NOV 2012 1) First it was the chest pain center. Gosh this was a popular as leisure suits and Nehru jackets. Now that chest pain centers are out of style. But I always thought –what about TIA centers? Indeed these are becoming a bit of a rage at this point, but there may be a cheaper way of doing this. They admit the only real reason to admit TIA patients is to expedite the work up and to make sure they get TPA immediately if they actually stroke out, but why not do this in a same day clinic that will just do the CT and Duplex of the arteries and good education of the patient to come back if there are stroke symptoms? (Neuro 77(24)2082) This is a cost analysis and as I always tell you – this depends on the assumptions, and in this case – whether your population can afford the clinic or will be complaint, but it sure does sound like a good idea. TAKE HOME POINT: There is no rush on most TIAs to do the CT and Duplex in the ED- these can be done in a same day clinic. For those of you who have never been to Hamtramck, here

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is a Nehru Jacket and leisure suit Rick- could this have been you when you were younger? 2) You are watching a marathon (of course if you watch things, you need to get a life) and are called to the tent to see a runner that collapsed after a run. This is most probably due to exercise induced collapse which is a benign event probably due to sudden stopping of exertion. But there is a need to rule out other sources of collapse such as cardiac arrest, exercise induced hyponatremia and exertion heart stroke. If these have been ruled (I think cardiac arrest would be pretty hard to miss)– rest and oral hydration are all that is needed. (BJ Sports Med 45(14)1157) TAKE HOME MESSAGE: Collapse after a race
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probably is benign but rule out hyponatremia or heat stroke. Oral therapy suffices for most cases. 3) Breast abscesses – let's first go over the basics- mastitis does need to continue lactation and also probably antibiotics. Breast abscesses – admission and incision and drainage. Well they used to be the basicsLike many other abscesses you can now do ultrasound or CT guided aspiration and saline lavage. There is less damage to the ducts this way too. And you do not need the OR nor admission any more (Radiographics 31 (6)1683). The key here is not to miss inflammatory breast cancer. They also recommend antibiotics, for which I would like to see some evidence. Actually, I would like to see evidence for their guideline in any case, although I suspect it is correct TAKE HOME MESSAGE: Breast abscesses do not need incision and drainage but rather aspiration and watching-(don’t observe for too long, you don’t want to embarrass anyone) Let us take this opportunity to introduce our guest quotes of the month. In most animal species the female is anatomically different, maybe with less colorful feathers, but they basically act the same. Not with us humans. Despite my teasing my wife that I have an innate understanding of the female psyche, I like most (actually all) men – have no idea how the females of our species think. Let's take a look .Thanks to thirty years of feminist striving, the category “woman” has expanded to include anchorpersons, soccer
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moms, astronauts, firefighters, and even Senator or Secretary of State. But “female” still tends to connote the oozing, bleeding, swelling, hot flashing, swamp creature side of the species; its tiny brain marinating in the primal hormonal broth. Barbara Ehrenreich. “Women are just machines for making children “Napolean Bonaparte “The male chromosome is an incomplete female chromosome. In other words the male is a walking abortion; aborted in the gene stage. To be male is to be deficient, emotionally limited; maleness is a deficiency disease and males are emotional cripples” Valerie Solanos.” Feminism is just a way to mainstream ugly women” Rush Limbaugh “A woman needs a man like a fish needs a bicycle” GLoria Steinum Enough Guys- - get to your

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respective corners and wait till I call you

4) This study scared the wits out of me. If you exercise - your rate of ACS is similar to those who don't. Let's qualify that a little- that is in patients with chest pain. The point is that in chest pain, the fact that they exercise vigorously is not a reason to discount ACS. (AJEM
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30(1)57). The actually rate for ACS in all patients was low as there were not that many patients in the study to start with. Furthermore this was done in Stoney brook – which is not exactly reproducible to the rest of the world as this is a very affluent area. Furthermore, “those who exercise vigorously” was based on questionnaires; there could be some error in that. Nevertheless, we decided to contact Adam Singer, an author on this paper and an EMU reader for many years. His take on this: Yosef,
The main purpose of the study was to demonstrate to the cardiologists that the ability to exercise regularly, especially if without chest pain, cannot be used to r/o ACS as a cause of chest pain in patients presenting to the ED. From time to

Thanks Adam TAKE HOME MESSAGE: Athletes get ACS just like folks who are sedentary. 5) The use of anesthetic creams on an abscess can cause the abscess to drain and therefore there may be no need to open them. Just rub on the cream and you are set. The question is how and why this works (ibid p104). Actually I think the data proves just the opposite. It caused spontaneous drainage only in 26 out of 300 patients and only in three did it actually preclude the need for further intervention TAKE HOME MESSAGE: EMLA may cause spontaneous opening of abscesses. I don't believe it though. The reason women don't play football is because 11 of them would never wear the same outfit in public. (Phyllis Diller) My cooking is so bad my kids thought Thanksgiving was
time we have had cardiologist blow off patients who have atypical symptoms when they are physically fit.

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to commemorate Pearl Harbor. (ibid) “I’m at the age that my back goes out more often than I do.” (ibid). You know your old when your walker has a airbag(ibid) Never go to bed angry- stay up and fight”(ibid) 6) Lactate- I haven't found this to be that useful in the ED, but the ICU guys do love it- it does help for prognostication. However, in many EDs it is hard to get and sometimes we even have to send the blood up to the ICU to get results. Learn to use base excess. Base excess which is a measure of the amount of base that is required to return the blood to 7.4. This means a base deficit is a measure of acidosis and indeed the deficit of -4 correlates well with a lactate of 3- and is a lot more available (ibid 30(1)184) TAKE HOME MESSAGE: Base excess can be a good substitute for lactate And we did get some feedback on this from our ICU guys Pinny Halpern from Ichalov in Tel Aviv says: I use BE in lieu of
lactate all the time. I believe the literature is strong that the correlation between the two is very good, and pretty good that both are good predictors of mortality in multiple conditions, from trauma to sepsis. The only caveat is that if the phlebotomist reports a very small vein, prolonged vein occlusion and slow draw, a falsely elevated BE may ensue, so a second draw may be warranted.

