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Dogma in Critical Care
10 Plays3 years ago
In this episode of the podcast, we will discuss dogma in critical care medicine. How do we fight dogma when the evidence is weak? Our guest is Dr. Mervyn Singer, an internationally recognized critical care clinician, investigator, and educator. Dr. Singer is professor of intensive care medicine at University College London.
Additional Resources:
Challenging management dogma where evidence is non-existent, weak, or outdated. By D. A Hofmaenner and M. Singer
https://link.springer.com/article/10.1007/s00134-022-06659-4
Link to Gapminder, an independent educational non-profit fighting global misconceptions
https://www.gapminder.org/
Think Again: The Power of Knowing What You Don’t Know. By Adam Grant
https://amzn.to/3bceyLu
Books Mentioned in this Episode:
Factfulness: Ten Reasons We're Wrong About the World--and Why Things Are Better Than You Think. By Hans Rosling
https://amzn.to/3S4kWFj
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Challenging Dogma in Critical Care
00:00:33
Speaker
There are many interventions and beliefs in critical care that we hold true on face value.
00:00:37
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We believe in them because that is what we were taught.
00:00:40
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We do it this way because that is the way it was done before us.
00:00:43
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This is the way we were taught to do it during our training.
00:00:46
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We often refer to this type of knowledge as dogma.
00:00:49
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In today's episode of the podcast, we will discuss how to challenge such dogma, especially when the evidence is absent or weak.
Guest Introduction: Dr. Mervyn Singer
00:00:58
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Our guest is Dr. Mervyn Singer.
00:01:00
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Dr. Singer is an internationally recognized critical care clinician, investigator, and educator.
00:01:05
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He is a professor of intensive care medicine at University College London in London, United Kingdom.
00:01:10
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Dr. Singer has been a true inspiration for myself and countless of intensivists around the world.
00:01:15
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Through his research, publications, and dynamic and always entertaining presentations, he has pushed me to think outside the box and question convention.
00:01:24
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From the role of mitochondria and septic shock to a more rational approach to hemodynamic monitoring or new definitions for sepsis, his work has been instrumental in moving our field forward.
00:01:34
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It's a true honor to have him on as a guest today.
00:01:36
Speaker
Mervyn, welcome to Critical Matters.
00:01:39
Speaker
Thank you very much indeed, Sergio, for the lovely invitation.
The Origin of Challenging Medical Dogma
00:01:43
Speaker
So the genesis of our conversation today was a wonderful article you recently published in Intensive Care Medicine entitled Challenging Management Dogma Where Evidence is Non-Existent, Weak, or Outdated.
00:01:55
Speaker
Before we dive into the topic itself, tell me how this came about.
00:02:00
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Well, very simply, my co-author is a Swiss doctor called Daniel Hoffmaner, who was spending a year or so in my research lab, wanted to write a review article.
00:02:13
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And I said, well, yeah, we could write something dull and boring and worthy, or we could be a little bit more provocative.
00:02:19
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And it's something I rail against, the use of dogma.
00:02:24
Speaker
in medical management so I said well why don't we just pick four examples and we had a whole list that we could pick from and use those four examples and go into the literature and see if there's any actual truth that underpins the belief.
Definition and Impact of Dogma in Medicine
00:02:41
Speaker
Excellent and I think as we dive into the topic it's always good to start with definitions and how would you define dogma?
00:02:49
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Well, dogma comes from the Greek, and it means that which one thinks it's true.
00:02:56
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So, in other words, it's sort of a derivation of another Greek verb called dokein, meaning to seem, to think, to accept.
00:03:05
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So, it's separate from fact, which is, you know, a much harder truth or reality.
00:03:15
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And I think that in medicine, we talk about facts a lot when they're probably not such, right?
00:03:20
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We kind of use the word facts very loosely in terms of just justifying what we believe or what would be considered to be dogma.
00:03:28
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Would that be a fair statement?
00:03:30
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100%.
00:03:30
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You know, I think we're taught at our mother's knee.
00:03:34
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This is the way things happen.
00:03:35
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This is the way things are.
00:03:37
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It's written in one textbook.
00:03:39
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The next textbook simply copies what's been preached before, and then it becomes a self-perpetuating fiction.
00:03:48
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Yes, you know, patients seem to...
00:03:51
Speaker
survive either because or in spite of the perceived fact.
00:03:57
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But, you know, as I'm sure we'll no doubt discuss, sometimes we overreact, sometimes we do the wrong thing because it's dogma and not hard fact.
00:04:09
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Absolutely.
Philosophical Perspectives on Dogma
00:04:10
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And I'm a big believer that philosophy has a lot to teach us because if we still talk about what other men thought thousands of years ago, it must be because there's value in it.
00:04:22
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And I noticed, I mean, in the introduction of your paper that you were pointing out some philosophical differences in how dogma was considered or approached between Plato and Aristotle.
00:04:34
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Can you maybe expand on that a little bit?
00:04:36
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Yeah, no, indeed.
00:04:38
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So there were two different schools of thought.
00:04:40
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So two great philosophers and
00:04:45
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Plato considered doxa, which was this sort of cousin of dogma, a belief unrelated to reason, and he framed it as the opponent of knowledge, whereas Aristotle, on the other hand, took the view that this was practical, it was used commonly, and it was the first step in finding knowledge.
00:05:05
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So Plato was sort of repelled by assumptions of truth, whereas Aristotle felt it was part of the journey.
00:05:14
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So as you discussed in the paper and as we know, dogma is present in our everyday clinical work.
00:05:22
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But how could it be valuable for clinical practice in the ICU?
00:05:26
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What's the positive side of dogma?
00:05:28
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Well, I think the positive side is that
00:05:32
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There's unfortunately many, many, many things we do every day to our patients that aren't grounded in hard evidence.
00:05:41
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And so they by and large stood the test of time and we know that they're generally safe and generally applicable.
00:05:49
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And so we translate
00:05:51
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that management protocol or whatever into everyday practice.
00:05:55
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And the danger is sometimes, you know, we sort of merge these things into a one-size-fits-all hard guideline, a protocol, a policy, when the reality is that some patients may benefit from that approach and other patients may actually be harmed.
00:06:17
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What's the counterside to that?
00:06:18
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What would be the dangerous aspect of dogma in clinical practice?
00:06:22
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Well, I think making the assumption that doing it one way, a certain way, always benefits every single patient.
00:06:30
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So we need to retain a degree of flexibility in our thinking and approach the patient as an individual.
00:06:38
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So we can apply standard principles, but we should be allowed to deviate
00:06:45
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just in case the patient doesn't follow the rules.
00:06:49
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And often patients don't follow the rules, so we should have the flexibility of thought to be able to think, why isn't that patient responding in the appropriate way?
00:06:58
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And that should make us reconsider the diagnosis or how that patient is responding to that particular treatment.
00:07:07
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Excellent.
00:07:07
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And it almost feels, Mervyn, like what you're saying is that dogma provides us answers, but perhaps as clinicians, our job is to have more questions.
Integrating Evidence-Based Medicine with Clinical Expertise
00:07:17
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Absolutely.
00:07:17
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So it's a good basis as a starting point, but we shouldn't just rely on the dogma alone.
00:07:24
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We should be able to expand and think beyond that.
00:07:28
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In fact, there was one of the gurus of evidence-based medicine was a guy called David Sackett, who I believe was Canadian but spent a lot of his time in Oxford.
00:07:39
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And he wrote a wonderful editorial,
00:07:43
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25 years ago in the British Medical Journal, where he talked about what evidence-based medicine is or isn't.
00:07:50
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And he made the point that, yes, we want to apply evidence-based medicine to our patients, but the evidence doesn't always apply.
00:07:59
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So you should absolutely not divorce the literature from clinical gestalt and expertise and the two need to be married.
00:08:09
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And he was actually very...
00:08:12
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use the word dogmatic, about the fact that you've got to marry the two together.
00:08:17
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Neither alone is sufficient.
00:08:20
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Excellent.
