Advanced Trauma Life Support

I just attended a two day course to certify in advanced trauma life support, a requirement for ICU fellows. On the one hand, it seems like there's some formal certification process for every little thing these days, but on the other hand, I did learn a bit. Whether certifications make a difference at all is a topic for a different blog. But ATLS training is designed for surgeons, emergency physicians, and other physicians who might encounter the surgical trauma patient. It covers the initial triage and assessment of victims of penetrating and blunt injuries, from gunshot wounds to stab wounds to falls to car accidents. We learn the skills to place chest tubes, decompress blood from outside the heart, and place splints. Some of the material involves things I know well - how to secure an airway (taught at a very basic level) while other things I seldom encounter (when was the last time I saw a gun shot wound at Stanford?). Interestingly enough, much of the material I remember from being a medical student in the trauma intensive care unit at SFGH. Ultimately, I think it's unlikely I'll be the lone responder for a trauma patient, but I suppose it's good to refresh my knowledge of trauma care.

Image is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Innovation

"Discovery is seeing what everybody else has seen, and thinking what nobody else has thought." - A. Szent-Gyorgyi.

Medical innovation struggles with an odd paradox. Those who understand medicine the best - health care providers, physicians, nurses, therapists - tend to be risk-averse late adopters. We shy away from innovation. We do things "because that's the way they've been done." The training is so long that by the time we're done, we have trouble thinking outside the box. There's a reason for this. We don't want to "experiment" on our patients. We worry that deviation from a standard of care will cause patient harm or invite lawsuits. We self-select into this career because we're risk averse; we want a stable job with a defined path to get there.

Innovators, inventors, and designers, however, must think outside the box. They break out of the norm, find creative solutions, and reframe problems in different lights. They don't mind trying and failing. In fact, failure is the iterative process by which they improve their approach to problems. My friends who are entrepreneurs think totally different than me and are willing to accept a much larger measure of risk. They carve out their own path in the world, and when things deviate from the expected, they get excited.

In order for us to push the boundaries of medical innovation, we need to weld these two approaches to problem solving. Whether it is training one group to think like the other or building multidisciplinary teams, I think the future lies in the medical innovator who understands what it's like to be a doctor but sees things like an inventor.

Sorting Through Surrogates

Similar to the previous situation, ethics consults are occasionally obtained when it's not clear to the treating team who the surrogate decision maker is or how to navigate conflicts between decision makers. In California and by our policy, a surrogate decision maker can be anyone who knows the patient and his values well enough to make decisions on his behalf. There is no predetermined hierarchy of relationship; a neighbor may be a better surrogate than an estranged spouse who hasn't seen the patient in a decade. It's not uncommon that we find ourselves in complex family and friend relationships with multiple spouses, children, cousins, friends, and parents who all want a say in medical decision making. We hope that all the stakeholders are on the same page and work together to determine what's best for a patient, but this is rare. Especially in the intensive care unit, situations can be emotionally-laden and challenging to achieve a consensus. Furthermore, it's quite important to identify a single spokeperson if possible. Having been in a lot of these situations, I find that having a point person for the medical team to communicate with who then distributions information to the rest of the family is much more effective than having too many people giving and receiving too many messages.

The ethics committee is a good tool to sort through these issues when they get complicated. We are willing to take the time, speak to all the players, navigate the conflicts, and pinpoint the relationships between all the relatives and friends with the patient. By divorcing ourselves from the treating time, we can maintain a little more objectivity in assessing the appropriate surrogate. When conflicts develop between key decision makers, we can broker that communication, almost playing the role of a counselor.

Representing Patients

One situation when an ethics consult is required is the case where a patient is unable to make decisions for himself and has no one to make it on his behalf. It's fairly rare, and pretty sad when we a patient in this situation, but it happens. An immigrant whose relatives we have not been able to reach has a stroke and is in a coma. A homeless man comes in with a rampaging infection and needs surgery. While a procedure or surgery can be done emergently if someone's life depended on it, other more nuanced decisions need a decision-maker. We feel that patients with no representative are some of the most vulnerable, and as a result, we mandate an ethics consultation in the case of any decisions that normally would require a patient or surrogate's consent. That way, we don't have unquestioned medical decisions. From the ethics team, we've consented for blood transfusions, surgeries, and changes in the care plan for patients who cannot communicate their wishes and have no family or friends to speak for them. We hope that this way, we do the right thing for all of our patients.

