Problem with medicine is its uncertainty. Everything in it keeps evolving; widen disease definition, new drugs, new diagnostic test, new surgical method, and so on. What is considered as beneficial today may be classified as harmful tomorrow. Thus, in order to prevent patients from harm of outdated medical practice, experts develop new approach in practicing medicine, Evidence Based Medicine (EBM).
I learned about it when I was in medical school. It was the module where you were taught about how to read a paper, assess validity of a trial, and find answer of clinical query. At the end of the module, I was equipped with the ability to criticize journals so that I can be more careful in seeking answers through all the available evidences.
EBM training aims to help doctors provide tailored up to date medical practice based on the latest available evidence. This skill is expected to assist doctors in their lifelong learning of medicine. So when we have graduated for 30 years long, our knowledge can still be equally up to date compared to fresh graduates. That's the dream. However, what happens in reality (as in hospital, clinic, etc, other than teaching hospital) is not as beautiful as how it should be. If teaching hospital was a city zoo, the other hospitals would be Amazon.
Internship is the first taste of real world for me and my colleagues, as fresh graduates. I captured (so many) misconducts of medicine during my first 4 months posting and the biggest problem lays in how patients diagnosed and treated.
Few weeks ago, there was a 60% burned surface patients who had been cared in ICU for 3 weeks. At that moment, she appeared to be lethargic with high temperature, high respiratory rates and high leukocyte counts. We also found some evidences of organ damage in her lab results. We were all agreed that she was in severe sepsis. In this kind of condition, there may be some beneficial use of corticosteroid.
Though its use remains controversial, but the last systematic review and meta-analysis published in JAMA on 2009 concluded beneficial effect on short term mortality outcome by low dose administration of corticosteroid. I then, suggested to her attending surgeon, the use of low dose corticosteroid to our patients.
*Systematic review is a paper which review all other papers using clear method of inclusion and exclusion criteria while meta analysis is a study which pool all trial results, which included based on the previous systematic inclusion and exclusion, into one big spreadsheet and count the overall outcome together. Thus, systematic review and meta analysis provide strongest evidence among other type of studies.
However the attending surgeon who took care of this patient denied my idea of using corticosteroid and argued how corticosteroid would increase the severity of her condition since its effect in decreasing immune response and therefore it would make her more susceptible to infection. That sounded plausible, at first. But he didn’t aware that what actually made septic patients died was their immune reaction, instead of their infection.
Our body has the ability to defense our self from outsider such as, bacteria. When we recognize their invasion, we will automatically release our first soldiers, the innate immune system. Imagine them as cavilary soldiers with standard weapon. Later, these soldiers will call for other help, the chemoatractant (think of them as the army with radio connection which control distance weapon and control media). During all these activities, there is also undercover special forces among these armies who study the invaders tactic, known as adaptive immune system. Right after enough learning, these special forces will attack the invaders with specialized weapon according to their weakness.
If all our immune system response correctly and the bacteria is defeated, we will bnot be sick. However, sometime in special condition in which there are misresponse soldiers or too many enemies, our body will suffer from our overreacting and overactivating defense mechanism. The chemotractant will be released abundantly and therefore disrupt our body function. This is what happen in sepsis. What we need now is something to calm down our body reaction. Theoretically, corticosteroid which work in suppresing immune reaction will help our patients.
Evidence Based Medicine is designed for this kind of situation. When you are faced with life and death decision, looking through all previous trials are the only reliable ways. Unfortunately, this is where the attending surgeon is lacking. Rather than looking for evidences, he relied his judgement on basic medical knowledge.
This is what I actually find from the paper I mentioned before:
For a dying patient, I think the result of this study is worth trying.
There are reasons why we do a lot of trials in medicine and why we practice medicine using Evidence Based Medicine approach. Our basic science of medicine is most of the time useful to help us diagnose disease but it is often misleading if we bluntly translate it into how we should manage our patients. In medicine, it is dangerous to continously feel intelligent enough or competent enough because, truthfully we can never be too smart in this field. What we thought theoretically correct are many times wrong in real practice. As mysterious as medicine can be, the wisest thing is might be to follow what the great Steve Jobs told us to do, “Stay hungry, stay foolish”.