And Carmie Bartel from

Soroka in Beer sheva says they have lactate in the ED, so they do not use the base excess too much- but I still am not sure how this test helps us much as it is more of a prognostic indicator and a measure of how you are doing in your treatment. Thanks Carmi and Pinny. And a word from our peer reviewer:      You  are  right  that  base  excess  is  a  good  surrogate  fort  Lactate.    The  truth  is,  

lactate  is  readily  available  in  most  EDs  in  the  US.  We  get  it  with  the  blood  gas  results.  I   think  the  value  of  lactate  in  the  ED  is  as  an  end-­‐point  for  resuscitation,  especially  in  sepsis.  

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7) Helluva a nice guy, bright, and one of the premier physicians in EM today. Yes I know you were thinking about me (and if you weren'twatch it, bucko) but I really was thinking about Shamai Grossmananother EMU reader. Shamai studied near syncope versus syncope. Well syncope could be bad but what about near syncope? They noted that adverse outcomes were similar between both groups – although not all the adverse outcomes were adverse by all definitions. The problem is that near syncope patients were much less likely to gain admission. (ibid p203) I will say that if you look at the numberssyncope is still worse, and I think we would consider a near syncope in an 80 year old much differently from syncope in a 25 year old but it is a point well taken. Good paper Shamai. TAKE HOME POINT: Near syncope should be concerning to you just like syncope. Hair is everything (Diana Ross) I took my parents to the airport today. They leave tomorrow (Margaret Smith) Great people talk about ideas, average people talk about things, and small people talk about wine. (Fran Leibowitz) Gosh, I hope Father Greg is not reading. For those
Vital  signs  are  not  good  enough.  If  you  resuscitate  to  normal  vital  signs  but  the  lactate  is   still  elevated,  you  have  to  continue  resuscitating  until  the  lactate  starts  to  normalize.

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who do not know Father Greg- here is a picture: Just to pacify Father Greg, let’s quote Julia Child “I love cooking with wine. Sometimes I even put it in the food” 8) This should be pretty obvious, but I will state the case. While you might love ultrasounds, but in urolithiasis it doesn't help much. It will identify a big stone; it will help in detecting hydronephrosis but doesn't change the clinical impression of physicians. CT of course is much more helpful. (ibid 218) Truth be told, I do not do ultrasounds on renal colic but I do not do a lot of CTs either. People whose pain can not be controlled, people whose creatinine has risen greater than 1.5, people with stone disease and fever with the correct clinical picture- these folks need a CT. I do a bedside ultrasound to make sure that I am not missing a dissection – which I just check to see the diameter of the aorta. TAKE HOME MESSAGE: Ultrasound doesn't help you much more than clinical judgment in urolithiasis.

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9) OK, I'll be serious- if you are a real wino so you know that you can get a fix by dipping into the ethanol hand cleansers in the hospital. You would imagine that if it is just ethanol it is probably benign and most of the ingestions in this study were benign, but many of these contain isopropyl or chlorhexidine combos that can lead to dialysis. (CCM 40(1)290 ) TAKE HOME MESSAGE: Ethanol hand cleansers are safe for hands and for drinking- mostly. Most do well, but I would still admit them I base my fashion sense on what doesn't itch.(Gilda Radner) "Never mind" (ibid). A woman who doesn't wear perfume has no future (Coco Channel). This quote for reasons not clear to me made

me think of this picture . Five points if you know who this is. Just to help you, here is what John Elway, Hall of Fame quarterback had to say about this gentleman: “He had no teeth, and
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he was slobbering all over himself. I’m thinking “You can have your money back, just get me out of here. Let me go be an accountant” He was knocked out on this play. While we are the subject of sports, women have a unique perspective on that as well. I do not like football ….I have a contempt for a game in which the players have to wear so much equipment. Men play basketball in their underwear which seems just right to me “ Anna Quindlen 10) Dr. Raz doesn't read EMU, but he is a big ID guy from HaEmek hospital in Afula Israel, and sings the praises of fosfomycin. If you do not know this antibiotic, get to know it. It is taken just once for uncomplicated cystitis and has a lot pluses. The resistance rate has stayed fairly stable at 1-3% This is probably due to the fact that it is not related to any other antibiotic (don't let the -mycin fool you – it isn't a macrolide) but it could be because basically no one uses it. Best news is that it works against 98% of ESBL- that scary bug that is resistant to penicillin and cephalosporins and quinolones. It also works without adjustments in mild renal failure and can help recurrent uncomplicated cystitis when taken with macrodantin. (Clin Micro Inf 18(1)4) . He doesn't mention that it is not one of the stronger antibiotics but that is implied in "uncomplicated cystitis" In a related article-they searched Europe, the USA, Australia and Canada for forgotten antibiotics as solutions for resistant bugs. Many are no
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longer manufactured but do not forget Nafcillin, dicloxacillin and fosfomycin. TAKE HOME MESSGE: Fosfomycin is a good antibiotic for uncomplicated cystitis." I think there's a difference between ditzy and dumb. Dumb is just not knowing. Ditzy is having the courage to ask!" Jessica Simpson. " I am in favor of capital punishment because people who do bad things should get just punishment and this will teach them for the next time" Brittany Spears 11) Idea was great, the article wasn't (doesn't this sound like marriage?) Why not just home treat cholecystitis? They did and it worked (Euro J Int Med 23(1)e10). Here are the problems. Only were 25 patients – who knows how many were serious and how many where mild. All got Ertepenem-an antibiotic which I have of a case of sitting in my house. How many got pancreatitis? Not clear. I got a good idea- why not just operate immediately? I know you aren’t supposed to operate when they are infected – but we open abscesses all the time without cooling them off with antibiotics. Think I am nuts? Well, I am, but I am not alone See Ann Surg 227(4)468. TAKE HOME MESSAGE: You may be able to home treat some diseases- is biliary colic one of them? Whenever I am a room with a guy- I think “if we were the last two people on Earth, would I puke if he kissed me?” (Helen Hunt from Girls Just want to Have Fun)

