How the NEJM and Star Wars May Just Have Predicted My Future in #FOAMed

It sometimes is a bit wondrous how our past actions can influence how our future pursuits.

I have discussed how #FOAMed has made an impact on research, discovery, and my professional pursuits here and here. To be quite frank, I can't imagine how my life would be if I was not engaged in social media.

But obviously, at one point, I did, and I may have predicted my own engagement in #FOAMed without even realizing it. In addition, I think I have the New England Journal of Medicine (NEJM) and the Star Wars franchise to thank for this foretelling of my future.

This week, five years ago, as I was in the midst of applying and interview at programs to pursue post-graduate training in emergency medicine pharmacy, I was also putting the final touches of an essay for a contest that I will confess that I entered as a sort of joke that I had with one of my co-residents.

At the time, the NEJM put forth a call for student and residents to enter an essay contest in commemoration of the 200th anniversary of the journal. The question surrounding the essay was as follows:

In the last twenty years, the internet and social networking have brought profound changes in how information is communicated. How can we harness this technology to improve health?

The editors of the journal would select 150 winners of the essay contest, and those student and trainees who won would be invited to a full-day symposium of the 200th anniversary of the journal at Harvard Medical School in Boston. In addition, all of the winning essays would be featured on the NEJM 200th anniversary website.

When I received the email, I was on my drug information learning experience, and there was some opportunity for me to write during downtime. I showed the email to my co-resident, who stated that I was lucky that she was not entering the contest as her essay would "blow all the others out of the water. " I took this as a challenge and said to her that I would enter, and that I may very well prove to her that I could win. We both laughed, and I proceeded to write, not thinking much of it, but I did have a tiny glimmer of hope of being one of the lucky 150. Once I submitted the essay, I forgot about it in the haze of everything else that was occurring at the time.

A short few months later, on a spring day in March, as I was checking my email,  one subject heading that caught my eye in my inbox was "Results of the NEJM Essay Contest." Once I clicked it open, I read congratulatory notes on having won the essay contest with further details related to registration and traveling to the Boston to attend the 200th anniversary symposium. I was shocked and gleefully laughed as I showed my co-resident the email, and she commended me on my efforts.

After being granted full permission to do so from the editors of the NEJM, I have reproduced my essay below. For all I know, the title may have pushed this essay over the edge for the judges.

"Electronic Information Technologies in Healthcare: May the Source Be With You

It is difficult to imagine the world without the existence of smartphones, personal computer tablets, and other devices that we currently utilize as a means to obtain and communicate information.

Social networking websites such as Facebook and Twitter are tools we use every day to receive the most up-to-date information on a minute-to-minute basis. With these resources, we can literally carry the world at our fingertips.

The advancements in the availability of information via electronic means have changed the way healthcare professionals practice. Many medical journals utilize an electronic table of contents (eTOC) for subscribers to receive information regarding newly completed and ongoing clinical trials, the latest review articles and treatment guidelines, and interesting case reports that can be applied to our clinical practice. If we have questions or need clarification regarding indications,appropriate dosing, or adverse effects of medications, various mobile applications that contain a wealth of drug information are available to us to research the information and are only a touchscreen away.

Social networking has allowed for communication between healthcare professionals who share the same field of practice that would not have been otherwise possible. This has established a foundation for the exchange of ideas through the development of workshops and conferences regarding the latest therapeutic updates, which has fostered an environment for collaborative practice amongst healthcare professionals. In the setting of natural disasters and other types of emergency crises, social networking websites can serve as a means of sharing information with the public regarding preparedness and response to these typesof situations, especially when determining the status of local hospital operations and emergency room access. Governmental agencies such as the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) provide the general public with information regarding the latest news in the media regarding healthcare on a regular basis.

With the growing interest in the promotion of health literacy, both the Internet and social networking websites can serve as useful vehicles for healthcare professionals and patients aliketo make appropriate health decisions. As health literacy initiatives continue to grow and progress, patient safety and health outcomes will improve, which can eventually lead to a reduction in medication errors and decreased healthcare costs.

Through these instances, we can see that the Internet and social networking websites have become an essential component of the healthcare setting. As healthcare organizations continue develop innovative means to utilize this technology, stakeholders will be able to influence the means  in  which both patients and healthcare professionals can acquire and gain access to health information. With the evolution of these technologies, healthcare providers have the responsibility to evaluate the accuracy and clarity of these resources for use by the general public, which is a huge challenge that will need to be addressed and overcome in the future. In doing so, we can ensure that the practical application of information obtained through these technologies will ultimately improve the quality of life for our patients."

