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The Changing Paradigm of VTE Care

The EMBER Project is having a good day. Despite the cold and snow on our first day of spring, it’s also the first of what I hope will be many new broadcasts using the Google+ platform.  I’m excited about the potential of adapting this tool for medical education. In an era of specialty care, disease entities intersect with multiple disciplines, and optimal care often requires a collaborative approach.

Venous Thromboembolism is one of those diseases that crosses most specialty boundaries. I was lucky enough to get Dr Akhilesh Sista to talk about the changing paradigm of VTE management, and to answer my questions about novel oral anticoagulants, endovascular interventions for post-thrombotic syndrome, and who needs a hematology referral. There are lots of great pearls in this talk. You can view it from the Youtube link above or here on the Event page which will give you the show note links to other great bundled educational material.

The EMBER Project reflects my interest in technology’s ability to enhance the culture of learning and expand our conception of a community of medical educators. Blogs, podcasts, and other social media platforms continue to break down traditional institutional and geographic boundaries, and Google broadcast is another tool that’s especially suited for multi-disciplinary discussions on common disease entities when a team-based approach that does away with traditional specialty care boundaries just makes sense. I’m optimistic we are working towards a time when there is no “upstairs care” or “downstairs care” only good care everywhere.

I hope you enjoy this first broadcast. Please forgive any technical flaws as I work out some of the kinks. Thanks again to Dr. Sista for being such a good sport!


Why is the CDC Still Selling Tamiflu?

In a recent post I asked,” Who are the Stewards of Healthcare?” The CDC comes to mind. Its roll to protect the public from diseases both new and old make it an important pillar of our public health system. The CDC was certainly trying to fulfill its role last week when it notified us about emerging concerns that this years flu vaccine might have reduced efficacy due to antigenic drift. Despite this news, the vaccine may still have some efficacy and likely remains a useful tool in the prevention of influenza and its complications.

This CDC update unfortunately also came with a marketing plug that couldn’t have made the makers of Tamiflu more ecstatic:

Because of the detection of these drifted influenza A (H3N2) viruses, this CDC Health Advisory is being issued to re-emphasize the importance of the use of neuraminidase inhibitor antiviral medications when indicated for treatment and prevention of influenza, — CDC advisory 12/4/14

Apparently, the CDC felt this was a wonderful opportunity to throw its weight behind a dubious class of drugs, and does not feel obliged to protect the public or precious healthcare dollars from unscrupulous drug companies. If you go to the CDC website it seems that despite all evidence to the contrary, antivirals to treat flu should be taken early and often by almost everyone.

“Can flu be treated” they ask? The answer is YES. Who should take it? If your young, your old, your really sick or you just want to feel better, then take it. Of course the page is careful worded, to avoid criticism, but the implication is clear: if your a doctor  prescribe this drug; if your a patient ask for it. If you don’t you’re not following standard of care. Many doctors who read this, will hear “give it to your patients, come on what’s the harm, and if you don’t, then won’t you feel terrible when you realize it’s your fault Mrs Smith’s grandmother died because she didn’t get the Tamiflu?” This type of powerful marketing is what continues to make Tamiflu a multimillion dollar bonanza for its manufacturer.

Yet this flies in the face of everything we know about the drug. Current evidence shows it is not preventing disease, or saving lives, or even preventing complications of the disease. In fact some of the evidence is still being hidden by the drug company who makes Tamiflu, and unpublished negative studies that the company hid for years had be forced into the open.

You expect drug companies to aggressively market their wares, but the CDC is entrusted to hold the public interest above all things. Given the recent FDA furor over Zohydro and its approval of this potentially harmful drug (against the advice of even of its own independent advisory panel) it makes you wonder if now the CDC can also be trusted when it comes to its drug approval process.

Endorsing drugs like Tamiflu with no strong evidence of benefit, drains the system of critical resources and fills doctor’s offices and ERs with patients who have an expectation of getting ‘the Tamiflu prescription” –while they inadvertently spread the virus around to others — it undermines public trust in an important institution, and reenforces the idea that marketing and corporate influence come before public health and safety.

