1. Three Pubs on Acute Stroke Treatment
A. ACEP Clinical Policy: Use of IV tPA for the Management of
Acute Ischemic Stroke in the ED
Brown MD and
the Clinical Policies Subcommittee on Use of Intravenous tPA for Ischemic
Stroke. Ann Emerg Med. 2015;66:322-333.e31
Summary
This clinical
policy from the American College of Emergency Physicians is the revision of a
clinical policy approved in 2012 addressing critical questions in the
evaluation and management of patients with acute ischemic stroke.1 A writing
subcommittee conducted a systematic review of the literature to derive evidence-based
recommendations to answer the following clinical questions:
(1) Is intravenous tissue plasminogen
activator safe and effective for patients with acute ischemic stroke if given
within 3 hours of symptom onset?
Level A
recommendations: None specified.
Level B
recommendations
With a goal
to improve functional outcomes, IV tPA should be offered and may be given to
selected patients with acute ischemic stroke within 3 hours after symptom onset
at institutions where systems are in place to safely administer the medication.
The increased risk of symptomatic intracerebral hemorrhage (sICH) should be
considered when deciding whether to administer IV tPA to patients with acute
ischemic stroke.
Level C
recommendations
When
feasible, shared decisionmaking between the patient (and/or his or her
surrogate) and a member of the health care team should include a discussion of
potential benefits and harms prior to the decision whether to administer IV tPA
for acute ischemic stroke. (Consensus recommendation)
(2) Is intravenous tissue plasminogen
activator safe and effective for patients with acute ischemic stroke treated
between 3 to 4.5 hours after symptom onset?
Level A
recommendations: None specified.
Level B
recommendations
Despite the
known risk of sICH and the variability in the degree of benefit in functional
outcomes, IV tPA may be offered and may be given to carefully selected patients
with acute ischemic stroke within 3 to 4.5 hours after symptom onset at
institutions where systems are in place to safely administer the medication.
Level C
recommendations
When
feasible, shared decisionmaking between the patient (and/or his or her
surrogate) and a member of the health care team should include a discussion of
potential benefits and harms prior to the decision whether to administer IV tPA
for acute ischemic stroke. (Consensus recommendation)
B. Implementation of an inpatient EHR with computerized
physician order entry is associated with improved outcomes for patients
admitted with ischemic stroke.
Ballard DW, and
the KP CREST Network. Ann Emerg Med. 2015 8 Sept [Epub ahead of print].
Study
objective: Electronic health record systems with computerized physician order
entry and condition-specific order sets are intended to standardize patient
management and minimize errors of omission. However, the effect of these systems
on disease-specific process measures and patient outcomes is not well
established. We seek to evaluate the effect of computerized physician order
entry electronic health record implementation on process measures and
short-term health outcomes for patients hospitalized with acute ischemic
stroke.
Methods: We
conducted a quasi-experimental cohort study of patients hospitalized for acute
ischemic stroke with concurrent controls that took advantage of the staggered
implementation of a comprehensive computerized physician order entry electronic
health record across 16 medical centers within an integrated health care
delivery system from 2007 to 2012. The study population included all patients
admitted to the hospital from the emergency department (ED) for acute ischemic
stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We
evaluated the association between the availability of a computerized physician
order entry electronic health record and the rates of ED intravenous tissue
plasminogen activator administration, hospital-acquired pneumonia, and
inhospital and 90-day mortality, using doubly robust estimation models to adjust
for demographics, comorbidities, secular trends, and concurrent primary stroke
center certification status at each center.
Results: Of
10,081 eligible patients, 6,686 (66.3%) were treated in centers after the
computerized physician order entry electronic health record had been
implemented. Computerized physician order entry was associated with
significantly higher rates of intravenous tissue plasminogen activator
administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but
not with significant rate differences in pneumonia or mortality.
Conclusion:
For patients hospitalized for acute ischemic stroke, computerized physician
order entry use was associated with increased use of intravenous tissue
plasminogen activator.
Associated editorials
1. PR
Newswire: Electronic Health Records with Decision Support Help Optimize ED Care
for Ischemic Stroke Patients: KP study shows patients received recommended and
proven therapy safely and more consistently
2. EHRIntelligence:
How CPOE Adoption Helps Clinicians Treat Stroke Effectively
C. Low-Versus Standard-Dose Alteplase for Ischemic Strokes within
4.5 Hours: A Comparative Effectiveness and Safety Study.
Kim BJ, et
al. Stroke. 2015 Sep;46(9):2541-8.
BACKGROUND
AND PURPOSE: The low-dose (0.6 mg/kg) alteplase strategy to treat acute
ischemic stroke patients became widespread in East Asian countries, without
rigorous testing against standard-dose (0.9 mg/kg) alteplase treatment. Our aim
was to investigate the comparative effectiveness and safety of the low-dose
versus standard-dose intravenous alteplase strategy.
METHODS: A
total of 1526 acute ischemic stroke patients who qualified for intravenous
alteplase and treated within 4.5 hours were identified from a prospective,
multicenter, and nationwide stroke registry database. Primary outcomes were a
modified Rankin scale score of 0 to 1 at 3 months after stroke and occurrence
of symptomatic hemorrhagic transformation. Inverse probability of low-dose
alteplase weighting by propensity scores was used to remove baseline imbalances
between the 2 groups, and variation among centers were also accounted using
generalized linear mixed models with a random intercept.
RESULTS:
Low-dose intravenous alteplase was given to 450 patients (29.5%) and
standard-dose intravenous alteplase to 1076 patients (70.5%). Low-dose
alteplase treatment was comparable to standard-dose therapy according to the
following adjusted outcomes and odds ratios (95% confidence intervals):
modified Rankin scale score 0 to 1 at 3 months and 0.95 (0.68-1.32); modified
Rankin scale 0 to 2 at 3 months and 0.84 (0.62-1.15); symptomatic hemorrhagic
transformation and 1.05 (0.65-1.70); and 3-month mortality and 0.54
(0.35-0.83). The associations were unchanged when the analysis was limited to
those without endovascular recanalization.
CONCLUSIONS:
The low-dose alteplase strategy was comparable to the standard-dose treatment
in terms of the effectiveness and safety.
2. Time to Epinephrine and Survival after Pediatric In-Hospital
Cardiac Arrest
Andersen LW, et
al; for the American Heart Association Get With the Guidelines–Resuscitation
Investigators. JAMA 2015;314(8):802-810.
Importance Delay in administration of the first
epinephrine dose is associated with decreased survival among adults after
in-hospital, nonshockable cardiac arrest. Whether this association is true in
the pediatric in-hospital cardiac arrest population remains unknown.
Objective To determine whether time to first
epinephrine dose is associated with outcomes in pediatric in-hospital cardiac
arrest.
Design,
Setting. and Participants We performed
an analysis of data from the Get With the Guidelines–Resuscitation registry. We
included US pediatric patients (age less than 18 years) with an in-hospital
cardiac arrest and an initial nonshockable rhythm who received at least 1 dose
of epinephrine. A total of 1558 patients (median age, 9 months [interquartile
range [IQR], 13 days–5 years]) were included in the final cohort.
Exposure Time to epinephrine, defined as time in
minutes from recognition of loss of pulse to the first dose of epinephrine.
Main Outcomes
and Measures The primary outcome was
survival to hospital discharge. Secondary outcomes included return of
spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome.
A favorable neurological outcome was defined as a score of 1 to 2 on the
Pediatric Cerebral Performance Category scale.
Results Among the 1558 patients, 487 (31.3%) survived
to hospital discharge. The median time to first epinephrine dose was 1 minute
(IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to
epinephrine administration was associated with lower risk of survival to discharge
in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute
delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was
also associated with decreased risk of ROSC (multivariable-adjusted RR per
minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours
(multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and
decreased risk of survival with favorable neurological outcome
(multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]).
Patients with time to epinephrine administration of longer than 5 minutes
(233/1558) compared with those with time to epinephrine of 5 minutes or less
(1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233]
vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93];
P = .01).
Conclusions
and Relevance Among children with
in-hospital cardiac arrest with an initial nonshockable rhythm who received
epinephrine, delay in administration of epinephrine was associated with
decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and
survival to hospital discharge with a favorable neurological outcome.
