Suicide: Sailing on Uncertain Seas

Hi All

Last week I was lucky enough to be able to present this talk to the SWEETS Emergency Medicine Conference in Stockholm.

Thanks to Dr. Katrin Hruska for the invitation.

This is a video of my lecture and slides as presented by myself and local Broome Psych resident Dr Nick Gilbert.

The first 15 minutes is my discussion of suicide risk assessment, then 5 minutes from Nick on the biochemistry, future and therapy for suicidal patients.

Summary take home messages:

  1. Suicide is tough to predict
  2. You have to ask about suicide in your daily practice
  3. Formal risk assessment tools are sensitive, but very non-specific
  4. Predicting behaviour and making a “risk assessment” are not the same thing.
  5. To make the best call you need to delve deep into the cognitive processes that your patient is experiencing
  6. Empathy is key – you need to be able to understand their perspective
  7. Imagine that you and your patient are sailing together over some rough seas – do you have all the data, resources and share a common goal?

OK, if that makes no sense then listen to the podcast and hit me on the comments below:

DIRECT DOWNLOAD HERE 

Casey

 

PODCAST: Shared decision making

Shared decision making.

This is one of the hot concepts in healthcare right now.  It is not new – but it is being embraced in many fields as a part of the trend towards more evidence-based practice and the changing culture of medicine where “doctor knows best” is no longer an acceptable platitude.

If you read or listen to a lot of the FOAMed resources – then you will hear a lot of discussion about engaging our patients in a shared decision making process.  Whether that be to help us decide on the right investigation, treatment or indeed to make the decision to not investigate or treat a given problem.

Here is the ideal model as taught in most EBM courses:

Evidence_Based_Medicine_Graphic_web

Now that is a nice diagram – and it certainly sounds like a good idea.  Out with paternalism, in with patient choice, add a sprinkling of evidence and voila – we can all go home happy.

But….. and there are a few here… how does it all actually work on the ED floor, in the busy GP clinic or specialist suite?

Have a listen to the latest Broome Docs podcast – and hear my dissection of how it could, should and might work in everyday practice.

DIRECT DOWNLOAD HERE

PODCAST: Shared decision making

Shared decision making.

This is one of the hot concepts in healthcare right now.  It is not new – but it is being embraced in many fields as a part of the trend towards more evidence-based practice and the changing culture of medicine where “doctor knows best” is no longer an acceptable platitude.

If you read or listen to a lot of the FOAMed resources – then you will hear a lot of discussion about engaging our patients in a shared decision making process.  Whether that be to help us decide on the right investigation, treatment or indeed to make the decision to not investigate or treat a given problem.

Here is the ideal model as taught in most EBM courses:

Evidence_Based_Medicine_Graphic_web

Now that is a nice diagram – and it certainly sounds like a good idea.  Out with paternalism, in with patient choice, add a sprinkling of evidence and voila – we can all go home happy.

But….. and there are a few here… how does it all actually work on the ED floor, in the busy GP clinic or specialist suite?

Have a listen to the latest Broome Docs podcast – and hear my dissection of how it could, should and might work in everyday practice.

DIRECT DOWNLOAD HERE

Clinical Case 113: Feeding Me Softly

Today’s case comes from Dr Trent Little – chronic Broome JMO and now my right-hand man in the Education Department (  i.e.. we share a desk ;-]  ).  This is a great Kimberely case – all the usual mix of third and first world medicine that just doesn’t happen much in the city.  Lets jump right in:

Solomon is a 44 y.o. man, he presents to the ED with a painful finger.

On examination he has a gangrenous looking right index finger. He is febrile, but not particularly looking that unwell. He also incidentally complains of having an increasing productive cough over the last week.

He is however well known to our department here and has a long medical history.
Previous TB
Chronic pancreatitis
Malnourished and ETOH abuse
Chronic normocytic anaemia
CKD stage 2
Smoker

He reluctantly agrees to admission and is brought into hospital with presumed osteomyelitis and commenced on IV piperacillin / tazobactam tds to cover his chest and finger.

Some clever doctor thought we best do a full blood work up given his history which showed:
Hb =98
Na = 124 (134-146)
K = 2.4 (3.4-5.0)
Cl = 86 (98-108)

Urea = 8.4 (3.0  – 8.0)

Creat = 183 (about double upper range of normal for US readers.)

Phosp = 0.92 (0.8-1.50)
Mag = 0.38 (0.7-1.10)
Cal = 2.20 (2.15-2.60)
Alb = 37 (35-50)
CRP = 220  [Ed: we do not encourage the use of CRP around here, but if you must….]
Lipase = 220 (ever so slightly elevated)

His electrolyte abnormalities were thought to be largely due to malnutrition and chronic disease.

In addition to his anti-microbial cover he his given initially IV K + Mag and then high oral doses. 2g oral Mag tds and 1200mg BD slow K.
His K rises slowly as planned, but despite the high doses oral Mag his serum Mag concentration does not reach >0.4.

