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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

December 27, 2012

PHARM FOAMed Airway Curriculum

Minh gets himself a CL-1 on... himself
In addition to the countless posts and presumably a real job, Minh Le Cong has been putting together a free online airway curriculum. So far he has 4 episodes, here's what we have so far:

#FOAMEd Online Airway training Program – Anatomy review lecture by Dr Seth Trueger
we discuss airway anatomy

#FOAMEd Online Airway training Program – POSITIONING AND BLADE USE with Trueger and Faust
we talk about positioning and some techniques for laryngoscopy
featuring special guest and magnesium enthusiast Jeremy Faust

#FOAMEd Online Airway training Program – more Anatomy, blade technique and topicalisation by Dr Seth Trueger
Featuring a guest appearance by Minh's glottis

PHARM Podcast 52 : #FOAMEd Online Airway training Program – Airway Decision making
Featuring one of my airway mentors, the incomparable Reuben Strayer, and a tough case from Alexei Wagner

December 21, 2012

Outstanding Reference Award

  • appears in a legitimate publication
  • quotes a fictional character
  • cites of Wikipedia
  • Bonus Points awarded for referencing the Will Rogers Phenomenon.

Congratulations to Brendan Carr & Robert Welch for the first MDaware Outstanding Reference Award for #6 in Traumatic Intracranial Hemorrhage, Value in Health Care, and Being Important (currently e-pubbed).

The article is a very nice piece on patient-centered care and evidence for GCS-15 ICH patients and is worth a read.

The ORA is given here for:

UPDATE 11/1/2014:
Bret Nelson sends in a critical letter to the editor:

Jeremy just showed me your best reference awards. From 2012, yes, but I'm still catching up on the internet. I am surprised Annals allowed a Wikipedia reference in this case since it is obviously not the primary source of the quote used.
The spider man reference, "with great power comes great responsibility," should have looked something like:

Lee, Stan (w), Kirby, Jack (p), Ditko, Steve (i). "Introducing Spider Man" Amazing Fantasy 15 (August 1962), New York, NY: Marvel Comics
With the caveat that the original comic book text as written was 

Of note, according to Wikiquote:
The saying pre-dates"Amazing Fantasy. The phrase "with great power goes great responsibility" was spoken by J. Hector Fezandie in an 1894 graduation address at The Stevens Institute of Technology - "The Moral Influence of a Scientific Education", The Stevens Indicator, Volume 11, Page 217. The exact phrase was repeated during a speech by President Harry S. Truman in November 1950 - Public Papers of the Presidents of the United States: Harry S. Truman, 1950 (published 1965), Page 703. A UK Member of Parliament implied in 1817 that a variant of it was already a cliché Thomas C. Hansard, ed (1817). Parliamentary Debates. p. 1227. Retrieved on October 10, 2013.
Bret Nelson

December 3, 2012

Tweet-in-Brief: Truncated Vent Edition

November 29, 2012

Guest Glossary Term: Unparalyzed

Don't forget to check out the other glossary entries!

from Steve Carroll (@embasic):

rocuropenia - noun

In need of endotracheal intubation, and, more to the point, paralysis.

That trauma patient was being rowdy with signs of rocuropenia...

   hypoplastic vocal cord syndrome

November 7, 2012

GERD Gives Me Chest Pain

From EM Clinics of North America:
Relieving factors

Many individuals incorrectly assume that because a patient's chest pain is relieved with nitroglycerine, the pain is more likely to be cardiac in nature. In examining this question, Henrikson and colleagues [39] found a higher incidence of relief of chest pain in patients without ACS than those with active ischemia. Steele and colleagues [40] also found that nitroglycerine relieved chest pain in 66% of patients who were ultimately diagnosed with noncardiac chest pain. This data shows that chest-pain relief by nitroglycerine had no value in predicting or disproving ACS. Similarly, physicians have used the GI cocktail (a mixture of antacids and viscous lidocaine) to prove the likelihood of a GI cause and disprove the presence of ACS. There is no recent literature supporting the use of the GI cocktail for differentiating these types of pain, but the practice persists. Many physicians believe that burning substernal pain relieved by antacids is clearly caused by esophagitis or gastritis. Subsequent studies have actually shown that “burning” chest pain or pain described as “indigestion” may be as strong a descriptor of ischemia as chest pressure. [28],[31] In a small descriptive study, Wrenn and colleagues [41] found indiscriminate use of the GI cocktail for various ED complaints. In this subset, a significant portion of patients who were subsequently admitted with possible myocardial ischemia reported total or partial relief after administration of a GI cocktail.

In summary, chest-pain relief with either nitroglycerine or GI cocktail does nothing to improve the diagnostic accuracy for ACS and should not be used to influence decision making. (emphasis mine)
Relief of symptoms with nitroglycerin is not helpful in distinguishing ACS from GERD. Unfortunately, most ED patients with GERD-like symptoms therefore also have anginal-like symptoms, and most will need an ACS workup. It's not that the ACS workup relieves GERD symptoms; rather, in the ED we don't diagnosis patients. We "risk-stratify" (particularly with potential ACS) and determine which life-threatening diagnoses are potentially present, and whether the chance of that life threat is worth is sufficient to warrant workup (or treatment).

So in a sense, yes, the ED treatment for heartburn is an ACS workup.

But maybe someday without a stress test.

[39]  Henrikson C.A., Howell E.E., Bush D.E., et al: Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 139. (12): 979-986. 2003.

[40]  Steele R., McNaughton T., McConahy M., et al: Chest pain in emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM 8. (3): 164-169. 2006.

[28] Goodacre S.W., Angelini K., Arnold J., et al: Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM 96. (12): 893-898. 2003.

[31] Lee T.H., Cook E.F., Weisberg M., et al: Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 145. (1): 65-69. 1985.

[41]  Wrenn K., Slovis C.M., Gongaware J.: Using the “GI cocktail”: a descriptive study. Ann Emerg Med 26. (6): 687-690. 1995.

November 1, 2012

The Easiest Blood Draw

Peter Cushing as Dracula
Warning: this may sound crazy at first. But hear me out, listen to my anecdotal evidence* and then try it out for yourself.

