Intern Report Collection, Vol. 7

intern-report

To kick off your weekend reading pleasure, here’s another batch of our monthly excellent write-ups from the EM interns at UT Southwestern (@DallasEMed) courtesy of Alex Koyfman (@EMHighAK) . Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

[Note: These are PDF files.]

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Errore cognitivo e medicina d’emergenza-urgenza

Nasce un gruppo di studio promosso anche da soci Simeu

 

Dott. Paolo Balzaretti, redazione Blog SIMEU

Su Twitter: @P_Balzaretti

 

Circa il 10-15% delle diagnosi che formuliamo risultano errate (Graber 2013): da sola questa stima ci fa comprendere l’importanza di questo argomento, finora trascurato nella formazione e nell’aggiornamento in medicina. Anche la Medicina d’Emergenza-Urgenza non può considerarsi esente dal problema, soprattutto in considerazione della necessità di valutare molti pazienti in poco tempo, in condizioni ambientali oggettivamente difficili. Infatti, sebbene il nostro intuito ci guidi nella direzione giusta nella maggior parte dei casi, impiegando alcune “scorciatoie” cognitive, è ormai noto che può trarci in inganno, sebbene se non ci piaccia ammetterlo.

Quali sono dunque gli errori in cui possiamo incorrere quando facciamo affidamento sul nostro intuito? È possibile migliorare le nostre capacità di formulare dei ragionamenti diagnostici corretti? Per rispondere a questi interrogativi si sta costituendo il gruppo di studio promosso da un gruppo di medici d’urgenza iscritti alla SIMEU sugli aspetti cognitivi della diagnosi e sull’errore diagnostico, in collaborazione con l’Agenzia Regionale di Sanità (ARS) della Toscana, nella cui bellissima sede di Firenze il 14 gennaio si è tenuta la sua prima riunione.

Si è così raccolto un gruppo eterogeneo di professionisti composto, oltre che da medici dell’urgenza e di altre specialità, anche da un filosofo, il dott. Augusto Cevolani, ricercatore presso il centro per la logica, il linguaggio e la cognizione del Dipartimento di Filosofia e Scienze dell’Educazione dell’Università di Torino, e da un psicologo, il dott. Marco Franchini, a sottolineare il carattere multidisciplinare dell’iniziativa. Non vi erano purtroppo infermieri, per i quali è previsto un coinvolgimento futuro.

I lavori sono stati aperti dal dott. Alessandro Rosselli, già direttore del DEA dell’Ospedale “Santa Maria Annunziata” di Firenze, attualmente consulente proprio dell’ARS Toscana. Nell’introduzione alla giornata Rosselli ha sottolineato come il progresso tecnologico in campo medico verificatosi negli ultimi decenni non ci ha messo al riparo dalla possibilità di sbagliare, in parte proprio per la nostra tendenza ad affidarci in modo acritico soprattutto ai moderni test di imaging. Un altro punto, emerso successivamente più volte nel corso della giornata, riguarda la necessità di superare il binomio tra errore e colpa, riuscendo al contrario ad accettare il primo come parte integrante della nostra pratica clinica.

Il dott. Franco Aprà, direttore della Medicina d’Urgenza dell’Ospedale S. Giovanni Bosco di Torino, ha poi ribadito il concetto di inevitabilità dell’errore di ragionamento, proponendo l’esempio di altri campi dove questo tema è già stato affrontato e da cui si potrebbero prendere in prestito alcune idee, come l’impiego di checklist.

In relazione all’indirizzo cui si orienterà il gruppo di studio, si è inoltre precisato che la prospettiva del Risk Management, sebbene tenuta in considerazione, non sarà predominante nell’affrontare il problema dell’errore diagnostico da parte del gruppo di studio, il quale vuole concentrarsi sulle basi cognitive dell’errore.

