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NOV 20121)First it was the chest pain center. Gosh this was a popular as leisure

suits and Nehru jackets. Now that chest pain centers are out of style.

But I always thought what about TIA centers? Indeed these arebecoming a bit of a rage at this point, but there may be a cheaper wayof doing this. They admit the only real reason to admit TIA patients isto expedite the work up and to make sure they get TPA immediately ifthey actually stroke out, but why not do this in a same day clinic thatwill just do the CT and Duplex of the arteries and good education ofthe patient to come back if there are stroke symptoms? (Neuro77(24)2082) This is a cost analysis and as I always tell you thisdepends on the assumptions, and in this case whether yourpopulation can afford the clinic or will be complaint, but it sure doessound like a good idea. TAKE HOME POINT: There is no rush on mostTIAs to do the CT and Duplex in the ED- these can be done in a sameday clinic. For those of you who have never been to Hamtramck, here

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is a Nehru Jacket and leisure suitRick- could this have been you when you were younger?

2)You are watching a marathon (of course if you watch things, you needto get a life) and are called to the tent to see a runner that collapsedafter a run. This is most probably due to exercise induced collapsewhich is a benign event probably due to sudden stopping of exertion.But there is a need to rule out other sources of collapse such ascardiac arrest, exercise induced hyponatremia and exertion heartstroke. If these have been ruled (I think cardiac arrest would be

pretty hard to miss) rest and oral hydration are all that is needed. (BJSports Med 45(14)1157) TAKE HOME MESSAGE: Collapse after a race

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probably is benign but rule out hyponatremia or heat stroke. Oraltherapy suffices for most cases.

3)Breast abscesses let's first go over the basics- mastitis does need to

continue lactation and also probably antibiotics. Breast abscesses admission and incision and drainage. Well they used to be the basics-Like many other abscesses you can now do ultrasound or CT guidedaspiration and saline lavage. There is less damage to the ducts thisway too. And you do not need the OR nor admission any more(Radiographics 31 (6)1683). The key here is not to miss inflammatorybreast cancer. They also recommend antibiotics, for which I would liketo see some evidence. Actually, I would like to see evidence for theirguideline in any case, although I suspect it is correct TAKE HOMEMESSAGE: Breast abscesses do not need incision and drainage butrather aspiration and watching-(dont observe for too long, you dontwant to embarrass anyone) Let us take this opportunity to introduceour guest quotes of the month. In most animal species the female isanatomically different, maybe with less colorful feathers, but theybasically act the same. Not with us humans. Despite my teasing mywife that I have an innate understanding of the female psyche, I likemost (actually all) men have no idea how the females of our species

think. Let's take a look .Thanks to thirty years of feminist striving, thecategory woman has expanded to include anchorpersons, soccer

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moms, astronauts, firefighters, and even Senator or Secretary of State.

But female still tends to connote the oozing, bleeding, swelling, hotflashing, swamp creature side of the species; its tiny brain marinating

in the primal hormonal broth. Barbara Ehrenreich. Women are justmachines for making children Napolean Bonaparte The malechromosome is an incomplete female chromosome. In other words the

male is a walking abortion; aborted in the gene stage. To be male is tobe deficient, emotionally limited; maleness is a deficiency disease andmales are emotional cripples Valerie Solanos. Feminism is just a way

to mainstream ugly women Rush Limbaugh A woman needs a manlike a fish needs a bicycle GLoria SteinumEnough Guys- - get to your

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respective corners and wait till I call you

4)This study scared the wits out of me. If you exercise - your rate of

ACS is similar to those who don't. Let's qualify that a little- that is in

patients with chest pain. The point is that in chest pain, the fact thatthey exercise vigorously is not a reason to discount ACS. (AJEM

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30(1)57). The actually rate for ACS in all patients was low as therewere not that many patients in the study to start with. Furthermorethis was done in Stoney brook which is not exactly reproducible to

the rest of the world as this is a very affluent area. Furthermore,those who exercise vigorously was based on questionnaires; therecould be some error in that. Nevertheless, we decided to contact AdamSinger, an author on this paper and an EMU reader for many years.His take on this: Yosef,

The main purpose of the study was to demonstrate to the cardiologists that the ability to exercise regularly, especially if

without chest pain, cannot be used to r/o ACS as a cause of chest pain in patients presenting to the ED. From time to

time we have had cardiologist blow off patients who have atypical symptoms when they are physically fit. Thanks

Adam TAKE HOME MESSAGE: Athletes get ACS just like folks who are

sedentary.5)The use of anesthetic creams on an abscess can cause the abscess todrain and therefore there may be no need to open them. Just rub onthe cream and you are set. The question is how and why this works(ibid p104). Actually I think the data proves just the opposite. Itcaused spontaneous drainage only in 26 out of 300 patients and onlyin three did it actually preclude the need for further intervention TAKEHOME MESSAGE: EMLA may cause spontaneous opening of abscesses.I don't believe it though.The reason women don't play football is

because 11 of them would never wear the same outfit in public.

(Phyllis Diller)My cooking is so bad my kids thought Thanksgiving was

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to commemorate Pearl Harbor. (ibid) Im at the age that my back goesout more often than I do. (ibid). You know your old when your walkerhas a airbag(ibid) Never go to bed angry- stay up and fight(ibid)

6)Lactate- I haven't found this to be that useful in the ED, but the ICUguys do love it- it does help for prognostication. However, in many EDsit is hard to get and sometimes we even have to send the blood up tothe ICU to get results. Learn to use base excess. Base excess which isa measure of the amount of base that is required to return the bloodto 7.4. This means a base deficit is a measure of acidosis and indeedthe deficit of -4 correlates well with a lactate of 3- and is a lot moreavailable (ibid 30(1)184) TAKE HOME MESSAGE: Base excess can be agood substitute for lactate And we did get some feedback on this fromour ICU guys Pinny Halpern from Ichalov in Tel Aviv says: I use BE in lieu oflactate all the time. I believe the literature is strong that the correlation between the two is very good, andpretty good that both are good predictors of mortality in multiple conditions, from trauma to sepsis. The onlycaveat is that if the phlebotomist reports a very small vein, prolonged vein occlusion and slow draw, a falsely

elevated BE may ensue, so a second draw may be warranted. And Carmie Bartel fromSoroka in Beer sheva says they have lactate in the ED, so they do not use the base excess toomuch- but I still am not sure how this test helps us much as it is more ofa prognostic indicator and a measure of how you are doing in yourtreatment. Thanks Carmi and Pinny. And a word from our peerreviewer:YouarerightthatbaseexcessisagoodsurrogatefortLactate.Thetruthis,

lactateisreadilyavailableinmostEDsintheUS.Wegetitwiththebloodgasresults.IthinkthevalueoflactateintheEDisasanend-pointforresuscitation,especiallyinsepsis.

