Lessons Hard Learned: Dr Andy Buck

Today’s “Lesson” is all about knowing one’s limitations, scope of practice and appreciating the little voice inside one’s noggin.

Dr Andy Buck is an ED Physician who works all over Australia, but is based in Melbourne where he runs the very excellent Emergency Trauma Management course.

This is a case of procedural sedation which goes a little awry.  It is a nice counterpoint to all of the stuff we hear about safety, “fasting status” and the classic – “easy intubation, rocky extubation” scenario.

Please pop over to the ETM course page and read the blog – this is the sort of course you should do early in your development if you are a serious trauma doctor.  [Disclaimer:  I did write a small part of the course on rural trauma management and waffled about ultrasound a bit!]

Enjoy the podcast!


Stats, CRP and Sick Kids

So I have been having a particularly nerdy week.

After the recent review of the point-of-care CRP paper I got to thinking.  We all seem to have an opinion about CRP based on what we think we know – but I think most of us have a pretty shady understanding of the true diagnostic characteristics of the ubiquitous CRP.

So I have taken the raw data from the POC-CRP paper and boiled it down to the numbers.  Recall this is about using a Point-of-care CRP assay in children with an acute illness presenting to the GP (in Belgium). The baseline prevalence of serious bacterial infection in the population studied was 0.35 % or about 1 in 285…  which is about one truly sick kid a year if you see roughly one kid a day with acute illness!

To explain.

The “proportion of patients” indicates what percentage of the children tested with POC CRP had a result above the various cutoffs.  That is, in how many of your patients would the result be over this cutoff?

The rest are as per biostats school.


So what can we do with these numbers?  If we think about the test in terms of “yield” when you are dealing with a single patient sitting before you – how does it stack up?

First observation is that less than half of the patients had a CRP under the “magic 5″.  Sure it was 100 sensitive at this cutoff… but 54% will fall into the next bracket where the test performed very poorly.

Low – mid range CRPs were basically useless.  Insensitive and poorly predictive.  A + CRP around 20 in a patient from a low-prevalence (GP) population moved the risk of SBI from 0.35 to 0.7%.

Using a cutoff of 80 did improve the diagnostic performance.  I think this is the cut-off that makes the most sense to use.  The likelihood ratios are reasonably potent in both directions.  Unfortunately only about 1 in 20 kids will have a CRP over this level.

A CRP over 200 is two things – suggestive of a serious bacterial infection and quite rare.

So here is how I teach when it comes to the question: ” should I do a CRP?”

  1. Estimate the risk based on the clinical picture – use your history and careful examination.
  2. Next imagine that the CRP comes back as 42.
  3. Now decide what you would do with that information
    • Are you still worried about the patient?
    • Are you reassured?
  4. If you are wanting to “exclude a serious infection – you may get lucky and get a low… but you are more likely to return an annoyingly mildly positive result – in which case you are back at point 3.

At the end of the day we are “probabilisticians” – we are not trying to diagnose sepsis right now – we are trying to decide which kids get the empirical treatment or transfer into ED.  I would imagine it is worthwhile to treat a good number of children empirically in order to try and catch all cases of true infection.

The CRP as shown in this data set does very little to sort the deck.  It is a crude filter for the majority of patients to whom it may be applied.  I personally do not find it to be particularly useful in making these decisions.  I may be wrong.

I would love to see a trial comparing “clinical acumen”to “acumen + CRP” as strategies with the goal of testing if or how much the CRP adds to our accuracy and ability to define a smaller sub-group who may be at higher risk.  As of today though I am not convinced it adds enough to make it worthwhile – particularly in a low prevalence population e.g.. usually healthy kids attending the GP clinic.



On Sick Kids and CRPs

Today I am doing a post-publication review of an interesting paper that popped into my inbox this week.  This paper was sent to me by the University of Lueven where the research was based via a promotion email.

