Comments for ercast.org http://blog.ercast.org Emergency medicine podcasts, reviews and curbside consults Wed, 22 Apr 2015 07:14:35 +0000 hourly 1 http://wordpress.org/?v=4.2.1 Comment on Can fever melt the brain? by mike mhttp://blog.ercast.org/can-fever-melt-the-brain/#comment-976 Wed, 22 Apr 2015 07:14:35 +0000 http://blog.ercast.org/?p=4978#comment-976 thank you…I will definitely be going the spritzer/fan route.

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Comment on Amal Mattu on Low Risk Chest Pain by Rob Ormanhttp://blog.ercast.org/amal-mattu-low-risk-chest-pain/#comment-974 Sat, 18 Apr 2015 21:36:17 +0000 http://blog.ercast.org/?p=4709#comment-974 Hi Pierre, here is the response from Dr. Mattu….

Yes, clinical gestalt is fantastic in an experienced, well-read provider. Not everyone fits into that description, so the HEART score and other scoring systems can certainly help those people that are not as experienced.
I suppose if you have tracked your own personal data and you know you have a low miss rate, then that’s great. But if you haven’t tracked your own data, the HEART and other scoring systems can be used to give you some real numbers.

Back to the risk management issue, which is really the key to why I am talking about this stuff at lectures and on podcasts.
Practically all lawsuits are based on clinical gestalt. If an internationally-known plaintiff expert comes in and says that he/she disagrees with your clinical gestalt, and your gestalt was clearly wrong and that’s why the patient is dead, you’ve got a problem. But by having a scoring system that has been prospectively, externally, internationally validated that says that what you did is reasonable, you are in good position to win the case…or not get sued in the first place.

Almost all of the lawsuits I end up being asked to defend are patients that were deemed low-risk by the emergency physician based on gestalt. There are plenty of physicians out there whose gestalt is not working right. Many of these are not even questionable cases.

If you work in a place where risk mgmt is not an issue, and you are pretty sure that your clinical gestalt is damn good, then you don’t need any of this stuff.

This is primarily a risk mgmt issue.
This is primarily a risk mgmt issue.
This is primarily a risk mgmt issue.

In terms of the outcome of low risk patients sent home, we know that if you use the ADP or the HEART score, the risk is very very low. But those are patients deemed “low risk” based on these scoring systems. I’m guessing the listener is asking the question about the risk of “low risk” patients being sent home if “low risk” was based on gestalt. I don’t know if there’s good data on that, largely because gestalt can vary quite a bit amongst providers.

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Comment on The Constipation Manifesto by Roberthttp://blog.ercast.org/the-constipation-manifesto/#comment-973 Sat, 18 Apr 2015 00:22:13 +0000 http://blog.ercast.org/?p=1160#comment-973 You might need a stool softener, not a laxative. I had oral surgery and was prescribed amoxicillin (antibiotic) and endocet (pain reliever containing acetaminophen and oxycodone). In the patient prescription information for endocet it lists constipation as a possible side effect, and goes on to say “To prevent constipation, eat a diet adequate in fiber, drink plenty of water, and exercise.” I had not had side effects from medication before that I can remember, and unfortunately, I did not read all of this prior to using this medication. After the surgery I became severely constipated.

I had not eaten anything for several days, so when my bowl movements stopped I did not notice. Rarely in my life have I been constipated. Once I started eating again, I became uncomfortable within a few days and realized that I was constipated. I tried prune juice, laxatives such as Ex-Lax, Phillips Milk of Magnesia, SenokotXtra, and a self-administered rectal suppository. Nothing worked. Days were going by and I was becoming extremely uncomfortable and was very close to going to the emergency room for a rectal water enema. I decided to call my doctor (general practitioner) first to ask his advice, but he was on vacation so I spoke to another doctor in the office. I related the story above. Although I was seeking advice on what over the counter medication I should take, I was advised instead to go to the emergency room and have an x-ray because I might have a tumor. Of course, I thought that was ridiculous. I did not suddenly develop a tumor. Although I had not read it, it seemed to me my problem was the result of taking pills for several days while not eating much of anything. Then I called a pharmacist, who then recommended medications that I had already taken. No new ideas there either. Finally I called the oral surgeon who operated on me. This seemed at the time to be an odd question for him, but I was getting desperate.

He immediately said I needed a stool softener and recommended Colace. He said such problems were common in hospitals and this is what patients were often given. I bought it, took it, went for a long walk around the neighborhood and periodically walked around the perimeter of the backyard for 15 minutes at a time, and in 12-18 hours began to have relief. The stool came out in hard compact clay-like nuggets. It was difficult and a bit painful to pass and I squatted in the shower to do it, but once the process started I experienced relief in increments over the next 12 hours.

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Comment on Can fever melt the brain? by PEM Review 1 – April 2015 | PEMgeek.com – Curated paediatric #FOAMed resources from around the webhttp://blog.ercast.org/can-fever-melt-the-brain/#comment-972 Fri, 17 Apr 2015 17:13:55 +0000 http://blog.ercast.org/?p=4978#comment-972 […] ‘CAN FEVER MELT THE BRAIN?‘  A lively discussion on fever in children and neonates with Andy Sloas from PEM ED podcast. […]

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Comment on Can fever melt the brain? by Rob Ormanhttp://blog.ercast.org/can-fever-melt-the-brain/#comment-971 Wed, 15 Apr 2015 15:46:35 +0000 http://blog.ercast.org/?p=4978#comment-971 Hi Mike, Here is the response from Andy Sloas….

