Treatment: strategy and tactics The main principles of the strategy to combat DN are: 1. First, emergency care, then diagnostics and planned therapy.2. Complex treatment of DN.3. Determination and elimination of the main physiological mechanisms of DN as the basis for its treatment.4. Treatment

Tactics for fighting cancer tumors Tumors, like mushrooms, have a self-controlled growth mechanism; their cells secrete enzymes that dissolve the proteins of surrounding tissues. In most cases, a person does not know what kind of tumor process is developing in him. Ignorance of the species

Treatment tactics After detecting a rupture, anesthesia and suturing with catgut sutures are performed (due to the fact that they resolve). Bleeding from vaginal wounds usually stops after suturing the rupture. Individual ruptures of the vaginal wall, small and large genitalia

Treatment tactics After childbirth, the doctor and midwife must examine the cervix, vaginal vaults and external genitalia to detect ruptures. The examination is carried out using special vaginal speculums. If a third degree perineal rupture is suspected

Treatment tactics In a situation where a rupture of the uterine wall has begun or is threatening, a woman needs immediate qualified medical care. First of all, helping a woman consists of stopping labor with medication. In the future, when

Management and treatment tactics If a uterine rupture occurs, an emergency cesarean section is required while simultaneously carrying out resuscitation measures to replenish blood loss. As a rule, when the uterus ruptures, the fetus almost always dies. Operation

The choice of treatment tactics includes two different in nature, but closely interrelated stages:

obtaining written consent from the patient to carry out appropriate treatment measures.

When it comes to a major intervention such as abdominal surgery, these stages can be relatively complex and are formalized by signing the appropriate document*. However, they form an integral part of even a short medical consultation. When a doctor simply tells a patient what he should do, and the patient follows this instruction, it is implied that there is a recommendation on the one hand, and an agreement on the other.

* As the reader will see, obtaining written consent from the patient is a mandatory condition not only for a surgical operation, but also for any diagnostic or therapeutic manipulation that can harm the patient, including, for example, such safe methods as electrocardiographic exercise testing.

this, even if the first is not clearly substantiated, and the second is not formally recorded. Thus, decision-making on treatment tactics always involves two different processes, the failure to distinguish which is the source of frequent difficulties.

On the one hand, some doctors believe that they “know better” and expect the patient to agree with their recommendations without hesitation or asking for a “second opinion.” Such doctors usually feel a threat to their authority in the opinion of others, do not like it when the patient shows curiosity, and are ready to abandon the patient if he rejects their recommendations.

On the other hand, more and more doctors see their task as reporting “bare” facts without expressing their own opinions. Such doctors present to the patient all the specific information concerning him, but do not recommend anything themselves. It is difficult for the patient to deal with this type of doctor because of their aloof demeanor, unwillingness to take responsibility for the results of treatment and inability to inspire confidence in their professional competence.

Some patients specifically look for doctors of one of these types, recognizing the legitimacy of the approach they use, but now a truly competent specialist is increasingly considered to be one who can cope with both tasks - developing recommendations, explaining their essence to the patient and obtaining written consent from him to carry out appropriate therapeutic measures.

Let's consider what factors a doctor should take into account when making recommendations. We will then discuss the process of obtaining written consent, looking at the same factors through the eyes of the patient.

When discussing the safety of treatment, we focused on two parameters that characterize it - the likelihood of side effects and their severity. The same indicators apply to characterize the effectiveness of the proposed treatment method. Thus, theoretically, the doctor’s task when choosing treatment tactics comes down to comparing the probability and severity of the positive impact of each potentially applicable treatment method with the probability and severity of its negative impact. How to approach this complex analysis of potential benefits and dangers? Often the matter is limited to assessing probability alone. However, if the results of clinical trials are available, it is possible to compare risks and benefits using an indicator sometimes called experiencelarge number of patients. By calculating this number, we assume that patients in the experimental group (receiving treatment) have a better prognosis than patients in the control group (natural course of the disease); then to identify the benefit of this method, the required number of patients will be:

/Probability I of a good outcome in the experimental group

Let us now assume that, according to available data, the probability of a favorable outcome in the experimental group is 3/5, and in the control group, which is similar in all other respects, 2/5. Then the required number of patients to identify the benefits of the chosen method will be:

This calculation shows that to obtain one additional favorable result, it is necessary to use this method in five patients. The calculation is applicable for comparing different treatment methods or for comparing the benefits of the chosen method with its dangers*.

