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July 20131) A bit of a groaner, but could be helpful if you practice in someforsaken place like Alice Springs Australia, or YpsilantiMichigan. Those little bottles of bacteriostatic normal salinehave a preservative called benzyl alcohol which has mildanesthetic properties (ethyl alcohol probably has more) If youinject this before the IV, you will get some anesthesia,although less than by lidocaine. It is of course cheaper ( JPerianesth Nurs 27(6)399) Here are my comments. Firstly,kudos to the authors who have shown a good double blindedstudy done by nurses. Secondly, many nurses are not allowedto inject lidocaine but are allowed to inject this agent. Thirdly,we need to remember that IVs do sting and it is a humanething to do to take away the pain. On the other side, it wouldbe hard to say that this stuff works as IV are not that painfuland it was not that beneficial. In addition lidocaine is prettycheap. TAKE HOME MESSAGE: In a pinch- you can usebacteriostatic water as a local anesthetic before IV insertion.

2) Really, I am not just looking for pain and palliative carearticles since MD Anderson took us aboard- this is just what

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happened. In some hospitals you can call for a palliative careconsult- this does happen not infrequently in the ED wherethey do have this service and usually is used for young peoplewho meet with trauma or sudden death. (J Palliatve Care15(6)633) However- and Knox is free to disagree with me-these consults were for bereavement counseling. True that isuncomfortable for us, but I would like to see more instructionin palliative and comfort care- like making that end stage lungcancer who is gasping for breath (what a night mare) morecomfortable with out killing him. I should mention here thatpalliative care is a recognized subspecialty of EM and is anincreasingly popular career track for emergency physicians-https://www.abem.org/public/_Rainbow/Documents/Eligibility%20Criteria%20for%20Web.pdfTAKE HOME MESSAGE:Palliative care consults are appropriate in the ED. On a relatedsubject; here is an article that you should all not only read buttune in to what it means. Patients have fears- what they call"existential suffering." These are fears that add on thephysical suffering of being sick. They include death, anxiety,loss and change in their lives, loss of control of their lives, loss

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of dignity, fundamental aloneness, altered quality ofrelationships, the innate search for meaning in our lives, andmystery as to the unknowable. Be sensitive to this and Ipromise you will be the best physician you could be. (Arch IntMed 172(19)1501) TAKE HOME MESSAGE: Feel for youpatients- it isn't easy being ill.

3) One size fits all is a dangerous way to ventilate. Obesepatients have different mechanics and diminished endexpiratory lung volumes. This paper recommends step wiserecruitment maneuvers before PEEP applications which Ireally do not what that is, and tidal volume titration accordingto inspiratory capacity (Minerva Anest 78(12) 1136) Basically Ithink this is another call to not use formulas for tidal volume-go by plateau pressure. Remember the magic number is lessthan 30. TAKE HOME MESSAGE: Obese patients have differentventilator needs and should be titrated to cause the least lungstrain. China had a dilemma. Chinese is a very differentlanguage than English, yet the British had a colony calledHong Kong and insisted that all movies that were producedthere had to have English subtitles. The Chinese complied and

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during the era of popularity for Bruce Lee movies and thegenre of chop sockey movies some interesting tough guytranslations took place. Lets get started. * I threat you! I challenge you meet meon the roof tonight for a duet! * I am damn unsatisfied to be killed in this way.

4) I was leafing through the swimsuit edition of this journal anddiscovered a great article in between the pictures. There issomething called breakthrough varicella. This is a varicella ina vaccinated patient- and this can happen. This can be tricky-

There are fewer or no vessicles, no fever and the rash isn't incrops like the real thing. Yes it can still look like localized

herpes but it can look like an insect bite or poison ivy. You canstill test for it- serology, PCR, direct fluorescent antibody- but Iguess it is only relevant if you are pregnant or are aroundpregnant people. Should you want to see the article- or theswimsuits here is their reference (Pub Health Rep 127(6)585)

TAKE HOME MESSAGE: Varicella can still infect vaccinatedindividuals- the symptoms are very subtle however. Here are

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swim suits to whet (pun intended) your appetite

5) You knew this and I want you to skip this paragraph. There isno reason to repeat it so please scroll down- NOW. Gosh-hard to get kids to listen these days- Oxygen is not requiredfor MIs, CVAs, ROSC or obstetric emergencies. (BMJ 345:E6856) It just doesn't help unless of course they are hypoxic.And please give oxygen lightly toCOPDers. TAKE HOME MESSAGE: Oxygen is a drug and it isn't

for everyone- MI and CVAs do not need it. * Fatty, you with your thick face havehurt my instep. * A normal person wouldnt steal pituitaries.

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6) Welcome back. This you should also know. Syncope can becaused by PE- but not, in my opinion without some othersign. In this case series- these syncope patients with PE allhad hypoxia. I generally use saturations and pulse to guideme- if they are abnormal. If not, think of other possibilities ascauses for syncope (Int Med 51(8)2631) My peer revieweradds: Here you could mention the PERC score, which does notinclude syncope as a criterion so that if PERC (-) the patient isvery low risk with or without syncope. Of course it is nonspecific so that most people who are not PERC (-) withsyncope still wont have PE. TAKE HOME MESSAGE: Syncopecan be caused by PE- but you need more than just syncope. *You always use violence. I shouldve ordered glutinous rice chicken.

7) Time for some Cochrane- even though they always say moreresearch is needed sometimes you can read between thelines. Cranberries for UTI prevention- larger studies haveshown this doesn't work. Also, many people can't stomachdrinking that much cranberry juice. The pills may be animprovement- but no evidence exists.(Cochrane 1321). Here

is another Cochrane that we discussed not long ago- the useof ultrasound to aid in thromoblysis- albeit it only five studies-

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but it seems to help- NNT of only four! (ibid 8348) Who saidsteroids don't help for sore throats. Well, when used withantibiotics- they actually are pretty impressive- and a NNT ofonly 4 also. They reduced the time to complete pain relief by14 hours and started to work by 6 hours. (ibid 8268) TAKEHOME MESSAGE: Don't drink cranberries do drink steroids andif you get a stroke poke open the artery with an ultrasoundmachine. * Beware! Your bones are going to be disconnected.

