Zofran

Well here is the study that has had everyone talking for a while. Good old ondansetron category B now may cause congential malformations in the fetus. This study in the journal Reproductive Toxicology retrosp of 1349 infants concludes a risk for CV defect (septum specifically) is increased to a statistically significant degree. My favorite prior study looked at 608,000 pregnancies and concluded no malformation risk. This is in the NEJM. So I am much more likely to follow the recs of the huge NEJM study.

Now we could do more prospective studies of course to see if ondansetron is causing any true effects. And we can always use the promethazine, prochlorperazine class of drugs in these patients while in the ED or even for discharge. I still love good old extremely evidence-based ginger pills, also B6, diphenhydramine, not eating crap food, etc.

Discussion is welcome.

72 Hour Returns

Much has been written about ED recidivism. Ryan Radecki at EM Lit of Note has just reviewed another article about returns, this one looking at bounce backs from inpatient services as well. His conclusion is that 72 hours returns should not be used as a quality measure for ED metrics. His complaint is the nonspecific analysis of these returns. When we discuss 72 returns in our didactics, we attempt to focus on the cases from which we can learn how to prevent discharge of inappropriate patients. We are discussing shifting more toward discussing less cases with well defined take home points as we enhance didactics. Take a look at the Radecki commentary and if interested, the growing body of literature. If anyone is especially interested, a solid admin project / scholarly project would be to analyze our 72 returns over a longer period than a month. Drs Coleman and Platt presented a poster at CORD when we presented the Room9ER poster years ago.

Essay Contest

Hey guys its that time of year again for the Spears Essay Contest. See details below. We have had some finalists in the past. Inside information: not many people submit essays, you have very good odds.

Entries Due March 7!
The 2016 Richard Spear, MD, Memorial Essay Contest
Win $$ and get published in Louisville Medicine!

GLMS physician members, GLMS in-training (residents and fellows) members and all University of Louisville medical students are invited to enter this year’s Richard Spear, MD, Memorial Essay Contest. Cash prizes will be $1,500 for the winner in the practicing and retired physician category and $750 for the winner in the physician-in-training and medical student category.

Essay Contest Themes: All entries must be original, unpublished writing intended solely for publishing in Louisville Medicine. Essays must be pertinent to the following themes*:

1. Practicing and Retired Physician Category
“How Medicine Has Changed Me”
– or –
2. Resident/Fellow/Medical Student Category
“Social Media in Medicine”
 
*If you are a practicing or retired physician member, you must choose Category 1. If you are a resident, fellow, or medical student, you must choose Category 2.


Length: 800 to 2,000 words. 

Format:
Do not put your name on any page of your essay. Instead,include a separate cover letter with name, entry category, essay title and contact information. This allows judges to be blinded to author names.

Deadline: Monday, March 7, 2015.


Submission: Send via email as an attachment to Aaron Burch ataaron.burch@glms.org.  Email submissions are highly preferred, but if not possible, send entry by fax to 502-736-6341 or by mail to 

101 W. Chestnut St., Louisville, KY 40202.

The winning essays and Medical Writing for the Public Award will be announced at the annual GLMS Presidents’ Celebration and published in the July issue of Louisville Medicine

Finally

I am quite excited about this study but sad I was not the one to publish it. Out of South Florida, a study of 72 patients who received a NONCONTRAST CT Abdomen for various locations of abdominal pain.

Excluded were: trauma, pregnant, surgery in past 30 days, pain more than 3 days, MD discretion (thought usually to be suspicion for vascular emergency), unable to be reached for 7 day follow up, would not consent, unstable, suspected renal stone (as this is already the standard of care), known cancer, BMI < 18. Sounds like a lot of exclusions but this pared the population down to the general population of patients in whom I would consider the noncontrast CT abd for nonspecific abdominal pain. Notice suspicion for appendicitis was not an exclusion, many studies have shown minimal benefit to oral contrast in appendicitis. They also did not exclude very acute abdominal pain (ie using a minimum number of hours of pain).

The results: 0/72 patients had a missed diagnosis on the initial noncontrast CT. 3/72 had repeat contrasted studies which added little. Of the 31 patients discharged, no one had surgery, death, or repeat CTs done.

This is obviously a small sample at one hospital. Selection bias can be a factor, as MD discretion was an exclusion. I would love to see more studies like this, possibly RCTs. As more and more centers get the higher resolution CTs, we should see less and less contrast given for CT of the abdomen and pelvis.

