December 2016 Journal Club with First10EM

Welcome back the the last journal club with Dr Justin Morgenstern for 2016. [Yes, it is now 2017… but that’s life.]  Another batch of 10 delicious articles to satisfy your post-Christmas cravings for academic nerdiness.  There a bit of something for every taste this month.  Below are the articles with links to the full text PDFs:

You can read Justin’s written synopsis over at the First10EM blog here.

DIRECT DOWNLOAD

Here are the papers:


Seiger N, Maconochie I, Oostenbrink R, Moll HA. Validity of different pediatric early warning scores in the emergency department. Pediatrics. 132(4):e841-50. 2013.

Bottom line: According to this cohort, none of the available PEWS are good enough for clinical practice.


Motov S, Yasavolian M, Likourezos A. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 2016. PMID: 27993418

Bottom line: It is time to stop using any dose of ketorolac higher than 10mg.


DePeter KC, Blumberg SM, Dienstag Becker S, Meltzer JA. Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications? The Journal of emergency medicine. 2016. PMID: 27751698

Bottom line: This is another piece of evidence that NSAIDs don’t cause bone healing complications, and that we should just treat children’s pain


Beach ML et al. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Anesthesiology. 124(1):80-8. 2016. PMID: 26551974

Bottom line: Emergency department patients don’t need to be strictly NPO before sedation.


Simpkin AL, Schwartzstein RM. Tolerating Uncertainty – The Next Medical Revolution? The New England journal of medicine. 375(18):1713-1715. 2016. PMID: 27806221

Bottom line: A quote: “Key elements for survival in the medical profession would seem, intuitively, to be a tolerance for uncertainty and a curiosity about the unknown.”


Kawano T, Scheuermeyer FX, Gibo K. H1-antihistamines reduce progression to anaphylaxis among emergency department patients with allergic reactions. Academic emergency medicine. 2016. PMID: 27976492

Bottom line: Antihistamines probably don’t prevent anaphylaxis, but this retrospective data can’t tell you either way


Sutherland S. Late-night breastfeeding advice. Canadian family physician. 62(7):579. 2016. PMID: 27412213

Bottom line: Not all medical advice needs to involve medicine. We treat people, not diseases. Sometimes, you just need a warm bath.


Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis. The American journal of emergency medicine. 35(1):159-163. 2017. PMID: 27836316

Bottom line: Hyperpronation works for pulled elbows (but so does pronation-supination, or almost anything in my experience).

Clinical Case 112: looked at this same question


Akimau PI et al. Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal: a prospective, randomised, single-blinded non-inferiority controlled trial. The Bone & Joint Journal. 98-B(6):806-11. 2016. PMID: 27235524

Bottom line: Tensor bandage may be as good as walking cast for fifth metatarsal avulsion fractures, but this study is too small to promote wholesale practice changes.


Osterberg EC, Gaither TW, Awad MA. Correlation between pubic hair grooming and STIs: results from a nationally representative probability sample. Sexually transmitted infections. 2016. PMID: 27920223

Bottom line: Keep this data in mind the next time a medical conference brings you to Las Vegas


Ok, thats a wrap for 2016…  we hope you have enjoyed the journal club over the past 6 months.  As always we are striving to make your life easier – if you have any thoughts, tips, comments or corrections please hit us below on the blog.

Catchya in 2017,

Casey & Justin

Thoughts on the Newman Crimes

Dear Readers,

First a quick warning: this post is not a clinical post, however I have decided to write this in order to openly discuss some recent events that have caused a lot of unrest amongst the FOAMed community.  If you do not wish to read the rest of this please come back in a few days for the next routine post..

Last week David Newman, former New York Emergency Physician and FOAMed contributor, confessed to the sexual assault of four4 women whom he was treating.

I will not go into the details, you can read a summary of events here.  These events took place about a year ago, the judicial system has indicted Newman and his guilty plea will lead to sentencing.