8) I thought it would be worse. This difficult to quantify articleclaims that news representation of scientific articles isaffected by spin about 50% of the time meaning the public isgetting wrong information usually information that is overlypositive (PLoS 9(9)e1001308).There are factors here such asthe definition of spin and who reads and authors these newsarticles I would think usually laymen- but the average doctordoes not know how to read these articles either and thereforeabstracting services that do not evaluate articles may leadpractitioners down the wrong path. Did I just trash EMU? TAKEHOME MESSAGE: The press often over estimates the result ofmedical studies due to spin. Quiet or Ill blow your throat up.

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* You daring lousy guy.

* Beat him out of recognizable shape!

9) Don't you love to sound so technical when speaking toorthopedists about the shoulder? "Oh, yes, the Jobe test andHawkins Kennedy test were normal but the Neer test waspositive". (Please, oh please do not use these lines when youare going out for the first time). Could we be looking at a SLAP

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lesion? Yea you really are coolHowever none of these tests are that sensitive- only the shrugsign for osteoarthritis inched up above 80%. If you combinetests you do improve somewhat- but only marginally. Take agood history. (BJ Sports Med 46(14)964) Excellent article butnot done by orthopedists but by physical therapists, so you

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still can't conclude that orthopedists can write a decentarticle. TAKE HOME MESSAGE Physical exam of the shoulder iswoeful.

10)There have been some reports of local anesthetics causingdamage to chrondrocytes and therefore impairing healingwhen injected into sore joints. Well, those are case reportsand you know what they are worth. There have been some invitro studies that have shown mixed results. When the day isdone though, in most cases in the ED a one time treatmentrarely hurts although you would be right to say: prove it(Knee Surg Sports Traum Arthroscp 20(11)2294) (hope this

journal doesn't make tee shirts- how would you fit that all onyour shirt?) TAKE HOME MESSAGE: Lidocaine maybe harmfulto cartilage. How can you use my intestines as a gift?

* Damn, Ill burn you into a BBQ chicken!

11)Resuscitation-hey I am all with you, man- they all die, so whybother? Furthermore dead people are just the worst ofconversationalists. But what can I do? I am a mere conduit.

The folks at Lancet looked at 643339 patients with cardiac

arrest and found that half actually did have ROSC and 1 out of

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six was discharged from the hospital alive- there weresignificantly more survivors in hospitals where meanresuscitation time was 25 minutes compared with hospitalswith shorter average resuscitation times (16 minutes). The bigdifference was in asystole and PEA- those folks when workedon for that long actually did come back and did getdischarged alive. However, most of these patients wereseverely neurologically impaired (the technical term is"gorked") (Lancet 380:1451) Now I will leave this for the bioethicists but it seems you are not dead until you are dead.

TAKE HOME MESSAGE: That patient will have a better chanceof life if you continue CPR for at least 25 minutes. In a similarvein (or artery) there may be a place for beta blockade inCPR- since alpha agonism so important to increase coronaryperfusion pressure. While pure alpha stimulation byphenylnephrine has not improved outcomes but perhaps this+ a beta blocker+ a non beta pressor like vasopression wouldwork. It does in animals. This would be a marvel as it wouldreduce the oxygen demands that adrenalin causes. But thenagain Grandma is not a horse so we still need to see. (Resusc

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83:663) TAKE HOME MESSAGE: Beta blockade may have aplace in resuscitations. Here is Grandma playing chess-anyone recognize who the horse really is?

12)Technology strikes again. My disk on key died and with it wassaved the rest of this month's EMU- and of course it could notbe saved. We will try to reclaim what we can. Did you knowthat pneumonia can present with EKG changes? Sometimes itcan look just like..PE. If you are using an EKG to diagnose PE

you probably need to listen to lectures on how to put on aseatbelt that they give before take off, and you probably need

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a warning that irons are not to be used in bathtub s.

(AJC 27(6)1836) That beingsaid the changes in pneumonia are simlar to to those seenin right heart strain. This will be of fine service for you, you bag of the scum. I am sure you will notmind that I remove your manhoods and leave them out on the dessert flour for your aunts to eat.

"Yah-hah, evil spider woman! I have captured you by the short rabbits and can now deliver you violently to your gynecologistfor a thorough extermination.

13)No chance on the clinical quiz this month. If you get it you area genius and I will reward you with: editorship of the EMU for

the next three years, and free trip to North Korea (one wayticket only). You'll see this disorder in alcoholism. It is rare but

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they have altered mental status, seizures and multifocalcentral neuro signs which come from demylination of thecorpus callosum. This is of course? (no cheating please AJEM30(9)E7) Go ahead- give it a try- do feel lucky?

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14) Try another one. Be a real man. Visual acuity loss with

complex hallucinations caused by an occipital lobe lesion.

