Reducing the Budgetary Burden of Disease

Four years ago the Utopian College of Emergency for Medicine released a prophetic publication. After considering the economic cost of an ageing population, UCEM has devised new protocols to reduce the cost of care even further. Instead of actively hastening of inevitable outcome, measures to discourage use through inappropriate health service provision are being implemented. Although initially the Executive thought this  too callous to propose, the Council now salute the complete abandon for human suffering displayed by the new administration.

The authors of the initial UCEM report thus propose a new medical paradigm, the “Social Hippocratic Oath”. This oath encourages doctors not to treat a person as an end in their own right, but as a means to an end. After all, if a patient could no longer be seen to have a social value, should we still treat them?

The new Executive has added a tenet to the Social Hippocratic Oath, “above all else, do no harm to the Utopian budget”. The philosophical shift offered by the Social Hippocratic Oath allows for medical ethics and right wing medical economics to coexist and HealthCare can finally save dollars, not lives.

In light of the new education revisions offered by Utopia, we believed Darwinian ideas were under assault. Not so it seems on the social policy front. The new fee structure being implemented as a disincentive to seek care will hit the poorest. We expect that the policy will have lasting unforeseen sociological victories, like eradicating poverty.

Some believe that the GP fees could see people inappropriately using the ED as happens in the US. We propose the following measures to prevent this:

Measures to reduce inappropriate ED use

  • $100 up-front fee.

OR

  • Proof of membership at a yacht club.

OR Any Two of the Following

  • Golf club membership
  • Tennis club membership
  • Bridge club membership
  • Rotary club membership
  • Tax return showing taxable income of $80,000 or more
  • Ownership of a car worth over $70,000
  • Ownership of a property over $1,000,000
  • Career in Appendix A
  • Donations over $10,000 to political parties in Appendix B

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It’s getting hot in here!

The mercury on the outside thermometer is inching past 40oC for the third day in a row and for once you are grateful to be in the cool, air-conditioned emergency department.  The emergency phone snaps you back into alertness. The paramedics are bringing in a toddler that has been liberated from the back of a parked car.

Bottom Line

  • Despite widespread public information campaigns children are still left alone in cars every heatwave.
  • Just 15 minutes unattended is enough to raise the cars temperature to lethal levels.
  • Heat illness varies on a continuum from heat stress and cramps to heat exhaustion and then heat stroke.
  • Heat stroke is a medical emergency and is characterized by neurological deterioration, anhydrosis and a core temperature above 40oC

How big a problem is it?

During the recent heatwave in Melbourne, when the temperature topped 40 degrees for four days straight, Ambulance Victoria received 60 calls for children trapped in cars. Fortunately there were no fatalities. During the 1995-2002 period in the United States there were 171 entirely preventable fatalities.

Studies have suggested that on a hot day the temperature in a locked vehicle can rise as high as 51-67oC within 15 minutes. 75% of this rise occurs within the first five minutes of the door closing, so even short periods of leaving a child unattended can be dangerous. There is some evidence that leaving the window cracked can make a difference but all the data suggests that it has to be open at least 20 cm to make an appreciable difference.

Why are children at particular risk?

Even though kids have a larger body surface area-to-mass ratio than adults, they have much less effective thermoregulation. They have a higher metabolic rate so are really little furnaces.  Unfortunately they are less well able to regulate their cardiac output in response to heat stress and produce less sweat per apocrine gland compared to adults. Perhaps more importantly, unlike most adults, they cannot get out if they are left in the car seat on their own.

What's the difference between heat stress, heat exhaustion and heat stroke?

Words are important. What the lay public mean when they say heat stroke is very different from what the medical professional means.

Heat stress is what we all feel when the mercury rises – we’re grumpy, irritable, sweaty and often listless but not unwell. Core temperature is unaffected.

Heat exhaustion occurs as a result of salt and/or water depletion.It may be compounded by nausea, vomiting and excessive sweating. The core temperature may or may not be up altered.

