Friday, July 29, 2011

"Narcotic Bowel Syndrome"

I had never heard this specific diagnosis bandied about in an Emergency Medicine context - but, essentially, it's a gastroenterology entity (and diagnosis of exclusion) that entails, essentially, chronic, intractable, crampy abdominal pain of unknown etiology and concurrent narcotic use.  I can't even describe how many of these patients I saw each shift during residency - and how many of those people had multiple CT scans in the past year.  The key feature in this particular diagnosis, as described in their case, is they had extensive follow-up evaluation, were weaned from their narcotics, and had resolution of symptoms.

I think this is a diagnosis spectrum we see a lot in the ED - whether it be constipation, IBS, cyclic vomiting syndrome, "feeling sick", or the multitudinous abdominal pain of unknown etiology.  With more and more patients being prescribed (or secretly taking) narcotics, what we see in our EDs is not just the overdose emergencies, but the various side effect spectrums of dependence and withdrawal.

You'd think that with all our medical technological prowess we'd have better mechanisms to treat pain than they did thousands of years ago.

"Narcotic Bowel Syndrome"
http://www.ncbi.nlm.nih.gov/pubmed/21719232

Thursday, July 28, 2011

Endotracheal Tube Verification Via Ultrasound

I think I've discovered the new paradigm of research in ultrasound.  Every time you do a procedure or make a diagnosis, slap the ultrasound on someone and see if you can reliably identify anatomic changes.

It looks like, with their practiced ultrasonographers, that they can get some preliminary information regarding endotracheal tube placement by performing transtracheal ultrasound.  Their "gold standard" was waveform capnography - which is a fair gold standard, but not universally sensitive and specific for tube placement in all clinical situations.  Essentially, if the ETT is in the correct place, there is only one "air-mucosal interface" observed with high-frequency linear probe, and, if the ETT is in the esophagus, you have a second, posterior air-mucosal interface.

Seems reasonable.

Experts did it correctly with 99% sensitivity and 94% specificity, and the main advantage was speed.

"Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube
placement during emergency intubation."

Tuesday, July 26, 2011

Online Publishing of ED Wait Times

When a small city only has two Emergency Departments, you can run a study like this to see what effect publication of ED wait times has on visits.

While it is fabulously logical that if 18 to 40 people a day are looking at your Emergency Department wait times that some portion of those people will choose a facility with a shorter wait time - or choose not to come to the ED at all - or choose to come in when they might not have otherwise come in if the wait time is short - this study doesn't actually try to study the population of interest.  They need to somehow capture individuals who are using the published information to make decisions, rather than looking generally at their overall wait time statistics - because, even though they say their results "were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time", they are making a huge unsubstantiated leap.

Looking at their descriptive statistics, hardly anything changed to actually justify their conclusions, and, really, it looks like patients just based their decisions pretty heavily on which of the two hospitals was closer - particularly Victoria Hospital, which people only went to if it was nearer.  I do also find it fascinating that their mean wait time rose from about 105 minutes to 115 minutes, yet the amount of time their wait time was >2 hours (120 minutes) actually dropped from 13% to 9%.  This is how they justify their conclusion that the "spikes" are mitigated by online usage - and it may be true - but there are too many moving parts and they aren't actually asking people if they used the website and used the information from it.

"The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design."
http://www.ncbi.nlm.nih.gov/pubmed/21672236

Monday, July 25, 2011

Facebook, Savior of Healthcare

This is just a short little letter I found published in The Lancet.  Apparently, the Taiwan Society of Emergency Medicine has been wrangling with the Department of Health regarding appropriate solutions to the national problem of ED overcrowding.  To make their short story even shorter, apparently, they ended up forming a group on Facebook, and then posting their concerns to the Minister of Health's Facebook page.  This then prompted the Minister of Health to make surprise visits to several EDs, and, in some manner, the Taiwanese feel their social networking has led to a fortuitous response to their public dialogue.

So, slowly but surely, I'm sure all these little blogs will save the world, too.

"Facebook use leads to health-care reform in Taiwan."
http://www.ncbi.nlm.nih.gov/pubmed/21684378