What can we do? Hospitals and doctors should be taking the lead on upholding the public trust if the CDC won’t. Talk to your peers, review the evidence, and define a department or hospital policy. Give doctors support to do what they think is the right thing based on the evidence, not on CDC recommendations. Most importantly talk to your patients so that they can make informed decisions.

The Cochrane Collaboration

Bottom Line

  • Reduced mortality: NO
  • Prevents hospitalizations: NO
  • Makes people feel better faster: maybe slightly, but trade of off is about an equal number of bad side-effects (fewer days with fever and mylagias more with nausea and vomiting)
  • Helps high risk or sicker people: NO
  • Industry sponsored research: YES
  • Negative research results were hidden or suppressed: YES
  • Drug has been aggressively marketed for everything from the flu to bioterrorism preparedness, wasting millions of healthcare dollars with no proven benefit: YES

Surgical Airway Summary

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Our online walkabout on the emergency surgical airway is coming to an end. I hope you’ve found this helpful, I know I enjoyed doing it. The emergent cricothyroidotomy presents many educational challenges. It is a high stakes, low-frequency procedure performed in the stressful failed airway situation, where time is not on your side.

Preparing yourself for this scenario requires several key technical and non-technical skills outlined in summary here:

  • A working knowledge of airway anatomy and the confidence to quickly identify important anatomical landmarks.
  • Familiarity with the necessary procedural skills – ideally practiced and reviewed in cadaver as well as sim labs so that the muscle memory is there when you need it.
  • Situational awareness: a term that encompasses the logistical, emotional and psychological skills necessary to take appropriate and effective action. In this case it is defined by how effectively you can identify the failed airway and move through the failed airway algorithm in order to put scalpel to skin. It includes the recognition of normalcy bias and focus lock and the danger of repetitive attempts at laryngoscopy to the hypoxic patient,

This exercise is not a substitute for good clinical training, rather it is designed to highlight key concepts by drawing together disparate online resources into a coherent and educational narrative. As the name EMBER Project (EM Bundles & Education Research) suggests, our goal is to provide bundles of educational material and to discover innovative ways to bring it to you. This time. the entire bundle of resources presented over the last couple of weeks, along with commentary and opinions from other physicians and experts will be up on the EMBER Project’s Facebook page and on Storify today for review – and for future reference. Please join the conversation and add your insight. Until then, may the airway be ever in your favor!

 

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May the Airway be Ever in Your Favor!

May the Airway be Ever In Your Favor

May the Airway be Ever In Your Favor

Presentation for the 2014 Airway Course @NYP

This year I’m giving the lecture on emergency cricothyrotomy at our annual airway course. This is a relatively simple procedure, but it’s mastery presents several training challenges. Beyond knowledge of relevant anatomy, and familiarity with a rarely performed procedure, this low frequency event almost always occurs in the high stress/high stakes environment of the failed airway.

Success in this environment requires more than knowledge of anatomy, or familiarity with the steps of a procedure: it demands leadership and teamwork, situational awareness, logistical preparedness, and insight into how the mind works in moments of stress. Unless you can move quickly through the failed airway algorithm and arrive at the point where scalpel meets skin then your technical knowledge is useless.

Over the next two weeks the EMBER Project’s daily posts will highlight these technical and non-technical skills related to the surgical airway, and the environment in which it is performed. We will curate some great online resources, and guide you through a multiplicity of concepts to create a clearly demarcated roadmap to master the material. After the course “The EMBER” (a bundle of online resources) will be posted on Storify in a concise format that will offer a permanent reference and future resource for review.

If you’re attending the course, this will be an essential addition to your learning, and will prep your knowledge base for the upcoming sim and cadaver lab work. For others who want a good review, this is a free and open access resource. Before getting started, I want to thank all the great educators and airway experts out there out there, who have taken the time to make their experience and knowledge available to all of us.

The adventure will get started in earnest tomorrow, so get ready for some cricothyrotomy madness by following here, AND on Facebook or Twitter to get the full program. See you at the head of the bed, and may the airway be ever in your favor!