On the third day of his admission he absconds from the ward for a few hours to have a couple of cigarettes. On return he his tachycardic with a rate of 110. He is completely asymptomatic and he gets and ECG.

ECG shows:

ECG 1 113

new ST elevation in V3 V4 and perhaps V5. What do you think may be going on here? Would you treat for STEMI/ACS?

Advice from the remote cardiologist is sought.  Solomon is given

-aspirin,

– enoxaparin  1mg/kg bid

– bisoprolol (bisoprolol was thought to be a better B-blocker option given his respiratory history).

The next morning his ECG had returned to normal and his high sensitivity Troponins were all negative at 6 & 12 hours

Now we are confused. What other investigations?

His bloods were revisited that morning.
Na = 126
K  = 4.2
Cl = 90
Cr  = 186
Urea= 8.4
Cal = 2.12
Phosp = 0.44
Mag = 0.38
Lipase 979
CRP is now 10  [Ed: wooohooo! Cured, discharge – hurrah for us…  sorry I just really don’t like CRP as a test. CP]

So, what was all that about then?  Whats the diagnosis ??

He was diagnosed with refeeding syndrome. Our ICU friends thought that the ECG changes were presumed myocardial dysfunction secondary to refeeding syndrome.

How do we manage refeeding sydnrome?  We would be interested to hear anyones opinion who has experience in this area.

What patients are at risk of Refeeding syndrome?

The best way of preventing re-feeding syndrome is identifying those who are at high risk. This BMJ article gives a nice summary.

Anyone not feeding for more than >5 days is at theoretical risk of refeeding syndrome. Our common high risk groups patients groups include:

Anorexia nervosa
Chronic Alcoholism
Postoperative (particularly GI surgery)
Oncology patients
Patients with uncontrolled diabetes
Malabsorptive syndromes such IBD, CF and chronic pancreatitis
Some patients who we would be less likely to consider, but who are also at risk include long term antacid users (Mag and aluminium salt binding phosphate) and long term diuretic users (loss of electrolytes).

It is largely a clinical diagnosis with a few characteristic biochemical abnormalities. Here is a nifty flow diagram from the BMJ review of the NICE guidelines for managing referring syndrome

refeed mx

.

Clinical Case 112: Pulled Elbow Tricks

Your next patient is 2 year old Sadie.  She has presented to the ED with a very guilty looking father.  He says that he was “watching the kids” whilst his wife went to the store.  They were playing in the back yard when thing got a little crazy and he attempted a complete 360 vertical sling whilst holding her by the wrists.  She landed safely but has been refusing to use her right arm ever since…  that was 4 hours ago now.  He was hoping it would all get better before his wife returned from the shops… but no luck.  So here he is now at triage with a quiet little princess – who is cradling her right arm in a semi-flexed position by her side.

After calling his wife to check her date-of-birth and allergy history she is clerked into the ED….

[Seriously: is this an Aussie male thing – or is it a global phenomenon that most fathers cannot recall basic details for their children?  Let me know.  I assume the Swedish Dads are up to the task..]

Diagnosis:  too easy – a classic pulled elbow, “nursemaid’s elbow” or radial head subluxation – as it is formally known.

The mechanism of injury is usually a sudden traction on the extended forearm. See paper below for interesting review of actual activities involved.

Image from imgarcade.com

Image from imgarcade.com

The radius is distracted from its position in the elbow where it articulates with the capitellum. A band of the annular ligament that usually encircles the radial head slips in to the groove. thus a blockage to extension and rotation is in place – the kid will not extend the elbow.

How does this occur?  Well  found this huge [3000 kids]  retrospective case series on pulled elbows that managed to break down the mechanism by physical activity and by “carer gender” – i.e. was it the Mum or the Dad who was doing something with the arm when it popped.  Have a read of – No Longer a “Nursemaid’s” Elbow: Mechanisms, Caregivers, and Prevention by Rudloe et al in Paed Emerg Care 2012

The bottom line: Female carers tended to injury the kid in a more passive mechanism – eg. kid tripped or pulled away; where male carers were more likely to be doing wizzy-dizzies, wrestling, flinging kids about… no surprises really!  Note that there are a a fair percentage with an “uncertain” mechanism – so you may not get the classic traction story.

OK – so after taking the history and having a look at the kid you are happy with the clinical diagnosis.  So how do you fix it?

If you are new to Paeds ED or GP then this is one of those moments – you remember seeing this or maybe even doing it during your training  – but how does it go again?

So there are basically 3 ways to “reduce” a pulled elbow:

  1. Supination / flexion  (SF)
  2. Hyperpronation (HP)
  3. the “2 in A Room” technique – Wiggle it, just a little bit  [No evidence for this one!]

I was always trained (and have trained others) to use the flexion / supination technique – which works OK.  But how does it stack up to an RCT examination?  So what is your “go to” technique when you want to perform the magic and cure the kid with your bare hands?