Nurses are excellent at placing peripheral IVs. Occasionally, some patients are too tough and the nurses turn to us. Not because we're any better -- they place plenty more IVs than we do -- but because we can use sites they aren't allowed to (EJ), perform invasive procedures (CVC & IO), and have tools they usually aren't allowed to use (ultrasound -- great video from the US guys!). These are all methods that work, but take time, and sometimes the US-guided peripheral just won't take.

Sometimes the nurses get the line (hurray!) but couldn't get the labs (oh no!) -- which is frustrating (or at least, it used to be). The recourse I see a lot of people take is the arterial stick, invariably a blind radial draw. Seems reasonable -- you can feel the pulse, it only takes a few minutes, and is successful ~80% of the time.** If you're savvy at US then it's even more likely to be successful. But I have seen many a tiny and/or squirrelly radial artery, and those do not like being poked.

Here is my fail-proof method:

Ultrasound-Guided Femoral Stick

This may sound drastic. I used to reserve it for sick patients -- those critically ill enough to have pharmacologic or endogenous sedation, or at least those who seemed sick enough to warrant it. But mission creep set in, and now I will do it on nearly anyone who needs blood drawn but not a catheter.

This may seem extreme, particularly when the radial is an option. But in my head, this takes a 5 minute procedure with an 80% chance of success into a 30 second procedure with a 100% chance of success. In the words of Dogbert, it's like sandblasting a soup cracker.

I tell the patient that it may sound crazy, but that I really think this will be better than digging around in their arm for 5 minutes -- which they invariably just went through about 3-10 times before the nurse called me over.

Of course this is anecdotal, but when I ask (awake) patients if this was better or worse than a other sticks (i.e. peripheral IV placement or blood draw) they invariably say the groin was MUCH less painful. There was one even one awake guy with a fully functioning brain and nervous system where we had a conversation through the entire fem draw, and he didn't feel a thing. Nothing! He didn't believe I had even poked him until I showed him the 20 mL syringe full of his blood.

I've started telling patients that while it may seem scary and will hurt a bit because, well, it's still a needle, but that enough patients have told me it's better than the arm pokes that I feel comfortable telling them it's less painful than any other option. And afterward, every awake patient has agreed.

The simple steps:

  • 18g needle
  • 20-30 mL syringe (smaller if you only need 1 lab)
  • US with vascular probe
  • alcohol or chloroprep
  • gauze & tape
  • lab tubes (& ice if getting lactate or BG)
  • 3-way stopcock
  • vacutainer
  • lab labels
  1. Get ALL your gear together -- including ordering your labs and printing the labels, so you don't have to run around for them later
  2. Clean the groin
  3. US for the vessels
  4. Draw the blood under US guidance -- as I'm not placing a catheter, I usually just cheat and go straight down in plane with the US
  5. Fill the syringe
  6. Withdraw. Close the needle safely
  7. Hold pressure over the site with gauze. If the patient is awake and has use of their ipsilateral upper extremity, I have them hold pressure
  8. SAFELY transfer your blood into your tubes use 3-way stopcock & vacutainer so you can't poke yourself (excellent 1 min video by Whit Fisher, or one of these)
  9. Ask the patient if that was better or worse than the usual draw
  10. Give the patient a Press-Ganey survey
Some of you may have noticed that I have yet to specify femoral vein or artery. That's not an accident. If it's a sick patient, I want blood and I don't care where it comes from. Vein is probably preferable to artery -- less chance of complication such as fistula or pseudoaneurysm, and just for convenience, less time holding pressure when you're done.

I've also had a markedly lower rate of hemolysis than I expected.

In fact, if I have a sick patient and they look like they will be a difficult IV placement at all, I routinely advise my nurses NOT to try to get labs at all -- just focus on getting the IV and I'll take care of the labs. Makes for happy patient, happy nurses, happy doc, happy blood.

*Similarly, Aaron Johnston spoke about procedural sedation for manual disimpaction on Rob Orman's ERCAST. Sounds crazy at first, but once you see it, everyone is convinced. Level of evidence: A for Anecdotal

**Level of evidence: M for Made up number

Image: Peter Cushing as Dracula. Before blowing up Alderaan as Grand Moff Tarkin, he was a B-movie vampire. 

UPDATE 11/1/12:
response to radial arterial draws:

October 26, 2012

tweet-in-brief + QOTD: “Special”ties

October 25, 2012

Medicare at 67?

One of the ideas thrown around to save Medicare costs is to increase the age of eligibility from 65 to 67 (Social Security is undergoing a slow transition from 65 to 67, initiated by Congress in 1983). It seems to make sense: people live & work longer, so let's adapt and save some money.

But it looks like it wouldn't help very much.

These numbers below are from a 2011 analysis by the Kaiser Family Foundation I recently reviewed for journal club. For more (but not too much) detail, there's a great Executive Summary on page 5.

If the age change suddenly went into effect in 2014, this is what would happen in the first year:
  • Federal savings: 
    • $5.7 billion (1% of total Medicare costs)
  • Increased costs:
    • 65-66 year olds: $3.7 billion
    • Employers: $4.5 billion
    • States: $0.7 billion (via Medicaid)
    • Premiums: 3% increase for both Medicare recipients and those insured through the Health Insurance Exchanges
A word on their methodology: they make 2 useful assumptions. First, that the ACA stays in force as currently enacted, and implemented as expected (for simplicity, they assume every state expands Medicaid as directed by the ACA). Second, they assume an abrupt increase in the age of Medicare eligibility to 67 (if it were enacted, it would most likely be phased in gradually over at least a few years).