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Vitalsignsarenotgoodenough.Ifyouresuscitatetonormalvitalsignsbutthelactateis

stillelevated,youhavetocontinueresuscitatinguntilthelactatestartstonormalize.7)Helluva a nice guy, bright, and one of the premier physicians in EM

today. Yes I know you were thinking about me (and if you weren't-watch it, bucko) but I really was thinking about Shamai Grossman-another EMU reader. Shamai studied near syncope versus syncope.Well syncope could be bad but what about near syncope? They notedthat adverse outcomes were similar between both groups althoughnot all the adverse outcomes were adverse by all definitions. Theproblem is that near syncope patients were much less likely to gainadmission. (ibid p203) I will say that if you look at the numbers-syncope is still worse, and I think we would consider a near syncope in

an 80 year old much differently from syncope in a 25 year old but it isa point well taken. Good paper Shamai. TAKE HOME POINT: Nearsyncope should be concerning to you just like syncope. Hair iseverything (Diana Ross) I took my parents to the airport today. Theyleave tomorrow (Margaret Smith) Great people talk about ideas,average people talk about things, and small people talk about wine.

(Fran Leibowitz)Gosh, I hope Father Greg is not reading. For those

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who do not know Father Greg- here is a picture: Justto pacify Father Greg, lets quote Julia Child I love cooking with wine.Sometimes I even put it in the food

8)This should be pretty obvious, but I will state the case. While youmight love ultrasounds, but in urolithiasis it doesn't help much. It will

identify a big stone; it will help in detecting hydronephrosis but doesn'tchange the clinical impression of physicians. CT of course is muchmore helpful. (ibid 218) Truth be told, I do not do ultrasounds on renalcolic but I do not do a lot of CTs either. People whose pain can not becontrolled, people whose creatinine has risen greater than 1.5, peoplewith stone disease and fever with the correct clinical picture- thesefolks need a CT. I do a bedside ultrasound to make sure that I am notmissing a dissection which I just check to see the diameter of theaorta. TAKE HOME MESSAGE: Ultrasound doesn't help you much more

than clinical judgment in urolithiasis.

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9)OK, I'll be serious- if you are a real wino so you know that you can geta fix by dipping into the ethanol hand cleansers in the hospital. Youwould imagine that if it is just ethanol it is probably benign and most

of the ingestions in this study were benign, but many of these containisopropyl or chlorhexidine combos that can lead to dialysis. (CCM40(1)290 ) TAKE HOME MESSAGE: Ethanol hand cleansers are safe forhands and for drinking- mostly. Most do well, but I would still admitthem I base my fashion sense on what doesn't itch.(Gilda Radner)"Never mind" (ibid). A woman who doesn't wear perfume has no

future (Coco Channel). This quote for reasons not clear to me made

me think of this picture . Five points if you know

who this is. Just to help you, here is what John Elway, Hall of Famequarterback had to say about this gentleman: He had no teeth, and

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he was slobbering all over himself. Im thinking You can have yourmoney back, just get me out of here. Let me go be an accountant Hewas knocked out on this play. While we are the subject of sports,

women have a unique perspective on that as well. I do not like football.I have a contempt for a game in which the players have to wear somuch equipment. Men play basketball in their underwear which

seems just right to me Anna Quindlen10) Dr. Raz doesn't read EMU, but he is a big ID guy from HaEmek

hospital in Afula Israel, and sings the praises of fosfomycin. If you donot know this antibiotic, get to know it. It is taken just once foruncomplicated cystitis and has a lot pluses. The resistance rate hasstayed fairly stable at 1-3% This is probably due to the fact that it isnot related to any other antibiotic (don't let the -mycin fool you itisn't a macrolide) but it could be because basically no one uses it.Best news is that it works against 98% of ESBL- that scary bug that isresistant to penicillin and cephalosporins and quinolones. It also workswithout adjustments in mild renal failure and can help recurrentuncomplicated cystitis when taken with macrodantin. (Clin Micro Inf18(1)4) . He doesn't mention that it is not one of the strongerantibiotics but that is implied in "uncomplicated cystitis" In a related

article-they searched Europe, the USA, Australia and Canada forforgotten antibiotics as solutions for resistant bugs. Many are no

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longer manufactured but do not forget Nafcillin, dicloxacillin andfosfomycin. TAKE HOME MESSGE: Fosfomycin is a good antibiotic foruncomplicated cystitis." I think there's a difference between ditzy and

dumb. Dumb is just not knowing. Ditzy is having the courage to ask!"Jessica Simpson. " I am in favor of capital punishment because peoplewho do bad things should get just punishment and this will teach them

for the next time" Brittany Spears11) Idea was great, the article wasn't (doesn't this sound like

marriage?) Why not just home treat cholecystitis? They did and itworked (Euro J Int Med 23(1)e10). Here are the problems. Only were25 patients who knows how many were serious and how manywhere mild. All got Ertepenem-an antibiotic which I have of a case ofsitting in my house. How many got pancreatitis? Not clear. I got agood idea- why not just operate immediately? I know you arentsupposed to operate when they are infected but we open abscessesall the time without cooling them off with antibiotics. Think I am nuts?Well, I am, but I am not alone SeeAnn Surg 227(4)468. TAKE HOMEMESSAGE: You may be able to home treat some diseases- is biliarycolic one of them? Whenever I am a room with a guy- I think if wewere the last two people on Earth, would I puke if he kissed me?

(Helen Hunt from Girls Just want to Have Fun)

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12) I imagine you knew this but your nurse may not and yourneighbors and patients for sure dont. Fever is not dangerous, and maybe beneficial (although quite frankly we have been throwing around

this idea that it is beneficial for quite a while, and I havent really seengood patient oriented evidence- see Crit Care 15(3)222). But at leastin my ED, the nurses are quick to place ever so gently a suppository tolower fever in the nether orifices of some unsuspecting individual.They use a process with an RPG (rocket propelled grenade) to insertthese (I actually think a dynamite charge would have been enough butwho listens to me?) and I can understand that they may believe thathigh fevers cause brain damage, seizures and death- which what mostpatients and doctors think anyhow. (AFP 85(5)518). Now it may bethought that what is the difference if you give antipyretics- it is benign,but over half of parents give the incorrect dose. TAKE HOMEMESSAGE: Treating fever is for comfort only. Go and make itidiotproof and they will go make a better idiot Debbie Thorton

