A New Year's toast

With so many important clinical trials being published each year, it is easy to focus on the study methodology and conclusions, overlooking the years of careful clinical observation that preceded the trial development.

In this issue, Dr. Herbert Wiedemann, Chairman of the Department of Pulmonary, Allergy, and Critical Care Medicine at Cleveland Clinic, discusses the results of the Fluids and Catheters Treatment Trial (FACTT), of which he was cochair, and the impact that these results should have on the management of patients with acute lung injury and acute respiratory distress syndrome (ARDS).

The results are reasonably clear. Patients with ARDS should be treated with a strategy of low tidal volume ventilation (as previously shown) and also with fluid restriction and diuretics as needed in an attempt to reach the targeted low filling pressures (a central venous pressure < 4 mm Hg). But even with this aggressive fluid management approach, there was no consistent benefit from the early use of pulmonary artery catheters for pressure monitoring.

So my former attendings in the intensive care unit were right after all! I still remember them during my residency explaining how, with careful physical examination and vigilance, I could avoid the need for pulmonary catheters even as I attempted to avoid lung-stretching by “running the patient dry” and using lower ventilatory volumes. And they taught this on the basis of their knowledge of physiology and their clinical observations—the clinical trials had not yet been performed.

Multicenter networks of clinicians conducting trials such as FACTT represent major accomplishments of the medical system. These multicenter trials have the potential to generate useful information about complicated and sometimes uncommon diseases, and to change the way we practice medicine. But to me, the real accomplishments are made by the clinician in the trenches who, with eyes wide open,processes observational experiences and generates the questions that ultimately get tested in experimental trials.

The networks can accomplish patient recruitment, the “number crunchers” can generate the P values and perform their regression analyses, but it is the clinician with the bedside skills who often generates the meaningful questions.

So as we begin another year, certain to be filled with new and important research successes, I offer a toast to those clinicians who, despite the pressures of time, continue to hone their observational prowess, synthesize the published literature, develop the hypotheses that studies like FACTT address, and pass them on to their students—who may fondly remember them 25 years later.

With so many important clinical trials being published each year, it is easy to focus on the study methodology and conclusions, overlooking the years of careful clinical observation that preceded the trial development.

In this issue, Dr. Herbert Wiedemann, Chairman of the Department of Pulmonary, Allergy, and Critical Care Medicine at Cleveland Clinic, discusses the results of the Fluids and Catheters Treatment Trial (FACTT), of which he was cochair, and the impact that these results should have on the management of patients with acute lung injury and acute respiratory distress syndrome (ARDS).

The results are reasonably clear. Patients with ARDS should be treated with a strategy of low tidal volume ventilation (as previously shown) and also with fluid restriction and diuretics as needed in an attempt to reach the targeted low filling pressures (a central venous pressure < 4 mm Hg). But even with this aggressive fluid management approach, there was no consistent benefit from the early use of pulmonary artery catheters for pressure monitoring.

So my former attendings in the intensive care unit were right after all! I still remember them during my residency explaining how, with careful physical examination and vigilance, I could avoid the need for pulmonary catheters even as I attempted to avoid lung-stretching by “running the patient dry” and using lower ventilatory volumes. And they taught this on the basis of their knowledge of physiology and their clinical observations—the clinical trials had not yet been performed.

Multicenter networks of clinicians conducting trials such as FACTT represent major accomplishments of the medical system. These multicenter trials have the potential to generate useful information about complicated and sometimes uncommon diseases, and to change the way we practice medicine. But to me, the real accomplishments are made by the clinician in the trenches who, with eyes wide open,processes observational experiences and generates the questions that ultimately get tested in experimental trials.

The networks can accomplish patient recruitment, the “number crunchers” can generate the P values and perform their regression analyses, but it is the clinician with the bedside skills who often generates the meaningful questions.

So as we begin another year, certain to be filled with new and important research successes, I offer a toast to those clinicians who, despite the pressures of time, continue to hone their observational prowess, synthesize the published literature, develop the hypotheses that studies like FACTT address, and pass them on to their students—who may fondly remember them 25 years later.

With so many important clinical trials being published each year, it is easy to focus on the study methodology and conclusions, overlooking the years of careful clinical observation that preceded the trial development.

In this issue, Dr. Herbert Wiedemann, Chairman of the Department of Pulmonary, Allergy, and Critical Care Medicine at Cleveland Clinic, discusses the results of the Fluids and Catheters Treatment Trial (FACTT), of which he was cochair, and the impact that these results should have on the management of patients with acute lung injury and acute respiratory distress syndrome (ARDS).

The results are reasonably clear. Patients with ARDS should be treated with a strategy of low tidal volume ventilation (as previously shown) and also with fluid restriction and diuretics as needed in an attempt to reach the targeted low filling pressures (a central venous pressure < 4 mm Hg). But even with this aggressive fluid management approach, there was no consistent benefit from the early use of pulmonary artery catheters for pressure monitoring.

So my former attendings in the intensive care unit were right after all! I still remember them during my residency explaining how, with careful physical examination and vigilance, I could avoid the need for pulmonary catheters even as I attempted to avoid lung-stretching by “running the patient dry” and using lower ventilatory volumes. And they taught this on the basis of their knowledge of physiology and their clinical observations—the clinical trials had not yet been performed.

Multicenter networks of clinicians conducting trials such as FACTT represent major accomplishments of the medical system. These multicenter trials have the potential to generate useful information about complicated and sometimes uncommon diseases, and to change the way we practice medicine. But to me, the real accomplishments are made by the clinician in the trenches who, with eyes wide open,processes observational experiences and generates the questions that ultimately get tested in experimental trials.

The networks can accomplish patient recruitment, the “number crunchers” can generate the P values and perform their regression analyses, but it is the clinician with the bedside skills who often generates the meaningful questions.

So as we begin another year, certain to be filled with new and important research successes, I offer a toast to those clinicians who, despite the pressures of time, continue to hone their observational prowess, synthesize the published literature, develop the hypotheses that studies like FACTT address, and pass them on to their students—who may fondly remember them 25 years later.