On the occasion of meeting the nurse with whom I will now be working, five of my most memorable experiences with nurses. Please add on. 1. With my grandmother when I was 11 pubmed.ncbi.nlm.nih.gov/31282952/
2. August of my internship. Berated by a cardiologist, Dr. Marcus, for, as remember it, not being sufficiently obsequious. Despite profound sleep deprivation I held it together until a nurse hugged me and said, “don’t worry, we all know he’s a &@)$%bag.” I became a puddle.
3. September of my internship. Called into the room of an unresponsive patient. I froze. Nurse came up beside me and quietly told me everything I should do: vitals, blood glucose, EKG, blood gas…
4. End of my residency. Staffing ER. Terrible night. Lay down on a gurney at end of night to get 45 minutes of sleep. Awoke to nurse putting blanket over me.
5. The nurse with whom I worked at U of C for 19 year whose accuracy in predicting whether or not we’d be able to help a patient upon first meeting was breathtaking (area under ROC .9984).
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1/9 This thread is a waste of time. It will change nobody’s mind. Nobody should really care what I think—I am no expert here. But, given the response on twitter about this excellent article, I felt like I needed to articulate my thoughts. nature.com/articles/d4158…
2/9 I have spent most of my career as an EBM proponent, hollering about the superiority of the RCT. Hell, @vinayprasad and I wrote a whole book about it. (No reason not to mix in a little shameless self-promotion). amazon.com/Ending-Medical…
3/9 However, people often forget that EBM is not blind adherence to an RCT; nor is it refusal to act without an RCT. Fundamentalism in all forms is bad. EBM requires integrating clinical experience and expertise with the best available evidence from systematic research.
1/6
A tweetorial in the guise of a story.
A woman is hoping to have her elderly mother visit from out of town. She and her husband are asymptomatic and have been very careful about contacts. The mother, who is driving from Maine, is well, and has had no risk contacts.
2/6
The husband suggests that he and his wife get tested to assure that it is safe for his mother-in-law to visit. Is he being thoughtful or is he trying to get out of having her visit?
3/6
It is hard to get good numbers for the test characteristics for NP, PCR test for COVID-19. But here are some numbers I have seen (bear with me, if you don't like the numbers, change them, doesn't much matter).
Sensitivity: 95%
Specificity: 85%
LR+: 6.33
LR-: 0.58
As my busiest month of EBM teaching winds down, thought it was a good time for a quick tweetorial of reading RCTs (without my usual pathetic B/W slides). These are the studies we, appropriately, rely on most in medicine but they can be misleading. What would you add?
How RCTS can be misleading #1
For studies with subjective endpoints, was the control really adequate.
A tweetorial.
One of my favorite points to making when teaching diagnostic reasoning it to stress that positive findings are immensely more important than negative ones. I believe this so strongly that it is point 4 on my diagnostic reasoning yellow card.
As an example, hearing an S3 is very powerful when it comes to diagnosing heart failure (LR+, 11) but the lack of tachycardia in a patient suspected of having a PE is meaningless when it comes to excluding PE (LR-,1.0).