The number of patients in whom this treatment method is used, necessary for its adverse effects (complications of treatment) to manifest itself, is calculated in a similar way:

*When these numbers are used to compare different treatments, it should be taken into account that the length of time the different treatments were used may not have been the same in the experiments. However, if we know how long the treatment lasted in each case, this discrepancy can be taken into account by using a comparable basis for comparison. Note auto

Probability of complications in the control group

If, say, a certain complication is observed in two out of a hundred treated patients (from the experimental group) and only one out of a hundred untreated patients (from the control group), then the required number of patients to identify the danger of this complication when using the chosen method will be:

_____1 _______

2/100 - 1/100 = 100

Two parameters can be calculated in parallel: the number of patients in whom a given treatment method must be applied to obtain one additional positive result and one additional negative result. For example, you can calculate the number of patients who would need to be given a particular drug to prevent one case of myocardial infarction, and the number of patients who would need that drug to cause one additional complication, such as a stroke. If the first number is 5 and the second is 100, then the probability that the treatment will benefit the patient is 20 greater than the probability that it will cause harm. Often this is all that is required to make recommendations, especially if we consider cerebral stroke and myocardial infarction to be equally dangerous outcomes expected at approximately the same time.

However, the process described is not as simple as it seems. Doctors often have to rely not on objective results of clinical trials, but on their own, sometimes very rough estimates of the likelihood of a particular outcome (estimated probability). It is also necessary to take into account that the same outcome of the disease means different things for different patients, just as the timing of different potential outcomes is not the same.

Estimated probability implies a more or less reasonable assumption, which is based both on literary data on the effect of a certain treatment method on different groups of patients, and on information collected about a specific patient.

Real Consequences is the outcome of the disease from the patient’s point of view. Much depends on individual characteristics: it is known that the same outcome is perceived differently by different people, whether we are talking about the loss of a leg, blindness or even a cerebral stroke.

To formulate our recommendations, we must combine estimated likelihood with actual consequences. This can be done quantitatively using a method called decision analysis *, however, they are more often limited to a purely qualitative comparison, usually almost unconscious, without considering the individual components of the solution.

Whose point of view is more important - our own or the patient's? It is desirable that our recommendations take into account the patient’s opinion as much as possible, although this can be difficult. And yet, it is the patient who has the final word here - he must give written consent to implement our recommendations.

So, in the process of developing treatment recommendations and obtaining written consent, there are two sources of uncertainty - estimated probability and real consequences. Let us now turn to the process of obtaining written consent. First, we will consider the requirements for this process, and then we will discuss how to avoid many of the mistakes that await a doctor during the dual task of developing treatment recommendations, explaining their essence to the patient and obtaining written consent from him to carry out the appropriate treatment measures.

WRITTEN AGREEMENT

In accordance with the law and accepted professional standards, a patient who gives written consent to carry out diagnostic and treatment measures must:

* The methodology for analyzing decisions is as follows. A certain score is assigned to the probability of each outcome (from zero to one) and the treatment outcome itself (death - zero, complete recovery - one) and then these points are multiplied in pairs. The products are added together - the resulting sum characterizes the expected practicality of this treatment method. Using these values, different treatment methods can be compared. Note auto

Be able to make a decision;

Have sufficient information to make a decision;

Be free to make decisions*.

So, the first condition is that the patient must be able to make decisions. This is not just about capacity in the legal sense. The patient must understand the essence of the matter and delve into all the details. As defined by the Presidential Commission on Bioethics, the ability to make decisions requires a set of stable values ​​and goals, the ability to understand and communicate information, and the ability to justify and reflect on one's choices. Thus, we are talking about the fact that the patient must have sufficient intelligence to make his choice and report it, process the information received, evaluate the situation and its consequences for his own life. In other words, he needs to be involved in the intellectual work necessary to make a decision. Often this stage takes little or no time, since the patient is initially assumed to be capable of making decisions unless there is clear evidence to the contrary.

Assuming that the patient is able to give written consent to medical treatment, we must provide him with all the information necessary for this.

* In domestic medical practice, it is customary to limit oneself to an entry in the medical history of the type “the patient is familiar with the essence of the upcoming intervention, consent has been obtained.” Because the concept documentary evidencefull awareness patient about the essence of the upcoming medical intervention or diagnostic test is new for Russian doctors, we consider it necessary to give an example of a document that every patient in a US clinic must sign before undergoing one of the safest diagnostic tests - an electrocardiographic test with physical or medicinal stress. The document form used is that accepted at the clinics of the University of California at San Francisco. Due to lack of space, the text is reproduced with some abbreviations.

CONSENT TO CONDUCT AN ELECTROCARDIOGRAPHIC TEST WITH PHYSICAL OR DRUG STRESS

I will undergo a study, including recording of electrocardiograms we are during physical activity. This study is conducted to explore heart activity. Recording an electrocardiogram during physical exercise load in some cases allows us to identify the characteristics of cardiac activity qualities that do not appear in a state of rest.

To record an electrocardiogram, wires (electrodes) will be placed on my limbs and chest. Then I have to walk on a treadmill or pedal a special bicycle. The load will begradually increase until the heart rate reaches a certain level or until it becomes necessary to stop the load for another reason.

