Oct 2011 - LITFL: Life in the Fast Lane Medical Blog

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.
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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
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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
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
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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
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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.
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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?
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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
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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.
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
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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).
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.
We have written this before, but if Cochrane says there is
evidence, and makes recommendations already- then you gotta
believe it. Reparatory virus spread is most effectively prevented
through consistent hand washing. It doesn't have to be viricidal soap.
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Stopping people at ports and restricting entry really doesn't help. But
social distancing may help. Surgical masks work fine and just as well
as the fancy N95 masks. (Cochrane 7:6207). This won't help you
when that slob sneezes on you on the AA train in Manhattan (and
actually holding on to the straps or pole may be just as bad) but it
could help around the house. TAKE HOME MESSAGE: Hand washing is
for respiratory virus prevention as well.
I agree there is no science here, but managing break through
pain in cancer patients is tricky. In the past we used oral morphine and
in truth it does not work that fast. Fentanyl is in style now and can be
given by the buccal, nasal, mucosal and sublingual routes. (Curr Pain
Head Rep 15(4)244) Now another point I want to add- opioid
tolerance is real and some of these folks need astronomical amounts
of pain relief for control. Be sympathetic. TAKE HOME MESSAGE:
Fentanyl is fast acting and should be your go to drug for breakthrough
Have I sufficiently gotten over my rant against anesthesiologists
to talk about Ketamine? I think I am calm now.
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In any case this article says that there are some
new uses for ketamine. You can use this as a treatment for pain- I
wouldn't call this any thing new. However it may have opioid sparing
effect and restriction of tolerance to opioid effects. I think their
evidence is fair. The evidence is poorer for anti tumor effects, anti
inflammatory effects and neuroprotective effects. (BJA 107(2)123). If
you do use ketamine for pain, I have found that dosages above 0.10.15 mg/kg to already be dissociative. You know, I ask myself- can
this medication be used for pain safely in the clinic? Readers who are
FPs- what do you think? TAKE HOME MESSAGE: It is still early to say,
but ketamine may have other beneficial effects other than sedation
and pain relief. These could include anti tumor and anti inflammatory
ICU guys- just wanted you guys to know that low tidal volumes
are not universally agreed upon. The journal "Chest" recently brought
a point counterpoint on the subject- I only read the side that was
against because I couldn't imagine what that side would say. They
present a lot of math, but come to these conclusions- low tidal volume
isn't one size fits all, it could cause more atelectasis by not using the
whole lung and may increase sedation needs. (Chest 140(1)11) Now
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the way I see things this is not that relevant to the intubation and ship
up to ICU we see in the ED (unless you work at LAC USC), but I can
also understand not over stretching the lung with large tidal volumes
nor underutilizing the lung with lower tidal volumes. Could this also
cause more difficulty in weaning patients? This is not known. It is
clear we need more research. However in the interim you can arrive at
the ideal tidal volume by measuring trans pulmonary pressures and
lung volumes, but I do not know how to do this. (Scott? David D?
Chris?). Maybe SIMV is the solution when possible since it allows the
patient to take as much as he needs? TAKE HOME MESSAGE: Low tidal
volumes are not for everyone.
This article does deserve to be an essay, but I went over the
subject as an essay about three years ago, and so I will just
summarize the article. We are dealing with antiseptics and topical
antibacterial agents (Med Clin No Am 95:703).Let us start with
antiseptics. Alcohols and iodophors work really well but their effect is
short acting. Chlorhexidine and triclosan act slower but persist. So it
makes sense that a combination of chlorhexidine and alcohol would
give both effects and indeed that is what is in use in many places.
Chlorhexidine is also useful in mouthwashes to lower the incidence of
pneumonia in intubated patients –a subject we spoke about a few
months back. It has been shown to be superior to iodophors. .
Iodophors are very effective as well but need at least two minutes to
be work. No resistance has been documented to either agent.
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Triclosan is also very effective but is extensively used in soaps and
detergents and as such resistance is just beginning to be an issue.
