Category Archives: Education

Who are the stewards of healthcare?

Economist-Healthcare-Spending-Waste-Chart

I met a father yesterday in our ED who didn’t want antibiotics for his child’s otitis media.  He had read that a wait and see approach with appropriate analgesia might be a better option, and I was reminded that better stewardship of our healthcare is everyone’s concern.  It made me so happy to see a parent making such an informed choice, rather than thinking to myself (as I sometimes do) about how bad my Press Gainey score was going to be for being “the idiot doctor who didn’t want to give my child antibiotics for an ear infection”.

Our healthcare system is like recycling, carbon emissions or government spending: everyone agrees we should do more with less and be better stewards in theory, but when it comes to practice it’s always someone else’s problem. Is it because the system is so large we don’t feel that our actions matter, or do we feel entitled to use the resources we have, even if they offer no clear benefit to our patients? I don’t know the answer to this, but I do know that I still do unnecessary tests everyday in the emergency department.  Some are because of my concerns over missing disease in low risk patients, some are because I’m following “standard of care” or “best practice” based on poor evidence, some are because specialists want them or won’t admit or see the patient without them, sometimes its the end of my shift and it’s the path of least resistance.

The list of why unnecessary testing occurs is long and the vigilance required to stay on course and do what I think is right for each individual patient and the healthcare system as a whole is enormous.  In fact I would say a large percentage of my education time and practice is devoted to this one task.  The difficulty is in finding the support and resources to continue the process of informed and judicious use of medical resources against the onslaught of demands made by an avaricious, RVU/procedure driven, and risk averse healthcare industry.

The New York Times posted on a great resource for both patients and doctors that I believe is worth mentioning.  It is a list of the most commonly overused tests in seventeen different medical specialities.  Emergency Medicine is not one of the specialties listed (although it should be), however there are many emergency department relevant tests listed among the various specialty lists. I find this resource particularly helpful in stemming the tide of what other specialists ask of me in my Emergency Department (like PPI for GI bleed or pre-op echoes in cardiac patients) and in making decisions for why I’m admitting a patient.  If my major reason is an expedited workup with one of these unnecessary tests then perhaps I will think twice.

For example here are the top five recommended DON’Ts from the American College of Radiology:

1. Don’t do imaging for uncomplicated headache.

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.

5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

The other seventeen lists are just as good and have a great deal of information relevant to our daily practice.  Of course no list trumps clinical judgement.  The environment we work in, the prevalence of a certain disease in our community, the quality of our tests, and our testing threshold should ultimately determine what we order and what we don’t, but having the support of other specialty societies to NOT do tests is a welcome resource. Along with sites like The NNT and EMLITofNOTE it is another tool to continue improving our daily practice.

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Case Reports from the ED

The EMBER Project.002

Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),

Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday:  a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors.  It’s uncommon, but not a complete zebra.  The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.

The EMBER Project.003

The EMBER: as always, a collection of interesting information about this topic from around the web.

Paget–Schroetter disease – Wikipedia

First rib resection for Paget-Schroetter Syndrome – YouTube

Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) – Up To Date

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Postcards from the ED

Upper Extremity Hematoma

I was going to use this post to talk about potential spaces in the body until I made the mistake of mentioning it to a surgical friend of mine (yes, I have them) who got all upset that I was really talking about a compartment and not a potential space (apparently I’ve been inappropriately mixing anatomical spaces my entire career). While the definition of a compartment versus a potential space is still debated hotly among anatomy nerds (yes I called you a nerd), for an EP there’s nothing like a dramatic case to remind you that not all potential spaces (or compartments or whatever, hey will you relax please?) are created equal.The elderly and morbidly obese often have a lot more “potential” to extravasate into these spaces.

In the case pictured here, a minor fall in a small woman with abundant loose adipose tissue in her arms led to substantial blood loss before spontaneously rupturing through the skin. She arrived to the ED in class III hemorrhagic shock.

So I guess if you want to be clear about it, old people on Coumadin have a lot of “potential” to bleed copiously into what seem like rather small compartments.  Okay there, does that make you happy?  I know it does.

If you would like to review the difference between a compartment and a potential space here is a mind-numbing review for you. Anatomical spaces: a review. Newell RL. Anatomy Unit, School of Biosciences, Cardiff University, UK. Newell@cardiff.ac.uk

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Postcards from the ED

The EMBER: Here is a nice blogpost from someone who went through the experience.  Sometimes a well told patient story is better than any textbook.

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A Pitbull of the marine ecosystem, or just misunderstood?

