EMU Monthly – August 2015

All the EMU goodness for August 2015

AUG 2015
1) Gosh it was tough surviving the virus attack on my poor little website. But we are back and we will never bow to the pressures of liberal conservatives and republican democrats. Nor to the terrorist threats of pacifists or to fear of physical harm from handless individuals. We stand as a republic – dedicated to Liberate, Equalite and the Sigma Upsilon Rho Fraternite (actually we prefer the Sororitie). We welcome everyone back, and we give our best to continue servicing the most important people – you of the emergency medical community with significant issues.
2) Let’s get started. This was a meta-analysis – but it was 35 studies of more than 27000 patients. They found that patients way over estimated the benefits and underestimated the harms of medical interventions. As such, the authors claim that this is the reasons we overdo medical interventions and the reason that the USA is going bankrupt. (JAMA Int Med 175(2)274). I am sure Father has some other ideas on why the USA is going bankrupt. There are some problems with this study. This is a meta-analysis and that leads to all sorts of problems –were the patients equal? Were the interventions equal in their benefit /harm ratio? Were USA patients different than other countries? And how do you define benefit or harm? And the numbers were all over the place- in some studies 7% of patients overestimated benefits while in other studies 94% overestimated. But the conclusion is the key – be accurate – and if you do not know – look it up. TBTR: Patients think medical interventions are usually useful and not harmful. What a mistake.

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3) Another concept I want to introduce is indication creep. This is where there is an intervention that may help a few people that is then expanded to a whole population – for example therapeutic hypothermia which helped Woody Allen in Sleeper (this is actually a different machine but we won’t tell you what it was) image007

but then was unjustifiably expanded to all patients. Their solution: have professional societies cut this in the bud when they write your guidelines (JGIM 30(2)249) I would add get people off the guideline committees with research interests and industry connections that may affect their judgment. Or better yet – don’t make guidelines at all. TBTR: Be careful about indication creep. Or any creep.image009

This month’s quotes (are there people who only read EMU for the quotes? –Then get a life!) Delivery room quotes.
“When I went in to be prepped for a C-section, I left my bra and panties on because my boobs are uncomfortable without support, and I was leaky from my water breaking,” she recalls. “So, I had a pad on to keep me from sitting in a puddle, and the nurse that was taking my vitals looked at me and said, ‘You didn’t get in this position with them on, now get them off.’
4) Push fast and push hard. This has nothing to do with the above quote but rather CPR. Look, I know this was a manikin study, but I like manikin studies- there was a time that these were the only females I could get to go out with me. They determined that pushing hard led to greater fatigue (no surprise there) and of course less effective compressions- i.e. – they didn’t get as deep. (AJEM 32(12)1455) Almost there – I always maintained that push hard and fast leads to less effective CPR because it doesn’t allow good cardiac output, but we’ll wait TBTR: Push hard and push fast is fatiguing and not effective in getting to compression depth goals. Following what seemed like an unusually long labor, Jessica F. said her husband stepped out for a brief moment to notify the family of the progress. It was then that the baby was born. When her husband stepped back in, he was so frustrated he missed the actual birth. “When he returned he was all hurt and upset, and he said with a completely serious face ‘screw this, we are starting all over, put that baby back,”
5) Anaphylaxis- you want the vasoconstriction that epi is so good at giving – but there is the beta effects which may be less desirable. In the case report- epi failed and nor epi worked miracles. So what happened? This patient was in the OR and had an allergic reaction to vecuronium. They could not get the patient out of VF – and this being from a presumed cardiac source- and we know that epi is very arrhythmogenic- so as we expected; they did well with nor epi. (ibid 32(12)u306) Obviously, very preliminary stuff, but food for thought. TBTR: Nor ep for anaphylaxis- maybe the way to go. Colby S. recalls, after 17 hours of labor, spilling out, “Why can’t we just lay eggs?” Husband:(After he saw the placenta): I am in the mood for meatloaf
6) Clinical quiz time: Kinda of an easy one but with a twist. A patient with severe abdominal pain for a week. No vomiting or diarrhea. So what was it? Ok, I won’t be so mean – he did a CT and found thickening of the small bowel wall. Any ideas? Ok, Ok, he developed a rash a few days later. What was this? (EMJ 32(1)43) Husband: Oh neat, I can see your insides!” When pushing, the nurse told me to get on all fours — that it would help. My husband says something along the lines of — “Oh yeah, doggie style… That’s how the baby got in there!”
Another husband: “It’s no different than a cow giving birth”