The victims of these crimes have endured both the initial violation and the subsequent scrutiny that the media and the court system place them under.  It should be clearly stated that these acts are an abhorrent assault.  One which we as a community or broader society should never condone, conceal or minimise.  It is these victims we should consider when discussing the events. These are brave women who chose to speak out when they knew the upheaval that doing so could bring upon them.

What disturbs me the most about Newman’s actions is the breach of the fundamental social contract that exists between clinicians and their patients.  We are granted a powerful privilege when we take the Oath.  We conduct intimate examinations, discuss deeply personal thoughts and place our patients in utterly vulnerable positions as a “matter of routine”.  Although these moments are routine to us – they are anything but to our patients.

Imagine yourself undergoing anaesthesia, having a colonoscopy or discussing your marital disharmony with your doctor.  The trust you place in that other human is absolute.  This is why I find the assaults committed by Newman so disheartening, that trust was maliciously broken.

Sadly, David Newman is not an isolated case.  Physician sexual assault is alarming common. The numbers are hard to define but there are hundreds of disciplinary actions taken in the USA every year against doctors for sexual misconduct. (Reference ). Reading the reports, it appears that sexual misconduct is often hushed up, attributed to mental health issues or dealt with “behind closed doors” rather than in the criminal justice system.  This is not the point of my post, however, it does seem that we as a culture of clinicians need to change the way we talk about and deal with assaults such as these.

The crimes and confessions of David Newman have caused many in the FOAMed community to become angry, confused and pessimistic.  What should we make of this man – we have known him as a charismatic and compassionate physician, powerful orator, deep thinker, teacher and researcher.  He was a leader in the advancement of rational, evidence-based medicine and patient-centred care. And yet… he did the unthinkable.  How can we understand this paradox?

As Emergency clinicians we see everyday seemingly nice, normal people do strange and irrational things.  We are witness to human nature at its rawest moments. For us it is commonplace to see a wife bashed over a jealous quarrel, a child neglected or an older person mistreated.  Humans are messy and unpredictable at times.

I do not know or would guess as to the internal compulsion that occupied Newman’s mind when he committed these actions.  However, I do recognise that’s it is all too human to be duplicitous and that we are extraordinarily good at compartmentalising our lives – our ego often relies on this defence.  Good people do bad things, this I know is true.  I am in no way apologising for his actions. I am merely observing that it is possible and commonplace for a human mind to contain both good and bad intentions simultaneously.

So now we arrive at the big question.  As a community we are suffering cognitive dissonance.  How can we reconcile these facts?

1) Newman shared and taught some excellent ideas, knowledge that is beneficial to our patients and our peers.

2) Newman has broken the trust between doctor and patient- and as such should be condemned.  He is irreconcilably flawed.

This is a tough ethical question.  I can only speak for myself.

This I should how I shall proceed.

I do not feel it is helpful or productive to expunge the past material that Newman produced. He was primarily a populariser of ideas that others invented. These ideas remain sound, they are not tainted by the messenger’s transgressions.  I would posit that the only good that could come of all this is if the ideas that Newman shared remain intact and a new messenger carry them to educate us all.  In Aussie Rules football there is a saying: “play the ball, not the man.”  We need to separate the man from the ideas. Let us not burn his books, they contain ideas worth knowing. Instead let’s do something positive.

I am galvanized do by this tragic story to do better.  I will aim to teach professionalism and empathy to all my students.  I would try to create a culture in my ED where patients have a voice and any lapses in our sacred contract may be recognised and appropriately resolved.

Most importantly we need to listen to our patients when they have experienced unprofessional conduct. We have  a duty to our patients to protect them if we suspect a colleague has done wrong.  No more hiding in Hippocrates Shadows.

That is all I wanted to say.

I would be more than happy to hear your thoughts either here or by private correspondence if you prefer.

Casey

Lessons Hard Learned: Dr Victoria Stephen

If you enjoyed reading Clinical Case 137 – then you will love this podcast.  That case contained a number of pearls that will be repeated here…

This episode of Lessons Hard Learned comes from Johannesburg in South Africa – I am joined by Dr Tori Stephen to discuss a tough trauma case and some pearls from trauma on ultrasound and clinical decision-making in traumatic crises!  Sometimes things just are not what they seem!