Emergency Medicine is vast. Like a New York foodie on a restaurant binge, you could eat out every night and never come close to encompassing it all.  One of the techniques I’ve learned over time to accommodate this gluttony of knowledge is to find general principles that I can apply across a wide range of clinical presentations–ones that I can fall back on say when starting work in a new geographic location with unfamiliar local disease entities.

Take my first Moray Eel bite for example.  A Hilo fisherman diving on a local reef tried to reach in and get the fish he had just speared and found an eel on the other end who latched on to his hand and caused a wound similar to the picture shown below.

Now it’s safe to say in Manhattan that this is not a common chief complaint. But hey, its trauma, and it’s an animal bite, and I do this stuff all the time right?  While the general principles of treating mammalian bites certainly gets me 90% of the way on this one, I have to say I’d never quite seen a wound like this, and the issue of marine flora did make me take pause, so I’ve decided to do a quick review of the topic.

For my Aussie friends and other coastal dwellers with a reef for a back yard this post will not be news, but I found this information fascinating, and since I will no doubt be seeing more of these injuries, now’s as good a time as any to add that extra 10% to my knowledge base.

Classic Presentation of an Eel Bite to the Hand

There isn’t a lot of high quality evidence-based literature on the management of eel bites, and much of what I did review seems reminiscent of the controversies surrounding other mammalian bites (primary closure versus no closure, antibiotic prophylaxis, etc).

Fortunately, I was able to talk with Craig Thomas, an Emergency Physician in Hawaii and author of, “All Stings Considered: First Aid and Medical Treatment of Hawaii’s Marine Injuries“, and he has provided me with some useful pearls for this post.  There are also some interesting distinctions unique to marine life, and some fun facts about eels themselves that are worth mentioning.

“Something about the usual guidebook description of Hawaiian species of moray eel “Maximum size 4.5 feet” seems to be wrong here.” – Matt Standal

First, should your eel bite victim manage to kill the creature that attacked him or her, and try to present it as payment to you, I’ve learned it’s generally not recommended to eat these types of eels due to the reef fish they feed on, and the potentially high levels of Ciguatera toxin often found in their flesh.

Some ancient romans apparently found a creative way around this issue by populating salt water pools with eels and feeding their slaves to the hungry critters (who presumably had low levels of Ciguatera toxin, or really what would be the point) and according to the roman Pliny, eels tasted best when fattened on human flesh.

Needless to say this ingenious form of reverse aquaculture is unlikely to take off in the 21st century, and while it is probably more fiction than fact, it does point out the long historical relationship humans have with these creatures, and the primordial fear they engender.  Which leads us nicely into the unique mechanism of the eel bite.

Eels have some interesting physical characteristics. First their teeth are cat-like fangs, but unlike the puncture wounds of cats, eel bites tend to have a slashed appearance as noted in the first image.  As Craig puts it, ” Nobody I’ve encountered has ever been cool enough to hold still after an eel clamps onto their hand.”

Theoretically if you could stay calm long enough, the eel (being a fish who needs to push water through its mouth past its gills) will eventually need to open its mouth to breathe.  But when a creature dating back to the Pleistocene age attacks you (as he very likely attacked your small furry ancestors who were crawling around in tidal pools looking for food) your response is definitely from that primitive part of the brain that really doesn’t give a crap about anything but getting your hand back. So unless you’re Neo and can achieve a Matrix level of calm, waiting the eel out may be almost impossible. (PS if you can verify that you’ve managed this feat then you are definitely “the one” and need to reveal yourself).

So most of the slash pattern of the wound likely comes from whipping one’s arm around until the eel is ripped off the end of your hand, and these lacerations are often deep, and are at risk for nerve, deep fascia, vascular, and tendon injuries,

The sometimes vicious appearance of these wounds has also led to the idea that marine eels are pitbull-like creatures who never let go.  Craig notes, “the canard of the “bulldog moray” that requires decapitation for removal appears to be a macho diver’s hallucination.”

Another interesting thing about eels is they have a second set of pharyngeal jaws that latches on to its prey and moves it into their stomachs.  This adaptation, straight out of a Ridley Scott movie, is designed to overcome the eel’s inability to create sufficient negative pressure with its mouth to draw in its prey, and is possibly another reason for the slashing nature of the wound as it attempts to stick your finger(s) down its throat.

The eel’s teeth can often leave themselves deeply embedded in tissue.  Fortunately they are easily visible on x-ray.

All these lacerations are contaminated and so potentially at risk from both the usual skin flora, but also marine organisms such as Vibrio species.  Wound closure is acceptable in the right circumstances, particularly for cosmetic concerns on the face, and everyone should get their lifesaving tetanus update.