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12) I imagine you knew this but your nurse may not and your neighbors and patients for sure don’t. Fever is not dangerous, and may be beneficial (although quite frankly we have been throwing around this idea that it is beneficial for quite a while, and I haven’t really seen good patient oriented evidence- see Crit Care 15(3)222). But at least in my ED, the nurses are quick to place ever so gently a suppository to lower fever in the nether orifices of some unsuspecting individual. They use a process with an RPG (rocket propelled grenade) to insert these (I actually think a dynamite charge would have been enough but who listens to me?) and I can understand that they may believe that high fevers cause brain damage, seizures and death- which what most patients and doctors think anyhow. (AFP 85(5)518). Now it may be thought that what is the difference if you give antipyretics- it is benign, but over half of parents give the incorrect dose. TAKE HOME MESSAGE: Treating fever is for comfort only. Go and make it idiot proof and they will go make a better idiot Debbie Thorton 13) My goodness, my kid stepped on a cockroach and since it was still moving I intubated it. I can intubate mosquitoes with a Miller blade. But alas, as Ron Wallls has gone on record saying- I am old fashioned. Video laryngoscopes are more effective for difficult airways and more comfortable for the patient and the operator. (Anesthesiology 116(3)515) I guess you could be in a place which
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doesn’t have one-like most places I have worked in- so it pays to know the Miller way too. TAKE HOME MESSAGE: If you have spare cash sitting around your ED- buy a video laryngoscope-and then learn how to use it. 14) Now a bone for our ICU guys. Hyperosmolar therapy includes Mannitol and the new kid on the block- hypertonic saline (HTS). HTS seems to be more effective, but again this has not been proven in patient oriented studies. Regional necrosis has been reported but this has been in dogs, not in humans. But again I am unconvinced – the safety studies have not been that strong. HTS does not seem to cause central pontine myelinolysis when used for ICP which makes sense since most of these folks have no hyponatremia to start with. (AJ Resp CCM 185(5)467) No one asks the key question- does it change mortality? TAKE HOME MESSAGE: You can use HTS safely- I think "I think marriage is a great institution- but I am not ready for an institution yet (Mae West)."I 'd give half my life for one kiss from you, Miss West" "So kiss me twice" 15) Clinical quiz time- not a hard one but when you see it, you better think of it. 42 year old lady, 38 weeks pregnant, GDM and mild pre eclampsia- she requests an epidural. She was given one and immediately felt short of breath and proceeded to have a seizure. A few minutes later, cardiac collapse and she was intubated. CPR and epi
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resulted in no waveforms and an emergency c section was performed. She was started on an epi drip and an emergency hysterectomy was performed. She was given blood, vasopressors, and admitted to the ICU. She developed DIC and CXR showed pulmonary edema. Amazingly she was discharged home three days later with no neuro deficits but without a uterus and I am not sure why(why she is uterusless, not why she was sent home). So what did she have? (Anesthesiology 116(1)186) 16) Law time. Advanced directives are common today, but this area started with two sentinel cases. Karen Ann Quinlan went to a party in 1975 and took a combination of diazepam, detropropoxyphene and alcohol. She experienced a respiratory arrest and was in a persistant vegetative state due to anoxic encephalopathy. Her parents convinced the court that she would not have wanted to be kept alive and the courts agreed. The Supreme Court of the USA upheld such precedents in the Nancy Beth Cruzan case, where Ms Cruzan lost control of her car and was ejected from the car into a ditch full of water- she was also anoxic.. The courts agreed that a person can exercise the right to refuse treatment if it can be proven that they would not have wanted these extra ordinary means – in the Cruzan case -the life support was removed. Congress soon enacted a law that hospital workers must ask if an advance directive exists. The law now states that advance
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directives must be signed and two witnesses must be present. Physicians can not be proxy for an advanced directive. All advanced directives can be cancelled. Some problems that can arise include that most advanced directives are written in legalese and they can vary from state to state so there may be elements that cannot be honored in a different state. The directive goes into effect when the patient can no longer make decisions – but this can be problematic as mentation can be fluctuating, and in addition, a patient may still be able to make decisions but not be able to understand the medical decisions that need to be made. A proxy is helpful here, but often the proxy can’t make decision due to family dynamics or other considerations. Getting another proxy requires a court order. Physicians can refuse to give life support if in accordance with family wishes or if it is in good faith. They also have a right to refuse to participate in ending life support if it is contra to their ethical feelings. In truth- lawsuits against physicians for ending life or continuing life against the wishes of the family are few. Since what interventions are not uniform among all states, an advanced directive should be as well worded as possible. Quality of life by the way- has not been defined by the law and may not be a basis for observing the proxy’s request. Mush more in this article- if this interests you- get the article- a rare one written by a lawyer that wasn’t confusing (Chest 141(1)232) TAKE HOME
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MESSAGE: Advanced directives have alot of particulars that you need to know. So do not depend on this TAKE HOME MESSAGE and read what I wrote above. Here is a true Court Transcript: Judge: "What seems to be the problem". Bailliff" There is a cockroach on the exhibit table, Your Honor" Defense Attorney" Motion to Quash" Judge: “Granted". And back to Mae West" Long dresses cover a multitude of shins" "My goodness, Ms. West, what beautiful diamonds" "Goodness has nothing to do with it" (ibid)Come up and see me some time(ibid) 17) The triple rule out CT scan – which is a combined coronary, rule out PE and thorax scan, is remarkably less radiation then I thought. For males it turns out to be 3.8 millisievert, and for females 6.5(Invest Rad 47(2)109) As a reference, an abdominal CT is about 12 mSV, a head CT is about 3 and background radiation yearly is 3. A chest film is .05mSV. That isn’t to say you should be doing these scans – I think you should actually speak to and check the patient first, but it isn’t as bad as I thought. TAKE HOME MESSAGE: triple rule out chest CT have some radiation risk, but it isn’t a massive one- gives an increase of about 0.1-0.5% risk of lung cancer over a lifetime. "Marriage has no guarantees, if that's what you are looking for- go live with a car battery"(Erma Bombeck) "Never take a drink from a urologist".(ibid) Never lend your car to anyone you gave birth to"(ibid)

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18) Body packers that have the drugs inside for more than 48 hours are not an indication for surgery. Most are packed so well that it is unusual that they will burst open, and in their study they recommend that surgery be done only upon signs of intoxication or ileus. (Langenbecks Arch of Surg 397(1)125). (I do not know who Langenbeck is but I bet he looks like SpongeBob Squarepants). The only problem I had with this tiny study is that 25% of the patients did experienced rupture of the packets although only one died. TAKE HOME MESSAGE: You can observe most body packers with out an ileus or signs of intoxication 19) Some people get a lot of blood. Trauma patients (they tend to come back with new trauma a second time), sickle cell anemic patients, vampires, etc. Theoretically they could develop antibodies if they got unmatched type O blood. (J Traum Acute Care Surg 72(1)48) However if you analyze their data, only one patient really had a hemolytic reaction and only one patient developed antibodies to Rh. However, that is not a criticism; it is just the way the study turned outwhich is why power is important in a study. TAKE HOME MESSAGE: Avoid unmatched blood – you may have to deal with hemolysis in the near or distant future. I have flabby thighs, but fortunately my stomach covers them (Joan Rivers) Don't tell your kids you had an easy birth or they won't respect you. For years I used to wake up my
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daughter and say, "Melissa you ripped me to shreds. Now go back to sleep." (ibid). 20) We got the best falafel in the world. We got great hummus and harissa. But in Israel, we do not have Dexmetetomide. This stuff, according to this article is a sedative, and an analgesic, but the patients are more awake and interactive. Now not all intubated patients need analgesia, and not all need sedation but this seems to be a good compromise. Its role in EM is still undefined- but give me time (Am J Reps CCM 185(5) 486) TAKE HOME MESSAGE: Dexetomidate is the new sedative on the block- but the depth of sedation is less than the old timers