13) My goodness, my kid stepped on a cockroach and since it wasstill moving I intubated it. I can intubate mosquitoes with a Millerblade. But alas, as Ron Wallls has gone on record saying- I am oldfashioned. Video laryngoscopes are more effective for difficult airways

and more comfortable for the patient and the operator.(Anesthesiology 116(3)515) I guess you could be in a place which

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doesnt have one-like most places I have worked in- so it pays to knowthe Miller way too. TAKE HOME MESSAGE: If you have spare cashsitting around your ED- buy a video laryngoscope-and then learn how

to use it.14) Now a bone for our ICU guys. Hyperosmolar therapy includes

Mannitol and the new kid on the block- hypertonic saline (HTS). HTSseems to be more effective, but again this has not been proven inpatient oriented studies. Regional necrosis has been reported but thishas been in dogs, not in humans. But again I am unconvinced thesafety studies have not been that strong. HTS does not seem to causecentral pontine myelinolysis when used for ICP which makes sensesince most of these folks have no hyponatremia to start with. (AJ RespCCM 185(5)467) No one asks the key question- does it changemortality? TAKE HOME MESSAGE: You can use HTS safely- I think"Ithink marriage is a great institution- but I am not ready for aninstitution yet (Mae West)."I 'd give half my life for one kiss from you,

Miss West" "So kiss me twice"15) Clinical quiz time- not a hard one but when you see it, you better

think of it. 42 year old lady, 38 weeks pregnant, GDM and mild preeclampsia- she requests an epidural. She was given one and

immediately felt short of breath and proceeded to have a seizure. Afew minutes later, cardiac collapse and she was intubated. CPR and epi

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resulted in no waveforms and an emergency c section was performed.She was started on an epi drip and an emergency hysterectomy wasperformed. She was given blood, vasopressors, and admitted to the

ICU. She developed DIC and CXR showed pulmonary edema.Amazingly she was discharged home three days later with no neurodeficits but without a uterus and I am not sure why(why she is uterus-less, not why she was sent home). So what did she have?(Anesthesiology 116(1)186)

16) Law time. Advanced directives are common today, but this areastarted with two sentinel cases. Karen Ann Quinlan went to a party in1975 and took a combination of diazepam, detropropoxyphene andalcohol. She experienced a respiratory arrest and was in a persistantvegetative state due to anoxic encephalopathy. Her parents convincedthe court that she would not have wanted to be kept alive and thecourts agreed. The Supreme Court of the USA upheld such precedentsin the Nancy Beth Cruzan case, where Ms Cruzan lost control of her carand was ejected from the car into a ditch full of water- she was alsoanoxic.. The courts agreed that a person can exercise the right torefuse treatment if it can be proven that they would not have wantedthese extra ordinary means in the Cruzan case -the life support was

removed. Congress soon enacted a law that hospital workers mustask if an advance directive exists. The law now states that advance

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directives must be signed and two witnesses must be present.Physicians can not be proxy for an advanced directive. All advanceddirectives can be cancelled. Some problems that can arise include that

most advanced directives are written in legalese and they can varyfrom state to state so there may be elements that cannot be honoredin a different state. The directive goes into effect when the patient canno longer make decisions but this can be problematic as mentationcan be fluctuating, and in addition, a patient may still be able to makedecisions but not be able to understand the medical decisions thatneed to be made. A proxy is helpful here, but often the proxy cantmake decision due to family dynamics or other considerations. Gettinganother proxy requires a court order. Physicians can refuse to give lifesupport if in accordance with family wishes or if it is in good faith.They also have a right to refuse to participate in ending life support ifit is contra to their ethical feelings. In truth- lawsuits againstphysicians for ending life or continuing life against the wishes of thefamily are few. Since what interventions are not uniform among allstates, an advanced directive should be as well worded as possible.Quality of life by the way- has not been defined by the law and maynot be a basis for observing the proxys request. Mush more in this

article- if this interests you- get the article- a rare one written by alawyer that wasnt confusing (Chest 141(1)232) TAKE HOME

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MESSAGE: Advanced directives have alot of particulars that you needto know. So do not depend on this TAKE HOME MESSAGE and readwhat I wrote above. Here is a true Court Transcript: Judge: "What

seems to be the problem". Bailliff" There is a cockroach on the exhibittable, Your Honor" Defense Attorney" Motion to Quash" Judge:Granted". And back to Mae West" Long dresses cover a multitude ofshins" "My goodness, Ms. West, what beautiful diamonds" "Goodnesshas nothing to do with it" (ibid)Come up and see me some time(ibid)

17) The triple rule out CT scan which is a combined coronary, ruleout PE and thorax scan, is remarkably less radiation then I thought.For males it turns out to be 3.8 millisievert, and for females 6.5(InvestRad 47(2)109) As a reference, an abdominal CT is about 12 mSV, ahead CT is about 3 and background radiation yearly is 3. A chest film is.05mSV. That isnt to say you should be doing these scans I thinkyou should actually speak to and check the patient first, but it isnt asbad as I thought. TAKE HOME MESSAGE: triple rule out chest CT havesome radiation risk, but it isnt a massive one- gives an increase ofabout 0.1-0.5% risk of lung cancer over a lifetime. "Marriage has noguarantees, if that's what you are looking for- go live with a carbattery"(Erma Bombeck) "Never take a drink from a urologist".(ibid)

Never lend your car to anyone you gave birth to"(ibid)

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18) Body packers that have the drugs inside for more than 48 hoursare not an indication for surgery. Most are packed so well that it isunusual that they will burst open, and in their study they recommend

that surgery be done only upon signs of intoxication or ileus.(Langenbecks Arch of Surg 397(1)125). (I do not know whoLangenbeck is but I bet he looks like SpongeBob Squarepants). Theonly problem I had with this tiny study is that 25% of the patients didexperienced rupture of the packets although only one died. TAKEHOME MESSAGE: You can observe most body packers with out anileus or signs of intoxication

19) Some people get a lot of blood. Trauma patients (they tend tocome back with new trauma a second time), sickle cell anemicpatients, vampires, etc. Theoretically they could develop antibodies ifthey got unmatched type O blood. (J Traum Acute Care Surg 72(1)48)However if you analyze their data, only one patient really had ahemolytic reaction and only one patient developed antibodies to Rh.However, that is not a criticism; it is just the way the study turned out-which is why power is important in a study. TAKE HOME MESSAGE:Avoid unmatched blood you may have to deal with hemolysis in thenear or distant future. I have flabby thighs, but fortunately my

stomach covers them (Joan Rivers) Don't tell your kids you had aneasy birth or they won't respect you. For years I used to wake up my