Rapid blood test can rule out serious infections in children. Using a simple decision rule and a finger prick to test blood, general practitioners can now detect serious infections in children very quickly. This ensures that seriously ill children don’t have to wait for a diagnosis until they’re hospitalized – a delay that may have fatal consequences. The procedure also prevents unnecessary hospital referrals for less serious cases. That is the conclusion of a study conducted by a clinical team at KU Leuven (University of Leuven, Belgium) in collaboration with Ghent University and University of Oxford. In the early stages, serious infections such as meningitis, pneumonia, kidney or bone infections, or dangerous inflammations of the skin have symptoms that resemble those of more common viral infections. They are also very rare. “As a result, serious infections tend to stay off the general practitioner’s radar for too long. We asked ourselves how rapid diagnostic tests might help solve this problem,” says Jan Verbakel, general practitioner and postdoctoral researcher at the KU Leuven Faculty of Medicine. Testing is not a very common practice among general practitioners yet. “Testing is often complex, expensive, and most of all time-consuming: it usually takes a few days for the lab results to come in. But recently, various so-called point-of-care tests have become available. These simple diagnostic tests can be performed in the general practitioner’s office and provide results within minutes. For the detection of serious infections, point-of-care CRP testing by means of a finger prick holds potential. The test measures the level of the C-reactive protein (CRP) in a drop of blood. The concentration of this protein increases in response to a pathogen.” A one-year study involving over 3,100 ill children from across Flanders showed that 5 mg of CRP per litre of blood is a good threshold value to rule out serious infections, but only after the GP has performed a clinical evaluation of the patient’s symptoms and vital functions. “Point-of-care CRP testing cannot replace a general practitioner. Does the GP sense that something is off? Is the child short of breath, or running a fever of more than 40°C? If the answer to any of these questions is yes, it’s useful to perform a point-of-care CRP test. Our study showed that with this procedure, all serious infections were detected during the first visit to the general practitioner. But there’s no need to test all ill children.” “Thanks to the combination of a clinical examination of the patient, possibly followed by a point-of-care CRP test, general practitioners can detect serious infections more quickly and more objectively. And for children who are less seriously ill, the procedure prevents unnecessary hospital referrals and anxiety. The point-of-care CRP test is a valuable tool for general practitioners, but it has to be used responsibly,” Verbakel concludes.

The paper I am discussing is:

Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial 

Authors: Jan Y. Verbakel, Marieke B. Lemiengre, Tine De Burghgraeve, An De Sutter, Bert Aertgeerts, Bethany Shinkins, Rafael Perera, David Mant, Ann Van den Bruel and Frank Buntinx

It was published in BioMedCentral [full open access PDF] on 6th October 2016.   I found this paper interesting for a couple of reasons:

  1. It delivers some robust stats on the prevalence of serious bacterial infection amongst unwell children in a primary care setting.
  2. The conclusions / promotional statements are not really borne out by the data in my opinion (see analysis)
  3. The use of open-access, pre-publication peer review reports allows the reader to understand the process journals use to enhance the papers they receive.

I would like to thank Drs Tessa Davis, Anand Swaminathan, Andrew Tagg and Tim Horeczko for their pre-publication review of my review… how meta!

So lets first describe the study.  PICO-style…

This is a diagnostic study looking at point-of-care CRP +/- clinical criteria for the detection of serious bacterial infections in kids.

POPULATION:  ~ 3100 Children aged 1 month to 16 years presenting with an acute illness for a maximum of 5 days were recruited from 78 general (primary care) practices across Flanders, Belgium.  Now Belgium is one of those fantastic countries with excellent public health records and registries – so the data set is probably of high quality.  I imagine we are talking about a typical, well nourished, vaccinated and clean-living Western European cohort.

The exclusions from the study were:

  •  kids with “acute exacerbations of chronic disease” – unclear what this entails.
  • representation within the 5 days – fair enough
  • patients from GPs who recruited < 5 kids in the year… trying to remove “non-consecutive” recruitment – however this seems an odd and blunt way of doing so.
  • It should be noted that the base analysis of the groups showed the “selective testing group” to be significantly younger than the other group by almost a year on average.  3.6 vs 2.7 years… so this could be a problem. Younger kid = more risk and more likely clinician concern resulting in referral to ED etc.