7) NSAIDS – a frequent targetimage011 of mine can cause significant GI bleeding – but this article points out that up to 50% of GI bleeds from NSAIDS are from a source further down- yes I mean the large bowel. They say that this is because we are using PPIs in anyone with a stomach – so the stomach is protected. Curiously, Aspirin doesn’t cause as many GI bleeds distally. (Gastro Endo 80(6)1132). TBTR: NASIDS can cause GI bleeding – in the colon! More brilliant husband lines: “After 11 hours of labor and the epidural not working, my husband looked at me and said, ‘Honey, it can’t hurt that bad!’ I looked at him and replied, ‘come let me twist your testicles.’ He backed far, far away
1. 8) EMJ is against the use of Glucagon for food impactions in the esophagus as no studies have shown its effectiveness and it could cause vomiting (EMJ 32(1)85) Yea, maybe – but the studies were poor- It always worked for me TBTR: Glucagon for esophageal impactions? Maybe it doesn’t work. “He asked the doctor how soon we can have sex just seven minutes after I delivered our son.”
8) Fluids for pancreatitis- what could be simpler? Well, when you give more than maintenance amounts of fluids you end up with patients with more mortality: ARDS, ARF, lung injury, sepsis – sounds bad? No? (Pancreatology, 14(6)433) The key here is – how bad was the pancreatitis and how much fluid is too much fluid? Questions, questions. TBTR: Pancreatitis, maybe enough to give them the normal amount of fluids. What is normal? How should I know – do I have any semblance of being normal? “While delivering my son, I felt something coming out. I told my husband to get the nurse, so my dear, sweet, wonderful husband goes to the door and literally yelled into the hall, ‘MY WIFE HAS TO TAKE A DUMP!
9) Is this the magic potion for asthma or not? Yes, it is cheap, yes it is easy to give, and yes it has few side effects- what could be more glorious than magnesium- now in the compact kiddie version. The dosages are between 25- -50 mg/kg bolus followed by 40 mg/kg/ hr – or just give it nebulized and forget all the dosages IV. (Paed Resp Rev 15(4)319) The problem is that the studies they used studies that they used to prove all these benefits were tiny. Just recall that in adults Mg is indicated only for moderate to severe asthma. TBTR: Magnesium – should we be giving it to all asthmatics? Can I turn the TV up? I can’t hear over your moaning
10) Morning sickness – good ole hyperemesis gravidarum – the first step in appreciating our offspring so as to be better prepared for “Dad I need the car keys” when they get older. (which is much better than making Mom vomit in the mornings). AJOG 211(6)602 says we should reevaluate our approach here. Pyridoxine and Doxylamine are now approved for this indication. The former should be familiar to you – that is Vitamin B6. The latter is an antihistamine. They are down on ondansetron because of the FDA’s QT elongation warnings. I don’t know. I have little experience with the new drugs, (I have used doxylamine for sleep induction in some patients) but ondansetron always worked for my patients. I will point out – although it is totally irrelevant- that ondansetron and doxylamine are both category B, while pyridoxine is category C although as you know – we aren’t using these categories any more. TBTR: New drugs for pregos who are painting the porcelain. “To the doctor, he said, ‘Can you close that thing up? We won’t be needing it anymore’
11) I thought this article by our neighbors to the south would have deserved a better journal This was a double blind study in Saudi Arabia which double blinded used corticosteroids, honey or orabase for aphthous ulcers- and honey won out. Given that we do not really understand this entity and honey is cheap- why not? (Quintessence Int 45(8)691). This would make sense given the wound healing properties of honey. Then again, why not magnesium? It is also cheap and works in pediatric asthma. Just because it doesn’t taste as good? TBTR: Honey may be an option for aphthous ulcers.
12) Here is another soapbox. I know people prefer the clinical articles, but this is an important point and to satisfy Father, this was not written by the usual leftists he so loves. You- and I mean you – cannot control what your patients do. You are at the best an advisor. So why is your performance based on what patients do? Analysis of populations studies show that medical care only changes outcome in 10% while 50% can be attributed to patients changing behavior (exercise, stopping to smoke etc.) 50% of patients don’t take the medicine we ordered as prescribed , and, 30% never even fill the prescription. So why are we evaluated on patient outcomes? Aside from our patients ruining everything (see my Dr. House quotes in the past) there are other variables. For example educated individuals live 10 years longer than those without a high school education (it’s that darn algebra, I tell you). People who are positive and actively involved with other people-they live from 4- 10 years longer than negative people Negative(JAMA 312(24)2613) I liked this point especially because reimbursement is often based on these factors TBTR: Read it anyway. Husband: you are doing great honey. Wife: SHUT UP SHUT UP SHUT UP PUT A GUN UP THERE AND SHOOT IT
13) Of course with case reports – you can’t tell true incidence – but do understand that Rocephin can cause a hemolytic anemia. (J Ped Hem Oncol 37(1)e63) The problem here is that all the cases I found were in patients that were somewhat immunosuppressed. But still a good idea to be careful. TBTR: Rocephin can cause a hemolytic anemia. “When my brother was born, they had to use forceps to get him out. My mom saw them and screamed ‘THOSE ARE SALAD TONGS! YOU ARE NOT PUTTING ANY GODDAMN KITCHENWARE IN THERE!’
