As Summarized by Emergency Medicine Update ...
Tuesday, June 26, 2012
Friday, June 22, 2012
Annals of EM Survey: Minor Complaints (the other GOMER)
Ok , I had to. This is something we all wonder about ( I mean ... get ragingly and tirelessly furious about).
These guys surveyed people waiting in the ED for what were determined to be MINOR complaints. The data is interesting and not entirely what I expected:
Annals of Emergency Medicine S235
I was very surprised that 33.4% were actually referred by their PCP.
I am curious if this is because PCP's: 1) Don't like their patients , 2) Are overburdened and this is a form of "referring" 3) Are incompetent or ill-equipped to handle minor problems.
There are systemic failures at the base of this but it is interesting! Knowledge is power.
These guys surveyed people waiting in the ED for what were determined to be MINOR complaints. The data is interesting and not entirely what I expected:
172 Why Do Patients With Minor Complaints Prefer
Emergency Departments Over Primary Care
Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints.
Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP).
Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac.
Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival.
Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office.
We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED.
Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints.
Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP).
Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac.
Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival.
Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office.
We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED.
Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
Volume 58, 4S : October 2011
I was very surprised that 33.4% were actually referred by their PCP.
I am curious if this is because PCP's: 1) Don't like their patients , 2) Are overburdened and this is a form of "referring" 3) Are incompetent or ill-equipped to handle minor problems.
There are systemic failures at the base of this but it is interesting! Knowledge is power.
Thursday, June 21, 2012
Lessons from Telluride Patient Safety Conference
Hey, so to prove that I have not simply been mountain biking, hiking, sun bathing, and breathing fresh mountain air while consuming locally brewed IPA beer , I decided to make a few blogs on lessons from this excellent conference on patient safety that the department sent me to.
The first thing I wanted to talk about was a little-known law that is increasing throughout the country in state legislation. They are called apology laws. Apology laws come in different forms but all intend to exclude physicians' apologies or other interpreted acceptance of error into liability case testimony. This is an effort to encourage open discussion and apology of error with patients and their families, and reduce the current medical culture's fear of acknowledgement of error. There is growing evidence that these laws alleviate some of this and may actually reduce malpractice suits and thus healthcare costs.
This extraordinarily thorough paper outlines the current evidence and discussion regarding apology laws. New York does not yet have legislation of this type yet, but the more we educate ourselves on it the more push there will be to add this. The following is a quote from the paper:
The first thing I wanted to talk about was a little-known law that is increasing throughout the country in state legislation. They are called apology laws. Apology laws come in different forms but all intend to exclude physicians' apologies or other interpreted acceptance of error into liability case testimony. This is an effort to encourage open discussion and apology of error with patients and their families, and reduce the current medical culture's fear of acknowledgement of error. There is growing evidence that these laws alleviate some of this and may actually reduce malpractice suits and thus healthcare costs.
This extraordinarily thorough paper outlines the current evidence and discussion regarding apology laws. New York does not yet have legislation of this type yet, but the more we educate ourselves on it the more push there will be to add this. The following is a quote from the paper:
"Most patients and families who file a legal action report feeling angry, bitter, betrayed, or
humiliated. In cases where explanations were given, patients and family report feeling
dissatisfied—that the explanation was unclear, inaccurate, or sparse—even though 40% felt like
the explanations were given sympathetically. Most were informed of the error by hospital
administration in 70% of cases, and by the doctor in less than 10% of cases. This leaves one to
wonder whether a doctor’s direct acknowledgment and explanation of the error would have
changed the patient’s willingness to sue. "
Monday, June 4, 2012
Annals: Hydroxycobalamin , more evidence that it is the SHIT!
Check out this animal study in the Annals. It appears we should start throwing away our Thiosulfate:
Study objective
We compare the efficacy of hydroxocobalamin to sodium thiosulfate to reverse the depressive effects on mean arterial pressure in a swine model of acute cyanide toxicity and gain a better understanding of the mechanism of action of the hydroxocobalamin in reversal of the toxicity.
Methods
Swine were intubated, anesthetized, and instrumented with central arterial and venous lines and a pulmonary artery catheter. Animals (n=36) were randomly assigned to one of 3 groups: hydroxocobalamin alone (150 mg/kg), sodium thiosulfate alone (413 mg/kg), or hydroxocobalamin (150 mg/kg)+sodium thiosulfate (413 mg/kg) and monitored for 60 minutes after the start of antidotal infusion. Cyanide was infused until severe hypotension developed, defined as blood pressure 50% of baseline mean arterial pressure. Repeated-measures ANOVA was used to determine statistically significant changes between groups over time.
Results
Time to hypotension (25, 28, and 33 minutes), cyanide dose at hypotension (4.7, 5.0, and 5.6 mg/kg), and mean cyanide blood levels (3.2, 3.7, and 3.8 μg/mL) and lactate levels (7, 8.2, 8.3 and mmol/L) were similar. All 12 animals in the sodium thiosulfate group died compared with 2 of 12 in the hydroxocobalamin/sodium thiosulfate group and 1 of 12 in hydroxocobalamin group. No statistically significant differences were detected between the hydroxocobalamin and hydroxocobalamin/sodium thiosulfate groups for carbon monoxide, mean arterial pressure, cyanide levels, or mortality at 60 minutes. Lactate level (2.6 versus 2.1 mmol/L), pH (7.44 versus 7.42), and bicarbonate level (25 versus 26 mEq/L) at 60 minutes were also similar between groups.