Peroxide is a very poor antibacterial agent if it is effective at all. On the
other hand Benzolyl Peroxide is a powerful and broad spectrum killing
agent. Bleach is as well and is effective against the AIDS virus. Just
to bend your ear- it kills 99&% of Staph Aureus within 30 seconds. All
antiseptics impair healing by killing fibroblasts so avoid them in wound
cleansing- use water streams. As far as topical antibiotic agents are
concerned, mupirocin is a great drug but not for use in all casesresistance develops fast and may be as high as 65%. Topical
antibiotics- they like the neomycin, polymyxin and bacitracin combo
even though there is a high incidence of allergic reactions to the
neomycin. They have shown to have positive effects in wound healing
but this is not related to their antibiotic properties. They do not
mention this but we have spoken about wound healing in the past and
indeed moist wounds do the best and the vehicle may be the reason
why these agents help here. They do mention honey as well- we
discussed that last month. After I read this article I noticed in Pubmed
that this was a reprinted article from 2009 in another journal but it was
worth going over it again. TAKE HOME MESSAGE: Alcohols are fast
acting antiseptics, but wear off quickly. Chlorhexidine is slower onset
but more persistent- a combo is the best idea. Antibiotic creams
promote healing but probably not related to their antibiotic properties.
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OK, the disease is angry and it is back although this is not the
season. And I am not telling you what disease it is. Well, you know
me. I will tell you but you'll have to guess first and then go back to
see if the story fits. Neck stiffness, swollen glands, fever and trismus.
30% of the cases are asymptomatic. It was thought that since many
of us got vaccinated we wouldn't see this disease anymore. However
we may still need a booster. It can cause meningitis, orchitis,
oophoritis, mastitis, pancreatitis and deafness. IgM testing is often
negative even with the disease. (Can Fam Phys57:786)
I won't keep you hanging. Of course I would have made the
case much easier by saying it also causes parotid swelling. However
my main point is to stress that testing can be negative – make the
diagnosis on clinical grounds if necessary. The disease of course was
Only kidding- it was mumps. But you weren't fooled were you?
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A little new news on headache from headache guru Rich Lipton
from my alma mater Einstein. Present recommendations push for CT
and LP in all patients describing their headache as "first", "worst" or
"changed" but as the authors point out, this is almost every patient we
see in the ED with a headache. It does seem from the author that if it
took more than a few minutes for the headache to develop it is
probably not a SAH. They also present a rule system to suspect SAH
which I think is asinine- they point out it is 100% sensitive but it is not
very helpful. Examples of questions include age over 40, neck pain
(hard to swing and miss on that one), witnessed loss of consciousness,
systolic hypertension more than 165. To me these are either non
specific or not helpful. Another cause of headache is cerebral venous
sinus thrombosis much rarer than SAH, but good luck finding it. If you
get a patient with a headache and seizure – than this should be on
your list, but often presentations are more subtle. Most of these
patients are missed by the previous physician that saw them. Non
contrast CT and LP will not diagnose this problem. They like
metoclopramide for headache pain and the higher dosages do not give
more relief. Giving it with NSAID seems to be the most effective. In
kids, prochlorperazine seems to be the most tested drug and it seems
to work well at 0.15 mg/kg ( Curr Pain Headache Rep 15:302) TAKE
HOME MESSAGE: Cavernous sinus thrombosis- think of it with
headache and seizure. Metoclopramide plus a NSAID seem to be the
best idea for treatment of headaches.
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I get Prescriber's Newsletter, and they recently discussed the
issue of animal products in medications. They prohibit reuse of their
information so I will present the things I knew before I read this and
you can get their March issue if you want more information. This
information could be very important to vegans, Jews, Muslims and
Hindus. Thyroid hormones, insulins and pancreatic enzymes can all
come from animals; pigs are the most common animal source.
Vaccines are often grown on eggs. Estrogens can be from mare urinethus the name Premarin in the USA. Chondroitin is from animal
cartilage often sharks. Vitamin D can come from sheep, and calcium
from oyster shell. Gelatin capsules come from animal bones in many
cases. Sublingual preparations – such as some triptans can have
animal products in them. Magnesium stearate- a common binder in
pills is from animal or vegetable sources.
And now to trash honey yet again-Studies showing that honey
helps cough have shown some trend to helping cough, but never in
clinically significant terms and always when compared with
dexomethorphan which questionably works. Many of these studies
had methodological problems and many were sponsored by the Honey
Board (not the honey bucket for these who know what that is). So I
guess that is not overly convincing for using this stuff for cough. (Can
Fam Physician 57:435) I know that stings (pun intended) but look out
next month when we go to cough giant Dr. Richard Irwin for what
really does work.