Particolarmente interessante l’esperienza dell’”Autopsia Cognitiva”, illustrata dal dott. Marco Barchetti, che l’ha avviata nel Pronto Soccorso dell’Ospedale di Modena dove lavora. Questa è stata articolata fin dall’inizio in due fasi: nella prima vi è stata un’adeguata formazione preliminare sui temi degli aspetti cognitivi del ragionamento clinico, aperta a tutti i professionisti. Nella seconda sono stati analizzati, per mezzo degli strumenti e della terminologia della moderna psicologia cognitiva, alcuni casi reali gestiti in DEA, in cui vi erano prove del fatto che il processo diagnostico non fosse stato condotto in modo corretto, sempre con l’unico fine di promuovere le capacità personali di ragionamento diagnostico dei partecipanti.

Le intenzioni del gruppo di studio sono però quelle di andare oltre gli aspetti teorici del problema, fornendo strategie e strumenti concreti per aiutare i professionisti a limitare l’impatto dei tranelli cognitivi nella pratica clinica quotidiana. Il programma di lavoro prevede innanzitutto di aumentare la consapevolezza dei colleghi circa gli aspetti metacognitivi del ragionamento diagnostico, quelli per intenderci, indipendenti dalla nostra competenza ma legati al nostro modo di ragionare e al setting in cui operiamo. Per molti questi argomenti saranno completamente nuovi, data la loro assenza dal curriculum degli studi di medicina. Lo strumento suggerito è quello di un corso, corredato eventualmente da strumenti di valutazione per l’impatto effettivo sui discenti.

Altro punto sollevato è la ricerca di una soluzione ad uno dei problemi storici della pratica della Medicina d’Urgenza, ovvero la mancanza, nella maggior parte dei casi, di un feedback sull’esito delle decisioni cliniche prese in Pronto Soccorso. Infatti, solo poche volte riusciamo a sapere se abbiamo operato correttamente con i pazienti dopo averli trasferiti nei reparti o inviati al domicilio, non potendo dunque sapere se abbiamo commesso errori.

Questa esperienza, certamente pionieristica, è solo agli inizi. Chi fosse interessato ad aderirvi, può scrivere il gruppo di studio all’indirizzo gs.errorecognitivo@gmail.com.

 

More Discharges With HEART

Although, the observed improvements are probably more a result of their preposterously high initial admit rate.

The HEART score, already evangelized in multiple venues, is a tool for risk-stratifying chest pain patients in the Emergency Department.  Its advantage over other, competing scores such as GRACE and TIMI, is its specific derivation intended for use in the Emergency Department.  This trial, of note, is one of the first to do more than just observationally report on its effectiveness.  These authors randomized patients to the “HEART Pathway” or “usual care”.  The HEART Pathway was a local decision aid, combining the HEART score and 0- and 3-hour troponin measurements.  Patients with low-risk HEART scores (0 to 3) were further recommended to treating clinicians for discharge from the Emergency Department without additional testing.  The primary outcome was rate of objective cardiac testing, along with other secondary outcomes related to resource utilization.  Patients were also followed for 30-day MACE, with typical endpoints for cardiovascular follow-up.

With 141 patients each arm, the cohorts were generally well-balanced – specifically with regard to TIMI score >1 and accepted cardiovascular comorbidities.  Stunningly, 78% of the usual care cohort was hospitalized at the index visit.  Thus, the mere 60% hospitalized in the HEART pathway represented a massive improvement – and, such difference likely played a role in the 57% vs. 68% reduction in objective cardiac testing within 30 days.  17 patients suffered MACE, all at the index visit – and, even though the trial was not powered for safety outcomes, none occurred in the “low risk” patients of the HEART cohort.

The authors go on to state strict adherence to the HEART pathway could have eked out an additional 6% reduction in hospitalization.  Certainly, in a nearly 80% admit rate environment, scaling back to a 54% rate is an important reduction.  But, considering only 6% suffered an adjudicated MACE, there remains a vast gulf between the number hospitalized and the number helped.  Some non-MACE patients probably derived some benefit from their extended healthcare encounter as a result of better-tailored medical management, or detection of alternate diagnoses, but clearly, we can do better.

