EMLitofNote on EM:RAP

With Rob Ormon[sic] of ERcast, discussing how (hopefully) coronary CT angiograms don't become as popular as July's discussants propose.

Sorry, I don't have my own readily distributable copy of the clip – but I do have an article coming in a few weeks in EMJ BMJ summarizing my views.

"CT Angio Again!"
http://www.emrap.org/episode/2012/october/ctangioagain?link=episode-segment

Death By Horticulture

This case report, by the surgeons across the street at Baylor, describes a novel cause for bowel obstruction in children.  Apparently, in the course of plant cultivation, it is useful to have water-retaining gel spheres.  Advertised to retain water and grow to 400 times their original size, a child swallowed a "Water Balz" and developed a small bowel obstruction requiring laparoscopy and enterotomy.

More interestingly, the surgeons obtained five of these balls and evaluated their growth pattern.  The balls began life at ~0.95cm in diameter and, after 96 hours, reached a diameter of ~5.5cm, most of the growth in the first 12 hours.  Based on this, the surgeons estimate any swallowed balls would likely easily pass through the pylorus before resulting in complete bowel obstruction.

The claim of growth to 400 times size, however, is unfounded.  The balls they studied only grew to 200 times original size.

"Water-Absorbing Balls: A “Growing” Problem"

www.ncbi.nlm.nih.gov/pubmed/22987870

Trauma, the Hard Way

Anyone who has been to a surgery morbidity and mortality conference understands the cultural bias behind the desire to "pan-scan" all trauma patients.  If an injury is missed, and the body part wasn't scanned, someone is going to need to stand up and look foolish.

However, this article describes a trauma center in Boston that made a concerted effort to reduce CT scanning.  They came up with fifteen evidence-based guidelines for various scans and made a consensus to use these decision instruments to assist in their assessment for need for CT.  And, as you might expect, they identified significant reductions in CT scanning during their study period – 37% total reduction in number of CT scans.  If 37% doesn't sound like a big enough number, perhaps the $1.1M absolute difference in brain, chest, and abdomen/pelvis scan costs is enough to get your attention.

However, they have rather some weaknesses.  They state there were "no missed injuries", which is unusual because every study of CT in trauma patients fails to achieve 100% sensitivity – even in patients with liberal use of CT.  Then, they do have twice as many "complications" in their evidence-based scan group, as well as three times as many 30-day readmissions.  I'm not sure each complication follows from the scanning strategy, but it is an oddly significant difference.

Interestingly, they excluded patients who did not survive 24 hours.  Perhaps it complicated their abstraction process, but it is of slightly greater clinical interest to evaluate for potential missed injuries that resulted in immediate demise, rather than the misses that resulted in slightly longer-term morbidity.


"Evidence-based guidelines are equivalent to a liberal computed tomography scan protocol for initial patient evaluation but are associated with decreased computed tomography scan use, cost, and radiation exposure"
www.ncbi.nlm.nih.gov/pubmed/22929486

Pediatric Intubation – Not Always Successful

This is an observational study of pediatric medical resuscitation, published in Annals of Emergency Medicine, using video to evaluate the frequency of various adverse events during pediatric intubation.

As expected in a teaching institution, there is a fair bit of variability in initial success rates – ranging from 35% first-pass success for pediatrics residents up to 89% for PEM or anesthesia attendings.  Overall 52% had success on the first attempt.  Unfortunately, 61% experienced at least one adverse event during intubation.  These were typically not clinically important with regard to patient-oriented outcomes.

However,  what is more entertainingly concerning is how few of the complications make it into the medical record.  The written documentation overestimates first-attempt success, underestimates desaturation during the procedure, and even completely omits any mention of one of the two episodes of CPR required during resuscitation.

My guess is that Cincinnati Children's may have had a documentation quality review after this data were collected.


"Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review"
www.ncbi.nlm.nih.gov/pubmed/22424653