3. Postural modification to the standard Valsalva manoeuvre for
emergency treatment of SVT (REVERT): a RCT
Appelboam A,
et al. on behalf of the REVERT trial collaborators. Lancet 2015 August 24 [Epub
ahead of print]
Background
The Valsalva
manoeuvre is an internationally recommended treatment for supraventricular
tachycardia, but cardioversion is rare in practice (5–20%), necessitating the
use of other treatments including adenosine, which patients often find
unpleasant. We assessed whether a postural modification to the Valsalva
manoeuvre could improve its effectiveness.
Methods
We did a randomised
controlled, parallel-group trial at emergency departments in England. We
randomly allocated adults presenting with supraventricular tachycardia
(excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a
modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and
passive leg raise immediately after the Valsalva strain), or a standard
semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised
strain was used in both groups. Randomisation, stratified by centre, was done
centrally and independently, with allocation with serially numbered, opaque,
sealed, tamper-evident envelopes. Patients and treating clinicians were not
masked to allocation. The primary outcome was return to sinus rhythm at 1 min
after intervention, determined by the treating clinician and electrocardiogram
and confirmed by an investigator masked to treatment allocation. This study is
registered with Current Controlled Trials (ISRCTN67937027).
Findings
We enrolled
433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second
attendance by five participants, 214 participants in each group were included
in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to
standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214
in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI
2·3–5·8; p less than 0·0001). We recorded no serious adverse events.
Interpretation
In patients
with supraventricular tachycardia, a modified Valsalva manoeuvre with leg
elevation and supine positioning at the end of the strain should be considered
as a routine first treatment, and can be taught to patients.
Full-text
(free): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/fulltext
4. Concussion is confusing us all
Sharp DJ, et
al. Pract Neurol 2015;15:172-186.
It is time to
stop using the term concussion as it has no clear definition and no
pathological meaning. This confusion is increasingly problematic as the
management of ‘concussed’ individuals is a pressing concern. Historically, it
has been used to describe patients briefly disabled following a head injury,
with the assumption that this was due to a transient disorder of brain function
without long-term sequelae. However, the symptoms of concussion are highly
variable in duration, and can persist for many years with no reliable early
predictors of outcome. Using vague terminology for post-traumatic problems
leads to misconceptions and biases in the diagnostic process, producing
uninterpretable science, poor clinical guidelines and confused policy. We
propose that the term concussion should be avoided. Instead neurologists and
other healthcare professionals should classify the severity of traumatic brain
injury and then attempt to precisely diagnose the underlying cause of
post-traumatic symptoms.
5. Training the Mind, and the FDA, on Droperidol
Newman D. Ann
Emerg Med. 2015;66:243-245.
In 1956,
George Pickering,1 an eminent British
physician, picked a fight with the medical establishment. He criticized the
enormous content of “so-called facts” in medical curricula and singled out the
true purpose of medical education: “training the student's mind to collect and
assess data.”
Pickering's
admonitions were broadly appreciated and have been, for 60 years, largely
ignored. Today, despite bedside resources including the Internet, pocket
guides, smartphones, and more, students are still asked to memorize an
insurmountable quantity of factoids. Meanwhile, their minds remain untrained to
collect and assess the published data that define and continually redefine
their science.2 3 4 5
In this issue
of Annals , Calver et al6 present a
rigorous prospective examination of droperidol, labeled in 2001 by the Food and
Drug Administration (FDA) with a black box warning (the agency's strictest
caution) despite 3 quiet decades of safety data. The warning was apparently
based on 2 studies showing QT prolongation, 1 case of arrhythmia, and 65 events
from the FDA’s MedWatch system, representing 30 years, multiple countries, and
countless millions of administrations.7 8 9 10
Since 2001, however, this motley collection has been handily trumped by
a slew of published reviews and original investigations.11 12 13 14 15 16 17 18
19 20 21 22 The Calver report, a study
of droperidol for agitation in which no arrhythmia events occurred in 1,781
patients, is a coup de grâce.
It seems,
however, that data supporting the safety of droperidol were, even before 2001,
greater in quantity, quality, and source credibility than reports that led to
the warning. This should be unsurprising. The FDA’s MedWatch system, a
good-faith effort to ensure dangerous event reporting, undergoes no peer
review, includes no auditing for scientific veracity, can be used anonymously
without restriction, and demands no supporting evidence or contextual data for
evaluation of a causal link. It is the uncontrolled nature of these reports
that led to close outside scrutiny of the source data for the droperidol
warning. The findings, including irregular reporting (eg, 71 cases submitted on
a single day), duplication of many reports,11 13 19 and nonstandard dosing (up to 600 mg intravenously),19 have done little to relieve concerns about
the propriety and origins of the warning.10
In comparison, published, peer-reviewed literature in the years leading
up to 2001 appears to have produced neither a single case report nor a
prospectively documented event of ventricular arrhythmia or sudden death with
the drug,23 24 25 26 27 despite 1 review
of 74 droperidol trials with more than 13,000 subjects,25 another of 67,000 droperidol uses,26 and multiple comprehensive literature reviews
including case reports and observational data.23 24 27 Meanwhile, the MedWatch reports have spawned
at least 5 external reviews by 4 independent research groups, all of whom
challenge the black box warning as unwarranted.7 9 11 13 14
This leaves
the evidence-informed practitioner in an awkward spot—between a reasoned
approach to droperidol based on best evidence, and an alarming FDA warning—and
it is worth asking, how did it come to this? The answer of course is complex,
with acts of both commission and omission across the spectrum of stakeholders.
But first and foremost, the key players in this saga, practitioners and
regulators, have lacked Pickering’s training of the mind.
There are
few, if any, medical professionals who would not describe themselves as
“evidence based.” The same is true for most published data reviews, virtually
all guidelines, and, it seems, every grand rounds lecture. Indeed, the term’s
bastardization and empty deployment are major drivers of the evidence-based
medicine crisis,28 originating in
medicine’s triumvirate of influence: professional societies, journal editorial
boards, and government advisory committees. Despite the controlling presence of
prominent, highly educated medical professionals in these venues, all 3
commonly fail as stewards of integrity for medical science.
In perhaps
the most brazen dereliction, professional medical societies, the very face of
physician-scientist leadership, have broadly failed to ensure the validity and
credibility of clinical guidelines. The result of this failure is the crux of Pickering’s
“so-called facts”—a nod to the chameleon of accepted medical practice. From one
iteration to the next, guidelines often reverse even their strongest (class 1)
recommendations, suggesting an absence of scientific methodology and
consistency.
Peer-reviewed
journals, the defining source for medical science, also miscarry as a filter
for valid data and interpretation.33 34 35
The influence of this breakdown is concentrated, ironically, among
medicine's most prestigious and thus most cited publications.36 37 Yet the entropic force of this failure has
remained less visible, hidden behind a closely guarded peer review process that
operates on the peculiar and circular authority of its own criterion standard.
Finally,
government committees are failing. The credibility of FDA recommendations has
recently been questioned in a report identifying decades of drug approvals
based on surrogate endpoints, few to none of which translated into
patient-oriented benefits.38 Similar
problems39 40 41 42 have only compounded
a general sense that, despite the presence of respected physicians and
scientists working with and on government panels, the fruit of such work is
neither free of industry and political influence nor scientifically dependable.
The droperidol episode, a complicated misunderstanding of evidence hierarchies,
causal inference, and comparative validity, may not be isolated.
What Can Be Done?
In the case
of droperidol, medical science is defined, in the most practical sense, by
common practice. The standard-of-care concept rests on this foundation,
scientifically bereft as it may be…
The remainder
of the editorial (requires subscription): http://www.annemergmed.com/article/S0196-0644(15)00477-1/abstract
This is an
editorial in relation to Calver’s droperidol study (presented in Lit Bits, June
19, 2015). Full-text (free): http://www.annemergmed.com/article/S0196-0644(15)00222-X/fulltext
6. D-dimer Thresholds: Tailor for the Elderly and for the
Pregnant
A. An age-adjusted d-dimer threshold for ED patients with
suspected PE: accuracy and clinical implications.
Sharp AL, et
al. Ann Emerg Med. 2015 Aug 27 [Epub ahead of print].
Study
objective
We determine
the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism
in emergency department (ED) patients older than 50 years and describe current
ED practices when evaluating possible pulmonary embolism.
