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Keeping ‘em alive

ResearchBlogging.orgOne of the frequent complaints I hear about science-based medicine is that it is dangerous.  Of course, it’s true—so is riding in a train, but it sure beats walking.  And that’s the danger of this particular fallacy—yes, medicine is a sharp tool, but it’s also an effective tool, so we must use it properly.  And this is where the tools of evidence- and science-based medicine can give us a hand.

The potential harms of modern medicine must be approached carefully.  If they are ignored or approached in an ineffective way, we’ll miss an opportunity to save lives.  This comment from my other blog is typical:

You asked if so-called traditional Chinese medicine has ever eradicated any diseases. Well, yes. It pretty much eradicated one that is in epidemic numbers in the U.S. and most of the developed world: Iatrogenic disease.

This is wrong is so many ways.  The definition of “iatrogenic” is difficult.  The traditional definition is “adverse effects of medical treatment or advice.”  I suppose one could broaden this to include failure to give proper advice, as inaction by a physician has similar consequences to action, but perhaps that is a discussion for another day.

The way in which this is truly wrong is the false dichotomy. Yes, medical errors would be reduced to zero if we didn’t treat people, but the consequences would be rather dramatic.  Our goal should not be to abandon modern medicine because it sometimes causes harm.  Our goal is to reduce iatrogenic illness in a science-based way.

Strangely enough, this is being done.  A recent study in the New England Journal of Medicine (effectively discussed here) described a study in which surgical checklists reduced errors.  This study was based on earlier work by Peter Provonost of Johns Hopkins, the subject of a terrific piece in the New Yorker.  (Related commentary here.)

The basic idea is this:  intravenous  catheters in intensive care units (ICUs) often become infected.  While they are necessary for the delivery of medications and the monitoring of hemodynamic parameters, infections can be devastating.  This study made use of a large number of ICU beds (including 85% of ICU beds in my home state).  The project, called “Keystone”, asked the ICU staff to do one simple thing (emphasis mine):

The study intervention targeted clinicians’ use of five evidence-based procedures recommended by the CDC and identified as having the greatest effect on the rate of catheter-related bloodstream infection and the lowest barriers to implementation.1 The recommended procedures are hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.

Strategies to increase the use of these procedures have been described elsewhere.10 Briefly, clinicians were educated about practices to control infection and harm resulting from catheter-related bloodstream infections, a central-line cart with necessary supplies was created, a checklist was used to ensure adherence to infection-control practices, providers were stopped (in nonemergency situations) if these practices were not being followed, the removal of catheters was discussed at daily rounds, and the teams received feedback regarding the number and rates of catheter-related bloodstream infection at monthly and quarterly meetings, respectively. In April 2004, a letter and a baseline survey were sent to the chief executive officers (CEOs) of the participating hospitals. The letter outlined the evidence supporting the use of chlorhexidine1 and asked the CEOs to stock chlorhexidine in their hospitals before implementing the study intervention.

A checklist was used.  Supplies were provided. Non-emergent procedures were stopped if procedures weren’t followed.  And a checklist was used.

So what happened?

The baseline rate of catheter-related infections was about 2.7/1000 catheter days.  After implementation, the rate was zero.

Yes, zero.

One particular serious iatrogenic illness was effectively eradicated by a simple, easy-to-implement intervention.   My earlier commenter was correct; if we stop using modern medicine, we will have no iatrogenic disease.  We also will be left with a much sicker populace and a lower age of mortality.  It turns out we have a third path—use science-based medicine to solve the problem of iatrogenesis.  Not all problems will be solved so well as this one—there will always be some non-zero rate of serious medical complications, but as this study shows, it doesn’t always take a whole lot to make a big difference.

References

Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D. (2006). An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU New England Journal of Medicine, 355 (26), 2725-2732

Posted in: Science and Medicine

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10 thoughts on “Keeping ‘em alive

  1. Mark Crislip says:

    the other problem traditional Chinese medicine almost eradicated was old age. Before Western medicine the average life expectacy in China was less than 40 years.

  2. DevoutCatalyst says:

    Layperson speaking here. I was fascinated by a Canadian Broadcasting Corporation podcast on medical errors. One thing they are doing in Canada is tapping into the safety culture and protocols of aviation, in some cases bringing in pilots as consultants.

    The two part series on medical errors can be found here:

    http://www.ethos.ualberta.ca/?page_id=71

  3. jenl1625 says:

    Is this person honestly claiming that Chinese medicine has no side effects, no possibility of an overdose, no possibility of dangerous contamination, and no possibility of causing infection?

    Come on – herbs can be dangerous if prepared wrong, or dosed wrong, and acupuncture needles can spread infections….

  4. tarran says:

    This is how science based medicine will eventually supplant the so-called CAM systems; by experimenting with new treatments, by gaining a better understanding of how the human body works, breaks-down or gets diseased, and applying the lessons learned to do a better job.

    Currently I see several major ideas that are leading people to choose woo over rationality:
    1) Science based treatments for some very scary diseases are not guaranteed to cure,
    2) Science based treatments for some very scary diseases are uncomfortable and undignified.
    3) Science-based treatments are kind of pedestrian and uncool.

    There’s not much to be done about cause number three (except for jazzing up hospitals), but 1 and 2 are susceptible to improvement, (1) through science, (2) through better pain management and customer service, and through science (the invention of the MRI, for example, caused a dramatci reduction in the much more uncomfortable thing called exploratory surgery).

    Looking at the medical profession as a consumer, there is progress on all three fronts, and eventually acupuncture will be viewed with the same horror as purging and bleeding.

  5. jenl1625 says:

    Currently I see several major ideas that are leading people to choose woo over rationality:
    1) Science based treatments for some very scary diseases are not guaranteed to cure,
    2) Science based treatments for some very scary diseases are uncomfortable and undignified.

    And to be blunt about it, as long as purveyors of woo are willing to lie – to make guarantees that simply can’t be honored – there will be those who fall for it. One side is saying “here’s this treatment that will make you feel miserable throughout the 3-week (or 3-month, or whatever) course of treatment, but it’s got an 80% chance of curing you. The other side is saying “here, drink this and let us give you a massage – no side effects, the treatment makes you feel all warm and fuzzy, and we guarantee* you’ll be healed!

    The * of course, is in 1-point font, saying something like “assuming you have enough faith. If it doesn’t cure you, then clearly you failed to have sufficient faith.”

  6. TsuDhoNimh says:

    I have many resources on China, such as memoirs and missionary preparation materials that mention the Chinese medical and health situation during the pre-Communist era … starting with a book from 1699.

    It sucked!

    And recent memoirs, such as Wild Swans, make it clear that the Chinese Communist party elite preferred western medical treatment. The traditional medicine was for the masses, and it didn’t work too well.

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