Victoria is one of South Africa’s newest Emergency Physicians – having just sat and starred in her final exams.  She works in a medium-sized ED in Johannesburg, South Africa.  She deals with trauma every day and is also a wizard with the bedside US.

You can follow her very sensible comments on Twitter @EMcardiac

Also go and check out he excellent BAD EM blog from the excellent team in South Africa – Tori will be contributing to this project soon.

OK lets get onto the podcast.

DIRECT DOWNLOAD HERE
If you love BEDSIDE ULTRASOUND or just want to see some excellent teaching pics then check out the new project devised by Dr Michael Macias from Chicago – The POCUS Atlas

This project is supported by the USpodcast crew and I..

In the spirit of FOAMed you can contribute images to the site and get them published in the ebook once it comes out. Check it out and share your best pics for all to marvel upon and learn!!

 

casey

Clinical Case 137: It’s the quiet ones…

Another case from the Broomedocs archives.  This is a pretty simple case that contains a few good lessons.

Our patient is a 30 year old woman called Bessy who has been in a long term abusive relationship.  She has a long history of injuries including ulna fractures, facial fractures and burns to her skin.  Sadly this story is all too common in our world.

Bessy was seen in the ED yesterday with epigastric pain.  She was described as “a difficult historian”.  She had normal Obs and examination revealed RUQ tenderness with Murphy’s sign being positive.  She underwent a limited bedside US including a FAST and a gallbladder scan – both of which are documented as being negative.  No free fluid, no gallstones or cholecystitis changes seen.  In the absence of a firm diagnosis she has discharged with analgesia and asked to “return if worse…”

Now, 24 hours later at 10 PM Bessy represents to ED complaining of epigastric pain and has vomited x 1 just prior to arrival.  She is very quiet and laying still on the bed.

Her observations are all normal:  HR 80. BP 100/65, RR 15/min, SpO2 98% RA.

Abdo exam reveals tenderness and guarding across the epigastrium.  She has mild distension but there is no bruising or other evidence of trauma.

Time to review the history….

“When did this pain start?  What was going on at the time?”

“Oh, it started just after my partner kicked me…”   DOH!

Difficult History…. indeed!

This is now a trauma case.  The rules have changed.

Lesson #1 from this case:  victims of domestic violence are often reluctant to disclose specific details, even when it seems pretty obvious to us.  You need to approach this carefully and ask the right questions in the right manner, otherwise you will remain in the dark.

Back to the case…

Bessy agrees to be re-scanned as it is late and the CT tech is long departed.  Once again her RUQ is interrogated… and it is normal.  Despite having good going tenderness in the epigastrium her gallbladder is normal.  Given that we are now thinking trauma, this is unsurprising.  However, it means that we have definitely not found the source of her pain.  We are playing the probabilities – so a normal GB scan decreases the odds of biliary disease, BUT it also increases the chances of all the other possibilities e.g. an ulcer or visceral injury etc.

The error made the day prior can be partly subverted through a simple cognitive framing exercise when doing US in the ED.

Lesson #2  :  Before scanning a patient, think about the most probable diagnosis – then imagine what you expect to see when you apply the probe.  [ eg. In this case if you are expecting to diagnose cholecystitis, then you would expect to see gallstones with a thickened GB wall and sonographic Murphy’s sign…]  However, if you see something different… then that means something.  A normal scan means your hypothesis is wrong.  Normal is not normal… you need to either rethink the diagnosis or look harder for the pathology.  In Bessy’s case, the absence of gallbladder pathology would prompt one to re-examine the story or look further afield.