Methods
This was a
retrospective study of ED encounters for suspected pulmonary embolism from 2008
to 2013. We used structured data to calculate the sensitivity, specificity,
negative predictive value, and positive predictive value of different D-dimer
thresholds. We describe the incidence of pulmonary embolism, the proportion of
patients receiving imaging concordant with D-dimer levels, and the number of
“missed” pulmonary embolisms. These findings were used to estimate patient
outcomes based on different D-dimer thresholds.
Results
Among 31,094
encounters for suspected pulmonary embolism, there were 507 pulmonary embolism
diagnoses. The age-adjusted D-dimer threshold was more specific (64% versus
54%) but less sensitive (93% versus 98%) than the standard threshold of 500
ng/dL; 11,999 imaging studies identified 507 pulmonary embolisms (4.2%); of
these, 1,323 (10.6%) were performed with a D-dimer result below the standard
threshold. Among patient encounters without imaging, 17.6% had D-dimer values
above the threshold, including 5 missed pulmonary embolisms. Among patients who
received imaging, 10.6% had a negative D-dimer result. Applying an age-adjusted
D-dimer threshold to our sample would avert 2,924 low-value imaging tests while
resulting in 26 additional cases of missed pulmonary embolism.
Conclusion
An
age-adjusted D-dimer limit has the potential to reduce chest imaging among
older ED patients and is more accurate than a standard threshold of 500 ng/dL.
Our findings support the adoption of an age-adjusted D-dimer cutoff in
community EDs.
B. Gestation-specific D-dimer reference ranges: a
cross-sectional study.
Murphy N, et
al. BJOG. 2015 Feb;122(3):395-400.
OBJECTIVE: To
establish a gestation-specific reference range for D-dimer in healthy pregnant
women with a singleton pregnancy using the Auto-Dimer assay.
DESIGN:
Cross-sectional study
SETTING: Cork
University Maternity Hospital, Ireland.
POPULATION:
Healthy pregnant women attending for routine antenatal care.
METHODS:
Simultaneous-quantile regression was performed to construct a median, 5th
percentile, and 95th percentile, model of normal pregnancy D-dimer
concentration versus gestational week, ranging from week 6 to 42. Additionally,
pair-wise Mann-Whitney U-tests were performed to compare distributions of
D-dimer concentrations for each of the four discrete gestational sampling
windows with the distribution of D-dimer concentrations 48 hours postpartum.
MAIN OUTCOME
MEASURES: D-dimer concentrations (ng/ml) during normal gestation (approximately
week 6 to week 42).
RESULTS:
Seven hundred and sixty healthy pregnant women were investigated between
gestational age week 5 and 48 hours postpartum. There was a clear steady
increase in median D-dimer concentrations over the complete gestational period.
Additionally, the 95th centile estimates for all gestational time-points were
above the accepted non-pregnancy normal cut-off concentration (224 ng/ml). The
results of the Mann-Whitney U-tests suggested that the long-term postnatal
return to normal D-dimer concentrations begins in the immediate postpartum
period.
CONCLUSIONS:
We found that there is a continuous increase in D-dimer concentrations across
all gestations. This research is potentially beneficial to future diagnosis of
venous thromboembolism (VTE) in pregnancy using the new recommended 95th
centile potential cut-offs. Possible further investigation involves an
observational study comparing D-dimer concentrations in women with proven DVT
with those that don't, generating likelihood ratios.
7. Clinical Features and Outcomes of Takotsubo (Stress)
Cardiomyopathy
Templin C, et
al. N Engl J Med 2015; 373:929-938.
Background
The natural
history, management, and outcome of takotsubo (stress) cardiomyopathy are incompletely
understood.
Methods
The
International Takotsubo Registry, a consortium of 26 centers in Europe and the
United States, was established to investigate clinical features, prognostic
predictors, and outcome of takotsubo cardiomyopathy. Patients were compared
with age- and sex-matched patients who had an acute coronary syndrome.
Results
Of 1750
patients with takotsubo cardiomyopathy, 89.8% were women (mean age, 66.8
years). Emotional triggers were not as common as physical triggers (27.7% vs.
36.0%), and 28.5% of patients had no evident trigger. Among patients with
takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates of
neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean
left ventricular ejection fraction was markedly lower (40.7±11.2% vs.
51.5±12.3%) (P less than 0.001 for both comparisons). Rates of severe
in-hospital complications including shock and death were similar in the two
groups (P=0.93). Physical triggers, acute neurologic or psychiatric diseases,
high troponin levels, and a low ejection fraction on admission were independent
predictors for in-hospital complications. During long-term follow-up, the rate
of major adverse cardiac and cerebrovascular events was 9.9% per patient-year,
and the rate of death was 5.6% per patient-year.
Conclusions
Patients with
takotsubo cardiomyopathy had a higher prevalence of neurologic or psychiatric
disorders than did those with an acute coronary syndrome. This condition
represents an acute heart failure syndrome with substantial morbidity and
mortality.
8. Falls and Implementation of NEXUS in the Elderly (The FINE
Study)
Denver D, et
al. J Emerg Med. 2015;49:294-300.
Background
The incidence
of cervical spine injuries (CSI) in people over 65 years of age from low-energy
mechanisms is far greater than in younger populations. Algorithms and decision
rules exist for selection of trauma patients requiring cervical spine imaging.
Objectives
To determine
the validity of the NEXUS criteria in the elderly population with low-mechanism
injuries.
Methods
We
prospectively conducted computed tomography (CT) imaging in patients over 65
years of age presenting with fall from standing height or less to rule out
predefined clinically significant CSI. Eligible patients were prospectively
categorized into NEXUS positive or negative.
Results
There were
169 patients included in the final analyses. One hundred twenty (71%) patients
in the cohort were classified as “NEXUS positive.” Eleven patients (6.5% of the
cohort) had CSI detected on CT imaging of the cervical spine. Nine patients had
clinically significant CSI. The NEXUS decision instrument demonstrated 88.9%
sensitivity (50.7–99.4%) and 98% negative predictive value (NPV) (87.8–99.9%)
in detecting clinically significant CSI. The NEXUS decision instrument
demonstrated 81.8% sensitivity (47.8–96.8%) and 95.9% NPV (84.9–99.3%) in
detecting any CSI.
Conclusion
In our study,
the NEXUS decision instrument was not a valid tool to rule out imaging for
patients over 65 years of age presenting after a fall from standing height or
less. We advocate the liberal use of CT imaging of the cervical spine in this
cohort of patients to rule out cervical spine injury.
9. On the nature of work
A. Rethinking Work
By BARRY
SCHWARTZ. New York Times. AUG. 28, 2015
HOW satisfied are we with our jobs?
Gallup
regularly polls workers around the world to find out. Its survey last year
found that almost 90 percent of workers were either “not engaged” with or
“actively disengaged” from their jobs. Think about that: Nine out of 10 workers
spend half their waking lives doing things they don’t really want to do in
places they don’t particularly want to be.
Why? One
possibility is that it’s just human nature to dislike work. This was the view
of Adam Smith, the father of industrial capitalism, who felt that people were
naturally lazy and would work only for pay. “It is the interest of every man,”
he wrote in 1776 in “The Wealth of Nations,” “to live as much at his ease as he
can.”
This idea has
been enormously influential. About a century later, it helped shape the
scientific management movement, which created systems of manufacture that
minimized the need for skill and close attention — things that lazy, pay-driven
workers could not be expected to have.
Today, in
factories, offices and other workplaces, the details may be different but the
overall situation is the same: Work is structured on the assumption that we do
it only because we have to. The call center employee is monitored to ensure
that he ends each call quickly. The office worker’s keystrokes are overseen to
guarantee productivity.
I think that
this cynical and pessimistic approach to work is entirely backward. It is
making us dissatisfied with our jobs — and it is also making us worse at them.
For our sakes, and for the sakes of those who employ us, things need to change.
To start
with, I don’t think most people recognize themselves in Adam Smith’s
description of wage-driven idlers. Of course, we care about our wages, and we
wouldn’t work without them. But we care about more than money. We want work
that is challenging and engaging, that enables us to exercise some discretion
and control over what we do, and that provides us opportunities to learn and
grow. We want to work with colleagues we respect and with supervisors who
respect us. Most of all, we want work that is meaningful — that makes a
difference to other people and thus ennobles us in at least some small way.