For proper treatment, the blood supply to the heart will be examined during load time. If a test with physical activity is not enough for this, then I will be given a drug test. To do this, dipyridamole, dobutamine or another drug will be injected into a vein to create conditions for stress on the heart. As with the exercise test, electrodes will be applied. Then I will be injected into a vein with a drugincreasing dose until sufficient effect is achieved or until the full dose is administered. At this time, one of the methods will be additionally applied to “see” the heart: this will be an isotope or ultrasound examination. The purpose of these methods is to evaluate the effect of load on the heart's blood supply or function.The study may be complicated by heart rhythm disturbances (irregular lar contractions of the heart), a sharp increase or decrease in blood pressure, dizziness, shortness of breath, a feeling of lack of air. K reThe serious complications of the procedure ahead of me include severe daily attacks that can lead to death. All will be accepted necessary precautions, which include paying attention regular monitoring of heart rate and blood pressure before, during and after the study. Emergency equipment and medicines will be at the ready. The study will be conducted bya dedicated specialist or nurse under the direction of a doctor, I understood all of the above. The doctor answered all my questions. I give my voluntary consent to conduct the study.Signature:

Theoretically, the doctor is obliged to outline to him the main stages through which he himself went through before formulating his recommendations. As a result, the patient receives all the necessary information and freedom of choice. It is the responsibility of doctors and lawyers to decide what information is necessary and sufficient. American courts use three standards. Initially (in some states this practice still exists) it was used professionally orientedmove, according to which the doctor must tell the patient what his reputable colleagues tell their patients. Later, most lawyers began to use the standard reasonable person(it is also called objective): the doctor is obliged to report everything that a “reasonable person” who finds himself in the patient’s place would like to know. Recently it began to be used subjective, a patient-specific approach that requires the provision of all the information that the patient wants to receive.

Considering the inconsistency of all these approaches and the difficulties of fulfilling their conditions, one can understand how difficult it is sometimes for a doctor to determine what information a patient needs. This problem is usually solved this way: the doctor reports only the information that he used to compare different treatment options and make final recommendations. This amount of information, combined with answers to the patient's questions, appears to be a reasonable compromise. In particular, the information necessary for the patient must include the following mandatory information:

rationale for treatment: prognosis in its absence, prerequisites for using the recommended treatment method;

the main expected results of treatment and a discussion of those characteristics of the patient that may affect the result;

the major hazards of treatment, including the likelihood, severity, and timing of possible side effects;

discussion of alternative healing methods.

This information allows the patient to follow the progress of the doctor’s thoughts. A description of the main benefits and potential risks of the proposed treatment allows him to form his own opinion about the likelihood and severity of certain adverse consequences. Discussion of alternative treatment methods allows the patient to weigh the pros and cons of their use.

Having received the necessary information, the patient should be able to freely use and make decisions freely. The latter means the choice of treatment method is the prerogative of the patient. Freedom of choice, i.e., the absence of coercion, also implies that he must receive information in a form that would, to the maximum extent, exclude both a one-sided presentation of facts and hidden or even unconscious attempts to influence the decision being made. Absence of coercion means freedom from threats, including the threat of withdrawal of medical care. If the patient’s decision is unacceptable to the doctor, the latter is obliged to offer an alternative source of medical care, if, of course, it can be provided legally. Thus, written consent implies the ability to make a choice, possession of the necessary information and freedom of choice.

When a doctor gives recommendations, and the patient is faced with a choice, a number of medical errors are possible. Problems are most evident during the process of obtaining written consent, so it is convenient to use this process to analyze potential deviations from the right path. First of all, we will assume that the patient is competent to make decisions, and we will begin by obtaining the necessary information. Let’s discuss how the doctor’s and patient’s ideas about probability and outcome differ, how the third factor, which we will call, influences the decision attitude towards risk, We then turn to freedom of choice and consider how doctors, consciously or unconsciously, try to influence a patient's choices. Finally, we will return to the latter’s ability to make “”” decisions and analyze where its incorrect interpretation can lead.

Estimated Probability

A subjective assessment of the probability of a positive or negative treatment outcome for both the doctor and the patient is often determined by how easy it is for them to imagine this result. The possibility of negative outcomes is often replaced by the ability to imagine them. If a doctor has just had a patient die on the operating table, and in another patient a diagnostic test has caused serious complications or a side effect of a drug, then it is understandable that he will be inclined to overestimate the likelihood of such situations. In addition, many doctors have a superstition that success and failure come in stripes: sometimes you are lucky, sometimes you are unlucky. The patient is also inclined to assess the likelihood of a result based on the vividness of the idea of ​​it. If a friend or relative dies of lymphogranulomatosis or heart failure, the patient may be better able to weigh the risks and benefits of treatment, but at the same time he will likely overestimate the possibility of a bad outcome.

It is usually difficult for a person to assess the probability of any event. If this probability is actually below 1-2%, it is usually greatly overestimated or underestimated. Thus, both doctors and patients may overestimate the likelihood of dying from minor surgery or developing life-threatening complications from commonly used medications. Conversely, they may not consider such cases at all as too unrealistic and too scary to think about.