I learned about it when I was in medical school. It was the module where you were taught about how to read a paper, assess validity of a trial, and find answer of clinical query. At the end of the module, I was equipped with the ability to criticize journals so that I can be more careful in seeking answers through all the available evidences.
EBM training aims to help doctors provide tailored up to date medical practice based on the latest available evidence. This skill is expected to assist doctors in their lifelong learning of medicine. So when we have graduated for 30 years long, our knowledge can still be equally up to date compared to fresh graduates. That's the dream. However, what happens in reality (as in hospital, clinic, etc, other than teaching hospital) is not as beautiful as how it should be. If teaching hospital was a city zoo, the other hospitals would be Amazon.
Internship is the first taste of real world for me and my colleagues, as fresh graduates. I captured (so many) misconducts of medicine during my first 4 months posting and the biggest problem lays in how patients diagnosed and treated.
Few weeks ago, there was a 60% burned surface patients who had been cared in ICU for 3 weeks. At that moment, she appeared to be lethargic with high temperature, high respiratory rates and high leukocyte counts. We also found some evidences of organ damage in her lab results. We were all agreed that she was in severe sepsis. In this kind of condition, there may be some beneficial use of corticosteroid.
Though its use remains controversial, but the last systematic review and meta-analysis published in JAMA on 2009 concluded beneficial effect on short term mortality outcome by low dose administration of corticosteroid. I then, suggested to her attending surgeon, the use of low dose corticosteroid to our patients.
*Systematic review is a paper which review all other papers using clear method of inclusion and exclusion criteria while meta analysis is a study which pool all trial results, which included based on the previous systematic inclusion and exclusion, into one big spreadsheet and count the overall outcome together. Thus, systematic review and meta analysis provide strongest evidence among other type of studies.
However the attending surgeon who took care of this patient denied my idea of using corticosteroid and argued how corticosteroid would increase the severity of her condition since its effect in decreasing immune response and therefore it would make her more susceptible to infection. That sounded plausible, at first. But he didn’t aware that what actually made septic patients died was their immune reaction, instead of their infection.
Our body has the ability to defense our self from outsider such as, bacteria. When we recognize their invasion, we will automatically release our first soldiers, the innate immune system. Imagine them as cavilary soldiers with standard weapon. Later, these soldiers will call for other help, the chemoatractant (think of them as the army with radio connection which control distance weapon and control media). During all these activities, there is also undercover special forces among these armies who study the invaders tactic, known as adaptive immune system. Right after enough learning, these special forces will attack the invaders with specialized weapon according to their weakness.
If all our immune system response correctly and the bacteria is defeated, we will bnot be sick. However, sometime in special condition in which there are misresponse soldiers or too many enemies, our body will suffer from our overreacting and overactivating defense mechanism. The chemotractant will be released abundantly and therefore disrupt our body function. This is what happen in sepsis. What we need now is something to calm down our body reaction. Theoretically, corticosteroid which work in suppresing immune reaction will help our patients.
Evidence Based Medicine is designed for this kind of situation. When you are faced with life and death decision, looking through all previous trials are the only reliable ways. Unfortunately, this is where the attending surgeon is lacking. Rather than looking for evidences, he relied his judgement on basic medical knowledge.
This is what I actually find from the paper I mentioned before:
- There is no significant different in 28 day mortality between patients administered with corticosteroid and control, RR 0.84, 95% CI 0.71-1.00; P=0.5; I2=53% in randomised trials and RR 1.05, 95% CI 0.69-1.58; P=0.83 (don’t be intimidated with these numbers, it only means that the result is not significant)
- In the subgroup analysis, there is significant difference in 28 days mortality between patients received prolonged long term corticosteroid and control, RR 0.84, 95% CI 0.72-0.97, P=0.02 (it means that long low dose use of corticosteroid administration has significant protective effect toward septic patients).
For a dying patient, I think the result of this study is worth trying.
There are reasons why we do a lot of trials in medicine and why we practice medicine using Evidence Based Medicine approach. Our basic science of medicine is most of the time useful to help us diagnose disease but it is often misleading if we bluntly translate it into how we should manage our patients. In medicine, it is dangerous to continously feel intelligent enough or competent enough because, truthfully we can never be too smart in this field. What we thought theoretically correct are many times wrong in real practice. As mysterious as medicine can be, the wisest thing is might be to follow what the great Steve Jobs told us to do, “Stay hungry, stay foolish”.