Well there are a number of small trials in recent years that have looked at this – and they have remarkably consistent findings.  Here are the success rates

 Amer Journ of EM, July 2013. Gunaydin et al:  SF = 68%,  HP = 95%

Nigerian Journ  Clin Pract 2014, Guzel Comparison of hyperpronation and supination-flexion techniques in children   SF = 84 %  HP = 95 %

Cochrane review in 2012 by Krul et al looked at 4 small trials – they found a significantly better success rate with HP over SF with a RR of 0.45 [0.28  – 0.73 ]

So on review – hyperpronation seems to be the best first option.  Significantly higher first attempt success and to meet seems easier to visualise.

Here is a video from the great Dr Larry Mellick – he has heaps of Youtube videos of common ED procedures.  My main tip is to place your thumb over the radial head as you pronate / supinate – this allows you to feel the click as it pops back over the ligament – it is satisfying and usually means a successful outcome.

And in most of these studies where the first attempt failed (either HP or SF) then the other technique succeeded on nearly every occasion. But…

Have you ever had that kid with a dead set, certain Pulled elbow who you go through the motions,pull, reduce and walk away – come back 5 minutes later and they are still not using the limb?  I have – it is one of those moments.  Hmm… am I missing something?  What do I do next?

I reckon there are a few common scenarios where the routine “reduction” might fail.

  1. If the elbow has been “out” for a prolonged time (e.g.. overnight) – I find it takes longer for the kid to get over the apprehension of pain and start using it freely.
  2. If the diagnosis is wrong.  Could be a fracture: radial head, supracondylar..  though these usually present with a fall, trauma history
  3. You are being too gentle with your technique

So what do you do if you have tried, given it a proper wrench, tried the “other” technique and waited a good while for the kid to regain their confidence.  And still no luck?

You could do an Xray… but that is ridiculous!  Have you ever tried to interpret a 2 year old’s elbow Xray – it is really just a series of blobs floating in invisible cartilage!  There is a great guide to “Elbow Ossification in kids” on Radiopaedia here.  At age 2 [the mean age for pulled elbows] only the capitellum is even visible – the rest are ghosts!

Xray may reveal signs of a supracondylar or epicondylar fracture – e.g.. “fat pad sign” of effusion / haemarthrosis – which will make you feel really bad about the recent tweaking and twisting manoeuvres – though this is no reason to Xray every kid with a pulled arm.

So what about ultrasound.  Can we answer any of these questions with the bedside machine?

Interesting small study out of Korea – by Lee, Sohn and Oh in Clin & Exper EM in 2014 – showed that the finding of a displaced annular ligament on US was 100% specific for “pulled elbow” but only modestly sensitive 64.9%.  So US would be useful to “rule in” a pulled elbow – which would be very helpful in ruling out other diagnoses.

If you are worried about a possible occult supracondylar fracture – then ultrasound can be useful here also.  Eckert et al in Europ Journ Trauma Emerg Surg April 2014 looked at the diagnosis of SCFs in kids using US – it was pretty good.  Sensitivity of 100% in a small study using plain Xray read by Radiologist as the standard.

So in summary:

  • Pulled elbow is a clinical diagnosis [the history may not always be classical]
  • Hyperpronation should be the first line manoeuvre
  • Supination / flexion should be plan B
  • IF not winning after a few tries – then we need to consider imaging
  • Ultrasound is useful for ruling in a pulled elbow [using a displaced annual log as the sign of choice]
  • Ultrasound is useful for ruling in supracondylar fractures
  • X-rays can be very confusing – but if you need to then go on….

See you in Chicago

Casey

Clinical Case 111: Toddler’s Tibia Tale

Another quick ultrasound case.

I usually work nights and weekends – and that means that we have no onsite Xray services.  Hence there is always a reason to use ultrasound to enhance our diagnostics!  In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait.  The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray.  To me that is a heap of fun and very satisfying!

So onto today’s case.

3 year old girl is brought into the ED one Sunday morning.  She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom.  Her aunt went into the room and found her crying and holding her leg.  She was carried out and put to bed.

Fast forward to the next morning – and she is still not wanting to walk.  Refuses to put her foot onto the ground, insisting on being carried.

She is well, afebrile, no other symptoms.  She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg.  There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.

So – being me and it being a Sunday… ultrasound is indicated.

Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound.  Most show it is useful.  However toddler’s fractures are subtle – very subtle.  Even with a solid history and a good Xray it can be hard to see those spiral cracks.

So what did our patient’s tibia look like?

tibia fract

Well it is subtle.  This image is the result of a few minutes searching.  It is very easy to miss subtle fracture on ultrasound.  One really needs to be slow and methodical

 

Here is the plain film for comparison:

tib fract toddler The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.

  1. So my learning points from this case:
  2. (1)  that one needs to be careful and methodical
  3. (2) Use the contralateral limb for comparison – there are a heap of growth plates etc
  4. (3) Call any subtle anomaly if you see it – confirm on Xray if uncertain

Casey