There’s Been A Drive-By Lysing!

If you’ve been keeping up, a couple weeks ago JAMA had a theme issue for Neurology – which nowadays, apparently, is mostly tPA.  And, the latest and greatest – concierge Neurology!  In which they come to your house to give you lytics.

This is the Prehospital Acute Neurological Treatmentand Optimization of Medical care in Stroke Study (PHANTOM-S), conducted in Berlin, Germany, using the Stroke Emergency Mobile (STEMO) vehicle.  They compared time-to-thrombolysis during 46 weeks of standard care with 46 weeks of STEMO period – and, within STEMO period, operation of the vehicle was a week-on/week-off deployment.  Unsurprisingly, driving the tPA to the patient shaves 25 minutes off the alarm to tPA time.  Success!

MedPage Today, with it’s usual insightful analysis, breaks out a table of glowing secondary outcomes – improvements in in-hospital all-cause mortality, discharge to home, symptomatic intracranial hemorrhage, and overall tPA complications …

… before acknowledging all these improvements occurred even when the STEMO wasn’t deployed, and it was rather general stroke care improvements over the study period reflected in these secondary outcomes.  Additional praise is provided by James Grotta, who has started his own mobile stroke unit in Houston.  And, finally, Associated Editor Jeff Saver, of endless tPA conflict-of-interest disclosures, chimes in for the Editor’s audio summary.

I think it’s clear, between this and its preceding pilot study, that it is possible to drive a bus around with a stroke neurologist and a CT scanner and rule out intracranial hemorrhage.  The main concern might be over-treatment of stroke mimics, but these authors state the same number of patients treated in all observation windows ultimately received non-stroke diagnoses.  However, they report a baseline stroke mimic treatment rate of 2.2% – which is line with other literature describing institutions that don’t go looking very hard for non-stroke diagnoses after tPA.  Other institutions that require MRI signs of ischemic lesions have stroke mimic rates up to 15.5%, so I wouldn’t place much stock in this specific statistic as a measure of quality.

The last issue – a reasonable case can be made for safety as long as there’s a neurologist riding shotgun in the ambulance.  However, you’ll have to find neurologists willing to take such emergency call and support their salaries while they wait for deployment, which will end up being logistically and financially unworkable.  The next step, I presume, will be pre-hospital telestroke where paramedics are supervised by a remote neurologist.  A bright, or dim, future, depending on your view of tPA.

“Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic Stroke”
http://jama.jamanetwork.com/article.aspx?articleid=1861800

There’s Been A Drive-By Lysing!

If you’ve been keeping up, a couple weeks ago JAMA had a theme issue for Neurology – which nowadays, apparently, is mostly tPA.  And, the latest and greatest – concierge Neurology!  In which they come to your house to give you lytics.

This is the Prehospital Acute Neurological Treatmentand Optimization of Medical care in Stroke Study (PHANTOM-S), conducted in Berlin, Germany, using the Stroke Emergency Mobile (STEMO) vehicle.  They compared time-to-thrombolysis during 46 weeks of standard care with 46 weeks of STEMO period – and, within STEMO period, operation of the vehicle was a week-on/week-off deployment.  Unsurprisingly, driving the tPA to the patient shaves 25 minutes off the alarm to tPA time.  Success!

MedPage Today, with it’s usual insightful analysis, breaks out a table of glowing secondary outcomes – improvements in in-hospital all-cause mortality, discharge to home, symptomatic intracranial hemorrhage, and overall tPA complications …

… before acknowledging all these improvements occurred even when the STEMO wasn’t deployed, and it was rather general stroke care improvements over the study period reflected in these secondary outcomes.  Additional praise is provided by James Grotta, who has started his own mobile stroke unit in Houston.  And, finally, Associated Editor Jeff Saver, of endless tPA conflict-of-interest disclosures, chimes in for the Editor’s audio summary.

I think it’s clear, between this and its preceding pilot study, that it is possible to drive a bus around with a stroke neurologist and a CT scanner and rule out intracranial hemorrhage.  The main concern might be over-treatment of stroke mimics, but these authors state the same number of patients treated in all observation windows ultimately received non-stroke diagnoses.  However, they report a baseline stroke mimic treatment rate of 2.2% – which is line with other literature describing institutions that don’t go looking very hard for non-stroke diagnoses after tPA.  Other institutions that require MRI signs of ischemic lesions have stroke mimic rates up to 15.5%, so I wouldn’t place much stock in this specific statistic as a measure of quality.