How to make the assessment of the doctor and the patient more accurate? Several methods are used for this.

Calculation experienced number of patients allows you to present research data in a visual form. Consider this example: with prophylactic treatment with aspirin, one additional case of hemorrhagic stroke is expected per 2,000 apparently healthy middle-aged men, while myocardial infarction can be prevented in one case out of 100; It doesn't take much effort to absorb information about these rare events when it is presented in this form.

When we are talking about a small risk not exceeding 1-5%, it is more convenient to calculate chance, not probability. So, instead of a 2% chance, we can talk about a 1:49 chance (or rounded 1:50). The difference between the probability 2% And A% not easy to feel; Comparing the odds of 1:24 and 1:49 makes the difference more clear.

A widely accepted way of assessing rare events is to compare the risk associated with them with the risk that surrounds us in everyday life. Thus, doctors often use, and sometimes abuse, comparing the probability of a particular event with the probability of “being hit by a car.” If such an analogy correctly reflects the situation, then it is useful. However, the doctor must be aware that the risk of death in a car accident or death from acute myocardial infarction, although quite high, is still extended over time, while the proposed treatment may pose an immediate threat to life.

Thus, one of the most common mistakes made by doctors and patients is unrealistic ideas about the likelihood of a particular outcome. It is necessary to help the patient understand the numbers reported to him and compare them with his own life experience so that he can assess the probability more accurately.

Realconsequences

As already mentioned, the real consequences are the outcome of the disease in the patient's assessment. An important factor, especially when making difficult decisions, is the acceptability of life with varying degrees of disability. The choice between chronic hemodialysis and kidney transplantation, drug treatment of coronary heart disease and coronary artery bypass grafting, chemotherapy and symptomatic treatment of metastatic cancer depends on how the doctor and the patient view various forms of disability.

Some treatment results seem absolutely terrifying to both the doctor and the patient; in this case, there may be an overestimation of their severity, and in some cases, their likelihood. Life without a leg, with a colostomy or after a mastectomy seems unbearable to some. Fortunately, the patient's exaggerated fear is often not so difficult to deal with if you ask him to talk about his fears in detail. Talking with other people who are living happily and productively after a leg amputation, colostomy, or mastectomy can be very helpful for the patient and turn his fear into a very realistic concern.

In addition to different views on the outcome of treatment, doctors and patients often share a different understanding of the time factor. For a doctor, a year of a patient's life may simply mean half as much as two years. However, for the patient, this first year is much more important than the second, especially if it allows you to put your affairs in order, spend time with family and friends, and make a long-planned trip. In addition, patients may rightfully be more interested in the quality rather than the quantity of their remaining life. A long life in a hospital, full of suffering, is perceived as significantly less valuable than a short period of active work or entertainment. Thus, the results of treatment and the time factor may be perceived by doctors and patients completely differently. A doctor's underestimation of these differences is fraught with serious errors when making decisions about treatment tactics.

Risk attitude

Ideally, a doctor's recommendations are based on the estimated probability of a particular outcome and the actual consequences of the proposed treatment. If these factors speak in favor of a given treatment method, then theoretically the doctor should recommend it. However, often the doctor's recommendations and the patient's subsequent decisions are influenced by the attitude of both of them towards risk.

Doctors usually state their rational attituderisk aversion, about not being affected by emotions. In other words, they try to recommend a particular treatment method only when the likelihood of a favorable outcome outweighs the risk of possible complications*. In fact, only a few people (and doctors are no exception) are so rational as not to be afraid of rare but catastrophic events. Most people buy all kinds of insurance to protect themselves from major losses, regardless of the inevitable expenses in the form of insurance premiums. This behavior is caused by an unwillingness to take risks. On the other hand, in certain situations many people tend to take risks. They are ready for the inevitable small losses if they get at least a minimal chance of a big win in return, even if reason speaks against such a decision. Proof of this is the popularity of lotteries and gambling. Most people, to the detriment of rational calculations, strive to avoid risk or, conversely, take risks, depending on the circumstances.

Comparable to insurance and the lottery are widespread clinical situations in which a doctor or patient clearly has an irrational attitude to risk. Failure to recognize such cases is a source of serious errors. Patients tend to avoid risks if the situation is beyond their control and is associated with a low but tangible probability of a very serious outcome. Thus, most people fear plane crashes much more than car accidents. Likewise, many patients and non-surgeons are wary of surgery, regardless of the risks involved. Low but noticeable probability of such outcomes,

*Rational attitude to risk means that the doctor quantifies different treatment methods by calculating them practicality, and settles on the most practical option. Note auto

such as death on the operating table or pulmonary embolism in the postoperative period, may prompt the patient to refuse surgery. He, like a non-surgeon, will often prefer drug treatment, which is easier to control and does not threaten rare, but very dire consequences. In other words, both doctors and patients are at times risk averse due to the so-called insurance effect.