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That is ____(ibid E5)Cant figure it out? Go to the link on realmen.15)Zinc- does it work or not? Well first of all, it has only worked in

the Third World. In the developed world, we may just haveenough zinc to go around. In this study it worked with a NNTof 15 as an adjunct to therapy for serious bacterial infection.Less mortality which we would all agree is a good thing.(Lancet 379(9831)2072) The methods are hard to follow, buttreatment failure was defined as anything from feverreturning to death from all causes so I do not know how theycould know if zinc helped. Furthermore, we know that allheavy metals like Bismuth control diarrhea and has someantibiotic effect-and zinc is a heavy metal and most of theserious bacterial infections in this Indian study were diarrhea.Let's do some summarizing on Zinc from Cochrane. Zincdoesn't help to prevent ear infections (2012) Zinc doesn't helpas an adjunct to pediatric pneumonia (2013) Zinc can preventthe common cold if taken for five months and can reduce theseverity of the cold (2011)(but I have seen many papers thatdisagreed), it will help in pediatric diarrhea (2013) TAKE

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HOME MESSAGE: Zinc helps for diarrhea and the commoncold. The Jury is out on the rest. Your spear is useless You better use it for mixingexcretory. Now I feel flatulent, and you did it

16)Droperidol may be great for migraines, but in many places like my home country- it is just unavailable. So now they aremarketing a combo of naproxen and sumatriptan. This was agroup of kids that got frequent migraines- so there is referralbias. And surprisingly- the only conclusions they can make isthat it is as safe and effective as that well known migraine-giant- placebo. (Peds 129(6)e1411) Now there is a lot to sayhere- there were definite statistically significantimprovements with the combo but the p values were reallyunimpressive and this of course does not take into accountthe clinical differences that were negligible. But here isanother flaw in the treatment here. Sumatriptan is an abortivetreatment for headaches that must be used with in the firstfew hours of headache onset- otherwise it is effect is muchless. I do recognize that NSAIDS are good for head aches somy ED combo is Haloperidol- the closest cousin I can get toDroperidol (although in Israel now, they have made it illegal to

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give IV based on those darn Americans), dexamethasone(some good evidence in this preventing recurrence of theheadache) and a NSAID. Oh, and I forgot to mention thisstudy was performed by Dr. Glaxo, Dr Smith, Dr Klein and DrFrench- - guess who paid for it? TAKE HOME MESSAGE:Migraine cocktails vary, but sumatriptran/naproxen didn'twork so well I please your uterus. You kiss my toes. Its fair

17)Sippy cups pacifiers and bottles are designed sound- productfailure is rare. However injuries are not so rare, mostly beinglacerations in the mouth.(ibid p1104) This article was inPediatrics, not clear if the same findings can be generalizable

to adults in Ypsilanti

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18) Yes we have left Ypsilanti, and now are in Switzerland(Suisse) and in that country most people do have GPs.However, many go to the ED for minor problems. This studylooked at this and concluded people go to the ED- notbecause of convenience, and not because of 24/7 availabilitybut rather because they trusted the doctors in the ED morethan their GPs. (Swiss Med Week 142:w13565). I think we seethe same phenomena in a lot of countries and this behoovesus somehow to make our Family docs as strong as possible. Itis true that the academia mostly resides in the hospital, but ifyou are a FP-consider moonlighting every week in thehospital, or rounding with them and make sure you are as upto date as possible. It isn't convenient for most busy FPs toget to conferences and workshops, but at least betweenpatients-pick up an article or better yet- EMU. TAKE HOMEMESSAGE: Most people will bypass their GP to go to the EDeven with minor complaints just so they can get what theythink is better treatment

19) You have a baby and need urine. Why bother with messycollection bags, large bore needles to the bladder, or 26

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French catheters? They have this technique were they givethe kid a drink, tap on the bladder area, massage the backand viola! Out it comes fresh and steaming hot- just likeMama's. (Arch DIs Child 98(1)27) Sure is less invasive. Seethis picture and be convinced! I think in the study they gavethem beer to drink but I am not sure TAKE HOME MESSAGE:

Tapping on the bladder area and back massage is a techniqueto get urines from new borns that is non invasive.

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20) I am sure you have heard a bout Choosing Wisely.Basically they got the specialty societies together and eachspecialty decided what procedures and tests that they do are

inappropriate. Here are some to bark at your fellow doctorsabout. No urinary catheters to measure fluid output, and

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leave them in as short of a time as possible. No osteoporosisscreening in women less than 65 or men less than 70. Noroutine yearly EKGs in patients without symptoms (that one isa little tough for me-silent MIs are not that rare). No routinechest films in asthma. No acid suppression in GERD for kids- itdoesn't work. No CT or carotid imaging for syncope alone. Nopreoperative chest films and no routine ones for admission(interestingly enough the internists omitted the latter but saidthe former, the radiologists added the latter). No CT foruncomplicated headache.(this assumes you know what anuncomplicated headache is-but see the NICE criteria to aidyou with this) No tube feedings for demented adults- use slowassisted feeding- the pneumonia rate is the same. No benzosor antipsychotics for agitated demented adults (as a routineand chronically), and leave people over the age of 65 withHG1AC of 7.5 alone. Here are some more. No need forantibiotics in conjunctivitis- just clean them well, it goes awayby itself. No cough and cold meds to kids under age four (mycorollary- no cough meds to kids over age four either), no oralantibiotics for otitis externa, no antibiotics for sinusitis nor

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bronchitis, no NSAIDS in HTN, CHF or CRF, no opioids or barbsin migraine. Want more? See www.chosingwisely.org. TAKEHOME MESSAGE: I won't let you get away this time- read thewhole paragraph!