Conclusion
Sodium thiosulfate failed to reverse cyanide-induced shock in our swine model of severe cyanide toxicity. Further, sodium thiosulfate was not found to be effective when added to hydroxocobalamin in the treatment of cyanide-induced shock. Hydroxocobalamin alone was again found to be effective for severe cyanide toxicity.
Wound Care ... Take-Home Points From Tintinalli
Hey guys, anyone else annoyed at the lengthy Rosen's chapters? Remember we still have access to Tintinalli's for FREE online @ AccessEmergencyMedicine.com (login: nymh, pass: medicine). Sift through it at your leisure on your iPad instead of lugging the fat text around.
Here are what I think are some cool take-home points from the chapter on wound care:
#1 Important hx questions: blunt vs. sharp?, occupation & handedness? chronic med conditions? self-attempted wound care @ home & time elapsed until initial cleansing? hx of keloid?
#2 For adults: Ask if they feel a foreign body! Those who feel they do are much more likely to have a foreign body in the wound --> LR = 2.49 vs LR = 0.69
#3 Dirty wounds --> axilla, perineum, toe webs, intertriginous areas have *millions of bacteria per sq CM
#4 Finger Lac: finger tourniquets OK if less than 30 min, you CAN use lido with EPI for digital blocks/local!
#5 Sterility in wound care has no evidence for preventing infection! Use common-sense cleanliness.
#6 A "Bleeder" , if it is a small superficial vessel can be compressed using horizontal mattress or figure eight suture seen in the image above.
#7 Ultrasound can detect foreign bodies if they are hyperechoic *look for shadowing.
#8 You can use chlorhexidine/betadine AROUND the wound to clean the skin, but do not let it get in the wound or near edges as it impairs healing.
#9 Irrigation: a) do not SOAK
b) Low pressure = 0.5 psi (for delicate tissue e.g. eyelid, or uncontaminated wound)
c) high pressure = 7 psi for most wounds * 50ml syringe w/ 18G catheter = 20psi
d) Volume = 60mL per cm of wound, OR just remember 200mL's total for typical
e) USE STERILE SALINE (least toxic)
#10 Abx: Debris or feces, bites, or wounds in avascular areas ** GIVE
Human bites (anywhere) and mammal bites to the hands: give amox/clavulanate to cover
Pasteurella and Eikenella
Fresh water wounds or puncture through rubber/sneaker = cover pseudomonas
Duration of abc: 3-5 d for non-bite , 5-7 d for bites
Here are what I think are some cool take-home points from the chapter on wound care:
#1 Important hx questions: blunt vs. sharp?, occupation & handedness? chronic med conditions? self-attempted wound care @ home & time elapsed until initial cleansing? hx of keloid?
#2 For adults: Ask if they feel a foreign body! Those who feel they do are much more likely to have a foreign body in the wound --> LR = 2.49 vs LR = 0.69
#3 Dirty wounds --> axilla, perineum, toe webs, intertriginous areas have *millions of bacteria per sq CM
#4 Finger Lac: finger tourniquets OK if less than 30 min, you CAN use lido with EPI for digital blocks/local!
#5 Sterility in wound care has no evidence for preventing infection! Use common-sense cleanliness.
#7 Ultrasound can detect foreign bodies if they are hyperechoic *look for shadowing.
#8 You can use chlorhexidine/betadine AROUND the wound to clean the skin, but do not let it get in the wound or near edges as it impairs healing.
#9 Irrigation: a) do not SOAK
b) Low pressure = 0.5 psi (for delicate tissue e.g. eyelid, or uncontaminated wound)
c) high pressure = 7 psi for most wounds * 50ml syringe w/ 18G catheter = 20psi
d) Volume = 60mL per cm of wound, OR just remember 200mL's total for typical
e) USE STERILE SALINE (least toxic)
#10 Abx: Debris or feces, bites, or wounds in avascular areas ** GIVE
Human bites (anywhere) and mammal bites to the hands: give amox/clavulanate to cover
Pasteurella and Eikenella
Fresh water wounds or puncture through rubber/sneaker = cover pseudomonas
Duration of abc: 3-5 d for non-bite , 5-7 d for bites
Friday, June 1, 2012
EMU: Crazy Israeli EM Doc
Guys , this crazy EM doc from Israel scours the new literature and with significant bias (thanks to experience and wisdom) interprets the significance of these studies for our practice. Check out this months:
Priapism: when thinking about grandpa's nose hair won't help
Things we get hot and bothered (and sued) over in EM are usually things that cause loss of "life and limb" but I think erectile function should be included in the mantra. To some people, that is life. And to other lucky men, it is equivalent in size to a limb.
So, for those who missed my morning report lecture (or were sleeping). Here is a video of how to perform the priapism reduction from a great site that has many videos of commonly performed procedures, EM Procedures. Much thanks to @mdaware for the video!
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