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Time for letters. Greg Henry- a legal expert -surprises me. He
likes our trips down memory lane and asks if anyone remembers
Arthur Godfrey's ukulele teacher. I am astounded that Greg does not
know that it is a felony in fourteen states to be old enough to
remember Arthur Godfrey. Other than being the name of 41st in Miami
Beach, I have never heard of this guy. And ukuleles? I thought that
was Tiny Tim's forte alone (if you do not remember Tiny Tim- it is OK,
you are probably better off not remembering him). Well the answer is
Hani Loki (I couldn't find this on Google- nor is there a profile for this
guy). And if you are really intent on knowing who Arthur Godfrey was,
here is the link Arthur Godfrey. Thanks Greg for writing. Can I have a
swig of your Geritol (was it spiked?).
Ken Iserson who wrote a book on improvised medicine (I heard
him speak on the subject- and it was amazing! (But no plugs on the
book until I get a copy!) write us
Thanks for the two EMU issues.
Your piece on hiccups leads me to write about two methods I included in "Improvised
Medicine: Providing Care in Extreme Environments":
"Multiple drug and non-drug methods have been used to disrupt the hiccup reflex arc.
When a patient's hiccups are protracted and not due to significant medical problems like tumors or
subphrenic abscesses, home remedies are generally ineffective and other means must be employed.
One non-drug method uses a nasogastric (NG) tube. Insert the NG tube into the stomach;
immediately remove it. The hiccups should stop at once. If not, try a second time. It’s postulated
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that the mechanism involved is irritation of the posterior nasal mucous membrane and lower
esophageal sphincter.
"Another method that is relatively benign, generally available, inexpensive and simple is to
use intravenous lidocaine. On multiple occasions, it has worked successfully when other
medications failed. Reported successful procedures with lidocaine doses, both in children and
adults, have involved loading the patient with 1-2 mg/kg and then generally beginning a 2 mg/kg
(sometimes up to 4 mg/kg) drip for four to twelve hours. This often had to be repeated within 24
hours. My personal experience with this technique was in a remote location with an adult who had
had several severe and debilitating hiccup attacks over the prior decade. I used an infusion of 2
mg/kg lidocaine over 20 minutes, which stopped the hiccups as the infusion was ending. Although
they did not recur, I gave him the same 20 minute infusion of 1mg/kg each of the next two days.
He did not have a recurrence over the next 5 months."
Of course, this is copyright 2012 McGraw-Hill. Seems to me that the NGT is a
little drastic. Lidocaine IV maybe- what bout xylocaine 10% spray or viscous
Anat asks us why we routinely do a chest film when we think
about pulmonary embolus. The answer is that if your direction is V/Q
scan then you will need to see a chest film first to rule out atelectasis
and other pulmonary pathology that can influence the results of the
scan. Also if you use rules, Well's criteria does give three points for PE
being more likely as a diagnoses – that requires a chest film.
Obviously in a more severe case, CT should be done as it covers
everything and is fast. Thanks for writing!
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Ah yes, who were the original Not Ready for Prime Time Players
(see #4 above)? Clockwise from the left in the picture below: Larraine
Newman, John Belushi ,Jane Curtain, Chevy Chase, Dan Akroyd, Gilda
Radner, and Garrett
And yes you may remember Bruce Wayne- he was the disguise
name for Batman. Dick Grayson was the disguise name for Robin. See
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#6 above. Easy, no?
And don't start
up with me- I know Adam West played Batman, and Burt Ward was
EMU LOOKS AT: Spinning and Winning
I think you may find this month's essays the most important ones you will
read in a long time. They are scary, and they may reduce your confidence
level, but you will at least have the knowledge on your side. I strongly
recommend you re read these essays (actually an essay and a roundtable) a
few times. Let's jump in!
The essay deals with the common ED complaint of dizziness or vertigohow do you know that you are dealing with a peripheral cause and not a
central cause? You in the front- don't be so sure of yourself. Fasten your
seatbelts it's going to be a bumpy ride. The source for the article is CMAJ
183(9)1025). In this article they reviewed the literature.
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1) The cause of peripheral vertigo is really not so important; the
treatments in the ED and the FP clinic are basically the same no
matter what the cause of the peripheral vertigo was and include meds
and more effectively- maneuvers such as Eply, Selmont and the like.
