4th of July Games

4 teasers for the 4th of July weekend.

1. What is this and why is it dangerous?

Toxic Megacolon

2. Patient had a DVT + PE, then got an IVC filter, then had another PE. How?

3. Fun Sporcle quiz - 3 letter body parts, 2 min

4. Higher level Sporcle quiz - Doses and drips, 5 min (good for 2nd years)

Answers to 1 & 2 are below.


1. Toxic megacolon is a medical emergency. Susceptible people include people susceptible to volvulus, those w/ Crohn’s, or anyone w/ any type of colitis. Toxins released from the expansion of the colon can lead to a state of shock and severe sepsis and then death. These patients need decompression ASAP.

2. Patient had 2 IVCs. Up to 10% of people have 2 IVCs.

3. & 4. If you liked these, let me know and I can make more.

Quiz: How much do you know about heparin-induced thrombocytopenia?

Heparin Sodium 1,000UmL MDV 30mL Vial McGuffMedical.com3.5 out of 5 stars

Heparin-induced thrombocytopenia. Lovecchio F. Clin Toxicol 2014 Jul;52:579-583.


This is a good up-to-date review of heparin-induced thrombocytopenia (HIT). The following are some questions based on the discussion in the paper (click on each question to reveal the answer):

Onset of HIT is generally within 5-10 days of heparin initiation, and is heralded by a 50% of greater decrease in the platelet count.

HIT occurs in 1-5% of patients receiving heparin. It is more frequently associated with use of unfractionated heparin as compared with low-molecular-weight heparin.

This is a trick question. HIT is a condition that causes clotting, not bleeding. This is a crucial point.

Heparin forms an immunogenic complex with platelet factor 4 (PF4). This complex attaches both to the surface of activated platelets and to endothelial cells, causing release of additional PF4, tissue factor, and other mediators that promote clotting.

  1. Immediately discontinue all heparin (including line flushes).
  2. Start a non-heparin agent for anticoagulation (if no contraindication)
  3. Start warfarin when thrombocytopenia resolves (platelet count > 150,000/mcL).

Because of increase risk of thrombosis, the authors recommend that these patient be anti coagulated for at least 3-6 months if the patient has had a thrombotic event, at least 2-3 months otherwise.

On the Hobby Lobby: Your Boss’s Business?

This post also appears on Policy Prescriptions.

The Affordable Care Act (ACA) seeks both to expand insurance coverage as well as to ensure that offered plans include substantive benefits, including coverage of preventative services, so that Americans have access to necessary preventative care such as screening colonoscopies and mammograms. One provision that has publicly come under attack is Section 2713 of the Public Health Service Act which includes contraceptive services as a necessary preventative service with first-dollar coverage – no cost-sharing such as copayments or coinsurance will apply, and insurers will have to cover contraceptives fully whether or not the enrollee has hit their deductible. 

Religious groups who sponsor health plans, including affiliated schools and hospitals, are generally exempt from the requirement. In those cases, the insurer is required to pay for the coverage, which tends to save the insurer money, as prenatal and childbirth care is pretty expensive but birth control is not.

Opposition from some religious groups focuses on the first amendment religious freedom of the employers, arguing that without an exemption for religiously affiliated employers and schools, the “mandate even forces individuals and groups with religious or moral objections to purchase and provide [contraceptive] coverage if they are to receive or provide health coverage at all.”[1]

In Hobby Lobby, the Supreme Court recently addressed the same question but with a different group: a for-profit company, whose owners object to certain kinds of birth control on the basis that they consider them abortions (even though most scientists agree that they are not).

The question is whether a requirement to provide insurance that covers services that employers object to on religious grounds violates their right to exercise their religion.

However, the mandated coverage would not force any individual or group to partake in an activity they have a moral objection to. Rather, the mandate would compel employers who offer health coverage to their employees to include first-dollar contraceptive coverage for the employees in that coverage. The question at issue here pits the employer’s right of free exercise of religion against the employee’s rights to health coverage and fair compensation.