INTERVENTION:  This is an RCT. Children were randomised at a practice level to one of two diagnostic strategies.  This is reasonable for a primary care study where blinding is impossible for logical reasons.  The strategies being compared were:

  1.  POC-CRP testing in all children meeting inclusion criteria
  2.  Clinically-guided CRP testing, i.e. testing only children assessed as being at higher risk by a validated clinical decision rule.

The authors looked at a range of cut-offs for CRP from 5 – 200mg  which were the technical limits of the assay used.  They conducted analyses looking at the test characteristics of CRP > 5, > 20, > 80 and >200.

The clinical criteria are important as this is where we see how this test might fit into current / routine clinical practice.  Here they are:

  1. “Breathlessness” was defined as difficult or laboured breathing.  Yep, this is a known marker of more serious illness
  2. “Body temperature > 40 C!” was defined as the highest body temperature measured during the illness episode by the parents or the physician according to their usual practice. Before analysis, 0.5 °C was added to temperatures measured under the axilla or with a tympanic thermometer.  Not sure why? 40 C is very hot! I would think 39.5 by any measure would count?
  3. “Diarrhoea” was defined as loose or watery stools, increased in frequency and volume.  I think most of us find diarrhoea to be either unhelpful or mildly reassuring in kids.  Suggests gastro which is usually a good / better diagnosis than otherwise…
  4. “Clinician concern” was defined as a subjective feeling of the physician that something was out of the ordinary.  Notably this criteria was the most likely to result in further testing with CRP.  I imagine it also resulted in more referrals to the ED.

CONTROL / COMPARISON : MOST CRITICALLY – it should be noted that there is no true CONTROL ARM – there were no kids in a group that received “usual care” where the GP did what they would usually do.  As such one cannot make any conclusions about the ability of POC CRP to improve safety or detection of SBI above the current practice…

This trial compares 2 strategies, both of which utilise a POC-CRP in either all or selected patients.  So this could be said to be more a trial of the clinical criteria used to select who gets a CRP as that was the main difference in the groups.

OUTCOME:   The primary outcome was hospital admission (> 24 hours) for a serious infection within 5 days after initial presentation.  The definition of SBI included: sepsis, meningitis, appendicitis, pneumonia, osteomyelitis, cellulitis, bacterial gastroenteritis, complicated urinary tract infection.   This is a fair end-point for a diagnostic trial.

About 20% of the kids in the “selective CRP” group met the criteria to go onto have a CRP done.

There were 7 SBIs in the ‘CRP-all’ group and 4 in the ‘selective-CRP group’.  This was not statistically significant. As such any analysis of the merits of the 2 strategies is somewhat meaningless.

Unfortunately (or fortunately if you are a kid) there were only 11 SBIs found in the final wash up!  So that is 11/3147 sick kids, i.e. 0.35% of the cohort had the outcome. This is probably what you would expect from a primary care study in Western Europe.  I know our rates in Broome are much higher, so for me this is probably not applicable at home. However it is extremely reassuring if you work in Belgium as a GP!

Secondary outcomes were the need for referral to ED or the ordering of subsequent testing by the GP.  Note – the “need for referral” is a secondary outcome.  Turns out the there was no significant difference in “need for referral” between the 2 groups 2.1 vs 2.9%.  As such one cannot draw conclusions about the intervention, it is only able to help further research hypothesis formation.  Hold that thought when you read the author’s conclusions.


Both the Discussion section and the emailed promotional summary contain a number of conclusions which are either not supported or contradicted by the data in the trial.  I have a problem with this as to a casual reader who skimmed their email or read the abstract only might be mislead about the utility of point-of-care CRP testing in kids visiting a GP.

I have “cut ‘n pasted” a few sentences from the paper here along with my review.

In primary care, CRP testing can be restricted to children at higher risk of serious infection after clinical assessment.”

  • As CRP is not currently a ‘standard of care’ in GP clinics this is misleading.
  • There was no comparison to the status quo.  This is akin to measuring 2 goats, finding one to be a little larger than the other and concluding goats are bigger than sheep. Poor sheep never had a chance!
  • Additionally, there was no difference in the primary outcome – so at best this is a negative / non-inferiority finding between 2 new strategies.