21) I will mention this because it was an Israeli paper, but youreally should know this. They had 14 elderly patients withaltered mental status. They all ended up having nonconvulsive status epilepticus. (Eur J IM 23(8)701) This paperreally bothered me. It was written by an internists and thediagnosis was only made in the ward. I know this hospital andoften the patients are in the ED for a few days before goingupstairs. What this means is that the ED missed the diagnosis.And indeed all did response somewhat to anti epilepticmedication. Now the ones in the ED that they thought wereseptic from a UTI I can accept- and perhaps they reallydidn't have status- the EEG was equivocal in some of thesepatients, but six of the patients had a known seizure disorderand that should have been an alarm going off. Also remembermyxedema coma. TAKE HOME MESSAGE: Do not miss nonconvulsive status epilepticus. Don't mess this one up- G-d

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gave you a brain so use it please

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22)Everything you wanted to know and a lot of what you didn'tabout amnesia is found in this article. I leave it here as areference but these disorders are rare and this was morebasic science than clinically relevant (Lancet 380:1429)

23)We have lots of letters. I do not know why, but last month'sfirst paragraph elicited a response- if you recall it was aboutmedical education. I want to thank both Dr. Ls whoresponded- here is a letter that one wrote. Mazal tov on your son'sengagement

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Regarding your first comment I majored in modern languages and linguistics (I was the first person ever

to finish the degree with 1 major and 3 minor languages and also got departmental honors as a junior rather

than as a graduating senior) and minored in biochemistry. My essay for medical school was about the

experience of living in Israel during the first war in Lebanon and I convinced a crusty old thoracic surgeon

that the best preparation for a career in medicine was a degree in MLL he said I was the only liberal arts

major he ever recommended accepting! I'm not so sure Dr L that languages aren'tgood prep for med school. If you speak "drunk" you would be veryvaluable in many EDs.Last month I commented:Why they can not invent a physiologic fluid that is osmolar and contains other

goodies like potassium and calcium and anything else that is

floating around in most people's systems? - I do not know.

Scott Weingart was kind to respond:they have, isolyte, plasmalyte, normosol

good stuff.

Scott I just wanted to point out how important it is that you provideyour skills as an ICU /ED guys- because no one else pointed thisout. However, I just want to say that these materials are not foundin most EDs (cost) so we do need to find a way to get them intoand of course show that they are improvement over good old

normal saline. Here's a letter from Brian MacMurray in Tennessee:I enjoy EMU as ever. Love the House interludes.

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On the azithromycin and QT prolongation issue....is this written by the same sons ofBuicks that made it hard for us to get/use droperidol?Now, here is the thing in the good old USA....if zithromax caused CLINICALLYMEANINGFUL QT prolongation, the death rate in America would have now skyrocketed;torsades de pointes would be the most common arrhythmia in America; and our ERstaffing would be decimated especially because we ER doctors and our Nurses and Stafffolks take this potent antiviral A LOT. Just my fervent opinion. The heck with evidence-

based. Let's play the reality game.Actually Brian, the evidence is not that good.(of course you meant antibacterial). However, my point was different.Macrolides are not very effective antibiotics and we basically havebetter antibiotics for everything we use macrolides for.Azithromycin has a long half life and can cause really badabdominal pain, and if it is true that the mortality is greater thenon both accounts we have a long acting drug that will be around inthe system for a long time. And it isn't cheap.Thanks for writing.Here is a letter from Knox Todd down in Houston. While it is anadvertisement, if it could help someone or could help Knox- I ampleased to include it

Mazel Tov on the engagement!! Thanks to Yosef for his mention in this months EMU of the newDepartment of Emergency Medicine at the University of Texas MD Anderson Cancer Center. In addition

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to fellowships in pain and palliative medicine, we are recruiting for the second year of our Fellowship in

Oncologic Emergency Medicine and are seeking new faculty for our growing department. Please contact

me if you know of qualified applicants. Position descriptions appear below.

Director, Emergency UltrasoundThe newly established Department of Emergency Medicine at The University of Texas MD

Anderson Cancer Center seeks an Emergency Ultrasound Director to join our growing faculty.

Candidates must be board-prepared or board-certified in Emergency Medicine or Pediatric

Emergency Medicine and fellowship-trained in emergency ultrasound. Responsibilities include

providing patient care to patients with oncologic emergencies in our 45-bed Emergency Center;

providing training and oversight to our ultrasound program; educating medical students, residents,

and fellows; and engaging in academic pursuits to support the development of oncologic

emergency medicine as a distinct specialty.

Assistant or Associate Professor - Emergency MedicineThe newly established Department of Emergency Medicine at The University of Texas MD

Anderson Cancer Center seeks emergency physicians to join our growing faculty. Candidates must

be board-prepared or board-certified in Emergency Medicine or Pediatric Emergency Medicine.

Responsibilities include providing patient care to patients with oncologic emergencies in our 45-

bed Emergency Center; educating medical students, residents, and fellows; and engaging in

academic pursuits to support the development of oncologic emergency medicine as a distinct

specialty.

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Oncologic Emergency Medicine FellowshipThe Oncologic Emergency Medicine fellowship provides advanced training in the emergency

treatment of cancer patients. Trainees may focus on pain management, palliative care, or

operations research. The main goal of the program is to facilitate expertise in the diagnosis and

treatment of a wide variety of conditions that are specific to cancer patients presenting to the

emergency department as well as to advance scholarship in the growing subdiscipline of oncologic

emergency medicine. The duration of the program is 12 months with an optional 12 month

research extension.

Interested applicants should send a cover letter, CV and list of three references to:

Knox H. Todd, M.D., MPH

Professor and ChairDepartment of Emergency Medicine, Unit 1468

The University of Texas MD Anderson Cancer Center

PO Box 301402, Unit 1468

Houston, TX 77030-1402

or send via email to:

khtodd@mdanderson.orgAlso, remember that past issues of EMU are posted at www.empainline.org for your convenience. Thanks

again, Knox. Anyone else with availabilities- no problem with meadvertising to the EMU community- at least you know you aregetting a physician on the same page as you!

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And now from Ken Iserson- you know we he write it is going to berelevant and usefulA few comments on this months issue:

NNT for antihypertensives? You quote >100 for effectiveness. But, the following abstract from

Tulane (and experience) suggest otherwise:

Ogden LG, He J, Lydick E, Whelton PK: Long-Term Absolute Benefit of Lowering Blood

Pressure in Hypertensive Patients According to the JNC VI Risk Stratification.