00:08:20
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Now, something that comes to mind as maybe a reason of the perpetuation and maybe amplification of a lot of dogmatic beliefs and critical care, but in medicine in general, is confirmation bias.
00:08:36
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When I think about dogma and when I read your paper, confirmation bias keeps popping up as what I see over and over again at the bedside.
00:08:46
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as a way of maybe perpetuating, how would you relate confirmation bias to dogma and its perpetuation in clinical medicine?
00:08:56
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I think probably in a number of ways.
00:09:00
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An obvious one is that we follow dogma.
00:09:04
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the well-trusted and tried track and if the patient dies it's the patient's fault it's never our fault you know the patient just didn't respond their protoplasm was too poor their underlying strength you know comorbidities etc meant that they didn't respond that that was their fault not ours and i think that's one crucial point of confirmation bias the other thing also i think
00:09:33
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People who are attracted into critical care like numbers, like machines, like monitors, and we're sometimes guilty of chasing the number.
Dogma and Clinical Practices in Intensive Care
00:09:43
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And we can make the number look artificially good, and so we pat ourselves on the back that that represents an improvement, but the reality is that actually it may be storing harm.
00:09:54
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And a few simple examples, we can give vasopressors to get the blood pressure of the patient to their normal level,
00:10:03
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but there's a whole heap of harm associated with capitol amines that we don't necessarily see at the end of the bed.
00:10:10
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And so the patient died some days later of the complications, and we blame the patient.
00:10:17
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Another example, and again, the first sort of randomized trial in critical care that truly showed a difference was not overventilating.
00:10:26
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And certainly when I was a junior doctor, the maxim was, oh, make the numbers look normal.
00:10:33
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And we strove to make the numbers look normal.
00:10:36
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And then the penny dropped that that was injurious.
00:10:39
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And low tidal volume ventilations to try and prevent barotrauma, volutrauma, et cetera, was actually beneficial.
00:10:47
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So we didn't have to strive for normal but an acceptable degree of abnormality compatible with adequate organ perfusion, adequate oxygenation, and so forth.
00:10:59
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And it's also another area that's very interesting to me when we talk about this topic.
00:11:04
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And Mervyn, I would like to hear your thoughts is when you look at, when you think of dogma, textbooks come to mind immediately, right?
00:11:11
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What's like in the Oxford textbook of critical care?
00:11:15
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What's in Harrison's clinical medicine textbook?
00:11:19
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But
00:11:21
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From our era when we were students to now, textbooks are much less relevant it seems.
00:11:25
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People seem to get their information from a thousand other places.
00:11:30
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How do you think that impacts the propagation of dogma?
00:11:32
Speaker
Do you think it's a positive or a negative?
COVID-19 and the Formation of Dogmatic Beliefs
00:11:36
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Good question.
00:11:39
Speaker
I think probably a negative, well, both are negatives.
00:11:43
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I think textbooks also rely either on a few people writing the book or a multi-author approach where different people take on different chapters and you're relying on their bias, you know, and it's fair to say that
00:11:59
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Everyone has their own biases, which may or may not be relevant, they may or may not be aware of.
00:12:08
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And it's just a fact of life that you strongly believe in one course of action, one treatment to paradigm, and therefore you dismiss or downplay every opposing strategy.
00:12:21
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So I think it's fair to say that textbooks have flaws, but by the same virtue...
00:12:29
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When you pull a review off the internet or there are lots of actually very useful medical websites, Medscape and all of these other ones, which, again, aren't bad, but they do reflect the biases and the views of that particular person who wrote them.
00:12:51
Speaker
And I think that one of the interesting phenomenon that we've seen with COVID is that the value of expertise, of dedicating a life to studying, learning, and teaching a subject all of a sudden is less relevant because anybody can now reach thousands to millions of people with their opinion, whether it's based on evidence or not.
00:13:16
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100%.
00:13:16
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And I think it's one of the tragedies of COVID that there was this vainglorious rush to get the answer first.
00:13:26
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We can show the world that we've got there before everybody else.
00:13:30
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And a lot of the recommendations, as you said, were totally non-evidence-based.
00:13:37
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Hydroxychloroquine, azithromycin, ivermectin, yada, yada, yada, yada.
00:13:42
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But also, I think sadly, a lot of the trials are
00:13:47
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Randomized trials were very badly performed.
00:13:51
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Open-label, so-called pragmatics, so very little data were collected, hardly any collected blood samples, so we could better understand who did respond and who didn't respond to the therapy.
00:14:03
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So I think we had a great opportunity with COVID to really...
00:14:09
Speaker
take a single disease, sepsis is a syndrome encompassing a whole variety of different pathogens, different sites of infection.
00:14:18
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Here we have a single disease phenomenon and we could really have made much greater strides than we have.
00:14:24
Speaker
And if you look at the evidence, there's still a huge amount of conflicting evidence about steroids, tocilizumab, etc.
00:14:32
Speaker
And we don't know who best to use them in and who best to not use them.
00:14:37
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Yeah.
00:14:38
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Absolutely.
00:14:38
Speaker
And another aspect of the trials that has been kind of disappointing for me is that when you look at ivermectin or you look at maybe vitamin C, it seems that a lot of effort and money has been spent based on noise and not on a clear scientific pathway of plausibility.
00:15:01
Speaker
Yeah, no, I think that's true.
00:15:03
Speaker
It's an ability to manipulate the media to create that public storm.
00:15:10
Speaker
And unfortunately, often researchers and funding often follows the media hype.
00:15:18
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And I think it's interesting with COVID because in a two-year period, the dogma has been amplified and became dogma very quickly, right?
00:15:27
Speaker
I mean, in some practices, people were doing things in a dogmatic way almost with the argument, well, it can't hurt or it probably works and we don't have anything better.
00:15:35
Speaker
But it led probably to a lot of unnecessary treatments that probably were harmful or could be harmful.
00:15:42
Speaker
hugely agree with that statement and we where I work in London we resisted that on the ICU we had everyologist and to be fair it was you know done with the right intentions that they had the idea look I know I'm doing something this will work this will treat the patient you should give it
00:16:04
Speaker
And we resisted.
00:16:05
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We said, look, unless it's actually within a properly controlled trial, we're not just going to give ad hoc treatments just because it seems like a good idea.
00:16:15
Speaker
As a lovely example, there was a lot of hype in the medical literature on the Internet in Australia.
00:16:23
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lay media about cytokine storm.
00:16:26
Speaker
And even the first papers from Wuhan showed this didn't actually exist.
00:16:31
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But it didn't stop huge numbers of papers being written about cytokine storm.
00:16:37
Speaker
A good fiction, but it led a lot of effort in a misguided manner to look at a whole variety of drugs that were totally inappropriate for COVID.
00:16:49
Speaker
And I think it also illustrates another mechanism of amplification of these dogmatic beliefs because I still recently in a big group chat of intensivists here in Houston saw people asking about what do you think of using higher steroid doses in those patients with cytokine storm?
00:17:07
Speaker
And the question is, who are those patients, right?
00:17:11
Speaker
How do you find them?
00:17:14
Speaker
Well, exactly.
00:17:15
Speaker
And the lack of blood sampling to try and understand mechanism, pathophysiology, the subgroup of patients who could benefit from an intervention,
00:17:25
Speaker
That was all bypassed.
00:17:27
Speaker
And so we're no wiser.
00:17:29
Speaker
And to me, that's a huge tragedy.
00:17:31
Speaker
We missed a great opportunity.
Examples of Medical Dogmas
00:17:34
Speaker
So let's shift gears a little bit and talk about how we fight dogma, especially when evidence is weak, which would be non-existent evidence or evidence that is outdated and probably low quality.
00:17:47
Speaker
And what I would like to do, Mervyn, with your permission, is to just maybe touch on the four examples that you wrote about, because these were phenomenal.
00:17:56
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Every single one of them, I have to raise my hand and say, guilty, right?
00:18:00
Speaker
I've done all of these or believed in all of these, or at least behaved in a way that I have to do this because otherwise I get in trouble.
00:18:07
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And some of these actually have been causes of lawsuits and practices that I oversee.
