Oximeters

robert bell rmsbell200 at YAHOO.COM
Thu Feb 1 03:29:53 UTC 2018


Thanks Tom,

But what should be done?

I have mentioned before the Stethoscope could be the worst instrument/test that HCPs use when one takes into consideration experience and hearing loss at different ages.

Are proficiency tests used on medical schools?

Overall we know nothing abut the accuracy of the stethoscope.

Are there some HCPs that should not use a stethoscope?

When are we going to do something practical and sort much of this out?

What are other industries doing to make sure the support tests/procedures they use are as accurate as possible? How far behind are we?


Rob


> On Jan 31, 2018, at 4:03 PM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
> 
> Dr. Bell:
> Thanks.
> Having read the JAMA study, I completely unscientifically watched our Level 1 ER blood pressures.
> Then I watched my PCP office (yes; I get care...not very faithfully), the local blood bank, etc.
> All experienced people.
> n=~500 observations. 0% did all 11 steps. Most did <3 steps. These are the "pros."
> I smell a precision study.
> 
> If we're misdiagnosing hypertension (and the misdiagnosis is certainly over-diagnosis...I think, though not proven.) then people are being treated for a disease they don't have. I can think of no clearer example of misdiagnosis.
> This has practical and lethal implications. Treating non-existent hypertension will likely lead to more falls; see Beers' list.
> I guess that I worry about a culture wherein misdiagnosis is ok in one direction but not the other. I learned at the side of some great Internets: It's hard for your patient to get better on your treatment for a disease which they don't have.
> 
> The one I have seen rise in prevalence is PE. We now have an extensive literature base that, by switching from V/Q to CTA, we have increased the rate of PE diagnosis without impacting the lethality; see BMJ. The cost is borne out in more than $ (which are important, depending on which side of the stack you're on.) We are having more fatal bleeds from anticoagulants in people who didn't have the disease (PE which alters their life-course; patient oriented outcomes) for which they are being treated.
> 
> So the culture of sloppiness at the base creeps up.
> 
> tom
> 
> 
> 
> On Wed, Jan 31, 2018 at 4:40 PM, robert bell <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com>> wrote:
> Thanks Tom,
> 
> I checked on the JAMA Med Student blood pressure report - pretty awful. Here is the link to the JAMA network summary.
> 
> https://jamanetwork.com/journals/jama/article-abstract/2653029?redirect=true <https://jamanetwork.com/journals/jama/article-abstract/2653029?redirect=true>
> 
> Only 1 out of 159 medical students scored 100% on all elements of the BP challenge. Of the 11 elements the average score for all students was 4.1!
> 
> What does that say about the State of the Medical Industry!
> 
> Yes, it may be worse for the average HCP. I would be interested to know what it would have been at foreign medical schools.
> 
> I agree with the idea of focussing on the small things first to establish a culture. However I do think that culture needs some direction from above. 
> 
> And with bottom line concern that is not always possible.
> 
> Would it be worthwhile to triage the main problems and focus on them with or without help from other societies?  If we do not do this what will happen?
> 
> Will more people be placed on BP medicines when they do not need it, with this adding to the errors in diagnosis? 
> 
> Thanks again for your fine replies.
> 
> Rob
> 
> 
>> On Jan 31, 2018, at 10:19 AM, Tom Benzoni <benzonit at gmail.com <mailto:benzonit at gmail.com>> wrote:
>> 
>> I'd focus on the rampant, low-level, constantly-tolerated, worked-around errors.
>> These create an atmosphere wherein errors are ok.
>> Given human behavior, "We're ok with doing small jobs badly; we want big jobs done right."is the philosophy of failure.
>> Big jobs are based on small jobs.
>> 
>> It's also simple math: the result of any process cannot be more precise than the least precise of its components. (There are myriad sayings: weakest link, slowest runner, etc.) 
>> 
>> Excellence built into the system percolates up; it cannot drizzle down.
>> 
>> tom
>> 
>> On Wed, Jan 31, 2018 at 9:58 AM, Robert Bell <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com>> wrote:
>> Dear Tom,
>> 
>> Thanks - appreciate your illuminating comments/thoughts. If all errors, including diagnostic, are at times inter-related how does the diagnostic error movement move forward? Focus on the commonest problems/combinations or focus on those that produce the greatest damage? Or all. A massive big challenge.
>> 
>> Rob
>> 
>> 
>> Sent from my iPad
>> 
>> On Jan 31, 2018, at 8:04 AM, Tom Benzoni <benzonit at gmail.com <mailto:benzonit at gmail.com>> wrote:
>> 
>>> Dr. Bell:
>>> It's not well known, and is a double tragedy.
>>> Clinicians get beat up over endangering a patient when there was no expectant danger.
>>> This has the odd effect of causing interventions when none is warranted and making people less cognitive/aware.
>>> The way I know it is not well known: Hospitals have pages long protocols for procedural sedation, many written, in my not-very-humble opinion, to protect margins, and i've never seen this error discussed. (Don't make them aware; it's a marker I use for situational awareness.)
>>> 
>>> You've only scratched the surface of errors in BP readings. JAMA had a recent paper discussing med student errors in measurement.
>>> Fortunately, they didn't study attendings or nurses in practice; it would have been worse.
>>> And nowhere so I see awareness that automated cuffs do not measure BP; they find first turbulent flow (approximately MAP) then, using proprietary algorithms, calculate a systolic and diastolic. Find that method in AHA guidelines?
>>> I helped write, many years ago, the original ACEP guidelines to NOT normalize/treat asymptomatic BP elevations found in the ER. (Full-on discussion behind that one separately.)
>>> 
>>> If we tolerate this low level error systematically, how can we expect to address the large/few errors?
>>> High frequency-low consequence errors are arguably of greater import than low frequency-high consequence ones; driving to the airport caries greater risk of death than the flight itself.
>>> 
>>> tom
>>>  
>>> 