Those with religious objections to contraception are not compelled by law to engage in commerce, healthcare, or education. Even after the shared responsibility payments (a.k.a. “employer mandate” to provide health insurance) go into effect in 2014 2015 2016 employers are not compelled to offer insurance to their employees; there are simply penalties under certain conditions, which happen to be cheaper than providing insurance.Regardless, those with religious objections to contraception are not compelled to employ others or offer group insurance plans. If they choose to, then (before Hobby Lobby) they must follow the regulations that all employers must follow, particularly when it is not the employer who is engaging in any activity they may find objectionable.

In Hobby Lobby, the Supreme Court ruled that "closely held" private, for-profit enterprises can be exempted from such a requirement if it violates their religious beliefs. It's unclear exactly which companies would be included as "closely held"; IRS definitions include those where a group of 5 or fewer close individuals own and operate over 50% of the company. This probably would include Walmart.

I think my view on the issue is best captured in the decision in one of the lower court rulings on the way to the Supreme Court. A contraceptive coverage mandate does not infringe on the employer’s free exercise rights because an employer will not be:
prevented from keeping the Sabbath, from providing a religious upbringing for his children, or from participating in a religious ritual such as communion. Instead, plaintiffs remain free to exercise their religion, by not using contraceptives and by discouraging employees from using contraceptives…. The burden of which plaintiffs complain is that funds, which plaintiffs will contribute to a group health plan, might, after a series of independent decisions by health care providers and patients covered by [their] plan, subsidize someone else’s participation in an activity that is condemned by plaintiffs’ religion. This Court rejects the proposition that requiring indirect financial support of a practice, from which plaintiff himself abstains according to his religious principles, constitutes a substantial burden on plaintiff’s religious exercise. [emphasis mine][2]
The key point here is that there are a number of steps between the actions required of the employer and the acts being carried out which they find objectionable.

Let's also consider what insurance really is. Employer sponsored health insurance in this instance is offered as a fringe benefit to an employee, i.e. it is a form of compensation. Would we allow an employer to give an employee a 10% raise, on the condition that the employee not spend it on contraceptives? That would almost certainly be considered religious discrimination in violation of the 1964 Civil Rights Act[3]in addition to being absurdly difficult for an employer to police.

Would we allow exemptions for other medical treatments that some religious groups find objectionable? Surely an employee of a Jehovah’s Witness would take issue if their group insurance plan did not cover blood transfusions (it would certainly make them reconsider driving to work). What about a Christian Scientist employer who was opposed to vaccine coverage for their workers and their workers’ children?

Mandating first-dollar coverage for contraceptive services across the board protects the rights of employers and students in group health plans. An employers’ right to exercise their religious beliefs ends when it infringes on their employees’ rights – and their compensation.

This post is adapted from a paper I wrote the course Health Services & Law I took in Spring 2013 as part of my MPH.

[1] Catholic Bishops Call Obamacare Mandate “Unprecedented Threat” to “Religious Freedom.” Sep 27, 2011. http://www.impeachobamacampaign.com/catholic-bishops-call-obamacare-mandate-unprecedented-threat-to-religious-freedom/
[2] O’Brien v. Health & Human Services  (2012 WL 4481208 (E.D.Mo.))
[3] Equal Employment Opportunity Commission. “Religious Discrimination.” http://www.eeoc.gov/laws/types/religion.cfm

Best Case Ever 26 – Mike Betzner on Chloral Hydrate Poisoning & Cardiac Arrest

I met up with Mike Betzner at North York General's Update in EM Conference in Toronto. He is the medical director of Air Transport STARS air ambulance out of Calgary and an amazing speaker on the national lecturing circuit. His Best Case Ever on Chloral Hydrate poisoning & cardiac arrest describes a young man in cardiac arrest with resistant Ventricular Fibrillation and Torsades de Pointes. There is only one class of drugs that can get him back into normal sinus rhythm. Dr. Betzner describes how he recognized that this patient was suffering from Chloral Hydrate poisoning and how he saved his life with one simple intervention.

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The post Best Case Ever 26 – Mike Betzner on Chloral Hydrate Poisoning & Cardiac Arrest appeared first on Emergency Medicine Cases.