 

 

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C-Spine Clearance (Hawaiian Style)

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After two wonderful years in Hawaii, I’m returning to New York to take up new clinical and educational challenges.  Before I do, I thought it was appropriate to send one last “postcard from the ED”. This one comes from a case that reminded me that when it comes to decision rules, “there are more things in heaven and earth…than are dreamt of in your philosophy.” Here it is:

A 38 year old surfer comes into the ED by private vehicle. He was driven by a friend to get some pain medication for “spraining my neck”. After being hit by a large wave and tossed around he felt a pop and began to notice severe pain in his neck. At first he tried to paddle back out, but the pain forced him to come to the beach.  After about an hour the pain had not improved and he decided he needed some stronger pain medication.

He had no other injuries, no focal neurologic deficits, and had not been drinking. On examination he had no change in his level of consciousness, he had a normal neurologic exam.  The location of his pain was para-spinal located in the upper cervical muscles by the occiput, and he said “his throat hurt”. He was unable and unwilling to rotate his neck in any direction.

Based on NEXUS this patient could have potentially been cleared clinically.  However, having lived in Hawaii for some time, I have learned to respect the power of the ocean. For me any surf related injury is a high risk mechanism until proven otherwise. If you were not to treat this as a high-risk mechanism and were using the Canadian c-spine rule, you would have gotten to the “able to rotate neck” part before slapping that cervical collar back in place, which is what I did.  Below you can see the reformatted image of a C1 fracture. The patient was accepted for transfer to the trauma center, where he was treated and released with no neurologic deficits.

In hindsight I believe the absence of midline tenderness was due to the extreme amount of soft tissue pain he was in, and the muscular splinting of his unstable C1 fracture. To me it could have counted as a distracting injury however I’m not sure I’ve ever considered para-spinal strain as a distracting injury. Maybe it is a flaw in the language, since the word distracting means “taking your attention elsewhere”. This implies that the pain should be somewhere other than the neck.

Other than mechanism, the real red flag for me was his unwillingness to move his neck. In my experience the alert patient with an unstable c-spine fracture DOES NOT want to move!!!  I’ve also come to realize, working in rural community hospitals here in Hawaii, you paradoxically see more of the isolated serious walk in traumas than you do in a major trauma center. Often the rules of tertiary care practice do not translate. Here are some of the key take away points for me in this case.

North Shore Surfing Accident

Postcards from the Emergency Department (Hawaii)

  1. A patient with a mechanism that is unfamiliar to the physician may be overlooked as high risk due to lack of experience with that type of injury.
  2. For obvious reasons clinical decision rules in trauma are designed using a patient pool which is skewed towards common injury patterns. Unusual mechanisms or patterns of injury unique to your clinical environment (in this case surfing) should be treated as potentially outside the scope of these rules.

There has been some recent trauma literature suggesting that these rules don’t apply to trauma activation criteria patients, This was a reminder that they do not always apply to non-trauma activation patients either. We teach these clinical decision rules, but it is imperative that we also teach the inclusion and exclusion criteria used in the studies, the potential flaws in the human application of these rules, and the limitations of all studies to be generalizable to all patients, so that we can better decide if they apply to the patient in our ED at any given moment.

Finally, if you do use the rules I would consider the combination of NEXUS and Canadian algorithm.  Dr Scott Weingart has a compelling argument and a nice diagram showing how the two can work in synergy.  In this case my patient would have also failed to be cleared clinically based on the combined rule.

The EMBER is a small bundle of free open access resources to deepen your knowledge. Thanks to all the educators out there putting time and energy into teaching others.

http://emcrit.org/podcasts/cervical-spine-injuries-i/

http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/

http://hsc.unm.edu/emermed/resident_readings/EDArticles_PDF/Trauma/NEJM_03-%20CAN%20C-Spine%20v%20Nexus.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21610391


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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It’s De-lightful, it’s De-lovely, it’s De-winter?

New STEMI equivalents keep showing up all the time.  What is a STEMI equivalent you ask? For those ECG nerds out there (you know who you are, yes the one’s with the calipers in my ED) it is the rapidly expanding number of ECG patterns, beyond the traditional ST elevations, that suggest an acute coronary occlusion and therefore require emergent revascularization..  Here is one I was unaware of until just recently. Add it to your list.

Photo from Dec 3, 2012

The EMBER:

Dr Smith’s ECG Blog  Back Pain Radiating to the Chest in a man in his 40’s

Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction


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