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21) DON’T READ THIS PARAGRAPH!! I warned you. It‘s about everyone’s favorite disease-no, not that one (just take your Rocephin and stop talking about it)- but syncope. We see this all the time, and admit a great deal of it even though final etiologies are rare. However, if it happened more than once in a patient with a bundle branch block and you did work them up- and by work up I was serious-EPS study loop recorder- you found a reason in 83% of them. And these reasons were serious- some needed pace makers, some needed ICDs. (Eur Heart J 32(12)1353) Of course if I had been as aggressive with everyone, I may have found the same thing even in folks without a BBB. TAKE HOME MESSAGE: Don’t read such paragraphs. And look at syncope with BBB more seriously. Everyone probably thinks that I'm a raving nymphomaniac, that I have an insatiable sexual appetite, when the truth is I'd rather read a book.(Madonna). I had to get back to work. NBC has me under contract. The baby and I only have a verbal agreement.(Tina Fey) "Gracie, why are you putting hot water in the freezer?" "Because if I want a coffee, all I have to do is defrost it" Gracie Allen 22) You gotta work. And besides you got no time to go the doc and besides what does he know? He only reads EMU for the pictures. So you self medicate, and never see a doctor- even if you are still a med student. We self medicate and self treat. (Occup Med 61(7)490)TAKE
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HOME MESSAGE: We don’t need doctors- doctors are for patients. So the solution is to have your wife nag you….. 23) Apparently in Cook County they got a lot of druggies with no veins (I am truthfully shocked to hear there are people abusing drugs in Chicago. Then again, if I was a Cubs fan, I would probably use drugs as well) so ambulance personnel gave naloxone by nebulizer and these folks did wake up- not all were that happy. (Prehosp Emerg Care 16(2)289) The results are expressed as kappas which indicate to me that the study did not use a standard scale or form. Still, naloxone given by this route has not been studied (at least not in the last last 7 years which is as far back as I checked) so it is encouraging. However, be aware that while 22% had a complete response, 205 had no response. TAKE HOME MESSAGE: Try nebulized naloxone. Not on yourself silly! "If truth is beauty, why doesn't anyone ever have their hair done in a library (Lily Tomlin)" When other little girls wanted to be ballet dancers I kind of wanted to be a vampire.”(Angelina Jolie) 24) Take 18 patients seen by their GP. All had ocular pain, and all but one had photophobia, a red eye and blurred vision. 7 of these patients were referred to the ED, but the other 11 got antibiotic drops and some even got steroid drops- so these folks waited an average of 9 days to get to the ED and many referred themselves. This is of course uvietis and could have led to blindness due to inept family docs.
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A unilateral red eye is usually trouble and if you do not have a slit lamp- you better get help (Eur J Gen Pract 18(1)26) TAKE HOME MESSAGE: Uvietis is serious – don’t miss it. 25) You are not a pig. But you are being fed garbage. By who? Oh that cute little drug rep that would be so hurt if you just didn’t use her Cutaneous Reacting Anti Pruritic (If you didn't get it yet, check out the initials of that medication) and she has the studies to prove that this is the best stuff since Fentanyl Encrusted Capsular Entero Salicylate. Well look at the studies well. Of the medication trials evaluated in this study- they had to throw out 116 because they used a surrogate primary endpoint (for example it lowered CRP levels instead of telling us if the patients got better) Another 106 used composite endpoints (it lowered CRP or made folks better, or lowered WBC or lowered ESRthese always look better). Among the studies that looked at mortality – they looked at disease mortality and not at all cause mortality (a medication may not make people worse from the disease being treated but may kill them for another reason) Furthermore, positive results were often reported in relative terms. A fifty percent drop in mortality sounds great but not if it was from 2 deaths to one. Of course most of these were commercially funded (JGIM 26(11)1246). So next time that drug rep tells you about a Terrific Unbelievable Remarkable Drug tell them that is Steaming Hogwash in Totality. TAKE HOME MESSAFGE:
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Many commercial studies have subtle but obvious flaws. "Only time can heal a broken heart, just like it can heal his broken arms and legs" Miss Piggy "Never buy beauty products at a hardware store" (ibid) Nurse Piggy "But I love him" "but you are a nurse" That is true, but I am a woman first" "No , you are a pig, I do not think woman is even in the top ten" 26) The author says that cooling doesn’t help in ortho injuries because of hetrogenous muscle injuries and depth of cooling. It does work in animals. However, no evidence is presented on patient oriented outcomes, only surrogate markers, so we’re kinda of cool to this study (Br J Sports Med 46(4)296) TAKE HOME MESSAGE Cooling hasn’t been proven to help in sports injuries 27) This is getting long, so we will present some of the remaining articles as bullets. Venlafaxine overdoses can cause hypoglycemia (Clin Tox 50(3)215) 28) First trimester miscarriage- give them mifepristone immediately and you may save them the need for a D and C (AJOG 206(3)e1) Maybe, but this was open labeled. 29) Steve Selbst legal briefs are always a good read and I did pretty well this month- I wouldn't have gotten sued at all, although all the patients would have died. (PEC 27(10)992) The one that could have gotten away was a rash that was itchy and didn’t respond to
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antihistamines. It was Stevens Johnson- but I guess I would have made easier had I told you the patient took anitconvulsants TAKE HOME MESSAGE: Itchy rashes that do not getter- consider Steven’s Johnson "Every woman should have four pets in her life. A mink in her closet, a jaguar in her garage, a tiger in her bed, and a jackass who pays for everything" Paris Hilton 30) Norepi is supposed to kill kidneys. In this double blind study they checked kidney function in shock and there were better hemodynamics with Norepi, not worse which would have been expected. This was based both on blood tests and histology of the kidney. (AJEM 29(8)922). OK, so don’t get so picky- it was done on pigs. (But not Miss Piggy) But the pigs felt better! TAKE HOME MESSAGE: Norepi may actually help the kidneys in shock and is good as a toilet bowl cleaner as well. 31) Conjunctivitis- if you are sure of the diagnosis- see 24 abovegets better without antibiotics. Period (BrJ Gen Pract 61(590)e542).Do not forget that this is often due to blocked nasal passages and therefore does not need antibiotics drops, creams, or antibiotic laced milk bones. 32) Ron Goldman- EMU reader and one of the best things to come out of Vancouver since Butchart Gardens shows us in a nice stud that a single dose of dexamethasone has a long half life and is a potent
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anti-inflammatory. He gives 0.3mg/kg IM or preferably .6mg (Can Fam Phy 57(10)1134) TAKE HOME MESSAGE: Dexa for asthma is more potent than prednisolone and can be given just once." I think the doctor put my pacemaker in wrong. Every time my husband kisses me the garage door opens" Minnie Pearl 33) Hey it looks like asthma- but it isn’t. What else could it be? Here are some possibilities- GERD, CHF, Vocal cord dysfunction, bronchietasis, upper airway obstruction aspiration, CF. A chest film is critical, as are PFTs in the clinic if you are not sure. This article was funny as it was an important subject in a strange journal- so to justify it, they state it is important to diagnose these so the patients can be battle ready (Military Medicine 176(10)1162) TAKE HOME MESSAGE: Asthma mimics can be serious- look for them with a chest film. And tell that patient to start breathing on the double. And that’s an order, son. 34) Heere’s another bullet- WBC cannot rule in or out a serious infection- especially the latter. CRP can rule in a serious infection, but it is modest help. (J Peds 160(1)173) Guess you will have to look at the patient, huh? Secret for a good marriage – when you let your husband lick the batter off the mixer- turn it off first" Phyllis Diller" I am great housekeeper- everytime I get divorced I keep the house"(she divorced 9 times) Zsa Zsa Gabor .Actually I have to interrupt this EMU with an ad lib I just did with a med student who wants to be a
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psychiatrist and did his first rectal exam. I convinced him to enter the field of psycho proctology "So tell me, how long have you been a---( this is a family newsletter, so we’ll let you finish the sentence)?" 35) The picture in nine is former Pittsburgh linebacker Jack Lambert. Down boy, down, boy 36) We got a lot of letters this month! Dr. Kent Robinson from Down Under writes how he enjoys EMU (thanks, I do too) and he has a blog dedicated to medical education. You can access it at: www.emergencyeducation.net . I did and it is very interesting. Ken Iserson writes from Baffin Island (no that is not near any towns in Michigan and we are going to go through the month without mentioning our favorite Bakersfield California). Here is what he has to say about the October issues law discussion: Hi Yosef
Still way up North. Got your October EMU. Thanks. But, you know it was Robert DuVall who said "I love the smell of napalm in the morning." The article most concerning to me was the one about the Good Samaritan ruling at the California Supreme Court. (Strange, don't you think, that it appeared in Singapore, rather than in a U.S. journal?) Anyway, the link took me only to a citation, so I delved further. It seems that the court ruled that these actions did not fall under the Good Samaritan Law because yanking the woman out of a car that showed no evidence that it was on fire or could cause any