Hypertension.2000;35:539-54

AbstractBlood pressure (BP) levels alone have been traditionally used to make treatment

decisions in patients with hypertension. The sixth report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) recently

recommended that risk strata, in addition to BP levels, be considered in the treatment ofhypertension. We estimated the absolute benefit associated with a 12 mm Hg reduction in systolic

BP over 10 years according to the risk stratification system of JNC VI using data from the National

Health and Nutrition Examination Survey Epidemiologic Follow-up Study. The number-needed-

to-treat to prevent a cardiovascular event/death or a death from all causes was reduced with

increasing levels of baseline BP in each of the risk strata. In addition, the number-needed-to-treat

was much smaller in persons with 1 additional major risk factor for cardiovascular disease (risk

group B) and in those with a history of cardiovascular disease or target organ damage (risk group

C) than in those without additional major risk factors for cardiovascular disease (risk group A).

Specifically, the number-needed-to-treat to prevent a death from all causes in patients with a high-

normal BP, stage 1 hypertension, or stage 2 or 3 hypertension was, respectively, 81, 60, and 23 for

those in risk group A; 19, 16, and 9 for those in risk group B; and 14, 12, and 9 for those in riskgroup C. Our analysis indicated that the absolute benefits of antihypertensive therapy depended on

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BP as well as the presence or absence of additional cardiovascular disease risk factors and the

presence or absence of preexisting clinical cardiovascular disease or target organ damage. I findthis very interesting, Ken. My only comment is that often we cannot be sure a patient really has HTN as few measurements aretaken before the diagnosis is given. In addition, this is assuming anabsolute benefit of 12 mm reduction which may or may not betrue. Furthermore, this data is 13 years old- why isn't it be applied? and lastly there may be a closer NNT to NNH with patientswithout risk. Did I say I only had one comment?

Im pretty sure that I previously sent you something about using intravenous lidocaine forintractable hiccups. I described it in Improvised Medicine and used it successfully in Antarctica.

Tattooing a DNR on the chest? It is a no-go ethically, as I explained in: Iserson KV: The `no code

tattooan ethical dilemma. Western Journal of Medicine 1992;156:3:309-312. The reasons are

that, as you noted, it is undecipherable, the person may have changed his/her mind, and the order

itself has many permutations. The photo below (from the article) is from an EM colleague who got

it on his 65th birthday.

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Bravo on both accounts! I recently had anoncologic patient that I used viscous lidociane but it didn't work-perhaps I had to use IV.

Finally, Dr. Houses misanthropic remark that we became doctors to treat illnesses, not patients,

has always bothered me. Thats the surest way to burn out as a clinician. My take has always been

to find out something about the patients I treat. Some fascinating folks come through the ED. We

only have to discover them to remain interested in medicine and become more interesting people.

Best wishes, Ken

This is sage advice and probably the real reason we are doctors-after all engineers also diagnose but their patients have no life( sometimes neither do they- I would know I was an engineer).What is interesting is that when I prepared that EMU, I foundmyself strangely drawn to this character that I have never seen.

To be eccentric, always right and sardonic has an appeal- then Irealized that sub consciously that is our revenge- we get abusedall day by patients who do not want to be here, while our

colleagues have their carpeted offices and never get spit on orthreatened. And true, with that comes burn out. But as you

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pointed out that is the exactly wrong attitude. Our patients doappreciate us and our efforts; they just often just don't knowhow to express themselves. Thanks for writing Ken.

24)Yes, in 11 that was the Mister ED. Clinical Quiz in 13-Machiafava-Bignami disease. And the line about feeling luckyis from Dirty Harry- played by Clint Eastwood. 14 was CharlesBonnet Syndrome. Now as a another little present- Tako

Tsubo was not a real person- the syndrome of normalcoronaries and MI changes on EKG with billowing and

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hyperkinesis on echo was named after the Japanese Octopustrap which the echo resembles (AJEM 30(9)E3)

EMU LOOKS AT:BleedingI know this has been all over the news lately but it is time for us to giveour opinion. The new anticoagulants have been heavily marketed and wewill speak about them, based on an article fromAJEM 30:2046. I wouldalso like to thank Joe Lex- a real friend of EMU who has dedicated his life

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to EM education and has graciously agreed to allow me to use some ofhis lecture notes from a lecture he gave on the subject.1) As I said the new anticoagulants have been heavily marketed andindeed this optimistic study has some industry involvement. What did wehave up to now? Well Warfarin is cheap, and familiar, but does have aninitial prothrombotic effect and also there are dosing issues due to geneticdifferences in people. It does have an antidote but it needs monitoring,and has lots of interactions (this is why the following patient ended up

have a CVA The clotting factors have differenthalf lives, and they will be inhibited at different times so warfarin may not

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achieve anticoagulation for a few days and indeed - you need to add afaster acting agent like the LMWHs or else clots can still occur. Justremember once you are above 3- every 1 unit increase in INR doublesthe bleeding risk. If someone is bleeding; stopping warfarin will result infactor recovery in about 50 hours. Vitamin K can reduce this to 24 hours.IV can cause anaphylaxis but the diluent has been changed and this isvery rare now. You can give it by mouth but it takes longer to work (justput the IV liquid in a cup.). SC administration doesn't work and should beavoided. Vitamin K dosage is one mg for minor bleeding, and 2-5 formajor bleeding. FFP is also used but it takes almost an hour to thaw,takes about six hours to give the full dose of 15ml/kg (about four units)and since its INR is 1.7- that is as low as you can get with FFP. It can bea lot of fluid- 4 units are about 3 liters. PCC is more concentrated andcan be used as an antidote, but you w ill still need vitamin K, and the USAPCC is lacking one of the factors. Skin necrosis rarely happens with

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Coumadin and there isn't much you can do to prevent it.

