Friday, July 13, 2012

It's Nothing Like "ER"

This is a fun little article regarding the realism of the Emergency Medicine environment showcased on the popular U.S. television show "ER".  As the authors state in their introduction, the viewers of the show have been surveyed, and a significant portion of the viewers believe the content of the show to be valid clinical information.  However, the televised outcomes are frequently unrealistic (CPR success rates, patients emerging from comas, etc.), and lead to inaccurate public perceptions.

This team of authors watched all 22 episodes from a single season of "ER" to evaluate the types of patient encounters depicted, and then compared their findings with representative data from the NHAMCS dataset.  Overall, there were 192 patients during the 22 episodes, and they differed from the real-world by:
 - Weighted heavily towards 25-44 years of age, rather than infants and elderly.
 - More male and white, rather than black and female.
 - Depictions of lower pain levels.
 - Far more traumatic injuries.

And, this analysis only observed the patients - the responsibilities and skills of the treating medical students, residents, and attendings are also wildly dramatized, of course.

So, it's nothing like "ER".  It's really more like "Scrubs"....

"ER vs. ED: A comparison of televised and real-life emergency medicine."

Wednesday, July 11, 2012

Flumazenil - Seizures, But Not Frequently

It seems as though, when teaching trainees about benzodiazepine overdose, flumazenil is discussed - and in the same breath, the commandment to use it never or with extraordinary caution.  The fundamental issue is whether an underlying pro-convulsant state can be unmasked if the protective effect of benzodiazepines is removed.

The answer from this study, a retrospective review of a decade of flumazenil use in California, is clearly yes.  However, the "yes" is only 13 seizures out of 904 reviewed cases, most of whom had some sort of co-ingestant that contributed to the pro-convulsant state.  The authors also note, for the cases in which data was available, flumazenil was therapeutic (and potentially diagnostic as well) in 53% of administrations, with return of alertness from unresponsiveness or drowsiness.

So, the answer to the clinical question - whether flumazenil use should be as taboo as current dogma - is more complex, and, unfortunately, descends into that dark area where risks must be weighed against benefits.  Is the risk of poor clinical outcome secondary to resuscitative efforts in the field, delayed/missed intubations, etc. greater than the 1-2% risk of seizures?  Or can the patient be safely observed with minimal intervention in a monitored setting?  Or, if flumazenil is effective, how much money was saved by reducing the need for the expansive medical testing performed on unresponsive individuals?  I don't believe a single blanket answer suffices to cover each individual clinical situation.

"A poison center's ten-year experience with flumazenil administration to acutely poisoned adults."

Monday, July 9, 2012

NICE Agrees - No PPI in UGIB

It's hard to fight this battle in the United States.  It's like hyperkalemia - where you carefully talk down the rotating IM intern from giving albuterol, terbutaline, bicarbonate, insulin, Kayexalate, and calcium to the K+ of 5.7 in your dialysis patient - and then the nephrology fellow on-call tells 'em to give it anyway.  Sigh.

But, in any event, despite the lack of evidence for benefit in patient-oriented outcomes for intravenous proton-pump inhibitors in UGIB, invariably the GI fellow wants it.  There's even a suggestion of harms associated with IV PPIs in some of these studies - in addition to everything we're learning about how gastric acidity contributes to the total body immune defense.  For all its criticisms, I think NICE - the clinical effectiveness consensus group in the United Kingdom - has gotten it right for UGIB.  Terlipressin, which isn't available in the United States, appears to be beneficial in variceal bleeding.  Somatostatin analogues, not included in this guideline, may or may not be beneficial, and I agree that it was appropriate for them to be excluded.

In the meantime, I'll keep fighting the inanity, one patient and one resident at a time....

"NICE clinical guideline 141 - Acute upper gastrointestinal bleeding: management"