Tuesday, 20 January 2015

The Art and Science of Clinical Decision Making

Clinical decision making is an important skill physicians utilise in their daily work. It may not be well taught in medical school as a distinct process, but knowing how physicians think, come to a diagnosis or generate a list of differentials, and make a decision on testing or treating, is an important first step in figuring out how the process work and how to make the best decisions.
Take this real case as an example:
A middle aged man with a past history of hypertension and old stroke with good recovery presented to the ED after he was punched repeatedly in the face and head. There was no loss of consciousness nor amnesia, but patient complained of dizziness and 2 episodes of vomiting at presentation. There were no neck complaints or other injuries.
GCS was 15, there were bilateral periorbital swelling, abrasions on the face as well as minor scalp hematoma and lacerations. There was no neurological deficit and cervical spine was examined normal. CT head was reported as no acute intracranial hemorrhage or infarct and CT face showed right orbital floor and left medial orbital wall fractures. ENT and EYE doctors on duty both saw the patient, were happy with their evaluations, and patient was discharged with close followup in the SOC.
However, patient represented 36 hours later with persistent dizziness and 3 further episodes of vomiting. At the morning of presentation, wife found patient slightly drowsy and he also complained of pain around both eyes and generalised weakness. Right pupil could be seen and was reactive and brisk. Left pupil was obscured by eyelid swelling. Neurological exam was repeated, determined to be patient's baseline and neck remained supple. A repeat plain CT brain was performed, and reported with findings as before; there were no suspected intracranial bleeding, delayed or otherwise.
Should we now proceed to dispose of this patient as post-concussion syndrome with admission or observation? Or is there something else?
Post-concussion syndrome is a possibility here, and the diagnosis is made based on a heuristic known as 'pattern recognition'. It doesn't require much thinking, and we draw upon our past experience or exposure to similar cases or patterns of presentation.
In this case, a patient presenting with minor head injury as the initial problem, now re-presenting with probable neurological complaints of dizziness and vomiting, must be having a condition related to the head injury in the 1st place (or so we assume).
But, this type of heuristic thinking may be fraught with certain biases, like anchoring bias and premature closure.
So, the ED team switched to another type of heuristics, this time using analytical thinking. We simply sat down and thought about the other differential diagnoses that were possible with this patient's re-presentation, and worked through the patient's symptoms, signs, and probabilities for each of the differential. Of course, we had a bit of help from Google's friendly search and Uptodate.
Not surprisingly, one of the differentials came out as a prime suspect. The gummed up left eye of this patient, in which we could not see the pupil, had a hazy cornea. We called EYE to come put a tonometer on patient's left eye as we suspected traumatic secondary glaucoma. The pressure in patient's left eye measured 80 mmHg. The diagnosis was made, and patient was immediately started on eyedrops and azetalomide.
If we had admitted the patient as before, he might not have the diagnosis made until many hours later when the respective specialties perform the reviews as inpatient. Who knew if the patient's sight might or might not have been compromised.
Therefore I urge all readers to read the following article on "The Art and Science of Clinical Decision Making", examine your thought processes and clinical decisions as you continue  in your daily practice. You will be surprised and amply rewarded.

Saturday, 17 January 2015

Webucation 17/1/15

This edition of web wisdom brings you weird and wonderful and in rainbow colours as well. Be sure to credit the original content creators.
The last link provides yet another example of how the world is collectively wisening up to the dangers of irradiation and importance of wholistic care.

Sunday, 4 January 2015

Checked on my own list

So our 1st post of the new year will serve a reminder to me most of all rather as education for others. Its about not spilling blood.


A patient with COPD and IHD presented with SOB and a wheeze to the department and bronchodilators were started with a normal looking CXR.
He was looking much better but suddenly went into a malignant broad complex rhythm and was promptly defibrillated. ROSC was achieved in a few minutes and a decision was made to intubate him for hypoxia as well as post arrest airway protection.
A RSI checklist was commenced and I was asked by a competent nurse whether a 2nd IV line was needed. For a brief few seconds I thought about forgoing that step and to quickly proceed with what looked like a difficult intubation and the myriad of complicated following steps...
Somehow and from somewhere, cooler thoughts prevailed and I got an available med student to insert one under guidance.
In compliance with Sod's Law; prior to intubation, blood was seen to be leaking from the trolley and pooling on the floor from the site of the accidentally avulsed 1st IV line.
Disaster mitigated, undoubtedly, by nurse and papyrus safety net!
Last line of this masterpiece by "The Boss" goes - God have mercy on the man who doubts what he's sure of.

Our checklists can be found here.
The debate (funny one) rages on here.
Extreme checklist mania here.

Have a fruitful 2015.

Thursday, 25 December 2014

It's Christmas, should you go watch a cartoon movie with your kid?

So, Frozen is my 5 year old daughter's first full length animated movie. It still makes her excited, even after > 10 viewings (counting home and school), and possibly > 100 plays of "Let it go".
The only downside, is the fact that I have to counsel her on two counts: that Hans REALLY is the bad guy, and that Anna did not really die. ("Phew!")
As the festive holiday comes, and I think about what other cartoon movie I might want to screen at home, I read a clever article published in this Christmas edition of BMJ, aptly titled: "CARTOONS KILL: casualties in animated recreational theater in an objective observational new study of kids’ introduction to loss of life"
In this study, the authors gleefully reviewed on their own TV screens, 45 top grossing children's animated movies, with a comparison group of 90 top grossing adult movies (Fabulous methodology). The primary outcome was the elapsed time of film on which the first on screen death of an important character occurred. For secondary outcomes, authors note two contextual factors which could be particularly traumatic for children: instances when the first on screen death was a murder, and instances when the first on screen death was of a parent of a main character. Data was collected by trained research assistants with a standardised coding protocol, and a panel of film critics (amateur) resolved ambiguous or unclear events by consensus. 
What were the results? Interestingly, the risk of on screen death of important characters was higher in children's animated movies than in comparison adult film (hazard ratio 2.5, 95% CI 1.3 to 4.9). The risk of on screen murder of important characters was also higher in children's animation (hazard ratio 2.78, 95% CI 1.02 to 7.58). 
The authors conclude:
  • Important characters in children’s animated films die more quickly than important characters in dramatic films aimed at adults
  • Children who watch animated films are often exposed to scenes of murder
  • Children who watch animated films are not spared gruesome causes of death such as gunshots, stabbings, and animal attacks
There already is too much death and violence in western TV, and children watch too much TV anyway. Better think twice before the next Disney cartoon movie; maybe I should bring the kids instead to Disney on Ice. 
For the adults, I recommend "The Grand Budapest Hotel". It is really good.

Friday, 19 December 2014

Bronchiolitis revamp

This article is from Medscape Emergency Medicine Briefs:

AAP Releases New Guidelines on Management of Bronchiolitis CME/CE

News/CME Author: Laurie Barclay, MD

CME/CE Released: 11/19/2014 ; Valid for credit through 11/19/2015

CLINICAL CONTEXT

On the basis of recent evidence, the American Academy of Pediatrics (AAP) has revised its 2006 clinical practice guideline on diagnosis and management of bronchiolitis in otherwise healthy children 1 to 23 months old. Each practice statement includes the underlying level of evidence, benefit-harm relationship, and level of recommendation.
Bronchiolitis is commonly caused by viral lower respiratory tract infection and is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, resulting in increased mucus production. Typical signs and symptoms initially include rhinitis and cough, sometimes followed by tachypnea, wheezing, rales, use of accessory muscles of respiration, and/or nasal flaring.