A bit more detail:
  • 5 million enrollees would be affected (there are roughly 50 million now, 42 million >65 years old and 8 million <65 but disabled)
  • Medicare would decrease spending by $31 billion but the total federal savings would only be $5.7 (about 1% of Medicare spending) billion due to increased costs in Medicaid, subsidies through the exchanges, and decreased revenue from Medicare premiums
  • Out-of-pocket costs for 65-66 year olds would rise $3.7 billion
  • Employers would spend an extra $4.5 billion
  • Premiums would increase for 2/3 of 65-66 year olds (about $2200/year each)
  • Premiums would decrease for 1/3 of them, largely through subsidies through the exchanges
  • 42% of 65-66 year olds would receive insurance through employers
    • half would still be working
    • half through a spouse or through a retiree plan
  • 38% would get insurance through the exchanges
  • 20% would get insurance through Medicaid
  • Premiums in Medicare and the exchanges would both increase about 3%
    • Will Rogers phenomenon: the healthiest seniors would leave Medicare, making both the Medicare pool and the non-Medicare pool sicker on average
It's worth noting that over time, the federal share of those covered under the Medicaid expansion slowly drops from 100% to 90% in federal funding, so over time, the federal share will drop a small amount but state costs will increase a bit.

One other point I will add here is that while life expectancy has certainly gone up since Medicare's inception, a lot of that increase is because fewer people die as infants and children. It's not like everyone used to die at age 65 and now everyone dies at age 78 -- many/most of those who made it out of early childhood a century ago lived into their 70s, and many of the big improvements in population health has been in stopping those early childhood deaths (bringing up the overall average).

What if the ACA is repealed? The fed will save a bunch more money -- very roughly, I would estimate $20 billion based on these numbers.** So let's call that 4% of total Medicaid costs saved. But in the absence of the ACA, the 65-66 year olds would only have 3 options for insurance:
  • Medicaid (if they're poor enough)
  • Employer-sponsored (if they're either working or eligible as a retiree or through a spouse)
  • Private individual market
And a lot of them wouldn't be able to get affordable insurance on the individual market -- without the ACA guaranteed issue regardless of preexisting conditions, and the other premium control mechanisms and subsidies, many 65-66 year olds find it basically impossible to get coverage.

So yes, Medicare is costs a lot. And we need to reign in costs. But increasing the age of eligibility 2 years looks like it will only shave 1% off of Medicare costs, while shifting a huge burden onto individuals, employers, and states. 

NB This post refers to the US Medicare program -- government health insurance for the elderly & disabled.

*nothing below this point is from the KFF paper

**$31b minus $7b in premiums and roughly half of the increased Medicaid costs ($8.9b, so another $4b)

October 15, 2012

Is Roc vs Sux Moot?

I'm a big fan of rocuronium for RSI. The argument is succinctly -- and arguably definitively -- made by Reuben Strayer in 8 minutes.

One of the cornerstones of the argument is the landmark paper by the Benumof Brothers*: patients will invariably desaturate before the sux wears off.

The ubiquitous "time to hemoglobin desaturation curve" that is shown in every airway talk, chapter, paper, etc:
Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997 Oct;87(4):979-82. 
...not only comes from this paper, but was specifically made to demonstrate that the patient will desaturate before the sux wears off.

But wait a minute. This is from 1997. This was before NODESAT -- the use of nasal cannula during laryngoscopy to maintain oxygen saturation.

Does nasal oxygenation during laryngoscopy bring succinylcholine's shorter duration of action back into the question?

My thoughts are below this other mandatory airway management picture:

My answer is no: roc still beats sux.

  • Sux risks hyperkalemia, i.e. succinylkalemia
  • When the sux wears off, the patient won't be breathing calmly & cleanly. They will be fighting like heck because people are stabbing them in the back of the throat
  • The patient who can't get intubated in 8 minutes still needs to be intubated (there is no "cancel case" in the ED) -- and more paralyis is helpful for bagging, placing an LMA, cric, etc
  • Intubating conditions are as rapid and as good with roc
  • Sux may lead to faster desaturation, because even with NODESAT...
  • NODESAT is amazing but not 100% perfect:
This is just an anecdote** of course, but I had a patient who was preoxygenated perfectly with 100% oxygen via NIV with PEEP using DSI, and even with the nasal cannula at 15 L/min during laryngoscopy, desaturated within 15 seconds.

So I still think roc wins. But of course, I was trained by big fans of roc.

*There are 2 Benumof authors on the paper -- Jonathan and Reuben. I don't know for certain but I like to think they are brothers, and I think they should play the Brugada Brothers in a game of basketball.

**Level of Evidence: A for Anecdote

October 14, 2012

Guest Glossary Term: Little Bitty PE

Don't forget to check out the other glossary entries!

from Casey Parker (@broomedocs):

lung lint - noun

The small, subsegmental PE you wish you had not diagnosed as it almost certainly clinically irrelevant.

"Who ordered the d-dimer?!"

October 13, 2012

Another Glossary Entry: Make 'em Glow

hypoCTemia - noun

The state or condition of urgently needing a CT scan, possibly due to low levels of endogenous CT.

Don't forget to check out the other glossary entries!

October 1, 2012

A Spoon in the Bucket?

I got in a recent twitter discussion with a number of people -- mostly @movinmeat -- on the impact of low acuity patients in the ED. He responded with an excellent, well-reasoned, but probably incorrect blog post (update: recently reposted at KevinMD). This is largely a response to both that conversation (edited Storify version here) and his excellent post. He asks: are low acuity patients congesting the ED? And his answer is yes. But I disagree. And it's fun to argue with people who you generally agree with.

Nobody likes the low acuity patients who come to the ED. Few of us went into EM to take care of not-so-sick patients, there's a lot of charting, and there are just so many of them, which is why for years everyone thought that they were cause of crowding in the ED. But they're not. It's been studied very well, and the overwhelming cause of ED crowding is the boarding of admitted inpatients. ACEP has a report about it. There's even a big IOM report about it. Low acuity patients are frustrating, but not the problem.

When it comes to crowding, are low acuity patients just a drop in the bucket?*

The basic model is input/throughput/output. There are so many patients who come to the ED (input), they take so much time in the ED getting histories, IVs, xrays, etc (throughput) and then they eventually leave (output). The patient with the cold takes, say, an hour. The patient getting serial troponins for chest pain takes 6 hours. The patient admitted for an appy takes 4 hours... PLUS whatever time he sits around waiting for a bed upstairs (boarding). It's easy to see why 1 admitted patient waiting around for an upstairs bed takes up a much bigger piece of the pie than the silly URIs.

