Friday, October 3, 2014

ARISE: Keep Calm and Go Be "Doctors"

This week I had an opportunity to waive my pharmaco-nerd flag with the online release of the ARISE trial.  I could have bought myself a psych eval ticket the way I was running around my shared office with the other pharmacy faculty, printing off copies to share in the ED and asking everyone else what they thought of ARISE, ProCESS and what... oh God what will ProMISE show!?

But my excitement aside, the paper should be read by everyone who has the slightest involvement in the care of septic patients. Of course there are a plethora of FOAMed links to summaries, even my own take on it in Pharmacy Times, this is a paper (including the appendices) that is critical to know: simply because it will be a force to help change practice.  

While the most obvious change is to remove the rigid protocols of early goal directed therapy (EGDT), the less obvious, but more important change is to recognize that we should let "doctors" (and when I say doctors, let's just assume it's the whole team in the ED: nurses, patient care techs, pharmacists, physicians) be "doctors." When "doctors" are allowed to be "doctors," they use their knowledge, experience, and critical reasoning skills to determine the optimal treatment for any given patient.  This change goes beyond arguing whether we should or shouldn't follow a 'cook-book' medicine approach in favor of a laissez-faire 'art of medicine' approach.  So we shouldn't regard these trials as proving EGDT is a failure; but rather celebrate the fact that medicine has improved sepsis patient care as a whole. 

Remembering Bloom's taxonomy, we've established knowledge, applied protocols, analyzed their impact and evaluated the new norm. But there is one more step to consider because of Bloom's revised taxonomy: creating.  This is something FOAMed is getting pretty good at: collective crowd sourced knowledge, understanding, analysis, evaluation, AND creative/divergent thinking to see more than one answer to a problem.  I, for one, am eagerly waiting (and will try to do my part, however small it may be) to see what answers we can come up with.

So, go be "doctors."