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daughter and say, "Melissa you ripped me to shreds. Now go back to

sleep." (ibid).20) We got the best falafel in the world. We got great hummus and

harissa. But in Israel, we do not have Dexmetetomide. This stuff,according to this article is a sedative, and an analgesic, but thepatients are more awake and interactive. Now not all intubatedpatients need analgesia, and not all need sedation but this seems tobe a good compromise. Its role in EM is still undefined- but give metime (Am J Reps CCM 185(5) 486) TAKE HOME MESSAGE:Dexetomidate is the new sedative on the block- but the depth ofsedation is less than the old timers

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21) DONT READ THIS PARAGRAPH!! I warned you. Its abouteveryones favorite disease-no, not that one (just take your Rocephinand stop talking about it)- but syncope. We see this all the time, and

admit a great deal of it even though final etiologies are rare. However,if it happened more than once in a patient with a bundle branch blockand you did work them up- and by work up I was serious-EPS studyloop recorder- you found a reason in 83% of them. And these reasonswere serious- some needed pace makers, some needed ICDs. (EurHeart J 32(12)1353) Of course if I had been as aggressive witheveryone, I may have found the same thing even in folks without aBBB. TAKE HOME MESSAGE: Dont read such paragraphs. And look atsyncope with BBB more seriously. Everyone probably thinks that I'm araving nymphomaniac, that I have an insatiable sexual appetite, when

the truth is I'd rather read a book.(Madonna).I had to get back towork. NBC has me under contract. The baby and I only have a verbalagreement.(Tina Fey) "Gracie, why are you putting hot water in thefreezer?" "Because if I want a coffee, all I have to do is defrost it"Gracie Allen

22) You gotta work. And besides you got no time to go the doc andbesides what does he know? He only reads EMU for the pictures. So

you self medicate, and never see a doctor- even if you are still a medstudent. We self medicate and self treat. (Occup Med 61(7)490)TAKE

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HOME MESSAGE: We dont need doctors- doctors are for patients. Sothe solution is to have your wife nag you..

23) Apparently in Cook County they got a lot of druggies with no

veins (I am truthfully shocked to hear there are people abusing drugsin Chicago. Then again, if I was a Cubs fan, I would probably usedrugs as well) so ambulance personnel gave naloxone by nebulizer andthese folks did wake up- not all were that happy. (Prehosp Emerg Care16(2)289) The results are expressed as kappas which indicate to methat the study did not use a standard scale or form. Still, naloxonegiven by this route has not been studied (at least not in the last last 7years which is as far back as I checked) so it is encouraging.However, be aware that while 22% had a complete response, 205 hadno response. TAKE HOME MESSAGE: Try nebulized naloxone. Not onyourself silly! "If truth is beauty, why doesn't anyone ever have theirhair done in a library (Lily Tomlin)" When other little girls wanted tobe ballet dancers I kind of wanted to be a vampire.(Angelina Jolie)

24) Take 18 patients seen by their GP. All had ocular pain, and allbut one had photophobia, a red eye and blurred vision. 7 of thesepatients were referred to the ED, but the other 11 got antibiotic dropsand some even got steroid drops- so these folks waited an average of

9 days to get to the ED and many referred themselves. This is ofcourse uvietis and could have led to blindness due to inept family docs.

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A unilateral red eye is usually trouble and if you do not have a slitlamp- you better get help (Eur J Gen Pract 18(1)26) TAKE HOMEMESSAGE: Uvietis is serious dont miss it.

25) You are not a pig. But you are being fed garbage. By who? Ohthat cute little drug rep that would be so hurt if you just didnt use herCutaneous Reacting Anti Pruritic (If you didn't get it yet, check out theinitials of that medication) and she has the studies to prove that this isthe best stuff since Fentanyl Encrusted Capsular Entero Salicylate.Well look at the studies well. Of the medication trials evaluated in thisstudy- they had to throw out 116 because they used a surrogateprimary endpoint (for example it lowered CRP levels instead of tellingus if the patients got better) Another 106 used composite endpoints(it lowered CRP or made folks better, or lowered WBC or lowered ESR-these always look better). Among the studies that looked at mortality they looked at disease mortality and not at all cause mortality (amedication may not make people worse from the disease being treatedbut may kill them for another reason) Furthermore, positive resultswere often reported in relative terms. A fifty percent drop in mortalitysounds great but not if it was from 2 deaths to one. Of course most ofthese were commercially funded (JGIM 26(11)1246). So next time that

drug rep tells you about a Terrific Unbelievable Remarkable Drug tellthem that is Steaming Hogwash in Totality. TAKE HOME MESSAFGE:

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Many commercial studies have subtle but obvious flaws. "Only timecan heal a broken heart, just like it can heal his broken arms and legs"Miss Piggy "Never buy beauty products at a hardware store" (ibid)

Nurse Piggy "But I love him" "but you are a nurse" That is true, but Iam a woman first" "No , you are a pig, I do not think woman is even inthe top ten"

26) The author says that cooling doesnt help in ortho injuriesbecause of hetrogenous muscle injuries and depth of cooling. It doeswork in animals. However, no evidence is presented on patientoriented outcomes, only surrogate markers, so were kinda of cool tothis study (Br J Sports Med 46(4)296) TAKE HOME MESSAGE Coolinghasnt been proven to help in sports injuries

27) This is getting long, so we will present some of the remainingarticles as bullets. Venlafaxine overdoses can cause hypoglycemia(Clin Tox 50(3)215)

28) First trimester miscarriage- give them mifepristone immediatelyand you may save them the need for a D and C (AJOG 206(3)e1)Maybe, but this was open labeled.

29) Steve Selbst legal briefs are always a good read and I did prettywell this month- I wouldn't have gotten sued at all, although all the

patients would have died. (PEC 27(10)992) The one that could havegotten away was a rash that was itchy and didnt respond to

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antihistamines. It was Stevens Johnson- but I guess I would havemade easier had I told you the patient took anitconvulsants TAKEHOME MESSAGE: Itchy rashes that do not getter- consider Stevens

Johnson "Every woman should have four pets in her life. A mink in hercloset, a jaguar in her garage, a tiger in her bed, and a jackass who

pays for everything" Paris Hilton30) Norepi is supposed to kill kidneys. In this double blind study they

checked kidney function in shock and there were better hemodynamicswith Norepi, not worse which would have been expected. This wasbased both on blood tests and histology of the kidney. (AJEM29(8)922). OK, so dont get so picky- it was done on pigs. (But notMiss Piggy) But the pigs felt better! TAKE HOME MESSAGE: Norepimay actually help the kidneys in shock and is good as a toilet bowlcleaner as well.