>>> On Tue, Jan 30, 2018 at 10:21 PM, Robert Bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
>>> Thanks Tom,
>>> 
>>> That is something to consider. How many HCPs know about that? 
>>> 
>>> What about, Ipsilateral sphygmomanometer cuff - oximeter reading error!!
>>> 
>>> And do not get me started on the frequency with which blood pressures are taken with the wrong sphygmomanometer cuff size, and through clothing (some times thick). 
>>> 
>>> I have in my postings to the list here always been interested in the level of error in the things we do to help us with diagnoses. I strongly believe that we need, to not only be improving our diagnostic abilities, but also work to improve the errors of support tools at the same time. Both need to be worked upon to get to our goal of significant reductions in diagnostic error. That could be done with partnering with another society or societies, more dedicated to standard errors, with time related goals to help get there soon.
>>> 
>>> Robert Bell
>>> 
>>> On Tuesday, January 30, 2018, 2:57:56 PM MST, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>> wrote:
>>> 
>>> 
>>> Orthopedic changes do not effect them.
>>> Skin thickness does not but we don't use these over callused areas.
>>> They can read black skin. Melanin has a different spectral absorption.
>>> Very cold extremities where the capillary beds are clamped down can cause erroneous readings as can patients in extremis from end-stage myocardial disease...but don't need a pulse ox there.
>>> An interesting error source comes from blood pressure cuffs. Because the cuffs are usually set to automatic, intermittent low readings occur not from the patient but from temporary occlusion of the artery by the cuff if on the ipsilateral arm. If you're not aware of this error source, you can think the patient on whom you're doing a procedure is in trouble when they're fine. And you might terminate the procedure or make an unnecessary intervention on a well person.
>>> What is that type of error?
>>> 
>>> tom
>>> 
>>> On Mon, Jan 29, 2018 at 11:49 PM, robert bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
>>> I was thinking also of the accuracy in elderly patients with osteoarthritis, bent fingers, and soft skin versus hard thickened skin and also the differences with different fingers.
>>> 
>>> Yes, alarms are a problem.
>>> 
>>> Rob Bell, M.D.
>>> > On Jan 29, 2018, at 3:11 PM, Rory Jaffe <rjaffe at CHPSO.ORG <mailto:rjaffe at CHPSO.ORG>> wrote:
>>> >
>>> > Interpretation is a big issue. Pulse oximetry is very insensitive to hypoventilation when a patient is on supplemental O2. Also tends to have lots of false alarms--the default limits are not very usable and ideally, people would use patient-specific alarm limits.
>>> >
>>> > -----Original Message-----
>>> > From: Grubenhoff, Joe [mailto:Joe.Grubenhoff@ CHILDRENSCOLORADO.ORG <mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>]
>>> > Sent: Monday, January 29, 2018 8:55 AM
>>> > To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> > Subject: [No SPF Record] Re: [IMPROVEDX] Oximeters
>>> >
>>> > Pretty accurate in my experience - the problem may be in how this single value is interpreted in the context of the whole clinical picture:
>>> >
>>> >
>>> >
>>> > Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.
>>> >
>>> > Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S.
>>> >
>>> > JAMA Pediatr. 2016 Jun 1;170(6):602-8. doi: 10.1001/jamapediatrics.2016. 0114.
>>> >
>>> >
>>> >
>>> > Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.
>>> >
>>> > Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR.
>>> >
>>> > JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
>>> >
>>> >
>>> >
>>> >
>>> >
>>> > ´╗┐On 1/29/18, 09:49, "Robert Bell" <0000000296e45ec4-dmarc- request at LIST.IMPROVEDIAGNOSIS. ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>>> >
>>> >
>>> >
>>> >    How accurate are oximeters? Are the errors big enough to make wrong decisions?
>>> >
>>> >
>>> >
>>> >    Rob Bell, M. D.
>>> >
>>> >
>>> >
>>> >    Sent from my iPad
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>>> > http://LIST.IMPROVEDIAGNOSIS. ORG/ <http://list.improvediagnosis.org/> (with your password)
>>> >
>>> > Visit the searchable archives or adjust your subscription at:
>>> > http://list.improvediagnosis. org/scripts/wa-IMPDIAG.exe? INDEX <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
>>> >
>>> > Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
>>> >
>>> > To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>> > <a href="http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>" target="_blank">http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1></a>
>>> > </p>
>>> 
>>> To unsubscribe from the IMPROVEDX:
>>> mail to:IMPROVEDX-SIGNOFF-REQUEST@ LIST.IMPROVEDIAGNOSIS.ORG <mailto:to%3AIMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>>> or click the following link: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> Address messages to: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> For additional information and subscription commands, visit:
>>> http://www.lsoft.com/ resources/faq.asp#4A <http://www.lsoft.com/resources/faq.asp#4A>
>>> 
>>> http://LIST.IMPROVEDIAGNOSIS. ORG/ <http://list.improvediagnosis.org/> (with your password)
>>> 
>>> Visit the searchable archives or adjust your subscription at:
>>> http://list.improvediagnosis. org/scripts/wa-IMPDIAG.exe? INDEX <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
>>> 
>>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
>>> 
>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>> <a href="http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>" target="_blank">http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1></a>
>>> </p>
>>> 
>>> 
>>> 
>>> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> To unsubscribe from IMPROVEDX: click the following link:
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/ <http://www.improvediagnosis.org/>
>>> 
>>> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> To unsubscribe from IMPROVEDX: click the following link:
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>>> 
>>> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> 
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/ <http://www.improvediagnosis.org/>
>> 
> 
> 
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> 
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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