Monday, August 27, 2012

Who's Burned Out? We Are!

In a survey of U.S. physicians, published in Archives of Internal Medicine, Emergency Physicians hold the dubious honor of being the most "burned out" specialty.  This estimation of burnout is based on survey questions regarding emotional exhaustion, depersonalization, and personal accomplishment.  Unsurprisingly, dermatology was not a terribly burned out specialty – likely because they also ranked quite highly in time for personal and family life.  Surgical specialties, despite ranking at the bottom for family life, were only in the middle of the road for burnout – probably indicating the nature of the work plays a role in the strain.  Self-selection bias always plays a role in these surveys, of course, considering the response rate was only 26%.

Compared with the employed general population, physicians were more burned out and had less time for family – which may or may not be related to the 25% more hours per week worked, although, there were many differences between the physician cohort surveyed and the comparison.  

The New York Times discusses this article and uses a vignette of a "missed diagnosis" as symptomatic of the disruption of quality of care due to burnout.  While it may be true that burnout relates to healthcare quality, the specific case presented seems to fall more into a category of reasonable conservative management of the most likely condition, with appropriate further enquiry made at a re-visit due to persistent symptoms.

"Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population"

Friday, August 24, 2012

Head to Head With Head CT Rules

The "headline" you'll see from this article is that the Canadian Head CT Rule outperforms the New Orleans Criteria for radiographic imaging in minor head trauma.  Specifically, it outperforms it in this prospective, observational cohort from several hospitals in Tunisia, consecutive patients with blunt trauma to the head and at least one symptom secondary to the head trauma.

The most striking thing about this article, however, remains the gruesome number of false positives generated by each of these head CT decision rules.  While, obviously, the intent is to capture all the cases requiring neurosurgical intervention, the New Orleans Criteria could not rule out potential need for neurosurgical intervention in 1,180 out of 1,582.  When the theoretical purpose of these rules is to prevent "scanning everyone", we're not getting much bang for our buck.  The Canadian Head CT Rule was better – but still indicated a need for scan in 656 out of 1,582.

While the article focuses mostly on the need for neurosurgical intervention in GCS 15 patients, it's interesting to see their "secondary outcomes" which did not need "intervention".  Only 34 total patients in their cohort required intervention – while they found 133 skull fractures, 41 subdurals, 45 epidurals, 69 subarachnoids/hemorrhagic contusions, and 1 case of pneumocephalus.  The Canadian rule would have missed 11 of the 218 "clinically significant" findings, for a sensitivity of 95%.  The article does not specific precisely which types of findings were missed, but, clearly, many of those may be argued to be not significant.  Unfortunately, deriving a better rule based on a more liberal definition of "clinical significance" is likely to result in more missed interventions – but it's still probably worth trying.

"Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study"

Wednesday, August 22, 2012

How Fast Can We Rule-Out AMI?

Six hours?  Two hours?  One hour?  McDonalds' drive-thru?

This is the paper from Archives of Internal Medicine that's been making the rounds in the lay press regarding how quickly the ER should be able to detect your AMI with the new highly-sensitive troponins.  This is the APACE, prospective, international, multi-center study evaluating patients with "symptoms suggestive of acute myocardial infarction" and onset within the last 12 hours.

In this cohort, 1247 patients were recruited – and >300 were excluded for either going straight to the cath lab or having "another procedure performed" at the 1-hour time mark – and received hs-cTnT at index, 1, 2, 3, and 6 hours after presentation.  Myocardial necrosis was defined as a hs-cTnT >99th percentile, which for this assay is 14 ng/L, and a diagnosis of acute MI was made by two independent cardiologists upon review of records and lab results.