2) Heparin has a very short half life. Protamine is the antidote but is rarely

used. Dialysis patients who bleed more than two hours after dialysis- don't

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give protamine- the bleeding is not from the heparin. SC heparin is rarelygiven anymore but it worked well and was much cheaper than LMWH.3) Enoxaparin and fondaparinux do need monitoring but they have noantitode and they need to be injected.4) These new anticoagulants work by inhibiting the conversion offibrinogen to fibrin (dagibitran) and or the conversion of prothrombin tothrombin (rivaroxaban and apixaban).They are derived from leeches

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They need no monitoring, are given orally,have few interactions and a wide therapeutic window. They have all beenapproved for use in non valvular PAF and rivar has been approved forDVT prophylaxis. As of this writing, no approval yet for ACS or DVTtreatment for any of these agents, but it is on the way. Interestingly

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enough, the ACCP has approved dagibitran as their first line treatment for

CHADS2 score higher than2 25) Dagibitran is given as 150 mg twice a day with a reduction to 75 twicea day if the patient has a lower creatinine clearance. It does causedyspepsia, and interestingly enough, there were higher rates of MI whencompared to warfarin- but that is with the higher dose. ICH was lower

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than warfarin . 150 mg showed the best efficacy over warfarin with similarbleeding rates in the rest of the body. The problem is that this was anopen label study.6) Rivaroxaban also showed less intracranial bleeding than warfarin butmore GI bleeding. Apixaban also showed lower bleeding rates thanwarfarin7) Really want to know how you are doing with regards toanticoagulation? Then you need an Ecrin clotting time, which I carryaround with me in my pocket along with a front loader, an I beam and acopy of Frankie Yankovic's polka favorite "Who Stole the Kishka?" (Ohplease, father Greg, please stop dancing. We are not in Hamtramck). PTTmay help for rivaroxaban or apixaban but here to you will be plagued bylack of standardization8) Bleeding? Well, four factor PCC- which we have in Israel may helpfor rivaroxaban but not for dagibitran. If it is minor bleeding, they haverelatively short half lives, so you can just stop the medication. Dialysishas been recommend but these drugs are only partly dialysable,

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9) and now for the other side of the story

. Dagibitran doesn't work well withProtein C or S deficiency. It did beat warfarin in PAF for stroke andembolism prevention but the NNT was 172 for benefit over warfarin.

Although to be fair- the NNH for MI (we said above they cause somemore MIs) is only 1 in 500. Dagibitran starts to work within an hour and

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needs no bridging. Its half life is 12-17 hours which beat warfarin. Unlikewarfarin, you can't miss a dose because the factors rebound fast and thishas caused it to be black boxed in the USA. Antidote- there is none, andthey have tried everything including tranexamic acid, DDAVP, andrecombinant factor VIIa.10) Rivaroxaban and apixaban have shorter half lives-6 to seven hours.However; the NNT over warfarin for PAF is 222. These are protein boundso don't even think about dialyisis. Factor VIIa and PCC seem to work at least partially- although they were tested in healthy patients. PT mayhelp as a measure here your Ecrin bleeding time will not help.11) Remember none of these new drugs are approved for mechanicalvalves and they may not work for this entity.13) Warfarin with INR testing in the USA amounts to 80$ a month whilethe new boys on the block costs about $250

For our second essay, we have a roundtable featuring David Levy fromNew Zealand, Mike Drescher from UCONN and formerly the interim headof trauma at Tel Hashomer (although not being a surgeon but an EP), aswell as a site reviewer for the American College of Surgeons Committee

on Trauma. Yoram Klein is the head of Surgery at Kaplan Hospital here in

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Israel and the chairman of the Israeli Trauma Society. And of courseyours truly. Here is the first question:1) Many have said that trauma is no longer a surgical disease since so

many previously surgical conditions are treated expectantly- what do youthink?

Yoram:

Trauma was, is and will always be a surgical condition, regardless of theprevalence of emergency surgical interventions. There are multiple reasons for

that. A) Surgeons will always intimately understand the Pathophysiology oftrauma for the simple reasons that we creating trauma in our patients on a dailybasis. Our understanding of hemorrhagic shock or tissue damage is based onthe fact that most our procedures involve inflicting this type of pathology. B) Thehead of any team should be able to make the most crucial decision regardingthe subject that the team treats. No non-surgeon will ever be able to make thedecision to take the patient to the OR. Let me remind you that even in placeswhere the ER is running completely surgeon-free, the minute the option ofsurgical intervention in raised a surgeon is called. Even in non-dramatic cases

such as acute appendicitis. C) Who will take care of the severely injuredpatients if not the surgeons? Let us remember that the time that a trauma

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patient spend in the ER is just a tiny fraction of his hospitalization. D) There arenumerous surgical conditions that are being treated by surgeons despite thefact that a surgical intervention is rarer than in trauma (i.e acute diverticulitis,acute cholecystitis, acute pancreatitis etc.)David:As I enter my 25th year of practice I have seen the EPs roles inmanaging the trauma patient expand. I recall hearing a lecture in the

1980s where a renowned trauma surgeon made the following statement

the only role of ER doc in trauma should be to take the blood

pressure. Weve come a long way baby. I believe emergency medicine

trained doctors are the most qualified to run the initial

resuscitation and stabilization of the trauma patient. We are the

resuscitation specialist and are able to take a holistic view of the

patient. Patients more and more present with underlying complex

co-morbidities that require concomitant medical management. Once the

patient is stabilized, and we can then direct the patient to the

appropriate specialties for assistance in caring for secondary and

tertiary injuries if necessary.