00:18:12
Speaker
Yeah.
00:18:15
Speaker
Yeah, exactly.
00:18:17
Speaker
And so we picked four things that are common statements in critical care or in acute medicine management in general.
00:18:27
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And so we thought, well, what's the provenance of these statements and what's the evidence that they actually do work, are beneficial, are accurate?
00:18:36
Speaker
Excellent.
00:18:37
Speaker
Go ahead.
00:18:37
Speaker
Sorry.
00:18:39
Speaker
Sorry, I was going to say I should give the rider that we'll discuss them later, and it doesn't necessarily mean we shouldn't do the right thing.
00:18:46
Speaker
So I'm not saying we'll talk about antibiotics and meningitis.
00:18:50
Speaker
So I'm not saying there should be delay, but we looked at the evidence saying, well, does every hour count?
00:18:57
Speaker
It's not that strong.
00:18:58
Speaker
So don't get me wrong.
00:19:00
Speaker
I'm not advocating we can sit in our hands and do nothing, but
00:19:04
Speaker
the sheer driver for the belief isn't underpinned by hard fact.
00:19:11
Speaker
And one of the things that motivated me to talk about this topic, in addition to my interest and obviously your expertise, is that as we established in the introduction, dogma has a positive side and a negative side.
00:19:26
Speaker
And it's nuanced, right?
00:19:27
Speaker
And what we're trying to do is understand things better and move forward with
Questioning Established Practices
00:19:32
Speaker
clarity.
00:19:32
Speaker
Because one of the phenomenon that I've noticed, Mervyn, and I don't know if you have also seen this, is that with the explosion and dissemination of what people call free open access medical education, where it be the Twitter world, Instagram, YouTube, podcast, Instagram,
00:19:51
Speaker
The younger generation has, I think, a very iconoclastic attitude.
00:19:55
Speaker
And it's almost like the gotcha, we shouldn't be doing this, seems to sell more than really just asking good questions.
00:20:03
Speaker
And I think that that's not what we're talking about today because we're going to explore these four items in more detail.
00:20:10
Speaker
But like you prefaced your comments by saying, I'm not saying don't do this.
00:20:15
Speaker
I'm just looking at this in more depth.
00:20:18
Speaker
I think I agree.
00:20:20
Speaker
And the thing I'd add to that is I think we're guilty as a profession of just looking at headlines.
00:20:28
Speaker
So it's the abstract, the short Twitter feed, et cetera, the headline, and we don't bother to actually read the paper.
00:20:36
Speaker
I'm...
00:20:37
Speaker
perhaps trending, attending more towards the obsessional.
00:20:40
Speaker
So especially if a paper grabs my attention or doesn't make sense to me, I'll delve in more detail.
00:20:47
Speaker
And often there's a huge amount, a wealth of data buried in the supplement, which perhaps sometimes undermines the message that the authors of the paper with their academic bias want to portray.
00:20:59
Speaker
So in some papers, I'll delve deeper.
00:21:03
Speaker
I think some of the COVID-19
00:21:04
Speaker
Papers we talked about earlier was one such example where actually just digging below the surface reading the paper as a whole looking at the supplementary data
00:21:16
Speaker
opens up an Aladdin's cave of fascinating data.
00:21:20
Speaker
Absolutely.
00:21:22
Speaker
So let's start with loop diuretics.
00:21:25
Speaker
And I guess the statement is loop diuretics are needed to treat acute heart failure.
00:21:29
Speaker
I can't imagine that any of our listeners has not done this, right?
00:21:34
Speaker
And the question is why?
00:21:36
Speaker
Well, I think we see the end of the needle, almost end of the needle, a response of the patient.
00:21:43
Speaker
They're breathing after...
00:21:46
Speaker
10 minutes or so becomes easier, and we see a big bag of urine, and we take that as a sign of, oh, this is success, haven't we done well?
00:21:55
Speaker
Patient symptomatic improvement, big bag of catheter bag containing lots of urine, the two must be related.
00:22:04
Speaker
However, just simply, the pharmacology doesn't fit in that a diuretic, given intravenously, the diuretic action kicks in after about 20 to 30 minutes, by which time the patient's already got considerably better.
00:22:20
Speaker
and it's well known that fluid doesn't redistribute quickly from the lungs back out and the main mode of removal of excess fluid pulmonary edema from the lung is actually lymphatic drainage and this takes time often the patient
00:22:38
Speaker
It has still got wet-looking lungs when they're fit and ready to leave hospital.
00:22:43
Speaker
So it's a slow improvement, but we're seduced by the X-ray, the wet-looking X-ray, and ergo, giving them a diuretic to dry them out must be the answer.
00:22:55
Speaker
But yes, in the isolated example where the patient is truly intravascularly volume overloaded,
00:23:03
Speaker
Totally agree.
00:23:04
Speaker
Or they're chronically on a diuretic and their kidneys become habituated to being on diuretic.
00:23:10
Speaker
So in those situations, I continue them on the same dose.
00:23:15
Speaker
But I think it's worth asking the question, why does the patient improve within 10 minutes with ferrozamide, for example, before the diuresis kicks in?
00:23:26
Speaker
And it's because the drug causes vasodilation.
00:23:31
Speaker
The other problem I have with a diuretic is I want the vasodilation, but do I necessarily want the diuresis?
00:23:38
Speaker
I'm sitting here in fluid balance at the moment talking to you, Sergio.
00:23:43
Speaker
It might induce crushing central chest pain.
00:23:45
Speaker
I might suddenly collapse to the floor, frothing at the mouth with pulmonary edema.
00:23:50
Speaker
So I hadn't suddenly gained three liters of fluid out of the air to give me pulmonary edema.
00:23:56
Speaker
It's come internally from within my body.
00:23:59
Speaker
So obviously from...
00:24:01
Speaker
the intravascular compartment into the lung and obviously pulling tissues a fluid out of the tissues and the cells and so my total body volume is not increased if anything by the time i get to hospital it will have decreased i'll have sweated vomited mouth breathed not drunk and so total body wise i'm negative so the doctor comes in gives me a diuretic i get the instant
00:24:29
Speaker
relatively instant benefit symptomatically the gases improve doctors nurses pat themselves on the back saying job well done i gush lots of urine a few hours later my kidneys are desperately now trying to hang on to fluid because i'm quite deplete nurse rings doctor oh
00:24:49
Speaker
Mr. Singer had a good response to his furosemide.
Reevaluating Treatment Approaches in Heart Failure
00:24:52
Speaker
He's now only peeing 10 mils an hour.
00:24:53
Speaker
What shall I do?
00:24:54
Speaker
He's still got a wet x-ray.
00:24:56
Speaker
Let's give him a double dose.
00:24:58
Speaker
Let's give him 80 of furosemide or 100.
00:25:02
Speaker
And then the renal function goes off.
00:25:04
Speaker
And, oh, well, it's Mr. Singer has, you know, poor kidneys.
00:25:09
Speaker
You know, we'll do what we can, but he may well need a dialysis machine.
00:25:14
Speaker
rather than thinking, actually, we've desiccated this patient.
00:25:18
Speaker
He's intravascular volume depleted.
00:25:21
Speaker
And perhaps what he actually needs is fluid.
00:25:24
Speaker
Or perhaps what he actually needs is not the diuresis in the first place.
00:25:29
Speaker
So I've made the argument that vasodilation is what the patient needs.
00:25:34
Speaker
And I would argue especially arterial dilatation to reduce the resistance against which the heart has to pump.
00:25:41
Speaker
Then why not just give a vasodilator?
00:25:44
Speaker
So we have, again, we call it glycerol trinitrate, in the US, nitroglycerin.
00:25:50
Speaker
It works quickly.
00:25:51
Speaker
Studies show that four puffs of nitrolingual spray, you can get a result as quick or even quicker than a bolus of furosemide, and then you could be setting up the infusion in the meantime.
00:26:05
Speaker
So you're getting the benefits of vasodilation, symptomatic relief, without desiccating the patient.
00:26:13
Speaker
And it's a good trial.