The authors split their cohort into two groups, a derivation cohort and a validation cohort, and did some statistical wrangling to come up with two cut-off strategies – one for rule-in and one for rule-out.  They were able to make diagnostic decisions on ~76% of their cohort at the one-hour time point, and 52 ng/L at presentation or an increase within an hour of 5 ng/L or more was ~94% specific for AMI.  Likewise, 12 ng/L and an increase less than 3 ng/L at 1 hour was ~100% sensitive for AMI.  The remaining 25% of their cohort was in a non-diagnostic zone.  At 30 days, there was one death in their rule-out cohort, for a 99.8% survival rate.

So, can you use this strategy?  If you feel as though this study is externally valid to your populations and you're using the same Roche Diagnostics test, you certainly may.  Every piece of data is something you can incorporate to your discussions with a patient regarding diagnostic certainty and risk.  Even an extra hour occupying an ED bed rather than moving out to a chest pain observation facility can significantly impede ED flow, while observation admissions are costly and inconvenient to patients.  The ideal strategy will depend on the capabilities of individual departments.

This study, along with the primary author, are sponsored in part by Abbott, Roche, and Siemens.

Monday, August 20, 2012

Intensive Blood Pressure Control in ICH

Not much works to treat ICH – and this retrospective analysis of INTERACT1 tries to coordinate a couple leaps to pull a different spin out of old data.  Unfortunately, it's still a re-analysis of essentially a negative trial, and that limits its utility for the purists.

INTERACT1 randomized patients with ICH to either "intensive" blood pressure lowering or conventional treatment – most of whom received some BP control – and noted significant improvements in hematoma volume.  However, the 90-day safety/clinical outcomes data did not show any difference in mortality or dependency.  This publication reverses the strategy, taking a look at the associations between good clinical outcomes and hematoma volume – and finds that increases in hematoma volume at 24 hours clearly predict poor clinical outcomes.

So, if intensive BP control reduces hematoma expansion and reduced hematoma expansion improves clinical outcomes, then why was INTERACT1 negative?  I suspect we'll find out more when INTERACT2 is published....

"Hematoma growth and outcomes in intracerebral hemorrhage: The INTERACT1 study"

Sunday, August 19, 2012


Medication shortages are affecting many hospitals – we're low/out of prochlorperazine, injectable metaclopromide, etomidate, propofol, brevital – and one of the replacements we've recently been introduced to is "Propoven", a European manufacture of propofol.

It has only minor differences from propofol, but it should be noted it requires strict sterile technique when handling and has more medium-chain fatty acids.  An informational letter from Kabi describing a few of the differences is here:

AHRQ Infection Control @ ACEP

Jeremiah Schuur, featured on EM Lit of Note for his timely critique of the inadequacy of the "quality" measure for non-contrast head CT, passes along a notification of a pre-ACEP conference in ED infection control practices.

Sponsored by AHRQ, ACEP, and infection control societies, find more information about the conference here:

Friday, August 17, 2012

Honey For Pediatric Cough

Sponsored by the Honey Board of Israel, this small study supposes to demonstrate that honey is superior to control in the treatment of pediatric nighttime cough.  Specifically, honey is superior to silan date extract, which apparently resembles and tastes like honey.

This is a prospective, double-blind study of three different honey arms and one control arm.  Each group had approximately the same pre-intervention symptomatology severity – cough severity, bothersome nature of the cough, and sleeplessness for bother parent and child – and all interventions improved symptoms.  The scores, supposing clinical relevance to a 0.75 difference in score on a 4-point scale, were significantly improved by all interventions.  Then, the various types of honey all either strongly trended towards or reached statistical superiority over the silan date extract.

So, if your child has a cough – honey seems to be a reasonable intervention.  If you don't have honey, give them silan date extract!  If you have neither – well, just don't use dextromethorphan.  And, 20% of infant botulism cases are traced to contaminated honey, so the current recommendation is not to give honey to patients aged less than 1 year.

Incidental note is also made by the authors that some children likely disliked the more aromatic eucalyptus and citrus honeys.

