Archive for the ‘Medical Studies’ Category

Literature Pearls

Wednesday, March 7th, 2012

A few interesting topics caught my eye in the literature lately.

From the Journal of Emergency Medicine (full article on Medscape): Tessalon Perles can be dangerous in an overdose. This case report shows how a teenager who took 10 pills in a suicide attempt presented in cardiac arrest, was successfully resusciatated, then ended up losing her eyesight and developing permanent psychiatric problems.

From an eMedHome.com Clinical Pearl: Aggressive diuresis in patients with neurogenic pulmonary edema may worsen outcomes. Delayed cerebral ischemia is the most common cause of secondary neurologic injuries in patients with aneurysmal subarachnoid hemorrhage. By reducing preload through diuresis, the resulting hypovolemia may decrease cerebral perfusion pressures and cause additional neurologic injury. Recommendations are instead to maintain normovolemia and use positive pressure ventilation to maintain respiratory status. References here and here. Has any one tried this?

The constipation may be nasty, but the treatment can kill you. Retrospective review shows that Fleets enemas in standard doses can cause renal failure, severe electrolyte abnormalities, and even death in elderly patients. Back to the ol’ “high, hot and helluva lot” soap suds enemas?

The Angry Mime

Friday, February 17th, 2012

An older gentleman comes in because he has a “sinus infection” for the past couple of days.

As soon as the triage nurse brings him back, she’s already whispering to the other nurses. Later, I learned that she told them to make sure that I get the patient. She’ll get her paybacks later.

The man was upset because the ZeePack he got from his primary care physician wasn’t working after he had taken a couple of doses. He wanted some stronger antibiotics “like Augmentin or some Levaquin 750s” to make sure that his sinus infections went away. Triage nurse is really going to get her paybacks.

I examined him. He had no sinus infection. He had sinus congestion at best, but even that was questionable.

I dutifully explained that even if he did have sinusitis, studies show that antibiotics confer little or no benefit on patients with uncomplicated sinusitis. In fact, the best things for sinus congestion/sinusitis are topical decongestants and nasal irrigation. I even printed out a copy of the JAMA study and handed it to him. Then I gave him a couple of squirts of Neo-Synephrine in each nostril. Ten minutes later, he was much less congested and felt much better. He thanked me and promised to go home and use the nasal rinses.

That was about 7PM.

At 2AM, he shows up again and he is hot under the collar. I walked into the room and asked him what happened.
“That Neo-Synephrine makes my blood pressure go too high and I read that those nasal washes can give you brain infections, so I’m not taking them. I haven’t slept yet tonight and I want some Levaquin NOW!”
I told him that Levaquin wouldn’t help and that I wasn’t going to prescribe it for him. I started to mention that he could use sterile water in the nasal irrigation and try some Benadryl for his congestion/sleep problems, but he interrupted me.
“Well then, this was a complete waste of time.”
And with that he got up and walked out of the door.
Or at least he tried to walk out the door.

Only problem is that the doors are locked and patients have to be buzzed in and out of the department. When you’re angry, there isn’t an exception to that rule. He went to the regular exit, tried to open the door, pounded it a couple of times and walked back in the department toward the ambulance bay. People ran after him calling “Sir! Sir! This way, sir! Wait!”

He would have none of it.

He got to the ambulance bay doors and tried to pull them open with his bare hands. Nope. You have to use a button to open those, too. Then he started shaking the doors. Nope. They still won’t open.

We have cameras all over the place, so while he’s freaking out and people are trying to help him, everyone else is watching his antics in the camera and admiring his technique. It’s like a new reality TV series.

Then the patient makes one final mighty effort to pull the ambulance bay doors apart. And in the camera he looks just like an angry mime straining against an immovable object. His body shakes ever so slightly. His face gets red. Then … the doors open.

Waaait a minute. We looked across the nurse’s station to the control panel. The respiratory tech stood there smiling.
“Hey, he was going to break the door if he kept it up.”

And with a one-finger salute, the patient stormed out of the emergency department and into the ambulance bay, in further search of the holy grail of mucous sterilants: Levaquin 750s.

Doesn’t it figure that now he’s twice as likely to get a Press Ganey survey.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

By the way, completely unrelated, but any time I think of mimes, this video comes to mind. Don’t know why.
Just like any time I think of pipe fitters, this story comes to mind.

Government Safety

Saturday, October 29th, 2011

Remember how the government health care wonks at the CDC thought random HIV testing in the emergency department would be such a great idea?