00:26:14
Speaker
If you're finding relatively low doses of nitrate drop the pressure, that should make you think, are they intravascularly volume deplete?
00:26:22
Speaker
Is there an obstruction in the circulation?
00:26:25
Speaker
For example, a valve stenosis or a tamponade or whatever.
00:26:33
Speaker
Sorry, long answer, but hopefully that's explained my physiological rationale.
00:26:39
Speaker
Absolutely.
00:26:40
Speaker
And I think that the other issue that I think is commonly an obstruction or an impediment for us advancing from dogma is
00:26:49
Speaker
is that it's so established that if you propose to randomize people with these symptoms to diuretic or something else, people would say there's no equipoise, right?
00:27:02
Speaker
Indeed.
00:27:02
Speaker
Well, there have actually been a few trials.
00:27:06
Speaker
Unfortunately, though, even though the clinicians were encouraged not to use diuretics, they still use them regularly.
Challenges in Conducting Clinical Trials
00:27:15
Speaker
almost as much as in the control group where nitrates weren't given.
00:27:20
Speaker
And so you're not getting the pure benefit of the nitrate because you're compromising that care with the same dose of diuretic.
00:27:29
Speaker
Absolutely.
00:27:30
Speaker
And other questions that come to mind as you discuss the diuretic story is I've also seen people give diuretics in cases where the symptoms are present, but the x-ray doesn't look so bad, but they argue, well, this is a chronic patient and blah, blah, blah, blah.
00:27:46
Speaker
And we still give the diuretics, right?
00:27:49
Speaker
And again, I mean, to what extent?
00:27:51
Speaker
Probably to the point where their cryonin now suffers.
00:27:54
Speaker
And then we say, oh, it's a cardiorenal syndrome.
00:27:57
Speaker
And like you said, we go down another route.
00:28:00
Speaker
Yep.
00:28:02
Speaker
Again, I agree with you.
00:28:04
Speaker
I used the word physiology, but physiologic.
00:28:09
Speaker
Yeah.
00:28:09
Speaker
And I think the word logic should be applied...
00:28:13
Speaker
What's the rationale for doing so?
00:28:15
Speaker
What's the physiologic rationale for doing so?
00:28:20
Speaker
And often when you pin the doctor down gently to the ground and say, well, why did you do that?
00:28:28
Speaker
What was the rationale?
00:28:29
Speaker
Often it's a case of, oh, well, they weren't passing much urine, so I thought I'd help.
00:28:34
Speaker
Yeah.
00:28:35
Speaker
Yeah.
00:28:36
Speaker
Does that actually help the patient?
00:28:38
Speaker
It might prevent the night staff being run by the nurses and they're just delaying the problem until the following day.
00:28:48
Speaker
So it's a short-term temporizing measure, but is it actually helping the patient?
00:28:53
Speaker
I think it's a great example.
00:28:54
Speaker
Let's talk about heparin now.
00:28:57
Speaker
So every ICU patient should get heparin thrombo-prophylaxis to the point where now hospitals, at least in the U.S., and I'm sure it's the same in the United Kingdom, have computer systems that alert you when you're not giving heparin.
00:29:12
Speaker
There's probably the DVT prophylaxis police lurking around the ICU.
00:29:16
Speaker
And this is a common, somebody had a PE, oh, they didn't get trauma prophylaxis on day one and they got to pee on day two.
00:29:25
Speaker
It's your fault and it's a legal case.
00:29:27
Speaker
Can you talk a little bit about this?
00:29:30
Speaker
So, again, it's drummed into us.
00:29:33
Speaker
It's in guidelines.
00:29:35
Speaker
We're beating over the head if the patient doesn't get it and there's no contraindication.
00:29:41
Speaker
but let's look at the evidence.
00:29:42
Speaker
And people say, oh, well, it prevents DVTs and pulmonary emboli.
00:29:46
Speaker
And I'm of an age, some gray hairs and a few lines on my face where I preceded the advent of thromboprophylaxis.
Thromboprophylaxis and Evolving Patient Care
00:29:57
Speaker
And I don't remember swathes of patient collapsing and dying in hospital with pulmonary emboli.
00:30:04
Speaker
Hmm.
00:30:05
Speaker
We have to also remember that
00:30:07
Speaker
CT scanning has come in.
00:30:09
Speaker
We have now the later generation CT scan machines with far better resolution.
00:30:15
Speaker
So many, many more...
00:30:17
Speaker
pulmonary emboli are being detected but the mortality rate actual sorry the numbers dying of pulmonary embolus hasn't changed so the mortality rate's dropping because the denominator's expanded because those small pulmonary emboli in tiny pulmonary vessels are now being detected whereas in latter years they weren't but the numbers dying of pulmonary emboli haven't changed even though
00:30:45
Speaker
the percentage mortality rate has decreased so that's how you can use statistics to your advantage if you so wish you can abuse statistics um so again looking at the evidence there are very few trials in critically ill patients most of the strongest evidence for using
00:31:07
Speaker
thromboprophylaxis comes in patients, orthopedic patients, you know, for example, hip fracture repair, knee injury, but other types of surgery.
00:31:17
Speaker
There are Cochrane reviews show, for example, no difference in vascular surgery, even in medical patients.
00:31:25
Speaker
again, the evidence isn't that strong or it's actually lacking.
00:31:29
Speaker
And there are very, very few trials in intensive care patients.
00:31:33
Speaker
And these are actually largely historic, where patients were sedated and ventilated far longer than I think we do nowadays.
00:31:43
Speaker
They weren't mobilized.
00:31:44
Speaker
So I think practice has changed as well.
00:31:48
Speaker
So the world has shifted, but the dogma still persists.
00:31:53
Speaker
The other really interesting thing, and I must admit, when I was researching with Daniel for this article, we actually came across a few good studies showing that in critically ill patients, standard thromboprophylactic doses of low molecular weight heparins are usually subtherapeutic.
00:32:18
Speaker
Well, usually 30%, 40% of the time subtherapeutic.
00:32:22
Speaker
and that's using anti-factor 10a activity levels
00:32:27
Speaker
So we'll put two hematologists in a room and get three different points of view as to how useful or not anti-10A is.
00:32:35
Speaker
But we're used to giving everyone the same dose unless they've got renal dysfunction or they're very, very obese.
00:32:43
Speaker
But essentially, you can be 40 kilograms or 80 kilograms, you'll get the same dose.
00:32:48
Speaker
But the blood levels, the anti-factor 10A levels, are hugely variable.
00:32:53
Speaker
And the same was actually reported in COVID.
00:32:56
Speaker
Ward patients in general had higher levels with the same dose of enoxaparin or whatever, much higher doses compared to ICU patients given the same dose.
00:33:10
Speaker
So we have two problems.
00:33:12
Speaker
A, the lack of a good evidence base.
00:33:14
Speaker
B, not knowing if what we're actually giving is therapeutic or not.
00:33:21
Speaker
So we don't have, like you said, evidence that this actually works.
00:33:25
Speaker
And then when we dig a little bit deeper, what we're doing probably doesn't even meet the criteria that we need it to meet to work in the case it works.
00:33:34
Speaker
So it's really like a double problem there.
00:33:38
Speaker
The other thing, Mervyn, that I'm a big believer in using appropriate biomarkers to guide treatment.
Tailoring Treatments Using Biomarkers
00:33:47
Speaker
And I think that's a good idea.
00:33:48
Speaker
We wouldn't,
00:33:49
Speaker
manage a ventilated patient without knowledge of the oxygen and the co2 and You could extra extrapolate the same point to for example antibiotics huge variability in the dose of antibiotics we give to our patients concentration same dose given to
00:34:08
Speaker
a group of patients and there'll be huge variability some will be overdosed in terms of an ideal in inverted commas therapeutic range a large number of patients are significantly underdosed so we don't know what we're doing and yet we continue with one dose fits all one size fits all sort of dosing regimens
00:34:30
Speaker
The other aspect of the thromboprophylaxis story that I find fascinating and I would love for you to comment on is the lessons learned from COVID.