31) Conjunctivitis- if you are sure of the diagnosis- see 24 above-gets better without antibiotics. Period (BrJ Gen Pract 61(590)e542).Donot forget that this is often due to blocked nasal passages andtherefore does not need antibiotics drops, creams, or antibiotic lacedmilk bones.

32) Ron Goldman- EMU reader and one of the best things to come

out of Vancouver since Butchart Gardens shows us in a nice stud thata single dose of dexamethasone has a long half life and is a potent

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anti-inflammatory. He gives 0.3mg/kg IM or preferably .6mg (CanFam Phy 57(10)1134) TAKE HOME MESSAGE: Dexa for asthma is morepotent than prednisolone and can be given just once." I think the

doctor put my pacemaker in wrong. Every time my husband kisses methe garage door opens" Minnie Pearl

33) Hey it looks like asthma- but it isnt. What else could it be? Hereare some possibilities- GERD, CHF, Vocal cord dysfunction,bronchietasis, upper airway obstruction aspiration, CF. A chest film iscritical, as are PFTs in the clinic if you are not sure. This article wasfunny as it was an important subject in a strange journal- so to justifyit, they state it is important to diagnose these so the patients can bebattle ready (Military Medicine 176(10)1162) TAKE HOME MESSAGE:Asthma mimics can be serious- look for them with a chest film. And tellthat patient to start breathing on the double. And thats an order, son.

34) Heeres another bullet- WBC cannot rule in or out a seriousinfection- especially the latter. CRP can rule in a serious infection, butit is modest help. (J Peds 160(1)173) Guess you will have to look atthe patient, huh? Secret for a good marriage when you let yourhusband lick the batter off the mixer- turn it off first" Phyllis Diller" Iam great housekeeper- everytime I get divorced I keep the house"(she

divorced 9 times) Zsa Zsa Gabor.Actually I have to interrupt this EMUwith an ad lib I just did with a med student who wants to be a

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psychiatrist and did his first rectal exam. I convinced him to enter thefield of psycho proctology "So tell me, how long have you been a---(this is a family newsletter, so well let you finish the sentence)?"

35) The picture in nine is former Pittsburgh linebacker Jack Lambert.Down boy, down, boy

36) We got a lot of letters this month! Dr. Kent Robinson from DownUnder writes how he enjoys EMU (thanks, I do too) and he has a blogdedicated to medical education. You can access it at:www.emergencyeducation.net . I did and it is very interesting. Ken Isersonwrites from Baffin Island (no that is not near any towns in Michigan andwe are going to go through the month without mentioning our favoriteBakersfield California). Here is what he has to say about the October

issues law discussion:Hi Yosef

Still way up North. Got your October EMU. Thanks. But, you know it was Robert DuVall who

said "I love the smell of napalm in the morning."

The article most concerning to me was the one about the Good Samaritan ruling at the California

Supreme Court. (Strange, don't you think, that it appeared in Singapore, rather than in a U.S.

journal?) Anyway, the link took me only to a citation, so I delved further.

It seems that the court ruled that these actions did not fall under the Good Samaritan Law because

yanking the woman out of a car that showed no evidence that it was on fire or could cause any

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other problem was not a "medical" intervention. Given their own abstract of the case, I suspect that

there was also an element of gross negligence that influenced their ruling.

In any event, this should in no way ever prevent a physician or other healthcare professional fromstopping to render aid. Ever! In fact, I strongly suggest that every trained EP carry an emergency

medical kit in his or her car to use when it is REALLY needed.

I've attached the CA Supreme Ct's official abstract of the Torti case.

Best wishes in the midst of icebergs. Ken. Write me if you want the abstract. Andyes I do carry an emergency kit with me. Dr. Crown wrote me about lastmonths cool quotes: you should keep randolph powell around to make important (orimpertinent) points and quotes. compare to the noted theologian franz bibfeldt(Wikipedia) whom authors used for years to buff up their bibliographies with bogus stuff

(or maybe that was by politicians) thank you for the info this month. Oh, I think youhavent heard the last of Randolph Powell. Since he has appeared in nofilms, there are plenty of quotes available that he never said. Dr, Nochimsonasks about probiotics Do you have any recommendations on specific probiotics? Asalways enjoyed the issue. I had Dr. Shapiro answer: Is the question in regard to which strainsofprobiotics?To be honest, I have seen that each manufacturer has their own mix, which makes it a bit hard to judge. I have not seen

good studies on particular strains. Here in Israel, I usually recommend Mega Probiotic by Gramse. They have a mixtureof lactobacillus acidophilus, lactobacillus casei, lactobacillus rhamosus, lactobacillus plantarum, b. longum, b. bifidum,

lactobacillus lacti, s. thermophilis, b. breve, b. lactis. For whatever that's worth. Ithink the key point is

that yogurt just doesnt have enough. And yes good studies that go into thespecifics are lacking. Thank you to you both. Rafi Kayam who is a wonderful

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person, a great physician, a model of the community, a very handsome man,and my boss (can I have a raise?) writes that he isnt convinced that lateralfilms provide much in the way of information on k ids and he also thinks that

thrombocytopenia is an earlier finding in Kawasaki than we think. Heprovides articles for these assertions:

.8-Paediatr Child Health. 2003 Nov;8(9):566

Shows the following conclusion: There is no randomized controlled trial evidence to support theadditive value of the lateral to the frontal chest x-ray in the diagnosis of children with pneumonia.Further prospective studies are required to determine if the addition of the lateral chest x-ray will

modify therapy, prevent complications or whether it is cost-efficientAnd on KawasakiAFP59(11)3093"Thrombocytosis is frequently present after the first week of illness and may be marked . I

am just a little guy here so I will wait for Lisas reply. Dr. Veysman wrotethe following: As always, incredible treat for us all. Thank you so much. The productinspires by being so easy on the mind. Of note, , but have you taken a Myers Briggs? I am

wondering if you are an INTP, based on the associative and visual way in which you think

and teach. There are very few in Emergency Medicine as often that personality rebels

against many requirements of the work, but ones who master (conform to...) the work often

stand out like you do. . . Being far from the authority on the matter but finding the subject

interesting and having nothing to teach you in return for your thinking generosity, perhaps

this can be my humble contribution. Personology is a fascinating feast for the enquiring

mind so perhaps you'll enjoy it. So I took this test and found that I have a

unique talent in writing prime medical material for optimal bathroomreading. Well, not really. His analysis of the results was: Very cool. You

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are an enigma of focus and productivity. So there is some thing to be gained bybeing a deviant. But seriously- anyone who wants more on the subject-the test was fun, the analysis interesting- Ill make the contacts if you

are interested.

