eligible for financial assistance or subsidies. Enrollment won’t just magically happen, and the process might take you a bit of time. But, if you can spend hours (or weeks, or even months) trying to reach new milestones in your training, how can you truly tell yourself that finding a few hours to understand and acquire health insurance isn’t doable? 

Many community organizations are available to help with this process. Where I live, in Ann Arbor, Michigan, the Washtenaw Health Initiative has had success working with young adults in need of health insurance. They also distribute this very useful pamphlet. There are a growing number of similar resources across the country. While I know that many people reading this won’t need to use most of the coverage elements of their health insurance plan, and rarely – if ever – even see a doctor, you’re gambling with your future if you remain uninsured.  

I have been deeply moved by the outpouring of support for Kevin Ogar in the week since his injury, and it serves to show the strength of a community when one of its own is in need. I've read the articles that focus on the incident, the intensity of competition, and the community that remains devoted to pushing to the absolute maximum every day. When I show up for training I expect my coach to challenge me in new and often somewhat painful ways – that’s why I keep coming back. But that intensity comes with risk, the most serious aspects of which are completely unpredictable. All post-collegiate athletes, regardless of skill or intensity level, must have health insurance in order to protect themselves and their futures.

Aviram Giladi, MD, is a recently “retired” rugby player who now spends his athlete time working on improving in his CrossFit training. He is a resident in plastic and reconstructive surgery living in Ann Arbor, Michigan, and is currently also a Master’s student in the Health and Health Care Research program through the Robert Wood Johnson Clinical Scholar’s Program at the University of Michigan. You can reach or follow Avi @theaviram

Avi also got me through organic chemistry, so this is all his fault.

January 8, 2014

Why the Individual Mandate?

Screencast of a 12 minute talk on the ACA Marketplaces I gave to our residents, with a focus on the theoretical framework (i.e, why the individual mandate?)

January 6, 2014