00:34:41
Speaker
So we always assume that if it's good for sick people, it's probably better for sicker patients.
00:34:47
Speaker
And we take it to the ICU, right?
00:34:49
Speaker
And the COVID story has actually pointed out maybe that we were wrong with that assumption.
00:34:56
Speaker
Yeah, it's a minefield.
00:35:00
Speaker
I've read there's been probably about three or four fairly large studies now on thromboprophylaxis in COVID patients, either ICU patients, ward patients, or
00:35:16
Speaker
studies covering both and it's all a bit of a mess and there's no clear answer is there a big benefit over doing nothing to doing something should it be standard dose or double prophylactic dose or full anticoagulation and my reading of the literature is
00:35:35
Speaker
I don't know what to believe.
00:35:37
Speaker
You know, the results are just incredibly conflicting.
00:35:41
Speaker
Absolutely.
00:35:42
Speaker
So let's move on to sodium.
00:35:46
Speaker
The other question is, we don't know why.
00:35:49
Speaker
These trials didn't collect any blood, so we can't measure, for example, anti-10A or whatever.
00:35:55
Speaker
And so, again, we have these conflicting results, but we have no way of explaining why.
00:36:02
Speaker
And so my plea earlier on for having good trials where we actually try and understand mechanisms and pathophysiology and treatment responses, it just highlights that's a beautiful example of where we don't know the answer, and we still don't know the answer.
00:36:19
Speaker
Absolutely.
00:36:20
Speaker
And I think that the why, obviously, is it's very interesting, Mervyn, that when you look at the inception or the creation of statistics as a field, they almost deliberately walked away from evaluating causation.
00:36:34
Speaker
Right.
00:36:34
Speaker
I mean, correlation is not causation is what the first thing you learn when they teach you statistics.
00:36:39
Speaker
But ultimately, what we really care about is the cause and the why.
00:36:42
Speaker
And I think that we have to really focus more on understanding that in order to break down these dogmas.
00:36:49
Speaker
Agree, agree, agree.
00:36:52
Speaker
So the next area of dogma that I wanted to talk about a little bit is sodium correction.
Sodium Correction Challenges
00:36:59
Speaker
And I find this quite fascinating, Mervyn, because it's not... Well, hyponatremia obviously is the most common electrolyte abnormality in hospitalized patients.
00:37:09
Speaker
But severe hyponatremia and especially the complications of what we believe is associated with rapid corrections, which is CPM or central pontine malignolysis, is not that common.
00:37:21
Speaker
Yet it's a very common cause of legal litigation in the United States.
00:37:27
Speaker
And based on what?
00:37:30
Speaker
Yeah, exactly.
00:37:32
Speaker
So, you know, I do some medical legal work for the National Health Service, and not infrequently, CPM crosses my path, and I basically try and refute the dogma with, actually, if you look at the evidence, let's see what the evidence is.
00:37:50
Speaker
So, firstly, CPM can happen without hyponatremia.
00:37:55
Speaker
It's probably more common in alcoholics and malnourished patients.
00:38:00
Speaker
And so maybe the combination of alcoholism, malnutrition, and hyponatremia is a sort of unholy trinity.
00:38:11
Speaker
Next fact, you can get CPM with CPM.
00:38:17
Speaker
relatively normal levels of sodium or mildly depressed levels or obviously severely depressed levels you can get CPM even with very slow correction
00:38:30
Speaker
patients many patients if you look at the studies that are out there many patients have rates of correction far exceeding guidelines we'll talk about guidelines in a second the majority of those don't develop cpm so it's a whole mishmash of uh what should you do how severe is it how quickly should you correct it and what's the actual truth behind it there's
00:38:58
Speaker
a reliance obviously on observational data because it's not that we'll see loads and loads and loads to do big randomized trials but by and large you know the message has been sold that you've got to do it very slowly however when you look at guidelines there's no consensus different guidelines from learned groups recommend different rates of correction so
00:39:25
Speaker
because of the lack of evidence, but it's presented as dogma and therefore it basically gives a stick with which the litigation lawyers can beat up the poor doctor.
00:39:38
Speaker
And the other thing I'd actually mention is anyone trying to correct sodium levels slowly, it's a challenge.
00:39:46
Speaker
It isn't that easy.
00:39:47
Speaker
Even with very scrupulous regular monitoring, blood sampling, etc., it can be a challenge.
00:39:54
Speaker
I was actually on call last week, and we had a patient with hyponatremia, an alcoholic found collapsed.
00:40:01
Speaker
He came in hemodynamically compromised.
00:40:05
Speaker
He had a low blood pressure.
00:40:06
Speaker
He had a lactate of four or five.
00:40:08
Speaker
I can't remember exactly what.
00:40:10
Speaker
And the sodium, I think, was 114.
00:40:14
Speaker
Clearly, he needed volume resuscitation, but the volume to resuscitate must contain saline.
00:40:21
Speaker
So you've got this balancing act where we actually have to restore organ perfusion, but at the same time, do we necessarily want the sodium jumping up hugely?
00:40:31
Speaker
So you're left in that sort of Damocles hanging over you.
00:40:38
Speaker
You have to do the right thing.
00:40:39
Speaker
CPM, as you said, is a rare complication.
00:40:44
Speaker
So it presents interesting dilemmas which litigation lawyers don't necessarily appreciate.
00:40:51
Speaker
not only dilemmas, but also sometimes leads to almost a little bit of a schizophrenic approach, right?
00:40:56
Speaker
You're trying to raise it, then you're giving them something to dilute it.
00:41:01
Speaker
You're going back and forth, back and forth, so you can stay on that target.
00:41:04
Speaker
And it seems like a lot of extra lab testing, a lot of extra intervention for something that perhaps has an impact, but most likely we just don't know.
00:41:14
Speaker
That is also something I often find that we're going back and forth, back and forth, and
00:41:18
Speaker
it just seems to prolong the agony for that poor patient.
00:41:22
Speaker
Yeah, exactly.
00:41:24
Speaker
And I think if you look, the very first descriptions came out 30-odd years ago.
00:41:31
Speaker
And in these patients, there was very, very aggressive correction.
00:41:37
Speaker
And so we're looking at sodiums going up by 30 millimoles in 24 hours.
00:41:42
Speaker
And even then, not every patient developed CPM.
00:41:47
Speaker
So it's the high correction rates.
00:41:49
Speaker
There was an increased association, but these were very high correction rates.
00:41:53
Speaker
And at least my distillation of the literature, by and large, you can be perhaps a bit more conservative, or liberal rather, in the correction rates.
00:42:03
Speaker
And in the article, we suggested that actually 0.75 millimoles per liter per hour seems to be a safe upper limit.
00:42:13
Speaker
So that means...
00:42:15
Speaker
That's about 18 millimoles over 24 hours, whereas some authorities recommend 6 to 8 millimoles in 24 hours.
00:42:25
Speaker
So it just shows how different the interpretation of literature is.
00:42:32
Speaker
Absolutely.
00:42:33
Speaker
So the last one is about treating meningitis and how every hour has a tremendous impact on mortality.
00:42:41
Speaker
And this is something that has also been discussed back and forth in the septic shock world, right?
00:42:48
Speaker
A world that obviously you're obviously very involved with as well.
00:42:52
Speaker
But tell us a little bit more about here.
00:42:53
Speaker
And I guess just to reemphasize for our listeners, you're not saying don't give antibiotics or just sit on the antibiotics.
Urgency in Treating Meningitis
00:43:01
Speaker
You're just trying to take a more critical look into where does this come from and does it really matter?
00:43:07
Speaker
Thank you for emphasizing that point.
00:43:09
Speaker
So each hour counts.
00:43:11
Speaker
So when does the meningitis begin?
00:43:17
Speaker
Most of the studies looking at each hour counts actually times it from arrival in hospital, but clearly the patient's got to be sick enough for long enough or short enough, depending on how quickly the trajectory of the illness, to present to hospital.
00:43:34
Speaker
and then they've got to be seen, then it's got to be diagnosed.