It happens that the unknown (will an event happen? If so, when?) is completely unbearable for the patient and the doctor. However, the doctor can help the patient be less afraid of the risk. To do this, you need to create in the patient the feeling that he is, at least partially, in control of the situation. For example, if you explain to the patient that early activation reduces the risk of pulmonary embolism, which means that after surgery you need to quickly move into the “walking” category, the influence of the insurance effect will decrease. A patient who quits smoking or loses weight before surgery not only reduces the risk associated with the operation, but also actively participates in the treatment process, which is now partly under his own control. Some patients admit that risk reluctance makes them prefer the “status quo” to the unknown outcome of treatment. Naturally, avoiding risk is the patient’s complete right. People vary greatly in their susceptibility to the insurance effect. Some patients deliberately choose forms of treatment that are beyond their control but are associated with a lower likelihood of severe complications. This allows them to evade responsibility for participating in the treatment process, which sometimes requires a person to change established behavioral patterns. Thus, two people with the same chance of a particular outcome may, based on their attitudes to risk, choose different treatments.

Another common situation in which neither doctors nor patients remain indifferent to the risk is the rapid deterioration of the patient's condition. When the disease progresses and treatment does not bring the expected result, patients become prone to gambling, risky decisions. Doctors and patients, like basketball players who feel that time is running out, often “rush to shoot.” This sports analogy is apt to explain many heroic efforts that have little chance of success. Both doctors and patients will find it difficult to give up trying to change the situation if there is even minimal hope.

In the current US medical system, patients who are willing to take risks usually have every opportunity to do so. It is too difficult for a doctor alone to resist their demands. Professional norms, traditions of the medical institution, the opinion of colleagues are means that help weaken this lottery effect.

Thus, errors in developing treatment tactics are often due to the difficulty of assessing the probability and severity of the expected outcome, as well as an irrational attitude towards the risk of complications. Now we will see that errors can also be associated with the method that the doctor chooses to communicate the necessary information to the patient. So, let's turn to the problems that arise when patients make decisions.

freedom of choice

Although open threats to not provide medical care to “unruly” people are easy to recognize and deflect, communicating information to the patient in a form that does not in any way limit his freedom of choice is an extremely difficult task. An element of coercion is always present when the doctor presents the facts one-sidedly, so that the patient does not have a complete picture of what is happening. The doctor may get carried away by the visual and present the facts in such a frightening form that the patient will develop an unjustified sense of fear of the disease or a specific treatment method. Thus, by emphasizing the real, although very low, chance of contracting AIDS through a blood transfusion, the patient can be persuaded to refuse surgery. Likewise, the small risk of perforation of a duodenal ulcer may be used to obtain consent for surgical treatment of the disease.

Everyone knows half empty effect- half full glass: the physician may emphasize either a 5% chance of death or a 95% chance of survival. The patient’s decision largely depends on what exactly he selects. Although this effect is difficult to completely eliminate, its effect can be minimized by presenting the facts in both ways, for example, first emphasizing the possibility of death and then the possibility of healing. In addition, sometimes it is useful to ask the patient to tell what exactly he understood from the information given to him. This will make it easy to determine whether he sees a “glass half full” or “half empty” and then draw his attention to the ambiguity of the situation.

The described effect depends not only on our words, but also on our tone. A dispassionate, without pause, listing of facts usually gives the patient the impression of the doctor’s high professionalism and his confidence in what was said, but does not reflect the complexity of the task facing the doctor and the patient. In addition, doctors usually speak more confidently about the doses of medications, the routes of their administration, etc., than about the advisability of using a particular treatment method. “We would like your consent to administer 60 mg of intravenous Adriamycin every three weeks” sounds much more impressive than “we consider it necessary to try treating you with Adriamycin.” It is difficult to completely get rid of compulsion. In fact, those doctors who are most likely to establish productive interactions with patients are the ones most likely to use their influence for subtle coercion.

Having discussed with the patient the likelihood of one or another outcome of the disease during its natural course, the benefits and possible dangers of treatment, and provided him with the necessary and sufficient information in a form that excludes coercion, the doctor, as a rule, convinces the patient of the correctness of his recommendations. Sometimes the doctor and the patient at least agree on what they disagree about. However, at times it can be difficult for a doctor to understand why a patient refuses a given treatment or insists on a particular option. In such cases, it is useful to revisit the patient's ability to make decisions.

Decision making ability

If the patient was initially considered capable of making decisions, then we cannot deny him this ability because the course of his thoughts is incomprehensible, and the choice he made does not suit us. Sometimes the choice of an adult seems illogical, but it can be based on a well-established system of views, for example religious ones. However, if the doctor has any doubts about the patient’s ability to make decisions, he must be able to move on to the difficult process of assessing it. The ability to understand is clearly impaired in people with clouded consciousness. However, understanding requires more than just a clear mind and the ability to concentrate. We often judge understanding by the sustainability of decisions made. When doubts arise, you should check the stability of the patient’s decision by asking him the same question after some time. If the patient changes his choice every few hours, this usually indicates that his decision-making ability is seriously impaired.