---

Here is what still surprises me: I wrote this essay prior to my engagement in #FOAMed - nearly a full year prior, to be exact. That is to say that at the time that I wrote this essay, I had never even heard of #FOAMed. In addition, at the time of writing the essay, I was not yet on Twitter - I thought it was only for celebrities - and I was on the brink of closing my Facebook page for good, which I did later on that year. Much of what I knew about social media at the time of writing the essay came from my own research on the topic from other disciplines. The way that I kept up with the latest in the medical and pharmacy literature came from my own subscriptions through electronic tables of contents of various journals - that was it. Admittedly, all that I knew back then was that people used blogs as live journals to record the occurrences of daily life and to share recipes, and podcasts were for listening to books on tape and for folks to discuss the latest in pop culture. This was the limited scope of knowledge that I had about social media, and yet, there was something that made me push forward in writing about its role in medicine.

I also find it ironic that it may have very well been a journal - a traditional, 200-year-young print publication - that sparked my initial interest in social media and medicine.

Reading this now, there are certain themes in the essay that emerge that are #FOAMed-like in nature, if not, fall within the very realms of #FOAMed. In reflecting upon this, maybe I had some sort of gut feeling that in time, social media could be leveraged for some good.

Funny how things turn out.

Managing Alcohol Withdrawal In The ED

 

Author: Kim Iwaki, MD (EM Resident Physician, PGY-3, NUEM) // Edited by: Teddi Rusinak, MD // Expert Review: Howard Kim, MD

Citation: [Peer-Reviewed, Web Publication] Iwaki K , Rusinak T (2016, November 29). Managing Alcohol Withdrawal In The ED [NUEM Blog. Expert Commentary By Kim H]. Retrieved from http://www.nuemblog.com/blog/etoh-withdrawal


Over 16.3 million adults have an alcohol use disorder as defined by the NIH [1]. Though the emergency department (ED) sees its fair share of intoxicated patients, many patients also present to the ED with withdrawal symptoms. Several of these patients come to the ED seeking symptomatic relief after intentionally trying to cut down on drinking, while others go into frank withdrawal secondary to an acute illness that prevents them from drinking.

What are the Symptoms of Alcohol Withdrawal?

Mild withdrawal symptoms including tremulousness, mild anxiety, palpitations, headache, diaphoresis, and GI upset, begin 6-36 hours after the last drink. Seizure may also occur between 6-48 hours after the last drink. Alcoholic hallucinations typically begin within 12-48 hours. Finally, Delirium tremens – with delirium, agitation, hypertension, fever, and diaphoresis - likely will occur between 48-96 hours after the patient’s last drink [2].

How do you treat Alcohol Withdrawal?

Benzodiazepines are used to treat the symptoms of alcohol withdrawal. Diazepam is often preferred since it is long-acting. Chlordiazepoxide is also a popular agent given it is long-acting and is thought to be less addictive. However, lorazepam may be preferable in those who metabolize the drug more slowly including the elderly and those with advanced liver disease. Lorazepam has a shorter half-life and therefore, its active metabolites are less likely to reach toxic levels [3,4].

What dosing is recommended?

Below is a treatment regimen recommended by Mayo-Smith MF et al [5].

Symptom-triggered Regimen, CIWA-Ar scores > 8:

  • Chlordiazepoxide: 50-100mg q hour
  • Diazepam: 10-20mg q 10 min
  • Lorazepam: 2-4mg q 20 min

Symptom-triggered vs. fixed-schedule dosing

Saitz et al [6] performed a randomized double-blind, controlled trial on 101 patients admitted to the Veterans Affair Medical Center. Exclusion criteria included patients who were also being admitted for acute medical or psychiatric illness, a history of seizures from any cause, an inability to take PO, and current use of benzodiazepines, opiates, clonidine, barbiturates, or beta blockers. Subjects were randomized to the fixed-schedule group or the symptom-triggered group. The baseline characteristics for each group – including initial CIWA-Ar score, prior hallucinations, prior detoxification, prior delirium tremens, and age were not significantly different (P>.05). The fixed-schedule group received chlordiazepoxide scheduled every 6 hours. The first 4 doses were of 50mg each and the next 8 doses were of 25mg each, for a total of 12 doses. In addition, their CIWA-Ar scores were assessed 1 hour after each dose of medication and they received an extra 25-100mg of chloriazepoxide when their CIWA-Ar scores were greater than 8. The symptom-triggered group received a placebo every 6 hours for 12 doses with nurses again calculating their CIWA-Ar score after every dose, giving them between 25-100mg of chlordiazepoxide based on their score. The primary outcome was the duration of medication treatment and the total amount of benzodiazepines administered. The duration of treatment was determined after the patient maintained a CIWA-Ar score less than 8 for 24 hours. An intention-to-treat analysis was used and they found that the duration of treatment was significantly shorter in the symptom-triggered group (9 hours vs 68 hours, p<0.001). The symptom-triggered group also received significantly less chlordiazepoxide (100mg vs 425mg, P<0.001).