We want these
things so much that we may even be willing to take home a thinner pay envelope
to get them. Lawyers leave white-shoe firms to work with the underclass and
underserved. Doctors abandon cushy practices to work in clinics that serve
poorer areas. Wall Street analysts move to Washington to work as economic
advisers in government.
You might
object that those are examples of professionals — people who have the financial
security to care about more than just their paychecks and the privilege of
working in fields in which it is possible to find meaning and personal
satisfaction. What about the janitor? The phone solicitor? The hairdresser? The
fast-food worker?
I submit that
they, too, are looking for something more than wages. About 15 years ago, the
Yale organizational behavior professor Amy Wrzesniewski and colleagues studied
custodians in a major academic hospital. Though the custodians’ official job
duties never even mentioned other human beings, many of them viewed their work
as including doing whatever they could to comfort patients and their families
and to assist the professional staff members with patient care. They would joke
with patients, calm them down so that nurses could insert IVs, even dance for
them. They would help family members of patients find their way around the
hospital…
B. Time in the bank: A Stanford plan to save doctors from
burnout
By Brigid
Schulte, Washington Post. 2015 August 20
PALO ALTO,
Calif. — It was just before noon on a recent Friday when Greg Gilbert, an
emergency room physician at Stanford Hospital, made it home from another of
what would be six overnight shifts in a row. Bleary-eyed and hungry, the divorced
single dad was thinking about how to squeeze in a nap before it was time to
pick up his three kids from his ex later that afternoon.
He spied a
cardboard box from Blue Apron, which delivers all the makings of a home-cooked
meal, and a black bag from the Munchery, with gourmet ready-made meals, waiting
for him on his front porch and cracked a weary smile. They meant he’d have
grilled flat iron steak salad for lunch, instead of his usual fast-food burger.
And for dinner, he wouldn’t have to think of what to make or go to the grocery
store but could just cook what was in the box and have time to play with the
kids.
All of it is
courtesy of the Stanford Department of Emergency Medicine. As was Gilbert’s
freshly cleaned condo, the gift cards he’d given his assistant to thank her for
her work, and the life coach he’s worked with to find better balance in his
life.
“This gives
me more bandwidth at work,” Gilbert said. “And because I can hang out with my
kids and not be exhausted all the time, I’m able to be the kind of parent I’d
always hoped to be.”
The meals,
housecleaning and a host of other services — babysitting, elder care, movie
tickets, grant writing help, handyman services, dry cleaning pickup, speech
training, Web support and more — are part of a groundbreaking new “time
banking” program aimed to ease work-life conflicts for the emergency medicine
faculty.
Doctors can
“bank” the time they spend doing the often-unappreciated work of mentoring,
serving on committees, covering colleagues’ shifts on short notice or deploying
in emergencies, and earn credits to use for work or home-related services.
The simple
idea is aimed at addressing a complex challenge: Doctors, on average, work 10
hours more a week than other professionals, with nearly 40 percent working 60
hours or more, according to a 2012 study published in the Archives of Internal
Medicine.
It found that
“an alarming” 1 in 2 physicians report at least one symptom of burnout and that
they’re twice as dissatisfied with their work-life balance than those in other
professions. Within 10 years of joining an academic medical faculty, 5 of every
10 doctors leave, and four leave academic medicine entirely.
And that is
just as concerns about a coming physician shortage are reaching a fever pitch.
The Association of American Medical Colleges projects a shortfall of as many as
90,000 physicians by 2025 as doctors retire, aging baby boomers need more care
and mandates of the Affordable Care Act kick in.
Stanford’s
time bank, part of a two-year, $250,000 pilot funded largely by the Sloan
Foundation, showed big increases in job satisfaction, work-life balance and
collegiality, in addition to a greater number of research grants applied for
and a higher approval rate than Stanford faculty not in the pilot…
The rest of
the essay: http://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/
10. Images in Clinical Practice
Man with
History of Multiple Abscesses
Related
discussion: Probing the Utility of the Rectal Examination
Elderly Woman
Presenting After a Collapse
A Child with
Gross Hematuria
Single Bubble
— Pyloric Atresia
Gastric
Pneumatosis
11. A RCT of IV Haloperidol vs. IV Metoclopramide for Acute
Migraine Therapy in the ED
Gaffigan ME,
et al. J Emerg Med 2015;49:326-334.
Background
Emergency
Department (ED) headache patients are commonly treated with neuroleptic
antiemetics like metoclopramide. Haloperidol has been shown to be effective for
migraine treatment.
Study
Objective
Our study
compared the use of metoclopramide vs. haloperidol to treat ED migraine
patients.
Methods
A
prospective, double-blinded, randomized control trial of 64 adults aged 18–50
years with migraine headache and no recognized risks for QT-prolongation. Haloperidol
5 mg or metoclopramide 10 mg was given intravenously after 25 mg
diphenhydramine. Pain, nausea, restlessness (akathisia), and sedation were
assessed with 100-mm visual analog scales (VAS) at baseline and every 20 min,
to a maximum of 80 min. The need for rescue medications, side effects, and
subject satisfaction were recorded. QTc intervals were measured prior to and
after treatment. Follow-up calls after 48 h assessed satisfaction and recurrent
or persistent symptoms.
Results
Thirty-one
subjects received haloperidol, 33 metoclopramide. The groups were similar on
all VAS measurements, side effects, and in their satisfaction with therapy.
Pain relief averaged 53 mm VAS over both groups, with equal times to maximum
improvement. Subjects receiving haloperidol required rescue medication
significantly less often (3% vs. 24%, p less than 0.02). Mean QTcs were equal
and normal in the two groups and did not change after treatment. In telephone
follow-up, 90% of subjects contacted were “happy with the medication” they had
received, with haloperidol-treated subjects experiencing more restlessness (43%
vs. 10%).
Conclusions
Intravenous
haloperidol is as safe and effective as metoclopramide for the ED treatment of
migraine headaches, with less frequent need for rescue medications.
12. Perioperative Bridging Anticoagulation in Patients with AF
Background It
is uncertain whether bridging anticoagulation is necessary for patients with
atrial fibrillation who need an interruption in warfarin treatment for an
elective operation or other elective invasive procedure. We hypothesized that
forgoing bridging anticoagulation would be noninferior to bridging with
low-molecular-weight heparin for the prevention of perioperative arterial
thromboembolism and would be superior to bridging with respect to major
bleeding.
Methods We
performed a randomized, double-blind, placebo-controlled trial in which, after
perioperative interruption of warfarin therapy, patients were randomly assigned
to receive bridging anticoagulation therapy with low-molecular-weight heparin
(100 IU of dalteparin per kilogram of body weight) or matching placebo
administered subcutaneously twice daily, from 3 days before the procedure until
24 hours before the procedure and then for 5 to 10 days after the procedure.
Warfarin treatment was stopped 5 days before the procedure and was resumed
within 24 hours after the procedure. Follow-up of patients continued for 30
days after the procedure. The primary outcomes were arterial thromboembolism
(stroke, systemic embolism, or transient ischemic attack) and major bleeding.
Results In
total, 1884 patients were enrolled, with 950 assigned to receive no bridging
therapy and 934 assigned to receive bridging therapy. The incidence of arterial
thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging
group (risk difference, 0.1 percentage points; 95% confidence interval [CI],
-0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was
1.3% in the no-bridging group and 3.2% in the bridging group (relative risk,
0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).
Conclusions
In patients with atrial fibrillation who had warfarin treatment interrupted for
an elective operation or other elective invasive procedure, forgoing bridging
anticoagulation was noninferior to perioperative bridging with
low-molecular-weight heparin for the prevention of arterial thromboembolism and
decreased the risk of major bleeding.
13. Ann Emerg Med Reviews
A. What Is the Clinical Utility of
Bedside US in the Diagnosis of Acute Cardiogenic Pulmonary Edema in the
Undifferentiated Dyspneic Patient?
Summary: In
patients with a moderate to high pretest probability of acute cardiogenic
pulmonary edema, sonographic B-lines help to confirm the diagnosis. In patients
with a low pretest probability, a normal lung ultrasonographic result nearly
excludes cardiogenic pulmonary edema.
B. Does Colchicine Improve Pain in an
Acute Gout Flare?
Summary: Low-quality
evidence suggests that both high- and low-dose colchicine decreases pain in
acute gout flares; however, high-dose regimens are associated with more
frequent adverse effects.
