August 28, 2014 4 Comments
When I am ‘on-call’ for my sports medicine clinic practice I receive a mixed bag of phone calls. The calls come in from patients we take care of, to emergency physicians looking for help triaging patients, to community physicians looking for consultation. Because I do non-operative, primary care sports medicine, I’m rarely involved in an emergency when ‘on-call'; any urgent or emergent issue I need to manage typically occurs when I am on a sideline and not nominally ‘on-call.’
Last week, I received an interesting query about muscle pain in a high school runner who had been doing some intense pre-season training. The physician seeking my advice had felt obliged to check the patient’s creatine kinase (CK) and told me the level was 1400 U/L. He had already obtained a urine for myoglobinuria (negative), and he was asking if he should be clearing the patient to return to sport.
Most of my clinical work involves taking care of fractures or concussions, spondylolysis or osteochondritis dissecans. As with a lot of clinicians, I suspect, for the conditions I treat in high volume I have the facts usually at the tip of my tongue. Though I have manged the condition, I don’t routinely treat patients where rhabdomyolysis is in the differential. And so, with this specific phone consultation, I assured the physician the patient was in no imminent danger, but I wanted to get back to him later that day after I had done a literature search.
Though I did not think about this explicitly at the time, I later realized that this little vignette represents an example of “Evidence Based Medicine” (EBM) in use. As Sackett et al. state in 1996, “Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”
In this particular case, I wanted to find some of the primary research done on CK levels in athletes in this age group. Among the articles I pulled were two from CJSM: “A Cluster of Exertional Rhabdomyolysis Affecting a Division I Football Team” , which was published in 2013; and a ‘Brief Report’ that was available only on-line until it was just published with the new, September CJSM, “Creatine Kinase Levels During Preseason Camp in National Collegiate Athletic Association Division-I Football Athletes.”
The former study I have actually profiled in these blog pages before.
There can be limits to the application of EBM in making decisions about ‘individual patients.’ Read more of this post