Limitations of this study included the following:

  • The as needed dose of chlordiazepoxide ranged from 25mg to 100mg. The study does not report how they determined whether to give a 25mg dose vs a higher dose (ie 50 or 100mg).
  • The study was not powered to detect differences in rare complications including seizures and DTs.
  • A history of hallucinations, DTs, and prior detoxification were more prevalent in the baseline characteristics for the fixed treatment group, though this did not reach clinical significance.
  • The study was performed in an alcohol detoxification unit with nurse who are trained to use the CIWA-Ar scale, which limits its generalizability to other medical centers without specialized training and the outpatient setting.
  • The study consisted mostly of men, which may limit its applicability to women
  • The study excluded those with a history of withdrawal seizures. This is a limitation under the assumption that a fixed-schedule regimen will prevent abrupt rebound symptoms and decrease the likelihood of withdrawal seizures.
  • The study only evaluated the use of chlordiazepoxide, so the findings cannot be applied to the use of other benzodiazepines.

CIWA-Ar (taken from aafp.org) {Insert scoring sheet}

Disposition: Inpatient vs. Outpatient

Patents may be safely discharged home if they have mild symptoms. Outpatient detoxification is often safe and more cost effective than inpatients treatment if the patient can be assessed daily by a medical provider. Only short prescriptions of benzodiazepines should be given to ensure close follow-up [8,9,10]. Because of the potential for rebound withdrawal with symptom-triggered treatment, some believe that a fixed-schedule regimen should be used though this is not evidence-based. Indications for inpatient admission include a history of withdrawal seizures, a history of delirium tremens, a history of severe withdrawal symptoms, multiple prior detoxifications, recent high levels of alcohol use, concomitant psychiatric or medical illness, pregnancy, and lack of an outpatient support system [10].


Take Home Points

  • Treating alcohol withdrawal must be individualized.
  • Evidence has demonstrated that symptom-triggered treatment is more effective than fixed-schedule dosing, leading to decreased medication requirement and faster recovery. However, this study excluded patients with prior withdrawal seizures.
  • Outpatient management may be appropriate and cost-effective for patients with mild symptoms, without prior severe withdrawal symptoms, and without comorbid conditions.

Expert Commentary

Hi Kim,

Thanks for the good review of managing alcohol withdrawal in the ED and the benefit of symptom-triggered therapy. Patients presenting with alcohol withdrawal can present anywhere on the spectrum of disease severity, and having a nuanced treatment strategy can make the difference between a good and bad outcome.

Obviously, the first step to effectively treating alcohol withdrawal is to diagnose it properly. In addition to the classic symptoms of withdrawal that you described, I look for physical exam findings that cannot be feigned, such as tachycardia, hypertension, and diaphoresis. Other findings such as tremors and tongue fasciculations may also be relevant, however, can be gamed more easily and have poor inter-rater reliability. I do not typically rely on patient history when considering the possibility of alcohol withdrawal, since time to onset of symptoms is highly variable and patient reporting is notoriously unreliable. Don’t forget that severe alcohol withdrawal can look very similar to sepsis (fever, tachycardia, tachypnea, leukocytosis) so keep this in your differential diagnosis when evaluating what you think may be an infectious complaint. Vice versa, pause to reconsider your diagnosis of alcohol withdrawal in a patient that does not appear to be responding to treatment.

As you point out, benzodiazepines are the mainstay of treatment of alcohol withdrawal. Whether you use diazepam or lorazepam is a matter of preference, but I would recommend staying consistent with whichever benzodiazepine you select. I often see ED providers give a smorgasbord of medications in severe cases of alcohol withdrawal (e.g. diazepam 5mg IV, lorazepam 0.5mg PO, lorazepam 1mg IV, diazepam 10mg PO), which can make it difficult to assess treatment effect and calculate total dosing requirements.

It is worth noting that the doses of benzodiazepines you have listed are more appropriate for cases of severe alcohol withdrawal and not minor withdrawal symptoms. For patients with severe withdrawal, my personal approach is to give escalating doses of lorazepam q 15min until the desired response is achieved: e.g. 2mg IV, if no/poor response then 4mg IV, if no/poor response then 6mg IV, of course reconsidering my diagnosis at each step. Patients with mild withdrawal symptoms do not require this attentive dose escalation strategy and can be managed with lower doses of benzodiazepines as needed.