Whether to give prophylactic antibiotics in these cases appears to suffer from the same poor data, referral bias, and fear-based expert opinion that land mammal bites have. A minority will develop an indolent infection that will need antibiotics, and a rare few will develop a fulminant infection.  On land, we don’t give everyone who scraps their knee or has an animal bite prophylactic antibiotics, and I don’t see any literature that adding the average marine environment to a scrap or cut warrants up front antibiotic mega-guns either.  My guess is fisherman have been getting cuts and bites daily all over the world and very few of them die of septicemia 8-24 hours later.

That being said, the ocean has plenty of bacteria, the five most notable for disease being: Aeromonas species, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Vibrio vulnificus, and Mycobacterium marinum.  I found one paper that cultured a predominance of Pseudomonas and Vibrio species from the mouths of a few captive Moray eels, and there is enough case based literature to strike fear into any litigation wary emergency physician.

Vibrio sp. appears to have the most potential for fulminant disease and septicemia, and most of the the concern for Vibrio species in wounds cites surveillance based literature for outbreaks in recreational waters, from the ingestion of Vibrio from tainted seafood (which are the majority of Vibrio cases), or wound infections related to aquaculture workers who were exposed daily to high levels of bacteria and cut themselves frequently while handling fish.

These populations seem like a poor comparison to our group of single bites in a healthy person swimming in the open ocean who then comes to the emergency department and gets good wound care.

I would tend towards antibiotic prophylaxis if the location of the marine environment was known to be  particularly dirty or contaminated beyond the average seawater, if the wound was more extensive or particularly deep, or it involved a deep puncture wound that I couldn’t irrigate adequately.  Certainly injuries that need to go to the operating room for debridement or deep hand, wrist or foot injuries are another reason for considering antibiotic prophylaxis, particularly if the wound has potential to enter the tendon sheaths or deeper planes of tissue.

An immunocompromised patient, one with haemochromatosis, diabetes, or severe liver disease might derive greater benefit from antibiotic prophylaxis, but I think overall the risk/benefit of prophylactic antibiotics is a fluid line with no clear boundary, so it deserves a full discussion with your patient given the lack of definitive evidence.

Summary

  • They may look like snakes but they’re fish, envenomations are not a big concern
  • Take radiographs to exclude teeth or other foreign bodies embedded in the wound
  • Closure is okay in the right wound, particularly if cosmesis is a concern.
  • Good irrigation and wound care is likely the most important factor to reduce infection.
  • Prophylactic antibiotics are a discussion to have with your patient, but has no good evidence for the average injury
  • Deep injuries of the hands, wrists, feet likely warrant antibiotic prophylaxis
  • Consider antibiotics in the immunocompromised (HIV, transplants,steroids, etc), diabetic, hemachromatosis, or liver disease patients.
  • If antibiotics are given it should include coverage for Vibrio sp. and Pseudomonas.
  • Finally, don’t go sticking your hands in places they don’t belong.

If anyone else out there has lots of experience with marine bites, and has some pearls on this topic or good literature to reference please send it my way.

MacKenzie State Park, Big Island, Hawaii

References

The emergency management of moray eel bites. Erickson T, Vanden Hoek TL, Kuritza A, Leiken JB. Ann Emerg Med. 1992 Feb;21(2):212-6.
Source Toxikon Consortium, Section of Clinical Toxicology, Cook County Hospital and Medical Center, Chicago, Illinois.

Moray eel attack in the tropics: a case report and review of the literature. Riordan C, Hussain M, McCann J. Wilderness Environ Med. 2004 Fall;15(3):194-7.
Department of Plastic and Reconstructive Surgery, St James’s Hospital, Dublin, Ireland. CRiordan@rcsi.ie

Goldfrank’s Toxicologic Emergencies, Ninth Edition. Lewis Nelson, Neal Lewin, Mary Ann Howland, Robert Hoffman, Lewis Goldfrank, Neal Flomenbaum. Chapter 116. pp 1629-1640. Author D. Eric Bush, July 2010

Soft tissue infections following water exposure, Larry M Baddour, MD, FIDSA, UpToDate, Literature review current through: Jun 2012. | This topic last updated: Nov 5, 2010.

Vibrio vulnificus infections, UpToDate, Author J Glenn Morris, Jr, MD, MPH&TM, Literature review current through: Jun 2012. | This topic last updated: Jun 19, 2012.

