Monday, May 7, 2012

Outpatient Management of PE - With ERCast

Hosted by the mellifluous Rob Orman, we discuss a couple recent articles regarding the outpatient management of low-morbidity pulmonary emboli.  Short summary:  overdiagnosis of pulmonary emboli of uncertain clinical significance notwithstanding, the key to managing physiologically intact patients with pulmonary emboli is close follow-up to minimize the length of time patients are subject to dual anticoagulation.

Listen at:  ERCast - Pulmonary Embolus Outpatient Treatment

The Legend of the Therapeutic Arterial Line

As many Emergency Physicians can probably attest, one of the curious practices of critical care is to catheterize every potential organ system - as though the presence of these catheters in some way improves outcomes.  And, the theory is - the non-invasive numbers are not accurate enough upon which to base treatment options.

So, this is a simple study performed in an intensive care unit in which patients with arterial blood pressure monitoring receive non-invasive measurements at the arm, ankle, and thigh (not everyone in the ICU will have an accessible arm).  And, essentially, the results show - even in the critically ill, even on vasopressors - that the mean arterial pressure in the arm is probably a accurate measurement, with a mean bias of 3.4 mmHg.  The systolic and diastolic numbers, as well as the ankle and thigh values, were not quite as precise or accurate.

For the Emergency Department, it probably tells you it's OK to do what you probably already do - critically ill patients get arterial lines only if there is a luxury of time available.  Someone else with half an hour to spare can poke around fruitlessly in the radial wrist before surrendering to the femoral....

"Noninvasive monitoring of blood pressure in the critically ill: Reliability according to the cuff site (arm, thigh, or ankle)"
www.ncbi.nlm.nih.gov/pubmed/22425818

Saturday, May 5, 2012

Rational Clinical Examination: GI Bleeding

This series of articles, "The Rational Clinical Examination" in JAMA is by far one of my favorite approaches to medicine.  They ask simple clinical questions, and they do literature searches to find evidence to apply.  Additionally, the form in which they distill the evidence tends to be likelihood ratios - a far more useful statistical construct in estimating how a particular finding contributes to ruling-in or ruling-out disease.

This most recent literature review covers gastrointestinal bleeding - and it covers a few worthwhile points.  Most encouragingly, the authors are exceedingly skeptical about the utility of NG tube placement - reasonable positive LR for UGIB, but, as the authors note, a suspected source is usually well-established prior to NG tube placement.  Additionally, they note that the NG lavage does not tend to influence final patient-oriented outcomes - and lean towards not recommending its use.  Secondly, they also cover the Blatchford and Rockall scores, which are decision instruments that might have value in helping triage patients for outpatient management.

"Does This Patient Have a Severe Upper Gastrointestinal Bleed?"
www.ncbi.nlm.nih.gov/pubmed/22416103

Thursday, May 3, 2012

How Medical Students Choose Residencies


Turns out, it's only mildly earthshaking - for some students, location is more important.  For other students, the program "fit" is more important.

The article goes on to evaluate whether there are specific factors that residency directors can influence in terms of attracting the right candidates and, obviously, none of the location-based factors are easily influenced by program leadership.  The top location-based factor was simply the attractiveness of a particular geographic location, with proximity to family being the next most important factor.

Drilling into the features of individual programs that residency directors can modify, it seems as though candidates base their decision mostly on "gut feeling" - coming down to how well they clicked during the interview session or when meeting with current residents.  After "fit" characteristics, then factors such as curriculum, length of program, and reputation came into play.  Relatively unimportant features were compensation, program size, and websites/social media run by a program.

Unfortunately, the article does not delve into what specific program characteristics residents were looking for - presumably 3-year programs were preferred to 4-year, and one of the popular curriculum questions during visits is regarding the presence of "floor" months.  However, it is an interesting overview of how candidates self-report the importance of their ranking influences.

"Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs"

Tuesday, May 1, 2012

"Consequences" of Conflict of Interest Disclosure


As if physicians are children, and truths must be hidden from them, three consultants of the healthcare industry have published a commentary in JAMA regarding the possible adverse effects of conflict of interest disclosure. 

They provide cautionary justification for their belief that physicians who have conflicts of interest will overstate or exaggerate their results.  They believe this will happen either as a compensatory mechanism to overcome any skepticism created their reported COI, or because physicians will use their disclosure as an excuse to provide biased results "because the [audience] has been warned."  They also feel that disclosures of conflicts of interests to patients might make them anxious, which would impact the therapeutic relationship built on trust.  And, finally, they believe that all this hullabaloo about disclosure distracts from the real COI issues associated with fee-for-service and other financial arrangements that should be prioritized for reform.  I tend to think these are narrow, paternalistic arguments that downplay the critical importance of transparency.

Additionally, given a ten citation limit, they cite their own prior articles six times.  I'm not sure if this is an effective strategy to build trust in their evidence or the legitimacy of their message.

But it got them in JAMA.

"The Unintended Consequences of Conflict of Interest Disclosure"