Monthly Archives: September 2012

So You Have a Plan Right?

I saw a patient on the Big Island of Hawaii with serious intracranial bleeding on Pradaxa. Now it’s rural here, which means a dearth of specialty care. And so three months ago when his brilliant doctor in a major city on the mainland, switched him to Pradaxa for his atrial fibrillation (so he wouldn’t have to check his INR while he got settled comfortably into his retirement in Hawaii) his fate was sealed.  He arrived at the nearest hospital to him which had no intervention other than Vitamin K.  No platelets, no FFP, no neurosurgeon. Rapid diagnosis and a flight to Oahu for neuro/icu care was still meant several hours of continued bleeding. Things did not go well for him.

After I got home that night I watched the news about BP settling its federal lawsuit and I thought, what do the Deepwater Horizon disaster and Pradaxa have in common?  It seems obvious that any endeavor with a potential for serious risk should have a clear plan to deal with the most likely adverse outcome(s). In the case of offshore drilling, you shouldn’t be looking for oil at 1800 feet below seal level if you don’t have a viable plan to contain an oil spill.  In the case of Pradaxa, you shouldn’t be giving anticoagulants to patients if you don’t have a viable plan for  the most likely adverse outcome, bleeding. It’s really just asking for trouble.

To highlight this problem, the management of an overdose with the new oral anticoagulants was recently published and then discussed on one of my favorite blogs, The Poison Review, and the most notable revelation about these collaborative guidelines is that the best option ten organizations who focus on thrombosis and anticoagulation could come up with was, wait for it, wait for it….SUPPORTIVE CARE.

I understand that anticoagulation in certain patients is a valuable tool. But we all know the rapid spread of highly marketed medications to questionable patient populations is a given, and we already have an effective anticoagulant, it’s called Coumadin. Coumadin is far from perfect and the search for safer, more user-friendly medications is a worthwhile endeavor, but let’s be honest, we’re still far from a perfect solution.

Is Pradaxa safer? Did it show benefit over Coumadin? No. But when you watch the  ads for Pradaxa it sounds like huge benefit. Of course the fine print is that the benefit was found in patients with sub-therapeutic INR.  Maybe it’s not as “convenient” as the newer drugs, but even with reversal agents this medication causes a lot of morbidity, hospitalization, and death. So please explain to me how an expensive drug gets mass marketed before there is a way to appropriately treat the potentially fatal side effects when there is an equally effective drug we can reverse?  Never mind, I know the answer…

The EMBER

(As always, a collection of emergency medicine focused resources for our topic)

Guidelines for reversing overdose of dabigatran (Pradaxa) and other new anticoagulants

Anti-coagulated Patients In The ED – LITFL

Dabigatran (Pradaxa®) Principles and Guidance for the Reversal of Effect and Management of Life Threatening or Major Bleeding

Paucis Verbis: Overanticoagulation and supratherapeutic INR

Anticoagulation Reversal – ERCAST


Evernote Meet Google

 

Maybe it’s a hold-over from my childhood days, but September is the month of organization.  You know, the ritual purchasing of three-ring binders, pencil holders, graph paper, all with the hope and optimism that this year things will stay organized.  Inevitably by the end of the year you’re digging around your overstuffed backpack for that piece of paper with the homework assignment on it.

Now instead of three-ring binders I hoard information online: downloading, tagging, and clipping, all in the vain hope that it will stay organized for some future use. And why not.  I spend a lot of time reading and searching online for emergency medicine information for my particular learning needs. Unfortunately, most of it collects digital dust on my hard drive or cloud – the junk drawers of the digital age.

So here is a great new tool that is actually getting me to use the information I’ve already collected.  Evernote meet Google.  Evernote now allows you to simultaneously search Google and your Evernote folder on any web browser.  Want to review subtle ECG findings suggestive of STEMI?  Type STEMI into Google and it gets you 1,700,000 hits, but now it also gives me 3 notes from my Evernote account.  Since I’ve already clipped these to my account the likelihood that they are valuable to me at the moment I want it is high.

Sure enough clicking on the Evernote icon shows me I have an article from Amal Mattu about high risk ECGs, a review of subtle STEMI patterns by Dr Smith from his ECG blog, and a link to another good online ECG education site.

Wow, my preselected information side by side with the power of Google, all at my fingertips on a web browser.  Finally, I’m ready for school (can I redo fifth grade please)?

 

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