Monday, August 12, 2013

Don't just stand there! DO SOMETHING!

I hear that all the time. Apparently, standing by the bedside and giving medications isn't enough for some people.

There's a pervasive idea that a high-priced invasive procedure has to somehow be better than doing something simple and conservative. I suppose this is human nature. Our ancestors gravitated toward human sacrifice on the instinctive belief that a deity that demanded human life has to be more powerful than one who wanted rice.

And I'm not knocking surgery, or surgeons, or other invasive procedures. In many cases they are critically important and life saving.

But let me tell you some stories.

The cardiologists have a remarkable technology called the stent. It's a tiny piece of metal that can help prop open a closing artery to restore blood flow. It's changed a lot of the way heart care is practiced during my career.

So it's only natural to extrapolate this technology to arteries of the brain. Instead of doing surgery, or using ho-hum medicines, we started putting high-tech stents into arteries supplying the brain, too.

Guess what? A study found boring old pills beat snazzy stents!

Here's another example:

For acute strokes, TPA is the big thing (I'm not going to argue about how effective it really is). But there's all kinds of things we can do beyond just plain old TPA. After all, how exciting is it to slowly drip some liquid into an IV line?

(crickets)

But it can be so much more exciting! What if we give TPA by threading a catheter all the way up to the brain and drip it right onto the clot? COOL! Or we could also use REALLY flashy technology ("technology always implies it MUST be good, doesn't it?). There are tiny gadgets we can thread all the way up to the brain, screw them (gently) into the clot, and pull it out (WOW! Like a cork!). Or another gadget we can use to punch a whole in the clot and restore blood flow.

Sounds all science fiction-y, huh? Well, we DO have the technology to do all those things.

But does it work? (Wait, who DARES ask such a question of advanced technology?!!!)

Um, no.

That's it folks. 2 studies (here and here) found that all this advanced stuff was no better than boringly watching TPA drip into an IV line. Ho-hum.

Now, the companies who make the fancy gadgets, and the doctors who use them, will gladly point out all kinds of flaws in the studies, and some of them may be legitimate. But some complaints, like "we need to select patients better," translate simply as "let's stack the deck in our favor."

In medicine we hear the phrase "Do something!" a lot. But usually we already are doing something. The problem is that many people think that unless it involves a lot of razzle-dazzle and medical voodoo, we aren't.

And in some cases that's quite far from the truth.

30 comments:

Mal said...

It's the placebo effect in action - or rather the lack of it.

Patients report more positive results when there is some ritual or procedure (even changing the color of a sugar pill can have an effect).

Surgery seems more impressive than a shot to the IV line.

Also, the waiting and uncertainty after a stroke sucks. The patient and the family want the reassurance that they - and you - are doing everything possible to ensure a possitive outcome.

Bringing in a rehabilitation specialist or physio to discuss recovery option as soon as possible could help.

Anonymous said...

This is even more appropriate in the management of back pain.

ER's Mom said...

Speak it, bro.

I tell patients that patience is a virtue. Tincture of time works well in many cases.

Moose said...

That's funny, I have the reverse problem. I can't get doctors to STOP trying to do things.

Very long story short -- don't give Bactrim to someone with anemia. The research is clear and dates back to 1975. (Plus, I had warned them up front that heavy doses of antibiotics cause a very low WBC and RBC in me. Their response was to be condescending.)

The "cure" for the resulting severe anemia is to stop taking bactrim and start taking iron pills. Not, repeatedly call the patient telling them they're going to die if they don't come in for more testing, then send them a registered letter telling them that they're at risk of DEATH!!!(!!!).

I'm going back in later today, I can't wait to ask them what they recommend I do so that I never am at risk of DEATH(!!!). They must have some fountain of youth for that, right?

Occam's Razor, man.

DRamsdell said...

Commenting at 4am Doc? You must be back from vacation or posting under the covers of your bed so the light from the laptop doesn't wake Mrs. Grumpy.

Anonymous said...

"Apparently, standing by the bedside and giving medications isn't enough for some people."

Wow, Dr. Grumpy, your post is making rather grumpy this morning.

The average patient who is sick and scared is probably going to ask for any and all potentially applicable meds and procedures that they read about in magazines or hear about on tv or from the mouths of their own physicians. They often don't have the means to conduct their own research to determine the efficacy of the various bullshit meds and procedures that are being pimped to them. I don't work in the medical profession but am reasonably well educated, and it is very difficult for me to sort out fact from fiction when I am presented with various treatment options for my condition. I just don't remember much of the chemistry and biology I learned in college 20 years ago, so it takes me a while to read through medical journals and process what is being said.

