Friday, June 3, 2011

Testing For Pulmonary Embolism is More Harmful Than Helpful

This is, in my opinion, the most conceptually important article I have read in the few months I've been posting to this blog.

This is where Dr. Newman and Dr. Schriger, outstanding clinicians and analysts of data, present a compelling case regarding the diagnosis and treatment of pulmonary embolism.  In brief, the authors try to estimate, based on the limited evidence, both the benefits and harm of diagnosis and treatment of pulmonary embolism.  In their review, very few patients were found to benefit from treatment of pulmonary embolism - the existing evidence is weakly supportive of anticoagulation.  Additionally, they show a great many patients were harmed by excessive testing and treatment of clinically unimportant pulmonary embolisms.

This is, while a complicated opinion piece, a lovely summation in a nutshell of the concept that finding more "disease" does not equal better outcomes.  And, depending on the risks of testing and treatment - the barbaric contrast, radiation, and rat poison that diagnosis of PE typically entails - more people would be alive today if we all stopped testing for pulmonary embolism.

This is not unique to pulmonary embolism - this is partly the same issue we encounter with overtesting our low-risk chest pain patients, particularly with CTA.  What this means - and, of course, subject to legal challenge in our bizarre society - is that with our current methods of detection and treatment, society would be better off as a whole if we missed a few pulmonary embolisms in order to find and treat the few clinically relevant ones.  The only shame in this article is that not nearly enough people will read it and take it to heart.

Thursday, June 2, 2011

Liability Protections For Emergency Services

Smart folks at ACEP - tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don't think anyone graduating now knows how to practice without scanning everyone, as it's become generally the standard of care.  The "quality of care" argument is a little new to me - but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren't tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it's not just us - so many PMDs refer their patients to the ED for a CT scan - whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection - Press-Ganey protection - for all these patients who expect answers, and CTs at the minimum, and aren't going to fill out very favorable patient satisfaction surveys without getting what they want....

Wednesday, June 1, 2011

Hurricane Season

June 1st marks the start of Hurricane season.

Many Emergency Physicians are acutely aware of the need for disaster preparedness, but there are also many areas that have not sustained significant natural calamity and may be complacent.

Most of the expert predictions are expecting above-average Hurricane activity - and the Eastern Pacific wind environment that pushed all of last year's storms out to sea in the Atlantic is not present this year.

We will have a major hurricane event somewhere on U.S. soil this year.  Or, at least, we should be preparing like there will be one.

And, on a related note, where disasters are like to occur:

Two Months

So, it's been two months since I started this little professional development experiment.

April: 31 posts, 49 pageviews
May: 30 posts, 221 pageviews

Still working off the "if you build it, they will come" premise that if I create a resource that people think is worthwhile and important, it will gather steam of its own accord and slowly gather an audience and referrals with minimal intervention.

The next thing I am working on to complement the blog is an audio digest podcast for each month.  I'm about halfway through April and it's fun, but a little time consuming.

Update: I finished the April Podcast - and it's really not very good.  It's going to stay on the cutting room floor.  I'm going to rethink the format and content before recording another month.

Tuesday, May 31, 2011

72-Hour Returns - Fun, But Not Useful

Our EMR lets us generate reports of our 72-hour returns - and it's a fun toy, but, reading through it is rarely illuminating.  On a rare occasion you see a "true miss", where one of your colleagues finds something through another line of thinking.  But, mostly, it's wound checks, admissions for failed outpatient antibiotic therapy for cellulitis, or the town drunk coming back in again.  It is a valuable tool, at least, in the sense that our ED is the only one for 40 miles and is the only tertiary center for 90 miles, so we should get most of our own bouncebacks.

And, this study essentially confirms my anecdotal observations - most people who come back return for non-emergent conditions, do not require significant additional testing, and are no more likely to be admitted.  Their conclusion, then, is that 72-hour returns are of limited utility as a quality measure - something of which I tend to agree...although, if it were, the unintended consequence of discouraging that 2-day wound check/abscess repacking might finally put abscess packing to rest....

Monday, May 30, 2011

Bypassing The ER With STEMI

This is a paper cited in the most recent ACEP Weekend review that tries to draw more profound conclusions than it probably should.

It's another piece of the growing body of literature that says "Hurry!  Prehospital activation is all we need in STEMI!"  From Israel, it's a retrospective review of performance variables and patient outcomes between a cohort that was assessed in the ER and a cohort that went straight to the lab.  They draw a few conclusions, some of which are valid.

First, time.  One of the two "primary" outcome variables is door-to-balloon time.  No argument that skipping steps along the way will save you time.  No study is needed to prove that.

The second "primary" outcome variable is MACE within 30 days - another combined endpoint kludge of death, CHF, reinfarction, CVA, TIA, and urgent revascularization.  This one favored the direct-to-ICCU group, 22% to 30%.  How is 30-day CVA/TIA directly related to the effectiveness of PCI?  Looking at their secondary outcomes - death was not significantly different - but CHF was 8% different, which therefore accounts for essentially the entire difference between groups in this primary outcome.

And the problem?  Well, they also show in a secondary outcome that LVEF >30% was 7% greater in the direct-to-ICCU group...from which it follows there would obviously be less heart failure in that group.  But, in their demographic information, they don't know the pre-intervention LVEF for their patients - only the Killip class on presentation, which is a measure of the heart failure associated with the acute cardiac event, not their pre-existing LVEF.

So, the only thing they've effectively proven in this study is that skipping steps saves time.  And, they don't comment on the number of false positives in each group, either.

Sunday, May 29, 2011

Fluid Boluses Increase Mortality In Children

...or, at least, that's the gist of the New England Journal Article making rounds in the news.

And, while a close reading of the article doesn't offer great support for harm, it certainly supports saying that albumin, saline, or nothing were equivalent.

The absolute difference in survival was 3% - and, looking at the demographic breakdown, there were 2-3% differences or trends in favor of the control group regarding dehydration, acidemia, base-deficit, and bacteremia.  Enough that it lets me cling in denial to standard practice and teaching here in the U.S., in addition to whatever you want to say about external validity of a study in resource-poor settings in Africa.

It is an odd and unexpected finding, so say the least.  The authors attribute at least part of the unusual discovery to the high percentage of malaria cases they treated, and that fluid resuscitation in malaria is controversial - but regardless, this is going to be a frequently discussed study on the Pediatric Critical Care side of things for some time.  I also expect follow-up confirmatory studies to be a tough sell to U.S. IRBs.