Central causes include posterior fossa CVA, cerebellar bleeds and
verterbro basilar dissections. Obviously you do not want to miss these.
So what may help you diagnose central causes of dizziness??
2) Type of Dizziness (rotating, the room spins, I feel spinning etc) often
helps make the diagnosis. MYTH. Can't help you.
3) I was taught that acute onset favors a peripheral cause. MYTH.
(Maybe). Two uncontrolled studies showed that it favors a central
cause but no studies have shown that it favors a peripheral cause. This
is the opposite of what I was taught.
4) Prodromal dizziness: Always thought this was a good sign that it was
central. FACT (sort of) Isolated episodes before the attack do not point
more to central or peripheral, however ,recurrent episodes over a few
weeks or months do seem to predict a central cause.
5) Triggers: these portend more to peripheral causes, especially the Dix
Hallpike maneuver. MYTH. They even say to pass on doing this test.
Exacerbation of symptoms with change of position is found in both
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cases. They do not speak about extinguish- ability which I still believe
could help in diagnosing a peripheral cause.
6) Associated Neurology: Especially diplopia and numbness was thought
to point to a central cause. FACT- however with two caveats. One is
that often the neuro signs are very subtle like severe versus moderate
truncal ataxia, nystamgus with vertical or torsion vector). Just to point
out- spontaneous nystagmus does not help to direct you. Secondly the
absence of neurological signs does not rule out a central cause.
7) Proportion of symptoms: Central causes typically are not proportional.
That is there may be severe gait disturbance with relatively mild
dizziness. FACT- probably. One study showed this was a marker of
brainstem pathology.
8) Auditory symptoms. Is nothing sacred? This is of course peripheral.
MYTH. The nerves supplying auditory are from the posterior
circulation and may represent a stroke.
9) Neck pain can mean that the vertebral artery has been dissected
FACT- if it is there. One quarter of the time pain is absent.
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Risk factors. The elderly should point you to a central cause.
MYTH and FACT- 25% of the central causes in their literature search
showed central causes in people under the age of 50.
Depressed yet? So I will tell you what can help you. Severe
truncal ataxia defined as the inability to sit with arms crossed unaided
was not seen in peripheral causes in this study. How many of you do
this test already? Want to hear more?
Here it is friends- the best test. It is a more sensitive test than
MRI. A normal result is a stroke. An abnormal result is peripheral most
of the time (this is giving me a headache). We are speaking about the
head impulse test. I know that you already do this, but I do not know
what this test is and the article doesn't say. Don't despair; here is a link
with a film. (head impulse test) But in this link they state that they do
not like this test and to be honest with you, I don't know who is going to
do this test in the ED, nor the vibration test they recommend. Oh you
can use the gaze evoked nystagmus and skew deviation which can
have a high specificity but low sensitivity. I personally do not feel I
could interpret these tests.
CT according to the authors is "grossly inadequate". MRI is 80%
sensitive in the first 24 hours meaning you miss 1 out of five.
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What if you miss the diagnosis? 10-20% of patients get much
worse in the first three day after so that jolly patient you send home
could be in pretty bad shape two days later.
So let's take the best way out- punt! Call in your neurologist!. Er,
1/3 of the time these patients will lack signs that even the neurologist
can pick up. Good luck and Have a good day!
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Really can't leave you that way. This study did not and can not
measure the accuracy of checking all of these signs together. This is
what I use. Has it worked? Well let me quote M*A*S*H
Frank Burns: "I'm a good doctor, you know. Just ask anyone of my
BJ MacIntyre: "Frank, we can't dig up a person just for that"
Our second essay is another installment of EMU ROUNDTABLE. This issue
we will be discussing legal medicine and I have been fortunate to have
amassed some of the biggest names in this business. Greg Henry should be
a familiar name to all EPs. He is a former ACEP president and he has been
a consultant for insurances companies and private physicians, consulting on
over 3000 cases. A gifted orator and teacher, I am honored to have him
sitting with us. Greg and I by the way met at the Israeli Scientific Assembly
two years ago and have built a nice relationship despite the fact that I am a
total teetotaler. (Greg: can we have the pop of the month?)
