The more I learn about the human machine, the more I am amazed at the intricacies and complexity of the system. Every cell, every molecule has a role to play in maintaining the all-important level of balance in our body. It is called homeostasis, and basically means equilibrium or “staying the same”.
If there is a rise in blood pressure, for example, several sensors in diverse areas such as the kidneys and blood vessels sense the change and a multitude of signals go out in the form of nerve impulses and hormones and enzymes. Each message is sent to a specific area with a specific goal. Blood vessels relax and expand, the kidneys crank up the volume and get rid of extra fluid sucked out of the blood stream. Some effects are meant to be short term, such as the relaxed blood vessels, others more long-term, such as getting rid of fluid. All in the name of maintaining homeostasis: in this case, the optimal blood pressure: enough to get blood to all areas of the body, but not so much as to damage fragile capillaries and organs.
A hole somewhere that allows blood to leak out of a vein or artery causes a complex cascade of factors to be released, building up a blood clot and stimulating growth of new cells to repair the hole in the blood vessel wall. If only one out of the thirteen factors is missing or in short supply, the whole cascade is affected. hemophiliacs, people who are missing a factor, have dangerous bleeds from tiny incidents because the clotting cascade can’t work properly
The amazing and delicate balance can be thrown off in so many ways: invading organisms (pathogens) that cause disease, injury, malnutrition, toxic substances: drugs, cigarette smoke and alcohol, malnutrition or poor environmental conditions such as extreme heat and cold. Even the body itself can have a system go wrong, as in cancer and autoimmune disorders like Lupus. An autoimmune disease is one where the body’s own defensive system, the immune system, doesn’t recognize itself and attacks its own tissues.
When it comes to finding and fixing a problem, a physician or nurse practitioner has to be like Sherlock Holmes, looking at signs and symptoms of errors or breaks in the system. Some clues are obvious: bleeding or coughing. Or are they? Bleeding can be from a trauma, a coagulation disorder, or a broken spot somewhere inside the body like a perforated ulcer. A cough could mean a problem in the lungs, or it could point to a heart condition, or a reaction to a drug.
Medicine is a science, but also an art. It takes keen observation, intuition, deduction and skill. And lots of experience. No health care provider will ever know it all. Learning never stops.
Nurses are good in at looking for signs and symptoms. We are geared from day one to observe nuances in our patients. It was our job to see how the treatments the physicians order are actually working. Is there a subtle change in the patient’s level of consciousness? Is that little rash new? Is the pain any less? Is the amount, color, consistency, smell of any substance coming out of the body different? Is the patient moving around better, or not? How is the breathing? The heart rate? And what do all of these things mean? Is what we are seeing life-threatening? Should we notify the physician at 3 AM, or is this expected or normal? There is an enormous amount of responsibility and skill involved with nursing. Too bad that hospitals think a “patient care technician” (formerly known as nurse’s aid) can take tasks that nurses used to do, and think that it doesn’t affect patient care and mortality rates for that matter (a subject for another day). The time nurses used to spend bathing and assisting patients to the bathroom for example, were opportunities to gather a mother-lode of information. More on that later.
Now, as a future nurse practitioner, I get to augment and utilise those nursing skills at a higher level. Now I will look at the patient to diagnose the problem, instead of assessing response to treatment. I am looking forward to this chance to solve the riddles. The education I am receiving now is fine-tuning the assessment skills and adding the treatment modalities to the skills mix. It sure is easier to look at a script or treatment ordered by someone else and criticise it, than it is to make a decision and order something yourself! It is a definite step up in responsibility, and a real opportunity to help people.
Now a bit about evidence based practice (EBP). I have taken more than one course utilizing the concept of EBP. At first glance, it is a wonderful thing. You read research and base your treatment on things proven to work by research.