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other problem was not a "medical" intervention. Given their own abstract of the case, I suspect that there was also an element of gross negligence that influenced their ruling. In any event, this should in no way ever prevent a physician or other healthcare professional from stopping to render aid. Ever! In fact, I strongly suggest that every trained EP carry an emergency medical kit in his or her car to use when it is REALLY needed. I've attached the CA Supreme Ct's official abstract of the Torti case. Best wishes in the midst of icebergs. Ken. Write me if you want the abstract. And

yes I do carry an emergency kit with me. Dr. Crown wrote me about last month’s cool quotes: you should keep randolph powell around to make important (or
impertinent) points and quotes. compare to the noted theologian franz bibfeldt (Wikipedia) whom authors used for years to buff up their bibliographies with bogus stuff (or maybe that was by politicians) thank you for the info this month. Oh, I think you

haven’t heard the last of Randolph Powell. Since he has appeared in no films, there are plenty of quotes available that he never said. Dr, Nochimson asks about probiotics Do you have any recommendations on specific probiotics? As always enjoyed the issue. I had Dr. Shapiro answer: Is the question in regard to which strains
of probiotics? To be honest, I have seen that each manufacturer has their own mix, which makes it a bit hard to judge. I have not seen good studies on particular strains. Here in Israel, I usually recommend Mega Probiotic by Gramse. They have a mixture of lactobacillus acidophilus, lactobacillus casei, lactobacillus rhamosus, lactobacillus plantarum, b. longum, b. bifidum, lactobacillus lacti, s. thermophilis, b. breve, b. lactis. For whatever that's worth.

I think the key point is that yogurt just doesn’t have enough. And yes good studies that go into the specifics are lacking. Thank you to you both. Rafi Kayam who is a wonderful

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person, a great physician, a model of the community, a very handsome man, and my boss (can I have a raise?) writes that he isn’t convinced that lateral films provide much in the way of information on k ids and he also thinks that thrombocytopenia is an earlier finding in Kawasaki than we think. He provides articles for these assertions:
Paediatr Child Health. 2003 Nov;8(9):566-8 .

Shows the following conclusion: There is no randomized controlled trial evidence to support the
additive value of the lateral to the frontal chest x-ray in the diagnosis of children with pneumonia. Further prospective studies are required to determine if the addition of the lateral chest x-ray will modify therapy, prevent complications or whether it is cost-efficient And

on Kawasaki AFP

"Thrombocytosis is frequently present after the first week of illness and may be marked. I am just a little guy here so I will wait for Lisa’s reply. Dr. Veysman wrote the following: As always, incredible treat for us all. Thank you so much. The product inspires by being so easy on the mind. Of note, , but have you taken a Myers Briggs? I am wondering if you are an INTP, based on the associative and visual way in which you think and teach. There are very few in Emergency Medicine as often that personality rebels against many requirements of the work, but ones who master (conform to...) the work often stand out like you do. . . Being far from the authority on the matter but finding the subject interesting and having nothing to teach you in return for your thinking generosity, perhaps this can be my humble contribution. Personology is a fascinating feast for the enquiring mind so perhaps you'll enjoy it. So I took this test and found that I have a

unique talent in writing prime medical material for optimal bathroom reading. Well, not really. His analysis of the results was: Very cool. You
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are an enigma of focus and productivity. So there is some thing to be gained by

being a deviant. But seriously- anyone who wants more on the subjectthe test was fun, the analysis interesting- I’ll make the contacts if you

are interested. 37) Number 15-Yes I thought also that this was eclampsia or cardiomyopathy but indeed this was amniotic fluid embolism. DIC occurs rather frequently- no one is sure why. It seems that c section is a risk factor. Treatment is supportive with mortality being about 25%. ECMO may be an option. TAKE HOME MESSAGE: Sudden collapse and DIC may be an amniotic fluid embolism. Treatment is aggressive and supportive. Left uterine displacement and immediate c section may be lifesaving.