Humanity

This is a commentary on this article by a resident reflecting on life, trauma, and death. The  resident’s self-reflection is a nice read and something with which we can all identify. But the “meta-reflection,” if you will, is something we do not usually get to see in our EM journals. We read one or two essays in each Annals, sometimes in Academic EM and in JEM. I tend to read these first or tear them out and hold them until I can read in a quiet room and really concentrate on them. And I do my own reflecting on the themes and ideas presented by that person.

The commentary article describes the difficulty in a self-analyzing essay. The schizophrenia and detachment involved in presenting your own thoughts in this way. Dr Ratzan reviews some of the (sadly few) accomplished physician writers and their themes. William Carlos Williams was a poet/writer and physician. Richard Selzer, a retired Yale surgeon, is still living and I hope still writing. His books are so rich and he is so talented a writer that I can hardly read more than 20 pages at a time. Brilliant physician writers are rare but essential to the humanity of our profession.

And emergency medicine in particular, with its intensity and ?necessary detachment, might need this humanity more than any other specialty. I recommend we all read something either in the medical humanities, or something seemingly unrelated to medicine. You might think the literature or the book of humor or the young adult futuristic death competition book is non-medical. But connecting, or reconnecting, with that part of yourself that is separate from the ED will make you a better doctor and healer.

It can become trite to say feelings are important, we need to have empathy, there is a human side to this job of ours, etc. And it is a difficult jump from reading a feel-good essay to the next day walking into the room of a patient with fibromyalgia and trying to channel that empathy you were just reading about. But trust me, if you make an effort to do this you will appreciate your patients. Good advice I read from a Brazilian shaman: “remember that the world does not revolve around you.” you have to really think about that to understand. Try to picture the world through literally through other people’s eyes, makes yourself and your troubles seem smaller.

The patient you are seeing in the ER is likely having the worst day of his month or year or even life. Try not to forget that. Happy Thanksgiving.

NEXUS in the Elderly

Hopefully everyone is using the NEXUS criteria or the Canadian C Spine rule in evaluation of patients who have undergone neck trauma. Those familiar with both know one major difference, age criteria. NEXUS does not use age, Canadian C spine does. Using both rules together, like PERC with Well’s, increases sensitivity at expense of specificity.

Well here is a study on falls in the elderly (i.e. low mechanism which is another difference between NEXUS and Canadian) and application of NEXUS. Turns out, probably shouldn’t be using NEXUS in patients over 65. Liberally scan these folks, radiation is less of a concern, and the cost is justified due to morbidity of missed injuries. And of course do not bother with plain films (in adults).

Hot off the Press, Droperidol is Still Safe

Yet another quality article illustrating the safety of the most magical drug, droperidol. Not sure where people are getting it, as it is not being manufactured currently. We have none at any of my hospitals in Louisville. It is sad but perhaps someday we will get it back. In the same Annals issue an indictment of professional societies, journal editorial boards, and government advisory committees with their misinterpretation of “so-called facts.” Great reading, Dr Newman is the man.

Chest Pain Admission Dilemma

Hey guys here is an interesting article with actual patient oriented outcomes related to admission for chest pain.

Several take home points:

1. From highest quintile of admission rate to lowest (81% to 38%) the rate of MI and death went up by 3.6 per 1000 and 2.8 per thousand. This correlation implies that when you admit more patients you save lives.

2. It is VERY IMPORTANT to note the patient population. These are Medicare patients with average age of 71 years. So we ARE NOT talking about low risk chest pain ED patients.

3. Even though it looks impressive to save these lives, the NNT or number needed to admit to prevent one MI is 250 and to prevent one death is 333. Thats a lot of admissions. And admitting geriatric patients is often not a good thing for them. May be why the decrease in deaths is less than the decrease in MIs. They were dying because of a hospital acquired infection or deconditioning or something else.

4. It is striking to see how different the practice patterns are at different hospitals regarding admission of a fairly homogenous cohort of patients.

Appreciate any further comments.

Just get a walking O2 sat

In patients with some suspicion for PE, even with a negative d dimer, I have often ordered a walking O2 sat and HR. This was not really evidence based, but maybe now could be. Below is the abstract for a prospective cohort study of patients known to be with and without PE. Interesting data even if only 114 patients. Cannot get full text yet.

Take home point. Combined sensitivity of HR increase of 10 BPM AND Sat decreased of >/= 2% was 100%.

ie if HR does not go up by 10 or more AND sat does not drop by 2 or more they are very unlikely, based on this small study, to have a PE.

 

 

CJEM. 2015 May;17(3):270-8. doi: 10.1017/cem.2014.45.

Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test.

Abstract

OBJECTIVE:

Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonaryembolism.

METHODS:

This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessedambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism.

RESULTS:

We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) forpulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0).

CONCLUSION:

In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.