EMU Monthly – February 2006

1) This study looked a flying and noticed that there was significant falls in saturation on commercial flights. Patients that averaged 97% saturations on ground found themselves with a sat of 93% in the air. This has obvious implications for smokers and other breathing impaired individuals who are flying (Anaesthesia May 2005). This does sound ominous, but there were limitations to this study- only 84 patients and from ages 1-78. Still, it is important to consider this with the other hazards of flying that we have spoken about before (economy class syndrome, dehydration).

 

2) Plavix (clopidgel) is a standard for cardiac patients, and some TIA folks get it (although we in the past have brought two articles about aspirin plus dipyridamole being better for TIA than aspirin and Plavix). This study does describe a subset of patients that do not respond to this expensive drug i.e. there is some resistance to this drug to the tune of 4-30% (Journal of the American College of Cardiologists 19 Apr 05) –

 

3) Statins are now routine early in MI, and maybe in stroke (see Neurology, 2005) but now they are being touted for sepsis due to their reducing inflammation and stopping the activation of the coagulation system. (Circulation 12 April 05) We are still waiting for the magic bullet here, but statins are more available than nitric oxide scavengers, and sildenafil for sepsis but I think we are a long way from proof. Still, keep it in mind.

 

4) Rigors are good for you- it implies a more robust response to infection, and indeed patients with rigor have higher survival rates. Yes there is bacteremia with this, but it is transitory (Journal of Internal Medicine May 05) We often see this in the emergency department people with UTIs- especially young women who had rigor and do just fine with antibiotics at home. I in any case give them a dose of once4 a day gentamycin

 

5) Where else would you see such a study if not in EMU? Is recollection of information (short and long term) better with presentations that use writing on transparencies and projecting them or by a fancy power point presentation? They used the same lecturer and they found that it did not make a difference (Teaching and Learning Medicine Spring 2005)

 

6) There are many reasons for missed lumbar punctures, but length of needle is not usually one. In this study, they measured by MRI the average distance to the spinal cord from the skin and it was 62.8 mm. The average needle is 90mm long. (Neurology 12 April 05)

 

7) I always believed that Acetaminophen was the safest pain reliever, but there are some caveats. The Journal of Rheumatology reported last year that this drug does remain the first line in arthritis despite being less effective than NSAID for pain. The journal called Hypertension (2005 (46)) reported that daily use could increase blood pressure in women, although it was an observational study and there are always problems with such studies. Now the American Journal of Respiratory and Critical Care Medicine (1 May 05) reports that exacerbations of Asthma and COPD occur with use of this drug. It is thought the mechanism is by glutathione reduction.   This was also an observational study. Still, it is still the safest drug for pregnancy for sure and there is a lot better studying that has to be done.

 

8) Yet another article that says that buckle fractures do not need to be casted. However the two groups (control and study group) consisted of 18 and 21 patients each (Journal of Pediatric Orthopedics May-June 2005) I believe this is true but you cannot make science with lousy proofs.

 

9) My goodness- I can not tell you much about how they did this study- something to do with a high frequency, low frequency and entropy analysis, but in any case the attempt is to find a difference in the medications propofol and midazolam (Dormicum, Versed) Both dump blood pressure, both effect respirations- of course propofol lasts a lot less time than midazolam. Seems through this analysis, propofol causes a net parasymphathetic response (heart rate barely changes) while midazolam causes more of a sympathetic response. Where is this important? In heart patients. (Anesthesia and Analgesia July 05)

 

10) The parents of kids saw a video of their doctor stating how antibiotics are overused and how we must not use it for the disease currently being treated- yet most of the patients still ended up with antibiotics (Pediatric Infectious Disease Journal June 05) In Israel there remains the feeling that you can not go wrong with Augmentin, but we do see psudeomembraneous colitis with this antibiotic, and the gastrointestinal symptoms are tough. I still believe all of us should use our head before using this class of drugs.

 

11) Guess What? Most homeless do want full CPR and most do not have surrogate wills (Chest June 05)

 

12) Last month we spoke about colored sputum in COPD patients. However, in regular folks, these are usually not bacterial and do not need antibiotics (JAMA 22 Jun 05)

 

13) Rare article but worth noting- anorexia patients do have significant effects on their heart parameters such as QT, LV end diastolic pressures, echo findings, but this all returns to normal after they regain their weight. (European Journal of Pediatrics, June 05) Note these are not clinical effects but it still says something

 

14) Taking blood pressure in kids- some tips. Use a cuff that is the right size. Measure BP with feet on the floor instead of having them dangle their legs. Inflate 30 mm hg above the systolic pressure measured by disappearing radial pulse. Take

BP in leg if in arm is high- do not forget coarctation (Circulation 8 Feb. 05)

15) Lastly for our EMS readers, over the head CPR does work and is easier to do in the back of an ambulance (Anesthesia Analgesia July 05) Also Academic Emergency Medicine in May reports that BLS crews can give albuterol (salbuterol in Israel) safely if given a protocol to not give to people with a heart history. However, they do not consider cardiac asthma if it is a first time manifestation