The last issue – a reasonable case can be made for safety as long as there’s a neurologist riding shotgun in the ambulance.  However, you’ll have to find neurologists willing to take such emergency call and support their salaries while they wait for deployment, which will end up being logistically and financially unworkable.  The next step, I presume, will be pre-hospital telestroke where paramedics are supervised by a remote neurologist.  A bright, or dim, future, depending on your view of tPA.

“Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic Stroke”
http://jama.jamanetwork.com/article.aspx?articleid=1861800

Healthcare Reform Update: Doc employment won’t lead to lower healthcare spending, research shows | Modern Healthcare

You don’t say.

Market share and prices tend to climb among hospitals that employ doctors but not for hospitals with looser contracts with independent physicians, according to newly published research. The findings, the authors say, suggest that integration itself does not produce the savings that many health system executives and policymakers promise from closer coordination between hospitals and doctors.

Hospital prices, according to the study, increased 2% to 3% each time physician-employing hospitals’ market share increased by one standard-deviation. The results were drawn from an analysis of roughly 2 million hospital bills submitted to private insurers between 2001 and 2007. Overall spending on services at the hospitals that employed physicians grew, while the utilization of services at those hospitals didn’t change.

via Healthcare Reform Update: Doc employment won’t lead to lower healthcare spending, research shows | Modern Healthcare.

Captain Question Strikes Again!

smacc-gold-audience

Sit back, relax, and remember. You’re at a conference and a speaker has just given a reasonably interesting talk on something relevant to your speciality. You’ve listened and learned a few new things, heard a couple of surprising facts that you’re going to go away and think about. You’re just pulling out the conference program to see what’s up next and then the moment happens. The session chair invites questions…….

200px-Captain_Falcon_cosplayer_at_FanimeCon_2010-05-30_1

Captain **&*%%&&ing Question puts his hand up again and you can’t quite believe it. He’s asked some form of stupid, irrelevant, annoying, self-focused question to every speaker in the session thus far. You scan the room for another hand, you pray that someone else, anyone else will think of something to say, to ask, something interesting relevant and useful to you or anyone else in the audience. You meet the session chair’s eyes as they scan past yours and in that brief moment you realise that you are on the same search, but neither you nor he find a palm of hope in the auditorium. Slowly, sadly, reluctantly the chair turns to the raised hand and utters the request for the microphone to be handed to Capt. Question. He take it in his raised hand, brings it to his lips and utters the immortal words that dishearten all hypo-caffeinaemic delegates..

‘Thank you for that talk. I have 3 questions and a comment. Interestingly, in my experience, and based on a study I did 2 years ago I think you will find that……….’

Lightning_in_ArlingtonAt that moment a bolt of lightning defies the laws of physics and appears in the auditorium striking from the rafters to the very spot where Capt. Question sat. As the smoke clears the audience cheer and moves rapidly for the exit and coffee. Capt. Q has demised, perhaps by divine intervention and as the crowd leave they discuss the paradoxical feelings of relief and shame inherent in their Schadenfreude.

Do you know a Captain Question? I’m sure you do, I certainly do and in all honestly I suspect that there have been times when I’ve worn that uniform myself (weekends only) but we should be able to do better. Conference questions are a tradition in medicine and it’s unlikely that we will be able to abandon them at any time in the near future, so let’s think about how we might do better.

I recently embroiled Rob Rogers and myself in a bit of a viral episode on twitter when I tweeted a tongue in cheek guide to asking conference questions.

Carley
It was clearly designed to be an amusing aside between friends, but it clearly hit a chord with the world. To date the algorithm has been retweeted, modified and retweeted again over 1000 times nearly burning out Rob’s twitter account in the process. An updated version of the algorithm is shown below and please feel free to use this in any talk or conference you attend, it may get a laugh and perhaps it might stop Captain Question in his tracks.

Screenshot 2014-05-09 10.50.21

So, that’s a bit of fun around a serious point. Time is precious for all of us and time in conferences where we can learn, interact and network is precious, too precious for it be wasted by irrelevant self centred questions, but it’s not enough for us to just complain and poke fun. We need to do this differently. We need to find a way of making sure that everyone has an opportunity to ask questions, that they are relevant, that they can be managed as part of a conference program and for us to hope that they will add value for everyone and not just to the person asking the question.

