there are rules and then there are rules

Tuesday, June 19, 2018

According to commentators and purists, Phil Mickelson did something bad this weekend. He willfully broke one of the rules of golf to minimize that damager that an errant putt might have caused him. Not only did he break the written rule, but he also broke the intention of the rule book, and that is supposedly a mortal sin, whether playing in a tournament or having a leisurely round of golf with friends.

In medicine, rules are probably the lowest in the hierarchy of clinical decision making and taking action to care for a patient. Rules, guidelines and protocols are not the same. Clinical rules in medicine help measure potential for both good and bad outcomes. A rule is developed to help with guidance for a specific clinical situation and the doctor at the bedside needs to decide whether they are appropriate to use.


The Canadian Head CT Rules help decide whether a scan is appropriate to perform in a patient with a head injury. If the patient meets all the criteria, then a scan may not be needed…but there are caveats. It has been validated for patients from age 16 to 65, and may not be used in the pediatric population. PECARN (the Pediatric Emergency Care Applied Research Network) has developed rules for head injury in that age group. But should a doc use the Canadian or PECARN rules for a 15-year-old football player who is 6 feet tall, weighs 200 pounds and looks like an adult? The rules of nine, help measure the body surface area when caring for burn victims and calculating how much skin has been burned. It needs to be modified for infants and children whose heads are larger compared to the rest of their body, and some studies suggest the rule doesn’t necessarily work for people heavier than 80 kg (176 lb.)



Guidelines are written from a clinical perspective to help guide the medical care of patients. Rules may be used to develop guidelines ort may be incorporated into them. The American Heart Association routinely publishes and updates guidelines on the steps to care from acute emergencies like heart attack and stroke to guidelines on controlling chronic conditions like high blood pressure and high cholesterol. But there may be completing guidelines for the same situation and it is up to the doctor and the patient to decide what might be the best treatment strategy to consider.

  • The American Academy of Family Physicians and the American Urological Association sometimes spar about the use of PSA, a blood test to screen for prostate cancer.
  • For cancer patients who develop blood clots, treatment options recommended by the American College of Chest Physicians and the National Comprehensive Cancer Network differ. One isn’t right or wrong; both are out there.

Protocols are rigid. They are a recipe with specific steps that need to be taken when caring for a patient. Often, they are provided by a medical provider to allow others to care for patients. Imagine EMTs or paramedics caring for patients at the side of the road or nurses working in an extended care or nursing facility.

So the sequence might look like this. A doctor caring for a burn patient would use the rule of nines to calculate the percent of the body that was burned. That percentage would be plugged into the Parkland formula to calculate, as a guideline, how much intravenous fluid that would be needed to rehydrated the patient and the hospital protocol would require that all major burn patients be transported to a burn unit for further care.

The art of medicine is to keep up with the rules, guidelines and protocols and understand that they are ever changing. There may be times when it is appropriate to deviate from the mainstream recommendations when the individual patient may benefit. The standard line is that guidelines and protocols work until they don’t. In that way, Phil Mickelson and the medical community have found common ground. Rules can be bent or broken when the goal is to maximize benefit.

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narcotics, alcohol and smoking

Tuesday, May 29, 2018

There is an opioid epidemic in the United States. Whether it involves prescription narcotics or street drugs, people are overdosing and dying from drug abuse. Understanding how narcotic naïve people went from no use to death is important to understand, and it’s also important to know how some pharmaceutical manufacturers helped stoke the fires of narcotic addiction, but it’s also important to question our societal outrage when it comes to the consequences of narcotic abuse.

There are two major sources of opioids:

  • Prescription medications like oxycodone (Percocet, Oxycontin), hydrocodone (Lortab, Vicodin), tramadol (Ultram)
  • Street drugs like heroin and fentanyl (which is normally a prescription medication that is easily manufactured in street labs)

A confluence of unfortunate circumstances came together many years ago to cause an excessive number of narcotic prescriptions to be issued by health care providers.

  • There was a societal push to consider pain as the fifth vital sign (after blood pressure, heart rate, respiratory rate and temperature) and regardless of the reason for a medical visit, patients were asked about their pain. In the office for a routine blood pressure check…how would you rate your pain today? Teenager visit for a pre-participation physical…how would you rate your pain today? Cancer patient in for palliative care…how would you rate your pain? A subjective pain scale of 1 to 10 was used (and a smiley face, frowny face equivalent for little kids). Presumably, the expectation from either doctor, patient or both was that the goal was a pain rating of zero, regardless of how many drugs it took to get there. Federal mandates still demand that the pain question continue to be asked.
  • About the same time, corporate medicine began using patient surveys to rate provider satisfaction. How well did the doctor, nurse practitioner or physical assistant met your needs as a patient? The satisfaction metric rested next to productivity as an influence on salary and other benefits. If a patient was unsatisfied that their pain was not completely gone, then the doctor’s income could be negatively impacted. It was another impetus to aggressively prescribe pain pills.
  • And then there was Purdue Pharmaceuticals, maker of Oxycontin, a long acting narcotic pain pill. If only there was a wonder drug that could control pain and yet not become addictive, the world would be a better place. It seems that Purdue aggressively marketed their pain drug as just that, non- addictive, presumably backed by research that confirmed that contention. Providers started to write prescriptions and patient addiction grew quickly. It seemed that Purdue management had failed to act ethically when it came to their pursuit of profit.

Increased funding will be needed to address the opioid epidemic. In 2016, 116 people died every day from drug overdose. According to researchers, the opioid abuse will cost the US economy about $200 billion in 2020. In an article published in the Journal of the American Medical Association Journal-Psychiatry, authors from the Harvard University and the University of Michigan called on Congress to increase research funds, monies to purchase naloxone, the opioid overdose reversal drug, clean syringe and safe drug injection programs, foster care programs for children of addicts and funding of rural health care addiction programs.

We care a lot about drug overdose deaths, often because the victim is younger and there is an immediacy between taking the drug and the time of death. It seems that we don’t care as much and don’t have congressional hearings when there is a large time lag between ingestion, disease and death.

According to statistics from the Centers for Disease Control and Prevention (CDC), there are twice as many alcohol related deaths each year (88,000) as there are from opioids. In 2010, the CDC estimated the cost of excessive alcohol consumption was $2.49 billion, 25% more than opioids. People rarely die immediately after a drink or two or many, but chronic alcoholics shorten their lives by about 30 years, and alcohol is responsible for 10% of all deaths in working adults.

When it comes to tobacco, the death statistics are graver. 480,000 deaths each year are tobacco related. That works out to 1,300 deaths per day, more than ten times as many due to opioid overdose. That includes the 41,000 who die each year of second hand smoke. In all smoking causes 20% of all deaths in the United States and costs the economy more than $300 billion yearly.

Alcohol and tobacco are institutionalized and historically grandfathered as acceptable drug ingestions. Aside from drunk drivers, the death and destruction rarely happens contemporaneously. Society sees those diseases and deaths as reasonable collateral for acceptable social behavior, not to mention a great source of tax revenue to fix roads and pay for schools. Opioid abuse can be an immediate killer and those deaths make headlines. The deaths are indiscriminate and afflict people from all social and economic classes. The war on tobacco and alcohol failed. History will decide whether the current war on drugs will fare any better.

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