Mike Kessler knows the other participants at the table, although we have
never met. Mike is not a physician but rather a plaintiff's lawyer and a
partner of my good friend Sandy Rosenbloom. His credentials in the field of
legal medicine are impressive. Take a look yourself: Board Certified in Medical
Malpractice Law
(American Board of Professional Liability Attorneys)
Vice President, New York Academy of Trial Lawyers
Chair-Elect, Traumatic Brain Injury Litigation Group
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(American Association for Justice)
Selected for Best Lawyers in America
Selected for New York SuperLawyers
And you know something? I really believe him when he says that his goal is
patient safety and reducing malpractice- because he has really taken upon
himself to lecture EPs on the subject of legal medicine.
Rick Bukata- what can I say about this incredible man? A pioneer, a
visionary, and educator. Rick first accompanied me through the rolling hills of
central Pa when I worked at Berwick General, and then followed me to when
I fulfilled my life long dream to come to Israel. Obviously not physically but I
listened to his tapes and grew as a physician. Rick's Emergency Medicine
Abstracts needs no recommendation from me- its quality is unsurpassed as
a literature update and was my inspiration for EMU. Recently Rick- again
recognizing the need of EPs- embarked on a series called Risk Management
Monthly together with Greg. I think if you are not a subscriber, you are
missing critically important pointers that will not only save you the
aggravation of a lawsuit but will increase patient satisfaction and safety. You
can accesses at sample issue at http://ccme.org/riskmgmt/. I my self subscribe
and marvel each month at how much I have learned. Rick- we the EM
community – owe you a note of gratitude. Thanks for making us the best we
can be.
The last guy sitting at this prestigious table is me, - and my credentials are
that my father and sister are lawyers.
Well, let's get started. The first question wasn't asked in the right waybut the answers will make the issue clearer: You always have the right
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to choose the lawyer even if you are assigned one. What qualities
should you look for in a lawyer?
Let's have Rick start the proceedings.
Me: This requires a lot of digging to know you are getting such a lawyer. But
see Greg below – it may be worthwhile to do this research.
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Key point by Greg- they can settle without your permission. Want to fight
this? You must pay on your own all future expenses. Another point –
sometimes the court can decide that the payment is greater than policy
limits- just keep this in mind- it could cost you your Mercedes.
And Now Mike:
In the usual situation the malpractice insurance carrier will select the attorney
to defend the practitioner. However, it should be noted that even though such
attorney is being selected by the insurer, the attorney has an obligation to
protect the interests of the physician even where they conflict with the interests
of the insurer. The attorney’s obligation is to protect the client. So for example
if there are claims that are within the scope of the coverage and claims that are
not covered the attorney must act on behalf of the client and may not advocate a
defense that would leave the doctor without coverage. In addition, the physician
may, at his own expense select his own attorney, and if there is a conflict, the
insurance company may be obligated to pay for this lawyer. In some jurisdictions
such as New York, the insurance company is obligated to inform the physician of
his or her right to obtain their own counsel at their own expense. A physician
should also be wary of being represented by an attorney who is simultaneously
representing co-defendants—even in the same group--since that may pose a conflict
and violate the undivided duty of the attorney to the physician.
Just as would be the case in choosing a physician, the doctor should be seeking an
attorney who not only has good technical skills, knowledge and experience, but who
can effectively communicate with the defendant and create a level of comfort and
loyalty to the client’s interest.
Me: Key points from Mike. I think this an ideal, but pressures from insurance
companies can cloud the picture. The co defendant issue has been
mentioned many times in the past by Greg and is critical. You must have
your own lawyer.
Next question: As well, many of us are directors- what qualities from a
risk viewpoint do you look for in terms of staff?
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Greg deferred on this question. Mike, you'll begin:
Since it is likely that the medical group will be held legally responsible for the
acts of a staff member—either as an actual employee or agent, or an implied agent,
it is critical to seek staff who are qualified and who know when they need to seek
help. Obviously “hands on” staff supervision is very important, as is the creation
of protocols and standards that are easily understood, and which will apply to
almost all commonly encountered situations. Use of checklists to make sure, for
example that when tests and imaging are ordered, that there is follow up to get and
communicate the results. Many times I have seen medications requested but never order or
even if ordered, never given.