As for the ability to rationally use information, it may suffer due to a significant weakening of attention, intelligence or memory. These abilities of the patient must be tested from the very beginning by asking him to retell in his own words what he heard from the doctor. Naturally, the latter is required to clearly state the necessary facts. You should also make sure that the patient understands what he actually agrees to; To do this, you need to ask what he thinks will happen when he gives consent. The patient’s ability to correctly assess the situation and its consequences is more difficult to verify, but questions like “what disease do you have?” or “what do you see as the point of the operation?” often help identify people with poor decision-making ability.

The level of assessment of the situation and its consequences can first be clarified by simply asking the patient what most influenced his decision to resort (or not to resort) to this type of medical intervention. If the patient gives arguments like “I want to get rid of the pain” or “this operation is too dangerous,” it means that he adequately assesses the situation.

Assessing a patient's ability to make decisions can sometimes be very difficult, and if in doubt, the doctor may need to consult with colleagues or even lawyers. When this ability is present, as it usually is, it is useful to apply a method known as judgment analysis.

Analysis of judgments helps to understand the situation when it is difficult to understand the patient’s decision. There are two widespread types of violations of the process of constructing judgments, and the doctor must recognize them.

First, there may be cases when the choice that the patient makes at the moment does not correspond to his past behavior or his known views. A woman who requests amniocentesis to determine whether the fetus has Down syndrome, but at the same time advocates a complete ban on abortion, may either be overly reliant on a favorable prognosis or may not recognize her own inconsistency. Often, a simple explanation helps to cope with such inconsistency in decision-making: “On the one hand, you insist on amniocentesis, but on the other hand, you are not going to have an abortion if Down's disease is detected. Please explain your train of thought.” Questions of this type can force the patient to reconsider his conclusions. Ultimately, patients have every right to be illogical and give birth to children with Down syndrome, but the doctor is obliged to recognize ambiguous situations, not to follow the patient’s lead, but to try to help him make an internally consistent decision.

The second common cause of poor judgment is related to the mental state of the patient, which prevents him from properly concentrating on making a decision. Anxiety and depression are common causes of absent-mindedness and poor judgment. Although these conditions do not usually render the patient incapable of making decisions (and should not be considered incompetent), they may interfere with the patient's ability to hear what the doctor is saying, process information, and form judgments. When there are problems due to emotional factors, it is often more useful to postpone the question of a final decision and pay attention to the mental state of the patient. Correcting anxiety and depression will help the patient concentrate and fully use their ability to make choices.

According to the judgment analysis method, the patient's ability to comprehend information is closely related to how and when it is communicated to him. A woman who has just learned that she has breast cancer is usually not ready to make immediate decisions. It takes time to understand the new reality and make subsequent choices.

When the patient's decisions seem meaningless, you need to make sure that he correctly understood the information. To do this, it is not enough to simply repeat the basic information to him - it is necessary to find out what prevents the person from perceiving and comprehending it. Often the patient can be helped with questions like “what do you think will happen next?” or “what are you most afraid of?” Such questions often make it possible to understand what exactly frightens the patient and prevents him from perceiving what he hears.

Sometimes patients are unable to overcome their horror of pain, of being connected to an artificial respiration machine, or to get rid of analogies with a relative who died during surgery. To help the patient make a judgment that reflects his true intentions, it is useful to understand his train of thought. For example, patients often have false associations of this kind: “If I have a lot in common with my name, then I will react to treatment in the same way as he does.” If a friend who took this drug developed a peptic ulcer or impotence, then the patient can expect the same for himself. Identification of such associations allows us to eliminate the problem by slightly modifying the proposed treatment method, taking additional precautions, or simply explaining to the patient what is special about his case.

It is even more difficult with patients who confuse cause with effect and believe, for example, that the cause of a bad outcome may not be the disease itself, but the means of its treatment. The line of reasoning here might be: “My mother died six months after she started taking blood pressure medication. So, the same thing threatens me.” Such patients, who do not understand how illogical their judgments are, are the most difficult to help. Usually they are deaf to all arguments of reason. It is sometimes possible to overcome their persistent prejudice either by involving other family members in the conversation, who will remind them how seriously ill the mother was before the prescription of the notorious antihypertensive drug, or by persuading them to start with a low dose, which allows them to avoid side effects and gain confidence in the proposed treatment method.

So, the process of developing treatment tactics includes two independent, but closely related stages: developing medical recommendations and obtaining written consent from the patient to carry out appropriate treatment measures. Errors caused by underestimation of each stage are widespread in medical practice. The immediate cause of an erroneous decision may be a difference in assessments by the doctor and the patient of the probability and significance of a particular treatment result; sometimes the source of error is the unequal attitude to risk between the doctor and the patient.