(One bit of background: there's some decent work that shows that time in the ED is a great estimate for overall resource use in the ED -- patients who are there longer take up nursing time, ask the doctors questions, use more tests, take up a spot, etc.)

Next, consider what clogging the system really means.

We are quick to think about low-acuity ED visits as "unnecessary visits" -- like the healthy patient with a cold. Isn't the admitted patient boarding in the ED in the ED unnecessarily?

Here's a simple example: a patient comes in with a twisted ankle. We do 2 main things: make sure this was a mechanical fall (history) and apply the Ottawa rules (physical), which is negative (assessment) and we tell the patient that they don't need an xray (plan). Rx 800mg ibuprofen, send home with return instructions. Explain again that they don't need an xray. Realistically, this takes an hour from door to door (although it probably shouldn't).

Now a 50 year old with diabetes and CAD comes in with chest pain, with some concerning T-wave changes. Took his aspirin just before he got here. Is otherwise rock-stable. Slam dunk admission. Write some notes & orders, talk to the hospitalist. Done in 10 minutes. Now they just need to go to that inpatient bed. What happens if they board for an hour? or 4? or 12 hours?

When I was in residency we would routinely board 30 patients at least 6 hours each every weekday. That's 180 patient-hours. As MM notes, the total facility time is a great estimate for resource load.

So even if we are pessimists and assume every ankle and URI takes an hour, that's still 180 URIs we could have seen.

Here's a graph that MM posted showing distribution of ED patients by LOS and disposition:

His conclusion: "The lower-acuity patients are there less time, it is true. About 1-2 hours on average."

Lots of discharged patients are in the ED for a few hours. But I think this graph is misleading with respect to how much time they spent in the ED.

I reran his same numbers (being as true as possible from these graphs). I broke this up into 3 groups: discharged in 2 hours or less, discharged but LOS 2.5 hours or more, and admitted.

One major caveat: with these data, anyone who stayed 6 hours or later is counted only counts for 6 hours. That is, my numbers underestimate the burden of the patients with high LOS (which is 1/3 of the admitted patients)

How many patients were there in each group?

DC 0-2h: 41%
DC 2.5-6h: 39%
Admit: 20%

How was LOS divided among these patients?

DC 0-2h: 20%
DC 2.5-6h: 45%
Admit: 35%

That is, 40% of the patients are discharged in 2h or less, but only take up 20% of the hours. The 20% of patients who got admitted take up 35% of the LOS, and again, that underestimates their share because it treats everyone over 6 hours as taking only 6 hours. And, this is assuming that everyone who is discharged in 2 hours or less is a low-acuity patient.

So maybe not a drop, and maybe more than a spoon. But the quick discharges are taking only a small portion of the total resources. And remember, this is only 1 hospital, and it's a hospital with remarkably little boarding.

But even further: is that even the right group of patients to consider as "low acuity" or "shouldn't be in the ED"?

It's very tough to properly measure the low-acuity patients.

I agree that the 8% figure frequently quoted by ACEP is misleading. Not only is it based merely on triage category, which as @movinmeat notes may be incredibly misleading, but those recommended to-be-seen times are entirely made up. And it's very hard to figure this out based on administrative data.

These are all patients that we frequently see and discharge with neck pain:
  • mild fender bender
  • serious MVC
  • 30th visit for chronic neck pain (gabapentin refill)
  • 80 year old who was worked up (appropriate or not) for a cervical artery dissection

Is discharge from the ED a sign that the visit was unnecessary? Of course not. How many patients get seen for potentially worrisome chief complaints and end up being discharged home? (Hence the prudent layperson standard.)

About 80-85% of all ED visits get discharged. Were these all visits that didn't need to be seen in the ED? What are the alternatives? Primary care offices? Urgent care center? Walgreen's? How easy is it to get into any of those? What are the hours? Most PMD offices are open during business hours, which is when many of us are actually at work. If you twist your ankle and don't know if it's broken, is it inefficient to come to the ED, where the lights are already on, the x-ray machine is running, and the tech is there?

I don't enjoy the low-acuity patients. They're not that interesting, they make the haystack bigger (when a big part of our job is looking for needles), they talk back more, and if I wanted to work in an outpatient clinic I work in an outpatient clinic.

But low acuity patients:

*I had modified that to a spoon in the bucket

UPDATE 11/8/2012
I fiddled around with the graph a bit and made this graph. The light blue and light red are the same as movinmeat's: number of discharged and admitted patients for each LOS. The dark blue and dark red are their "patient-hours." Each dark bar shows the total number of hours in the department for the patients in each group, e.g. the 17.5% of patients who are there for 1 hour get shown as 17.5 patient-hours (17.5x1-17.5) and the 12% of patients there for 2 hours are 24 patient-hours (12x2=24).

This demonstrates 2 things. First, the admits have an outsized influence in patient-hours (which we know): the 7% of admitted patients who were there for 6h get 42 patient-hours of care (!). And further, the group in the middle -- patients who hang around the ED for a while but eventually get discharged -- seem to take up a big chunk of patient-hours. This is in line with a recent study from Steve Pitts, Michael Handrigan, Art Kellermann, and Jesse Pines, where they looked at NHAMCS data** and showed a big influence on  crowding is ED workup: labs, imaging, etc., a lot of which might be resource-saving in the long-run because it avoids admissions. But it does look like "output" is no longer the only culprit in ED crowding: "throughput" may be as big of a factor. But it's still not input (not yet, anyway).

**There was a great recent paper by Steven Green pointing out some weaknesses in NHAMCS -- primarily, up to a quarter of patients who were intubated did not go to either a critical bed or die (although at my residency hospital, a lot of intubated patients went to the floor). I admit that NHAMCS has some limitations (as any giant database will) but it's still probably a useful database and the best we have right now. Although admittedly I'm biased, as I'm currently working on an analysis of NHAMCS data with Steve Pitts and Jesse Pines.... 

September 17, 2012

Chest Pain Gives Me Chest Pain

Low risk chest pain (or any of its analogues) is one of the most common chief complaints in the Emergency Department (I think it's #2?) yet there is a huge amount of practice variability (more on this at the end), discrepant teaching, and huge unanswered questions.

