EMERGENCY MEDICINE UPDATE
MAY 2012
It is May already and I just want to remind you- if you are a resident finishing your residency in June, you should send me an e mail that will continue with you when you finish.
1) Work in an Urban ED? Work in Europe, or Israel? You are going to see smokers even among some of the health care workers. And you can make a difference in your taking the opportunity to warn them not to smoke. This study was done in Camden NJ (Hi Al) and while this is not a popular vacation destination (I am not sure why) it is a place with a lot of smokers. Many folks have no money in Camden although they do have enough money to buy cigarettes (and perhaps other smokable substances). The investigators offered these people to go to a stop smoking clinic and only 43% were interested. They then gave them the price per visit- either 150$- the regular fee, 20$- a reduced fee or 0 $ (no fee) (although not clear to me how they decided who got what fee) It didn't matter much—only one person out of the cohort of 577 patients followed up with the clinic. (AEM 18(6)662). Now I know the same issue of AEM had another smoking article that had a high rate of people agreeing to smoking cessation, but that isn't my experience (ibid 18(6)575). I think we can conclude that many smokers are just happy enough smoking and I am not sure what will motivate them to stop. Let us conclude with what Mark Twain once said: Quitting smoking is the easiest thing in the world. I have done it a thousand times". TAKE HOME MESSAGE: You can mention to smokers the importance of stopping during their visit but cost is not a consideration in whether they make the effort to stop. Willingness is.
2) Can we go a month without mentioning propofol? Propofol is white because it is lipid based- egg lecithin /phosphatide and soy oil. Yet when they gave it to kids with documented egg allergies – even ones with anaphylaxis to eggs- they did well. Well, almost- one kid had a non anaphylactic reaction but he was a very allergic kid to a lot of substances. (Anest Anlag 113(1)140) Still you can't say much about only 28 kids. And no one was in the group who had a soy allergy. But my experience is that allergy is pretty rare. I have never seen it, but let me know if you have. It could be that IgE egg allergy involves a different mechanism and so the patients are not sensitive to lecithin. TAKE HOME MESSAGE: Propofol seems to be safe in egg allergic kids if you already gave it to them. Now I am trying not to get angry but I will get personal and I hope that if Jacki O is reading this he will back me up. This article says that only doctors who are anesthesiologists should administer propofol. Now this brings us back to the dark ages that I had to call an anesthesiologist to get permission to use midazolam for an intubation way back in 1992. (Eur J of Anaes 28(8)580). Now this would probably not bother me as much if the writer was from Europe- I do not know their polices. But the writer is an Israeli. So let me put it this way. Aside from the evidence in the EM literature that shows it's safe in our hands, their restriction of our use of the drug- where we can mange complications much better than them- (most anesthesiologists do not handle emergency airways but rather controlled airways) is frankly none of their business. And it definitely deprives patients of painless and sympathetic care. Prove we use this medication in an unsafe way instead of just crowing how only you – Dr. Perel and pals- know how to use it. Patients should not be in the middle of senseless turf wars. I'll stop here before I blow a head gasket. But I won't stop yet. Another article takes a less aggressive approach- allowing us to at least use ketamine in the ED. But claim that it has a narrow safety window although neither ketamine nor propofol caused any deaths in their series, only adverse respiratory events (what is that?). They bring only one article from an EM journal in their references (Anesthesia 68(8)653). Can't anesthesiologists go back to what they do best- that is raising and lowering tables?
