Comments for ercast.org http://blog.ercast.org Emergency medicine podcasts, reviews and curbside consults Mon, 25 May 2015 09:44:27 +0000 hourly 1 Comment on The Subarachnoid Enigma by Scott C http://blog.ercast.org/the-subarachnoid-enigma/#comment-1001 Mon, 25 May 2015 09:44:27 +0000 http://blog.ercast.org/?p=4989#comment-1001 Great podcast guys. Gotta agree with Sid though -6 RBCs is a negative tap. I don’t keep patients for > 12 hours waiting for xanthrochromia, a crappy test and an unnecessary admission. I tap and if I get a clean csf ( < 100-200 rbcs). -- I am done. Blood in csf needs further work up. My trick for getting clear taps is to use my lignocaine needle to suck out lp needle hub prior to collecting csf…
Cheers

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Comment on Scott Weingart on the State of Things by Luke Embley http://blog.ercast.org/scott-weingart-on-the-state-of-things/#comment-1000 Sun, 24 May 2015 03:58:42 +0000 http://blog.ercast.org/?p=5003#comment-1000 Excellent podcast guys. You are hero’s to many and it’s cool to know more about you.

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Comment on Scott Weingart on the State of Things by Rob Orman http://blog.ercast.org/scott-weingart-on-the-state-of-things/#comment-996 Wed, 20 May 2015 20:50:45 +0000 http://blog.ercast.org/?p=5003#comment-996 Hey Mike!
I agree with you 100% (or is it 10%?). It seems like whatever bit of crit care or EM I listen to just before working, comes through the door in the next 12 hours and I am able to apply the knowledge directly to patient care.

Thank you for the kind words.

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Comment on The Subarachnoid Enigma by mjasumback http://blog.ercast.org/the-subarachnoid-enigma/#comment-995 Wed, 20 May 2015 20:44:06 +0000 http://blog.ercast.org/?p=4989#comment-995 I tend to discuss this with my patients. Basically quote the Perry article, advise them of the risks/benefits of LP/no LP. and have them decide. In my practice SAH is a transfer out as no one local does aneurysm anymore. Thus, this is a relatively high stakes game, independent of the risk of SAH complications.

I would suggest, though, that we have become slaves of the medicolegal industry. Reading Joe and YoneAmuka’s comments is telling. We have been forced into believing that this is a “CAN’T MISS” diagnosis and have harmed many more patient’s than we have helped by slavishly doing CT/LP. Listen to Newman’s podcast on this.

1. Aneurysmal SAH is rare (8% in the highest risk cohort, the Perry study)
2. CT is extraordinarily good in the 12 hrs same as 6-12 (ct for other reasons and not EBM, more CYA/Pt Sat)

My practice for traumatic tap or positive LP is CTA. I am told, that a negative CTA after the above, is good enough to DC pt home. Whether true or not, my local Neurosurgeons and consultant neurosurgeons at tertiary centers have both said this.

When I was first in practice, in the days of the 4 vessel angio, I was told that a negative 4v angio= go home and get a repeat in 3 mos to rule out thrombosed aneurysm.

All of this falls apart when you have the dreaded patient:
Bad HA, CT neg, LP positive for RBCs who is one of the 5% of pts with an asymptomatic aneurysm.

All this for a rare disease, because the lawyers (and Stuart Swadron) have agreed that this is “CAN’T MISS”

Mike Jasumback

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Comment on Scott Weingart on the State of Things by mjasumback http://blog.ercast.org/scott-weingart-on-the-state-of-things/#comment-994 Wed, 20 May 2015 20:05:43 +0000 http://blog.ercast.org/?p=5003#comment-994 Well guys I’ve been listening now for nearly 6 years. I like to think my practice is more than 10% better than it otherwise would be because of you two, but I suspect it might not…..

I appreciate Emcrit and ERcast because, I suspect, I’m like you two, This podcast proved that. I too, feel a bit less good about my practice if I don’t listen to a podcast on my way to work. I love ED and Critical Care, I search out good articles to read. I like a good nut brown ale in the winter, etc..