14. Wound Care of Pretibial Thin-skin Lacerations with the
Combined Use of Sterile Adhesive Strips and Sutures
Andreana L,
et al. J Emerg Med 2015;49:345-346.
Elderly
patients and patients chronically treated with corticosteroids often have thin
and inelastic skin. Traumatic skin lacerations, especially of the pretibial
area, are particularly difficult to treat in these patients, due to skin
retraction and fragility.
In a recent
publication, Davis et al. described a technique combining the use of the
Steri-strip™ (3M, St. Paul, MN) and simple suture ( Figure 1A) for wound care
on thin skin, providing an acceptable opposition of skin edges and reducing the
risk of suture cutting through the tissue (1).
We aim to
describe a different technique that may be more appropriate for managing
pretibial lacerations and that has potential advantages compared to the one by
Davis et al (1).
This specific
technique was proposed for the first time in a prospective observational study
published in 2001 (2). The study included 147 patients with pretibial
lacerations and showed an average healing time of 26 days for flap lacerations
and of only 16 days for linear lacerations(2).
After wound
disinfection and debridement, sterile adhesive tape is applied parallel with
both sides of the wound margins. Better opposition of wound edges may be
obtained using a simple suture carefully applied through the adhesive strip.
The most
important and difficult part of the procedure is the careful manual layout of
the skin, eventually helped by sterile gauze. This technique will enable
maximal tissue stretching prior to sterile adhesive application, as well as
prevention of blistering and folding of the skin. Wound edges are then
stretched with the application of a suture across the laceration through the
adhesive strip, applying additional tension on the skin, while the strip
protects the skin from the suture cutting (Figure 1B, interrupted).
To have
additional tension relief, the same procedure can be performed on a large flap
itself, this time by inserting the suture through the adhesive strip deeply to
the fascia or muscle (Figure 1B, immobilizing).
The discussed
technique tries to overcome the two main elements causing problems that arise
during attempted closure of pretibial thin-skin lacerations: suture cutting
through the skin and optimal wound-edge opposition.
Compared to
the technique described by Davis et al., where suture is just reinforcing the
adhesive strip, the above-mentioned technique results in additional skin-margin
opposition (1, 2). The parallel application of the strips offers more tension
and better adhesion of the wound edge. It is a quick and easy technique that
also can be used in other body areas when difficult skin-edge opposition is
expected.
References:
2. Silk J.
Injury 2001;32:373-376.
15. Outcomes of Daytime Procedures Performed by Attending
Surgeons after Night Work
Govindarajan
A, et al. N Engl J Med 2015; 373:845-853.
BACKGROUND
Sleep loss in
attending physicians has an unclear effect on patient outcomes. In this study,
we examined the effect of medical care provided by physicians after midnight on
the outcomes of their scheduled elective procedures performed during the day.
METHODS
We conducted
a population-based, retrospective, matched-cohort study in Ontario, Canada.
Patients undergoing 1 of 12 elective daytime procedures performed by a
physician who had treated patients from midnight to 7 a.m. were matched in a
1:1 ratio to patients undergoing the same procedure by the same physician on a
day when the physician had not treated patients after midnight. Outcomes
included death, readmission, complications, length of stay, and procedure duration.
We used generalized estimating equations to compare outcomes between patient
groups.
RESULTS
We included
38,978 patients, treated by 1448 physicians, in the study, of whom 40.6% were
treated at an academic center. We found no significant difference in the
primary outcome (death, readmission, or complication) between patients who
underwent a daytime procedure performed by a physician who had provided patient
care after midnight and those who underwent a procedure performed by a
physician who had not treated patients after midnight (22.2% and 22.4%,
respectively; P=0.66; adjusted odds ratio, 0.99; 95% confidence interval, 0.95
to 1.03). We also found no significant difference in outcomes after
stratification for academic versus nonacademic center, physician’s age, or type
of procedure. Secondary analyses revealed no significant difference between
patient groups in length of stay or procedure duration.
CONCLUSIONS
Overall, the
risks of adverse outcomes of elective daytime procedures were similar whether
or not the physician had provided medical services the previous night. (Funded
by the University of Toronto Dean’s Fund and others.)
16. Comparison of Clinician Suspicion vs a Clinical Prediction
Rule in Identifying Children at Risk for Intra-abdominal Injuries after Blunt
Torso Trauma.
Mahajan P, et
al. for PECARN. Acad Emerg Med. 2015 Aug 20 [Epub ahead of print].
OBJECTIVES:
Emergency department (ED) identification and radiographic evaluation of
children with intra-abdominal injuries who need acute intervention can be
challenging. To date, it is unclear if a clinical prediction rule is superior
to unstructured clinician judgment in identifying these children. The objective
of this study was to compare the test characteristics of clinician suspicion with
a derived clinical prediction rule to identify children at risk of
intra-abdominal injuries undergoing acute intervention following blunt torso
trauma.
METHODS: This
was a planned subanalysis of a prospective, multicenter observational study of
children (less than 18 years old) with blunt torso trauma conducted in 20 EDs
in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians
documented their suspicion for the presence of intra-abdominal injuries needing
acute intervention as less than 1, 1 to 5, 6 to 10, 11 to 50, or over 50% prior
to knowledge of abdominal computed tomography (CT) scanning (if performed).
Intra-abdominal injuries undergoing acute intervention were defined by a
therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal
hemorrhage, or intravenous fluid administration for 2 or more days in those
with pancreatic or gastrointestinal injuries. Patients were considered to be
positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion
≥ 1% was compared to the presence of any variable in the prediction rule for
identifying children with intra-abdominal injuries undergoing acute
intervention.
RESULTS:
Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled
in the parent study. Intra-abdominal injuries undergoing acute intervention
were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED
in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled
patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI =
32% to 34%) patients with clinician suspicion less than 1%. Sensitivity of the
prediction rule for intra-abdominal injuries undergoing acute intervention (197
of 203; 97.0%, 95% CI = 93.7% to 98.9%) was higher than that of clinician
suspicion ≥1% (168 of 203; 82.8%, 95% CI = 76.9% to 87.7%; difference = 14.2%,
95% CI = 8.6% to 20.0%). Specificity of the prediction rule (4,979 of the
11,716; 42.5%, 95% CI = 41.6% to 43.4%), however, was lower than that of
clinician suspicion (9,217 of the 11,716, 78.7%, 95% CI = 77.9% to 79.4%;
difference = -36.2%, 95% CI = -37.3% to -35.0%). Thirty-five (0.4%, 95% CI =
0.3% to 0.5%) patients with clinician suspicion less than 1% had
intra-abdominal injuries that underwent acute intervention.
CONCLUSIONS:
The derived clinical prediction rule had a significantly higher sensitivity,
but lower specificity, than clinician suspicion for identifying children with
intra-abdominal injuries undergoing acute intervention. The higher specificity
of clinician suspicion, however, did not translate into clinical practice, as
clinicians frequently obtained abdominal CT scans in patients they considered
very low risk. If validated, this prediction rule can assist in clinical
decision-making around abdominal CT use in children with blunt torso trauma.
17. Can your state’s ED nurses administer deep sedation meds?
They can now in New Mexico. Here’s how it came about.
Controversy Surrounds
Nurse-Administered Emerg Physician– Supervised Sedation in the ED: New Mexico
Registered Nurse Board Issues New Policy
Jan Greene.
Ann Emerg Med 2015;66:A18-20.
Registered
nurses (RNs) in New Mexico now have clear authorization from the state nursing
board to administer sedating drugs such as propofol and ketamine under the
supervision of emergency physicians, as long as they have appropriate training.
The change in
state policy was championed by emergency physician Eric Ketcham, MD, working in
close concert with emergency nurse organizations. They advocated for more than
2 years against strong opposition from anesthesiology representatives who
argued that only those with training in anesthesiology should be giving
sedation.
Emergency
nurses in New Mexico say that the rule change simply codifies actual practice
in emergency departments (EDs), where nurses not only have the expertise to
administer sedation but also the training to recognize and deal with a
patient’s adverse reaction to the drug.
“Imagine if
the physician was there setting a broken leg and the patient had the need for
more sedative,” said Kevin McFarlane, RN, MSN, president of the New Mexico
Emergency Nurses Association. “The physician would have to stop what he is
doing to administer the sedative. Typically, it is the nurse who gives the
medications.”
