Normally this post would be on Status Iatrogenicus, but the implications for "evidence" and the EBM movement are too important, so it goes here.
For those not inclined to read about the Rosenhan Experiment, a brief history. In the early 1970s, Dr. Rosenhan a Stanford psychologist, was concerned about the validity of psychiatric diagnoses. So he and a half dozen confederates faked mental illness and presented themselves to several prominent psychiatric facilities. Their feigned symptoms were sufficient to have them admitted with psychiatric diagnoses, usually paranoid schizophrenia. After admission, they behaved normally. Nonetheless, they had been diagnosed, put on psychotropic medications, and not allowed to leave until they signed documents swearing to continue the medications upon their release. The damning report of this experiment was published in Science Magazine in 1973 with the title "On Being Sane in Insane Places."
Psychiatric hospitals were blindsided, having been caught unawares and humiliated. They challenged Rosenhan to "do it again", but the second time they would be vigilant about these disimulations. Send us some more fakes, they said. On the second experiment, they determined that 40 some patients were confederates. But Rosenhan had the upper RosenHand - he had send no confederates. Sensitivity, if it can be called that, suffered to specificity on round two.
Previously I have complained about patients who are intubated but needn't have been (see here, and here.) Oftentimes, after the fact, it is difficult to determine whether the intubation was necessary, especially with alleged upper airway compromise, and with obese patients. With the latter, roentgenograms of the chest are difficult to interpret because of "fatelectasis" or atelectasis in obese persons, "flatelectasis" due to recumbency, fluid loading after paralysis and intubation, all which may require high PEEP to counteract. If you were not present prior to intubation, it is very difficult to determine if respiratory distress preceded the intubation, or if "won't breathe" was mistaken for "can't breathe". The differentiation between those two entities is "critical".
A man in his late 40s was sent to us recently for "acute respiratory failure" on the ventilator receiving 100% FiO2 and PEEP of 16. EMS responded to a call to his 18-wheeler that he could not breathe. His SpO2 was in the 50% range and he was admitted to a local hospital. There were basilar opacities, and oxygen was administered. He weighed near 500#. The opacities were said to represent pneumonia and he was given antibiotics. Not long after admission, in the middle of the night, he could not be aroused, an ABG was obtained, and his PaCO2 was 90-something with a pH of 7.10 or thereabouts. This was interpreted to represent acute hypercapneic respiratory failure, on top of his "acute hypoxemic respiratory failure" and an hour-long intubation ensued. Afterwards he was sent to us on the aforementioned high ventilator settings.
For those not inclined to read about the Rosenhan Experiment, a brief history. In the early 1970s, Dr. Rosenhan a Stanford psychologist, was concerned about the validity of psychiatric diagnoses. So he and a half dozen confederates faked mental illness and presented themselves to several prominent psychiatric facilities. Their feigned symptoms were sufficient to have them admitted with psychiatric diagnoses, usually paranoid schizophrenia. After admission, they behaved normally. Nonetheless, they had been diagnosed, put on psychotropic medications, and not allowed to leave until they signed documents swearing to continue the medications upon their release. The damning report of this experiment was published in Science Magazine in 1973 with the title "On Being Sane in Insane Places."
Psychiatric hospitals were blindsided, having been caught unawares and humiliated. They challenged Rosenhan to "do it again", but the second time they would be vigilant about these disimulations. Send us some more fakes, they said. On the second experiment, they determined that 40 some patients were confederates. But Rosenhan had the upper RosenHand - he had send no confederates. Sensitivity, if it can be called that, suffered to specificity on round two.
Previously I have complained about patients who are intubated but needn't have been (see here, and here.) Oftentimes, after the fact, it is difficult to determine whether the intubation was necessary, especially with alleged upper airway compromise, and with obese patients. With the latter, roentgenograms of the chest are difficult to interpret because of "fatelectasis" or atelectasis in obese persons, "flatelectasis" due to recumbency, fluid loading after paralysis and intubation, all which may require high PEEP to counteract. If you were not present prior to intubation, it is very difficult to determine if respiratory distress preceded the intubation, or if "won't breathe" was mistaken for "can't breathe". The differentiation between those two entities is "critical".
A man in his late 40s was sent to us recently for "acute respiratory failure" on the ventilator receiving 100% FiO2 and PEEP of 16. EMS responded to a call to his 18-wheeler that he could not breathe. His SpO2 was in the 50% range and he was admitted to a local hospital. There were basilar opacities, and oxygen was administered. He weighed near 500#. The opacities were said to represent pneumonia and he was given antibiotics. Not long after admission, in the middle of the night, he could not be aroused, an ABG was obtained, and his PaCO2 was 90-something with a pH of 7.10 or thereabouts. This was interpreted to represent acute hypercapneic respiratory failure, on top of his "acute hypoxemic respiratory failure" and an hour-long intubation ensued. Afterwards he was sent to us on the aforementioned high ventilator settings.
