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!