Recently, the European Society of Cardiologists determined that some cardiologists now contend that unstable angina is no longer a thing, much like hypertensive urgency, the American auto worker, travel agents, and rock saxophonistsThe ESC concluded Some cardiologists argue that high-sensitivity troponin (hsTn) is sensitive enough to rule out ALL acute coronary syndrom (ACS).
If hs troponins are completely neutral in a patient with chest pain, it’s impossible that the patient has significant coronary disease. (Freek Verheugt, Dutch cardiologist)
I hope he's right. But I don't think he is. I of course respect cardiologists, the European Society of Cardiologists, and recognize that I am but a junior emergentologist (and resuscitationist). And, I would love for it to be true. If we had an accurate biomarker for ACS, we could admit fewer patients, do fewer unnecessary stress tests and caths, and offload a lot of potentially unnecessary hospital admissions, decompressing some nontrivial level of ED & hospital crowding.

I humbly submit my dissent based primarily on the fact that there are plenty of simple questions left open by the data on hsTn. I am also intentionally not putting robust references in this post precisely because I think there are more questions than answers -- enough that I want readers to have to go to the literature to draw their own conclusions.*

First, some simple background.
The spectrum of acute CAD:
  • none
  • stable angina / baseline CAD: established over time with a PCP or cardiologist.
  • unstable angina: diagnosed based on H&P, ECG, and (arguably) with stress, CTCA, cath, or observation (e.g. autopsy)
  • NSTEMI: diagnosed by cardiac enzymes
  • STEMI: diagnosed by ECG
We care about UA/NSTEMI/STEMI, or what we call ACS, and we include UA in that spectrum of "things we care about" because patients with UA go on to have MI +/- death, which we agree is bad. And all of the money (figuratively & literally) is in UA because MI is "easy" to diagnose, while it is nearly impossible to differentiate stable from unstable angina, or non-cardiac from cardiac causes of chest pain.

If hsTn works, that would be great. But my read of the evidence is that it's not. 

What does that mean?
I think there is a subset of chest pain patients who are hsTn negative, but still have ACS/UA, and are therefore at increased risk for MI or death in the short term.
What to do with them? Stress test may not help; CTCA is probably just another stress test. And PCI during UA probably doesn't help most patients. (except maybe for patients with Wellens syndrome?)

So now what? That means we have patients who have chest pain, aren't having MIs, and might be having UA. Stressing or cathing them probably doesn't add much, but they are still at risk. Is admission the answer? The benefits of admission are essentially monitoring (if your UA progresses to NSTEMI or STEMI it will hopefully be caught in-house), medication optimization (ensured you're put on aspirin, BP managed, etc), scared straight (tobacco cessation?).

Again, I'm not sure what to do with all of this. But back to widely divergent practice patterns:

I recently spoke with a friend who was a year ahead of me in residency. At his hospital group, if you have 2 negative troponins (not high-sensitive) and a normal ECG, you go home. At the same time, a malpractice insurer for a hospital network in the same geographic area told all their ED docs to admit every chest pain because too many cases of ACS were being missed. So the standard of care is somewhere between doing nothing and everything.

UPDATE 9/18/2012

Amal Mattu pointed out yesterday on the twitter that the Third Universal Definition DOES indeed include the concept of UA:

And to the source:

page 5: Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. Circulation. Aug 24 2012.
My apologies. I trusted the Cardiology News article cited above and Dr. Verheugt as quoted in the article. The TUD is actually a straightforward and very concise read -- I should have gone there in the first place. I amended the original posting here as the ESC did not discard the diagnosis of UA -- "some cardiologists" have. -- Seth Trueger.

*EMCrit explained this tactic at one point, can't find it now. Obviously it's not good to do all the time and can be abused to cover laziness, but there's such divergent information on chest pain that I think it applies here.

I've been kicking around my thoughts on low risk chest pain for a few years now. Special thanks to Manrique Umana for pushing me over the edge.
Also thanks to Nick Genes, Ryan Radecki, Dave Newman, Luke Hermann, and Richard Body for being the main influences to my gestalt & interpretation of the evidence on this.

September 11, 2012

(Landmark vs US) vs (DL vs VL)

This is adapted from an email I sent to Minh Le Cong.

Haney Mallemat recently hosted a number of us what will hopefully be the first in a long series of international EMCC real-time discussions, with participants including Haney, Scott Weingart, Rob Bryant, Jeremy Faust, Steve Caroll, myselfLaleh Gharahbaghian, and of course, the ubiquitous Minh Le Cong. (video of the discussion should hopefully be up at some point)

Two related topics came up:
  1. Is DL dead? 
  2. Is ultrasound necessary for IJ & femoral lines?
It is not lost on me that these are very similar questions, and I come down on different sides with each.* I want to explain why I see 2 very similar situations and come to 2 different conclusions.

With respect to ultrasound for IJ & femoral lines, I think that it is clear that the landmarks are simply not reliable. I don't have hard references (although people who taught me assure me they exist) but the Sinai US guru Bret Nelson loves to take junior residents, show them the nice "NAVEL" shot and then scan up and down and show how the anatomy changes -- the relationship between the femoral artery and vein is much more complex, variable, and dangerous. I have done this on nearly every femoral line I have done** and it is shocking. Similarly, Scott Weingart has shown data on the IJ similarly just not being reliably related to the carotid.

I think Marik is possibly (probably?) correct and in the era of monitoring CLAB, space-suit CVC placement, and DVT prophylaxis, the infection & DVT rates might be less of a problem.

But the placement issues -- bleeding, neck hematoma, RP hemorrhage, pseudoaneurysm, fistula, or just not being able to place the line -- do still exist.

Plus, IJs and femoral veins both collapse during most cases of hypotension, making blind placement even more difficult. In cardiac arrest, the femoral vein might have the pulse.

Further, once you get over the learning hump (maybe 5 lines in someone who is remotely savvy?) I think that it is easier AND faster to place the lines under US.

And lastly, Scott Weingart puts it very well today: people don't immediately die if I can't get the line in (unlike failed airways).

