Next Day: Survival ##VERIFIED##
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Next Day: Survival
The best chance of being enrolled in a sold out class is to add your name to the waitlist. Click the "waitlist" button or link next to the class and complete the form. There is no obligation to register if a spot opens. If the waitlist shows enough demand, additional sessions may be added.
Newsletter Previous Article Next Article Performance of Physicians at Judging Survival in Congestive HeartFailureWally R. Smith Richmond, VirginiaRoy Poses, Donna McClish, and I have been investigating how physiciansmake judgments of the probability of important outcomes, especially forthe common clinical problem of congestive heart failure (CHF), a clinicalsyndrome characterized by the inability of the heart to pump blood adequatelyfor the body's needs. Acute CHF may be a medical emergency and may resultin a decision to admit a patient to an intensive care unit (ICU). Currentguidelines suggest that physicians should base ICU triage decisions inpart on their judgment of the probability that the patient will survivein the short-term (and imply that patients with a very small likelihoodof survival should not be admitted to an ICU because care for them therewould be futile.) We have shown that physicians' judgments of survivalfor patients with acute CHF made at the time the triage decision has tobe made are poorly calibrated (overly pessimistic) and have minimal discriminatingability. So our next questions were how do physicians use relevant clinicalcues when making these judgments, how well does a model of their judgmentsbased on such cues predict survival, and how well do such cues actuallypredict survival.We enrolled a sequential cohort of patients visiting Emergency Departments(ED's) at one of three hospitals, an urban university hospital, a VA hospital,or a community hospital in one metropolitan area. We excluded patientswith acute myocardial infarction (or "heart attack," who are physiologicallyand clinically different from other patients with acute CHF), and excludedpatients who died or developed an acute complication requiring ICU carein the ED (because there would have been no question about the triage decisionfor them.)We collected data about clinical cues from a chart review, about survivalfrom multiple sources, and about physicians' judgments prospectively atthe time of the ED visit using a standardized instrument. We selected ascues variables that previous research or our clinical judgments suggestedmight be related to survival for patients with acute CHF.We modelled the relationship of these variables to 90-day survival usinglogistic regression (survival model), and the relationship of the sameset of variables to the logit of the physicians' survival judgments (judgmentmodel) using linear regression.The R squared for the judgment model was .20. The area under the ROCcurve for the survival model was .76. Of the eight variables that independentlypredicted judgments or survival (Table), one predicted only judgment, fivepredicted only survival, and two predicted both.Varialbep, Judgmentp, SurvivalAge.0001 .0007Sodium.9982.0003Low systolic blood pressure.0602.0411Orthopnea or paroxysmal nocturnal dyspnea.7608.0002Acute Coronary Artery Disease symptoms.0120.6402Prior requirement of ACE inhibitor.1771.0281Charlson comorbidity score.2217.0138Functional status (ED judgment).0001.0001Physicians' judgments of survival for patients with acute CHF may be inaccuratebecause they fail to use cues that predict survival while using othersthat do not predict survival. Developing better predictive models and teachingphysicians how to use them may improve clinical prediction and thus clinicaldecision making.Contact Wally R. Smith
It was a typical night for me, up late making a jewelry piece that had to be finished by the next day. It was getting late, so I was rushing to get to bed in time to get a fresh start for the next day. I accidentally dropped a bead in my shirt. I jumped up and felt around in my shirt to find it. I noticed a strange lump on my right breast to the left of my nipple. It immediately caught my attention. First I thought, "Wow that's definitely a lump," but I breast fed my girls for a least a year each and maybe my breasts were still a little lumpy from that. But my youngest was already 6 years old so I ruled out that theory. I felt the other breast and knew it was different. At that point I was freaked out, but I tried to erase the ideas from my head so that I could finish the piece and get into bed.
