Healthcare Update Satellite — 06-10-2014

See more health-related stories from around the web on my other blog at DrWhitecoat.com.

The doctor will call you now …
Rural health clinics increasingly turning to telemedicine. The story gives an example of a South Dakota clinic physician who used a video feed to get advice on how to insert a chest tube – while a patient was in the room with a hemothorax.

Want to see some of the trick questions that plaintiff attorneys will throw at you during a malpractice trial and see some good responses to those questions? Good examples in this article from Colorado’s Cortez Journal.

Even though your state may have approved medical marijuana, don’t forget that marijuana is still banned by federal law.
DEA cracking down on Massachusetts physicians associated with medical marijuana dispensaries.

Kind of ballsy approach to managing uncomplicated appendicitis in kids. Researchers find that children 7 to 17 years old with pain less than 48 hours, WBC count < 18k, appendix < 1.1 cm on CT or ultrasound, and no evidence of abscess or fecalith can be effectively managed with antibiotics instead of surgery.
I’d be interested in information about relapse rate. If a child has a propensity toward developing “medically managed” appendicitis, it better to just have the appendix removed than to have the patient risk relapses requiring repeat hospital visits for IV antibiotics and CT scans/ultrasounds?

Do you prescribe steroids to patients with acute low back pain? This study found no benefit in doing so. However, note that the study population was limited to patients with a “bending or twisting injury.” Patients were excluded if they had suspected nonmusculoskeletal etiology, direct trauma, motor deficits, or local occupational medicine program visits.
I’m still giving steroids for exacerbations of chronic pain and for radiculopathy.

Potential patients gone wild … Colorado man shot in emergency department parking lot after “confronting” police with a knife.
Lesson #1: Don’t run around in a parking lot wielding a knife
Lesson #2: Don’t use a knife to threaten a man with a gun

Speaking about guns … you know how the incidence of gun-related deaths is increasing over the years? Well it isn’t. A Pew Research study (.pdf link) shows that firearm homicides dropped by 50% and non-fatal firearm crime has dropped 75% between 1993 and 2010. 56% of people think that gun crimes have gone up in the past 20 years.
Wonder why accurate facts like this aren’t being publicized in the evening news?

Woman lays dead in a Paris emergency department for six hours before someone checks on her and realizes that she is cold. Unidentified French official is matter of fact about the death. “People die every day in the emergency room.”

Fortunately, marijuana is a harmless drug … NY Times reporter writes about how she laid in a “hallucinatory state” for eight hours and thought that she had died after eating a pot candy bar in Colorado.

More ideas from people who know little about the effects of the policies they create. Prohibiting people using food stamps from purchasing sugar-sweetened beverages “expected to” improve nutrition and drive down diabetes. And these authors just assume that everyone uses their food stamps legitimately.
I’m not going to pay for the entire study, but I’d wager that they don’t consider how often people misuse food stamps. Therefore the authors are putting invalid data into their calculations. It is not uncommon for people to act as “straw purchasers” of grocery items. I’ve had people offer to do it with me on more than one occasion. You have cash, they’ll purchase all your groceries if you give them half of the total cost in cash. Grocery stores will also purchase food for half of its retail value. I recall reading one article about how bottles of soda were used as a currency of sorts by people in a rural community with people filling up pickup truck beds with cases of soda and bartering the cases for money, cigarettes, and other items – but couldn’t find the article on a web search.
Who cares, though? The authors are now published in a reputable magazine. Their conclusions must be valid.

Chicago files lawsuit against world’s largest narcotics manufacturers accusing the drugmakers of concealing the health risks associated with taking pain medications.
Next up: Suing alcohol companies on behalf of alcoholics and suing fast food restaurants on behalf of overweight people.
Here’s hoping that the drug companies file a counterclaim against the City of Chicago.

Senior Report 7.14

Case Presentation by Dr. Arun Rajasekhar, MD

 

CHIEF COMPLAINT:  Right leg injury.

HPI:  A 43-year-old man stated that another person landed on his right leg.  He felt and heard a snap and then he immediately experienced severe right knee pain.  This happened within 1 hour prior to admission.  He was brought here by EMS.  He complains of severe right knee pain.  He has not done anything for his symptoms.