“At a threshold of 5 mg/L, CRP still has limited diagnostic value in ruling in serious infection (at most, 1 in 40 children will have serious infection) but it does rule out serious infection and the need for hospital referral.”

  • Agree that a CRP > 5 is a poor test for “ruling in disease” in this data set more than half the kids had a CRP > 5.   A coin toss would fair as well!  One wonders what the mean CRP in well kids would be?
  • CRP is not used to “rule in” severe infection even in higher prevalence populations (eg. tertiary Paeds EDs) – as such it is difficult to imagine it working in a primary care setting.

On the sensitivity side:

  • Does it really rule out serious infection?  Table 3 shows 0/11 of the cases were missed by POC-CRP <5, suggesting 100% sensitivity. But …
    • Table 4 lists all the kids with CRP < 5 whom were referred for ED / further testing and I can see 3 turned out to have a UTI, 2 of these 3 had high fevers, hence met the trial’s primary outcome definition of a SBI.  Confusing…
  • Imagine if just a single SBI slipped through. The number would then be 1 miss & 11 catches, the sensitivity would drop to an alarmingly low ~ 91% which shows the fragility of this data set.
  • Regardless – with such a low absolute number of SBIs (11 cases) in the cohort I feel it is somewhat intrepid to state that “a CRP < 5 rules out SBI”.  

“Our results support the implementation of clinically guided CRP testing to help rule out serious infection and the need for hospital admission.”  AND ” for children who are less seriously ill, the procedure prevents unnecessary hospital referrals and anxiety”

See above – POC-CRP is not being compared with current practice.  Ergo, widespread implementation is not supported by this data.

  • The need for ED referral and subsequent admission was:
    • A: not a primary outcome
    • B: not statistically significantly different in the 2 groups
    • Hence this conclusion is unjustified by the data presented.
  • More than 25% of the children tested had a CRP > 20 which would probably be a cause for concern for either the parents, GP or both.  Over-testing is a well known source of patient anxiety.  I would imagine it is more difficult to give calm reassurance to a family once a high CRP is returned.



This study compares 2 diagnostic strategies.  The goal was to show some benefit to using universal OR selective POC-CRP testing in unwell children in a GP setting.  The prevalence of serious infections was very low, and it is unsurprising that the null hypothesis prevailed given the small numbers of positive cases.

The author’s conclusions are not supported by the findings.  You could argue that the findings in fact show the disutility of POC CRP in primary care, or the relatively good performance of clinical acumen.

Primary care clinicians do worry about missing serious illness in children.  Missing a SBI is a nightmare for anyone working in a GP practice.  We have to work hard to ensure appropriate safety netting and follow-up occur.  In order to make these tough diagnoses in a timely manner we rely upon  serial review, advice to attend ED if the parents notice deterioration and our clinical judgement.  As an ED doctor I do not see “referral for review” as a failure of GP, rather as a sensible strategy on the part of the GP.  It is nigh impossible to observe an infant for 2 hours in a busy GP clinic – this is a relatively cheap and effective screen for SBI in my opinion.

It would be truly excellent if there were a simple “finger-prick” test that allowed us to exclude SBI.  However, as of 2016, there is not.  This paper gives the illusion that we may have a “holy Grail” without any good supporting data.

Widespread implementation of POC-CRP may in fact result in the false reassurance of well-meaning GPs.  A negative result may bias their usual decision-making process and result in holes in the safety net.  [Ed: I have no data to support this conjecture, just a hunch.]

So please read the fine print. Trash the email summary and make up your own minds.


September 2016 Journal Club with Justin & Casey

Its a new month and that means a new episode of the First10EM / Broomedocs Journal club.

I have learned so much by just hanging out with Justin and reading the papers he digs up each month.  I hope you are learning the easy way too!  This month we have 10 papers for you with topics ranging from massive haemoptysis to “Tweeting drunk en route to ED”… apologies in advance as there is a lot of me harping on about ultrasound as the solution to everything!!

So sit back, grab a beverage and listen in for the JC with J&C.  As always the full text papers are available here [click on the titles to read] as is Justin’ written commentary on the articles.  Or pop over to the First10EM blog for more excellent ED stuff in general.


Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. The New England journal of medicine. 339(15):1030-5. 1998. PMID: 9761804
Combining ipratropium (Atrovent in Canada) with salbutamol for asthma patients is reflex for a lot of us, but sometimes it is good to remind ourselves why we do what we do. This is an double-blind RCT of 434 children in the emergency department with moderate to severe asthma exacerbations. All patients received 3 ventolin nebs over 1 hour and an oral steroid. They compared ipratropium (500mcg) nebulized with the 2nd and 3rd ventolin doses to saline. Overall, the rate of hospitalization was decreased in the ipratropium group (27% versus 37% with a borderline p value of 0.05, NNT=10). Comparing subgroups, there was no difference in patients with moderate asthma, but hospitalization was decreased with severe asthma. This is a good lesson for all of our therapies – the less sick you are, the less a benefit you will see. However, in this study there were a lot more severe patients than moderate patients (271 severe vs 169 moderate), which is not the normal distribution. Therefore, we might expect that the majority of non-trivial asthma patients seen in the emergency department will benefit from the addition of ipratropium to their beta-agonist.   [The Aussie Paeds Asthma Plan is here if you are interested]
Bottom line: Ipratropium decreases hospitalization rates in moderate to severe pediatric asthma exacerbations

#plastered and emergency room visits
Ranney ML, Chang B, Freeman JR, Norris B, Silverberg M, Choo EK. Tweet Now, See You In the ED Later? Examining the Association Between Alcohol-related Tweets and Emergency Care Visits. Academic emergency medicine. 23(7):831-4. 2016. PMID: 27062454
It probably won’t help you, but I love this look at big data to predict busier times in emergency departments. The authors searched a sample of Twitter posts for terms considered to be “alcohol related” and compared those tweets to the number of visits at a single high volume urban emergency department that were deemed to be alcohol related. There was a statistical association with the number of alcohol related tweets and the number of alcohol related visits (but not non-alcohol related visits.) In case you were wondering, the alcohol related keywords were “alcohol, beer, wine, cocktail, booze, drunk, partying, clubbing, wasted, plastered, and tipsy”. Although this data is far from definitive, I think social media is an interesting potential source of medical information.
Bottom line: If #plastered is trending, you might be in for a busy shift

It’s just a dislocated shoulder – aren’t you getting a little carried away with the ultrasound stuff, Justin?
Gottlieb M, Edwards H. BET 1: Utility of ultrasound in the diagnosis of shoulder dislocation. Emergency medicine journal : EMJ. 33(9):671-2. 2016. PMID: 27539978
One of the Best BET review series, this time looking at ultrasound in shoulder dislocation. They identified 2 relevant prospective observational studies, which were unsurprisingly small and heterogenous. Both papers report 100% sensitivity for both dislocation and reduction, but there were a few false positives. Of course, like all ultrasound studies, the reproducibility might depend on who is holding the probe and interpreting the images.
Bottom line: Ultrasound seems pretty good for shoulder dislocation. I use it routinely (both to confirm humeral head location and to guide intra-articular lidocaine) as long as I remember to bring the machine in the room before starting the procedure.

Blind art lines? Why do we even have an ultrasound machine?
Melhuish TM, White LD. Optimal wrist positioning for radial arterial cannulation in adults: A systematic review and meta-analysis. The American journal of emergency medicine. 2016. PMID: 27624367
Wrist positioning for radial artery cannulation is not a topic we normally think about in evidence based medicine. When placing art lines, we generally just do whatever our teachers showed us. That is why I like this small systematic review. They identified 5 papers totalling 500 patients that fit their inclusion criteria. All of the included studies were RCTs or crossover studies that used the same patient as their own control, and in general these studies were of high quality. The biggest problem with the studies is that they tend to use healthy volunteers, so it is not clear if the results would be the same in sicker patients, or patients already found to be difficult to cannulate. First pass success rate was better at 45 degrees wrist extension than 30 degrees (RR 0.77, 0.61-0.98, p=0.03) and also looked better at 45 degrees than 60 degrees, but not statistically so (RR 0.79, 0.56-1.12, p=0.19). The time to cannulation was also statistically faster at 45 degrees than either 30 or 60 degrees, but only by a few seconds.
Bottom line: If you are starting a radial arterial line, it appears that 45 degree of wrist extension is the best position for success