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38) Yes, Ron, (#32) I knew that Butchart Gardens is in Victoria and not Vancouver but it is on Vancouver Island and that is enough. Just wanted to see if you were really reading. 39) And now a look at the starlets that contributed to this issue's quotes. Note we did not use Rita Rudner or Roseanne who are really

funny- but just wait. Phyllis Diller

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Fran Leibowitz


Zsa Gabor

Brittany Spears:

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Jessica Simpson:

Paris Hilton:

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Miss Piggy



Minnie Pearl
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Joan Rivers

Mae West

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Erma Bombeck

Gracie Allen

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Eleanor Roosevelt:

EMU LOOKS AT: Sleep deprivation and Iron supplementation
We have discussed this before – it was about 5 years ago, but this is an update, and it is on everyone’s mind. The source for the essay is an article from Cleveland Clinic JOM 78(10)675 Jet Lag

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1) Working night shifts, taking the red eye flight, - we all know the feeling. The drive to sleep is related to deprivation and maxes out at about 40 hours (basically means that if you been up for 40 hours- you will not be up much longer). It helps with people with sleep disturbances to have them take a sleep diary and also note what medications they take that may affect sleep patterns. Also, many folks have evolved over their lives to “night owls” or early birds”- it pays to identify 2) Now on to jet lag. Since our circadian rhythm is slightly more than 24 hours- we can always readjust flying westward since we can extend our internal clock. 3) Age has an effect? Well some studies how it is harder to reset the older you are, other studies show age may be protective. 4) If it is a short visit- it is best to try to stay on your home schedule. 5) This wasn't so clear to me- if you are going east- avoid light when landing- even wear sunglasses. Going the other way- - get bright light. This helps in resetting, but I do not know how practical it is. 6) Yea, drugs- that is the ticket. Melatonin is safe. The studies seem to endorse this, but I couldn’t evaluate the quality. Benzos- improve sleep but studies are lacking. Most studies have been done on agonist like Zolpidem. Caffeine has been shown to improve wakefulness- is that a surprise or is that a lot of Bull? Red Bull that is.
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7) Shift work is definitely harder for older individuals- see last month’s EMU. Again- here you want to avoid bright light. Short naps seem to help as does Modanifil. Four hours of anchor sleep will help as well if possible. Past articles I have reviewed have made it clear that one day to recover form a night shift is not enough. IRON OD. Source for this article is PEC 27(10)978 1) Firstly – Iron is rarely taken in elemental form- rather as a compound. However-toxicity is measured by how much elemental iron is ingested. For example- a 325 mg pill of ferrous sulfate has 60 mg of elemental iron, ferrous fumarate- 1067 mg Ferrous Gluconate has 300 mg. Multi vitamins generally have up to 20 mg in peds preparations, 50 in adults and up to 100 mg in prenatal. While 20 mg/kg of Iron can show toxicity, generally sever toxicity is seen at 60mg/kg. There are five phases. 2) Phase one: This occurs up to six hours after ingestion and is due to GI mucosal damage. There may be vomiting, diarrhea, and GI bleeding. Basically if nothing is seen for six hours; there is little likelihood of toxicity 3) Phase 2:- six to 24 hours post ingestion. The patients actually feel better and the nausea is better. Toxicity is ongoing and be aware that phase 2 may be absent.

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4) Phase three – usually 12- 24 hours post ingestion but can be earlier if high doses are taken. Shock and acidosis. Coagulopathy is not related to the liver- rather direct effect of iron on the clotting cascade. Iron is a negative inotrope so hemodynamic instability occurs. 5) Phase four- the livener becomes afflicted. However frank liver failure is unusual especially at iron levels of less than 1000 micrograms. 6) Phase five is recovery with strictures and fistulas possible in any area of the GI tract. Gastric outlet obstruction is the most common area. 7) First aid- - ingestion of more than 40mg/kg of elemental iron needs the hospital if it is an adult formulation. GI symptoms also go to the hospital. Children’s formulation home observation can be enough. No charcoal no emetics. Look good six hours later- send them home. 8) Lab tests other it an iron level are generally not useful. An abdominal film may show pill fragments, but if it is negative it means nothing. TIBC is useless 9) Treatment. None in those who ingested less than 20 mg/kg, carbonyl or pediatric iron preps, or those who are symptom free for 6 hours. 10) We do not lavage for iron ingestion or for anything for that matter. Whole bowel irrigation probably works- evidence is lacking. Give 500 ml/hr to a 9m-6yo, 6-12 y/o/ 1000, 13 and older 2000ml/hr. 11) No cathartics, no EDTA. Bicarb is usually not necessary unless there is a serious metabolic acidois. No phosphates even though they
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bind with iron- they also cause hyperphosphatemia. Magnesium and kaexylate do not really work. 12) Desoforaxamine- this does work and is recommended when iron levels are above 500, or there is metabolic acidosis or clinical manifestations of poisoning. We give 50 mg/kg IM every six hours or 15mg/kg for one hour IV followed by 125mgqhr. The IV infusion is more effective. When to stop treatment is a question with no good answer. Renal failure, hypotension, yersinia sepsis, ARDS are side effects. This treatment can be given in pregnancy. 13) Dialysis will not work. Exchange transfusion worked with plasmaphoresis in a case report. “Women speak because they wish to speak, whereas a man speaks only when he is driven to speech by something out side of himself like , for instance he can find any clean socks” Jean Kerr 14) Now for the roundtable we have been waiting for – on EMS issues. Sitting around our table- firstly from Bellingham, Washington State: Marvin Wayne- a publishing machine and a CPR and EMS guru. Steve Parrillo hails from my home town in Philly and he has impressive credentials as well_ Chief, Division of EMS and Disaster Medicine, Einstein Healthcare Network, Philadelphia Medical Director, Philadelphia University Disaster Medicine and Management Masters program

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Assoc Prof, Emerg Med, Jefferson Medical College and Phila College of Osteopathic Medicine Lastly we have Keith Wesley whose credentials are also impressive. Keith Wesley, MD FACEP is a board certified emergency medicine physician practicing in St. Paul, MN USA. He oversees the operation of HealthEast Medical Transportation that transports 40,000 patients a year. Dr. Wesley is the former Minnesota and Wisconsin state medical director. I am sitting here as well, and while I am not an EMS guy, I have some experience because my father is a lawyer and may have chased an ambulance or two. Here are the questions. Question number 1: 1) How can we train and keep our EMS staff current? How do you assure their knowledge base, update their protocols and test procedure competency?