Marine bacteria complicating seawater near-drowning and marine wounds: A hypothesis, MD J.K. Sims, MICT Philip I. Enomoto, MD Richard I. Frankel, MD Livingston M.F. Wong, Annals of Emergency Medicine, Volume 12, Issue 4 , Pages 212-216, April 1983

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Notecards in Verse

Inspiration comes from the strangest places.  Yes, I studied English and Philosophy as an undergrad, but I wouldn’t have considered iambic pentameter as a tool for EM education.  Then again, if you asked me whether I preferred a mnemonic to a good limerick for remembering important information I would definitely take the limerick.

Then I stumbled upon a beautifully creative new app from Doormouse mfg, that recreates the beauty and imperfections of an old-fashioned Remington on your iPhone.  Go to their website and check out the creativity of some of the cards in their gallery. Here are some of my favorites to give you an idea of how creative people can be if given the tools to play with.

Once I bought the app for myself, I was addicted, and couldn’t put it down.  I started sending type-writer notes on the app’s “high quality card stock” to people, and was amazed at the responses and positive comments I received.  There is something elusive and fascinating about what sticks in our brains and what passes through unnoticed.

Why my next thought was Emergency Medicine notecards made in this fashion deserve to be in verse I can’t explain. But here we are. This card is based on a study by K. Inaba & Co about chest tube size in trauma.

So here’s the deal.  Each card embodies some key concept from a recent paper in the EM literature I’ve read.  Usually, it will be in verse, but not always (now that I’m a temperamental artist a can’t be bound by such rules)  Click on the card and go to my shared Evernote folder where the reference literature from which the questionable gobbet of educational doggerel was created a gallery of similar cards are available.  I’ll keep adding them as long as the Bard continues to inspire.

Type written cards in verse may not be the answer to all your learning needs, and if you recite them on rounds you may get odd looks, but you can be comforted by the fact that any step closer to the company of William or e.e cummings, and away from Powerpoint is a good one.

PS. if you want to try your hand at a few of these cards yourself just download the app, email your cards to me, and I’ll add them to the collection.  I’m sure a “Selected Works of Poetry in Emergency Medicine” is just a few lyrical verses away.


The EMBER Project’s Education Manifesto – An Introduction

An underground handbook for surviving and thriving on your shifts as an EP

BPP - Oakland 1969

There is a knowledge gap in Emergency Medicine.  It lies within the difference between the way we teach and the way we learn.  Bridging this gap is the EMBER Project’s educational manifesto of sorts.  It starts with the belief that our continuing education as Emergency Physicians should not be an endless continuation of the traditional didactics we’ve become accustomed to in our formal training as physicians. Instead it should be a more complete and thoughtful examination of what makes us successful in our daily EM practice.

Over time we become suffused with a host of accumulated skills, knowledge, wisdom, tools, and relationships, and we develop conscious and unconscious strategies for success in the emergency department. Sadly, most of this knowledge is not recognized by us or even taught to new physicians, and falls into what I like to call the “crash and burn” school of medical education.

Perhaps because we have had to learn much of it by personal experience, we have difficulty recognizing its central importance in our development as good physicians – much less being able to describe how we became proficient in these areas to others. Teaching is a skill.  We learn by watching others.  I learned how to teach ECG interpretation by being taught by someone else, but how do you teach skills that have never been taught to you?

The second tenet of the manifesto is that physician well-being and patient care are inextricable.  Success in Emergency Medicine starts with accepting that our physical and emotional resources are finite, and that the practice of Emergency Medicine is challenging. For generations I believe that publicly acknowledging our limits and the fear that we will be seen as lazy have been conflated in our profession.  The stereotype of the tireless physician and the fall out from this impossible ideal still haunts us.

We have limits, rather than ignore them, we must learn to minimize the impact  of those things which are a drain on us, and maximize the supportive resources we have around us.  Doing this well is part of becoming an efficient practitioner of the EM art, and is essential to longevity and well-being in our profession.

The Smooth Sailing series takes both of these concepts to heart.  It is a re-examination of our development as Emergency Physicians from a personal well-being perspective, in order to define the strategies that help us develop a sustainable career of continued growth, improve how we care for our patients, and getting you home at the end of hard shifts happy and healthy.

I’m excited to begin exploring what makes us successful and healthy emergency physicians in this series.  I hope you find it as useful and interesting as I do, and that you will share your insights and comments with me along the way.  Perhaps in discussing how we acquire these skills they will become part of a more conscious strategy for success that we will be able to pass on and teach to others.  Stay tuned, the first chapter in this series is coming very soon.  In the meantime please check out the last Smooth Sailing post to get an idea of where we’re headed.


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