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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...

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