14) I use ketamine for pain control. I use it for fibromyalgia. I use it for sedation, I use it for RSD. I use it for constipation. I use it for large boogers. OK, maybe not for constipation or boogers. But now you can use it for alcohol withdrawal. Maybe. They rejected a lot of patients and in the end had just 23 patients. And that is the major weakness of this paper. But it did work better than benzos and the ketamine was given not at sedation dosages but rather pain dosages. (Ann Pharm 49(1)14). In addition it seems that this was given IV continuous drip for up to 38 hours so I do not think that this is really an ED option. But it could be. TBTR: Ketamine may be superior to Benzos for alcohol withdrawal. I don’t know why I am thinking about this, but Father announced on Risk Management Monthly that his favorite fruit is a maraschino cherry. I think the last urine sample Father gave had an olive floating in it. “When my sister was in labor, she was screaming and our mom was trying to be comforting: ‘It’ll be OK. Take some deep breaths. It’ll be over soon.’
Then my sister looks up at our mom and says ‘You have no idea what this is like.
15) I am giving this to you only as a reference. I know that one of the pressing questions that has affected your daily functioning is: are MRIs dangerous in pregnant women? The answer is that there is a lot of bad evidence and a lot of speculation but what is somewhat clear at this point is that the presence of an IUD is not a problem if you want to do an MRI. (Mag Reson Imag Clinic Nor AM 23(1)59) TBTR: MRI is probably safe in pregnancy but no one really knows. They say men can never experience the pain of childbirth. They can…if you hit them in the goolies with a cricketbat for fourteen hours.
~ Jo Brand
16) Scores for appendicitis were popular for years until someone discovered that ultrasound and CT may work. image014The one that lasted the test of time was the Alvarado score but I always was concerned because this didn’t give enough weight to real RLQ tenderness (should be worth 10000 points and not 2 points). The AIR score does take that into account and includes also consideration for higher WBCs and also level of fever to what we are used to – above 38.3 C (Alvarado is 37). Same goes to percentage of PMNs. It also takes into account CRP. AIR did beat the Alvarado score but both still missed about 8%- good but not better than the imaging tests we have – CT and US. (WJS 39(1)104) TBTR: You can use scores to help out diagnosing appendicitis – but do imaging. On the one hand, we’ll never experience childbirth. On the other hand, we can open all our own jars.
~ Bruce Willis
17) A good study and this will be a help to you. DVT- the garden variety that we see every day – do they make silent PEs? This cohort study says – yes they do -66% of the time. However, it doesn’t really matter because most are not clinically significant. (BMC Cardiovas 14:178) This could be simply because once you know there is a DVT – you will start anticoagulation which will effectively treat the PE too. TBTR: You do not have to search for silent PEs in DVT. To my embarrassment, I was born in bed with a lady.
~ Wilson Mizner
18) Killing time was immediate – effective killing time -12 seconds.image015 Inhibits biofilm formation. Look up in the sky? Is it iodine? Is it chlorhexidine? No it is hypochlorous acid – if that sounds familiar- it is closely related to sodium hypochlorite which is household bleach (actually hypochlorous acid isn’t stable but they used a stabilized form). This is also used in chlorinating swimming pools. And it caused less tissue toxicity than the above agents.(Wounds 26(12)342) Of course this article can’t say much – it was done completely in the laboratory and did not study patient oriented outcomes- but we do know that household bleach can kill the AIDs virus so it could be true. It should be pointed out that most agents do kill host tissue – it is far more important to do irrigation than antisepsis. TBTR: Hypochlorous acid- which is like bleach – may be the antiseptic of choice in the future. Somewhere on this globe, every ten seconds, there is a woman giving birth to a child. She must be found and stopped.
~ Sam Levenson
19) Wow-we don’t see many papers like this one. If you watch when they take your blood for a routine blood test – it hurts less than those who look away! OK, it is true that 75% of people do not look – but in this study – they had pain scores twice as high as those who did look (Eur J Pain 19 (1)97) Now these were Brits and other cultures may act differently, but is very interesting to me. This could mean if you watch your own colposcopy it will hurt less! TBTR: Watching noxious stimuli may reduce the pain. To enter life by way of the vagina is as good a way as any.
~ Henry Miller
20) What an important article – what a dumb publisher. You did know that medications can contain gluten. So these fellows called up companies and checked data bases and made a nice list. (AJ Health Sys Pharm 72(1)54 However, you cannot access the article without paying for the article and there is no phone number or website to get this information. TBTR: Gluten content of medications – see inside. To heir is human.
~ Dolores E. McGuire
21) Hey here is a great idea- send e mail reminders to patient to improve compliance. And in this study those who received these reminders were very gratified. (AEM 22(1)47) Only problem was that it didn’t work to get people to be more complaint. But actually- this may have worked- I think it depends on the type of patients you are dealing with. And in primary care this actually may work very well – if your patients have e mail – or know how to read. Then again your doctor has to know how to read as well, so this may not work for surgeons. TBTR: E mails to remind patients are appreciated although they don’t change much.