You can't blame the patients, blame the manufacturers and your greedy, unethical colleagues who put profit over the best interest of the patient and, unfortunately, make all of you all look bad.

Don said...

Technology can be wonderful, when used in an appropriate way. And designing it can be a heckuva lot of fun, speaking from a long career in mechanical design.
Yet, too often, the new technology that replaces older designs is, in a lot of ways inferior to the older designs. Many of the older designs were more robust, and lasted longer. But the new designs are snazzy looking, and show up well in the trade magazine ads.
I suspect this is the same in the medical field, whether with treatments or new, high tech gear.

bluetoothbuddha said...

I actually have a lot to say about how much of what we do for our patients is really necessary/ useful/ makes an effing difference at all.

So I won't.

I'll tell you a story, however, of my time as an intern in neurology.

Our professor was trying to quickly go around a thousand patients (it seemed like), when a patient's visiting carer, who was a cousin seventeen times removed, started going on about some Japanese 'magnetotherapy' treatment for cerebral stroke that he had read about on the in-flight journal.

The professor is like: "Well, I haven't really heard of it..."

And the carer goes, "You really should be up-to-date on these new 'cutting edge' therapies, that's the problem with medicine in India, etc."

He may have said 'state-of-the-art' or even 'miracle therapy'. It was a decade ago. Sigh.

Anyway, after quite a bit of this, the prof calmly takes the case notes from my hand and writes in an uncharacteristically legible scrawl, "Referred to Japan for magnetotherapy."

He was set on a forced discharge, and would even have gotten away with it, if it were not for other, closer, relatives of the patient, like his wife and children, affirming that they were happy with the traditional treatment.

The seeker of innovative therapies was packed off home, no doubt finding many more genuine, evidence-based, peer-reviewed medical research in between ads for duty-free booze and perfumes.

Packer said...

We buried my mother in law last week, she was 88. Sometimes the best thing is to do nothing, nothing at all, except hold hands.

So how was your vacation.

brent said...

Two comments: 1) what the establishment can charge for IV TPA is peanuts compared to what going to the cath lab and threading an catheder to the brain and inserting a stent would be (dang-I need to come up with a payment for my 3rd condo, hmmm).

2) I remember the wise words from one of my instructors 25 years ago. "Don't just do something, stand there!"

Q said...

I love TPA! And pills! And also all my doctors that refuse to put filters in me or clips into my baby aneurysm in my head. I've got a whopping case of Behcets disease, with all the fun rare add-on side effects, like getting the brain problems and the like. Last November I got a massive straddle pulmonary embolism kind of out of the blue, and a few DVTs.

Doctors put me in the ICU and put me on TPA plus Heparin and I sat there for five days and read a bunch of books while letting that drip do its magic. Totally worked, and now I'm alive. There was talk about some sort of daisy filter, but since I'm young enough (39) and healthy enough, except for this Behcets BS (weight is completely normal, I'm super healthy except for all the vasculitic problems in the world), we're keeping me off the surgical train for as long as possible.

I didn't realize there were major risks with TPA until after I got out of the ICU. Then again, I had no idea what a massive straddle PE was until much later either.

Anyways, so if I'm ever in your hospital, you probably won't hear me say 'do something', because I don't care that much. I figure whatever happens, happens. It'll all come out in the wash. But I prefer not to have bionic parts in me until later. Thanks.

Don said...

Just last week, my 18 year old male cousin developed a blood clot in his leg. It went from behind the knee up into his abdomen.

He lost circulation to his foot and was in danger of losing his leg.

The doctors did one of those high tech procedures, where they threaded a special catheter the length of the clot and dripped heparin into the clot.

The high tech method worked, and they saved his leg.

He is home now and is very sore, but a very lucky young man.

In their testing, the doctors said his veins are smaller than the average person. His Mom has 2 genetic defects, that have caused her to have problems with clots her whole life. It appears he is going to have similar problems.

Ivan Ilyich said...

Sometimes an invasive procedure is the better choice, but isn't known to be in advance. IvIg is an easy treatment for certain neuropathies, but does not always produce the desired result. The alternative, plasma exchange, is more invasive and requires high-tech equipment and specialized training to administer, but can be effective when IvIg is not.

I'm all for a conservative approach to medicine, but on the other hand think I'm very fortunate to have the advanced treatments of modern medicine available when needed.

bobbie said...