What could be wrong with that? (Check back to my post: A new study shows…)
I’ll tell you. Statistics and research results can be biased, inaccurate and are only as good as the data you put in, and the method used to obtain the data. Kinda like computers: garbage in, garbage out. You can read ten studies, and depending on research methods, you can get ten different results.
Reading a research study is not a fun/easy thing. There is a language you have to learn first: P values, blinding, correlations, standard deviations, etc. etc. etc. Once you get that, it is necessary to know what type of studies they are conducting and the relative values: is it double blinded, is the cohort large enough to reach statistical significance, is there a control group, etc. Then look at who is paying for the study, this will make a huge difference. The people paying for a study have a bias and will set up a trial to get the results they want, yes, I know that sounds cynical, but let’s be real here.
I’ll give you an example. A study showed that St. John’s Wort is not useful to treat major depression. You have also read that in Germany, St. John’s Wort is the most prescribed medication for depression. Huh, how can that be. Look again, but more closely, MAJOR depression. The study was funded by a pharmaceutical company who manufactures antidepressants. They want people to use their product, so it is first necessary to debunk the use of a product that they can’t make a profit from. If you look further, you will find that St. John’s Wort is shown to reduce minor or moderate depression in some cases. As a matter of fact, if you take it with an antidepressant drug, you are in danger of serotonin syndrome, a form of overdose for antidepressants. So, the study result was biased and designed to give a false impression that the herb does not help in depression, but it is not helpful only for MAJOR depression.
Keep reading we are almost to the EBP part…
What you need is a meta-analysis, You read ALL the studies you can find on a particular subject, Then weed out the ones that are designed poorly, or which don’t cover exactly what you are looking for. I recently did a meta-analysis on whether cranberry is useful for urinary infections. After wading through I don’t remember how many studies, I ended up with about 12 that were applicable. The result was that cranberry is useful to PREVENT urinary tract infections (UTI) in WOMEN who had a history of recurrent UTI. Notice, it does not apply to men, and it is only useful to prevent, not treat UTI. (It so happens that cranberry prevents those nasty little bacteria from sticking to the inside of the bladder and growing there, and has nothing to do with acidifying the urine as I previously believed). Oh, and cranberry capsules are the cheapest and easiest to use for this. So, the EBP thing to do: recommend a woman who has had multiple episodes of UTI, to take cranberry capsules daily to prevent getting so many infections. UTIs are no fun, I have had them.
Okay, so, EBP is great, and all clinicians should participate in the plan and prescribe only things proven to work, right? Not so fast. Remember what I said about bias and inaccuracy? Back i the 70’s, when I had my children, we were lectured by the medical establishment that our infants needed to sleep on their stomach or side to prevent SIDS (sudden infant death syndrome). Studies showed that the little darlings choked on saliva or spit-up if they slept on their back. Guess what EBP says now? “Back to sleep”. Evidently new research showed that the rates of SIDS went UP when infants slept on their stomachs, and now we are to have them sleep on their back.
So, here is the bottom line. EBP is great, but professional experience and individualised treatment plans should also be in the mix. Sometimes research lies, or it forgets something important. The recent guidelines put out by the government about breast cancer screening is an example of what I am worried about. The government guidelines state women under 50 ( actually the 40-50 year range) do not need screening for breast cancer, that breast self exam is not useful and not to be recommended. This was based on a statistic. Supposedly, if you take a whole population (women in this case) and extrapolate how much lifespan you save over the entire population with a screening test (mammograms for under 50 years of age), if the result is less than one month, the test is not financially worthwhile. The 40-50 year olds evidently did not meet this goal. So, new guideline.
My worry is that the government and insurance companies will make these types of guidelines mandatory practice. Ask any oncologist how many forty something breast cancer patients they have treated. Each one of those women are not considered statistically important, but their families sure consider them important.
EBP is a great tool, but each finding is not carved in stone, new research may change it at any time. Health care providers need to use the tool, but it should not be a bludgeon used by the government or health insurance companies to control cost.