258 karma · joined November 19, 2015
To give you an idea of the weight difference, an average human IgG[1] antibody is about 500 more massive than a pretty average small molecule antibiotic like levofloxacin[2]
I'll add one more reason not explored by the authors: antibodies don't "leak" in the environment, in contrast to the antibiotics which are everywhere.
For example, if I'm vaccinated against S. pneumoniae (one of the bacteria that can cause pneumonia), the bacteria have to get inside my body to gain exposure to my vaccine-induced antibodies. This makes the emergence of resistance very unlikely because :
(1) the number of bacteria that are exposed to the antibody is relatively small, because the antibody response is pretty fast and happens before the bacteria had a chance to multiply to significant numbers; (2) any bacteria clones who evolve resistance to the antibody remain susceptible to the myriad of other immunes peptides, to macrophages, and so on. In other words, as long as I survive my pneumonia, no resistance can ever emerge, because I will kill all the resistant clones through other means.
Contrast this to antibiotics. I have pneumonia, I take antibiotics, I'm cured. However, I excrete those antibiotics in urine and stool. Outside of my body, enormous numbers of bacteria are exposed to minute doses of antibiotics. The number of surviving clones is likely to be very high, and those survivors do not face any supplemental threat. Thus, resistance to that antibiotic can be transmitted to later generations.
Probably not. Or, better stated, not that I am aware of.
Let's think. Seeing a doctor instead of a PA is associated with better outcomes if, and only if, your condition can benefit from the doctor's specialized knowledge. That means it requires treatment, the treatment is time-sensitive (i.e. worse outcomes if there's a delay), and there are significant adverse effects in case of a lack of appropriate treatment.
The problem is, these conditions are either too rare to be studied in any meaningful way, or the patients' very obviously sick and taken directly to the hospital, where he is obviously seeing a doctor and not a PA.
A lot of people go to the doctor for pretty benign ailments which don't really require a treatment, or for conditions that any intelligent, motivated patient is theoretically able manage himself without a doctor. Examples : virus infections, sprains, acid reflux, chronic conditions like hypertension, diabetes, and so on. E.g. : someone has type I diabetes, understands how and when to give himself insulin, checks his feet for infection and so on. In a case like this, the doctor can barely bring any plus value apart from ordering the regular blood work.
Another frequent scenario is when the patient does have a time-sensitive, treatment-required condition, but does not follow the treatment. Again, him seeing a doctor is unlikely to result in any appreciable benefit.
Is based on the premiss of a smaller incision and more precise tissue manipulations leading to better outcomes. Nothing to do with a camera ;)
> presence of cameras automatically makes medical care low-quality.
Of course not. My point is that it does adds ~ nothing to the quality of care, just like cooking thru a webcam should not be expected to result in tastier meals.
Doctor’s observations are a complex synthesis of information obtained through the five senses (and not only by seeing) and “gut feeling”. They can help narrow down the diagnosis, and predict forthcoming complications. This cannot be captured by a camera.
I’ll give you an example of the “holistic understating” kirse was probably alluding to.
A 80-yo guy is admitted at 9pm for COPD exacerbation, is treated with the usual drugs, gets better. Was very anxious and well awake on arrival. You come to check back on him at 2h AM, and he seems a bit slower, and uncharacteristically relaxed. You suspect he’s getting hypercapnic, order a blood gas, and discover that he is indeed. You proceed to treat him with a BiPAP, and save the day.
If you did not see the patient before, it is very easy to interpret his sleepiness and relaxed breathing as a totally normal state for a 80-yo guy. It is indeed very easy to think he’s got better. See, he’s finally sleeping, breathing calmly, everything’s fine.
Even a family member sitting by the guy side since his admission is likely to miss the subtle signs, precisely because his observation is continuous, and the change is slight and slow. Discrete episodes of reassessment by the same qualified person is key !
Sources :
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pubmed/21747093
Call number is dependent on the acuity of patients' condition, and the ability of the house staff (i.e. residents on site) to manage minors problems without immediately consulting the attending by phone.
I may sound crazy, but I really believe my GSD has some sense of language and is not just barking instinctively.
His "I want to pee", "I want to eat", and "I need to poop" barks are different enough that I can reliably understand him.
When he is outside in the yard and wants to get back in, he calls me with a short guttural bark, whereas with my wife he uses a long whiny call. When we are both home, the type of call seems to correlate pretty well with the person he wants to see. It's like he's given us names.
