The war on sepsis.


A friend of mine posted this article:
It talks about the need for guidelines, checklists, various specialists, and simulation to improve medical care in the USA.

As we know though, despite all of these things, the US spends more on healthcare than any other country in the world. Several years ago the New England Journal of Medicine published a WHO study showing the USA was at best 42nd and at worst 47th in effectiveness of all the countries surveyed.

One of the things I noticed when I read the paper was that in order to fare worse, you had to go to Africa or any number of underdeveloped nations in the world.

With all sorts of specialties, technologies, guidelines, and checklists, the lack of effectiveness of US healthcare is often attributed to greed. But while reading this article, I am starting to have my doubts.

You see, in particular the UK, and more and more other countries are starting to follow the methods of the US healthcare system. While I have not seen any papers on effectiveness, many of the providers I talk to regularly seem to feel that the level of patient care and outcome where they are is noticeably decreasing.

The solutions seem to be basically doubling down on the same things that are already being done. More hyper-specialized medical practitioners, more expert consensus guidelines, checklists, simulators, and merit badge courses which must be regularly recertified.

I don’t harbor any doubt that these things have been, are, and can be beneficial. But what I have noticed is that these solutions were once adjuncts to good medicine, now they are the definition of good medicine. Like any crutch, it is just not as effective and an actual leg to stand on.
The first rule I ever learned in respect to resuscitation was “get ahead of the pathology.” In other words, anticipate and work to mitigate what happens next. I have noticed this takes a combination of experience and formal education. Basically learning what to expect when and then managing it before it becomes a critical issue.

Sun Tzu is credited with saying ““Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”

So here is how The Art of War applies to medicine…

Checklists, guidelines, protocols, merit badge courses, simulators, etc. are all tactics. They do not constitute a strategy and they are reactionary in every respect. “If/when you see X, then you do Y.”

Doctors for the most part practice reactionary medicine. A great example that I am proud to not be a part of is antibiotic therapy in women. You see, from experience, I know that when a female takes clindamycin they almost always get a major yeast infection. The same holds true when they are on multiple antibiotic therapy for actual or suspected STIs. So as part of my routine practice, I prescribe the fluconazole with the initial therapy with instructions to take it at least 3 days after the stopping of the antibiotics. Knowing what antibiotics do to upset the natural balance of microorganisms, I anticipate what pathology is next. I address it before it becomes a problem. Before the lady has to make another appointment and suffer to get relief. Some Gyns would suggest instead lactobacilli, but it takes time and doesn’t always work. I like to go right for the money shot. Patients seem to appreciate it.

The same is true in the ICU. You can wait until you see clinical signs of XYZ, but in many patients, my colleagues and myself can tell you it is simply a matter of when, not if. Sepsis in children is a great example. A septic child in decompensated shock can have a normal BP, a normal pulse, and a “normal” urine output. That is to say the volume of urine is normal. (The content is not) If you do not anticipate an abnormal content, there is no reason to test for it. Treatment can be delayed until the child crashes, which is usually when they start to actually “look bad.”(active dying in a child usually looks bad) Of course at this point resuscitation attempts are often futile.

Putting this in the context of the “outside facility” mentioned in the article, many outside providers are usually in deep before they realize a transfer to tertiary care is needed. At the same time, they are operating with the purpose not to need to refer every patient to tertiary care. They know the surviving sepsis guidelines. They know ACLS. They are skilled at following guidelines. They are likewise shocked when they don’t work. Some even protect their sanity by the idea “sometimes no matter what you do shit happens.” (Which is true, I just doubt as often as they accept.)

Medicine in general has a known strategy that is taught in every medical school I have ever heard of: Primary prevention, which is preventing the disease to begin with. Vaccinations, Well child checkups, industrial safety, public safety, are all examples of the strategy of primary prevention. Secondary prevention: Stopping the disease from getting progressing or slowing its progression. This is where a major part of medicine fails. You see, most doctors believe that secondary prevention is exclusive to the primary care provider. (Note to Emergency docs, in 2014 you are a primary care provider! Your opinion on whether or not you should be is not relevant to the fact.) But many specialty doctors, and surgeons especially, do not even consider, much less practice secondary prevention. But it is still a relevant part of the strategy, just on a smaller level. It is the practical application of anticipating what happens next and taking steps to prevent it. Here is an example. Whether or not you practice vascular or cardiac surgery, you operate on blood vessels. You know the parts of these vessels. You know about the clotting cascades. You know when you expose vWF you are going to have clotting. That is why these patients are heparinized, to prevent their condition from worsening. The same holds true in resuscitation. Your prevent hypothermia in trauma patients because it causes clotting disorder. You do not wait until your trauma patient has a clotting disorder to warm them. You anticipate and stop the disease process from worsening! The final part of the strategy is treatment, attempting to return the patient to as close to normal as possible. All the drugs and surgeries and stuff are tactics to effect these strategies.

If you are practicing in a reactionary way, you are simply making noise before your defeat. All the guidelines and simulation in the world will not help. A million super-specialists doing the same will not help. You will spend a lot of money doing it. Your outcomes will not be better.

You must think and act differently. You must act before you are forced to react. You must anticipate; in order for that you need education on how things work and why. You need to think strategically, not just tactically. Do not forget secondary prevention! Stop the disease from getting worse.

Nobody was ever septic before they had an infection. The next time you hear “it is just a virus” remember that opportunistic infection is secondary to viral infection. If you are worried about antibiotic resistance, don’t. The theory of conservative antibiotic administration is fundamentally flawed at the basic biology level. Plus, I offer you my loyal assurance, as soon as there is a market for newer better antibiotics, a lot of smart people will get a lot of money to make them. All organisms evolve over time, the idea a single treatment will always work forever is just stupidity. Don’t leave that kid to get better or worse on their own. Prevent them from getting worse. That is the secret to better sepsis care.


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