That
Voodoo That You Do |
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By
Calvin
L Weisberger, MD
Evidence-based
medicine is the cornerstone of today's practice. Our young doctors are
taught to practice based on the evidence from double-blinded, controlled
studies. They learn to order tests for every complaint and react to
the tests. They learn which therapies result in which statistical results.
They are overwhelmed by the sheer mass of data. They are taught to evaluate
the data and the results published in the literature to seek answers
to the clinical problems that face them. If they make a decision not
based on the evidence, they learn there may be legal consequences. Making
decisions affecting other's lives should be based on the best evidence
available. When there is no real evidence available, our new doctors
are unfortunately less prepared to be creative. The modern environment
makes me somewhat nostalgic for the old days. I would not want to go
back to the fly-by-the-seat-of-the-pants past; but we did achieve some
good results, and we did have the freedom to be creative.
I remember
that during my internship, one of the other services had admitted a
large psychotic woman. She had serious diabetes and hypertension in
addition to being psychotic. The woman also was aggressive and angry.
Her ward team was unable to deal with her. She had been combative with
all efforts to treat her and to deal with her. The team wanted to treat
her with thorazine, our main antipsychotic injectable at that time.
She needed insulin and antihypertensive therapy. As I walked down the
hall past her room, loud noises of combat arose. The room was full of
house staff and security people all involved in the unsuccessful effort
to get thorazine into the lady. The intern and resident on her case
came out and sat at the nursing station with me. They were exhausted
and frustrated. They were about to call for more security to hold the
lady down. Not being involved with the lady, I volunteered to try and
gain her cooperation. I walked into the room to try to calm her and
asked the security folks to step out of the room. She and I had a conversation.
It was difficult because of her psychosis, but I was able to calm her
and get her to express her needs. It turned out, she wanted an orange.
The house staff didn't want to give the diabetic lady the orange without
her getting her insulin. I promised her I would go out of the room and
bring her an orange. I kept my word to the lady. There was no evidence
that an orange would help her. There was no evidence that injectable
thorazine would be absorbed through the GI tract. Needing creativity,
however, I obtained an orange and injected several hundred milligrams
of thorazine into the orange. I came back to the room and presented
the angry lady with the orange. She ate it happily. Within an hour,
the house staff had a much more cooperative patient.
I don't
know now and didn't then whether anyone had before or since tried the
thorazine-in-the-orange gambit. Something needed to be done to try and
achieve a clinical result. The bruises and other potential damage from
fighting with the very large woman would have been significant. I made
a creative extrapolation from my understanding of physiology and pharmacology,
and it worked. Scientifically, the anecdote proves nothing. I'm afraid
that the conditions extant in medicine today might well exclude the
ability to apply such a creative therapy.
The ability
to create a solution and have fun doing it is an important part of my
medicine experience. I hope that today's doctors still have the opportunity
for creativity and fun. Medicine goes back far into history. We have
ties back to medicine men, witch doctors, and voodoo health practitioners.
There still is an art to medicine and a history of art in medicine.
I may have done some voodoo with that particular patient long ago. If
it helps my patient of today, then evidence deficit or not, I may still
do that voodoo that I did that day.
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