Heat stroke is a medical emergency and typically classified as either exertional (think running a marathon on a hot day)  or non-exertional (sitting in a hot car).  As the core temperature rises above 40oC the patient often becomes more lethargic and delirious. Seizures, then coma, eventually ensue.

How do children lose their excess heat?

Heat is lost via radiation, conduction, evaporation and convection with these latter two being most amenable to change.

How can you manage a child with heat related illness?

As with all potentially toxic exposures (to heat in this instance) removal from the source is vital. The child should be managed in a cool environment if possible and attention paid to their ABCs.

  • Airway – they may require intubation if clinically indicated
  • Breathing – if they need to be intubated then mechanical ventilation will need to be initiated
  • Circulation – children suffering from heat stroke are often profoundly dehydrated with challenging IV access. Don’t hesitate to break out your favourite intraosseous device. As peripheral cooling is instituted more blood is returned to the central circulation increasing the risk of pulmonary oedema.
  • Disability – seizures should be treated with benzodiazepines initially but you should check the UEC urgently and assess the sodium for hypo- or hypernatraemia depending on whether salt and water depletion or pure water depletion predominates.
  • Exposure – having discovered a high core temperature then it is time to do something about it. Techniques can range from the simple – remove clothes, ice packs in the axillae and groins, cool fans, cold IV fluids to the Macgyver – creating a cooling tent. This can be done by soaking a sheet in cold water and draping it, suspended, over the patient with a fan to push air through it. The aim is to maximize heat loss via convection, conduction and evaporation.

They've got a temperature, shouldn't you give them some paracetamol/Tylenol/acetaminophen?

There is no evidence that antipyretics lower the temperature in cases of heat related illness.

Disposition for the sick patient is straight forward. They need admission to HDU/ICU. But what should you do for the well appearing child?

There is no consensus as to how long a patient should be observed but common sense would dictate that if their temperature has normalized and they are rehydrated then they are fit enough to go home.

Should you involve social services??

That is the million dollar question. Certainly, in Australia, Section 231 of the Children and Young Persons (Care and Protection) Act 1998 clearly states:-

A person who leaves any child or young person in the person’s care in a motor vehicle without proper supervision for such a period or in such circumstances that :

(a) the child or young person becomes or is likely to become emotionally distressed, or
(b) the child’s or young persons health becomes or is likely to become permanently or temporarily impaired is guilty of an offence.

Hasn’t the distraught parent been through enough?  This excellent piece from the Washington Post, entitled Fatal Distraction eloquently puts a parents struggle into words.

Outcome

Little Nelly is brought in, nearly naked and crying. Her rectal temperature is 38oC and she tolerates a delicious icy pole. Her mother is beside herself. You discuss the case with the local social services who agree to follow up.

References

McLaren C, Null J, Quinn J. Heat stress from enclosed vehicles: moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Pediatrics. 2005 Jul;116(1):e109-12. PubMed PMID: 15995010

King K, Negus K, Vance JC. Heat stress in motor vehicles: a problem in infancy. Pediatrics. 1981 Oct;68(4):579-82. PubMed PMID: 7322691.

Grubenhoff, Joseph A., Kelley du Ford, and Genie E. Roosevelt. “Heat-related illness.” Clinical Pediatric Emergency Medicine 8.1 (2007): 59-64.

Guard, A., and Susan Scavo Gallagher. “Heat related deaths to young children in parked cars: an analysis of 171 fatalities in the United States, 1995–2002.”Injury Prevention 11.1 (2005): 33-37.

http://lifeinthefastlane.com/education/ccc/heat-stroke/ accessed 21st January 2014

Bouchama, Abderrezak, and James P. Knochel. “Heat stroke.” New England Journal of Medicine 346.25 (2002): 1978-1988.

Wexler, Randell K. “Evaluation and treatment of heat-related illnesses.”American family physician 65.11 (2002): 2307-2313.