Clinical Ethics

I spent my elective time working with the clinical ethics service at our hospital. Few people are aware of the ethics consult team; I think I was probably a couple years into residency when I learned who they are and what they do. In fact, most large hospitals have a clinical ethics consultation service. Modern medicine can involve so many complex decisions, moving parts, uncertainty, decision-makers, and competing interests that occasionally, situations arise where the right thing isn't completely clear. A patient with near-certainty of death has a family who wants everything done. An unidentified trauma victim has nobody to make decisions on his behalf. A committee has to decide how to allocate organ donation. A parent demands treatment for her child based on irrational fears. The scare of Ebola asks how much danger we expose our practitioners to in the care of potentially infected patients? How do we navigate these situations? How do make sure we aren't violating any ethical (or legal) principles? How do we justify the decisions we make?

The ethics committee at Stanford is a multidisciplinary committee co-chaired by a physician and a non-physician (a PhD ethicist). It consists of physicians of different specialists, nurses, residents, therapists, community laypersons, and community physicians. When we are called for an ethical dilemma, we examine all the various factors playing into the situation, from medical facts to achievable goals to patient (or surrogate's) desires to quality of life. We work very closely with the palliative care consultation team, and occasionally with risk management (the legal team) to ensure a comprehensive look at the problem. We meet with the patient, the family, the medical team, and the consultants. And hopefully, we provide an objective, ethics-centered way to navigate the dilemma. Sometimes, it is a simple as backing up and supporting the medical team (ie. a second opinion). Other times, we have to examine the law and policy to determine whether an intervention is appropriate. Each case is individual and different, and spending several weeks with the ethics team taught me a lot about how to think about cases in this related but nonmedical framework.

Gone Fishing

Sorry about the lack of posts. I've been tramping around New Zealand on vacation. We visited the south island which is absolutely gorgeous, did the Heaphy track on the north side, seeing a whole smattering of different ecosystems, then traveled down to the south tip to do the Hump Ridge track. We saw tons of sheep, dolphins, and birds, ate amazing food, kayaked on beautiful lakes, visited dozens of waterfalls, and slept a ton. I had expected to have more internet access, but even when I did, I got distracted from blogging. We'll hopefully be back on schedule shortly.

A recent Medscape Physician Lifestyle Report finds that critical care physicians are the most burnt out specialty at 53%, though anesthesiologists a little better at 44%. Burnout (loss of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment) has increased substantially since the last report two years ago. This is a big deal. Half of physicians have these negative reactions to their job. And as a critical care fellow, I see a lot of it reflected in my peers, my trainees, and my supervisors. Burnout affects health, physicians leaving their jobs, risk of suicide, and patient outcomes. If any other industry had half their workers this unhappy, changes would be made. Most of the causes of burnout are bureaucracy, work-hour, income, and loss of autonomy related.

In any case, I bring this up because the survey mentions that perhaps outside activities like spending time with family, travel, exercise, reading, and cultural events may reduce our work-related burnout. I feel so much more recharged after this vacation. I'm more alert, attentive, interested, and excited to jump into clinical practice. Encourage your physicians and peers to take time off and watch for feelings of burnout.

Mr Clean

Medicine changes incredibly quickly. Since graduating medical school five years ago, our therapeutics have evolved dramatically; even in the last year, I'm seeing noticeable changes in the way we treat major diseases. One great example is stroke therapy. When I started medical school, I was taught that ischemic strokes are treated with medications and only in very limited circumstances (within three hours of the stroke onset). In my clinical years, I heard about endovascular therapies where an interventional radiologist or neurologist goes in with a cannula to try to remove a clot, but at that time, it was only for strokes in particularly troubling territories (basilar artery, posterior circulation). Perhaps it was around that time when studies helped relax the tPA window to 4.5 hours.

In the last year or so, we've been seeing way more patients going to the catheterization lab for interventional endovascular therapies. Newer devices such as the one shown above give a proceduralist more ability to do clot-directed interventions. A host of trials including the recent MR CLEAN trial have supported the use of IR-based therapies like this. Hopefully we are reducing the morbidity of strokes, which are so common and can be so devastating. But it's also increasing the cost of medical care. I can't imagine where things will be five more years from now.

Image of the mechanical thrombectomy device is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

The Macrobiome

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Names of Clinical Trials

I'm not sure who started it, but at some point, some investigator decided to create cute acronyms for clinical trial names. Large clinical trials often have bulky, unwieldy titles like "Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands." We started giving these trials acronyms, and this, fortunately, shortened to "MR CLEAN." Some liberties are always taken to get that memorable acronym. "Bisphosphonate and Anastrozole Trial - Bone Maintenance Algorithm Assessment" shortens to "BATMAN." There are trials with the word "SMART," "AWESOME," "HOPE," and "CURE." Some are named after Greek Gods. Others like "VICTORY" and "TORPEDO" are just amusing. However, trial names with cute acronyms aren't just for giggles; someone looked at this and realized a memorable name means a trial is cited more often and probably remembered by our medical students a little longer.