37) Number 15-Yes I thought also that this was eclampsia orcardiomyopathy but indeed this was amniotic fluid embolism. DICoccurs rather frequently- no one is sure why. It seems that c section isa risk factor. Treatment is supportive with mortality being about 25%.ECMO may be an option. TAKE HOME MESSAGE: Sudden collapse andDIC may be an amniotic fluid embolism. Treatment is aggressive andsupportive. Left uterine displacement and immediate c section may belifesaving.

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38) Yes, Ron, (#32) I knew that Butchart Gardens is in Victoria andnot Vancouver but it is on Vancouver Island and that is enough. Justwanted to see if you were really reading.

39) And now a look at the starlets that contributed to this issue'squotes. Note we did not use Rita Rudner or Roseanne who are really

funny- but just wait.Phyllis Diller

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Fran Leibowitz Zsa

Zsa Gabor Brittany Spears:

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Jessica Simpson: Paris Hilton:

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Miss Piggy Lily

Tomlin: Minnie Pearl

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Joan Rivers Mae West

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Erma Bombeck Gracie Allen

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Eleanor Roosevelt:

EMU LOOKS AT: Sleep deprivation and IronsupplementationWe have discussed this before it was about 5 years ago, but this is anupdate, and it is on everyones mind. The source for the essay is an articlefrom Cleveland Clinic JOM 78(10)675Jet Lag

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1)Working night shifts, taking the red eye flight, - we all know thefeeling. The drive to sleep is related to deprivation and maxes out atabout 40 hours (basically means that if you been up for 40 hours- you

will not be up much longer). It helps with people with sleepdisturbances to have them take a sleep diary and also note whatmedications they take that may affect sleep patterns. Also, many folkshave evolved over their lives to night owls or early birds- it pays toidentify

2)Now on to jet lag. Since our circadian rhythm is slightly more than 24hours- we can always readjust flying westward since we can extendour internal clock.

3)Age has an effect? Well some studies how it is harder to reset theolder you are, other studies show age may be protective.

4)If it is a short visit- it is best to try to stay on your home schedule.5)This wasn't so clear to me- if you are going east- avoid light when

landing- even wear sunglasses. Going the other way- - get bright light.This helps in resetting, but I do not know how practical it is.

6)Yea, drugs- that is the ticket. Melatonin is safe. The studies seem toendorse this, but I couldnt evaluate the quality. Benzos- improve sleepbut studies are lacking. Most studies have been done on agonist like

Zolpidem. Caffeine has been shown to improve wakefulness- is that asurprise or is that a lot of Bull? Red Bull that is.

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7)Shift work is definitely harder for older individuals- see last monthsEMU. Again- here you want to avoid bright light. Short naps seem tohelp as does Modanifil. Four hours of anchor sleep will help as well if

possible. Past articles I have reviewed have made it clear that one dayto recover form a night shift is not enough.

IRON OD. Source for this article is PEC 27(10)9781)Firstly Iron is rarely taken in elemental form- rather as a compound.

However-toxicity is measured by how much elemental iron is ingested.For example- a 325 mg pill of ferrous sulfate has 60 mg of elementaliron, ferrous fumarate- 1067 mg Ferrous Gluconate has 300 mg. Multivitamins generally have up to 20 mg in peds preparations, 50 in adultsand up to 100 mg in prenatal. While 20 mg/kg of Iron can showtoxicity, generally sever toxicity is seen at 60mg/kg. There are fivephases.

2)Phase one: This occurs up to six hours after ingestion and is due to GImucosal damage. There may be vomiting, diarrhea, and GI bleeding.Basically if nothing is seen for six hours; there is little likelihood oftoxicity

3)Phase 2:- six to 24 hours post ingestion. The patients actually feelbetter and the nausea is better. Toxicity is ongoing and be aware that

phase 2 may be absent.

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4)Phase three usually 12- 24 hours post ingestion but can be earlier ifhigh doses are taken. Shock and acidosis. Coagulopathy is not relatedto the liver- rather direct effect of iron on the clotting cascade. Iron is

a negative inotrope so hemodynamic instability occurs.5)Phase four- the livener becomes afflicted. However frank liver failure is

unusual especially at iron levels of less than 1000 micrograms.6)Phase five is recovery with strictures and fistulas possible in any area

of the GI tract. Gastric outlet obstruction is the most common area.7)First aid- - ingestion of more than 40mg/kg of elemental iron needs

the hospital if it is an adult formulation. GI symptoms also go to thehospital. Childrens formulation home observation can be enough. Nocharcoal no emetics. Look good six hours later- send them home.

8)Lab tests other it an iron level are generally not useful. An abdominalfilm may show pill fragments, but if it is negative it means nothing.TIBC is useless

9)Treatment. None in those who ingested less than 20 mg/kg, carbonylor pediatric iron preps, or those who are symptom free for 6 hours.

10) We do not lavage for iron ingestion or for anything for thatmatter. Whole bowel irrigation probably works- evidence is lacking.Give 500 ml/hr to a 9m-6yo, 6-12 y/o/ 1000, 13 and older 2000ml/hr.

11) No cathartics, no EDTA. Bicarb is usually not necessary unlessthere is a serious metabolic acidois. No phosphates even though they

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bind with iron- they also cause hyperphosphatemia. Magnesium andkaexylate do not really work.

12) Desoforaxamine- this does work and is recommended when iron

levels are above 500, or there is metabolic acidosis or clinicalmanifestations of poisoning. We give 50 mg/kg IM every six hours or15mg/kg for one hour IV followed by 125mgqhr. The IV infusion ismore effective. When to stop treatment is a question with no goodanswer. Renal failure, hypotension, yersinia sepsis, ARDS are sideeffects. This treatment can be given in pregnancy.

13) Dialysis will not work. Exchange transfusion worked withplasmaphoresis in a case report. Women speak because they wish tospeak, whereas a man speaks only when he is driven to speech bysomething out side of himself like , for instance he can find any clean

socks Jean Kerr14) Now for the roundtable we have been waiting for on EMS

issues. Sitting around our table- firstly from Bellingham, WashingtonState: Marvin Wayne- a publishing machine and a CPR and EMS guru. Steve Parrillo hails from my home town in Philly and he hasimpressive credentials as well_ Chief, Division of EMS and DisasterMedicine, Einstein Healthcare Network, Philadelphia

Medical Director, Philadelphia University Disaster Medicine andManagement Masters program

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Assoc Prof, Emerg Med, Jefferson Medical College and Phila College ofOsteopathic MedicineLastly we have Keith Wesley whose credentials are

Keith Wesley, MD FACEP is a board certified emergency.also impressive

medicine physician practicing in St. Paul, MN USA. He oversees thethat transports 40,000operation of HealthEast Medical Transportation

ents a year. Dr. Wesley is the former Minnesota and Wisconsin statepatiI am sitting here as well, and while I am not an EMS guy, Imedical director.

have some experience because my father is a lawyer and may have chased:number 1tions. Questionan ambulance or two. Here are the ques

1) How can we train and keep our EMS staff current? How do you assuretheir knowledge base, update their protocols and test procedurecompetency?