“Use a condom. The world doesn’t need another you.”
― Carroll Bryant

22) EMS giving charcoal? This is safe, and it doesn’t delay transport (AJEM 33(1)56). Why stop there- this stuff should be stocked at home. And the pub. “The thought of getting pregnant again is terrific birth control.” Bethany Lopez
23) This was a retrospective study, but I don’t think that matters much- epistaxis is pretty much a diagnosis that can’t be confused with much else. There were frankly some surprises here. Yea, sure if you take Coumadin that is a risk for recurrent epistaxis, but aspirin and Plavix use was not .And also, the INR level doesn’t affect the risk – even an almost normal one is a risk. Yea, HTN is a risk factor too, but CHF and DM even more so- probably from ASCVD? URI, sinusitis, deviated septum, substance abuse- were not risks. (Mayo Clinic Proc 89(12)1636) TBTR: CHF is a risk for recurrent epistaxis. Aspirin use is not. “One of my favorite moments is when a guy, at that certain point in a relationship, says something desperately hopeful like, ‘Are you on the pill?’ I simply say, ‘No, are you?” Roxanne Gay
24) Legal briefs- pain behind the eye is never- well almost never- conjunctivitis- think optic neuritis, think perhaps scleritis or endophthalmitis- but please don’t forget aneurysm. (PEC 31(1)77) Here are some lines from OB Nurses: Q: When does a woman’s biological clock start ticking?
A: Right after she looks in the mirror and thinks, “On my God, crow’s feet!”

Q: What is the most common pregnancy craving?
A: For men to be the ones who get pregnant.