Advocates of
the change argue that it’s safer to use sedatives such as propofol for
procedural sedation in the ED because it is better tolerated and wears off more
quickly than other drugs.
“The
alternative is old-school sedation with morphine or Versed, which is not the
optimal combination and leads to a longer recovery period for the patient,” Mr.
McFarlane said.
But
anesthesiologists also cite patient safety in their opposition to giving RNs
easier access to sedatives. For more than a decade, anesthesiologists have
watched propofol gain wider use in outpatient settings such as gastroenterology
clinics. The American Society of Anesthesiologists (ASA) has drawn a clear line
against nonanesthesiologists administering intravenous sedation in any setting,
ED or outpatient clinic, says ASA President J.P. Abenstein, MD. He is not
swayed by the argument that the ED, unlike a physician’s office or clinic, is
well versed in quick rescue of patients with an airway emergency.
“Every
procedural suite that wants to go off on its own has started out saying, ‘You
don’t understand; we’re different,’” Dr. Abenstein said. “They all think they
are uniquely competent to do what they do. We stick by the science and our
experience.”
The
profession of anesthesiology has worked hard to reduce adverse reactions to
sedatives and as a result may have left the impression “that anesthesia and
deep sedation is so easy anyone can do it,” Dr. Abenstein said. “We’re very
leery of these trends. Propofol and ketamine are particularly potent, and how
individual patients react to even small doses of the medication can be
unpredictable. You can be doing a procedure with sedation, and it can easily
get out of control.”
The
anesthesiology group stands by its contention that even in an ED setting,
procedural sedation should be managed by an anesthesiologist or a certified
registered nurse anesthetist (CRNA).
“We get
called to the emergency room to rescue airways” in procedures managed by other
specialties, Dr. Abenstein said. He questions the efforts of emergency
physicians to allow RNs to use sedatives. “The emergency physicians do a
fabulous job, but in my opinion they are pushing the envelope [seeking RN
access], and I would recommend against it.”
Dr. Ketcham,
who is medical director of emergency medicine at San Juan Regional Medical
Center in Farmington, NM, argues that there is no safety concern with the 1
physician, 1 nurse model used in many EDs.
“We wanted to
get policies written to support modern practice,” he said. “This is just about
good practice, and good patient safety.”
Dr. Ketcham
compiled an exhaustive literature review to bolster the case for regulatory
change; it is summarized in an article in the October 2013 Emergency Nurse.1
In the article,
Dr. Ketcham—along with Frances Lopez Bushnell, RN, a nursing professor at the
University of New Mexico, and Cindy Ketcham, EdD, CCHP-RN, clinical director of
patient care services at San Juan Regional Medical Center—offers evidence
largely from research on the use of specific sedatives by emergency
nurse/physician combos.
The article
argues there is no evidence in the literature of poor patient outcomes in these
scenarios. “The availability of [physician-directed nurse-administered
procedural sedation] dramatically reduces the anxiety and pain of patients
undergoing a range of procedures including abscess drainage, bronchoscopy,
cardiac instrumentation, cardioversion, chest tube placement endoscopy, and
fracture and dislocation reduction.”
Ms. Bushnell
said emergency nurses, working with emergency physicians, are capable of
administering sedatives and recognizing adverse patient reactions. But there’s
also the practical issue of staffing EDs with anesthesiologists or CRNAs.
“That would
be ideal, but they don’t exist, and they don’t want to work [those hours],” Ms.
Bushnell said. “Sure, we’d use them if we could find them, and we could afford
them.”
Mr. McFarlane
argues it’s just not realistic to have anesthesiology coverage of EDs, and
particularly not in rural areas.
“They just
don’t have an anesthesiologist on site 24/7, if at all,” he said.
The rest of
the article (full-text free): http://www.annemergmed.com/article/S0196-0644(15)00421-7/fulltext
Related
study: Vinson DR, et al. The safety of one doc/one nurse sedation (full-text
free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582522/
18. Here’s How Doctors Get through Their Day
Sanaz Majd,
MD, Business Insider. August 14, 2015
I will never
forget a particularly unsettling incident in the operating room while I was a
young and impressionable medical student on my first surgery rotation:
Attending
Surgeon: "Intern, what’s the story on this patient?”
Resident
Intern (replies sheepishly): "This patient is a 51-year-old with a left
breast lump, and 17 out of 20 lymph nodes positive for cancer, returning to the
operating room.”
Attending Surgeon
(in a very matter-of-fact tone): “Oh, she’s F-----.”
It felt as
though the room temperature fell below zero for a moment — not because the OR
is preserved like a freezer, but because the surgeon’s response seemed so cold.
The intern fought hard not to appear uncomfortable in light of that deadened,
crude response. But because medical school and residency have constructed a
strict hierarchy, not unlike the military, there was no way that this intern
was going to speak up in return — despite having a parent that also suffered
from breast cancer.
At the time,
being so low on the totem pole, I found myself peering over the sterile field
in the corner and thinking:
A. I’m so
glad surgery is not my field of interest. (Sorry, surgeons, but some of you can
be pretty uninviting.)
B. How in the
world do physicians reach this surprising level of stoicism?
Last week, I
discussed how challenging it can be to say goodbye to patients, despite this
unnerving feeling that we as physicians are not supposed to allow ourselves to
feel for them. Why is that? Why do we seemingly model our behavior after
vampires? And how can we effectively treat patients if we don’t display
compassion?
Primary care
doctors are stereotypically more of the warm and fuzzy kind (relatively speaking),
although I have met some very down-to-earth and compassionate specialists.
However, there is still an underlying, unspoken culture among physicians across
all specialties, including primary care, that frowns upon the expression of
emotions in the medical field.
In some
circles of health professionals, showing emotion is simply a big no-no
As a patient,
you may be curious about how this trend of stoicism evolved. When were
physicians first taught of this unspoken ideology, which encouraged them not to
feel?
I can recall
as far back as my Gross Anatomy class while in medical school. In the early
stages of the course, I was part of a small group of three or four eager
medical students forced to confront our first real deceased human.
There was no
denying how real he initially felt to us. He had a tattoo on his arm of
someone's name, and it was clear he cared for that person. He had numerous
surgical scars, more than we could count. Who was this man? How did he come to
leave this world? Who did he leave behind? My peers and I contemplated the
answers to these mysterious questions, even though we'd never discover their
answers, while respectfully dissecting our mysterious cadaver.
When the
course initially began, the medical school required its students to attend a
“support group” of sorts. They understood the potentially emotional transition
that may occur for us students as we likely faced death for the first time in
the flesh.
I remember
the support group instructor seeking our candor as he asked, “How are you all
emotionally dealing with dissecting a cadaver?” I was relieved to hear this
question. And asking it was appropriate and very professional on the faculty’s
part, a way of addressing our internal struggles head-on. I have always been grateful
for my education at Drexel University, and this is one of the numerous reasons
why.
In my
conversations with other medical students, a few did reveal their emotional
struggles (whether it was spiritual, religious, or personal) with encountering
a corpse face to face. However, when the instructor asked for our personal
perspectives, I was surprised to find that no one voiced their thoughts, their
unsettling feelings about working with cadavers for the first time.
My classmates
were afraid to discuss their emotions in an atmosphere where “sharing your
feelings” is typically discouraged, despite how much our instructor prodded.
How can you blame them?
Finally,
there was one student who spoke up, and whose words I will never forget. He
said that he sought to view the cadaver as an “object,” so that he could
complete the dissection tasks. But it was only when he viewed the cadaver’s
hands that this person became "real" to him. “You do a lot with your
hands,” I remember him saying.
He, too, was
struggling to resist those emotions…
19. Opioid Prescribing in a Cross Section of US EDs.
Hoppe JA, et
al, and the Prescribing Opioids Safely in the Emergency Department (POSED)
Study Investigators. Ann Emerg Med. 2015;66(3): 253–259.e1
STUDY
OBJECTIVE: Opioid pain reliever prescribing at emergency department (ED)
discharge has increased in the past decade but specific prescription details
are lacking. Previous ED opioid pain reliever prescribing estimates relied on
national survey extrapolation or prescription databases. The main goal of this
study is to use a research consortium to analyze the characteristics of
patients and opioid prescriptions, using a national sample of ED patients. We
also aim to examine the indications for opioid pain reliever prescribing,
characteristics of opioids prescribed both in the ED and at discharge, and
characteristics of patients who received opioid pain relievers compared with
those who did not.
