Category Archives: Philosophy

Serial Lab Testing: Worthwhile or Worthless?

November 16, 2017 The Trauma Pro Leave a comment

We’ve all done it at some point. Serial hemoglobin. Serial sodium. Serial serum porcelain levels. What does serial mean to you? And what does it tell us about or patient?

Today and tomorrow, I’d like to present an example from real life. For today, have a look at the daily sodium tests done for a patient with a head injury. The concern was for cerebral salt wasting, which is probably grounds for its own blog post.

So have a look at this series of sodium determinations. It represents serial values based on daily testing.

Day/time	Na
Day 1 18:30	131
Day 2 05:59	133
Day 3 07:18	127
Day 4 07:45	125
Day 5 04:04	126
Day 6 04:42	127
Day 7 05:22	134

At what point, if any, would you be concerned with significant hyponatremia, and begin some type of supplementation?

Tomorrow, I’ll provide a little more info on levels and treatment

Philosophy

When Is A Physician Too Old To Practice?

October 26, 2017 The Trauma Pro Leave a comment

There are about a quarter of a million physicians who are currently 65 or older and in practice. This represents about a quarter of those currently practicing. Unlike other professions like federal judges, FBI employees, and nuclear materials couriers, there is no mandatory retirement age for doctors. Although not forced to retire, commercial pilots are more closely monitored after they turn 65. But our profession has not really done a very good job of policing itself. It relies on voluntary action to identify struggling colleagues, who are generally reluctant to report a partner.

We are all living longer, and physicians are no exception. This means that many continue to practice well beyond the “customary” retirement age. What exactly happens to us? One study gave a quick cognitive test to a group of physicians and compared them to non-physician controls. Here are the results:

Ages ranged from 30-80 years. Note that the physician scores were consistently higher than the controls for all age groups, but declined significantly with age just like the controls. The big problem is that individuals have difficult recognizing (or accepting) their own cognitive decline.

The American College of Surgeons (ACS) assembled a workgroup to address this issue. They recommended that surgeons undergo voluntary, confidential testing of their baseline vision and physical examination starting at age 65-70, with regular re-evaluation afterwards. So far, only 3 or the more than 5,000 hospitals in the US do this. Canada has a mandatory age of 70 for commencing regular peer evaluations of competence. Obviously, the US does not.

There are really two components at play: wellness (which includes cognition) and competence. The problem is the neither correlates well with chronological age, but rather physiologic age. And the latter is impossible to quantify.

So what do we do? This is a problem that can’t be ignored from a patient safety standpoint. But it does not readily lend itself to simple pronouncements of a mandatory retirement age. There are many physicians who can and do provide excellent service to their patients well past the customary retirement age. They are able to apply a lifetime of lessons learned that their younger colleagues simply do not have.

We need uniform adoption of mandatory, not voluntary, testing of wellness and competence. Individual hospitals need to heed the recommendations of national organizations like the ACS to implement these mandatory programs to ensure fairness and avoid the specter of age discrimination lawsuits.

I’m no spring chicken anymore, and I think about this every time I find myself searching for the name of that weird retractor I need. How old is too old? What do you think?

Reference: The Aging Physician and the Medical Profession. JAMA Surgery 152(10):967-971, 2017.

Imaging, Philosophy

If A Tree Falls In A Forest…

October 20, 2017 The Trauma Pro Leave a comment

After yesterday’s analysis of a not-so-good pan-scan vs selective-scan abstract, it’s time for a little philosophy today. There seem to be two camps in the world of initial diagnostic testing for trauma: selective scanning vs scan everything. I admit that I am one of the former. Yes, the more tests you do, the more things you will find. Some will be red herrings. Some may be true positives, but are they important? Here’s the key question:

“If a tree falls in a forest and no one is around, does it make a sound?”

There is a clinical corollary to this question in the field of trauma:

“If an injury exists but no one diagnoses it, does it make a difference (if there would be no change in treatment)?”

Here’s an example. On occasion, my colleagues want to order diagnostic studies that won’t make any clinical difference, in my opinion. A prime example is getting a chest CT after a simple blunt assault. A plain chest xray is routine, and if injuries are seen or the physical exam points to certain diagnoses, appropriate interventions should be taken. But adding a chest CT does not help. Nothing more than the usual pain management, pulmonary toilet, and an occasional chest tube will be needed, and those can be determined without the CT.

Trauma professionals need to realize that we don’t need to know absolutely every diagnosis that a patient has. Ones that need no treatment are of academic interest only, and can lead to accidental injury if we look for them too hard (radiation exposure, contrast reaction, extravasation into soft tissues to name a few). This is how we get started on the path to “defensive medicine.”

Bottom line: Think hard about every test you order. Consider what you are looking for, what you might find, and if it will change your management in any way. If it could, go ahead. But always consider the benefits versus the potential risks, or what I call the “juice to squeeze ratio.”

References:

George Berkeley, A Treatise Concerning the Principles of Human Knowledge, 1734, section 45.
paraphrased by William Fossett, Natural States, 1754.

Philosophy

Why Is So Much Published Research So Bad?

September 28, 2017 The Trauma Pro Leave a comment

I read lots of trauma-related articles every week. And as I browse through them, I often find studies that leave me wondering how they ever got published. And this is not a new phenomenon. Look at any journal a year ago. Five years ago. Twenty years ago. And even older. The research landscape is littered with their carcasses.

And on a related note, sit down with any serious clinical question in your field you want to answer. Do a deep dive with one of the major search engines and try to get an answer. Or better yet, let the professionals from the Cochrane Library or other organization do it for you. Invariably, you will find hints and pieces of the answer you seek. But never the completely usable solution you desire.

Why is it so hard? Even with tens of thousands of articles being published every year?

Because there is no overarching plan! Individuals are forced to produce research as a condition of their employment. Or to assure career advancement. Or to get into medical school, or a “good” residency. And in the US, Level I trauma centers are required to publish at least 20 papers every three years to maintain their status. So there is tremendous pressure across all disciplines to publish something.

Unfortunately, that something is usually work that is easily conceived and quickly executed. A registry review, or some other type of retrospective study. They are easy to get approval for, take little time to complete and analyze, and have the potential to get published quickly.

But what this “publish or perish” mentality promotes is a random jumble of answers that we didn’t really need and can’t learn a thing from. There is no planning. There is no consideration of what questions we really need to answer. Just a random bunch of thoughts that are easy to get published but never get cited by anyone else.

Bottom line: How do we fix this? Not easily. Give every work a “quality score.” Instead of focusing on the quantity of publications, the “authorities” (tenure committees and the journal editors themselves) need to focus in on their quality. Extra credit should be given to multicenter trial involvement, prospective studies, and other higher quality projects. These will increase the quality score. The actual number of publications should not matter as much as how much high quality work is in progress. Judge the individual or center on their total quality score, not the absolute number of papers they produce. Sure, the sheer number of studies published will decline, but the quality will increase exponentially!

Philosophy

Why Is NPO The Default Diet For Trauma Patients?

September 25, 2017 The Trauma Pro Leave a comment

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.
Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.
Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet!

Home of the Trauma Professional's Blog