Me: I am not sure about the differences between an agent and implied
agent but I think hiring staff that feel comfortable in asking questions is key
and rarely mentioned in hiring interviews. Protocols are tough- they are
usually poorly written, overly wordy and found in some dusty corner in the
ED. Hands on supervision is usually when a problem is indentified or on
junior staff. The question of follow up is also very important- in our ED we
can not order tests that will not come back on the same day. Roentgen is
also a consideration if there is no over read or someone responsible for
communication of information. Orders of meds not given? I would like to
hear from my nurse readers how this happens.
Me: Being that many of us not risk aversive knowledge of risk is important.
How many of us were asked in our interview how we would handle a sample
case of possible malpractice? Would wee correct the chart? Would we
discuss this with our peers? All of this is fatal in the legal sense, but not all
of us know this.
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Next Question:
Many of us have physicians who are residents or non boarded. Some
of us are assigned to be the Chief attending for the day, some of us
are docs who oversee large operations, like HMOs- Where does
your responsibility start and end if an error occurs? Are you expected
to be on top of a doctor at all times?
Greg, you lead off:
Me: Let me echo – this is a criminal offense- check a patient you sign off on
even if you do not have the risk Greg mentions.
Mike supplements to Rick's answer. Mike- your turn:
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The simple answer is yes! There may or may not be personal legal responsibility of
a managing physician overseeing a large operation. However, particularly with the
management and supervision of non boarded physicians, residents, nurse
practitioners, and physician’s assistants, someone with the requisite training and
experience must be responsible to assure the safe management of the medical and
nursing care provided and that it is within the standard of care. As discussed
above, the use of checklists and protocols are helpful, but they too are worthless
if a culture exists where they are ignored. It may not be necessary to “be on top
of a doctor at all times,” but that doesn’t mean that a supervising physician can
just leave such physicians alone, particularly if their training, experience and
skill level is less than desired. A culture must be created where they feel
comfortable in seeking help if patient safety is at issue and they are less than
sure about the proper course of treatment.
Me: this goes back to what we said above: we need physicians that are
willing to learn, listen and ask. However, Mike's answer in the first line is
worrisome. Saying there may or may not be individual responsibility implies
that the law is still not clear on this and that means one can be brought to
court on this.
Next Question: I knew I would get heat for this one and I did. Here is the
Is it better to write down your neuro exam for example as non focal
and then explain the my usual and customary exam includes a
complete exam including x,y, z, or is it better to write it out and then
take a chance that the lawyer will ask - what about the plantar reflexesie you forgot to document one aspect?
Mike will start off:
Answer: Speaking as a plaintiff’s attorney this is a problematic issue. The only
way that this scenario will occur is if the thing that isn’t documented turns out
to be the problem. And then either way—whether recorded specifically or in general
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terms--the failure to document will be called into question. The expression that
“if it isn’t documented, it wasn’t done,” carries a lot of weight, and therefore
in my opinion, it is always better to document in specific terms what was done. In
my experience, the failure to document isn’t merely a failure to document, it’s
because it really wasn’t considered and that’s where the problem was. It’s sloppy
care—not a failure to document that gets patients and their caregivers in trouble.
Me: Well, documentation is everything, and the decision making process
which shows how you thought is the most important. Mike implies if you at
least thought of it, and write why you thought it wasn't- that this has some
worth. Also "not documented, not done" has some truth, but "my usual and
customary" can be used as a last ditch. Better to document but that doesn't
mean it wasn't done.
Me: I have little to add. Greg does refer to computer generated charts which
he has mentioned his opposition in the past. Is it protective? I think this also
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Fourth question:
Since most patients read at an eight grade level, and so the
legal-ese written in refusal to do a procedure or be admitted forms
are worthless- what is our best protection in these cases where
patients refuse our advice?
Rick in the opening tap: DOCUMENT WHAT YOU WANT TO DO, THE OTHER
Me: Good points from both of you. I think most of us take comfort when a
difficult patient bolts for the door. And forcing them to sign on documents is
worthless. Most of us with higher education can't understand what is written
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in these legal documents. Enlist who you can and document the elements
that Greg mentioned.
