aspirin, statistics and super bowl coaching

Monday, February 2, 2015

In medicine, much is made of statistical analysis and its importance for determining which test might be appropriate to make a diagnosis and what treatment might follow. The rigors of statistics try to persuade even the most skeptical person about the benefit or risk of a situation.

Consider this situation. A decision needs to be made that in one analysis will be successful 20% of the time, will have no change in 40% and will result in harm the other 40%. Another study looking at similar data over a longer period of time and concluded that success would be achieved only 41% of the time. It would be difficult to recommend the routine use of such a treatment unless there was a compelling situation. With just a few seconds left in this year’s Super Bowl, the Seattle Seahawk coaches chose to pass the ball on the one yard line, instead of letting their “beast mode” running back Marchand Lynch carry the ball. Disaster befell the team as the pass was intercepted, New England wins and Pete Carroll is thought to have made the worst coaching blunder in the history of football.

Back to the numbers from statistics pros Nathan Jahnke, and Neil Greenberg. Jahnke writes for profootballfocus.com and reports that in the 2014 season, Lynch had 5 attempts from the one yard line and had scored once, had no gain twice and had lost yardage twice (20%, 40%, 40%). Greenberg, of the Washington Post, reviewed Lynch’s whole career and found that he scored from the one yard line in only 15 of 36 attempts (41%). Though much of statistics are mental gymnastics, this time it seems that the national outcry for the Seahawks to run the ball may not have been 100% warranted.

Monday morning quarterback is a tough position to play, even though most people feel well qualified and sometimes compelled to assume the role. It begins with knowing what happened and then presupposing that a positive outcome would occur had a different, “better” decision been made. The basis for most of these day after analyses often rely upon dogma and how can that ever be wrong. Dogma is a set of principles or facts that laid down by an authority that are incontrovertibly true. In medicine, changing dogma is an arduous process akin to changing the course of a large ship. It takes great time and effort to alter its direction since momentum can be a very powerful force to overcome.

Aspirin is a great drug and is recommended in many situations and its use to decrease the risk of heart attack and stroke is correct…but at what cost. According to researchers, regular aspirin use may decrease the risk of nonfatal heart attacks by 20% and all heart events by 10%. However, those aspirin users were 30% more likely to have a serious gastrointestinal bleed (bleeding from the stomach lining or ulcer). There is a concept of numbers needed to treat. In this case, it takes 162 people taking daily aspirin to prevent a nonfatal heart attack, but in that group, two people would develop serious bleeding episodes. Aspirin helps make platelets less sticky, decreasing the ability for blood to clot, but it also is irritating to the lining of the stomach and intestine. Remember that aspirin is really an acid, salicylic acid.

There are good studies that show that aspirin is very beneficial in patients who have already had a heart attack, decreasing the risk of a second heart attack by 20-30%. For people with atrial fibrillation, aspirin may be the drug of choice to thin the blood and prevent stroke. The key for doctors and patients is to individualize the use of aspirin to the patient’s clinical situation and balance risk and reward. The US Preventive Services Task Force recommends the use of aspirin on a case by case basis. The dogma that everybody should take aspirin is being tempered with the daylight that comes when researchers ask why a treatment is being recommended. “Because it has always been done that way” is no longer an acceptable answer.

It’s always good to hold dogma’s feet to the fire and quarterbacking on a Monday morning offers a prime opportunity to do so. The success of day after opinion is always 100% but that statistic is also open to interpretation.

PLEASE DO NOT STOP TAKING ASPIRIN IF IT HAS BEEN RECOMMENDED BY YOUR DOCTOR.

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shoulders and elbows

Tuesday, January 20, 2015

Medical advice can only work in two given situations: if the patient chooses to seek that care and if the patient chooses to follow that given advice. It comes as no surprise that those two situations were ignored by two Seahawks in their playoff game. Earl Thomas dislocates his shoulder, reluctantly runs to the locker room and is back on the field minutes later. Richard Sherman sprains his elbow and refuses to come near a trainer or doctor, but instead, stays on the field grimacing in pain. NFL players and other driven athletes tend to ignore damage to their body because the will to play and win is stronger than the pain that they experience. But a warning should appear on the video screen: “Trained professionals. Do not try this at home.”