Another source of error can be the incorrect way of communicating the information the patient needs to make a decision. Finally, despite the sufficiency of information and complete freedom of decision-making, some patients are simply unable to adequately perceive the information received. The doctor must be able to recognize such situations and help the patient to fully use his abilities.

Making decisions about treatment is a difficult process. It is impossible to achieve complete independence in decision making and perfect understanding of the situation. Therefore, the patient is often tempted to throw his hands up and rely entirely on the doctor’s opinion. However, do not rush to the conclusion that the patient does not want to participate in the decision making; try to get him to cooperate. Having done this, you will be surprised to discover how much the patient really strives for it. Fortunately, no special art is required here. The main thing for the doctor is to calmly state his recommendations, justify the choice of this treatment method and report on the main expected results and possible dangers. Then you need to answer the patient’s questions. Despite the inevitable difficulties involved in making a decision, it does not take much time and attention to significantly improve the results of this process.

Good decisions are not a guarantee of a good outcome, but they do provide a chance of success and a basis for an unbiased assessment of the results if the results are worse than expected. However, good decisions mean little if they are not implemented correctly. Therefore, now it’s time to pay attention to the next stage, namely, the implementation of therapeutic measures.

Effective therapy for any disease is possible only after an accurate diagnosis has been made. Therapeutic tactics for each pathology are determined individually: the doctor will necessarily take into account a lot of factors that influence the outcome of therapeutic procedures. Control of cure is carried out within the time frame specified by the doctor - you need to listen to the doctor, carefully and accurately following the specialist’s instructions.

Treatment includes various options and methods of influencing the body of a sick person.

Factors influencing the choice of treatment tactics

Based on the results of a full examination, the doctor will make a diagnosis, which is the starting point for prescribing effective treatment. Without understanding what needs to be dealt with and what the nature of the disease is, it is better not to start any treatment procedures. The following factors are important when choosing therapy:

• age and gender of the patient;
• accurate diagnosis;
• risk to life;
• concomitant types of chronic diseases;
• drug tolerance;
• the presence of certain physiological conditions.

In case of serious pathology, treatment tactics are always individual: even with the same diagnosis, different people may have different therapeutic approaches. Sometimes a sick person may have a choice - the doctor will offer treatment options, but more often the doctor determines what to do and which methods will be most effective.

Therapeutic tactics - options and methods

Treatment is always a creative process: even if there are standards of therapy determined by instructions and ministerial orders, the treatment tactics of each doctor are individual, which is explained by the following factors:

• own experience;
• knowledge;
• intuition;
• clinical thinking.

The last factor is the most significant - it is not the disease that needs to be treated, but the person. Everything in the body is interconnected, therefore, at any stage of the diagnostic and treatment process, an experienced and thoughtful doctor will look at the sick person as a whole and look for the pathology that is the root cause of the disease (if you look only at the current symptoms, you can miss a lot of related problems and hidden diseases) .

Therapeutic tactics involve the use of the following main treatment options:

1. Surgical;
2. Medication;
3. Physiotherapeutic;
4. Sanatorium-resort.

Surgery is one of the main treatment methods

It is used in cases where pills and injections cannot change the situation: the main postulate is that the best operation is the one that is not done. If it is possible to cure without partial or complete removal of an organ or tissue, then you must definitely use this chance. However, a large number of diseases cannot be cured without surgery (oncology, acute surgical pathology, congenital defects). involves the use of the following treatment methods:

• ingestion of tablets, mixtures, powders;
• insertion of suppositories rectally or vaginally;
• injections of medicinal solutions;
• instilling eye drops or spraying a spray into the nose.

Important therapeutic factors are the dose of the drug and the frequency of administration - in each specific case, you must strictly follow the instructions prescribed by the doctor.

Physiotherapy and spa treatment are rehabilitation and restorative therapy after the acute process has subsided.

Outcome of the disease

Some diseases cannot be cured, sometimes the disease can be cured temporarily, but most often the doctor can completely cure the pathology. Effective treatment tactics imply the following treatment outcomes for any disease:

• recovery;
• temporary improvement;
• transition to a chronic form;
• no effect;
• deterioration.

In the last two cases, the reason must be sought in the diagnosis: either it is inaccurate, or additional aggravating factors have appeared. After additional examination and clarification of the reasons for the ineffectiveness of therapy, the next course of treatment is carried out.

Cure criteria

We can talk about complete or partial recovery according to the following criteria:

• no complaints;
• improvement of general condition;
• disappearance of symptoms;
• normalization of indicators in analyses;
• no problems during the follow-up examination.

The correct treatment tactics, selected by an experienced doctor, taking into account the diagnosis and a thorough diagnostic assessment of the sick person’s body, will help cope with most diseases that occur in people. It is important to contact a specialist in time to identify pathology in the early stages of its occurrence, which is especially important in oncology.