At our county hospital in Denver, we had success using phenobarbital early in the course of severe alcohol withdrawal, although evidence for phenobarbital is limited to single-center studies [11], use in this context remains off-label, and phenobarbital does carry an increased risk of hypotension and mental status depression. My general advice would be that if your specific institution does not have familiarity with (and ideally a protocol for) use of alternative agents such as phenobarbital in severe alcohol withdrawal, then it would be best to stick to the devil you know in benzodiazepines.

Howard Kim, MD

Clinical Instructor, Research Fellow, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine


References

  1. National Institute on Alcohol Abuse and Alcoholism (2016, January). Alcohol Facts and Statistics. Retrieved from <http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics>.
  2. Etherington JM. Emergency management of acute alcohol problems. Part 1: Uncomplicated withdrawal. Can Fam Physician. 1996;4(2):2186.
  3. Turner RC, Lichstein PR, Peden JG Jr, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432.
  4. DeBellis R, Smith BS, Choi S, Malloy M. Management of delirium tremens. J Intensive Care Med. 2005;20(3):164.
  5. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278(16):1317-8.
  6. Saitz R, Mayo-Smith MF, Roberts M, Redmod HA, Bernard DR, Calkins DR. Individualized Treatment for Alcohol Withdrawal. JAMA. 1994;272(7):519-523.
  7. Sullivan JT, Sykora K, Schneiderman J, Nranjo CA, Sellers EM Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). J Addict. 1989;84(11):1353-7.
  8. Abbott PJ, Quinn D, Knox L. Ambulatory medical detoxification for alcohol. Am J Drug Alcohol Abuse. 1995;21(4):549–63.
  9. Hayashida M, Alterman AI, McLellan AT, O’Brien CP, Purtill JJ, Volpicelli JR, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med. 1989;320(6):358–65.
  10. Bayard M, Mcintyre J, Hill KR, Woodside Jr J. Alcohol Withdrawal Syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-1450.
  11. Rosenson J, Clements C, Simon B, Vieaux J, Graffman S, Vahidnia F, Cisse B, Lam J, Alter H. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013 Mar;44(3):592-598.e2. 

The ABC of ICU – The A is for antibiotics

This talk by the Alfred ICU’s Steve McGloughlin is republished from the SMACC website and podcast.

Sepsis is incredibly dangerous for our patients and very topical in ICU and Emergency. In intensive care and emergency medicine we rightly dissect and discuss extensively how best to resuscitate patients, Airway, Breathing, Circulation – the ABC! Our training focuses on the urgency and adequacy of resuscitation and the provision of excellent supportive care. However, for the critically ill, especially in sepsis, we have very few therapies available that actually change the natural history of illness and can cure our patients. Surely that is what being a doctor is all about – helping people and changing the course of their illness – giving the patient a chance to survive! Over 75% of patients in ICU will receive antibiotics and the choice, timing and dose will directly influence your patients’ chance of surviving. Antibiotics are one of the few truly disease modifying therapies we have available and by far the one we utilize the most. In addition, no other therapy is important to not only get right for the patient you are treating but, in the case of antibiotics, the therapy for one patient may influence other patients. Attention to correct antibiotic use might save the patient in front of you. However thoughtless antibiotic use might make it harder to save the next patient by increasing antibiotic resistance in your unit. How and why must we get antibiotics right?

AUDIO

SLIDES

For more SMACC talks, go to the SMACC website or the podcast on iTunes. Check out Steve’s previous SMACC talk “The Dying Traveller“.

The post The ABC of ICU – The A is for antibiotics appeared first on INTENSIVE.

DFTB17 : Registration open!

Book your leave and prepare for an incendiary educational experience; DFTB17 is now open for registration!

REGISTER NOW!

For three days next August, prepare to be wowed by a variety of changemakers from Australia, the UK and USA, who have altered the face of paediatric healthcare, in keeping with our theme “Making a difference”.

Our speakers have made a difference, not only via research and clinical practice, but through social activism, media, reforming healthcare policy and education, and building foundations and clinics where they are most needed. They will share their stories, lessons and knowledge that you can take forward to make a difference in your own clinical practice.

The eclectic program includes cutting-edge research from the PREDICT Group, a session from the Radiopaedia.org team and covers the broad spectrum of acute paediatrics with sessions covering: infectious diseases; simulation; advice for the new consultant; retrieval; radiology; surgery. For those with an eye for detail, there is gender parity within our presenter cohort.

In addition to the academic program, there are a number of social events, including welcome reception, a fun run, and a glamorous marquee evening celebration “Don’t Forget the Party”, hosted at the Queensland Art Gallery’s breathtaking Watermall Gallery.

It’s our first year, so numbers are limited & will sell fast. What are you waiting for?

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