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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Medical Myths Medical Myths
 

Real-Time Medical Care


February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Last reviewed and revised February 27, 2013

Medical care is often portrayed on television and in the movies as a race against the clock. In real life, however, most medical treatment can safely proceed at a decidedly slower — and less exciting — pace.

There are a few exceptions, of course, where the "need for speed" can mean the difference between life and death. For example, cardiac arrest (when the heart stops) and respiratory arrest (when breathing stops) require immediate care. This may include urgent resuscitation measures, such as chest compressions or electrical shocks to the chest. These help maintain circulation and restore a normal heart rhythm, at least until the victim can be taken to a hospital.

But treatments for most other conditions need time to work. It's important to be realistic about how soon you can expect to feel better or to see your condition improve. If you expect immediate relief, you might be tempted to stop treatment before it has a chance to work.

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When Speed Matters

Only a few of the most common causes of death in the United States require urgent treatment.

    • Heart attack – Minutes count when a person is having a major heart attack. Standard guidelines recommend a procedure (called percutaneous coronary intervention, or PCI) to open up blocked coronary arteries if fewer than 12 hours have passed since the start of symptoms and if PCI can be performed by experienced physicians within 90 minutes of arrival at the hospital.
    • Stroke – As with heart attacks, minutes matter in stroke; if blood flow to the brain is cut off for even a few minutes, brain damage usually occurs. A clot-busting medication may reduce brain injury during a stroke if given within three hours after symptoms begin. If not, the drug works poorly or not at all.
    • Accidental injury – Major trauma requires urgent treatment. Emergency medical personnel often refer to "the golden hour," the 60 minutes following major injury (especially when there is internal bleeding) during which victims must be stabilized, transported to a hospital and treated to maximize chances for survival. While the notion of a "golden hour" has been called into question, it's clearly true that the sooner trauma victims get definitive care, the better. In fact, following a critical injury, seconds count. Surgery to stop internal bleeding, repair damaged organs, support breathing and heart function are truly life-saving. Delay for even a few minutes may reduce the chances of survival.
  • Bloodstream infection (septicemia) – People with serious, body-wide infections need antibiotics and other supportive measures right away. A delay of minutes or hours may make the difference between survival and death.

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When Patience Matters

Even some of the most serious conditions require weeks, months or even years of treatment to see improvements — or prevent a recurrence. For example, a statin medication may lower cholesterol within a few weeks, while the risk of heart attack falls within six months. It may take years to "unclog" coronary arteries (a process called regression of atherosclerosis).

It can be painfully slow-going when it comes to treating other top causes of death:

    • Cancer – Generally, cancer is present for a long time — often years — before it is diagnosed. Even though surgery, radiation, chemotherapy or other treatments generally start as soon as possible, there is no urgency to do so within hours or days of diagnosis. And, while surgery may cure certain types of cancers right away (especially if it’s at an early stage), it can take months of chemotherapy or radiation (or both) to destroy a tumor.
    • Chronic lung disease – The most effective "treatment" for emphysema or other forms of chronic obstructive lung disease (COPD) is to stop smoking. Lung function generally improves, even though it may take months to years. Inhalers can ease breathing within minutes, although the effects may be temporary. Oral medications generally take longer to work. When breathing suddenly worsens, aggressive treatment may be urgently needed. But most COPD treatment is a long-term process.
    • Diabetes – The sooner diabetes is detected and treated the better. Occasionally, a very high blood sugar can cause problems requiring urgent attention. Two examples include diabetic ketoacidosis and hyperosmolar coma; treatment within hours can make a big difference. However, for most people with diabetes, the benefits of tight blood sugar control are often not obvious for many months or even years.
    • Pneumonia and influenza – Once diagnosed, supportive care and antibiotics are generally started right away. Most cases of influenza and pneumonia can safely be treated within a few days of the start of symptoms; it may take a number of days to feel better and weeks or even months to completely recover.
    • Alzheimer's disease – Unfortunately, medications offer modest benefits at best with stabilization of cognitive function over many months or years. Other supportive measures, such as physical therapy or exercise may provide benefits more quickly but they don’t alter the course of the illness.
  • Kidney disease – Chronic kidney diseases, such as nephritis (kidney inflammation), tend to cause a gradual loss of kidney function. Long-term treatments, including immunosuppressive and anti-hypertensive medications, often take months to show a benefit.

Other common, chronic conditions respond slowly to treatment as well. These include:

    • Osteoporosis – This disorder leads to weak bones that can fracture easily. Hip fractures due to osteoporosis often lead to loss of independence and, in about 5% of cases, complications that may cause death. Exercise and medications can restore some bone strength, but it takes months or years of treatment to reduce fracture risk.
    • Back pain – About 80% of people will see a doctor at some point in their lives for treatment of back pain. Degenerative arthritis, disc disease and muscle spasm are among the most common causes. Most back pain gets better on its own. When back pain persists and treatment is required, it usually takes several days, weeks or even months for pain to improve.
  • Arthritis – Treatment for osteoarthritis and rheumatoid arthritis typically require weeks or months to be effective.

Even when long-term treatment is necessary, prompt diagnosis and treatment often lead to quicker beneficial results.

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Be Realistic

If you're suffering, it's understandable that you'd want safe, effective and quick treatment. But your expectations of your doctor and the treatment need to be realistic.

The benefits of most medical care take time. Ask your doctor how long before you can expect relief or results from your treatment. Also, ask how you will know if the treatment is working. Benefits are easy to overlook sometimes. For example, the absence of a heart attack is the result of well-treated high blood pressure. Some arthritis medications prevent future joint damage while reducing pain within hours or days.

Medical dramas on television and in the movies may give you the impression that all medical treatments work (or don't) within minutes. For most conditions, that's a myth. A more realistic time frame is much slower.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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