Several thoughts...

"Gimmee that ole' time medicine, la-la-la"...

Q ~ congratulations on being alive after a straddle PE!!!

And last but not least comes the burning question ~ how did Craig's hair do on vacation???

Anonymous said...

Call me naive or silly but...

I'm going to take the advice of an individual who has devoted his or her young adult life to studying the sciences during his or her didactic years, spent years on the wards in clinicals, rotations, and intern hours, followed by 3-4 years of residency, and even more time as a fellow or learning a sub-specialty...as opposed to the eye candy salesgirl or fast-talking brawn that gets pimped out to sell these expensive "cutting edge" technologies.

Stacey Gordon said...

I've often heard it said that the best medicine is to do as much nothing as possible.

Patricia Baley said...

Right there with you buddy. "Don't make it worse" should be stenciled on every patients forehead or whichever part of the body you tend to be looking at.

Also, "remember there's a person attached to this body part" but that's another rant.

Anonymous said...

Doing something = higher cost and more collections.

Studies have shown that when doctors or hospitals are closed death rates go down.

a.generic doc said...

If people want voodoo medicine, give them voodoo medicine. Dress up in a mask and poke needles in a doll as you write the prescriptions for the same old medicines you've been giving.

And in a short time, you'll have even more crazy patients to write about on the blog.

Loren Pechtel said...

I think there's another factor at work. The big saves normally come from the surgeon or other invasive procedures. Thus when the situation is grim they want the big save--something invasive.

Never mind that the invasive things are done when there is something they can fix, it's not an automatic solution.

Abigail Cashelle said...

I think you should just quote the Mad Hatter. "This is the real quote: Don't just do something! STAND THERE!!!"

It'll make them shut up... at least for a little while.

Abigail

Anonymous said...

My experience (as a nurse)has been that endovascular treatment is used if the time window for tpa has expired or if the tpa was ineffective and the interventionalists thinks he can safely go in after the clot, but Tpa is the first line treatment option. Is that not the standard practice?

Moose said...

Actually, there IS a term called voodoo medicine, but it's not what "a.generic.doctor" thinks.

Some say that voodoo death conjures work (if you accept that they do) because part of it is making sure the victim knows s/he has been slated for death. The mind is an amazing thing, and if you think you're going to die, well, you may not actually die but your health WILL be impacted.

Voodoo medicine is when doctors make predictions of death or disease based on zero scientific basis, typically combined with prejudice and/or laziness.

Voodoo medicine is when you tell a 25 yr old with low blood pressure that they had a stroke and are going to die within 5 years, with no confirming tests (MRI, CT, etc.), solely because the patient is fat.

Voodoo medicine is when you tell someone they have cancer solely on the basis of low red blood cell count, with no physical exam or other symptoms to justify the diagnosis.

Voodoo medicine is doctors practicing junk science.

burnttoast said...

Dr. Grumpy, you do not get it. In today's world of corporate medicine, the MOST important thing is money. The second most important thing is "Will this look exciting on a billboard or TV ad?". Nothing else matters. Outcomes? They don't think about that.

Anonymous said...

"New" and "improved" are NOT synonyms, folks.
Wait...synonyms...that is two different word that mean the same thing.
And every one of us gets to vote..and most can reproduce....scary beings, we humans.
Hope you all had a great vacation.!

OldSquid said...

It is one of my many reasons why healthcare is more expensive in the US. Robotic surgery for example. Outcomes are generally no better that laparoscopy surgery, yet you see hospitals touting the advancement of robotic surgery on billboards (at least we have in my town) and surgical specialties rushing to get trained.

thethingspatientssay said...

This is part of the reason that procedures are reimbursed so well while using simple, effective thinking and medications are seen as something that lesser trained individuals are capable of doing for much less.

Anonymous said...

TPA kills. Yes it can nicely bust up a clot. It can also cause a brain bleed leading to brain death, causing a family to have to make a decision no one should ever have to make.

Anonymous said...

Dr G -

would also add,
individuals can keep on "doctor shopping' until they find someone to
a. give them the answer/surgery/procedure/gadget they THINK they need/WANT, even if not ethical/medically sound. b. see "a"

magnone65 said...

I don't know if this was posted or not (too lazy to read all the comments) but I do hear this in the ER all the time. "2 pills! That's all you're going to do?!" But at least 50% of the time, in my head, I am saying "none of this would be necessary if you would have cared for your heath, even just a little, for the past 40+ years!"

 
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