With central lines, the blind approach works very well most of the time. However, Marty Tobin put it very well:
But here’s the rub. The challenge of clinical medicine is not about taking care of the great majority of patients who do well irrespective of the methods employed by their physicians. Instead, the goal is to take feasible steps that have a high likelihood of circumventing a catastrophe in a small number of instances....Taking simple steps to prevent infrequent occurrences that lead to a clinical catastrophe should dictate the practice of medicine, rather than employing approaches that are convenient to physicians and successful in most patients. (PulmCCM; emphasis mine)
Compare with DL vs VL. As I mentioned during the discussion, the key points are that DL skills are translatable to VL; VL is easily defeated by a speck of blood, vomit, or mucus; equipment issues (ie what happens when your Glidescope blades are all getting strerilized?); and I had one more that I don't recall now. VL will get us the view in a higher percentage of cases (although you may not always be able to deliver the tube) but DL isn't as far behind as landmark lines are behind US lines. The gap is very different.

And I agree that the combo VL/DL devices are very different than the angulated devices, and allow for training of both juniors and skill maintenance over time. During my chief year I think I used the CMAC on nearly every tube but never looked at the screen unless I ran into trouble***

Lastly, Minh made a great but ultimately flawed analogy that I cannot let stand:
Giving someone a Glidescope doesn't make them a great intubator; it's not like how giving someone a lightsaber makes them a Jedi. - MLC (paraphrased
While the lightsaber is the weapon of the Jedi, it is not the source of the Jedi's power. For whatever reason, some people are just force sensitive (to varying degrees) and may be trained to hone those skills. (I do not believe the prequels to be canonical so we can ignore the microbiologic explanation of force sensitivity.)

Giving a monkey a McGRATH MAC doesn't make him an anesthesiologist, just as Luke didn't become a Jedi the moment Obi-Wan handed him his father's lightsaber.

*I do not want to simply explain myself out of some Jungian desire to resolve my cognitive dissonance (in fact, I don't even think Jung had anything to do with cognitive dissonance and simply used him here because he's the psychology giant whose name I know aside from Freud. Wikipedia states that Festinger coined the term) or some sort of unresolved father-issues. 

**both of them

***the jokes pretty much write themselves

August 27, 2012

QOTD: Sinuses

“Sinuses are air pockets in your face.”
(source: canned discharge instructions.)

August 19, 2012

tweet-in-brief + QOTD: Patient-centered care.

Death is a pretty worrying outcome."

Andy Neill

full context:

August 16, 2012


New parrot toy for the dogs made unfortunate "polly wanna cracker" noise when squeezed.



August 15, 2012

Needles, Haystacks & the New York Times

I am not going to review or discuss the entire case of Rory Staunton. WhiteCoat did that very well, twice.

Briefly: previously healthy 12 year old scraped his arm in gym, goes to ED for fever and abdominal symptoms, discharged after evaluation (labs drawn but not resulted at the time showed elevated bands), and later came back with severe sepsis and unfortunately died. Jim Dwyer wrote an article about it in the New York Times that alleges that the sepsis was missed on the initial visit and shouldn't have been, and he names the ED doc who treated Rory on the initial visit.

What I will say is that while it's terrible that a healthy 12 year old kid died, from what we know about the case, this hardly seems like a "miss" or like it could have been avoided, unless we started admitting & antibiosing every febrile, tachycardic kid in every Pediatric ED. Which I think would cause many more problems than it solves. (What's the NNT for antibiotics for febrile/tachy kid?)

On WhiteCoat's second post on the subject, I made a comment ("Needle vs. haystack. Young healthy kids with non-dangerous viral infections can make bands, too.") and Jim Dwyer responded; for some reason my reply won't post.

So I emailed this to him directly (through the NYT website):
Mr. Dwyer, 
I tried to post a reply to your response on bands and infection, but for some reason it's not posting. 
You asked if the results (elevated WBC & high bands) were strongly  suggestive of a bacterial infection. They are not. While bands had previously been thought to be helpful in identifying serious bacterial infections, years of research have shown that they are a poor test, and are only indicative of a vigorous host response to infection or inflammation from any source, be it viral, bacterial, or non-infectious. 
There is a thorough review on the lack of utility of band counts here: 
Cornbleet PJ. Clinical utility of the band count. Clin Lab Med. 2002 Mar;22(1):101-36. 
Dr. Cornbleet reviews many studies, at least 18 of which are relevant here.
Some pertinent quotes from the paper are pasted below. 
The 84% false positive rate I quote from Cornbleet below demonstrates exactly what I meant by "needle in a haystack" -- of every 100 children with elevated bands, 84 of them do not have a serious bacterial infection. 
Seth Trueger
n.b. I am also posting this message to my website, mdaware.org

From Cornbleet:
Surprisingly, the clinical folklore of the band persists despite little mention of its diagnostic utility in current textbooks. Textbooks in internal medicine, hematology, and laboratory medicine do not recommend band counts for the diagnosis of infection, otherthan to mention that neutrophilia and left-shift typically accompany infection or inflammation.
Similarly, most pediatric textbooks do not advocate band counts for the diagnosis of infection in children over 3 months old.
The data indicate poor performance of the band count as a clinical laboratory test, with most positive likelihood ratios below 5 and most negative likelihood ratios above 0.2
Although Todd’s initial study showed fairsensitivity and specificity for the algorithm, later studies by Morens and Rasmussen and Rasmussen
did not report good results. McCarthy and Dolan applied Todd’s criteria to
hyperpyrexic children seen in the ED, but found an 84% false-positive rate.
Review of the literature provides little support for the
clinical utility of the band count in patients greater than 3 months of age.
Lots of smart people (in addition to WhiteCoat) have responded to (or should I say, against) Mr Dwyer, and I will concede that the situation is a bit unfair for him: our medical knowledge & training makes physicians well-suited to criticize his journalism...

August 13, 2012

Q&A with Haney on SCUS

The final chapter in my discussion with Haney Mallemat on ultrasound-guided central access. Unfortunately the recording got cut off but 12 minutes made it!

A plethora of related links below.