"Effect of Honey on Noctural Cough and Sleep Quality:  A Double-blind, Randomized, Placebo-Controlled Study"

Wednesday, August 15, 2012

Platelet Transfusion & Intracerebral Hemorrhage

This systematic review is published in Annals of Emergency Medicine under the section heading of "Best Available Evidence", which somehow to me seems to pleasantly understate the unfortunate lack of data on this topic.

Intracererbral hemorrhage in the setting of antiplatelet use unfortunately is one of those clinical situations where outcomes are so dire that the philosophy seems to be to throw the kitchen sink of potentially beneficial interventions at patients.  Use of clopidogrel, and to a lesser extent aspirin, are associated with increased hematoma size and poorer outcomes.  Platelet transfusions, using measures of platelet aggregation activity, are demonstrated to improve and reverse inhibition in approximately two-thirds of patients.  Therefore, it follows that platelet transfusions would improve outcomes in intracranial hemorrhage.

Unfortunately, the "best" evidence – which is mostly retrospective data of small cohorts – fails to demonstrate any improvement in mortality or morbidity.  It is not possible to say from the data whether the platelets do not show efficacy at treating the extension of the ICH, or whether the poor outcomes result from parallel transfusion-related complications.  The article concludes that withholding platelet transfusion should be considered to be within the standard of care.  I tend to agree that resource-intensive treatments should be required to demonstrate benefit before widespread adoption, and therefore agree with these authors.

The authors additionally note a prospective, multicenter trial is underway.

"Does Platelet Transfusion Improve Outcomes in Patients With Spontaneous or Traumatic Intracerebral Hemorrhage?"

Monday, August 13, 2012

Mistakes Were Made

This is a fascinating series in Pediatric Emergency Care in which interesting cases from published medical malpractice verdicts are featured.  Each case – typically ending poorly – is followed by a short editorial on the underlying disease processes, with pearls regarding treatment, diagnosis, and the case outcome.  Reading these cases, hopefully, will not contribute to recency bias, and ideally serve simply as brief reminders of clinical features of the rare sick children lurking in the haystack of walking well.

Medicine – as much as or greater than any other profession – is a delicate mix of confidence, humility, and the recognition of the underlying biases in our cognition and practice.  Most of this blog focuses on practicing based on evidence, applying the rules and probabilities of populations as guides towards the diagnosis and treatment of individual patients.  Therefore, when reading these Legal Briefs, I simply want to reinforce the dangers of anecdote-based medicine.

"Pediatric Emergency Medicine:  Legal Briefs"

Friday, August 10, 2012

Here Comes Gonorrhea (Again)

Good news for the monogamous – bad news for the rest – Neiserria gonorrhoeae is rapidly becoming resistant to cefixime, an oral third-generation cephalosporin.  The resistance rates are low – a maximum of 17% in Honolulu – but the fear is that continued cefixime use will carry-over into an increased resistance for ceftriaxone.

This follows the 2007 declaration that fluoroquinolone resistance had obviated their use.

For now, the CDC recommendations have narrowed to 250mg IM/IV ceftriaxone plus 1g oral azithromycin once or 100mg oral doxycycline BID for seven days.

"Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections"

Thursday, August 9, 2012

Cited in Journal Watch

My dabigatran article from Annals of Internal Medicine has been cited in Journal Watch.  Huzzah!

"Within 12 weeks of marketing approval, dabigatran was found to be 
responsible for more adverse events than nearly all other medications.
   By David Green, MD, PhD"

Dabigatran:  How Safe?

Wednesday, August 8, 2012

Ketamine - Cure For Everything

There aren't many medications I love using more than ketamine.  I use it for adjunctive pain control, to control agitation, and for induction prior to intubation.  Now, chances are, it's probably useful in seizures.

This is a case report and review of the literature for the use of ketamine in the control of refractory status epilepticus.  The literature is profoundly weak – the "review" is essentially a review of case reports.  And, the patient outcomes describe in the case reports are replete with "All died" or "Survived but severely disabled."  However, this is primarily due to the serious cause of the underlying disorders – encephalitis, neurosyphilis, meningitis, anoxic brain injury – and less likely the ketamine, although this does not provide the evidence to that effect.  The proposed mechanism is via NMDA receptor antagonism, which the author proposes works better by synergy with GABA antagonism, rather than either as monotherapy.