METHODS: This
observational, multicenter, retrospective, cohort study assessed opioid pain
reliever prescribing to consecutive patients presenting to the consortium EDs
during 1 week in October 2012. The consortium study sites consisted of 19 EDs
representing 1.4 million annual visits, varied geographically, and were
predominantly academic centers. Medical records of all patients aged 18 to 90
years and discharged with an opioid pain reliever (excluding tramadol) were
individually abstracted by standardized chart review by investigators for
detailed analysis. Descriptive statistics were generated.
RESULTS:
During the study week, 27,516 patient visits were evaluated in the consortium
EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients
and 17.0% of discharged patients) received an opioid pain reliever
prescription. For patients prescribed an opioid pain reliever, mean age was 41
years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was
7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever
prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity
fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers
prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%).
Greater than 99% of pain relievers were immediate release and 90.0% were
combination preparations, and the mean and median number of pills was 16.6 (SD
7.6) and 15 (interquartile range 12 to 20), respectively.
CONCLUSION:
In a study of ED patients treated during a single week across the country, 17%
of discharged patients were prescribed opioid pain relievers. The majority of
the prescriptions had small pill counts and almost exclusively
immediate-release formulations.
20. Time to Adopt High-Flow Oxygen Delivery Systems for
Emergency AW Procedures
High-flow
oxygen delivery via nasal cannula improved oxygen saturations and prevented
desaturation in patients with difficult airways undergoing flexible
bronchoscopic intubation.
Badiger S et
al. Br J Anaesth 2015 Aug 7 [Epub ahead of print].
BACKGROUND: Awake
fibre-optic intubation is a widely practised technique for anticipated
difficult airway management. Despite the administration of supplemental oxygen
during the procedure, patients are still at risk of hypoxia because of the
effects of sedation, local anaesthesia, procedural complications, and the presence
of co-morbidities. Traditionally used oxygen-delivery devices are low flow, and
most do not have a sufficient reservoir or allow adequate fresh gas flow to
meet the patient's peak inspiratory flow rate, nor provide an adequate
fractional inspired oxygen concentration to prevent desaturation should
complications arise.
METHODS: A
prospective observational study was conducted using a high-flow humidified
transnasal oxygen-delivery system during awake fibre-optic intubation in 50
patients with anticipated difficult airways.
RESULTS: There
were no episodes of desaturation or hypercapnia using the high-flow system, and
in all patients the oxygen saturation improved above baseline values, despite
one instance of apnoea resulting from over-sedation. All patients reported a
comfortable experience using the device.
CONCLUSIONS: The
high-flow nasal oxygen-delivery system improves oxygenation saturation,
decreases the risk of desaturation during the procedure, and potentially,
optimizes conditions for awake fibre-optic intubation. The soft nasal cannulae
uniquely allow continuous oxygenation and simultaneous passage of the
fibrescope and tracheal tube. The safety of the procedure may be increased,
because any obstruction, hypoventilation, or periods of apnoea that may arise
may be tolerated for longer, allowing more time to achieve ventilation in an
optimally oxygenated patient.
21. Regional Nerve Blocks for Hip and Femoral Neck Fractures in
the ED: A Systematic Review.
Ritcey B, et
al. CJEM. 2015 Sep 2 [Epub ahead of print].
OBJECTIVES: Hip
and femoral neck fractures are common in elderly patients, who are at an
increased risk of complications if their pain is suboptimally managed. This
systematic review seeks to determine if regional nerve blocks reduce pain,
reduce the need for parenteral opiates, and reduce complications, compared to
standard pain management with opiates, acetaminophen, or NSAIDs. Data sources
Systematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register
of Controlled Trials found 401 articles, of which nine were selected for
inclusion. Study selection Randomized controlled trials including adult
patients with a hip or femoral neck fracture (Population) who had a 3-in-1
femoral nerve block, traditional femoral nerve block, or fascia iliaca
compartment block performed preoperatively (Intervention). Comparison must have
been made with standard pain management with opiates, acetaminophen, or NSAIDs
(Comparison) and outcomes must have included pain score reduction (Outcome).
Data synthesis Eight out of nine studies concluded pain scores were improved
with the regional nerve block compared to standard pain management. A
significant reduction in parenteral opiate use was seen in five out of six
studies. No patients suffered life-threatening complications related to the
nerve block; however, more minor complications were under-reported. Most of the
studies were at a moderate to high risk of bias.
CONCLUSIONS: Regional
nerve blocks for hip and femoral neck fractures have a benefit in reducing pain
and the need for IV opiates. The use of these blocks can be recommended for
these patients. Further high-quality randomized controlled trials are required.
22. Radiology's Overdiagnosis Problem
Saurabh Jha,
MBBS, MRCS; Tricia Ward. Medscape Radiology. August 21, 2015
Journal Editor's
Note: Saurabh Jha, MBBS, MRCS, guest-edited the August 2015 print issue of
Academic Radiology devoted to overdiagnosis in radiology. Below is our
interview with Dr Jha about his goals in compiling this special edition of the
journal.
Medscape: Why did you want to devote
an entire issue of a radiology journal to the topic of overdiagnosis?
Dr Jha: My
intention was to get the issue to the forefront in radiology. One of the
pioneers who drew attention to this problem was the radiologist William Black,
in a famous essay with Welch published in the New England Journal of
Medicine.[1] But since then, much of the discussion on this topic has come from
outside radiology.
I spoke to
the editor of Academic Radiology, Sam Baum, who has had personal experience
with the healthcare system and feels that this is a topic that needs to be
highlighted by radiologists primarily. The important thing for radiologists to
do is to acknowledge that we are in the thick of overdiagnosis, whether we like
it or not. If we are involved in diagnosing, we are involved in overdiagnosing
as well.
To get the
broader radiology community to acknowledge this, it was important for a
peer-reviewed publication to come out on the topic, and Academic Radiology
delivered.
Medscape: You contributed some
perspective articles[2,3] to the journal in which you discuss over diagnosis vs
false-positives; can you expand on this for our audience?
Dr Jha: With
overdiagnosis, we are lowering the bar for what is considered disease. A
false-positive is when you call something a disease that is not really a
disease. A false-positive is a limitation of the test, whereas overdiagnosis is
"exuberance" of the test, so to speak.
The best
example is with pulmonary embolism (PE). As we go from the main pulmonary
artery to the subsegmental pulmonary arteries, which are very small, you could
diagnose a false-positive subsegmental PE—you called it, but it wasn't really
there. Or you could have a true subsegmental PE, but that is an overdiagnosis
because what you are calling disease is of such little significance that it is
equivalent to cracking a small nut with a sledgehammer. The sledgehammer can do
more harm to the nut itself. It can be an overreaction to a problem that is
quiescent. In this case, the true-positive is in fact an overdiagnosis.
False-positives
are a different entity, but the two are linked. They both lead to over-medicalization.
If you have a very big PE in the main pulmonary artery (a submassive PE) that
is catastrophic, it can lead to death, whereas with a smaller subsegmental PE,
you could cause more problems by treating it with anticoagulation vs leaving it
alone. The specificity of the test is a lot lower for these smaller arteries
compared with the bigger ones, so as the tendency toward overdiagnosing
increases, so too does the number of false-positives.
Medscape: Do you think the problems is
that radiologists are looking for more disease (the more you look, the more you
find), or is it that better technologies allow you to see things than you could
not see before (such as a very small subsegmental PE)?
Dr Jha: It's
a combination of both. We certainly are looking for more. With PE or example,
many people who come into the emergency department or other places have a blood
test for D-dimer, and when the blood test is positive, they are categorized as
having suspected PE. Patients who have cancer undergo more follow-up imaging,
and technologies have improved.
Problems
occur when we find something that we don't know anything about. Why don't we
just ignore it? Why do we feel compelled to overtreat? That bias is the biggest
driver of overdiagnosis and overtreatment. Just because a new technology
enables me to see something new, it doesn't mean that I should start jumping
off the building every time I encounter something I'm uncertain about. Why
don't I just ignore it?