Nice guys finish last (in total lawsuits)
Smith DD, Kellar J, Walters EL, Reibling ET, Phan T, Green SM. Does emergency physician empathy reduce thoughts of litigation? A randomised trial. Emergency medicine journal : EMJ. 33(8):548-52. 2016. PMID: 27002161
Thanks to Clay Smith and EMTopics for bringing this article to my attention. This is a randomized, controlled trial of a convenience sample of 437 patients sitting in an emergency department waiting room. The participants were shown videos of discharge instructions between a physician and a patient (actor). In half of the videos, there were two specific empathic statements included. The statements were: “verbalisations that (1) the physician recognises that the patient is concerned about their symptoms and (2) the patient knows their typical state of health better than a physician seeing them for the first time and did the right thing by seeking evaluation”. The participants were then asked how likely they were to sue the doctor if there were to be a missed diagnosis. The empathy group was statistically less likely to think about suing, although I am not sure how important the magnitude of the difference is (mean Likert scale 2.66 vs 2.95, difference -0.29, 95% CI -0.04 to -0.54, p=0.0176). The big problem is, obviously, that fake decisions to sue after watching a video are going to be very different from real decisions to sue. But I don’t care so much about being sued (maybe that is the Canadian in me); displaying empathy towards patient complaints on one of the scariest days of their life is just part of being a decent human being (let alone a good doctor).
Bottom line: A few simple sentences probably go a long way towards displaying your empathy towards emergency department patients (and maybe prevent lawsuits).

The only certainties in life are death and taxes – and we could stand to make both a lot more humane
McEwan A, Silverberg JZ. Palliative Care in the Emergency Department. Emergency medicine clinics of North America. 34(3):667-85. 2016. PMID: 27475020
This is a good paper. It’s probably better to read the original than relying on my very brief summary. I include it because of some excellent tips on communication at the end of life. If you haven’t heard of the SPIKES model for breaking bad news, I talk about it in my post on breaking bad news. They also discuss the NURSE mnemonic for addressing emotions (and displaying empathy). Name the emotion: “You seem to be frustrated”. Understanding: summarizing what you are hearing from the patient. Respecting or acknowledging the individual’s emotion. Supporting the individual (either alone, or ideally with the helps of others such as social workers.). And finally, exploring: asking specific focused questions or expressing interest in something that was mentioned in order to deepen the empathic connection.
Bottom line: Palliative care and communication around death are essential skills in emergency medicine

Twist and shout
Rey-Bellet Gasser C, Gehri M, Joseph JM, Pauchard JY. Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs. Pediatric emergency care. 32(4):256-61. 2016. PMID: 26855342
A young girl presents with right lower quadrant pain. You order an ultrasound to look for appendicitis, but what else should be on your differential? Ovarian torsion is an important but difficult diagnosis to make in this setting. This is a systematic review that identified 14 studies (all retrospective, including a total of 663 patients) that looked at the diagnostic accuracy of history, physical, and imaging for ovarian torsion in pediatric patients (up to 21 years, but median age 11 years). Unfortunately, I can’t get anything out of this paper that will help me identify patients with torsion. For example, only 80% of patients had a sudden onset of pain; only 33% described the pain as severe; and 12% of patients didn’t even have abdominal tenderness on exam. No test was perfect. Ultrasound was better than CT, but still was only 79% sensitive. I include this to remind people to keep torsion on the differential, because it is easy sometimes to get caught in a rule out appendicitis algorithm in patients with RLQ pain, but I am not sure what else to take away. This might be helpful to you is you miss a torsion – because my read of the evidence is that it is standard of care to miss this diagnosis.
Bottom line: Pediatric ovarian torsion is a very difficult diagnosis to make