Q: What is the most reliable method to determine a baby’s sex?
A: Childbirth.
25) I am definitely a name dropper- I turn to mush when I see Paul Marik articles and Ian Stiell articles Let’s start out with Paul’s article(Paul was in Pittsburg but now is at E Virginia) He has some new info on hypertensive crises. Retinopathy used to be used to determine end organ damage- but it is now known that a significant amount of hypertensive emergencies do not have this finding. Meds to reduce blood pressure vary from country to country but Nicardipine seems to be the preferred drug- coincidentally not available in Israel. However, Paul points out that Sodium Nitroprusside is out – it is very hard to control the profound hypotension that can occur in the ED. He then points out – and I am not sure I understand this – that the renin angiotensin system is activated and there is naturesis so giving fluid is reasonable. But that also implies that one should not use diuretics for BP control, and NTG should be giving with caution as it is only venodilator. (ICU Med 41:127) This information is useful, but I am one that is unsure that hypertensive emergencies exist. Let me explain – even Paul agrees most are precipitated by some other factor – stroke, pulmonary edema, acute renal failure, MI, aortic dissection. He points out that PRES can occur – posterior reversible encephalopathy syndrome with primary hypertensive emergencies- but I think we all agree that is rare. TBTR: some nice tidbits on hypertensive emergencies. Q: Should I have a baby after 40?
A. No, 40 children is way too many already.

Q: I’m two months pregnant now. When will my baby move?
A: With any luck, right after he finishes college.

Q: How will I know if my vomiting is morning sickness or the flu?
A: If it’s the flu, you’ll get better.

Q: Does pregnancy affect a woman’s memory?
A: Most of the ladies I asked don’t remember.
26) Where is the Ian Stiell article? We do have one – but that is next month. But we do have some education articles – The first was entitled: “Not Another Boring Lecture” –but it was a boring article. However there are some techniques in their list that may be useful if you are boring (are you?) but all their techniques –do involve some participation of the participants.( JEM 48(1)85)Some of them may even be fun – like writing our own guideline ( that’s fun?) But my way is to use small groups and frequent ADD breaks with some good jokes and voila- you have EMU. TBTR: Some lecturing techniques- see the article to make sure you aren’t’ putting people to sleep. Then next article was more interesting- and writing by an old friend who I haven’t seen in 25 – years – Gary Green – I think who is the same one that used to work with Roneet Lev on international EM. – Roneet is a reader- am I mistaken? My Gary Green was originally from Johns Hopkins. This article was actually more interesting and was about bedside teaching. They point out that teaching rounds – like on the wards- don’t adapt well to the ED – too crowded, too many interruptions, etc. This article is also too detailed to summarize here – but includes some things that we know already (they call it Aunt Minnie- – if it looks like Aunt Minnie- it is) (I prefer “if it quacks and waddles – it isn’t a zebra) but also some techniques like a small meetings before going on to the battle field to prepare the student , then having him present at bedside (EMJ 32:76) I have to say another technique I have often used in today’s era of cell phones that do everything including robotic surgery and Gyn exams –I say – here is a case of Giant Cell Arteritis – look it up on your phone and teach me all that you know about it. TBTR: Good tips for bedside teaching. Q: My breasts, rear end & even my feet have grown. Is there anything that gets smaller during pregnancy?
A: Yes, your bladder.

Q: Ever since I’ve been pregnant, I haven’t been able to go to bed at night without onion rings. Is this a normal craving?
A: Depends on what your doing with them.

Q: The more pregnant I get, the more often strangers smile at me. Why?
A: Cause you’re fatter then they are.

Q: My wife is 5 months pregnant and so moody that she’s borderline irrational.
A: So what’s your question?
27) There is a religion called the J Witnesses who refuse blood products. What do you do? They present a nice algorithm which starts with erythropoietin and iron. Then it gets interesting with hemoglobin based oxygen carries- most of these are hard to find and expensive but they can be lifesaving in these folks. They go through dosing and indications for each one. (Transfusion 84:3026) TBTR: Blood loss in a Witnesses patient? No problem. Q: What’s the difference between a pregnant woman and a Playboy centerfold?
A. Nothing, if the pregnant woman’s husband knows what’s good for him.
Q: Is there a reason I have to be in the delivery room while my wife is in labor?
A: Not unless the word “alimony” is a concern for you.
28) Letters: We have.But it is late already –we’ll try for next month
29) Number six was Henoch Schönlein purpura. The twist was that in 24% of the cases the abdominal pain can precede the rash.
EMU LOOKS AT: Boogers and Sludge
The two essays this month are from the BMJ 2014 g6537 and Emerg Clin NA 33:133
Noses
1) They speak about all these things you should take when ther is a history of nasal trauma, but most of them are pretty obvious. However, other than asking about taking anticoagulants, and epistaxis – ask about smell and sight. Vision could be a sign of facial fracture and a fracture through the cribriform plate could damage the olfactory nerve. This can easily be tested by passing gas near the patient and checking for a reaction (I was kidding – please don’t do this!!
2) You got to look for septal hematomas- they can cause damage to the cartilage and need to be opened- the look like thisimage018