See also:

Prequel: Subclavian Ultrasound
8 min screencast on how to place a subclavian under US guidance

Episode 1: Questions for Haney on SCUS
My response to his SCUS video

Episode 2: Answers from Haney on SCUS
Haney's response to my response to his SCUS video

Matt Pirotte: Why you should never (rarely) do a femoral line

PHARM: Podcast 20 : Femoral Vein Access the root of all EVIL? with Dr Mathew Pirotte

EMCrit's central line tutorial (including the safe way to place a blind SC)

Dr G on FEAST: Fluid therapy in shocked children - NEJM article
One of many responses to the FEAST trial (Dr G's is a nice, brief overview but the formatting on his site is off; highlight the text to make it readable -- ctrl-A or command-a works)

note: nobody involved is sponsored by Skype, Vimeo, the makers of rocuronium, or anything else mentioned

August 12, 2012

tweet-in-brief: business?

see also: Patients Aren't Customers

August 11, 2012

Answers from Haney on SCUS

Jeopardy! host Alex Trebek
Haney Mallemat responds to my response to his great screencast on placing subclavian central lines with US:

1) Doppler - This is a great point. Although most commercial point-of-care machines now have pulse wave Doppler, some older machines may not. My response?...get a new machine ;) , or use color Doppler which should work just fine. The only problem is when the vessels are very close and one vessel creates alterations of flow and color in the other vessel. To a person with a moderate amount of ultrasound experience this may not be a problem, but when I've taught folks with little to no U/S experience I find they have trouble with the color distinction. This is why I choose pulse wave Doppler; it allows you to put the interesting area in the middle of the sample volume (that thing that looks like an equals sign) and you get accurate information without the other "noise". Just a preference.

2) PTX in SC - True, the risk of PTX may be overblown and ultrasound might be like medical school (i.e., the more you know/see, the more paranoid you get…) However, I am a firm believer in that if I have the ability (and time) to do a procedure "un"blinded "and see anatomy, I will (and this logic goes for the puny, little radial arterial line too; I always try to use U/S). I'll will also play devil's advocate and ask, "should trainee's ditch the blind subclavian approach for U/S"? No, I think that would be a HUGE mistake as this line should be mastered blindly. The addition of ultrasound is just another trick up my sleeve that makes procedures safer and increases success when others can't get the line.  

3) Ultrasound Saves Time - I don't think that U/S adds time; I feel that's a perception and the U/S studies don't support that notion. 100% agree with you that U/S gets the line done sooner because it's done one time. I think people that argue against ultrasound are in the "generational" gap and don't want to learn something with a moderate learning curve. It might be cool if they just said that but I find it hard to believe (and argue) against people who state that they can do central lines WITHOUT U/S faster and with the same complications as U/S….the data doesn't support that. If true, however, those people should do a study and publish…that paper would be a "game changer"  

4) Femoral Lines - I'll insert your points with my comments in parenthesis:
Seth:Femoral lines are terrible in codes (Well...maybe not terrible, but not my first choice)
Seth: The vein collapses during hypotension, making it hard to find and harder to cannulate (Yes, I agree)
Seth: It can appear arterial (by palpation or US) as chest compressions push both ways (Yes, I agree)
Seth: Landmarks & anatomy are unreliable (Yes, I agree)
Seth: I'm not saying to never use place a femoral line, but if you do I really think you should absolutely use ultrasound (Yes, I agree. Always w/ ultrasound)
I personally wouldn't place an U/S guided IJ or SC during a code. My personal preferences in descending order are 1)IO 2)Fem w/ U/S 3)Blind Subclavian 4)Blind supraclavicular (one of my favorite procedures)

5) No Neck? - That left IJ is actually the subclavian I placed. We had to come anterior because the needle was not long enough and we went perpendicularly into the skin. The dialysis line was placed by IR during business hours. 

Questions for Haney on SCUS

Haney Mallemat (EM/IM/CCM@UMEM) just put together a great screencast on subclavian ultrasound for CVC placement. Definitely worth the ~8 min watch.

I had a few questions for Haney and some opinions of my own so I figured I'd put it here instead of in discrete, 140-character (minus @tags) snippets.

To be clear: I think this is a great talk about a simple way to improve a procedure; these are just little bits around the edges.

1) Doppler

You describe how to use doppler to identify the vein vs artery. I think that's a great idea (and I do it occasionally, mostly to ID the IVC when assessing fluid responsiveness) but it can be a little technically difficult, particularly since some machines (including one of my current ones) can't do it.

I use color doppler rather liberally to ID vessels -- arteries give you big, colorful, pulsatile bursts; veins smolder.

2) PTX in SC

You mention the risk of pneumothorax with SC, and I love the picture of the proximity of the pleura to the vein we generally stab at blindly. However, is the risk overblown? We know how to recognize & treat pneumothoraces, and Scott Weingart contends that with proper technique (needle stays parallel to floor the entire time) the risk is minimized.

3) Ultrasound Saves Time

People who are reluctant to use US often cite the extra time needed to use US when placing a line (you allude to this, too, despite your clear preference for US!).

My feeling* is that US saves time for central lines. Maybe not for the simple, 1&done easily placed lines.

But a lot of them aren't that simple. There's probably some bimodal distribution of lines: some go in right away and another big chunk involve rooting around in soft tissue and kinking the heck out of wires for 20-30 minutes. Facility with US really helps minimize the second group, increase the 1&dones, really adds only a minute to wheel over the machine and place a probe cover, and is not difficult at all. (And you can do all of this alone.) And it shows you exactly where to go.

I really think that once you get mediocre at US-placed lines, then it saves time on every line.

4) Femoral Lines

I don't want to rehash Matt's great femoral line argument with Minh, and I recently got in a twitter fight with @talesfromtheer et al on some of this, but some bullets:

  • femoral lines are terrible in codes
    • the vein collapses during hypotension, making it hard to find and harder to cannulate
    • it can appear arterial (by palpation or US) as chest compressions push both ways
    • landmarks & anatomy are unreliable
I'm not saying to never use place a femoral line, but if you do I really think you should absolutely use ultrasound. 