The next day, of course it was the only thing on my mind. In the shower that morning, I felt for it again, in case my perception was off from being up so late last night. There it was again, clearly a lump, about the size of a marble. It would move around pretty easily. My mind was racing, and I remembered my last gynecological visit just four months earlier. The doctor did a breast exam, and she asked me if I had a family history of breast cancer. I told her that my grandmother had it right before she died at 89. She dismissed a mammogram since I was only 37. But no mention of feeling a lump. Why didn't I insist on it? I knew women could still get cancer even before they were 40. I guess I just decided that I didn't need to worry about it.
After my ultrasound the nurses called me back to their offices because my doctor was on the phone. She insisted that I needed to come to her office the next day. That's when it started to hit me. I was in a daze; what was happening? I had to go back to work, cancel my meeting and figure out what to tell my husband. I just told him all I knew and went to that appointment the next day. My doctor told me it didn't look good, and she was scheduling an appointment with a breast surgeon for a biopsy. The next two days were a blur, with my emotions going up and down. I was trying to prepare myself for the worst but still hoping for the best. All I could do was wait to see what would happen.I told a few friends about the biopsy. They all had very encouraging words, but I still went to that appointment scared out of my mind. It wasn't until I met the breast surgeon that I began to feel reassured. She had this incredible way about her that made me feel that no matter what, I was in good hands.
The next week on, January 12, 2006, I went to the breast surgeon's office to get my results. I got there at 2:00 and sat and waited until 4:00 for my turn. It was very frustrating. Finally the doctor entered the room. She immediately started shaking her head, saying my name. I knew it was bad. The worst had happened ... it was Stage II breast cancer. I felt like all that positive thinking did nothing.Although she was very encouraging, each moment got worse and worse. All I remembered hearing was chemotherapy, very aggressive, radiation, children, family, support group, prayer. She called my husband in and told us both everything. I was a mess. There was a woman who stopped me on my way out and told me she was a survivor and gave me her number. I even had a few phone calls on my answering service when I got home from other survivors. I didn't talk to anyone but just knowing they were there was helpful. The biggest thing on my mind was how would I tell my kids and my family. That just broke my heart.
In-hospital cardiac arrest (IHCA) is a relatively uncommon event but is very resource intensive and associated with a poor outcome including a low rate of survival. Cardiac arrest in the hospital setting can be the result of a variety of etiologies. The progression of cardiopulmonary resuscitation (CPR) for these arrests can vary greatly between patients. Many factors including initial cardiac rhythm, duration of CPR, quality of CPR, and cause of the arrest account for these differences and the end prognosis for the patient.1 Even when given optimal care, survival rates for IHCA are still with the majority of patients are unable to regain proper and lasting circulation to discharge.
Introducing ECMO-CPR for select IHCA patients in the Lehigh Valley Health Network is a realistic way to produce positive outcomes for patients who would otherwise face grave prognoses and better the overall survival statistics for IHCA in the network.
About 59% of all of the IHCA patients were male and the remaining 41% female. Surprisingly, there was a difference in survival seen between male and female patients with rates of 23% and 35% respectively (Table 1). Rates of the initial cardiac rhythms at arrest between males and females were also found to be different but not significantly so (Figure 2). Survival rates varied for each initial rhythm with ventricular fibrillation or ventricular tachycardia arrests having a survival rate of almost 50%, statistically significantly (p values
The results show a few noteworthy trends within the IHCA data for 2011-2012 including gender differences in survival, survival rates in patients who code multiple times, and patients who may have benefitted from ECMO-CPR and the causes of their arrests.
The differences in survival rates between the genders in the two years have a few possible explanations. First, the small sample size and limited age range examined could have skewed the data. Secondly, there was a significantly smaller ratio of percentage of males versus females that went into ventricular fibrillation or ventricular tachycardia arrests than previous studies have found. This study found only 24% of male and 22% of female in-hospital cardiac arrests had an initial ventricular tachycardia/ventricular fibrillation rhythm, while other studies have found men to have a statistically significant larger percentage of arrests originating in this type of rhythm.4 Since an initial rhythm of ventricular fibrillation or tachycardia is well documented to have the highest rate of survival, this helps to explain the difference in survival found between the genders. This study confirmed the greater survival rate for this rhythm, with 55% of men and 43% of women surviving 30 days post arrest. 041b061a72