If you have no other way to cool the patient, then an ice bath is the recommendation. It’s associated with a greater mortality (but the subset you’d put in an ice bath would have a greater mortality bc they’re really really hot- not sure the ice bath is causal) and it’s impossible to do cardiac monitoring or CPR. Spritzing with warm water in front of a fan (evaporative) cools extremely fast 0.3-0.5 C per minute and decreases the chance of shivering. Shivering is bad in hyperthermia care bc it increases temperature and metabolism.

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Comment on Amal Mattu on Low Risk Chest Pain by Pierre Mikhailhttp://blog.ercast.org/amal-mattu-low-risk-chest-pain/#comment-970 Wed, 15 Apr 2015 14:13:49 +0000 http://blog.ercast.org/?p=4709#comment-970 I always enjoy ERCAST and Dr. Mattu. As a Canadian, I am constantly grateful that I don’t work in an environment where disposition decisions seem to be driven MOST by fear of litigation.

We heard that the HEART Score and one negative troponin portends a 2% risk at 45 days of MACE and that if you add a second troponin at 3 hours that risk decreases to 1%. I am not entirely sure that we know if that number is better than a good clinician using no rule and two markers in the real world. Also, Dr. Mattu stated that this approach has avoided admission in 20% of low risk chest pain patients. Since I (and I would suspect most of my Canadian colleagues) admit close to 0% of LOW RISK chest pain patients, I am not sure that this helps me at all. And what about the harm caused to low risk patients that have downstream testing done? I don’t think we have any evidence that admitting low risk chest pain protects them from anything but I’m pretty certain it is associated with a much higher rate of downstream testing which is not benign.

I’d be interested in knowing what the incidence of clinically relevant bad outcomes are in low risk patients sent home….. in other words, if you are sent home, but return with a more worrisome presentation that clarifies the diagnostic pathway (ie this time you present with ECG changes), is there anything wrong with that? As long as we are not sending people home in large numbers that have actual bad outcomes like death or MIs causing LV dysfunction, maybe it’s ok not to be 100% perfect?

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Comment on Can fever melt the brain? by mike mhttp://blog.ercast.org/can-fever-melt-the-brain/#comment-969 Wed, 15 Apr 2015 08:04:14 +0000 http://blog.ercast.org/?p=4978#comment-969 Thanks for the review.

I was puzzled by one comment, which was also made on the emrap episode involving medical management hyperthermia during marathons. On both podcasts the suggestion of ice bath immersion is followed by advice never to spritz cold water on the patient. Do people in ice baths not shiver?

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Comment on Can fever melt the brain? by Rob Ormanhttp://blog.ercast.org/can-fever-melt-the-brain/#comment-965 Thu, 09 Apr 2015 14:22:22 +0000 http://blog.ercast.org/?p=4978#comment-965 Oh yes! Men in Blazers and The Total Soccer Show are my two favorites. And my hope for this season’s EPL is that Burnley not get relegated. Of course, that will mean Hull, Villa, or Sunderland get relegated, but that’s how it rolls.

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Comment on Can fever melt the brain? by A.T.http://blog.ercast.org/can-fever-melt-the-brain/#comment-964 Thu, 09 Apr 2015 11:39:09 +0000 http://blog.ercast.org/?p=4978#comment-964 A reference to Men in Blazers?!? I feel like the two worlds of my favorite podcasts -- soccer and EM -- are colliding! Not like George Costanza…in a good way this time!
Good stuff as always!

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Comment on No CPR in Trauma Arrest? by mwells786http://blog.ercast.org/no-cpr-trauma-arrest/#comment-961 Fri, 03 Apr 2015 13:51:00 +0000 http://blog.ercast.org/?p=4877#comment-961 Hi Rob. On a similar theme to Sam, I was interested that in your podcast (and also in most of the other work I have heard / read on trauma arrests) you don’t comment on arrest rhythms. After all in a medical arrest pretty much the first thing we are interested in is the underlying rhythm as that defines our management.

It seems to me that there is an underlying assumption that in most trauma arrest cases we are dealing with a very low output state (which we’d typically call PEA) -- and that it’s therefore entirely logical to immediately treat this in any way we can via the HOTT mnemonic. I think I would apply this to in a case with aystole but recent documented signs of life (bearing in mind that signs of life can be defined as electrical cardiac activity -- what happens in terms of time based indications / CIs to thoracotomy if a ‘PEA’ traumatic arrest deteriorates to asytole?). But what if I encountered a traumatic arrest with a VF rhythm? I’d find it hard not to defibrillate before moving to tackle HOTT. Or would this likely suggest a medical arrest which had then gone on to cause trauma?

Very interested to hear other people’s views -- not least because I am in the middle of writing a traumatic cardiac arrest management protocol for my department, and I’ve got stuck at stage 1 -- rhythm recognition!

Mike

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