PAST MEDICAL HISTORY:  Denies diabetes, seizures, hypertension.
MEDICATIONS:  None.
ALLERGIES:  None.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 184/86, pulse rate 93, respirations 20, temperature 36.3.

GENERAL:  This is a well-developed, well-nourished 43-year-old man, awake, alert but uncomfortable due to pain.

MUSCULOSKELETAL:  Normal muscle bulk and tone.  He has a deformity of the right knee.  He has normal dorsal pedis and posterior tibial pulses.  He has good popliteal pulse.  He has a deformity of the right knee.

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Questions:
1)
The above xray shows anterior displacement of the tibia on the femur.  Which ligament is most likely to have been completely torn?

a) ACL

b) MCL

c) LCL

d) PCL

 

2) Which of the following is NOT a hard sign of vascular injury associated with knee dislocations

a) absence of pulse

b) expanding hematoma

c) paresthesias in leg

d) bruit over site of wound

 

3) Patient required conscious sedation for reduction of his knee.  Decision was made to use ketamine and propofol.   Immediately after infusion, Pt starts gasping for air and immediately becomes tachycardic and tachypneic.  He has equal breath sounds.  Trachea is midline.  What is your working diagnosis and which of the two agents is most likely responsible? What should be done?

a) Acute tension pneumothorax due to propofol administration.  Needle decompression

b) Acute laryngospasm secondary to ketamine administration.  Paralyze patient and intubate immediately

c) Acute laryngospasm secondary to propofol.  Attempt to bag patient through laryngospasm

d) Acute laryngospasm secondary to ketamine.  Perform cricthyrotomy.

 

Answers & Discussion:
1) A & D
2) C
3) B

1) PCL and ACL are both acceptable answers. The patient has an anterior knee dislocation. This is the most common type of knee dislocation. It is caused by hyperextension of the knee joint. Often both he PCL and MCL will be torn. With all knee dislocations it is important to have a high index of suspicion for popliteal artery injury. Initial assessment of the leg should include palpation of the dorsalis pedis and popliteal pulses. You can also perform ABIs to assess distal blood flow. It is important to note that PT and DP pulses will be normal in 5-15% of popliteal artery injuries. CT angiography can be used to detect arterial injury.

2) Parasthesias is the answer. Hard signs of vascular injury include active hemorrhage, expanding hematoma, bruit over wound, absent distal pulses, extremity ischemia (cold to touch, paralysis, pallor). In the setting of penetrating trauma, hard vascular injuries are 100% predictive of arterial injury and patient should be taken directly to operating room for surgical exploration. In the setting of blunt trauma, hard signs are less reliable and false positives are common. Repeat physical exam should be performed after resuscitation and reduction or orthopedic injury. If hard sign persists, get CT scan. Diagnosis of popliteal artery injury is time sensitive. Amputation rate increases the long repair is delayed. Rate of amputation is 90% eight hours out from the time of injury.

3) Patient is experiencing acute laryngospasm secondary to ketamine. This is a rare but known side effect of ketamine. It has been primarily reported in the pediatric literature. Patient’s will desaturate and decompensate quickly. In my scenario, the patient had a very visible reaction to the medication but there have been case reports of patients desaturating without showing a obvious signs of distress because of the sedative effect of the ketamine and the propofol. If a patient begins to desaturate and you are uncertain as to the exact etiology, the first and simplest thing to do is a jaw thrust maneuver to see if that relieves the hypoxia. You can also bag mask the patient. However, neither of these maneuvers will relieve laryngospasm. This patient needs neuromuscular blockade to relieve the laryngospasm and once the patient is paralyzed you should immediately proceed to intubation. Some sources stated that you could bag mask the patient until the paralytic wears off but I think if you are going to paralyze a patient, then you should give them a definitive air way.