Don’t rely on a written form to explain things and get a “refusal”: from the
patient. Make sure that the patient understands in layman’s terms exactly why the
physician believes that a procedure is required in the patient’s best interest and
the risk or danger of not performing the procedure. Could the patient die? Could
he lose a limb? Could he be paralyzed? Why are they refusing? Is it cost? Fear of
the pain etc. If the patient won’t listen or may not understand, get a family
member, and or social worker, chaplain involved in the persuasion process. If the
patient is a child and the parent is refusing or may not be compliant and there is
a potentially life threatening situation, it may be necessary to get a Court
Order. If none of that works, fully document the discussion with the patient in
the chart. Identify the efforts made to secure cooperation. It may be helpful for
a nurse or other witness to the discussion to document such efforts.
Me: Mike adds the issue of children who refuse care. You absolutely must
clarify what the law is in your area and ask to speak with hospital counsel
when in doubt. Do not depend on ED directors or administrators but insist
on speaking to counsel and of course document this also.
Last question. I know I am learning a lot.
Lawsuits and hearings are very stressful- what advice do you have to
get thought the emotional aspects?
We'll commence with Mike:
Answer: Being second guessed and having one’s conduct called into question are, of
course, stressful. Being sued doesn’t make a care giver a bad person, or even a
bad doctor, and he or she didn’t intend to cause harm. Remember that it’s not a
personal attack, but rather an inquiry about whether the care given to a
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particular patient at a particular time was within the standard of care. Even
usually very careful drivers occasionally fail to pay attention, go through a red
light and hurt someone. It is important to always keep in mind, that in all but
the most egregious cases—even when the malpractice is clear—that this is civil
litigation and the physician rarely needs to worry about losing a license or
privileges. The only advice I can give to reduce the stress of litigation is to
(1) make sure that you are in the hands of a competent attorney who is dedicated
to protecting your reputation and financial interests, (2) trust in the process.
It may not seem that way, but the system usually works in weeding out the
meritorious cases from those which are not. Defendants in malpractice cases win
over 80% of cases that are actually tried to a verdict. In today’s climate
physicians get the benefit of any doubt. Of course there are injustices, for both
sides, but if a physician can look at a case honestly and conclude that the care
provided was appropriate, it’s likely that a Court will agree with that
One further thought to reduce stress: Tell the truth. Don’t try to come up with a
scenario just top try to defend what happened. It almost never works, and I would
suspect adds stress to the process.
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Me: Excellent on all accounts. I will add to Greg- a lawsuit is not unlike the
stages of loss- denial, anger etc. And I am very pleased that Mike is
sensitive to this and believes in letting the process work- usually you will be
protected and my experience is that most error is less black and white but
usually gray and often just a bad turn of events. Like Rick has often said –
error is a systems problem usually and not a personal problem. The key is
not to go overboard- a bad outcome does not mean you must over test or
over admit, although this is the nature of most physicians. And never take it
personally. We all make mistakes. It never means you are a bad doctor.
I am really grateful for Mike, Greg and Rick for donating their time on this
crucial issue. I think we all agree that you have made a major step in
improving the care we EMU readers give to our patients.
And now our bonus essay from May 2007
EMU LOOKS AT: Athletes
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Some articles are just too interesting to ignore, and while this subject may
not affect your practice, it certainly is interesting, and you never know who
will walk in the door. We are speaking about the problems of marathon
runners and the featured article is from AJEM, 2006 24, 608-14, by Sanchez
et al. If your library does not carry this journal, you can get a copy by
contacting the author, L Sanchez MD MPH at
1) I did not know this. Quadriceps muscles must do braking for going down hill,
so there is more muscle stress and more release of CPK from these muscles.
In short, in patients who run a big uphill downhill race and present with
muscle pain- go check their CPK. Also remember that in rhabdo, you can see
elevations that are sky high within two hours, but the peak is in 1 to three
days, so even if you have gotten the numbers to fall on presentation, they may
still rise. However, most marathoners clear their CK rather well by oral
hydration alone.
2) Because of the redistribution of blood to the muscles during a race, there may
be a low flow state to the GI tract that may even result in ischemic colitis, but
this is usually in marathoners who are not yet in shape. Nevertheless, occult
and even frank GI bleeding are not uncommon While never studied, it would
make sense for such athletes to avoid NSAIDs. This is also another call for
marathoners to avoid hypovolemia and drink well.
