Too much of a good thing… Learning from the evidence.

Oxygen could kill you?

Who knew?

I knew it could give premature babies retinopathy, but critically ill adults?  Seriously?

Before you start to panic and demand physicians everywhere to remove oxygen from grandpa, allow me to explain…

Today, we saw all 6 of our patients in the first hour and a half (I saw them twice).  We didn’t have clinic scheduled today because the call schedule was late coming out and he doesn’t like to have patients scheduled on call days.  On a related note, we found out that we are on call all weekend.  ALL WEEKEND.  Surprise!   Not impressed (**whines).  Anyway, he decided it would be a good idea for me to go home early today (no complaints) but to read a few journal articles to be ready to talk about them tomorrow.

I am a big geek, so no problem there!  He suggested checking out last week’s Archives in Internal Medicine because it was interesting.

So I did.  And this is what I learned.

Something that caught my attention was the article Supplemental Oxygen in Medical Emergencies: More Harm Than Benefit?  It discusses how research is starting to point to the fact that our instinctive strapping on of oxygen to every sick person is not always good.  That people who are having ischemia can actually have more ischemia on oxygen.  Increased oxygen concentrations in the blood can cause vasoconstriction and free radical formation.  Thus, they can increase ischemia and tissue damage.  People who receive high concentration oxygen with normal saturation on room air can have poorer outcomes.  Wild!

I did further reading and found articles about oxygen administration and how we tend to over use oxygen outside of guidelines for requirements in hospitals.  The cost savings from more appropriate usage of oxygen would be ridiculous.  One study quoted 45% of oxygen administration is not medically necessary.  Plus, with what scientists are discovering about oxygen, imagine the impact.

I read another article entitled Effect of Aspirin on Vascular and Nonvascular Outcomes.  This was talking about the use of aspirin as prevention of cardiovascular events, cancer and death.  Interestingly, despite the medical profession’s view of aspirin as a benign drug, it still has side effects and in this study had no impact on cardiac death or cancer mortality.  It did reduce non-fatal MIs.  But the authors suggest that this needs to be weighed with the bleeding and GI side effects of the drug.  Crazy.  I have been in clinics where aspirin is prescribed to patients with any cardiac risk factors, even if they have not had an MI.  But apparently it is in people with known cardiac disease that it has shown benefit.  This is not to say there is no benefit.  Just that you need to think before prescribing or leaving it on the person’s drug list.

I don’t think I will stop giving oxygen to sick patients… If they need it.  But maybe I will re-evaluate more closely those who are receiving it and may not need it.  I will still prescribe aspirin, but maybe not to the healthy people with no risks and I won’t be as scared to remove it, especially with side effects.  I am still so new and learning.  But it is good to learn these things and the balancing skills now, before I am on my own with no preceptor to approve and co-sign my decisions.

Reading these articles about things that are so common, so reflexive in practice got me thinking.  Why do we do what we do?  We pride ourselves in being evidence-based, but do we always look at the evidence?  There are some things we do based on clinical experience or habit that are not necessarily the best.  Like ordering blood work every day.  Not always necessary.

Not that reading a single article on a topic will make me change my practice, but it should make me think about what I do.  Consider change.  Consider further reading.  Sometimes there are different subtleties in a research paper.  It takes more than one positive or negative study to really make changes.  But, even one should make you think.

I think it is good to think about why we do things.  Especially in medicine, but also in real life.

I set alarms for only 3 or 7 past an hour.  I have for years.  There is no evidence for this.  I am clearly just bat crazy.  But I think about why sometimes.  I think it is to give me an extra few minutes of sleep.  And because my OCD won’t allow me to change it.

I have a side of the couch.  I get agitated and anxious when someone sits on the other side.  Does that mean it is proven to be bad?  Nope.  I am just nuts.

But these are things that cause little harm (except to me and my poor spouse).  What about bigger things?

I drink coffee most every day.  It is a habit.  It isn’t the best habit.  It isn’t the worst.  If a research article comes out saying caffeine causes cancer, will I stop?  I don’t know.  Honestly, probably not.  It would take more than one article.  It would likely take first hand clinical experience.  But, is that what smokers once thought?

But bigger than that… Why do I go to church every week?  Why do I read my Bible every day?  Is it some sort of routine or ritual or is it something that is proven or real or legitimate?  For me, it is definitely the later.  I may not always be entirely realistic with my routines or rituals, but lets face it, church and bible reading and such, they aren’t as fun to most as drinking coffee or even sitting in a designated couch seat (though I admit that when the seating in church is really off, it bothers me a tad).  I feel like I need to test those desires, to make sure they are legitimate on a regular basis.  I need to worship God for who He is and what He is.  Not because I did it last week.  I need to do it because I know it is proven to be a good thing.  I see it in the lives of others, I read about it in the Bible.   I feel it.  I know that won’t be disproved or disputed.  At least not to a significant degree.  God is one of the few things we can’t have too much of.

I love reading about medicine.  I love learning about progress and how things affect our bodies and how the practice is shifting.   I especially find it crazy when something I thought to be so second nature, so common turns out to not quite be the best thing.

We can have too much of a good thing.  Just because it is what has been done for 50 years does not mean it is the best thing.

We need to evaluate our practices, both in medicine and in life.  Are our action the best for the circumstance, or do we need to adjust?

Please, share your thoughts!

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