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Ischemic stroke after use of synthetic marijuana “spice”. Freeman MJ et al. Neurology 2013;81:1-4.
This interesting paper, from the University of South Florida in Tampa, describes a brother and sister who at different times both developed ischemic strokes shortly after smoking a synthetic marijuana product.
The 26-year-old brother presented with dysarthria, expressive aphasia, and right-sided weakness after smoking “Spice” a few hours previously. Head CT showed a clot in the proximal middle cerebral artery. His symptoms resolved after treatment with thrombolytics.
The 19-year-old sister lost consciousness “a few minutes” after smoking “Spice.” On presentation, she had global aphasia and right hemiplegia. MRI showed a left MCA distribution infarct that the authors say suggested embolic etiology. The patient presented too late to be eligible for thrombolytic therapy. On a follow-up visit, she had persistent right hemiparesis and expressive aphasia. A serum screening test for synthetic cannabinoids (no details given) detected JWH-018, but was negative for AM-2201, JWH-019, JWH-073, and JWH-250.
Extensive workup of both patients failed to reveal any alternative cause for the cerebral ischemia.
Although a screen for synthetic cannabinoids was not done on the brother, and the two ascetic events occurred at different times, the authors note that both patients had received spice from the same supplier. Certainly the temporal association with smoking spice does not prove causation, but I find the symptomatic onset in both cases shortly after exposure compelling. Since exposure to JWH-018 is widespread and has not previously been associated with stroke, it is quite possible that some other drug not tested for was present in both samples of “Spice.”
The bottom line for clinicians: when a young, previously healthy patient presents with ischemic stroke, ask about use of synthetic cannabinoids.
The December audio issue of Annals of EM is now posted and available. Highlights include:
-New onset atrial fibrillation — should we anticoagulate in the ED?
-Atrial fibrillation in the ED: trends in Canada
-Review: High sensitivity troponins
-Capnography to diagnose PE: meta-analysis
-Observation is associated with less imaging for pediatric minor head injury
-Pediatric magnet ingestions
-Review: reversing warfarin in the ED
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My name is Sara Paradise. I’m a fourth-year medical student at the George Washington School of Medicine in Washington, D.C., and a very soon-to-be emergency physician. Like 99 percent of you docs and future docs out there, I am 100 percent passionate about my chosen specialty and future patients, but have zero understanding of how government and health policy really works.
Which is why, after nearly four years of living only blocks from the White House and the epicenter of political drama, I was pumped to have the honor and privilege of doing an internship with the American College of Emergency Physicians. These are the premier group of people responsible for representing the policies, education, advocacy, and regulatory interests of emergency physicians.
Fast-forward five days, and I feel like I’ve gone from a toddler to a tween in my knowledge of health policy, being taken under the wings of the brilliant people working at ACEP in D.C. to amass a much deeper understanding of emergency medicine and our role in health policy.
So, let’s talk about how things work.
Much of my week has been devoted to meeting with members of Congress, who hold almost daily meetings to educate themselves on issues related to health care reform. The people in attendance tend to be lobbyists, or individuals hired to represent major medical specialty organizations such as ACEP. I was instantly struck by the important role that the medical lobbyists hold in these meetings compared to other public and private groups, often seated next to the Congressperson and directing the conversation. Lobbyists are not only experts in the nitty-gritty details of the Affordable Care Act and how it affects their specialty, but have an unparalleled adeptness in navigating Washington, D.C. politics to convey doctors concerns in a passionate, yet appropriate manner.
The Congresspeople who represent issues that your particular medical specialty cares about are the ones you meet with most frequently. In our case, that means anyone who champions funding poison centers, drunk driving prevention, and SGR reform (that is, ensuring that we as physicians are not fiscally-penalized for seeing Medicare patients). These legislators admit they are not experts, and fight for our doctors despite being stuck in a muddy Congress.
So other than rub elbows with political figures, what else do health policy people do? Apparently, they attend a lot of special panels and webinars that discuss details of healthcare-related legislation. They use their strong voices to bridge the gap between those creating health care-related laws, often non-clinicians, and America’s doctors. One such panel discussed the “Two Midnight Rule.” This rule, I learned, states that any Medicare patient who is marked as “Observation Status” – regardless of whether physically in the ER or an inpatient bed – does not automatically qualify to have their skilled nursing facility (SNF) stay covered, even if they are observed for the required three days and it is medically indicated; an unintended loophole, if you will [read more here]. The panelists were policy makers set on changing the laws for the better, with our local and national community’s input.
One of the highlights of my week was most definitely attending the release of the December issue of Health Affairs at the National Press Club on “The Future State of Emergency Care.”
My personal favorite was a talk by Dr. Maria Raven on the urban myth that Emergency Department “frequent fliers” guzzle our health care dollars faster than a non-hybrid SUV consumes gas. She and Dr. Billings’ research found that those patients utilizing the ED on a “frequent” basis (about 10 times per year) visited their Primary Care MORE frequently than the average ED patient. Perhaps they just have more complicated, and many comorbid conditions! Another talk, by Dr. Jeremiah Schuur, was on changing our emergency medicine infrastructure. Why not bring the right resources to the patient via tools such as Telemedicine, rather than dragging patient to the resource (which is often time-consuming, costly, and ineffective)? In the era of Facetime and Medicare reimbursement for Telemedicine consultation, makes sense to me.
One really informative meeting was with ACEP’s Quality & Health I.T. Manager. Even though I have an extensive background in Electronic Health Records, I felt as though she was speaking a foreign language. HL7? CCDA-1?? MU2? I nodded my head, thinking “What do these codes mean?!” Jumping on the Internet, I discovered the how we are standardizing the language of Electronic Health Records in hopes that Health Information Exchange can become a reality, outside of utilizing the same brand of system.
The moment I felt my voice really matter was when I had informal discussion with my new colleagues about what I had experienced as a third-year medical student. Fresh off the wards of OB-Gyn, Medicine, and Psych, I had some solid opinions about how the Emergency Department interacts with each of these specialties and ways we could improve our health care system. I was shocked that they not only took my input seriously, but wanted to know more, leading to a number of meetings with different specialists on their calendars.
Reflecting on my first week, I now feel a much stronger responsibility to “represent” each and every G.W. medical student, future Emergency Physician, and maybe even late 20-something woman starting her career. I also want to emphasize: You, too, can set a meeting with these tremendous people and discuss your observations and ideas. You, too, can become an advocate and leader in your field. It takes a simple e-mail to your respective governing body, and a will to fight for something you believe in.
I’m already looking forward to what lies ahead…affter a quick detour to L.A. for a residency interview, I’ll be back for more next week!
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