Seems like a fair physiologic mechanism, and it's nice to have something additional to consider in refractory disease.  Ketamine also was noted in this case report to counteract the hypotensive effects of midazolam and propofol, consistent with prior literature describing its beneficial effect on cerebral perfusion pressure.  It's pretty much a "I tried this and I like it" article, but I think it's probably likable and not the last we've heard about ketamine for status.

"Early Ketamine to Treat Refractory Status Epilepticus"

Monday, August 6, 2012

When Do Patients Need Blood Cultures?

Another lovely JAMA Rational Clinical Examination article relevant to the Emergency Department – this time regarding the utility of blood cultures.  Blood cultures are frequently requested for febrile inpatients, however, the incidence of false positive ranges between 2.5% and 8%.  This leads, unfortunately, to additional patient harms from additional treatment or observation.

This article is a systematic review of several studies gathering clinical features of patients for whom blood cultures were requested, as well as the clinical outcomes of the cultures, in an attempt to identify features predictive of positive or negative cultures.  They also examine a couple validated clinical decision instruments to determine their potential utility in stratifying the appropriateness of cultures.

Essentially, based on a few pieces of decent evidence and a few pieces of poor evidence, the authors determine a few general categories of infectious etiology with varying pretest probability for bacteremia.  These are:
 • Cellulitis, community-acquired pneumonia, community-acquired fever: low (<14%) probability
 • Pyelonephritis: mid (19-25%)
 • Severe sepsis, septic shock, bacterial meningitis: high (38-69%)

In general, however, no individual clinical feature had a positive or negative likelihood ratio of sufficient magnitude to guide testing.  Combinations of clinical features – such as patients with SIRS – were capable of excellent sensitivity & negative likelihood ratios, but only had specificities of 0.27 to 0.47.

However, the more important clinical aspect of blood cultures and bacteremia is not addressed in this article, which is how frequently the true positives even change clinical management.

"Does This Adult Patient With Suspected Bacteremia Require Blood Cultures?"

Friday, August 3, 2012

Vancouver Chest Pain Rule in Tehran

Iran and Canada would be considered by most to be very different places.  However, from a cardiovascular standpoint, it seems they're not so disparate.

This is a prospective, validation study of the Vancouver Chest Pain Rule.  The Vancouver rule is one of many 2-hour accelerated rule-outs operating under the presumption that all disease can never be detected – sensitivity will never be 100%, but this assumes a context in which a discussion may be had with the patient about outpatient disposition.  Essentially, any patient under 40 years without a history of coronary artery disease and a normal EKG simply gets discharged.  Older than 40 and atypical chest pain is discharged either immediately after a CK-MB < 3.0 µg/L, or receives a 2-hour delta + repeat EKG if > 3.0 µg/L.  Essentially, the rule is designed only to ensure all unusual NSTEMIs are picked up.

In the initial study, the 30-day ACS rate for the discharged group was 1.2%.  In this Iranian study, the 30-day ACS rate of 292 very-low-risk patients is 1.3%.  Two of the four patients meeting criteria for discharge by CK-MB had positive troponins.  Considering CK-MB is nearly considered anachronistic now, most modern EDs would have not have discharged these patients based on troponin testing.  A third patient had EKG changes on the second EKG – which should fail the Vancouver rule, so I'm uncertain why it was included in their very-low-risk group.  Finally, the last patient had an entirely normal evaluation and a subsequent 70% lesion discovered on angiography a week later.  No mention of the hemodynamic significance/relation to ischemia of this lesion is noted.

A few hundred patients is hardly a definitive validation, but it's a nice demonstration that 50% of their cohort could have been discharged in two hours – and with the same 30-day event rate as the poor people being made to glow in the CCTA studies.