Me: Well, obviously I am a little bias here, but why should trauma be anydifferent than any other emergency- we stabilize the patient- we call for help. IN

addition we will never have to get any clearances for the patient- i.e.consultations about the internal medical problems, medication use, cardiac

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clearance, etc. On the other hand, EPs in my country rarely get involved intraumas- we get frustrated by the leaving us with little to do except "take ablood pressure"(see next question). Lastly, the tendency of many surgeons to

just pan scan and not use EBM frustrates us. Wish there was a middle groundMike: Can this question still be provocative? Seems kind of 1990s. But okFirst define terms: Trauma (from Greek , "wound") also known as injury, is aphysiological wound caused by an external source. So are all injuries surgical in thesense that they need an operation? Obviously not. There are plenty of injuredpatients that do not need surgery, or admission, or even believe it a CTscan. All of these are by definition not surgical diseases. So does one need ageneral surgeon to scrub out of the OR, or stop discharging patients from theward to come and sort this out? No, this is the daily bread of the trainedemergency physician, and is an area where the discipline of emergencymedicine has lead the way in research allowing us to identify with certainty, andoften without radiation who is in this subset of patients (see eFAST, NEXUS,Canadian Head CT rule etc etc.) For the few sick trauma patients - all needresuscitation by experienced and qualified people. A few of these need real, lifesaving, damage control trauma surgery. Thank God we have great surgeonsfor these patients, who really do have a surgical disease. So that rather than

worrying about the label, I worry about the patient. She needs rapid evacuationat the scene, recognition of injuries in the ED, judgment as to severity of

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injuries, competent resuscitation, skillful surgical intervention and ICU care asneeded, and rehabilitation. Trauma surgeons and emergency physicians are(should be) each others best friends. They both have to look at the injuredpatient holistically, physiologically and expertly. I want my severely injuredpatient admitted to the trauma service no matter (almost) what the injury. Thetrauma surgeon will take care of the whole patient, whether or not his disease issurgical.2) Many hospitals have trauma teams that include an ultrasound tech,

and anesthesiologist and an EP whose role is ill defined since there are otherpeople handling the airway or doing the ultrasound. Many EPs in Israel just don't

even bother going in to traumas. What is the role of the PE in a trauma?

1. Yoram: The role of the EP is like pornography a matter of geography.In other words the EP can be a team member, can be in charge of the airwayinstead of an anesthesiologist. Remember that theanesthesiologist crisis isnot going anywhere. And if Israel will follow the USA I would rather have anexperience EP over a nurse anesthetist in Israel, the current situation isproblematic, since most EP are internal medicine attending that continued toEM residency. Their experience in trauma won't allow them to lead a trauma

team. Maybe the direct residency to EM will change the situation.

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David:At Waikato Hospital in Hamilton, New Zealand (a major trauma centre),the emergency medicine consultants are the team leaders in all traumaresuscitations. Since we have emergency medicine registrars (akaresidents in US) they are assigned roles as are the surgical and ICUregistrars. Primary responsibility for the airway falls to theassigned EM registrar, with the ICU registrar serving as a back up.For major traumas, anesthesia also is available for back up. Weusually supervise the performance of the FAST exam; frequentlyperformed by the surgical registrar (we are still early in thecredentialing process for trainees). I feel it would be a majormistake for EPs to forego their leadership role.ME: I think we need more dialog on the subject- and we should join together toimprove research and practice. Ultrasound should definitely be ours, as shouldbe the airway- how many anesthesiologists have experience with emergencyairways? And with the Glidescope, this should be ours alone. CVP? ourultrasound skills can make the difference. I think the surgeons should be calledonly when necessary.Mike: Emergency physicians need to feel the full responsibility for the care of

injured patients. This includes expertise for difficult airway management,knowledge of principles of resuscitation, skills in performing trauma related

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procedures. They need to be able to direct the care of the patient before therest of the trauma team arrives, and if they are otherwise occupied withanother patient, say, or MCI.

This is the baseline on which to base the role of the EP on the trauma team.The implications for training are clear. Where there is an insufficient level ofcomfort or training on the part of the EP to take a defined role on the traumateam, this challenge should be overcome and not backed away from.

If an attending trauma surgeon is present the role is to support her in the care ofthe patient. Very naturally that includes airway control but can also, dependingon the team, be to help with other procedures, monitoring and managing fluidresuscitation etc. If there is no trauma attending the EP should be expected tocontinue to be in charge of the team and of resuscitative efforts.

Importantly, roles should be agreed on ahead of time (this by the way is acriterion for trauma accreditation by the American College of Surgeons).

3) We see so much minor trauma- "fender benders" - what kind

of hidden surprises have you found that we miss in minor trauma?

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Yoram: Basically three types: misleading mechanism (especially withpenetrating injury with hidden or innocent looking penetration wounds).Example: a 17 YO male, collapsed at home after a party. The paramedic

found him in cardiac arrest. After a short ACLS round he regainedspontaneous circulation. In the ER the EP noticed a pin-point puncturewound next to the left nipple and called the surgeon. In the OR I' found apericardial tamponade due to transaction of the LAD from a dagger. Thepatient had a coronary bypass and recovered. misleading patient (themechanism was really mild but the patient medical background is so severethat even this mild injury flipped him over the edge of his physiologicalenvelope). Example: a 62 YO female that arrived to the ER quadriplegic afterbeing involved in a low speed fender accident. Evaluation of her medicalrecord revealed severe chronic ankylosing spondylitis. The third is themisleading disease: the accident was really low energy but the reason for itwas a VF.David:The most frequent surprising injury from low speed crashes I have

seen has been C1-C2 injuries in elderly patients. I have also cared

for a patient with abruption of the placenta from an apparently

innocuous motor vehicle collision. Additionally over the years I

uncovered initially unsuspected intracranial injuries, intra-thoracic,intra-abdominal injuries, and long bone fractures (often in

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non-restrained or improperly restrained occupants). My mostembarrassing case was in caring for an autistic child with a presumed

minor mechanism of injury who was apparently tender everywhere, except

the left thigh (and over-imaging him) who eventually was discovered to

harbour a left femur fracture that I did not initially image

ME: We just see so many of these cases, just do not let your guard down. A bad

mechanism does not automatically portend to hidden badness, but keep you ears

perked. Elderly and pregnant patients always need extra attention, as do infants. This

being said- do not turf to others- no one is any better than you in determining trauma

(Can you imagine? I know some hospitals that they call a neurologist for head

trauma!!!?!) Be liberal with your ultrasound probe.