00:43:37
Speaker
Some papers look at time of arrival in hospital, some look at time of the diagnosis of meningitis, which will then prompt treatment.
00:43:48
Speaker
So I don't think any doctor, if there is a worry about bacterial meningitis, would delay, and there shouldn't be administrative delays, but you have to ask the question, why is there delay?
00:44:00
Speaker
And most of these papers, and this is another...
00:44:04
Speaker
problem you know you were talking earlier Sergio about correlations but what many of these studies have done is literally extrapolate the time for example from arrival in hospital and they go on and many of these studies show treatment was delayed for 24 48 72 hours sometimes even longer and clearly if you're leaving a patient that long then
00:44:30
Speaker
the risk of a poor outcome is much greater.
00:44:33
Speaker
And so if you do your straight-line correlation through that, not surprisingly, it looks bad.
00:44:39
Speaker
But if you narrow down on the first few hours, and we're saying actually within the first five hours, there isn't that much difference in mortality rates.
00:44:49
Speaker
I'm not saying delay, but you can perhaps understand why the patients who present in a non-typical manner
00:44:59
Speaker
they're the ones that take longer to diagnose, and they're the ones who often get, therefore, the delayed treatment.
Importance of Atypical Presentations
00:45:06
Speaker
And these are often, obviously, children or elderly adults who may just present without the classical autophobia, meninges, et cetera, but with just going off their legs, just being confused.
00:45:25
Speaker
an anecdote years ago and I was a resident we had a little old lady who came in she lived alone she'd just gone off her legs and we were humming and ahhing about should we do an LP on her she was moving around the bed she wasn't very still and so we ummed and ah'd and think well
00:45:43
Speaker
and this is you know that she wasn't better the following day and we ummed it on and actually sort of got four people to hold her down gently sedated her because we didn't want to over sedate this poor lady and iatrogenically push her backwards did an lp and it came out as she had listeria
00:46:01
Speaker
By chance, we didn't know this at the time, her favorite nephew turned up the following day, who was the then president of the Royal College of Physicians.
00:46:12
Speaker
And he was very impressed that we'd thought of a diagnosis of listeria.
00:46:18
Speaker
I didn't want to confess that this was after a lot of umming and ahhing and heart searching that we decided to do the LP.
00:46:25
Speaker
She lived to tell the tale, I'm pleased to report.
00:46:29
Speaker
As soon as you saw her, you knew it was Listeria, right?
00:46:31
Speaker
Oh, clearly.
00:46:35
Speaker
So in closing, I think that part of the examples, one of the things that you very eloquently show and share in the article is that this is more than just an academic discussion in terms that these dogmas have pros and cons, right?
00:46:51
Speaker
I mean, they have implications that might be meaningful for an individual patient.
00:46:56
Speaker
So for example, I think that when we talk about meningitis, in general, this is a serious disease that we don't see every day.
00:47:04
Speaker
So standardizing an approach for such a disease probably has advantages, right?
00:47:08
Speaker
And we've seen this with sepsis.
00:47:09
Speaker
Even if the elements of a bundle are not the perfect ones, just by the fact of standardizing and bringing attention to a disease in a time-sensitive manner probably moves the needle.
00:47:21
Speaker
unfortunately here in the United States a lot of what is practiced and I don't know the environment in the UK is really protective medicine right trying to protect people from themselves from litigation but could you give examples for example of the con specifically for the bacterial meningitis example what would be potential negatives of living and dying by
Standardized Guidelines vs. Alternative Diagnoses
00:47:44
Speaker
this dogma
00:47:46
Speaker
Well, actually, if I may, I'll broaden it out like sepsis in general.
00:47:51
Speaker
So the patient is often labeled
00:47:54
Speaker
they've got sepsis or meningitis or whatever.
00:47:57
Speaker
And then the doctor stops thinking because they've given a label to that patient.
00:48:02
Speaker
And there may be another diagnosis that they've not thought of.
00:48:08
Speaker
So, for example, oh, the patient's got a bad headache, we treat them for meningitis, but actually they've got, you know, the, you know, the,
00:48:17
Speaker
venous thrombosis in their brain, e.g.
00:48:21
Speaker
In sepsis, lots of studies now out there show that 20 to 40% of patients initially given the label of sepsis turn out to have a non-infectious diagnosis.
00:48:34
Speaker
and therefore the danger is that those patients wouldn't receive proper treatment because they've been labeled as being septic, and the doctor then goes to the next patient because I've started the antibiotics on this patient.
00:48:48
Speaker
etc so again i'll give you an anecdote oh this is pre-covid i saw a young 30 odd year old lady in the emergency department um she had she was labeled as a pneumonia she was needing a fair amount of oxygen and i saw her and she just didn't have a feel of being infected and
00:49:10
Speaker
She was too awake, too alert.
00:49:12
Speaker
She just didn't have that clinical gestalt, as it were, that she was actually infected.
00:49:18
Speaker
So, yeah, I thought it was wise to continue the antibiotic, but we sent off a vasculitic screen, and this was her first presentation with SLE, systemic lupus serratematosus.
00:49:31
Speaker
So it's just having that degree of awareness just to challenge the orthodoxy and not just label the patient conveniently and then blindly treat.
00:49:43
Speaker
Absolutely.
00:49:43
Speaker
Mervyn, I think two things come to mind immediately as you're sharing this.
00:49:47
Speaker
One is obviously labeling is basically anchoring bias, right?
00:49:52
Speaker
So as soon as we hear sepsis, we anchor ourselves in that diagnosis and we become much more narrow in our way of thinking of alternative possibilities.
00:50:01
Speaker
And that is probably detrimental to our patients.
00:50:04
Speaker
And then the other thing that I was just thinking, I was also on clinical service recently and
00:50:09
Speaker
It's not uncommon that I pick up a patient in the ICU service and I'm looking through their medications and rounding and why is this patient on antibiotics, right?
00:50:18
Speaker
And everybody looks at each other.
00:50:19
Speaker
Well, they have sepsis.
00:50:21
Speaker
From what?
00:50:21
Speaker
Right.
00:50:23
Speaker
And we can't figure it out.
00:50:24
Speaker
And I think that's also, like you said, a common occurrence that's worth, I mean, thinking about a little bit more.
00:50:31
Speaker
So before we kind of close on the way forward, a lot of what we discussed is dogma when evidence is weak, either outdated, not thoroughly available,
00:50:44
Speaker
But it seems that there's dogma that persists despite evidence being available that should make us think very differently.
Hypothermia Treatment in Cardiac Arrest
00:50:51
Speaker
And I just wanted to hear your comments on this.
00:50:53
Speaker
And one that comes to mind immediately is hypothermia postcardic arrest.
00:50:59
Speaker
We have to cool these patients.
00:51:01
Speaker
Yet when you look at the evolving studies, the better studies and the bigger studies say it doesn't make a difference.
00:51:10
Speaker
Yet some people cannot let go.
00:51:12
Speaker
What are your thoughts on this?
00:51:15
Speaker
I'm actually going to sit in the middle here.
00:51:18
Speaker
I think they could make a difference, but if you read the papers, the trials are on the whole rather poor because
00:51:26
Speaker
The logic is that you call the patient down, it reduces metabolic rate, you get a reduced reperfusion injury.
00:51:36
Speaker
Again, at least that's the rationale that I operate by.
00:51:40
Speaker
However, you think, well, actually, if you're going to get a reperfusion injury, it's going to happen quickly.
00:51:45
Speaker
And if you look at the vast majority of these studies,
00:51:49
Speaker
time to getting to target temperature or even 34 degrees, the upper range of the target, is about five to six hours.
00:51:59
Speaker
Now, is it the fault of therapeutic hypothermia or is it the fault of a poor methodology that meant the patient didn't actually get to their target temperature until probably the reperfusion injury has well established itself?
00:52:18
Speaker
So therefore, I'm sitting on the fence in that it could work, but the trials, to my mind at least, haven't been actually done properly.
00:52:26
Speaker
So we don't know the answer.
00:52:27
Speaker
Because you can do it in an animal model.
00:52:29
Speaker
Again, we have to extrapolate findings from animal models to human beings.