1) Let us start out with Marvin:Always a tough topic to answer since it is

so system dependent. For our Urban Rural EMS system we have State

and locally mandated CE requirements at both EMT and Paramedic

Level. For EMTs there is online CME, and active OTEP training. OTEP

is skill based. There is a minimum number of hours per year. The

online CMEincludes testing as well as teaching. For Paramedics there

is both locally mandated monthly training, which now can also be

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accomplished in part online. Paramedics also have annually mandated

intubation requirements. For the first 3 years after certification is one

intubation per month. Either in field or OR. For those beyond the first3 years it is one per quarter. Competency is based on testing and run

reviews by the supervisors and supervising physicians. Some, such as

myself, will go into the field and try to ride on calls with the medics.

2) Steve:There are two groups to consider here the MD/DO medical

directors and the BLS/ALS providers. Physician education is available

in a number of areas, but EMS-specific education is more of a

challenge. Most of the major national meetings include such

education, but in limited quantities. There are many online coursesthese physicians can use. NAEMSP offers an outstanding program

(and it offers the benefit of a resort venue). For medics and EMTs,

resources include local, state and national meetings, but there is no

substitute for regular sessions with the medical leadership. In addition

to the state-mandated yearly updates, medics should get regular

updates from their directors. Refreshers are always welcome, but the

career medic wants to stay on the cutting edge. Ultimately the

Medical Director is the arbiter of who is who is not competent.

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And Keith:Continuing education is critical to quality performance of our

providers. In the USA EMTs and Paramedics are required to attend

continuing education courses to maintain their licensure. For the EMT thatcourse of study is often dictated by the state. For the paramedic it may

have some general outlines for requirement but the content is frequently

approved by the medical director.

Medical directors should be intimately involved in the content of these

continuing education courses. When possible the medical director should

deliver some of the more vital components such as the care of patients

with respiratory distress, chest pain and of course the approach to caringfor cardiac arrest victims. The medical director should have direct

oversight of the educators to ensure consistency of content. At a

minimum medical directors should be present at least annually to observe

providers skills in various psychomotor skills such as patient assessment

and cardiac arrest care.

Maintaining protocols is a constant challenge to the medical director and

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though the science and evidence for change is frequently being updated

protocols should be reviewed and updated on at least a bi-annual basis.

One of the best ways to do this is to involve our providers by creating aprotocol committee that is empowered to make suggestions and track

needed updates.

I (Yosef) will just add that I am impressed that this is so well coordinated

in the USA and that some directors go out into the field to observe

competency. In Israel, the service is so large that I am not sure the CME

requirements are met, but I think the procedure requirements are met.

Next question:

2) The Israelis and Europeans have doctors riding the ambulances-in the USA it is often base station command- please give your opinion onwhich system seems better

Marvin: Im not aware of any convincing data that having a physician or

nurse on a land based ambulance adds much. In fact, there are some

studies that have shown delay in transport when a physician is on board.Most skills that may make a difference can be taught to paramedics.

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Further, the funding structure of EMS in the United States would prohibit

the cost of such a system. Some airmedical programs use nurses as well

as medics and some even MDs, but no data shows much difference.

Steve: There are definite advantages to having physicians ride and

respond assuming those docs are truly trained and prepared. The

biggest advantage is that treatment is brought to patients who might

then not have to be transported to the ED. In light of the ED crowding

crisis in the US, such off-loading would be helpful. However, for most

patients who will need definitive management, prehospital care given by

well trained and competent medics is enough. The physician team cando the rest at the ED or in the OR etc. In a setting in which transport

times are long, a physician on the truck might, for example, allow for

earlier lysis in a stroke situation but that treatment remains

controversial and would likely not be applicable in the US. In the US one

of the biggest issues to consider is the shortage of trained EM physicians.

Assuming the ride-along doc is an EM one, this would further stretch an

already scarce resource.

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Keith:Both systems have their pros and cons. The reality is that in the US

it is simply not financially feasible to have physicians on ambulances.

Therefore we are left with lower paid and often less trained and educatedproviders. However, in the states emergency rooms are often staffed with

board certified and even emergency medicine residency trained

physicians. There currently is no data to suggest that physicians in the

ambulance provide better care for the acutely ill and injured and there is

actually some evidence that advanced life providers to not improve the

mortality and morbidity of patients particularly in the urban environment

where definitive care is only minutes away.

Yosef: Well, in many places in Europe, the manpower problem is dealtwith by having anesthesiologists ride the ambulances. But in Israel,

many physicians are general practitioners who offer little advantage over

paramedics. Just wanted to add that in places with longer transport

times, it may make a difference. In France, the physicians riding the

ambulances do give first aid and often save the apptit an admission or

long ED wait.

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Question number three: Do the ambulance drivers in your system

get driving safety courses? Can an ambulance use sirens at will?can they

get a ticket for traffic violations?Marvin: All emergency vehicle operators have significant safe driver

training and must have annual retraining. This includes all fire based

systems and, I believe, most private services. They are not allowed

indiscriminant use of emergency sound and lights in most States and are

subject to ticketing and fines. If they cause an accident and are at fault

they have liability as does their system.

1. Steve:Driving an emergency vehicle is not like driving a car. In the

US, anyone who drives an ambulance must successfully complete anemergency vehicle operator course (EVOC) or an equivalent. The

course is 100 hours of classroom and actual driving. Among other

issues, students are advised about the appropriate use of lights and

sirens. The literature is clear that there are very few times when L&S

use make an actual difference in outcome. What we do know about

L&S use is that it increases the likelihood of vehicular accident with all

the attendant consequences. Emergency vehicle operators are held to

the same driving regulations as the general population. Run a red

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light, get a ticket. Speed, get a ticket. Do that enough times, lose

your license.

Keith:I

n the US the requirement for driver training is variable anddepends on each states requirements. I personally believe in driver safety

training and promote the use of "black box" technology that monitors and

alerts ambulance drivers to unsafe performance. Because of the litigious

US society the standard of care is that the ambulance driver operates

with "due regard" for the patient and public safety. The use of Lights and

Sirens does not by itself provide the ambulance "right of way" but instead

is meant to alert other drivers of the presence and/or approach of an

emergency vehicle.