3) I liked this concept and would like to hear from the lawyers that read EMU (yes we do have at least one and to the rest of my readers: you have the right to remain silent. Any thing you say can be and will be used against you. You have the right to representation ….)Informed consent discussions (I am not just talking about forms) are scary and burdensome. Indeed most people do not remember a thing that was explained to them. These authors feel that let's design these for the patients and not the lawyers. Give them what they want to know instead of giving them an overflow of information about extremely rare and reportable consequences of treatment. Answer questions and give them the options. (ibid 113(1)13). I like the idea but indeed the studies they bring to prove their points are very questionable. Maybe we should just ask the patients what they want to know- all the gory details or what is common and how safe the therapy is. Just as an addendum- another article showed that patients who do ask the questions- what are the benefits and harms, what are the chances of harm and what are my options got much more information in patient encounters (Pat Ed Counsel 84(3)379). TAKE HOME MESSAGE: Informed consent forms are tedious for patients. Tell them what risks there really are and what the options are. Now while we are on the subject, non verbal cues are very common in explaining mistakes. Males physicians tend to facial pleasantness to females who were angry than to males who were angry. Female docs tend to smile more and show more attentiveness. All touched the patient family more and also were friendlier. (Pat Ed Counsel 84(3)344). Problem is that this was a simulation, actual cases may be different. TAKE HOME MESSAGE: You will tend to be friendly and less attentive when explaining mistakes. Whether patients fall for it is a different story. And now here is an ethical/legal issue. In the UK it is illegal to willingly pass on an infectious disease. Now this paper discusses a fictional hepatitis B carrier who is a prostitute. What should you do if you were the one to discover the illness? The law doesn't require divulging the information in most countries but ethically you are releasing a very serious health risk back to the streets. I have no clear answers (J Med Ethics 37(10)623) Ken- what do you suggest? Another legal issue that might interest our readers – and you better like legal issues this month (see roundtable below) is can you tell the age of bruises by color. The answer they found here was not and they postulate that this is because hemoglobin metabolism varies between people (Med Sci Law 51(3)170). My only concern with this paper is that the folks evaluating these bruises where "forensic experts" and I am not sure what that means. TAKE HOME MESSAGE: Age of bruises by coloration is not an exact science and can not be depended on.
4) Do you know what the MPV is? Do you ever use it? (I am sure Chris N. does, but I don't) MPV is one of those parameters you get when you do a CBC (not sure why you are still doing CBCs but let's let that rest) that represents mean platelet volume. This can tell us something about platelet activation and as such the Chinese and the Turks did studies to show that this marker can tell about ACS (EMJ 28(7)569) and decompensated CHF mortality (ibid p 575). But don’t' use this test just yet. While there are a lot of Chinese- this study only had 41 unstable anginas and 28 MIs out of a total of 282 patients. And it still missed 25% of patients- the sensitivity and specificity were both in the seventies. They then report excellent ROC but as Prof Hoffman pointed out in the Mar EMU (you did read it, didn't you?) ROC doesn't help us because ROC is a continuum. We want to know yes or no- do they have it or not. The Turkish study showed the same problems. TAKE HOME MESSAGE: MPV may help tell us about mortality in CHF and who really has ACS but these studies don't help us much. It is not ready for prime time. Hey who were the original not ready for prime time players on Saturday Night Live?
5) Many localities bring intoxicated patients to the ED, and in Israel for example they bring every drunk in who is lying on the street. Which of these really do need emergency treatment? While they only had 99 patients in this study (that is all the drunks they could find in San Francisco?). They found that they could not really identify who really needed treatment and who didn’t. The paramedics also could not tell. Triage therefore can be difficult. (ibid p579) TAKE HOME MESSAGE: Intoxicated patients can be hiding serious pathology. No triage criteria exist to help identify these patients.
6) Fusidic acid works as well as chloramphenicol drops for neonatal sticky eyes. This is from the Best Evidence Topics from the EMJ (ibid 28(7)634) I would like to ask- how about using nothing? Maybe that would work just as well. TAKE HOME MESSAGE: Standard antibiotic drop therapy helps in neonatal conjunctivitis. (Before you (Lisa?) jump all over me, we are not talking about GC and the initial treatment after birth.) By the way this article was written by a Brit named Grayson. Now here is a real hard one- who was Dick Grayson?