Mike: I have seen patients with c-spine cord injury initially missed - beware upper

extremity weakness and pain out of proportion central cord syndrome. I saw an

elderly (danger! Danger!) man seen in the ED after falling forward onto his knees.

He was discharged to the nursing home and sent back soon thereafter not being able

to walk. Lo and behold he had bilateral patellar tendon ruptures. Lesson, have your

patients walk in the ED before going home (if they could walk to begin with).

Delayed diagnosis of liver laceration in otherwise stable patient. Low threshold for

LFTs in the patient with low right rib pains.

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4) The pan scan is just so convenient - yet so mindless- What are you doing inthing to change this - or is it worthwhile to?

Yoram: Guidelines are the key. Every place should develop evidence basedguidelines for imaging in trauma.David: Boy this is tough one. Despite the increasing role of ultrasound inthe initial management, the patient with major trauma usually

undergoes a pan scan. Whenever we try push back, it seems someone is

always citing a case of a missed injury secondary to lack of imaging.

We usually make these decisions in conjunction with the trauma

consultant. One safe guard we have in NZ is that radiology plays a

more active role in approving studies rather than serving as simple

conduit (this also has negative consequences when one has to battle

for a necessary study!) Bottom line for me is if the trauma surgeon

really wants the study, I put up minimal resistance

Me: Yoram- have Evidence Based Guidelines and we'll be doing a lot less scans. And

David- I don't like non clinicians- radiologists- dictating which scans we can do. Is

education the answer?

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Mike: First of all the question is right, the CT is very convenient for the doctor. Thatis why it requires thoughtful use for the patient. In isolated head injury we have some

good clinical rules that can absolve us from the CT. We should use those. In the

chest/abdomen I think the mechanism plays a big role in whether the stable patient

needs a scan. Of course in old people we have little to lose in terms of radiation risk

and a lot to lose in missed injury so the threshold needs to be low. The worry for

contrast induced nephropathy I would say is typically overblown especially with initial

normal creatinine.5) ATLS is required for most physicians but those who actually deal with traumahave gotten good training during their residencies and ATLS has often be criticizedfor being archaic. What do you think?Yoram: I think that the ATLS is still irreplaceable in creating a mutual basiclanguage for trauma caregivers. I think that today the ATLS should be aprecondition to start working in the ER (like the ACLS) and not toward the endof the residency.David: This is where I feel differently than the party line echoed by many

EPs that ALTS is merely a merit badge. I have been an ATLS/ EMST

instructor for over 20 years, teaching in different countries. ATLS

(or EMST in Australasia) provides a basic framework for all trauma

care providers. It is an opportunity for the multiple disciplines tolearn from a common playbook and interact in simulated scenarios. I

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always learn something new from any course I participate in, both frommy fellow instructors from various disciplines (surgery, anesthesia,

emergency medicine, critical care) and the student participants. I do

not think EPs who regularly manage trauma need to take the course more

than once, but I do think they should stay familiar with the updates

(even if they have a 5 year lag or more from actual practice).

Me: I am opposed to badge course- I think that good training and good updating (like

EMU) should be enough. Recerting is good thing in general for all specialties but cook

book approaches often cause more damage. I like the PALS philosophy the best- use

these courses to take a scary situation and be comfortable with them.

Mike: I will go along with the ACS Committee on Trauma criteria for trauma center

(all levels) accreditation: Trauma surgeons and board certified emergency physicians

need to have done ATLS once but need not be current. Non EM boarded physicians

taking care of injured patients need to be current in ATLS. It is a good course for

establishing the basics. It cannot keep up to date on the latest nuances by its nature.

Last question: 6) Please some pointers on trauma in the pregnant patient that

we may not remember.

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Yoram: lateral decubitus position to avoid excessive pressure from the venacava. B) Remember physiological changes of pregnancy (especially fluidoverload). C) the only guaranty to the well being of the fetus is the well beingof the mother D) early fetal monitoring (might be a sign of maternal distress aswell) the nemesis is placental bleeding and separation E) successful postmortem CS is mostly a myth and can create disastrous consequences. F) Ante-mortem CS should be carefully considered. G) evacuation of the uterus from adead fetus might improve the condition of the critically injured pregnant patient.The timing should be carefully planned by a team of the trauma attending, ICUand OB-GYN.

David:

The severity of the maternal injury may not correlate well with the

frequency of adverse pregnancy outcome. Even minor trauma can have

very serious consequences for the pregnancy.

Maternal acidosis may correlate with fetal outcome

No real value of Betke Kleihauer test in Rh positive females (really

doesnt change management)

Ultrasound may miss 50-85% of cases of abruption

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Me: Couldn't have said it better- all of these are serious concerns- just alsoremember seat belt injuries and that the intra abdominal organs aredisplaced. Be liberal with your ultrasoundMike: First principle: take care of the mother to take care of the baby. Alsoultrasound is especially useful both for assessing fetal movement and freefluid. There might be a baseline tachycardia that is physiology of pregnancybut dont count on it. Remember Lt lateral decub to alleviate pressure on theIVC. If the pregnancy is beyond ~20 weeks have fetal official fetalmonitoring by OB after admission or discharge from the ED is prudent.I really enjoyed this and I am sure we'll hear from you a lot of controversialpoints here. Write me Now!