I think the
best analogy comes from the legal system. They asked, "Is it better that
10 guilty men go free or that one innocent man is sent to the gallows?" In
effect, they have said, "We know that information isn't perfect; we know
there is a chance we are going to err. So we are going to err toward letting
the guilty men go free rather than letting the innocent get strung up."
The burden of proof is to prove that someone is guilty, not to prove that one
is innocent.
In medicine,
we have to prove that somebody is healthy rather than prove that they are
diseased. In effect, we have said, "It is better that 10 people who are
not going to be harmed by subsegmental PE get overtreated with anticoagulation
(and possibly bleed) than it is that one person gets undertreated and harmed by
the PE." That is a medical/ethical issue that isn't really explained by
the incentive system. I think it goes beyond that.
Medscape: Do you think part of it is a
fear of litigation? That is, missing a diagnosis is seen as a mistake, whereas
overtreating wouldn't be seen as an error if it's well intentioned?
Dr Jha: The
key phrase is "well intentioned." We think
"well-intentioned" means erring toward, "This subsegmental PE
could harm you," as opposed to erring toward the fact that I am going to
put you on anticoagulation, which could harm you.
I certainly
think the litigation culture is a large part of it. I sometimes wonder whether
our medical culture drives the litigation culture. I'm sure they are both
recursive, but if I were to identify what came first, the chicken or the egg, I
would say it's the medical culture.
There is so
much power in hindsight. We feel there is good intention in overtreating. It
means, "I care for you." Whereas if I ignore the subsegmental PE, I
sound flippant. The care and the intervention are so interlinked
psychologically that it is hard to disassociate one from the other. Subtractive
medicine is very hard to propagate culturally; it's very much a can-do culture.
I trained in
the National Health Service in the United Kingdom. I heard surgeons say to the
family that we are not going to intervene, we think it would be useless, a
waste of your time and our time. That is not the culture in the United States.
Mind you,
overdiagnosis is not entirely an American phenomenon. It is predominant in the
United Kingdom. It is predominant in South Korea, where they started screening
ultrasonography for thyroid cancer and found all of these small papillary
carcinomas of the thyroid, which aren't going to do anything.[4] All of these
patients had hemi-thyroidectomies, and so on and so forth.
It's an
incredible waste of money, but also an incredible imposition of morbidity on
people for no good whatsoever. It's like scoring an "own goal" in
soccer, and we keep scoring it.
Medscape: How do you propose reducing
the problem of overdiagnosis and overtreatment? Is this something the
professional societies and academic groups should address?
Dr Jha: We
need to have honesty. Using the subsegmental PE example, we need to stand up
and say that we are overtreating subsegmental PE, because we are overdiagnosing
it. To reduce the overtreatment, we are going to have to stop calling
subsegmental PE and accept that there will be somebody who will be harmed as a
result of that. That is the trade-off.
23. Micro Bits
A. Dustin & Angela Ballard
Podcasts: Tips to a Healthier and Happier Life
1. Is Coffee Good for You?
Dustin & Angela Ballard provide some insight from the medical literature in this latest podcast: http://dballard30.podbean.com/ (Episode #10; 24min)
Dustin & Angela Ballard provide some insight from the medical literature in this latest podcast: http://dballard30.podbean.com/ (Episode #10; 24min)
2. A Delicious New Gateway Drug
(e-cigs)
Dustin &
Angela explore the growing concern about e-cig use by youngsters. Parents be
warned! http://dballard30.podbean.com/ (Episode #11; 24min)
Cf. case
report: Gill N, et al. E-Cigarette Liquid Nicotine Ingestion in a Child: Case
Report and Discussion. CJEM. 2015 Apr 20:1-5. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/25892642
B. Study: Cough and throat clearing
often do not indicate GERD
Study data
from the Medical University of South Carolina showed 8% of patients with both
cough and throat clearing had a positive symptom index for gastroesophageal
reflux disease, compared with 26% of those who had just a cough and 22% of
those with only throat clearing. First author Mustafa Abdul-Hussein said
testing can eliminate patients who do not have GERD before beginning what would
be unneeded therapy. The study was published in the Journal of Clinical
Gastroenterology.
C. Epidural Corticosteroid Injections
for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis
Conclusion: Epidural
corticosteroid injections for radiculopathy were associated with immediate
reductions in pain and function. However, benefits were small and not
sustained, and there was no effect on long-term surgery risk. Limited evidence
suggested no effectiveness for spinal stenosis.
D. Studies: Longer work hours may
increase heart disease, stroke risk
Two reports
in The Lancet that analyzed multiple studies linked working 55 hours a week or
more to a higher risk of heart disease and stroke, compared with a standard
schedule of 35 to 40 hours a week. Paul Wright, M.D., at North Shore University
Hospital in New York said data showed people who work long hours were less
likely to see a physician for a medical evaluation.
E. Group calls for giving foods
containing peanuts to infants at risk of allergy
Infants 4 to
11 months old at high risk of peanut allergies should be given foods that
contain peanuts before they reach age 1, but they should first undergo allergy
tests before being given such foods, according to a recommendation from the
American Academy of Pediatrics. The guidance is in response to a British study,
which showed that at-risk children who ate peanut products as infants
experienced 81% fewer peanut allergies after five years than those who didn't.
The recommendation will be published online in Pediatrics.
F. Study links cardiorespiratory
fitness to risk of AF
A study found
84% of overweight or obese people with atrial fibrillation who had high levels
of cardiorespiratory fitness over four years no longer experienced the
potentially dangerous heartbeat, compared with 76% of those who maintained
adequate fitness levels and 17% in a low fitness group. People who also lost
weight reduced their risk of recurring atrial fibrillation even more,
researchers wrote in the Journal of the American College of Cardiology.
G. Why doctors are prescribing legal
aid for patients in need
PBS Newshour.
September 2
Though
lawyers are often the last people doctors want to see involved in patient care,
across the country many medical systems have begun establishing special legal
partnerships. Lawyers become allies for disadvantaged patients who need help
navigating problems with landlords and insurers. Special correspondent Jackie
Judd reports from Omaha, Nebraska.
H. Physician Prevention of Acute
Kidney Injury
In a
retrospective analysis of 170 hospitalized patients who developed acute kidney
injury during admission, 30% of episodes could have been avoided if physicians
had taken appropriate preventive actions.
I. Study: Ambulance diversion may
increase mortality risk
When
ambulances were diverted to a hospital emergency department farther away, heart
attack patients were almost 10% more likely to die within one year compared
with when ambulances were not diverted, researchers reported in the journal
Health Affairs. The study, which included almost 30,000 Medicare patients in 26
California counties, found patients also were slightly less likely to get
treatments such as angioplasty or coronary artery bypass graft to restore blood
flow, mainly because they were taken to hospitals that had less advanced heart
care technology.
J. 75% of US adults' hearts are aging
faster than they should, CDC study finds
A CDC study
published in Vital Signs found that 75% of Americans have functional heart age
that is older than their chronological age. Functional age is calculated based
on lifestyle and risk information including blood pressure, smoking status, BMI
and diabetes. The heart age of the average man is eight years older than his
chronological age, while for women heart age exceeds chronological age by five
years. The authors say people should learn their functional heart age so they
can then take steps to lower cardiovascular risks.
K. Safety and efficacy of digoxin:
systematic review and meta-analysis of observational and controlled trial data
Digoxin is
associated with a neutral effect on mortality in randomised trials and a lower
rate of admissions to hospital across all study types. Regardless of
statistical analysis, prescription biases limit the value of observational
data.
L. TV viewing increases PE risk
People who
spend at least five hours watching TV daily had a twofold greater risk of
suffering a fatal pulmonary embolism compared with those who spend less than
2.5 hours watching TV daily, according to a study presented at the European
Society of Cardiology meeting. Findings also show that adults under age 60 who
watched five hours a day had up to six times greater risk of a pulmonary
embolism, compared with those who watched less than 2.5 hours, while those who
spent less than five hours but over 2.5 hours watching TV daily had three times
the risk.
M. More parents seek antibiotics to
treat pink eye despite ineffectiveness
A study in
Clinical Pediatrics revealed that parents whose children were given a diagnosis
of "pink eye" were more likely to intend to use antibiotics despite
being told of the drugs' ineffectiveness to treat the symptoms, compared with
those who received a diagnosis of "eye infection." Parents also
thought symptoms of pink eye were more contagious than eye infection and were
less inclined to believe their children could go to child care.