7) This study was about sciatica but it really could have been about any malady. They interviewed patients to see what their perception of sciatica was and found that it was constant and intense. Patients wanted an explanation why this happened to them. (Spine 36(15)1251) I can understand the need for us to really understand what our patients are feeling and this is a tough issue for most of us. But in addition – and this study did not address this- are we worried enough about pain control? Additionally, are we making sure our patients can do activities of daily living? I would say not. TAKE HOME MESSAGE: Sciatica is poorly understood by patients and causes them much pain. Sympathy and proper pain relief are important.
8) OK, guys stop snickering. While this is a touchy subject (oh, that was terrible, I am so sorry) it is a serious concern. We won't go over the diagnosis, but some causes may not be well known to us. (Oh we are speaking about priapism). Here are some causes you may not have thought of- hemodialysis, leukemia, G- 6-PD deficiency and gout. Meds that are commonly used that can cause this include papaverine, alpha adrenergic blockers (terazosin, etc) propanolol, antipsychotics, heparin and warfarin, and cocaine. Scorpion bites and malaria. Treatment is aspiration with irrigation and infusion of an alpha adrenergic such as nor epinephrine or ephedrine. Other therapies given IV are less effective. (Urol Clin No America 3892)185). Interestingly enough misuse of Viagra type drugs doesn't seem to be on the list. My peer reviewer adds: and long term, low dose Viagra or other phosphodiesterase 5 inhibitors are used (off label) for prevention of recurrent priapism (Urology. 2006 May;67(5):1043-8.). TAKE HOME MESSAGE: almost anything can cause priapism, and the treatment that is most effective is aspiration and infusion of a sympathomimetic. PLEASE use sedation and do a penile nerve block. Thank you.
9) Shoulder dislocations- do they need a pre reduction x ray? In this retrospective study they say no, but only if they are in between 20 and 40. (I was blown away that they also calculated the amount of fractures in shoulder dislocations in the eight to tenth decade of life). (AJEM 29(6)609). This needs some commentary. I agree that you do not need the x ray to decide what kind of dislocation this is. Clinically you should be able to tell. And in young people a humeral fracture is less likely but clavicular fractures abound and can replacing a shoulder in a clavicular fracture make worsen the fracture? I doubt it but I do not know. Obviously the older patient needs an x ray and the frequent dislocater doesn't but I think in between is still a gray zone. In places where fractures are less important like finger dislocations, I do not x ray beforehand. TAKE HOME MESSAGE: patients with low risk for fractures (young people) do not need pre reduction x-rays.
10) This is disgusting, grody, gross, icky, and very yucky. Ever go to do an ultrasound and see the jelly is still glopped all over it? It seems that you can easily transmit MRSA from dirty probes, so please clean them between uses! (Ann Emrg Med 58(1)56) While we are at it do you clean your EKG contacts that are on sweaty patients? How about your stethoscope? OK, we won't exaggerate, but they look at pens we use and yes you can find MRSA there too. (Clin Micro Infect 17(6)868). Seems like they are winning, guys. TAKE HOME MESSAGE: Use those little wipes to clean everything you touch and use in the ED or you'll be bringing home unwelcome critters (MRSA).
11) Can I tell you something you do not know on asthma? I doubt it, but I can not ignore an article by Brian Rowe who is the Cochrane go to man for asthma issues. Most of what he says is not new, but there is one point that is worth mentioning. Inhaled steroids seem to help for the acute asthma exacerbations. I didn't think the evidence was that good and Brian agrees but there is some evidence. He feels this is from a vasoconstrictor effect and not from an anti inflammatory effect. (Curr Opin Crit Care 17(4)335). From time to time articles come out recommending the use of inhaled furosemide in asthma, 10 years ago I spoke to Brian about this but he chose not to include it here. Barry Brenner is also an ED asthma guru and is an EMU reader, would love to hear from you Barry. TAKE HOME MESSAGE: Inhaled steroids may help you patients with an acute asthma exacerbation.