Filed under: Senior Report

Fare di più non significa fare meglio: cinque raccomandazioni per rendere più appropriata la nostra pratica clinica

di Bartolomeo Lorenzati, redazione blog Simeu

@BatoLorenzati

La spesa pro-capite per l’assistenza sanitaria è molto elevata e, dal 2003 al 2011, il costo medio per un accesso in DEA negli Stati Uniti è aumentato del 240%, passando da 560$ a 1355$. Analogamente agli USA accade in Italia ed in tutti gli stati del mondo che possono offrire ai propri cittadini le più avanzate tecniche per i percorsi diagnostico-terapeutici.

La Campagna Choosing Wisely, lanciata nel 2013 dall’American Board in Internal Medicine e ripresa in Italia dall’associazione “Slow Medicine”, ha proposto alle principali società scientifiche di individuare 5 test (ematochimici o di imaging) ritenuti di poco valore diagnostico e pertanto eliminabili (vedi anche il post su SIMEU blog). L’American College of Emergency Physicians ha individuato:

  1. non richiedere la TC cranico nei pazienti con trauma cranico lieve che sono a basso rischio di sanguinamento secondo gli score validati;

  2. non posizionare il catetere vescicale in Pronto Soccorso per il monitoraggio della diuresi nei pazienti emodinamicamente stabili, o solamente per la comodità del paziente o dello staff;

  3. non ritardare l’attivazione delle cure palliative e dell’hospice per i pazienti che ne potrebbero trarre beneficio;

  4. evitare l’utilizzo di antibiotici e di esami colturali per i pazienti con infezioni cutanee non complicate o ascessi sottoposti a drenaggio;

  5. evitare il posizionamento di accessi venosi per la terapia reidratante nei bambini prima di aver provato la somministrazione orale.

Nel Febbraio 2014, da parte della “Partners Healthcare”, sono stati pubblicati su JAMA Internal Medicine (1) i risultati di un Consensus Development Project organizzato con la scopo di ridurre i costi nella medicina d’urgenza. Tale gruppo era composto da sei Emergency Physicians operanti in differenti ospedali del Massachusetts (due Ospedali accademici e quattro Ospedali pubblici), con un totale di più di 320000 passaggi annui.

Gli autori dello studio hanno elaborato l’indagine valutativa suddividendola in 4 fasi: inizialmente, hanno identificato una serie di accertamenti diagnostici di basso valore clinico e sotto il diretto controllo prescrittivo degli urgentisti, in un secondo tempo li hanno suddivisi in base a criteri di rischio/beneficio, costo ed accessibilità. Al termine sono stati ottenuti 64 esami successivamente sottoposti al giudizio del technical expert panel (TEP) appositamente formato che ha individuato 5 accertamenti di basso valore diagnostico.

Le di 5 raccomandazioni inserite nella top-five list sono:

  1. non richiedere la TC della colonna cervicale per eventi traumatici nei pazienti che non soddisfano i National Emergency X-ray Utilization Study (NEXUS) o del Canadian C-Spine Rule;

  2. non richiedere la TC torace con mdc per sospetto di tromboenbolia polmonare (EP) senza aver prima stratificato il rischio per EP;

  3. non richiedere la risonanza magnetica della colonna lombare per dolore in assenza di elevati fattori di rischio;

  4. non richiedere la TC del cranico per i pazienti con trauma cranico lieve che non soddisfino i New Orleans Criteria o i Canadian CT Head Rule;

  5. richiedere la coagulazione solamente nei pazienti con coagulopatia sospetta o emorragie in corso.

Nonostante sia universalmente riconosciuto che la medicina debba basarsi su prove scientifiche di efficacia, da tempo è stato evidenziato che molti esami e molti trattamenti sia farmacologici che chirurgici, largamente diffusi nella pratica medica, non apportano benefici per i pazienti, anzi rischiano di essere dannosi.

Anche presso l’Azienda Ospedaliera in cui lavoro, il S. Croce e Carle di Cuneo, da settembre 2013 è stato avviato il progetto Aziendale “Fare di più non significa fare meglio – Le 3 pratiche a rischio di inappropriatezza” con lo scopo di migliorare la qualità e la sicurezza dei servizi erogati dalla nostra Azienda.