Things didn’t quite turn out that way in France.

A study in France published in the Archives of Internal Medicine showed that out of 138,000 emergency department visits, 21,000 patients were offered testing and 12,754 actually received testing.
Out of those tested … drum roll … a rocking 18 patients received a new diagnosis of HIV. That’s 0.14%. Or .1400000000% if you want to thumb your nose at JCAHO.
But wait … that’s not all! Of those 18 patients, most were in high-risk groups, had previously been tested for HIV, and were in late stages of the disease. In other words, the patients probably knew that they had HIV before the testing and the docs probably could have told them they had a high probability of having HIV before doing the test.

An HIV test costs $200. Multiply $200 times 12,754 tests and you get $2.5 million spent on testing alone. Then throw in all the wasted nursing and lab time performing the testing instead of providing medical care. That money could provide a whole lot of childhood immunizations.

Oh, and while you’re at it, screen every patient for domestic violence, tuberculosis, substance abuse, heart disease; type everything into a computer so we can measure how quick you’re performing your tasks; see more patients with less resources and higher patient loads; make sure you wash your hands 100 times per day (which would require roughly 1/5 of your entire 8 hour shift to do so); fill out all the other ancillary paperwork involved in creating a safe work environment; and do anything else we think might make people safe but haven’t proven yet. Got all that?

But studies cited by the CDC in the US show that the rate of new diagnosis for patients at hospitals in Los Angeles, Oakland, and New York was between 0.8 and 1.5%. Does that mean that patients in those areas have ten times as much risky behavior as patients in France? Ten times the drug use? Ten times the unprotected sex? Maybe it’s just those French people creating false data trying to make the CDC look bad.

Every patient entering our rural hospital’s obstetrical ward has to either consent to testing for HIV or has to sign a refusal. So far, we’re batting .000 in catching those early asymptomatic cases of HIV.

Cost effective and medically necessary health care. These can be the only result of “safety” directives imposed by government agencies.  Kind of like a directive to perform blood cultures before instituting treatment for pneumonia. Oh, wait, I don’t recall seeing any scientific evidence showing the benefit of that directive, either.

Policymakers wonder why health care costs and delays in care are skyrocketing?

Its own mandates are the rocket fuel.

Got emphysema, asthma, arthritis, or inflammatory bowel disease? Eat broccoli.

Sunday, October 23rd, 2011

I was forwarded an article that seems boring, but had an interesting catch to it.

You  may not have known this, but denitrosylation of HDAC2 by targeting Nrf2 restores glucocorticosteroid sensitivity in macrophages from COPD patients.

The study showed that in some forms of chronic inflammatory diseases, such as COPD/emphysema, acute respiratory distress syndrome, asthma, rheumatoid arthritis, and inflammatory bowel disease, a chemical reaction within a transcription factor called NRF2 within the cells causes them to be less sensitive to steroid therapy. When study patients with COPD were given either glutathione or sulforaphane, the chemical reaction was reversed and macrophages within the alveoli of the lungs became significantly more responsive to steroids.

One food that is high in both glutathione and sulforaphane is … broccoli.

Did a little extra research on the internet and found that glutathione is also contained in asparagus, potatoes and many green leafy vegetables and that sulforaphane is also contained in cabbage, cauliflower, bok choi, and those same green leafy vegetables.

And … one of the things that depletes glutathione in the body is Tylenol.

Also ran across a study in 2009 showing that the Nrf2 factor also plays a role in Helicobacter pylori infections and that ingestion of broccoli sprouts decreased byproducts of H. pylori infection by 40%.

Makes me wonder whether these chronic inflammatory diseases may have some type of bacteriologic basis.

Now they just have to do a study to find out many people would rather have COPD exacerbations than eat broccoli or green leafy vegetables every day.

Dangerous Medications for Kids

Thursday, March 24th, 2011

From an eMedHome.com “Clinical Pearl”

Medications which, when taken even in small amounts, can have significant adverse effects on young children.