( What I didn’t know is that these tend to be bilateral – unilateral ones are rare)

3) Rhinorrhea is an ominous sign if it continues- it could be a sign of CSF leak.
4) Do they need an x ray? Actually not. Do they need an immediate reduction? Well, that isn’t clear to me. According to what I learned – you should wait until the swelling goes down and then try to reposition– usually after five to seven days. However, some say to jump on this. The article agrees with me, but it seems that if you catch these early you can try to reposition.

Organophosphate and Carbamate poisoning
1) Ah tox, always a lot of fun if you aren’t the patient. These are ubiquitous – since they are pesticides. But hey are also great suicide agents as you would know if you lived in India where in 2010 there were 25288 suicides with these agents while in 2012 – only three people died in the USA from exposure to these agents. These agents are AcH cholinesterase inhibitors.
2) Where will you find these agents? ? Bait for cockroaches. Shampoos for head lice. Pet shampoos, and collars, and of course in warfare- where they have been used by the Iranian’s, the Syrians and of course the famous Sarin incident in Tokyo. There is one medical use for organophosphates- Diisopropyl phosphofluoridate is used for glaucoma. Carbamates are used for medical purposes –and you are familiar with them –edrophonium for Myasthenia, physostigmine and tacrine for Alzheimer’s. Neostigmine was used for adynamic ileus and some snake envenomation. They are also very effective insecticides and fungicides, but they are also good a people- cides- as witnessed by the worst industrial accident tin history when 3800 people died from a leak in Bhopal India.
3) Pharmacology – you were all ready to skip this paragraph –I would also- so let’s make it brief. OGPs are lipophilic so there can be a delay in symptoms, they can cause prolonged toxicity, and they can redistribute to cause trouble down the line. Carbamates do not cause prolonged tox. Because of this, we have what is called intermediate syndrome, where there is weakness and even respiratory failure later on.
4) Because this inhibits Anticholinesterase, this causes the SLUDGE syndrome (unless of course it is inhaled where it acts like a nerve gas that is lethal within a few minutes). SLUDGE is S is sweating and salivation. L is lacrimation, U is urination, G is gastric emesis, but there is also bradycardia, wheezing, and constricted pupils. However, neuro symptoms include ataxia, coma, respiratory and circulatory depression. Delayed ventricular dysrhythmias also.
5) You also have to know about OPIDN – organophosphate induced delayed neuropathy. They get a hand and feet paresthesia progressing to ataxia, weakness, muscle flaccidity – this takes a while to return to normal and sometimes can be permanent.
6) Diagnostics- forget it- by the time you get the results back from any relevant blood test it will be years after the patient improves. Go by history.
7) Management- HAZ MAT – – decon: you can refer to protocols.
8) Treatment – give atropine – then more and more. Have to intubate? Avoid sux- it too needs anti cholinesterase and there will be prolonged paralysis. Use benzos aggressively to abort seizures.
9) How do you give atropine? Start with 1-2 mg, and give every five minutes until pulmonary secretions dry up. Then start a drip at 20% of the total you needed until l now – and give it per hour. Think you’ll use up all the hospitals supply of atropine and piss off the pharmacist? You are right! Atropine works only on muscarinic receptors and not nicotinic. (HTN, mydriasis tachycardia, fasciculation) Glycopyrrolate also can work as well as atropine.
10) Oximes improve outcomes and prevent OP aging. I mean we know this stuff works but the studies have not exactly shown any evidence Dialysis will not help. Treatment for intermediate syndrome and OPIDN is supportive.

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