La nostra divisione ha individuato:

  1. evitare il posizionamento di CVP (catetere venoso periferico) ai pazienti valutati in DEA che necessitano esclusivamente di prelievo venoso, ai quali si presume ragionevolmente una mancata necessità di terapia infusionale;

  2. evitare l’esecuzione della radiografia della colonna cervicale a pazienti politraumatizzati, coscienti, asintomatici, valutabili clinicamente e senza deficit mielici (criteri Nexus + Canadian Study);

  3. evitare l’esecuzione di TC cranio ai pazienti vittima di trauma cranico minore, e considerati low-risk per danni cerebrali (età, comorbidità, dinamica, sintomi), secondo score clinici validati.

L’idea della Top Five List, della Choosing Wisely campaign o del progetto “Slow Medicine” sono utili per farci riflettere sull’utilizzo delle indagini diagnostiche inopportune e costose nella nostra professione. Storicamente i medici operano rivolti ai propri pazienti e noi ai costi, così che nel 1984 Livinsky scrisse “When practicing medicine, doctors cannot serve two masters. The doctor’s masters should be the patient”. Oggigiorno tutte le professioni sanitarie devono confrontarsi con la pressione nel migliorare sempre la qualità dei servizi offerti e con la necessità di prestare attenzione ai costi dei servizi erogati. Trovo pertanto molto interessante la spinta auto valutativa che hanno fornito tali campagne nell’ultimo anno.

Bibliografia

  1. Schuur JD, Carney DP, Lyn ET, Raja AS, Michael JA, Ross NG, Venkatesh AK. A top-five list for emergency medicine: a pilot project to improve the value of emergency care. JAMA Intern Med. 2014 Apr;174(4):509-15. Link

Un poco de ética…

Creo yo (será porque me hago mayor) que cada día necesito más la bioética. No tanto pensar sobre ella, como aprender de ella para poder impregnar mi forma de trabajar. No maleficencia, beneficencia, autonomía y justicia son sus principios y día a día descubro que casi cada cosa que hago podría hacerla mejor si la pasara por su tamiz.
Y estando yo desde hace algún tiempo en estas reflexiones me encuentro con esta presentación de Pablo Simón Lorda que me ha parecido estupenda, nada ñoña y dando donde duele, nos duele. La presentó en el congreso de crónicos del 2013. El título, con las palabras claves en mayúsculas, lo explica bien:

CÓMO INCORPORAR los PRINCIPIOS de la ÉTICA para LLEVAR a CABO una PRÁCTICA CLÍNICA y ATENCIÓN HUMANIZADA

Pablo Simón tiene un blog que según dice en su presentación trata de:  bioética, salud, teorías de la justicia sanitaria y demás confines del mundo. Se llama El pájaro que cruza.

¡Disfrutadla!
 

Özen: Mattu – 20 dakika, 2 hasta ve tonlarca püf noktası! – 21 Nisan 2014

STEMI ve Perikardit Klinik semptom ve bulgular çoğunlukla güvenilmezdir İlk troponin de güvenilmez olabilir EKG bilgisayarının yorumuna inanmayın! EKG bulgularındaki farkları bilin ve adım adım yaklaşımı uygulayın. 1. Adım: STEMI tanısı koyduracak bulgular Herhangi bir derivasyonda resiprokal ST çökmesi (V1 ve aVR hariç) Horizontal veya konveks yukarı doğru (mezartaşı) ST yükselmesi DIII’deki ST yükselmesinini DII’dekinden ...

The Downside of Ketamine

The Long Term “K Hole”

The Downside of Ketamine

Great info being presented at the ICEM 2014 Toxicology Workshop by local Hong Kong speakers:

What are the long term side-effects of a wee intranasal dram*** of Ketamine?

(***apparently a popular student and young person’s past time in Hong Kong)

  1. K Cysitis – Significant Renal Injury associated with Long Term Ketamine Use. This is also known as Ketamine induced Vesicopathy. There is even an online support group: CLICK HERE
  2. K Cramps – Significant Abdominal Pain in regular users – again a support group online – CLICK HERE
  3. Psychiatric Effects – limited but may be significant

Conclusion – There’s nothing musical about the long term effects of Ketamine use – ye be warned.

We still like it for short term use though!

ketamine-the-musical-by-dr-natalie-may