 

 

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All Stressed Out and Nowhere to Go

Emergency departments (EDs) and psychiatric patients make poor bedfellows.  The acutely agitated, psychotic, or depressed child needs a calming, low-stimulation environment where they can develop a therapeutic relationship with trusted providers at their own pace.  EDs need quick-thinking, quick-acting staff, high turnover, and short length of stays in order to survive.  They are also one of the highest-stimulation areas of the hospital, with a constant barrage of sounds, lights, and movement.  Sounds like a crazy place to put a psych patient, right? How did it come to this?  I can make a helluva splint and perform RSI with my eyes closed, but I have no formal training in interviewing a cutter or de-escalating a psychotic patient.  Why are they here?  What do they want from us?  And what can we give them? Why are they here? Funding for psychiatric care decreased dramatically during the Reagan administration, and has been declining steadily since that time.  As a result, we are now seeing second generation psychiatric patients – their parents are products of inadequate psychiatric care in the 80’s and 90’s, and now these children have both a genetic and environmental load for psychiatric illness.  Kids are sicker, and they’re coming to the ER more often, because there is truly nowhere else to go.  Schools can’t afford the liability of “not acting” on a possible outcry (of bullying, suicidal thoughts, cutting, etc.), and most no longer have full time nurses or counselors on site.  Pediatricians can refer to therapists, but it can take weeks to get a patient in to be seen, and black box warnings on SSRIs make them reluctant to take on the liability involved with prescribing. What do they want from us? Patients and families want a clear plan, they want to feel like someone is listening, and they want to feel like their problem is important to someone.  Sticking them in an open room with a tech giving them the stink eye while they watch hordes of other patients come and go does not exactly convey these things.  What can we give them? For starters, let’s give them (and ourselves) a safe environment.  Our adult colleagues are well versed at managing intoxicated, agitated, and psychotic patients.  We can learn from them.  Ask your EM residents what they do – for restraining patients, for hospital security, for safety measures in their EDs.  Find out if you have policies in place at your facility for managing agitated patients.  If you do, are they appropriate?  If you don’t, ask your adult colleagues to share theirs. Next, let’s try to give them the therapeutic interventions they need.  If there is no psychiatric bed available in the county for the next four days, then we need to get our hospital psychiatric teams in the ED seeing these kids, get them started on medical interventions, and do something more therapeutic than locking them away on CVO for a week in an ED.  We may not have psychiatric training, but Emergency Medicine providers do know plenty about advocating for patients and convincing/cajoling subspecialists who are reluctant to consult.  We do it for our medical patients, we can do it for our psych patients, too. Finally, the problem won’t be solved until we speak up and make this problem known.  I’m not big on writing letters to my congressman, but it needs to be known that kids are stuck in our EDs for hours/days/weeks not getting needed interventions.  Many substance abuse programs are privately funded, and nearly all of them are for 18 and over.  The sponsors of these programs should know if there is a […]

Outstanding General Lecture on the ECG in Acute MI: 34 minutes by Dr. K. Wang.



ECG Manifestations of Myocardial Infarction from HQMedEd on Vimeo.
cited previous videos:
Ta Wave (Atrial Repolarization Wave), how it affects the ECG interpretation
http://hqmeded.com/ta-wave-atrial-repolarization-wave-2/

Usefulness of PVCs
http://hqmeded.com/usefulness-of-pvcs-2/

ST Elevation in Conditions other than Acute MI
http://hqmeded.com/st-elevation-in-conditions-other-than-acute-mi-2/

K. Wang, MD
Clinical Professor of Medicine
Cardiology Division
University of Minnesota

med.umn.edu/cardiology/faculty/wang/home.html

Cause di interruzione durante il triage

“Scusi quante persone ho davanti? , quando tocca a me?” “Scusi, hanno ricoverato mia zia, sa dirmi dov’è?” “ Scusi, dov’è il bar?” Quante volte sentiamo rivolgerci queste domande durante un turno in triage? Spesso domande non pertinenti che causano interruzioni nel triage provocano errori e ritardi nel trattamento dei pazienti. Colleghi americani hanno osservato e […]

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