Not everyone is like this.

One thing that you may have missed though is that perhaps just 1 pearl of wisdom may have dropped into someone’s head that made a much greater difference than 10%. We all have holes in our knowledge bases. I think one aspect of FOAMed is that it keeps those holes pretty small. That saves lives.

So take heart, I have no doubt that somewhere along the way you guys dropped a pearl, that someone picked up and saved lives. That far outweighs the 10% average.

To quote Mel- “What you do matters”

Thank you for that.

Mike

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Comment on The Subarachnoid Enigma by Sid W (@brawny dirigible) http://blog.ercast.org/the-subarachnoid-enigma/#comment-991 Thu, 14 May 2015 23:10:44 +0000 http://blog.ercast.org/?p=4989#comment-991 I have been in practice almost 15 years and I recently started using the six hour rule and I’m quite comfortable with it. Obviously there will be outliers but I trust my clinical judgment will steer me off strict inherence to the rule.

I do have to say though that last bit about a patient having six red cells on their LP and being in the 6 to 12 hour range could be a subarachnoid hemorrhage seems dubious. Recent presenters that I have heard including Billy Mallon, q I do have to say though that last bit about a patient having six red cells on their LP and being in the 6 to 12 hour range could be a subarachnoid hemorrhage seems dubious. Recent presenters that I have heard including Billy Mallon have used cut offs of 200. It would be a pretty hard sell to a consultant that a patient with six red cells has a subarachnoid hemorrhage and is not the result of the traumatic tap.

Criticism aside I very much enjoyed the presentation. I have had just 2 negative ct/positive LPs in my career but I’m sure I have given post LP headaches to countless patients as I strive for zero misses. The six hour rule is a welcome addition to my practice.

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Comment on The Subarachnoid Enigma by Daniel McKinney http://blog.ercast.org/the-subarachnoid-enigma/#comment-990 Wed, 13 May 2015 01:46:09 +0000 http://blog.ercast.org/?p=4989#comment-990 I overlooked MP’s post, so my post is some what redundant. It still raises the question, if there is a negative CTA, what is there to do?
Is there a study where negative CTs have been followed by CTAs as oppose to LPs? With so many of our patients on anticoagulants these days, I think this question needs to be answered.

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Comment on The Subarachnoid Enigma by Daniel McKinney http://blog.ercast.org/the-subarachnoid-enigma/#comment-989 Wed, 13 May 2015 01:37:14 +0000 http://blog.ercast.org/?p=4989#comment-989 Great Podcast Rob. What do our neurosurgical friends think of this practice? What is the role of CTA? If we have a positive tap or CT, but a negative CTA, is there any surgical intervention?

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Comment on The Subarachnoid Enigma by Hector Singson (@D0CT0REY) http://blog.ercast.org/the-subarachnoid-enigma/#comment-988 Wed, 13 May 2015 01:17:30 +0000 http://blog.ercast.org/?p=4989#comment-988 SAH with a negative initial CT, if no LP contemplated, at least give the patient the benefit of in-hospital neuro-observation and a repeat CT if and when situation calls for it. Maybe a challenge in terms of convincing different services in as far as referrals and admission, but sticking to your guns and gestalt and index of suspicion may be the one that will save the patient’s life and your life as well. This is a real challenge for us because tolerance for a missed diagnosis is almost zero. Great Podcast, you nailed it though. I hope that the journals stated herein are Open Access.

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Comment on The Subarachnoid Enigma by Rob Orman http://blog.ercast.org/the-subarachnoid-enigma/#comment-987 Mon, 11 May 2015 14:48:47 +0000 http://blog.ercast.org/?p=4989#comment-987 Hi Derek, Thanks for your comment! I have a slightly different (yet similar) take on the Perry data as explained in this video http://blog.ercast.org/explain-it-ct-and-subarachnoid-hemorrhage/

But, more importantly, what is your practice in the 6 hour group? What do you tell patients?

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