Is social media the bullet to fell Capt.Q?

SMACC have led the way in incorporating social media into conference questions. I’ve used their ideas as a speaker, questioner and as a session chair and I’m a big fan. Here’s how it works.

  • 1. Session chair announces in advance that questions will only be taken via twitter.
  • 2. A session hashtag is announced (this allows questions specific to the session to be easily found). e.g for a session on cooling post arrest at the CEM conference you might choose #CEMTTMQ
  • 3. You need a separate ‘twitter monitor to assist the session chair. It’s too much for the chair to do both.
  • 4. The twitter monitor selects questions for the chair to ask.
  • 5. The chair asks the question on behalf of the questioner, ideally also identifies individual in audience so the speaker an direct the answer to them (that’s polite).

There are clear advantages to this approach. It allows a degree of control and avoids the truly irrelevant conversations but there are potential disadvantages such as these.

  • 1. You have to have a twitter account! Not everyone has an account and that may disenfranchise some delegates (though this is a diminishing problem).
  • 2. The chair may paraphrase the question and get it wrong. Having said that questions should be clear if confined to 140 characters. If they are not clear then they are probably not a great question.
  • 3. The chair/monitor choose questions that ‘they’ think are important and that may not reflect the views of the audience. I don’t worry too much about this as it’s progress over an unfiltered approach from the random questioner. Consider it peer review ;-)
  • 4. Twitter attracts lots of questions and they cannot all be asked, but that’s no different to a real audience and that’s what the coffee break is for!

So, there are potential disadvantages, but on balance and having experienced the twitter solution to Capt. Question I’m a fan, and if like me you have experienced the burning hate of the irrelevant questioner you should really give it a try.

Simon Carley

http://www.stemlynsblog.org

The post Captain Question Strikes Again! appeared first on iTeachEM.

Gelungener Abschluß der DGINA Führungsakademie – Nach dem Spiel ist vor dem Spiel

Am letzten Freitag war der erfolgreiche Abchluß der 2. DGINA Führungsakademie in Hamburg. Die Teilnehmer waren äusserst zufrieden mit der Gesamtveranstaltung. Die Entwicklung der Kollegen ist unverkennbar und trägt die Schrift der Führungsakademie!

Herzlichen Dank an dieser Stelle an Hr. Fleischer sowie B. Hogan und M. Wünning, die das gesamte letzte Jahr erfolgreich begleitet haben.

Bei den einzelnen Prüfungen ist mir aufgefallen, dass die Kollegen ihre eigene Rolle meist noch zu wenig reflektieren. Aus meiner Sicht gibt hier ein exzellenter Artikel von Peter Drucker, einem der Väter der modernen Managementlehre, eine gute Übersicht. Managing Oneself ist häufig ein Schlüssel für den eigenen Erfolg!

Gleichzeitig möchte ich die Gelegenheit nutzen, um auf den Start der 3. Führungsakademie zu verweisen, welche in enger Abstimmung mit der Universität Witten/Herdeke durchgeführt wird. Nach dem Spiel ist vor dem Spiel …. schönen Start in die Woche!

Gelungener Abschluß der DGINA Führungsakademie – Nach dem Spiel ist vor dem Spiel

Am letzten Freitag war der erfolgreiche Abchluß der 2. DGINA Führungsakademie in Hamburg. Die Teilnehmer waren äusserst zufrieden mit der Gesamtveranstaltung. Die Entwicklung der Kollegen ist unverkennbar und trägt die Schrift der Führungsakademie!

Herzlichen Dank an dieser Stelle an Hr. Fleischer sowie B. Hogan und M. Wünning, die das gesamte letzte Jahr erfolgreich begleitet haben.

Bei den einzelnen Prüfungen ist mir aufgefallen, dass die Kollegen ihre eigene Rolle meist noch zu wenig reflektieren. Aus meiner Sicht gibt hier ein exzellenter Artikel von Peter Drucker, einem der Väter der modernen Managementlehre, eine gute Übersicht. Managing Oneself ist häufig ein Schlüssel für den eigenen Erfolg!

Gleichzeitig möchte ich die Gelegenheit nutzen, um auf den Start der 3. Führungsakademie zu verweisen, welche in enger Abstimmung mit der Universität Witten/Herdeke durchgeführt wird. Nach dem Spiel ist vor dem Spiel …. schönen Start in die Woche!