Till the age of eleven, I was essentially speaking only Russian. They did teach us some pretty rudimentary English at school, just enough to ask for directions in a foreign country.
Then, my family moved to Canada, and I had to learn French. It took about 2 years to attain a native-level proficiency. Then, I learned English as a "second language" (actually third, of course) here in Canada.
French is the language I use most. Thus, my largest and most precise vocabulary is in French, and this is obviously the easiest language to express myself.
However, I don't feel constrained by a language while talking/writing in English or Russian. Worst case scenario, I have to turn to Google to translate some precise French word when the English equivalent does not come fast enough.
In general, I think in whatever language I am using at the moment, and the best ideas can come in any of those three languages.
This will come naturally with expertise, and is not a state of mind where you actively "force" yourself to stop caring, but rather a kind of single-minded flow[1] where you can only feel completely relaxed and at peace with whatever's happening. This is important because it allows to function at your best and ensures you treat all you patients to the best of your ability, because your immediate motivation is not their wellbeing, but staying in the flow.
What do I mean by those "technical" acts? Anything that requires fine-tuned skill. Everybody thinks of fine-motor procedural skills (surgical techniques, intubation, difficult LP), but purely mental skills are exactly the same. Getting a history from a patient while forming diagnostic hypotheses feels good.
Of course, as soon as you'll be delivering bad news to your patients, you want be functioning like a highly skilled worker but as a fellow human being who can't do much more than commiserate. You wont be in the flow, and you wont feel any less for your patients just because you're the doctor.
For instance, take the Annals of Emergency Medicine (http://www.annemergmed.com/). More than 50% of corresponding authors use gmail.
The question is "in a given medical speciality -- internal medicine in this study --, are patient's outcomes related to the admitting physician sex?", not if women make better doctors than females. As such, your point about the best doctors not being in internal medicine is pretty a non sequitur.
Basically, I see two potential biais that could explain at least part of the difference in outcomes :
1. Its is "common knowledge" that male doctors tend to refuse admissions more often than females. (I am not aware of any hard data to prove this point) It could be that the patients that they do admit are somewhat sicker that those they let go directly home. That could explain both higher mortality and re-admission rates.
2. It is again, "common knowledge" (again, I'm not aware of any study) that women write better discharge summaries, including all co-morbid conditions. When coded in a database, those patients will appear sicker than similar ones treated by male doctors, and this could skew any analyses.
A final confounder is that patients often have many doctors during the stay, both male and female, and the study assigned as "the" doctor the one who billed most for the patient, which may not be the one who had the most impact on outcomes. It is difficult to say how this would advantage any particular sex, however.
Again, of course some of them are preventable, and nobody's saying its OK to install central lines without putting gloves on, and so on. However, there is a baseline rate of infection which is not preventable, and will continue to happen. Check the Figures S1 and S3 in this recent study : http://www.nejm.org/doi/suppl/10.1056/NEJMoa1500964/suppl_fi...
> many hospitals still don't adhere to those.
What is the source ? As far as I'm aware, around ~ 90% facilities do have checklists -- I do not follow this literature closely, though.
I am especially irked by the constant airplane analogies. Healthcare is not comparable to an assembly line nor modern aviation. The checklists/verifications/pathways only work when you take pretty healthy people and you submit them to a standardized, elective, safe procedure. In those cases, errors are obvious, and the efficacy of any quality improvement method is easy to assess.
Unfortunately, in most cases, healthcare works like a completely chaotic, black box kind of system, in which the output can hardly be predicted with any kind of certainty. It is easy to get excited by "quality initiatives" which may improve the one tiny and unimportant outcome that we measure, all while not realizing the severe side effects it causes on other outcomes.
(1) as logicallee has mentioned, we're getting better at treating patients and preventing death due to disease. The better we get, the more different treatments patients get, the higher is the risk of a medical error happening.
(2) it is very difficult to know exactly what proportion of "medical errors" are preventable. For instance, the seemingly "simple" case of healthcare-associated infection is far from simple, and except for a few cases (infection associated with elective surgery, and so on), there are NO known intervention to reduce risk further. I will give you an example: a patient needs a central catheter in order to survive. If we don't put it in, and he dies, he'll be classified as a "death due to primary disease X". If we do put a central line, and he acquires an infection (and a certain baseline rate of infection IS inevitable, because the catheter is indwelling and gets colonized by the patient's own flora), and dies 2 months later due to sepsis, it will be codified as "medical error". Adverse drug reactions are also codified as medical errors, even if the drug was administered in a life-or-death situation, when even the patient's ID was not known, even less his full list of medications (and thus, the error could not be prevented in any way). I could go on and on.