In the US ambulance drivers have been ticketed and in fact jailed for

failure to use "due regard" both while responding and transporting a

patient. It is impossible to defend the tragic consequences of a crash that

injures or kills an innocent motorist that crashed into an ambulance

transporting a patient with a non-lifetreatening condition.

Medical directors should develop or approve clear policy for the

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appropriate use of Lights and Sirens both for the response to an

emergency as well as the transport of the patient. There is no credible

evidence that the use of Lights and Sirens improves the care of thepatient during transport. In fact, there is evidence that is may negatively

impact that care by making patient care technically difficult.

Yosef: In many countries- there is no training, but in Israel- lights and

sirens need to be justified.

For EMS roundtablechreiber.Question number four from reader Dr. S-pediatric airway stabilization

ETT vs BVM

Marvin:We do intubate children as well as adults. We use the airway that

is best able to be achieved quickly and safely and provides the best care

for the patient. Supraglottic airways offer both a rescue airway and

alternative airway. We work hard, because of the limited number of peds

airways, to keep skills up with our airway lab.

Steve: Is there anything that scares the career paramedic (or the

seasoned ED physician) more than a child who needs respiratory or

ventilatory support? The question then, is how to best do that. While

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endotracheal intubation provides definitive airway management, it takes

time and most medics have had little experience intubating children

largely because so few need such aggressive care. Bag valve maskventilation will usually provide sufficient support to get the child to a

setting where more toys are available. In much of the US, medics are

not permitted to perform medication-assisted intubation. Additionally,

medics dont have access to fiberoptics or video laryngoscopy. Bottom

line BVM is sufficient most of the time. If there is a question about an

obstructing foreign body, direct laryngoscopy might permit life-saving

removal.

Keith:Airway management is often difficult for the pediatric airway.However, there is no evidence that an ET tube or non-visualized

supraglottic airway is superior to BVM. The vast majority of pediatric

airways can be successfully managed with proper BLS interventions such

as the BVM.

Yosef: I think the main point of Dr. Screiber was that maybe with peds

we need more scoop and run in view that intubation in the field has not

been shown to save lives. I am of the opinion that we need to teach EMS

to use LMA and bougies.

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Next question:Backboards and cervical collars. When and if to use, and

how soon to get off. VL vs DL for intubation. This was also sent in by

one of our readers, I apologize that I do not remember who.Marvin: We are getting away from a use always approach to C Collars.

Data suggests that in some patients we may do more harm than good.

More, in fact, can be said of the back board. It is ONLY a moving device

for patients. More and more we are using a vacuum mattress for

immobilization and transport. No one should be on a back board for any

extended period of time. Use the gurney pad and not the board unless

no other options. On issue of VL vs DL, our published data in Prehospital

Emergency Care clearly shows the benefit. (DL is direct laryngoscopy,video laryngoscopy) Also, with camera capture we have great QM and

teaching material.

Steve: The reader asked about the use of backboards and cervical collars.

Im going to limit the discussion to the latter because more has been

written about them. The standard for prehospital providers is to place

the collar whenever there is any reason by virtue of mechanism of injury

or physical exam to suspect a cervical injury. Unfortunately, most take

that to mean that even awake, alert patients who are physically capable

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of knowing whether or not they have neck pain should still be placed in

the collar based on mechanism alone. The very large NEXUS study

showed that most people without midline tenderness do not have asignificant cervical injury. (Reader should look over the actual criteria to

clinically clear the cervical spine). Some states now allow medics to make

a decision not to immobilize if the setting is one that rules out a neck

injury. When there is any question the collar goes on. (Reminds me of

the patient who arrived at the ED wearing a collar. Doctor said, We

have to get an X-ray of your neck. Why, doc, my neck doesnt hurt?

But you have a collar on. Better X ray the rest of me then. It doesnt

hurt either.)Keith:

Again, there is no evidence to support the use of backboards for spinal

immobilization and in fact there is sufficient evidence that they cause

harm and pain by skin ulceration and failure to support the spine in an

anatomic position. The National Association of EMS Physicians is

currently considering a policy statement promoting the use of backboards

ONLY for extrication then moving the patient directly to the cot as soon as

possible.

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The jury is still out on the use of cervical collars and again because of the

fear of a lawsuit their use continues.

Yosef: Just want to point out the Prehospital Emergency Care has studied

the question if paramedics can clear spines with NEXUS and the answer is

positive

You guys are doing great- let's get to the last question from Dr. Todd

from MD Anderson How about prehospital end of life decision making.

Corita Grudzen'swork from Los Angeles?

Marvin:

An area we teach inadequately and practice even worse. We need moregeneral training for all physicians as well as EMS providers. We also need toeducate the public that miracles are just that miracles and there is a needfor end of life decisions prior to the event. Our State has a POLST programbut it is not as well utilized as it should be.Steve: There are any number of initiatives in the US to try to let

patients die with dignity. The barriers include things like the requirementthat each such patient have in place (and on his/her person) a signed,

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properly executed document. If all is right, the medic can honor thatchoice. However, family members not uncommonly disagree with the choiceor dont understand it. There is an effort to get all states to approve use of

a form that should make the process more standard. The form is called byPennsylvania Orders for Lifetate it is POLSTIn my svarious names.life patient has such a form our-of-Once every endSustaining Treatment.

This formmedics will have a much easier time dealing with this problem.apply outsideapplies wherever the patient goes, whereas the DNR does not

There are also authorities who point out thatthe nursing home or hospital.it is time for us to recognize that there is a time to acknowledge that enoughis enough. Only in the US do we spend so much of our healthcare dollars inthe last few months of life.

Keith:In the US, EMS providers are rarely provided sufficient training andeducation to make these difficult decisions. This is where the role of "on-line" communication with a medical control physician over the radio orphone is vital. While it is vital that patients have the right to determine forthemselves what care is rendered during end-of-live conditions the reality isthat these decisions are often relegated to family members who have called9-1-1 for help. The optimum solution is the use of clearly written physician

orders that are available at the scene of such emergencies.

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Yosef: In Israel, paramedics can discuss this with the family and canpronounce death.I want to thank everyone- this was professional and informative- and great!

Our next roundtable is international EM in another four monthsIn conclusion let's quote one last female- in honor of Rick Bukata- it is oneof his favorite quotes and one of mine as well: It is better to light one candlethan curse the darkness. Eleanor Roosevelt andone more quote of wisdomfrom R. Dovid Kaplan: If at first you do not succeed- then maybe youshouldnt take up skydiving.