Sunday, April 23, 2017
The importance of science was highlighted by the worldwide marches of physicists, chemists, biologists and other scientists whose discoveries have made a difference in how lives are lived. From the houses where we live, to that water that we drink, the food that we eat and the electricity that powers our cellphone networks, each eureka moment is supported by thousands of smaller innovations that transform theory into something that actually works. In medicine, research in the lab needs to be translated into real world situations and interpreted by doctors and nurses at the bedside. The application of that research isn’t always neat and tidy.
This month, the US Preventive Services Task Force reversed its previous 2012 position on screening men for prostate cancer using the PSA (prostate specific antigen) blood test. The Task Force now recommends that primary care clinicians routinely discuss the potential benefits and harms of testing screening in men aged 55-69 and screen those men who desire the blood test. This change of heart relied on new research from Europe that suggested that there may be a moderate benefit in survival and life expectancy gained by testing, but that had to balance against the increased rate of potentially unnecessary operations and complications that would arise. The American Cancer Society and the American Urological Association (urologists treat and operate on prostate cancer) agree with the revised guidelines and urge patients to be screened. The American Academy of Family Physicians and the American College of Preventive Medicine disagree and recommend against PSA testing. What should the poor patient do? and does the decision depend upon what office the poor guy walked into? Welcome to the uncertainty of medical research.
While controversies might exist in preventive medicine, the hope would be that doctors and researchers could agree on how to treat the sickest of patients. One would hope, wouldn’t one.
When it comes to treating patients in septic shock, a situation where infection has spread throughout the body and overwhelmed its ability to respond, the standard of care for the past 15 years is being challenged and up for debate. Early goal directed therapy (EGDT) protocols use intravenous fluids, vasopressor and inotropic drugs to support blood pressure, as well as red blood cell transfusions to treat the septic patient and there is a time crunch to get it all done. The goal is to get everything possible started within 6 hours. The target goals aimed to meet arterial blood pressure, central venous pressure, central venous oxidation, and hemoglobin level goals. Lots of physiology needed to be measured and require invasive procedures to put intravenous catheters into the veins located within the chest near the heart and other catheters into arteries either in the arm or leg. The protocols were widely established for patient care after research was published in 2001 suggesting that by meeting these EGDT goals, patient survival increased by about 50%.
Not all doctors were convinced and controversy continued throughout the years, especially fueled by other research published in 2014 and 2015 that did not reproduce the initial success rates. And in March 2017, a major study published in the New England Journal of Medicine found no evidence that EGDT resulted in lower mortality than usual care.
This is may not be the end of the controversy. Perhaps the best summary about the treatment of patients with septic shock patients comes from Dr. Derek Angus of the University of Pittsburgh, a researcher whose research with the National Institutes of Health found no benefit to early goal directed therapy. In an interview with MedPage Today he was quoted as follows:
“It’s a little like American politics today. Everyone has an opinion. You won’t find many people who are ambivalent about President Trump. And there is really no one [in emergency medicine] who is ambivalent about early goal-directed therapy.”
Isn’t it nice to know that the medical care you and your family receive at the bedside is backed by science and research, or at least the science and research your doctor believes in. Perhaps it is another reason to ask questions to understand what your doctor is thinking. The idea of shared decision making is difficult. In times of crisis, it may be impossible to teach the patient everything they need to know to make an informed decision, but the bedside skill of nurse and doctor is sometimes measured by how well they can take confusion and make it understandable…and that presumes that they can understand the confusion that sometimes is medical research.This entry was tagged early goal directed therapy, EGDT, March for Science, medical research, MedPage Today, NIH. American Cancer Society, prostate cancer, PSA, septic shock, US Preventive Services Task Force