I might miss pediatric torsion, but I will find AAAs, right?
Metcalfe D, Sugand K, Thrumurthy SG, Thompson MM, Holt PJ, Karthikesalingam AP. Diagnosis of ruptured abdominal aortic aneurysm: a multicentre cohort study. European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 23(5):386-90. 2016. PMID: 25969344
This is another study about diagnosis, this time about abdominal aortic aneurysm. It is a chart review of 85 consecutive patients diagnosed with AAA at 2 centres over a 6 month period. The major weakness of this data is that only patients in whom the diagnosis of AAA was made were included. Patients in whom the diagnosis was missed would not be included and those presentation might be different. Not surprisingly, AAA is a disease of older men; 82% were men and the median age was 76. About 20% of patients had symptoms for more than 1 day prior to presentation to the ED (so it doesn’t have to be acute onset). 60% had abdo pain, 54% had back pain, and 30% had both abdo and back pain. The most concerning number is the 10 (12%) patients with no pain at all, but it seems like these patients still had symptoms that should alert you to the diagnosis, with 7/10 having syncope or an altered level of consciousness in the department. 21% actually had the full triad of hypotension, palpable abdominal mass, and either back or abdo pain.
Bottom line: Although no single presentation is perfect, but if you have AAA on your radar for older patients with back pain, abdo pain, or syncope, you are in good shape.

How long until stethoscopes can only be found in museums?
Leuppi JD, Dieterle T, Koch G. Diagnostic value of lung auscultation in an emergency room setting. Swiss medical weekly. 135(35-36):520-4. 2005. PMID: 16323069 [free full text]
This is a neat little study that will probably ruffle a few feathers of those who value the more traditional physical exam. They took 243 consecutive patients presenting to the emergency department with chest symptoms and had the internal medicine registrars make a diagnosis first on history alone and then after lung auscultation (all before any testing was done). The final diagnosis was determined by hospital discharge letter. 41% of diagnoses were correct on history alone. Lung auscultation was essentially useless. It improved the diagnosis in only 1% of patients as compared to history, but it actually caused the registrars to change their mind to an incorrect diagnosis in 3% of patients. I don’t know how good these specific registrars were at auscultation, but I imagine at least as good as I am.
Bottom line: Not surprisingly, lung auscultation is not a highly accurate diagnostic tool.

Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. The American journal of emergency medicine. 2016. PMID: 27614374
I have discussed the management of massive hemoptysis before on the blog. One of the key steps in managing these patients is selectively intubating the one lung that isn’t bleeding. But how is the average emerg doc (without fancy equipment like a bronchoscope) supposed to ensure that the endotracheal tube ends up in the correct main stem? This is a small prospective, randomized, blinded cadaver study in which 2 individuals attempted to intubate either the right or left lung using a bougie. The bougie was either turned 90 degrees clockwise (for the right lung) or counterclockwise (for the left lung), advanced until hold up, and then a 6.0 cuffed tube was advanced over the bougie. Of a total of 45 placements, confirmed by a blinded assessor using a bronchoscope, they were successful at intubating the target lung 100% of the time (resulting in a 95% confidence interval of 90-100%). The technique is easy, so I don’t imagine that these two individuals would be a lot better at it than the average physician. They don’t tell me how long each procedure took, but it is possible that accuracy would decrease when pressured by falling sats and blood coming up the tube. However, the results are reassuring for those of us who include this step in our massive hemoptysis action plan.
Bottom line: A bougie is a helpful tool for selective lung intubation.

Lessons Hard Learned: Dr Heidi James

This episode of “Lessons” is a little different.  My guest is Dr Heidi James, Canadian Primary care doc, and one of the voices of the Primary Care RAP podcast.

Heidi and I have worked together in the Hippo ED shed on the Primary Care RAP for a few years and we seem to have a lot in common when it comes to work, life and the all important balance.  So we decided to yarn about how we make it work with family, work and all the other stuff life throws our way.  Can we have it all? What advice would we give given what we know now?  There is even a tale involving fatherhood, faeces and the fruit section….

Hope you enjoy it.

You can hear more of Heidi on the PrimaryCare RAP podcast (not free, but very good value!)

Catcha soon for the next First 10 EM Journal CLub