REMI 1972. Antibióticos inhalados para la neumonía asociada a ventilación mecánica por bacterias multirresistentes

Artículo original: Reduction of bacterial resistance with inhaled antibiotics in the intensive care unit. Palmer LB, Smaldone GC. Am J Respir Crit Care Med 2014; 189(10): 1225-1233. [Resumen] [Artículos relacionados]
Introducción: Las bacterias multirresistentes (BMR), en especial los que causan neumonías asociadas a la ventilación mecánica (NAV) son un problema cada vez más importante en todas las UCI. Esta resistencia es en gran parte debida al uso previo de antibióticos, por los que los intensivistas se ven obligados a balancear dos opciones contrarias, emplear antibióticos de amplio espectro para reducir la mortalidad del paciente crítico e intentar limitarlos para evitar la aparición de resistencias. Los antibióticos aerosolizados (AA) alcanzan una concentración 100 veces más elevadas que la concentración inhibitoria mínima en las vías aéreas, por lo que pueden erradicar microorganismos sin producir toxicidad sistémica. Este estudio se diseñó para determinar si los AA son capaces de erradicar BMR en pacientes intubados sin facilitar nuevas resistencias.
Resumen: Se trata de un ensayo clínico enmascarado a doble ciego, aleatorizado, realizado en un solo centro. En él 27 pacientes fueron asignados a tratamiento con AA o con suero salino en aerosol durante 14 días. Los criterios de inclusión fueron estar intubado, con una expectativa de vida superior a 14 días, y con signos de infección respiratoria caracterizada como un esputo purulento y una puntuación CPIS (incluido el esputo) igual o superior a 6. El médico responsable del paciente determinó la administración de los antibióticos sistémicos para la NAV o cualquier otra infección. Los AA empleados fueron gentamicina o amikacina para Gram negativos y vancomicina para Gram positivos. Ambos grupos tuvieron características demográficas semejantes, salvo el APACHE II que fue significativamente más elevado en el grupo de AA. Los AA erradicaron  26 de los 27 microorganismos presentes en el momento de la aleatorización, comparados con 2 de los 23 microorganismos tratados  con placebo (P < 0,0001).  El microorganismo resistente original fue erradicado en los cultivos  y en la tinción de Gram al final del tratamiento en 14 de los 16 pacientes tratados con AA y en 1 de 11 tratados con placebo (P < 0,001). No aparecieron nuevas resistencias en el grupo tratado. La resistencia a los antibióticos sistémicos aumentaron significativamente en el grupo placebo. Los AA disminuyeron significativamente la puntuación CPIS con relación al grupo placebo (de 9,3 ± 2,7 a 5,3 ± 2,6 contra 8,0 ± 2,3 a 8,6 ± 2,10; P = 0,0008). Esta disminución continuó siendo significativa al excluir el esputo purulento del CPIS.
Comentario: Aunque se trata de un estudio pequeño y de un solo centro, la conclusión es que los antibióticos inhalados pueden ser una buena opción para la erradicación de BMR de las vías aéreas sin aumentar las resistencias. Deberían realizarse ensayos mayores para verificarlo así como averiguar su impacto sobre desenlaces clínicos más importantes, y para explorar otras cuestiones como la posibilidad de emplearlos sin antibióticos parenterales asociados.
Ramón Díaz-Alersi
Hospital U. Puerto Real, Cádiz.
© REMI, http://medicina-intensiva.com. Julio 2014
  1. Aerosolized antibiotics in critically ill ventilated patients. Palmer LB. Curr Opin Crit Care 2009; 15: 413-418. [PubMed
  2. Nebulized colistin treatment of multi-resistant Acinetobacter baumannii pulmonary infection in critical ill patients. Pérez-Pedrero MJ, Sánchez-Casado M, Rodríguez-Villar S. Med Intensiva 2011; 35: 226-231. [PubMed] [Texto completo]
Búsqueda en PubMed
  • Enunciado: Ensayos clínicos sobre el uso de antibióticos inhalados en la NAVM
  • Sintaxis: clinical trial AND aerosolized antibiotics AND ventilator associated pneumonia
  • [Resultados

Toscana: la polemica sui pronto soccorso di Pisa e di Livorno


La posizione Simeu: è solo la punta dell’iceberg della sofferenza dell’emergenza sanitaria toscana


In merito alle polemiche dei giorni scorsi sui pronto soccorso di Pisa e Livorno in seguito alle dichiarazioni sui social network di Enrico Rossi, presidente della Regione Toscana, riprese poi dai tradizionali mezzi di comunicazione, la Società italiana di medicina di emergenza-urgenza ha preso posizione come segue. Il comuincato è stato ripreso dall’Agenzia di stampa nazionale Ansa, che in un lancio dello scorso giovedì 26 giugno ha riportato la posizione del presidente regionale Simeu, Alessio Bertini.