3) Sudden death does happen to runners, which is usually due to a congenital
problem. We have reviewed this in the past
4) A serious problem can be hyponatremia. Usually due to drinking
hypoosmolar drinks, now sports medicine specialists have athletes drinking
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during races (my high school cross country running coach, Fred Catona,
forbid any drinking at all during practice or races), and many take pills that
have the salts in them that are likely to be lost. See the consensus statement of
the first international exercise associated hyponatremia conference published
in the Clin j of Sports Med 2005;15 (4) 208-13
Low flow can cause renal failure, but it is rare and most probably due to
rhabdo and not the low flow states. Hematuria occurs a lot. It does not seem
to be of significance- there can be ARF, but it is almost always a result of
Exercised induced asthma usually starts soon after the onset of exercise, but
there may be some rebound 3 to 12 hours later. Non-cardiac pulmonary
edema can occur, but the reasons are obscure. What is interesting is that all
cases of pulmonary edema after races were in folks with hyponatremia.
Most common reason runners seek treatment after races? Exercise associated
collapse. This is not related to dehydration, hypo or hyperthermia. Rather, it
is thought to occur because of the sudden cessation of exertion. Most get
better with oral hydration and rest. Those who collapse in the middle of a race
can have hyponatremia, heat stroke or heat exhaustion.
Seasons have a lot to do with medical problems. Spring races are notorious
for problems, as the training is done in the winter, and if it is a hot day, the
body is just not acclimated to the situation. As with most things, cardiac
complaints should not be ignored, and patients that look sick- whether it be
with abdominal pain or severe dehydration or any of the other signs and
symptoms we mentioned- those who look sick are sick.
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We have seen many articles on the use of pain relief in abdominal pain, and
while we all believe that it is indicated, the literature has not been the
strongest. EJ Gallagher, the head of emergency medicine at my alma mater
Albert Einstein is known for quality articles, and I thought this would be the
definitive article. Yet he himself mentions the limitations of the article with
some concepts that may not be understood by most of us, so I was
fortunate to have Dr. Lisa Amir, MD MPH review this article for EMU readers
The article is:
“Randomized Clinical Trial of Morphine in Acute Abdominal Pain “ Ann
Emergency Medicine Aug 06.
The link is:
Those who do not have access to the article may request a reprint from:
Lisa: I can't claim to have understood everything in the limitation and discussion section of the paper.
also note that Polly Bijur, a biostatistician who usually publishes in the peds lit, does excellent work and I
would tend to support the conclusions of a paper that she was involved with.
I don't think the limitations are fatal; they just prevent this research from being "the" definitive paper, which
proves that administering analgesia in the ED does not interfere with our diagnostic abilities. I actually like
their choice of diagnostic accuracy as the primary endpoint rather than concurrence between the provisional
and final diagnosis. I think this reflects the actual practice of emergency medicine (at least in kids). For
example, it doesn't really matter if the final diagnosis is intact ovarian cyst or ruptured ovarian cyst if in
either case the patient doesn't need surgery. It doesn't matter at all if the patient has irritable bowel disease
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or lactose intolerance. What does matter is if the patient has irritable bowel or appendicitis. By choosing
diagnostic accuracy as the primary endpoint, the first two cases would be coded as concordant and the last
as discordant. If you used final diagnosis as the primary endpoint, all 3 would be discordant (or at least 2 of
the 3).
Of the four limitations in internal validity, all are good points but I don't think threaten the quality of the
article. Regarding quirks of randomization, I would note (see table E1) that 29 of the morphine group but
only 19 of the control group went to surgery. This actually supports the case that morphine is not a problem
with surgical etiologies of abd pain.
For limitation of external validity, again, I think they are important (especially the young age of the study
population and the high percentage of Latinos) but not fatal.
I think this is a well done, well though out study with a very interesting limitation and discussion section.
Unfortunately, it is not "the" definitive paper, which proves we are right in giving morphine for severe
abdominal pain, but it is one more piece of evidence that we are certainly not wrong.
Yosef: Isn’t there beta error here? The numbers seem awfully small
Lisa: Beta or type II error occurs when one falsely concludes that an effective treatment is useless (alpha or
type I is when one falsely concludes that an ineffective treatment is effective). They found up to a 12%
difference in diagnostic accuracy, favoring either opioid or placebo. The wide confidence interval, -11% to
12% represents the low sample size. Indirectly, the authors addressed the problem of beta error by not
committing to the superiority of either treatment arm.
Yosef: Thanks, Lisa.
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