The shoulders is the most common dislocated joint of the body. The mechanism of injury can be a fall on an outstretched arm or from a blow that occurs when the arm is abducted (moved away from the body) and externally rotated it (forearm turned palm side up). The shoulder is a ball and socket joint and when dislocated, the humeral head or the ball of the joint, is ripped out of the socket, the glenoid fossa. The structures that hold the shoulder together are torn, including the labrum, the joint capsule, the cartilage and the ligaments of the rotator cuff. If a player is lucky, the shoulder can be popped back into place immediately on the field before the surrounding muscles start to spasm. That can make it tough to provide the traction needed to reduce the dislocation and return the bones to their normal position. For many patients, mild sedation may be needed to help with reduction, often because there is a significant delay getting to medical care.

 

shouledr norm

Normal

shoulder dislo

Dislocated

Once the shoulder is reduced, the goal is to allow the shoulder to heal and remain stable, meaning that it will not dislocate again. There is a balance between that healing and allowing range of motion to occur. It takes weeks for all the damaged tissue, from muscles and ligament to joint capsules to become strong and stable. If one waited until that happened to move the shoulder, it would stiffen and require weeks of rehab to help return range of motion. It is safe to say that Mr. Thomas did not heal in the few minutes that he was in the locker. Instead, he was fitted with a brace that prevented the shoulder from abducting or rotating, the movements that likely occur with reaching for a football or stretching to make a tackle. It is likely that this was not the first treatment option for the medical staff, but when a patient refuses to consider option one, negotiations likely occur to try to minimize future risk and damage. In general, a shoulder dislocation will require six weeks of treatment before return to play.

It is easier to speculate about the Thomas shoulder dislocation than Mr. Sherman’s elbow sprain. Practically, there are only two types of shoulder dislocation, anterior and posterior, and posterior is rare. The elbow is a much more complicated joint. Three bones come together, the humerus, the radius and the ulna, to allow both flexion and extension (bending and straightening) as well as supination and pronation, turning the palm upwards or toward the ground. The medical collateral and the lateral ligaments hold the elbow stable but they have different bundles that protect the elbow depending upon the position of each bone within the joint and the movement that is trying to be accomplished. As well, the biceps and triceps muscles of the upper arm and the muscles of the forearm also work to promote joint stability. Sprains of the elbow, like any other ligament injury are graded by severity of the damage. In grade 1 sprains, the ligament fibers are stretched, in grade 2, they are partially torn and grade 3 sprains denote a completely torn ligament but even a grade 1 elbow ligament sprain can allow the elbow joint to dislocate completely or partially dislocate (subluxate). Injuries to the area can cause bleeding within the elbow joint and a little blood goes a long way to cause significant pain, even with small movements. Mr. Sherman’s cradling his arm and wincing is a testament to the amount of pain a pro athlete can endure. And while his teammate saw visited the trainer and negotiated his care, Sherman refused to come off the field and when he did, tried his best to avoid being evaluated. Treatment of this injury depends upon what is damaged but the time to recovery is measured in weeks.

elbowligament

 

Playing through injury is the stuff legends are made of, but should not be considered the stuff of role model. The potential for long term damage is real when joints are damaged and not allowed to properly heal. There is a real risk that other injuries might occur because the player cannot react instinctively while still protecting the injured body part, but the invincibility of youth and the athlete often take precedence over common sense.

In the real world, patient compliance in following advice and instruction is somewhat lacking. Moderating diets, alcohol use and smoking are the big three but others follow close behind. Studies show that patients who take blood thinners because of blood clots or atrial fibrillation, often missed taking their medications 30% of the time. Patients do not complete a course of antibiotics, stopping when they begin to feel better. Post op physical therapy sessions get missed when they are not a patient’s priority. At the end of the day, the doctor’s advice has to be practical and apply to that specific patient’s situation and hopefully the patient will buy into that advice…hopefully, because the doc and the patient, just like in football, require teamwork to make the miracle of modern medicine happen.

 

Figure attribution: American academy of Orthopedic Surgery

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