Ritratto del Pronto soccorso di Pisa, 2009-2014

Il numero dei pazienti che stazionano in pronto soccorso in attesa di posto letto è in costante e continuo incremento. I primi mesi del 2014 hanno visto un significativo aumento degli accessi, in particolare dei codici rossi, i più gravi. Nel 2009 sono stati visitati circa 79.000 pazienti; oggi, 2014, stiamo andando verso i 90.000 accessi all’anno. Il personale è rimasto sempre lo stesso. Nel 2009 un codice giallo veniva visitato nella prima mezz’ora dall’arrivo, oggi, 2014, la media è superiore ai 60 minuti.

Ritratto del Pronto soccorso di Livorno, 2009-2014

Sono stabilmente circa 70 mila gli accessi dal 2009 al 2014, con un aumento sensibile però dei codici rossi, in seguito alla riorganizzazione della rete ospedaliera nella periferia di Livorno e di conseguenza dei percorsi di cura. Il mancato bersaglio del MeS, il Laboratorio in Management e sanità della Scuola superiore Sant’Anna, da parte della ASL 6 riguarda soprattutto la percezione degli utenti che sicuramente risente della carenza di personale, in particolare di infermieri rispetto alla media dei pronto soccorso toscani. Nel bersaglio MeS si rileva come questi elementi si associno a una percezione negativa dei pazienti riguardo al servizio erogato e anche a un clima interno non ottimale per gli operatori (http://performance.sssup.it/toscana/index.php per accedere al documento è sufficiente registrarsi sul sito).

Perché le aziende sanitarie regionali non ascoltano gli specialisti?

Ciò che si è verificato nei Pronto Soccorso di Pisa e di Livorno – dichiara Alessio Bertini, presidente Simeu Toscana – è solo la punta di un iceberg che affligge molte strutture anche in una Regione ‘attenta’ come la Toscana così come nel resto d’Italia.

Nel 2011 la nostra Società ha espresso indicazioni su come dovrebbero essere organizzati i Pronto Soccorso e sulle dotazioni organiche degli stessi (numero di accessi, presenza di Osservazione Breve Intensiva, e dell’area semi-intensiva, complessità della casistica) “Standard Organizzativi delle Strutture di Emergenza-Urgenza” (http://www.simeu.it/file.php?file=leggi&sez=articoli&art=3318), che alcune aziende, ma solo alcune, hanno iniziato a utilizzare per la riorganizzazione delle cure. Persino il MeS, il Laboratorio in Management e sanità della Scuola superiore Sant’Anna, ha individuato nei dati 2013 elementi di disparità nelle dotazioni organiche di infermieri e medici con il Pronto soccorso di Pisa che è tra gli organici (Medici e Infermieri) più risicati della Toscana. Ma anche questo segnale d’allarme è stato ignorato.

Se è vero che sono i cardiologi a spiegare come organizzare le UTIC, perché non vengono coinvolti i medici d’urgenza nell’organizzazione dei Pronto Soccorso?

Simeu raccoglie oltre 3.000 professionisti (medici ed infermieri dell’Emergenza-Urgenza) in Italia e, come società scientifica libera e volontaria, ha come obiettivo la qualità delle cure e l’efficienza delle strutture, gli stessi valori che interessano al cittadino.

Noi sappiamo, per esperienza quotidiana, quanto tempo è necessario dedicare a ciascun paziente per rendergli dignitoso il soggiorno in Pronto Soccorso e per adempiere a tutte le procedure necessarie per la sua sicurezza e per la tutela del rischio clinico.

In questi anni il sistema di verifica si è basato solo sulla misura dell’efficienza senza prestare troppa attenzione alla qualità delle cure e all’adeguatezza del personale. È possibile pensare di ridisegnare il sistema per “intercettare” entrambe queste necessità, ma non lo si può fare senza il coinvolgimento di chi il sistema lo conosce, lo governa e lo vive tutti i giorni”.