“The HEART Pathway Randomized Trial – Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge”

Fracture Fridays: Three Planes (re-post)

The case

A 15 year old skateboarder totally screws up a rail grind. After posting his wipeout to YouTube his friends call his mom, who notices that he has been unable to walk on his ankle – probably because of how ridiculously swollen it is.

swollen ankle

A gnarly swollen ankle

You get an XRay, because that’s what you do…

Ankle XRay

The ankle X-Ray you just got

The Diagnosis

Hmm, doesn’t look that bad right? Right? OK, this is an educational blog, so yes, it is bad. This is a big deal fracture. In fact it is a Salter-Harris IV fracture of the distal tibia. AKA the dreaded Triplane Fracture.

The fracture plane of this triplane fracture

The fracture plane of this triplane fracture

Why is it so bad? Well, aside from being accountable for 10% of the intra-articular ankle fractures in patients with open physes. Boys predominate, probably because they like to do things like rail grind on their skateboards. The peak age is 12-15 years. The fracture itself involves three planes:

  • Transverse through the physis
  • Sagittal through the epiphysis
  • Coronal through the distal tibial metaphysis

This diagram may help.

3D representation of the planes of the triplane fracture

3D representation of the planes of the triplane fracture

The main concern is not growth arrest, but rather the stability of the articular surface itself. That should lead you to assume (correctly) that these fractures generally need to be stabilized in the OR. More on that in a minute (of your reading time).

Management

As you can see from the initial X-Ray the initial findings are not 100% obvious in many cases. However it is still important to get them first (after applying the Ottawa ankle rules of course) as is a high level of association with concomitant fibula fractures. Normal ankle X-Rays show the ‘telephone’ sign, where the tibia and fibula (the handset) sit above the talus (the telephone base).

A normal looking ankle X-Ray

A normal looking ankle X-Ray

Asymmetry, and disruption to this normal orientation suggests a fracture. This is one fracture where a CT scan can be helpful, especially with the new 3D reconstruction modalities. Establishing the plane of disruption can be very helpful for your orthopedic colleagues.

Standard CT views in a triplane fracture

Standard CT views in a triplane fracture

A really cool 3D reconstruction of a triplane fracture

A really cool 3D reconstruction of a triplane fracture

In general orthopedists will first pursue closed reduction. Then, if a residual fracture gap of >2 mm exists surgical fixation is generally necessary. The likelihood of successful closed reduction (without need for surgery) is actually more likely if there is >3 mm of displacement initially. That doesn’t mean that you don’t have a role in the ED. Ater a careful neurovascular assessment you can provide pain medicines (these hurt quite a bit) and if transfer to another facility is warranted, place a posterior splint. These fractures should be seen urgently (within 24 hours) by an orthopedist.

For more information check out:

Ortho Bullets – Triplane Fractures

eMedicine – Triplane Fractures

Analysis of tibial fracture CTs

The post Fracture Fridays: Three Planes (re-post) appeared first on PEM Blog.

John Hinds on Airway at #RCEMBelfast

Screen Shot 2015-03-27 at 10.17.15

We managed to grab John Hinds after his fantastic talk on airway management in the ED at the RCEM Spring CPD conference.

At a time in which EM is establishing its position in airway management and developing strategies to advance care for patients in the Resuscitation room John gave us some fantastic advice on his approach to RSI. He talked about establishing strong working with Anaesthetics and ITU and working together to promote best patient care.

There were loads of take home messages including the importance of an RSI checklist (every time), issues around drugs choices for RSI and not only having a plan for the can’t intubate can’t ventilate scenario but most importantly ensuring it can be implemented swiftly and effectively.

Enjoy the podcast!

 

Osteosarcoma

Osteosarcoma

We all know that when you “hear hoofbeats, think of horses” and when you “see stripes, think of zebras.”  Unfortunately, the horses and zebras often look similar.  While tachypnea is most often due to a viral process like Bronchiolitis, or a Pneumonia, we must stay vigilant for it being one of those Subtle Signs of Heart Failure.  Keeping a keen eye and ear on alert for these zebras is part of what our job demands.  A child presenting with Back Pain should catch your attention just like a the child complaining of persistent leg pain.  While it is most likely innocuous, it could also be a zebra getting ready to stampede: Osteosarcoma.