Let us start out with Marvin:  Always a tough topic to answer since it is so system dependent. For our Urban Rural EMS system we have State and locally mandated CE requirements at both EMT and Paramedic Level. For EMTs there is online CME, and active OTEP training. OTEP is skill based. There is a minimum number of hours per year. The online CME  includes testing as well as teaching. For Paramedics there is both locally mandated monthly training, which now can also be
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accomplished in part online. Paramedics also have annually mandated intubation requirements. For the first 3 years after certification is one intubation per month. Either in field or OR. For those beyond the first 3 years it is one per quarter. Competency is based on testing and run reviews by the supervisors and supervising physicians. Some, such as myself, will go into the field and try to ride on calls with the medics.     Steve:  There are two groups to consider here – the MD/DO medical directors and the BLS/ALS providers. Physician education is available in a number of areas, but EMS-specific education is more of a challenge. Most of the major national meetings include such education, but in limited quantities. There are many online courses these physicians can use. NAEMSP offers an outstanding program (and it offers the benefit of a resort venue). For medics and EMTs, resources include local, state and national meetings, but there is no substitute for regular sessions with the medical leadership. In addition to the state-mandated yearly updates, medics should get regular updates from their directors. Refreshers are always welcome, but the career medic wants to stay on the cutting edge. Ultimately the Medical Director is the arbiter of who is who is not competent.    


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And Keith: Continuing education is critical to quality performance of our providers. In the USA EMTs and Paramedics are required to attend continuing education courses to maintain their licensure. For the EMT that course of study is often dictated by the state. For the paramedic it may have some general outlines for requirement but the content is frequently approved by the medical director. Medical directors should be intimately involved in the content of these continuing education courses. When possible the medical director should deliver some of the more vital components such as the care of patients with respiratory distress, chest pain and of course the approach to caring for cardiac arrest victims. The medical director should have direct oversight of the educators to ensure consistency of content. At a minimum medical directors should be present at least annually to observe providers skills in various psychomotor skills such as patient assessment and cardiac arrest care.

Maintaining protocols is a constant challenge to the medical director and

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though the science and evidence for change is frequently being updated protocols should be reviewed and updated on at least a bi-annual basis. One of the best ways to do this is to involve our providers by creating a protocol committee that is empowered to make suggestions and track needed updates. I (Yosef) will just add that I am impressed that this is so well coordinated in the USA and that some directors go out into the field to observe competency. In Israel, the service is so large that I am not sure the CME requirements are met, but I think the procedure requirements are met. Next question:

2) The Israelis and Europeans have doctors riding the ambulancesin the USA it is often base station command- please give your opinion on which system seems better Marvin: I’m not aware of any convincing data that having a physician or nurse on a land based ambulance adds much. In fact, there are some studies that have shown delay in transport when a physician is on board. Most skills that may make a difference can be taught to paramedics.
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Further, the funding structure of EMS in the United States would prohibit the cost of such a system. Some airmedical programs use nurses as well as medics and some even MDs, but no data shows much difference.      

Steve: There are definite advantages to having physicians ride and respond – assuming those docs are truly trained and prepared. The biggest advantage is that treatment is brought to patients who might then not have to be transported to the ED. In light of the ED crowding crisis in the US, such off-loading would be helpful. However, for most patients who will need definitive management, prehospital care given by well trained and competent medics is enough. The physician team can do the rest at the ED or in the OR etc. In a setting in which transport times are long, a physician “on the truck” might, for example, allow for earlier lysis in a stroke situation – but that treatment remains controversial and would likely not be applicable in the US. In the US one of the biggest issues to consider is the shortage of trained EM physicians. Assuming the ride-along doc is an EM one, this would further stretch an already scarce resource.

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Keith: Both systems have their pros and cons. The reality is that in the US it is simply not financially feasible to have physicians on ambulances. Therefore we are left with lower paid and often less trained and educated providers. However, in the states emergency rooms are often staffed with board certified and even emergency medicine residency trained physicians. There currently is no data to suggest that physicians in the ambulance provide better care for the acutely ill and injured and there is actually some evidence that advanced life providers to not improve the mortality and morbidity of patients particularly in the urban environment where definitive care is only minutes away. Yosef: Well, in many places in Europe, the manpower problem is dealt with by having anesthesiologists ride the ambulances. But in Israel, many physicians are general practitioners who offer little advantage over paramedics. Just wanted to add that in places with longer transport times, it may make a difference. In France, the physicians riding the ambulances do give first aid and often save the appétit an admission or long ED wait.

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Question number three: Do the ambulance drivers in your system get driving safety courses? Can an ambulance use sirens at will?can they get a ticket for traffic violations? Marvin: All emergency vehicle operators have significant safe driver training and must have annual retraining. This includes all fire based systems and, I believe, most private services. They are not allowed indiscriminant use of emergency sound and lights in most States and are subject to ticketing and fines. If they cause an accident and are at fault they have liability as does their system.   1. Steve: Driving an emergency vehicle is not like driving a car. In the US, anyone who drives an ambulance must successfully complete an emergency vehicle operator course (EVOC) or an equivalent. The course is 100 hours of classroom and actual driving. Among other issues, students are advised about the appropriate use of lights and sirens. The literature is clear that there are very few times when L&S use make an actual difference in outcome. What we do know about L&S use is that it increases the likelihood of vehicular accident with all the attendant consequences. Emergency vehicle operators are held to the same driving regulations as the general population. Run a red