That being said, I also see stupid preventable errors like quietly giving the drugs to the wrong patient going unreported. Hospital stay is certainly dangerous.
Those issues are roughly two-fold : (1) feeling entitled to a "balanced" lifestyle; (2) feeling entitled to help people. The first one is obvious: student want to leave early, they don't understand that patients always come first, that, sometimes, you have no choice but to be sleep-deprived for days, and so on.
The second one is a kind of "Mother Teresa Complex" when students experience uncontrolled anxiety and distress upon seeing a fully competent adult actively undermining his own care. I see it all the time when they try to talk a lung-cancer smoker into stopping for 30-40 minutes, come back almost crying that he's not interested, and can't believe that their "trying to help" means they are now late, and I'm not happy at all.
Some patients are so scared that they begin to cry even before the needle touches the skin, and they might subjectively be in great pain, but it's not due to the technique itself.
You can read a little bit more about the pain here: http://sci-hub.cc/10.1177/1460408611430175
Well, my point is that if they aren’t so bad, they don’t need IV fluids, and you can give them some juice with pretty much the same effect (I expect normal GI function).
> improve their comfort and reduce anxiety
The Lufthansa kit is great in that respect. Lots of Valium and Haldol to make plenty of passengers calm and happy.
> "Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore.
I know. That’s been the usual swinging pendulum through the years : give fluids, don’t give fluids, give just a little bit. I highly doubt all this matter except in a few situations in which the patients is pretty much assured to die on the plane: septic choc, severe bleeding, severe fluids loss (on flight cholera?).
Seriously, I’ve never seen an acutely sick patient who needed 500 of saline now. They either can wait till next week, or need 2L STAT. Now, the situation is completely different with the chronic/elderly patients slowly deteriorating during the course of many hours/days, and arriving in extremis, and being resuscitated with a little bolus. However, you don’t see those patients in planes because they don’t let them fly!
Not really. Even regular tablets begin to act in 20 min, even faster with the sublingual ones.
> Seems like a good idea for anaphylactic shock?
A very bad one, actually. Some people might want to give an antihistamine first (completely useless in anaphylaxis, by the way), and see what happens, instead of going straight to epi.
When you cannot know the provider's experience, its better to assume for the worse, and give one, and one only choice = EPI.
Unless you have a rare scenario where you've got an anesthesiologist/experienced paramedic, it is completely unrealistic to expect a random doctor to be able to use anything else.
I don't doubt you place IVs in sick patients, I only doubt those IVs make any difference. I am not very familiar with prehospital/EMT literature, and I don't know if any studies have been done, and I certainly don't have any hard data, but I do prefer when paramedics give aspirin, stick in a combi-tube, do basic stuff, and just rush the patient to the hospital instead of wasted time installing and IV on-site, giving fluids and what not. I've seen a great many "heart attacks" treated with fluids in full-blown congestive heart failure. This is anecdotal of course.
Again, for the 500 bolus, I am not aware of any literature to support it as a life-saving measure, and I do believe that if the patient is gonna code without a 500 bolus, he will code with a 500 bolus, too. We're talking of a previously healthy person suddenly dying here -- in those scenario fluid rarely makes a different unless its profuse bleeding, in which case 500 mL is not enough anyways.
The big problem I see with fluids, stethoscopes, IV benadryl, and the like, is that these things are DISTRACTIONS that make people waste their time trying to get a blood pressure when its obvious the patient's in shock (or equally obvious he isn't). A quick, focused history and exam + Epi + AED + Albuterol are the real life-savers and where the emphasis should be on.
1. Placing an IV in a sick, clamped patient IS difficult, even for experienced ER nurses.
If the patient is not sick, he doesn't need an IV. Its way easier to give drugs directly with a syringe than setting up an IV first.
2. In those situations, I'll just lift the patients legs up to give him that 500 mL bolus, which will take exactly 10 seconds, and not require any skills at all. Bonus points, if I realize he's not fluid-depleted, I'll just them back on floor -- et voilà!.