Osteochondrosis- the main nosological form of degenerative diseases of the joints, intervertebral discs (intervertebral discs) and ligaments of the spine, characterized by a chronic progressive course. The basis of the disease is an imbalance between anabolic and catabolic processes in the hyaline cartilage of the intervertebral disc, leading to disruption of the functioning of the vertebral segment as a whole.

Based on the morphology and anatomical structure of the m/n disc (up to 90% water in the nucleus pulposus and the presence of proteoglycans and collagen in a ratio of 65% to 20% and the content of collagen in the fibrous ring up to 90%), the main mechanisms for the development of degenerative changes are:

• insufficient protein glycan synthesis
• strengthening of catabolic processes
• activation of collagenase, phospholipase and cytokines
• hyperproduction of prostaglandins E2, etc.

These reasons, combined with constant microtraumatization of the vertebral segment from excessive or underdosed loads in everyday life, violation of nutrition rules among residents of megacities, constant stressful situations at work and at home, lead to inevitable wear and “flattening” of the m/n disc and the development of such complications as protrusion or hernia.

The most severe complication of traumatic spinal injuries is intervertebral hernia.
Clinical manifestations of the disease: sudden appearance of intense pain in the spine, significant limitation of mobility in the segments of the spine, irradiation such as “aches,” “burning,” “passage of electric current,” etc. along various surfaces of the arm or leg. Often, primary pain in the spine can do not appear due to the protective tension of the back muscles and the block of the damaged segment.In these situations, there is a gradual increase in weakness and muscle atrophy, leading to disability.
The main methods of treating intervertebral hernias are surgical and conservative treatment.

Treatment tactics

Currently, for intervertebral hernias, either surgical intervention or conservative therapy is prescribed.
Based on the results of many years of observations and the results of surgical and conservative treatment methods, we noted that the indications for surgery are:

• the size of the hernial protrusion is over 7 mm with the threat of sequestration;
• paresis and paralysis of the sphincters of the rectum and bladder;
• paralysis of limbs and segments;
• signs of muscle atrophy against the background of lack of functional activity of the root;
• ineffectiveness of conservative treatment for 3 months or more (individual approach).

Both in cases of surgical treatment and conservative treatment, the most effective and affordable medications are:

Analgesic therapy:
Analgin solution 50% -1.0 - Analgin 50% -2.0
B12-1000 mcg - No-spa -2g
No-spa-2g - Lasix-40mg
Reopirin-5.0 IM - Novocaine 0.25% -100.0 IM drops

Anti-inflammatory therapy
Voltaren 50 mg 3 times a day (suppositories - 2 times a day) Movalis 1t 2 times a day
Nise 0.1 2r per day

Local applications
Dimexide 50% pp + novocaine 0.5% -10.0 + hydrocortisone 75 mg

Drugs that relieve muscle spasms:
Sirdalud 2 mg - 3 rubles per day Miolastan 100 mg - 3 rubles per day Botox 25-75 units IM
Baclofen 10 mg - 3 times a day
Mydocalm
Stimulation of microcirculation
Trental 0.4 - 3 rubles per day Teonicol 0.3 g - 3 rubles per day Nicotinic acid 1.0-6.0 IM
Actovegin 2.0 - IM

Antioxidant therapy
Tocopherol (Vit E) - 0.3g per day Vitamin C 0.5g per day
Thioctic acid (Tioctacid, Espalipon, Berlition) 0.6 g per day - 3-4 months
Mexidol 0.125g - 3 rubles a day - 1 month or more

Correction of psychosomatic disorders
One of the main aspects of complex therapy is secondary (in early cases of diagnosis - primary) prevention of progressive processes of degeneration of cartilage tissue using chondroprotective therapy (chondroprotectors), causing:

• stimulation of the synthesis of proteoglycans and collagen fibers by chondrocytes
• decreased activity of lysosomal enzymes
• increased resistance of chondrocytes to the effects of cytokines
• activation of anabolic processes

Main groups of drugs:

• Glycosamine sulfate (DONA, Viatril, Arthril, Ostemin) - replenish the deficiency of glucosamines in the body, stimulate the synthesis of chondroitinsulfuric acid (1.5 g per day for 6 weeks, then a break for two months (with subsequent repetition) May cause insulin resistance
• Chondroitin - sulfate (Structum) - 1.5 g per day for 4-8 weeks
• Hyaluronic acid preparations (Hyaluronan, Sinvix, Ostenil, teraflex, arthra)
• Alflutop - contains mucopolysaccharides, peptides, amino acids, K, Ca) - inhibits the activity of hyaluronidase (i.m. 1.0 - 20 days)
• Diacerin
• Estrogens
• Non-saponifiable compounds of avocado and soybean (Piascledin 300) - stimulates the synthesis of protein glycans, collagen fibers, inhibits the production of plasminogen,
• percutaneous administration of anti-inflammatory drugs: PANTOGEMATOGEN and CARIPAZIM.