Vol. 17 •Issue 7 • Page 25
Is JASPA in the Spring Air?
Do you have JASPA? Chances are you do and you probably aren’t even aware this potentially fatal condition is treatable. JASPA (Journal Associated Score of Personal Angst) is a real live published condition.
Let me give you a little background on JASPA. It is an assessment scale based on a case study. Actually it was created by a senior physician who was admitted to the hospital with a fractured femur. His medical record shows he got up in the middle of the night, slipped on a pile of unread medical journals by the bed, fell and broke his leg.
In his history, he reports he felt an increasing sense of guilt and inadequacy associated with an inability to keep up with literature updates. Further investigation revealed the oldest journal in the pile by his bed was nearly five years old. His JASPA score was 5. Clearly intervention was needed.1
His clinicians named his condition “polythenia gravis” and hypothesize his case may just be the tip of the iceberg. But how do we keep up? It isn’t as hard as you think. There is a handy little tool out there called Evidence Based Medicine (EBM).
EBM is the practice of lifelong, self-directed learning to facilitate clinically appropriate care. It involves tracking down the best external evidence with which to answer clinical questions. Or you very simply:
Ask relevant, answerable questions based on the clinical problem.
Efficiently identify the pertinent data.
Assess the data for applicability.
Apply the results to the clinical problem.
Evaluate the outcome.1
NO TOUGH TASK
Sounds really simple, right? In reality, it is simple. Face it. There is an explosion of literature and resources out there. You can’t possibly keep up with everything. Begin your quest for knowledge not with the intent of assembling enough support for a doctoral thesis but by answering a simple clinical question about your patient. And use a systematic approach to conduct your inquiry.
Let’s look at a case study. Mr. Jackson is a 38-year-old accountant who presents to the ED with SOB and a dry non-productive cough. His ABG on room air is: PH 7.31, PCO2 65, PO2 65. What relevant questions should we ask Mr. Jackson?
How about asking what he was doing just before the onset of his symptoms. Is there anything that may have precipitated his illness?
Turns out he was in his office working on this week’s payroll when the fire alarm went off. Ah ha! Was there a fire?
Indeed there was. It was in an adjacent factory, and he inhaled the fumes. So given this pertinent data, we need to investigate “inhalation injuries.”
An Internet search brings up 1,234,672 results. Not terribly helpful. Let’s go back and talk to Mr. Jackson a little more. It seems he works in a pipe factory, so the chemical fumes he probably inhaled is polyvinyl chloride. Specifically we are looking for lung injuries related to that.
There is no need to search the world at large. Let’s confine the search to medical literature. A Medline search for polyvinyl chloride and lung toxicity yields 31 hits.
Now 31 articles are readable. But don’t read them just yet! First print out the titles and assess whether the articles are really applicable to Mr. Jackson’s case. Here is a sample of some of the articles that came up. Which ones would you choose?
1. Respiratory toxicity in mice exposed to mattress covers. Arch Environ Health. 1999 May-Jun; 54(3): 202-9.
2. Exposures to polyvinyl chloride, methyl ketone and other chemicals. The pulmonary and non-pulmonary effect. Int Arch Occup Environ Health. 1992;63(7): 503-7.
3. Toxicity of vinyl chloride and poly(vinyl chloride): a critical review. Environ Health Perspect. 1983 Oct; 52:61-6. Review.
4. Pulmonary function defects in nonsmoking vinyl chloride workers. Environ Health Perspect. 1975 Jun; 11:247-50.
5. A rapid quantitative method based on motility of bull sperm cells for in vitro toxicity testing of biomaterials. Biomaterials. 1985 Mar; 6(2):105-9.
Personally, I think 2 and 3 look reasonable. I am not even going to comment on the whole bull sperm motility thing in No. 5. This is a respiratory care magazine. But do you see how we have very quickly come from more than a million articles to two that are really applicable to our patient? It wasn’t even all that hard to do. We had a plan and we stuck to it.
The next step is to apply what we learn. We read the two articles, apply our clinical experience and judgment and develop a plan of care for Mr. Jackson. Reference 3 tells us we should look for “granulomatous reaction, with inclusion of PVC particles in macrophages and histocytes and associated interstitial pulmonary fibrosis.” We check the patient’s chest film, and sure enough there is early stage pulmonary fibrosis. Already we know we have a weaning problem if he goes on the vent.
Our plan becomes to do everything in our power (good pulmonary hygiene, close monitoring, pull rabbits out of hats) to keep him oxygenating, ventilating and off the vent if possible.
Evaluating our actions is the next step. Hopefully we are able to keep him off the vent, treat his condition and discharge him when appropriate. If Mr. Jackson is not cooperative though and demands that we intubate him, then we are prepared to appropriately manage his course on the vent because we know he has fibrotic changes.
Mr. Jackson, after all, is an accountant and may want to get his money’s worth from his insurance plan. How do we know all this? We used EBM and we got his number.
Haven’t we all known a few Mr. Jacksons in our day? These are the patients who present with a condition about which we know just a little.
Finding applicable answers to patient care questions can be easy and useful in providing quality care. The big news is EBM doesn’t require pixie dust. It is a straightforward process that can be used to answer clinical questions.
Before we close, I would be remiss if I did not tell you what happened to that senior doctor who started all this mess to begin with. He did recover from his injuries with the help of orthopediacs and physical therapy and donated his unread journals to needy doctors in the Third World.
His follow-up JASPA score fell to 0. Now what’s your score?
Margaret Clark is a Georgia practitioner.
Some EBM Resources:
• Health Information Research Unit–McMaster University http://www.hiru.mcmaster.ca/default.htm
• Cochrane Collaboration–dedicated to the creation, review, maintenance and dissemination of systematic overviews of the effects of health care http://www.cochrane.org
• Centre for Evidence Based Medicine http://www.cebm.jr2.ox.ac.uk
• Agency for Health Care Research and Policy (AHRQ) http://www.ahrq.gov