"Validation of the Vancouver Chest Pain Rule: A Prospective Cohort Study"

Wednesday, August 1, 2012

Tramadol: A Myth of Safety

For me, tramadol lands squarely in the gap between oral analgesics I might use for "no pain" – ibuprofen, acetaminophen – and analgesics I might use for "real pain" – hydrocodone derivatives.  The literature describing the analgesic properties of tramadol is bizarre, with multiple comparisons with placebo, nerve blocks, adjunctive epidural anesthesia, etc., and very few head-to-head comparisons to the sorts of medications we routinely use.  When there are comparative efficacy reports, they typically conclude that tramadol is effective...just as effective as the NSAIDs its being compared with.

The theory I've heard people use when considering use of tramadol is that it has a better safety profile than hydrocodone and is less dependence-forming.  These claims may be true, but I do not believe they are true to the extent that it is clinically relevant.  Tramadol still generates an opioid withdrawal syndrome and, as this article describes, overdose/abuse still results in apnea with need for ventilatory support.

Additionally, tramadol is a GABA antagonist, lowering seizure threshold.  Of the 525 patients overdosing primarily on tramadol retrospectively identified at this Iranian hospital, 19 experienced apnea and 242 (46.1%) experienced seizures.  This is retrospective and co-ingestants cannot be fully ruled out, but the propensity for seizure is far more surprising than the incidence of apnea.

Tramadol has a role in pain control prescribing, but, in my practice, that role is tiny.

"Tramadol-induced apnea"

Tuesday, July 31, 2012

The "Peripheral" IJ

Some patients just have no IV access – no superficial peripherals, no deep peripherals, no external jugular veins.  In a critical emergency, this is the perfect time for an intraosseous line.  But, what about the situation where IV access is simply necessary, but not urgent?  Placing a central line is the last thing we're interested in doing – draping, opening a costly central line kit, billing for an expensive procedure, exposing them to risks of over-the-wire techniques in the central circulation.

This technique, described formally here by folks from Highland Hospital, involves placing a standard, peripheral catheter into the internal jugular vein under ultrasound guidance.  While I think this is a fantastic idea – much faster and less expensive than a full multi-lumen central line set-up – I wouldn't characterize it as "risk-free", either.  The nine cases in this year-long review all demonstrated a lack of complications, but more data would help refine the procedural risks.

"The ultrasound-guided 'peripheral IJ': internal jugular vein catheterization using a standard intravenous catheter."

Monday, July 30, 2012

Excitement For/Failure of CCTA

The third of the big CT coronary angiography studies from the last year – and, yet again, this is positive for its primary endpoint.

However, that value of that endpoint is another matter – mean length of stay in the hospital.  For the CCTA cohort, that mean was 23.2 hours and the "standard evaluation" was 30.8 hours.  However, more illuminating – and further favoring CCTA – is that the median CCTA evaluation time was 8.6 hours compared with 26.7 hours in the "standard evaluation" group.  Just like in the previous studies, CCTA is faster, and, for some patients, much, much faster.

But, as you can probably gather from that mean/median discrepancy, a substantial cohort in the CCTA group went on to have some pretty extensive downstream testing and prolonged hospital stays.  This means, from a costs standpoint, the two strategies eventually even out.  No significant safety differences were detected between the two strategies.

Now that we've seen the full results of ROMICAT II, CT-STAT, and ACRIN-PA, we have a pretty good idea of what this test does.  If you must evaluate these low-risk chest pain patients with imaging of some sort, need to clear them out of your Emergency Department quickly, your cardiology team is excited to take on the false positives, and you're unconcerned about the downstream harms – then CCTA is the test for you.  If the potential harms, the poor specificity, and the non-functional nature of the test concerns you – then no one will fault you for dragging your feet.

The accompanying editorial gets it right - this is still a test looking for the correct application.  However, we don't just need a better test – we need a better consensus for whom we're simply not going to test.

"Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain"