Sunday, December 24, 2006

Publication Frustration

If I were my 13-year-old son, I think my response to this article would be "well, duh!" As it is, my response is hardly suitable for a family publication like this. From the conclusions in the abstract (all that's available without a subscription):

The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS (trauma injury severity score), although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP (Child-Turcotte-Pugh) C criteria must be considered when determining outcomes for patients posttrauma.
OK, let me review:
Cirrhosis? Bad. Cirrhosis + Trauma? Real Bad.

Did we really need yet another publication to get that simple point across? It's as if the authors of this retrospective review of their trauma patients seem to think that us hick surgeons in the sticks don't understand basic medicine. Oh, and although they offer ab-so-lute-ly no evidence in support of this statement, the last sentence in the article contains this gem:
These patients should be considered high-risk patients and should be cared for at a Level I trauma center.
OK. I get it. These are sick patients. In fact, this review of statistics at the authors' own Level I trauma center demonstrated a 64% mortality rate (9 out of 14) for trauma patients with Child's Class C cirrhotic patients --- so what exactly do they feel that a Level I center can provide that a Level II center cannot for these patients when they have demonstrated such a dramatic mortality rate? Well, the article holds no such answers.

Of course, when faced with a drunk driver who has just driven his VW Microbus into a telephone pole and is covered with blood and vomit, the first thing I do is calculate his Child's classification. What rubbish!! Our job is to care for the patient, and it would not be readily apparent that a patient had significant cirrhosis upon presentation --- when his most critical care will be delivered. I guess we should have a crystal ball available so that we can simply whisk the Child's C patients (but not the As or Bs!) off to the Miracle CenterTM with the Level I designation provided from on high.

What most of these number crunchers fail to realize is that trauma severity scores, Childs classifications, and a whole host of other "scoring" systems that have been developed to statistically analyze patients have absolutely no -- none, nada, zilch, the big goose egg, zippo -- clinical utility when we are actually caring for a patient. Clinicians do not calculate patients' "scores" while caring for them to make decisions; the final score tallies are often not done for days (if not ultimately at discharge). As a result, they are helpful in retrospective reviews of treatment, but by their very nature cannot be utilized to make prospective care decisions. Until these authors, or anybody else, can come up with some treatment strategies that differ from our current mode of therapy based upon CTP classification in trauma patients, I would suggest they report the facts and not make sweeping suggestions that "all such patients should be treated at your local Miracle CenterTM."

Sorry for the rant --- since I had to work on Christmas Eve, I thought I would catch up on my journal reading. Big mistake! Have a Merry Christmas!

The Train, The Train

Being sort of obtuse, I often find it useful to try to explain things to patients and their families using metaphors that make sense to the two Betz cells desperately clinging together for survival in my skull. I guess that is also the reason I pepper these random blog posts with pictures --- it seems I never graduated from the Dr. Seuss phase of my life.

In any event, I am not infrequently faced with presenting options regarding chemotherapy. I am not a medical oncologist, but it is certainly common (and, I think, normal) for patients to ask the opinion of the guy they let open their body cavities when they are weighing the pros and cons of chemotherapy. Given my innate inability to think creatively, I of course turned in my search for a suitable metaphor to that great guiding light of my misspent youth -- TV. Being a mere youngster at age 44, that means that glorious period in TV history dominated by the master of schlock, Aaron Spelling --- big hair, big b**bs, small plots. All in all, probably very bad juju for a teenage boy.

But which of these great shows would be best as a starting point? Starsky & Hutch, The Love Boat, Dynasty, TJ Hooker, Vega$? No, I had to look to the epitome of Western civilization in the 1970s -- Fantasy Island! Who could forget Tattoo shouting "Boss! Da plane! Da plane!" Ah, memories --- what, you haven't watched these over and over yet?

Da plane! That was it! And so, for a while I thought that taking a plane ride would be a reasonable way to explain chemotherapy --- you pay (a high) price for a ticket to reach a certain destination, and you cannot reach that destination easily in any other way. But I found as I thought about it that a plane ride really doesn't explain easily the potentials that a course of chemotherapy, or radiotherapy for that matter, can present. Fortunately, I didn't blow a fuse coming up with another, similar yet hopefully more helpful metaphor. And I can still pretend I'm Tattoo ---- Da Train! Da Train!

I think I can best explain what chemotherapy means to (most) patients is by describing that it is sort of like taking a train ride. One can get on a train in, say Denver, and plan to travel to Chicago. But there are two important things to remember about that train:

  1. There is no way to play "catch-up." In other words, if you plan on making it to Chicago --- if you plan to achieve the maximum benefit from a proposed course of therapy --- you have to get on in Denver, as there is no way to run the train down in Omaha and get on there without a whole lotta cost to your potential outcome.
  2. The train makes stops. If you get on the train with full intentions of making it to Chicago, but for one reason or another --- if you are simply flat done in by the therapy --- there is no train conductor that will force you to continue all the way to your destination. You can get off in Omaha or Des Moines, or anywhere else you feel like.
Of course, some train rides are considerably longer --- and more exhausting. Some trips require the traveler to get off and reboard a different train, or even change courses entirely. And some patients require series of different "rides" on different trains in order to reach their ultimate destination.

Some patients, presenting with disease that is beyond our current therapies, can never reach the destination they desire more than any other --- a cure. This is the most difficult scenario for me to approach of all, as it feels as if I am walking a tightrope between offering a pessimistic outlook and one that is overly optimistic. However, if we appropriately counsel these patients that a reasonable degree of palliation while trying to preserve a reasonable quality of life is a worthy goal, then they can "board the train" with realistic expectations ---- and when it is plain that staying on the "train" has limited or no potential for further "travel," it is easier for the patient and their family to get off the ride and stop the treatment.

And then, at the risk of stretching this metaphor to a breaking point, neither we nor they will "Train in Vain."

Saturday, December 09, 2006

Saturday morning surprise, surprise, surprise

I have to admit, I was surprised. After this year's election results, and all of the speculation and posturing that ensued, I seriously doubted that the outgoing Congress would make any serious attempts at legislation during the "lame duck" session. So, it was without warning that coffee spewed from my nose while I took in this morning's paper --- buried in an article (I can't find the original one from my paper online) about a last minute massive bill was this little tidbit:

Also driving the massive bill was an effort to prevent a 5 percent cut in Medicare payments to doctors scheduled to take effect Jan. 1 under a complicated government funding formula.
I will freely admit that this was a surprise, and one of no small magnitude. I don't anticipate that it will last forever, as the cold hard realities of Medicare funding will at some time catch up with us, but it's welcome just the same. At least 37% of my patients are Medicare recipients (with a much higher percentage if we look only at inpatient consults), so a 5% or greater reduction in payment gets my attention --- not to mention that all of our contracts are based upon RBRVS formulas, so we would absorb that reduction for insured patients as well.

Now, if I could just get the coffee grinds out of my nostrils....