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light, get a ticket. Speed, get a ticket. Do that enough times, lose your license. Keith: In the US the requirement for driver training is variable and depends on each states requirements. I personally believe in driver safety training and promote the use of "black box" technology that monitors and alerts ambulance drivers to unsafe performance. Because of the litigious US society the standard of care is that the ambulance driver operates with "due regard" for the patient and public safety. The use of Lights and Sirens does not by itself provide the ambulance "right of way" but instead is meant to alert other drivers of the presence and/or approach of an emergency vehicle. In the US ambulance drivers have been ticketed and in fact jailed for failure to use "due regard" both while responding and transporting a patient. It is impossible to defend the tragic consequences of a crash that injures or kills an innocent motorist that crashed into an ambulance transporting a patient with a non-lifetreatening condition. Medical directors should develop or approve clear policy for the

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appropriate use of Lights and Sirens both for the response to an emergency as well as the transport of the patient. There is no credible evidence that the use of Lights and Sirens improves the care of the patient during transport. In fact, there is evidence that is may negatively impact that care by making patient care technically difficult. Yosef: In many countries- there is no training, but in Israel- lights and sirens need to be justified. Question number four from reader Dr. Schreiber. For EMS roundtable pediatric airway stabilizationETT vs BVM Marvin:  We do intubate children as well as adults. We use the airway that is best able to be achieved quickly and safely and provides the best care for the patient. Supraglottic airways offer both a rescue airway and alternative airway. We work hard, because of the limited number of peds airways, to keep skills up with our airway lab.   Steve: Is there anything that scares the career paramedic (or the seasoned ED physician) more than a child who needs respiratory or ventilatory support? The question then, is how to best do that. While

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endotracheal intubation provides definitive airway management, it takes time and most medics have had little experience intubating children – largely because so few need such aggressive care. Bag valve mask ventilation will usually provide sufficient support to get the child to a setting where more “toys” are available. In much of the US, medics are not permitted to perform medication-assisted intubation. Additionally, medics don’t have access to fiberoptics or video laryngoscopy. Bottom line – BVM is sufficient most of the time. If there is a question about an obstructing foreign body, direct laryngoscopy might permit life-saving removal. Keith: Airway management is often difficult for the pediatric airway. However, there is no evidence that an ET tube or non-visualized supraglottic airway is superior to BVM. The vast majority of pediatric airways can be successfully managed with proper BLS interventions such as the BVM. Yosef: I think the main point of Dr. Screiber was that maybe with peds we need more scoop and run in view that intubation in the field has not been shown to save lives. I am of the opinion that we need to teach EMS to use LMA and bougies.

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Next question: Backboards and cervical collars. When and if to use, and how soon to get off. VL vs DL for intubation. This was also sent in by one of our readers, I apologize that I do not remember who. Marvin: We are getting away from a use always approach to C Collars. Data suggests that in some patients we may do more harm than good. More, in fact, can be said of the back board. It is ONLY a moving device for patients. More and more we are using a vacuum mattress for immobilization and transport. No one should be on a back board for any extended period of time. Use the gurney pad and not the board unless no other options. On issue of VL vs DL, our published data in Prehospital Emergency Care clearly shows the benefit. (DL is direct laryngoscopy, video laryngoscopy) Also, with camera capture we have great QM and teaching material.   Steve: The reader asked about the use of backboards and cervical collars. I’m going to limit the discussion to the latter because more has been written about them. The “standard” for prehospital providers is to place the collar whenever there is any reason by virtue of mechanism of injury or physical exam to suspect a cervical injury. Unfortunately, most take that to mean that even awake, alert patients who are physically capable

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of knowing whether or not they have neck pain should still be placed in the collar based on mechanism alone. The very large NEXUS study showed that most people without midline tenderness do not have a significant cervical injury. (Reader should look over the actual criteria to clinically clear the cervical spine). Some states now allow medics to make a decision not to immobilize if the setting is one that rules out a neck injury. When there is any question the collar goes on. (Reminds me of the patient who arrived at the ED wearing a collar. Doctor said, “We have to get an X-ray of your neck.” “Why, doc, my neck doesn’t hurt?” “But you have a collar on.” “Better X ray the rest of me then. It doesn’t hurt either.”) Keith: Again, there is no evidence to support the use of backboards for spinal immobilization and in fact there is sufficient evidence that they cause harm and pain by skin ulceration and failure to support the spine in an anatomic position. The National Association of EMS Physicians is currently considering a policy statement promoting the use of backboards ONLY for extrication then moving the patient directly to the cot as soon as possible.

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The jury is still out on the use of cervical collars and again because of the fear of a lawsuit their use continues. Yosef: Just want to point out the Prehospital Emergency Care has studied the question if paramedics can clear spines with NEXUS and the answer is positive   You guys are doing great- let's get to the last question from Dr. Todd from MD Anderson How about prehospital end of life decision making. Corita Grudzen'swork from Los Angeles?   Marvin:

An area we teach inadequately and practice even worse. We need more general training for all physicians as well as EMS providers. We also need to educate the public that miracles are just that miracles and there is a need for end of life decisions prior to the event. Our State has a POLST program but it is not as well utilized as it should be. Steve: There are any number of initiatives in the US to try to let patients die with dignity. The barriers include things like the requirement that each such patient have in place (and on his/her person) a signed,
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properly executed document. If all is right, the medic can honor that choice. However, family members not uncommonly disagree with the choice or don’t understand it. There is an effort to get all states to approve use of a form that should make the process more standard. The form is called by various names. In my state it is POLST – Pennsylvania Orders for Life Sustaining Treatment. Once every end-of-life patient has such a form our medics will have a much easier time dealing with this problem. This form applies wherever the patient goes, whereas the DNR does not apply outside the nursing home or hospital. There are also authorities who point out that it is time for us to recognize that there is a time to acknowledge that enough is enough. Only in the US do we spend so much of our healthcare dollars in the last few months of life. Keith: In the US, EMS providers are rarely provided sufficient training and education to make these difficult decisions. This is where the role of "online" communication with a medical control physician over the radio or phone is vital. While it is vital that patients have the right to determine for themselves what care is rendered during end-of-live conditions the reality is that these decisions are often relegated to family members who have called 9-1-1 for help. The optimum solution is the use of clearly written physician orders that are available at the scene of such emergencies.

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Yosef: In Israel, paramedics can discuss this with the family and can pronounce death. I want to thank everyone- this was professional and informative- and great! Our next roundtable is international EM in another four months In conclusion let's quote one last female- in honor of Rick Bukata- it is one of his favorite quotes and one of mine as well: It is better to light one candle than curse the darkness. Eleanor Roosevelt and one more quote of wisdom from R. Dovid Kaplan: If at first you do not succeed- then maybe you shouldn’t take up skydiving.

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