00:52:34
Speaker
And generally, we use younger animal models.
00:52:37
Speaker
And most people with cardiac arrest tend to be elderly.
00:52:40
Speaker
However, logically and physiologically, we've got to get there very, very, very quickly rather than six hours downstream.
00:52:49
Speaker
And even then, many patients don't get to the target temperature.
00:52:56
Speaker
The evidence as it stands says, yes, hyperthermia, ongoing hyperthermia, because many of these patients with the reperfusion injury remain hot.
00:53:07
Speaker
That's deleterious, but there's no added benefit from going normothermic to hypothermic, probably because that window of opportunity, the early window of opportunity has not been grasped.
00:53:22
Speaker
So definitely something, I mean, that like everything requires further and more detailed studying.
00:53:30
Speaker
But I think it's a great example.
00:53:32
Speaker
And maybe that's why, as an anecdote, when people fall on a frozen lake and have a cardiac arrest, sometimes they do okay, right?
00:53:39
Speaker
Indeed.
00:53:41
Speaker
Indeed.
00:53:42
Speaker
Exactly.
00:53:42
Speaker
So it's all, you know, again, in context.
00:53:46
Speaker
If we take things in context with the situation and apply them and apply the therapeutic rationale.
00:53:56
Speaker
So I would love to see, not advertising names, but the call guard type of technology where you can really call the patient down really, really quickly.
00:54:07
Speaker
And then let's see if that works rather than just a standard approach that's currently used.
00:54:15
Speaker
Excellent.
00:54:16
Speaker
So what's the way forward, Mervyn?
00:54:18
Speaker
What are things that you suggest that we should do?
00:54:22
Speaker
And maybe you can just give us some general thoughts and then maybe emphasize what each individual clinician should work on and what are perhaps more institutional or system level proposed solutions to move dogma forward.
00:54:39
Speaker
Well, obviously, I think number one should be education, education, education.
Education and Overcoming Dogma
00:54:43
Speaker
And it should start at the student level.
00:54:47
Speaker
And the education there should be don't believe everything your boss tells you.
00:54:53
Speaker
Challenge them.
00:54:55
Speaker
Challenge the evidence base because we're comfortable in, oh, I've been doing this for years.
00:55:01
Speaker
It seems to work in most people, as I mentioned earlier, that
00:55:05
Speaker
You know, there are casualties of war.
00:55:07
Speaker
Some people don't respond, but it's their fault, not my fault.
00:55:10
Speaker
So I think we have to train people to question students, medical students, trainee doctors.
00:55:18
Speaker
And we also have to actually attack ourselves as a more experienced clinician.
00:55:23
Speaker
We...
00:55:25
Speaker
easily go into our comfort zones and we don't necessarily read the literature we don't challenge ourselves so I think it's important to carefully scrutinize the underpinning literature many of it is actually now fairly ancient and medical practice has changed so I think we need to reevaluate I think a second solution
00:55:49
Speaker
we're entering the era of big data and there are lots of low incidence conditions where you won't be able to do the randomized double blind control trial
00:56:01
Speaker
It wouldn't be cost-efficient and you wouldn't recruit the number of patients, but there are still conditions that you do see from time to time that have dogma attached.
00:56:11
Speaker
So perhaps that's where big data can come into it.
00:56:15
Speaker
We can look at how the patients were managed and perhaps from these observational data get some understanding of how patients responded to different therapies and did it make a difference to their outcome.
00:56:31
Speaker
A colleague of mine is very convinced that doing nudge trials might be a good way to go.
00:56:40
Speaker
Increasingly, we have computerized systems, prescribing systems, etc.
00:56:46
Speaker
So the computer can actually do a randomized trial without a formal randomization.
00:56:54
Speaker
I'll use night sedation as an example.
00:56:56
Speaker
Sergio, what night sedation do you give your patient who can't sleep?
00:57:01
Speaker
Well, I try to avoid it, but people do different things.
00:57:04
Speaker
So in the ICU, some people like to put them on, depending if they're intubated on some dexmedetomidine, some people give melatonin, some people, I've used a little bit of everything, but I don't think anything really works very well.
00:57:18
Speaker
Absolutely.
00:57:19
Speaker
Dopiclone, whatever, whatever.
00:57:22
Speaker
So what works?
00:57:24
Speaker
Tamazepam, what works?
00:57:25
Speaker
So we don't know.
00:57:26
Speaker
So unless we actually do the studies, and probably even within the studies, there are the subgroups which will respond better to melatonin and others that will do better with dexmelatomidine, et cetera, et cetera.
00:57:39
Speaker
So again, you could do this sort of nudge prescribing where...
00:57:45
Speaker
you could suggest or the computer could suggest the intervention to the clinician and then you're recording the demographics of that patient and the comorbidities and the other medications and then recording actually did they sleep or not because the nurse will usually record whether they did get sleep and how many hours of sleep they got so potentially that's another way of trying to learn without doing formal studies and my fourth recommendation is
00:58:15
Speaker
We need to remove fear.
Empowering Clinician Discretion
00:58:19
Speaker
There's a lot of fear in hospitals, fear of litigation, fear of being bashed around the head by management because you're not following policies or these guidelines, which are rules of stone.
00:58:32
Speaker
I think we should be encouraged to apply discretion to the individual case and care, provided we justify it.
00:58:40
Speaker
I think we've increasingly become risk-averse to the point of becoming too risk-averse.
00:58:47
Speaker
And so therefore, we play overly safe, which may not be...
00:58:52
Speaker
for the benefit of the patient may actually be to their detriment because they're treated for longer, they're kept in hospital for longer, and that has knock-on effects in terms of flow of patients through the hospital efficiencies, etc.
00:59:05
Speaker
So I think we have to accept that there's always a certain risk.
00:59:10
Speaker
We try and minimize the risk.
00:59:12
Speaker
We try and identify patients who aren't responding or
00:59:17
Speaker
We've sent them home from the emergency department, for example.
00:59:20
Speaker
They should be given clear instructions as to when to represent if things aren't getting better.
00:59:25
Speaker
But I think the fear factor is something we need to not get rid of, but minimise.
00:59:32
Speaker
Absolutely.
00:59:33
Speaker
And I think really in terms of the take-home message is, from my perspective, that dogma is obviously present in our everyday clinical work.
00:59:44
Speaker
And it dictates, in many instances, how we treat patients in the ICU.
00:59:49
Speaker
However, when we really look at it a little bit more and more depth, the underpinnings of this evidence is thin at best.
00:59:57
Speaker
And that what I keep saying is we always...
01:00:01
Speaker
talk about ourselves as scientists as physicians but we usually don't behave like scientists we need a little bit more humility and doubt i believe and and i think medicine is also an art as well as a science so um i think there are strands of uh creativity imagination as well as good old-fashioned scientific fact
01:00:25
Speaker
Absolutely.
01:00:26
Speaker
Well, Mervyn, I want to be respectful of your time and I really appreciate you sharing your expertise and provoking us to think a little bit outside of the box and push a little bit the envelope.
01:00:39
Speaker
But I would like to finish the podcast in our usual way with some questions that are unrelated to the topic we discussed.
01:00:46
Speaker
Would that be okay?
01:00:47
Speaker
Pleasure.
01:00:49
Speaker
So the first question is about books that have influenced you the most or books that you have gifted often to others.
01:00:56
Speaker
I think a nice book that I really enjoyed reading and actually recommended to others or given my copy to other people is a book called Factfulness by a guy called Hans Rosling who was a Swedish, I think he was an epidemiologist from memory or a pediatric epidemiologist but he spent a lot of time in Africa and it's a really interesting book where essentially the world is a better place than perhaps we give it credit for and
01:01:26
Speaker
He has in this book a number of multiple choice questions at the beginning, asking, you know, what do you think illiteracy rates are amongst female adolescents and how many people are below the poverty threshold, etc.
01:01:42
Speaker
And it's quite staggering as to how wrong we are.
01:01:45
Speaker
And things actually are improving.
01:01:48
Speaker
Not perfect by any means, but we seem to...