 

Osteosarcoma: Basics

  • In the USA, cancer is the second leading cause of death in children.
    • Leukemia leads all other cancers – ~50 per 1,000,000 (CDC Stats)
    • Osteosarcoma incidence – ~5 per 1,000,000 (CDC Stats)
  • Osteosarcoma is the most common primary bone tumor in patients < 40 years of age. (Haddox, 2015)
    • Other important primary bone tumors = Ewing and Chondrosarcomas
  • High rates of metastasis.
  • Vast majority of osteosarcomas in children are High Grade. (Gorlick, 2010)
  • Survival has improved with advances in surgical, chemotherapeutic, and radiation care.
    • Before 1970’s, 5-year survival was < 20%.
    • Now it approaches 70%.
    • Generally, children have a better prognosis compared to patients 18-40 years of age. (Haddox, 2015)

 

Osteosarcoma: Presentation

  • Peak frequency = onset of puberty
  • Location:
    • Most arise in the intramedullary space of the metaphysis. (Gorlick, 2010)
      • Most often in the long bones of the lower extremities.
      • ~50% involve the knee (Distal Femur and Proximal Tibia)
      • Proximal Humerus is next most common site.
    • Possible relationship with Growth Plates.
    • In older pts, it is more common in the axial skeleton.
      • Spine involvement only in 4-5% of cases.
  • Primary complaint = Pain.
    • Often insidious
    • Pain with activity is most common complaint.
      • Just like everything else that hurts… it hurts more when you use it.
      • Growing Pains” is often the original misdiagnosis.
    • May present with limp due to pain.
    • Larger lesions may present with palpable mass.
    • Uncommon to have night sweats, fever, or other systemic symptoms initially.
    • Pathologic Fracture (Lee, 2013)
      • Can cause the initial presentation (5 – 12%)
      • Can also develop during treatment
      • Associated with poorer prognosis.
  • Appearance on Radiographs
    • Lytic and blastic bone lesion
    • “Sunburst” appearance
    • Periosteal elevation related to soft tissue mass producing “Codman’s Triangle.” (Gorlick, 2010)
  • Metastasizes to the Lungs and other Bones primarily.

 

So the next time you see the pre-teen who is complaining of knee pain after running in gym and you really want to blame “growing pains” or a minor strain… just pause and consider that those hoofbeats you hear are actually those of the stampeding Osteosarcoma Zebra.

 

References

Haddox CL1, Han G2, Anijar L1, Binitie O3, Letson GD4, Bui MM5, Reed DR3. Osteosarcoma in pediatric patients and young adults: a single institution retrospective review of presentation, therapy, and outcome. Sarcoma. 2014;2014:402509. PMID: 24976784. [PubMed] [Read by QxMD]

Vijayakumar V1, Lowery R1, Zhang X1, Hicks C1, Rezeanu L1, Barr J1, Giles H1, Vijayakumar S1, Megason G1. Pediatric osteosarcoma: a single institution’s experience. South Med J. 2014 Nov;107(11):671-5. PMID: 25365431. [PubMed] [Read by QxMD]

Botter SM1, Neri D2, Fuchs B3. Recent advances in osteosarcoma. Curr Opin Pharmacol. 2014 Jun;16:15-23. PMID: 24632219. [PubMed] [Read by QxMD]

Lee RK1, Chu WC, Leung JH, Cheng FW, Li CK. Pathological fracture as the presenting feature in pediatric osteosarcoma. Pediatr Blood Cancer. 2013 Jul;60(7):1118-21. PMID: 23281226. [PubMed] [Read by QxMD]

Kim HJ1, McLawhorn AS, Goldstein MJ, Boland PJ. Malignant osseous tumors of the pediatric spine. J Am Acad Orthop Surg. 2012 Oct;20(10):646-56. PMID: 23027694. [PubMed] [Read by QxMD]

Gorlick R1, Khanna C. Osteosarcoma. J Bone Miner Res. 2010 Apr;25(4):683-91. PMID: 20205169. [PubMed] [Read by QxMD]

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