Lesson #3:

Now let us talk about “FAST scans”.  Bessy had a FAST scan, well sort of…

The FAST scan was developed as a binary tool to decide on the best disposition for an unstable, shocked trauma patient.  Alas, the majority of “FAST scans” that I see being performed are:-

  1. done on stable, well perfused trauma patients in ED
  2. Not too fast, i.e.. they tend to take 5 – 10 minutes to search all the areas we traditionally look at!
  3. Should not be called “FAST scans”

I think this is one of the reasons that FAST scans have gotten a bad wrap – what some folk call a ‘FAST scan‘ is in reality a very limited abdominal ultrasound that tries to localise the injuries.  This is not a FAST scan.

Having a ‘sono-gander’ around the belly can be a very useful thing to do in a stable patient who may have on occult injury that one cannot find clinically and where other diagnostic tests are either unavailable or inappropriate.  However, can we please, please stop calling it a “FAST scan”?  Lets call it a “limited abdominal US” or a “Trauma Trawl…”

I am not saying that we should not look around if time and the clinical context permits… but we should appreciate that this “test” carries a very different set of diagnostic and practical characteristics to the traditional FAST exam. I have had many a good save as the result of some curious probing of the belly… however, I appreciate that this is a specific and very insensitive “test” and almost always mandates subsequent imaging if an abnormality is revealed.

OK, where were we… oh yes, Bessy has a normal gallbladder.  Lets do a bit of a trauma trawl.  He FAST [true FAST] shows no free fluid in the pelvis, LUQ or Morison’s pouch… but  when trying to look at the LUQ there is something odd going on.

Here pancreas1is a sagittal view through the epigastrium just left of midline.

 

If that is a bit confusing – here is an annotated version:

The red X is a large heterogenous mass of mixed echo texture which should not really be there… Huh?  What is that?  It could be the stomach – but on further scanning it was adjacent to the stomach… 

pancreasannotated

This is where you need to exercise a bit of insight.  Especially if you are starting out in POCUS it is easy to ‘not see’ the unanticipated anomaly – more so  when you are seeing it for the first time.  Your brain’s instinct is to gloss over tough, or noisy images… and this how we often miss important findings when learning..

So what is going on in Bessie’s epigastrium?

Just as you are thinking it through she spikes a fever… her pulse rate jumps up to 130 and she looks crook… time for action.

We need a diagnosis-  there is a clear story of trauma, a confusing mass in the abdomen and now a picture that looks like sepsis.

Off to CT. I want to know what that mass is ASAP.

CT revealed a complete pancreatic transection through the mid body and a large phlegmon with lots of retroperitoneal fluid and probable early necrosis.

no liver, spleen of hollow visceral injury was seen

This is one scenario where a laparotomy I see not a great option.

Lesson #4:   Although bedside US rocks, and can really shine a light in the dark, it I see often not enough..

A positive in this case combined with the clinical situation empowered me to push on an image aggressively.  Broome is a long way from everywhere-  so getting solid information and making a plan early is usually preferable to “wait n see” when dealing with sick patients. It took me a few years to work this out  – deciding to transfer to ICU once the patient crashes is bad medicine..

Stay tuned for more POCUS pearls on the podcast this week.

Casey

 

Lessons Hard Learned: What scared Ross Fisher?

At the last SMACC outing in Dublin there was a stand-out lecture by Dr Ross Fisher ( @ffoliet ) entitled:  Things that Scare Me.  Ross is a bit of a presentation guru – and hence he had plenty of pressure on to deliver a great talk…. and he did exactly that.  It was a pin-drop-silently, slideless baring of the soul.

Ross’s talk is now available on the SMACC podcast in video form or you can hear the audio here:

I was lucky enough to spend a bit of time chatting with Ross in Dublin and had a chance to hear more of the story that inspired this amazing talk.  I really wanted to share this story with the FOAMed community – as I feel there are a lot of tough lessons about how we treat one another, how we present ourselves and how we can sometimes get really lost in the dynamics of work and maybe lose sight of the bigger picture.

I don’t want to give away to much – so I recommend you listen to Ross’s talk from SMACC first and then listen to the backstory here:

DIRECT DOWNLOAD

Casey