01:01:52
Speaker
sort of downgrade our belief that the world is actually okay yes we have all the problems economic crisis at the moment climate change etc but we have made strides forward in preventing malnutrition vaccination programs literacy rates etc so i would encourage that it's an upbeat book
01:02:13
Speaker
Definitely.
01:02:14
Speaker
And I think as it applies to the concept of dogma, what factfulness broke for me was the dogmatic belief that the world is divided in developed countries, underdeveloped countries, developing countries.
01:02:31
Speaker
And the truth is that there are people who have access to the best and the worst in every single one of those countries.
01:02:39
Speaker
100% yeah absolutely absolutely so and what we need to do is try and obviously equalize things so we don't want those you know we want obviously to try and bring up the poor population so they have the opportunities afforded to everyone especially or not everyone but the more well off
01:02:57
Speaker
Absolutely.
01:02:58
Speaker
And I agree.
01:02:59
Speaker
I think especially after the pandemic or after the last two years of COVID and the political environment around the world, there's a lot of negativity and people seem to always believe that things are worse than they were before.
01:03:15
Speaker
But looking at data objectively and looking at the right parameters sometimes can give us a different picture.
01:03:20
Speaker
And I think that this is a great example of that.
01:03:22
Speaker
So we'll definitely link that in the show notes and encourage our listeners to read it, to pick it up.
01:03:29
Speaker
Indeed.
01:03:29
Speaker
The second question is, what do you believe to be true in medicine or life that most other people don't believe or maybe don't behave like they believe it?
01:03:38
Speaker
Yeah.
01:03:43
Speaker
I'll give you a few truths that I believe in.
01:03:48
Speaker
I think one I've mentioned already, don't believe everything you're told.
01:03:51
Speaker
Don't take things at face value, even if the person telling you it is old and seemingly wise.
01:04:00
Speaker
First, do no harm, I think is another maxim, another truth that's really important.
01:04:06
Speaker
Again, there are quite a few studies showing that iatrogenic harm
01:04:11
Speaker
is a common problem in bringing people into hospital or causing complications of inpatients.
01:04:20
Speaker
Many elderly patients are on a whole battery of medications, and I think 20% in some studies, if not more, of admissions of the elderly to hospital are drug-related or drug complication-related.
01:04:36
Speaker
The other proofs I'd like to add, I think I've learned as an intensivist, there's a time to jump and a time to sit on your hands.
01:04:46
Speaker
And it's something you gain with experience.
01:04:49
Speaker
And in my youth, I was more liable to jump.
01:04:53
Speaker
I still jump occasionally, but increasingly it's a case of, yep, the patient's going in the right direction.
01:05:00
Speaker
Leave them alone.
01:05:01
Speaker
Let them evolve naturally rather than trying to aggressively overpush.
01:05:08
Speaker
Absolutely.
01:05:09
Speaker
And I've asked this question multiple times, Mervyn, but it's the first time that I really have realized that what I should be asking is,
01:05:17
Speaker
What are dogmas that you believe in that nobody else does, right?
01:05:24
Speaker
Or the other way around.
01:05:25
Speaker
What are dogmas we do that I go, why?
01:05:30
Speaker
So, oh, there's a whole lot.
01:05:33
Speaker
I think my colleagues, I think they put up with me because I'm relatively benign and I don't insist we have to do it.
01:05:42
Speaker
So I challenge lots of things.
01:05:45
Speaker
Should I give you a few examples of things I...
01:05:48
Speaker
I challenge in standard practice giving phosphate to patients.
01:05:53
Speaker
Why do we give phosphate to patients?
01:05:56
Speaker
Oh, they get weak.
01:05:57
Speaker
Well, can you show me any evidence that they get strong?
01:06:01
Speaker
With the phosphate.
01:06:03
Speaker
With the phosphate.
01:06:04
Speaker
Or isn't it just epiphenomenal?
01:06:06
Speaker
And where's the evidence that giving phosphate actually makes a blind bit of difference?
01:06:10
Speaker
Iprotropium, I don't know if you use that in the United States.
01:06:13
Speaker
We do.
01:06:14
Speaker
Yeah, it's a guideline, standard guideline.
01:06:16
Speaker
Give it to every acute asthmatic who comes into hospital.
01:06:21
Speaker
Yet, Iprotropium is anticholinergic, so it thickens secretions.
01:06:25
Speaker
And what do we spend our life trying to do in intensive care?
01:06:28
Speaker
These sorts of intensive care patients is loosen the secretions.
01:06:32
Speaker
So we're giving a drug with...
01:06:34
Speaker
next to no useful bronchodilating properties, which just makes our life and the patient's life harder.
01:06:42
Speaker
Where's the evidence that we need to give every patient proton pump inhibitors?
01:06:46
Speaker
It wasn't actually that strong to begin with.
01:06:49
Speaker
Again, it's a historical throwback because stress ulcer bleeding was very common 50 years ago, and that's before people recognize about the adequate fluid resuscitating patients.
01:07:01
Speaker
But do we need to give every patient a PPI?
01:07:04
Speaker
Where's the evidence base?
01:07:06
Speaker
Antipyretic.
01:07:07
Speaker
So we feel a bit better when we lower the temperature.
01:07:11
Speaker
There's quite a lot of circumstantial evidence that temperature is beneficial.
01:07:17
Speaker
Septic patients who come into hospital with a pyrexia actually do better than patients who come in normothermic, who do better than patients who come in hypothermic.
01:07:28
Speaker
So should we be actively striving to lower a patient's temperature?
01:07:33
Speaker
Gastric stimulants, they're not absorbing their feed.
01:07:37
Speaker
Why should we be driving them with metaclopramide or something just to make us happier that we're driving them with food?
01:07:44
Speaker
You know, when I'm ill and I'm feeling sick,
01:07:46
Speaker
The last thing I want is to eat something to vomit it up.
01:07:50
Speaker
And that's essentially what we're doing.
01:07:52
Speaker
We're force feeding them and trying to give them a medication to try and make sure that it goes down.
01:07:59
Speaker
But do we, or our gut, does it necessarily want to be fed?
01:08:05
Speaker
So lots of examples, you know, carry on in that vein.
01:08:09
Speaker
We'll do a second edition of this episode with all the rest.
01:08:15
Speaker
But I think they're great points, right?
01:08:17
Speaker
And I think it again goes around what we're trying to convey here is that sometimes in medicine, questions are much more valuable than answers.
01:08:27
Speaker
And we should be always questioning what's in front of us.
01:08:31
Speaker
Well put.
01:08:32
Speaker
So the last question and the closing question, Mervyn, is what would you want every intensivist who's listening to us to know?
01:08:38
Speaker
Could be a quote, a fact, or just a thought.
01:08:43
Speaker
One of my favorite comments is patients aren't bed numbers.
01:08:49
Speaker
I correct my colleagues, the trainees, the nurses, when it's bed three, it's got a temperature, bed five has got X. And I said, no, we've got to humanize the patient because if we dehumanize them, we forget they're human beings with a family.
01:09:06
Speaker
So we've got to retain that humanity aspect and empathy.
01:09:11
Speaker
And if we don't refer to them as a human being, we're in danger of losing that.
01:09:18
Speaker
And I think that's the perfect place to stop.
01:09:20
Speaker
I really like the way you put that in terms of patients are not bed numbers because I probably can't recall a clinical day when somebody is not referred to a patient by the bed number.
01:09:39
Speaker
Mervyn, thank you so much for a wonderful conversation.
01:09:43
Speaker
Really appreciate you giving us your time and your expertise.
01:09:46
Speaker
Look forward to seeing you in person soon and also to having you back on the podcast.
01:09:51
Speaker
It's been a great pleasure, Sergio.
01:09:53
Speaker
Thank you very much for the invitation and hope your listeners have actually enjoyed it and stayed the course.
01:09:59
Speaker
Absolutely.
01:10:00
Speaker
Thank you.
01:10:03
Speaker
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01:10:07
Speaker
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01:10:13
Speaker
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01:10:17
Speaker
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