STUDY SYNOPSIS AND PERSPECTIVE

Management of bronchiolitis in children 1 to 23 months old no longer requires testing for specific viruses or a trial dose of a bronchodilator, according to new guidelines issued by the AAP and published online October 27 in Pediatrics.
According to a comprehensive evidence review, the new AAP guideline on diagnosing, treating, and preventing bronchiolitis updates the previous recommendations published in 2006. It targets pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children.
Bronchiolitis is the most common cause of hospitalization among infants younger than 1 year. The new guideline emphasizes that only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.
"Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants," write Shawn L. Ralston, MD, FAAP, and colleagues from the AAP. "Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring."
Changes from the 2006 guideline are that testing for specific viruses is no longer needed, because multiple viruses may cause bronchiolitis. Routine radiographic or laboratory studies are also unnecessary, and clinicians should diagnose bronchiolitis and assess its severity on the basis of history and physical examination.
The AAP also no longer recommends a trial dose of a bronchodilator, such as albuterol or salbutamol, because evidence to date shows that bronchodilators are ineffective in changing the course of bronchiolitis (evidence quality: B, strong recommendation). In addition, in accordance with a policy statement published in July by the AAP, the new guideline updates recommendations for use of palivizumab to prevent respiratory syncytial virus (RSV) infections: Otherwise-healthy infants with gestational age of 29 weeks or older should not receive palivizumab, but during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).
Other recommendations are that when making decisions about the assessment and management of bronchiolitis in children, clinicians should evaluate risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency. Finally, clinicians should not give epinephrine to infants and children diagnosed with bronchiolitis, nor should these children receive chest physiotherapy.
The authors have disclosed no relevant financial relationships.
Pediatrics. Published online October 27, 2014. Full text

STUDY HIGHLIGHTS

  • A new recommendation is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
  • Clinicians should diagnose bronchiolitis and determine its severity on the basis of history and physical examination.
  • Routine radiographic or laboratory studies are unnecessary.
  • When considering the evaluation and management of bronchiolitis in young children, clinicians should assess risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency.
  • A new recommendation is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis (evidence quality: B, strong recommendation).
  • Only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.
  • Otherwise-healthy infants with a gestational age of 29 weeks or older should not receive palivizumab to prevent RSV infections.
  • However, during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).
  • Infants and children diagnosed with bronchiolitis should not receive epinephrine or chest physiotherapy.
  • Infants with a diagnosis of bronchiolitis in the emergency department should not receive nebulized hypertonic saline.
  • However, infants and children hospitalized for bronchiolitis may receive nebulized hypertonic saline.
  • Clinicians may choose not to use continuous pulse oximetry for infants and children diagnosed with bronchiolitis.
  • Infants and children with bronchiolitis should not receive antibiotics unless there is a concomitant bacterial infection, or a strong suspicion of such an infection.
  • Infants with a diagnosis of bronchiolitis who cannot maintain oral hydration should receive nasogastric or intravenous fluids.
  • All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis, or hand-washing with soap and water when alcohol-based rubs are not available.
  • Clinicians should encourage exclusive breastfeeding for at least 6 months to reduce the morbidity of respiratory tract infections.
  • When evaluating a child for bronchiolitis, clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and should also provide counseling on smoking cessation.
  • Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention in bronchiolitis.

CLINICAL IMPLICATIONS

  • A new recommendation in the updated AAP guideline for bronchiolitis is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
  • Another new recommendation in the updated AAP guideline is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis.

Saturday, 13 December 2014

More trouble in deWinter...

Dr Amal Mattu from Maryland shares another case of an early warning indicator in ECGs. He advocates this and other early signs of proximal occlusions to be STEMI equivalents. He will probably be proved right in the coming years. 



For another of his talks on deWinter, see here.

For more of his vids or older cases, go to www.ekg.umem.org

Monday, 8 December 2014

Webucation 8/12/14


Webucation took a break due to some holidays but is back with pearls from radiology, cardiology and paeds philosophy. As always pls credit the content creators.


The last link resonates with a lot of older physicians and docs who still practice without blood tests or CT scanners (some through no choice of their own). We think the community will be fine so long as agree that we need guides, not rules.