 

 

EMU LOOKS AT: Making Mistakes

Learn from other people’s mistakes, you cannot possibly live long enough to make them all your self Sam Levenson

 

I am still smarting from my respected friend LA s comment that Porphyria oh it is so boring, so I decided to take a non-clinical subject this month. Why are mistakes done in medicine? Are there bad doctors or are they impaired in a different way? The basis for this essay are two outstanding articles entitled Five Pitfalls in Decisions About Diagnosis and Prescribing by Jill Klein in the 2 Apr 05 issue of the BMJ, and The Cognitive Psychology of Missed Diagnosis by Don Redelmeier in the 18 Jan 05 issue of the Annals of Internal Medicine.   It goes without saying that we all make mistakes, that improvement not punishment is the right way of dealing with this, and that documentation is helpful, although not necessarily related to quality issues

 

1) Intro- remember the word heuristics. This is a fancy name for strategies and shortcuts that help us sort through the information that we are provided and arrive to the diagnosis. These strategies help us sift through the irrelevant information, and streamline our thought processes. In emergency medicine especially we must be very focused and to the point- we have little time with the patients, and must ask the right questions to get the right answers, as well as knowing when to quit the search. Shortcuts are not a bad thing- indeed they are typically correct.

 

2) THE REPRESENTATIVENESS HEURISTIC OR IRENE IS HERE YET AGAIN.

We all have seen the scenario- Irene has been to the emergency department 5 times in the last three days with the usual complaint- electrils going up and down her arm. She has been under treatment with Risperdal for years, and collects empty plastic bags.   She has diabetes which she for which she does not take any pills.

 

The problem: Psych patients complain a lot, but diabetics have MI s. Which do you give more weight to?

 

The solution: Be aware of the disease occurrences and risks before factoring in the additional confounding information.

 

Yea, I know, you were all brilliant and said that Irene did infarct. Let us see how you do with your next drug abuser coming in with shortness of breath after a fight with his girlfriend!

 

3) THE AVAILABILITY HEURISITIC OR IT IS AN AORTIC DISSECTION NIGHT

 

We often most remember the most complicated or interesting case we saw recently.

That is, Jane saw a lady with neuro symptoms who had porphyria (sorry) and now everyone you see with parasesthias has the same thing in your mind. The easiest retrieved is not necessarily the correct information.

 

4) OVERCONFIDENCEOR EVERYONE KNOWS I AM G-D S GIFT TO MEDICINE

 

Do not need to say much here- we are all overconfident according to the studies. I say doubt yourself, try to punch holes in your reasoning, and do not ignore little added details that make the whole hypothesis collapse. Then make your patients aware, and if possible part of the reasoning process.

 

Example: I often tell patients- look you are very constipated now, and that is not to say that you do not have an underlying process, but with all this constipation, it confuses the picture. Here is some laxative, and go to your doc tomorrow to be reevaluated.

 

5) CONFIRMATORY BIAS, OR YOU HAVE THE DISEASE I WANT YOU TO HAVE

 

Here we read the nurses note or the referring doctor s note and automatically put the person in a specific category. This will affect what questions you ask, and how you interpret the information you are given. I would not say always to start again, because in the emergency department that is not always practical, but keep your ears peeled for pieces of information that do not fit. This is also known as anchoring bias, and reflects the stuck in gear philosophy

 

Example: The ankle has no swelling therefore the X ray is normal. I would suggest you look at the x ray first, then the ankle than the x ray again

 

6) ILLUSORY CORRELATIONS OR THE PATIENT GOT BETTER BEFORE MY EYES

 

This is the tendency to relate two events without considering if this is a coincidence or two non-related facts. Examples include the improvement before the storm seen in epidurals and in iron poisoning. Voltaren may have helped his pain in the back, but did nothing for his aortic aneurysm.

 

7) FRAMING BIAS, OR YOU CAN NOT BE PREGNANT BECAUSE YOU SAY YOU ARE NOT

 

The way it is presented makes a difference, and is not that different than confirmatory bias. For example if you present the chances of dying at 10% people will panic. If you say it is a 90% survival, people breath easier. Same with us- fever shortness of breath and cough makes PE leave our mind. Be a devils advocate and thing that perhaps you are not hearing the full story.

 

8) BLIND OBEDIENCE OR IT IS MY WAY OR THE HIGHWAY

Here the attending told you what to do, or a consultant or a better doctor.   Think how ridiculous this would sound in a court of law, and what a star you will be for thinking of something else. And guess what? It makes us all better doctors

I would add just two other factors for EM- one is always, and I mean always think of the worse thing this could be and make sure you rule it out. Also, remember the exhaustion factor- if it is the end of the day, do not take simple solutions- tough problems come in the end of the day too.

Many EM programs put in as the last line in the chart Medical Decision making and explain what they thought. Maybe you should too!

It is OK to make mistakes, just do not become a legend at it!

Peter Viciellio, MD FACEP

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