While a subclavian seems inconvenient during a code, if you need a central line it's probably much better, particularly because there are ligamentous structrues tethering it open, even when BP is nil. And the landmarks are actually reliable (as opposed to the IJ & fem). But go ahead and use an US!

Or better yet, place an IO. (drill, baby, drill)

(My main theory on the popularity of femoral lines during codes is that notion that the intern can mess around with the line while the important people do important things closer to the head of the bed.)

5) No Neck?

This is all in good fun, but it looks like the patient you used as your example in the video actually has a left IJ and another line on the right (possibly an HD line?) -- screenshot above.

Again, great video and I'm looking forward to trying it out.

*I don't have evidence or data. I didn't even look it up.

August 8, 2012

tweet-in-brief: on doctoring

July 30, 2012

More MDA on PHARM: Airways & Human Factors

Minh Le Cong interviewed me on:
  • A little bit on why I'm doing health policy
  • Transition from resident to attending
  • Not torturing intubated patients
  • Critical airway case discussion
  • My first intubation as attending
  • Human factors tips for airway & team management
  • My love for ETCO2
  • A little rehash of our cricoid pressure debate

Thanks Minh!

July 27, 2012

3 Simple Rules to Avoid Torture

Don't do this.
Scott Weingart has another great but unfortunately sad post about post-intubation sedation.

The fact that this needs to be discussed at all makes me sad, which inspired me to share some pearls.

Not sure which of these I learned from Scott Weingart specifically (most likely: all of them). Special thanks to Scott for teaching me to fix patients without torturing them.

(nb - I'm going to use the terms "sedation" and "sedative" even though the first line should be analgesia. see EMCrit 21)

Here are 3 simple things that I do to not torture my patient:

1. Sedation is an RSI med

Ask for your sedative the same time you ask for your RSI meds.

If you're planning on intubating a patient, it should be no surprise to you that very soon you will have an intubated patient that requires sedation.

This is easy.

Sample interaction:

"Can you please get me 100 mg of roc, 100 mg of ketamine, and a fentanyl drip?"

2. Paralysis is NOT sedation

Just because your patient is sitting there calmly does not mean they are comfortable, particularly if you have given them a paralytic. This is relevant in 2 ways.

a) If you used roc to intubate, your patient is paralyzed for some time, so remember to sedate them.

b) Don't use paralytics as post-intubation sedation.

"10 of vec" is NOT a sedative. Don't use it. Forget that it exists. It makes your life easier but is unequivocally terrible.

I won't say "never" because there are a few RARE circumstances where paralysis may be necessary in the intubated patient. Namely, this is at the very end of the algorithm for the ultra-severe asthmatic, and certain special circumstances of ventilator-dyssynchrony. But in both of these cases, your patient should be sedated FIRST and DURING paralysis.

If you're not really sure what I'm talking about here (and even if you are) then make sure you talk to an intensivist before you use paralytics here; or (more likely): NEVER use paralytics for the already-intubated patient.

3. Don't use pain as a pressor

see: EMCrit - Pain and Terror as Effective Pressors

The ETT comes with sedative, period. Treat the blood pressure as you would anyone else -- resuscitate, add pressors, or dial down PEEP (you actually have one more option than in the non-intubated patient).

2 options to maintain MAP in the hypotensive intubated patient:

a) no pressor, no sedative, yes torture

b) yes pressor, yes sedative, no torture

If you're not sure which of these is a better idea then... well I don't have a polite way to end this sentence.

July 17, 2012

Residents: Please Read

This is adapted from an email I sent to the incoming EM residents as I graduated a few weeks ago. Of course, no monetary conflicts of interests of any kind, and these recommendations are just personal tips (and see also):

As outgoing academic chief, one thing I cannot stress enough is that you really need to read during residency.

You cannot just show up for shifts.

You need to do more than listen to EMCrit, and all of the other great sites like Life in the Fast Lane, ERCAST, PHARM, SMARTEM, etc. (I know I left a lot of great sources out -- there are too many to name). Not that you shouldn't read or listen to this stuff, but recognize that the topics covered are generally things that are sexy: interesting, controversial, or very practical or technical tips & tricks. But those are all different than a core curriculum.

And while you should listen to EMCrit etc., that sort of clinical information is not sufficient for board prep nor for core topics, especially the tough/less popular ones that are over-represented on the boards and under-represented in our patients (and nobody likes) like ophtho, derm, and even bread & butter simple illnesses like gastroenteritis.

Other than reading a textbook (which I wish I had done much more of), top things I think you can do to be both a better doctor & better board prepped: the idea should be to focus on building a foundation of core content, without getting completely distracted by the some of the more fun bells & whistles out there. There are lots of places to find great EM core content curricula; here are some examples: 

EM:RAP -- probably the best "core topic" podcast. It comes free with a resident EMRA membership. Worth figuring out how to download. They cover major topics, and last year introduced their "C3" project where they review core topics for board prep.

Read Annals of Emergency Medicine. Every month. You don't need to read it cover to cover, but at least browse through the abstracts & editor reviews. I will admit that at first it seems to cover obscure topics, but after reading for a few months I realized that something relevant from a recent Annals came up every single shift. Articles are picked by the leaders in our specialty, and they're quite good at it. I keep mine in the bathroom and slowly get through it.

Emergency Medical Abstracts -- also free with resident EMRA. great podcast that started in the late 1970s (they used to mail out cassette tapes) by Rick Bukata & Jerry Hoffman (who is probably the most worthwhile EM figure out there). They go through 30 abstracts from recent journals of all stripes, all relevant, and discuss each one for 2-10 minutes, which includes a lot of banter on the topic. A lot of people are put off by the (brief) methodology discussion of each paper but I promise it's worthwhile.

Some others: Life in the Fast Lane and EM Basic both have plenty of excellent free core content.

Also: get on national committees. EMRA, ACEP, etc. Easy to get on, little work with huge reward, and most are just a matter of signing up.

Last tips: 
  1. be nice to everyone (it pays off)
  2. do what's best for the patient (not only is it the right thing to do but you get to win more fights)
  3. and remember: as Jerry Hoffman says: we have the best job in the world, and as Mel Herbert says, what we do, matters 

And please read.