  • Camphor, which is contained in many OTC products such as vapor rubs and Tiger Balm
  • Quinine, such as in some cardiac medications and in Placquenil which is used to treat lupus.
  • TriCyclic Antidepressants such as Elavil
  • Oral Hypoglycemics, such as diabetic medications glipizide and gluburide
  • Calcium Channel Blockers, which are fairly common blood pressure medications   
  • Methyl Salicylate, found in limaments such as Ben-Gay and as an artificial flavoring in peppermint, spearmint, wintergreeen (think of Life Savers and Altoids)
  • Theophylline, an asthma medication which has fallen out of favor in the US.    
  • Imidazolines, which are contained in the blood pressure medicine clonidine, but which can also be found in over the counter medications such as Visine and Afrin 
  • Lomotil, a medicine for severe persistent diarrhea.
  • Toxic Alcohols – such as methanol which is found in many paint removers/varnishes and which is metabolized to fomraldehyde and formic acid in the system. Ethylene glycol is also another toxic alcohol found in antifreeze and de-icing products.

If Poison Control Centers close under nationwide budget cuts, information like this (including treatment options) will be less availble.

Safety of Medical Care in US

Wednesday, February 9th, 2011

Remember that statistic from the 1999 Institute of Medicine report that trial lawyers like to throw in everyone’s face about how “up to 98,000 people in the US die each year due to medical mistakes”? It’s like TWO 737 jetliners crashing every day … and we’re doing nothing about it.

So today a news story was sent to my inbox that included Saudi Arabian Ministry of Health statistics on medical malpractice. The report shows that there were 1,356 cases of malpractice in Saudi Arabia in 2009 and that “129 people died from medical mistakes in 2009.” Of course, the 129 number seemed quite low to me given the 98,000 number that is constantly cited in the press. Maybe Saudi Arabia’s population is just smaller than I thought.

Nope. Saudi Arabia has a population of roughly 26 million – about 1/12 of the 310 million people in the United States.  Multiply those 129 Saudi Arabian deaths by 12 and the population adjusted death rate from medical mistakes in Saudi Arabia is 1,548 — versus 98,000 for the United States.

Look at it another way. Divide 98,000 deaths from medical mistakes in the United States by a population of 310 million and you get about 316 deaths per million population in the United States due to medical mistakes.
Divide 129 deaths from medical mistakes in Saudi Arabia by 26 million population and you get about 5 deaths per million population in Saudia Arabia from medical mistakes.
316 deaths per million in the US versus 5 deaths per million in Saudi Arabia.

Is medical care in the United States that much worse than in Saudi Arabia — even without the benefit of safety agencies such as the Joint Commission and HospitalCompare.gov?
Or do unrealistic requirements from “safety” organizations such as the Joint Commission and “quality measures” from our government actually cause more deaths from medical mistakes?
Or are the Institute of Medicine’s numbers so far off that they shouldn’t be believed?

I did a little more searching.

This parliamentary paper from the United Kingdom pegs deaths due to medical “incidents” at about 3,500 per year in England. In a country of 52 million people, that averages out to about 67 deaths per million population – still about one fifth of the alleged United States numbers.

Then I found a Canadian study showing that the range of deaths from “medical misadventures” in various industrialized countries ranges from 1 per million population to 10 per million population. The US is in the middle of the pack at about 6 deaths per million population per year – which equates to about 1,860 deaths per year from “medical misadventures” in the United States.

1,860 deaths versus 98,000 deaths

Why are the numbers in that IOM paper such outliers?

And why do the trial attorneys keep citing it as gospel?

New CPR and ACLS Guidelines Published

Saturday, November 27th, 2010

The “ABCs” that emergency medical providers have come to know and love has now been changed to “CAB” – as in Circulation first then Airway then Breathing.

Gordon Ewy finally gets well-deserved recognition for his compression-only model of CPR and its significant improvement in patient outcomes. Compress first, compress hard, ask questions later.

These are just a couple of the many changes in the updated CPR/ACLS Guidelines.

The entire set of guidelines is available for review and download at Circulation’s web site. Get them now for free while they are available.

Press Ganey Article

Friday, September 24th, 2010

Remember that survey that we did last fall about Patient SatisFICTION?

Two of the editors at EP Monthly finally used some of the survey results to create an article about Press Ganey.

Interesting reading …

2+2=7? Seven things you may not know about Press Ganey Statistics

Urine Toxicology Pearls

Saturday, August 21st, 2010

Drug seekers will love this post.

EMedHome.com recently published a set of pearls about urine drug testing that included several things I wasn’t aware of.

Did you know that …

  • Urine levels of “ecstasy” (MDMA) need to be quite high before they will be picked up by the urine drug screen since the tests have a low sensitivity for MDMA?
  • Zantac, Prozac, and labetolol can all cause false positive results for amphetamines?
  • Zoloft and Daypro can cause false positive drug screens for benzodiazepines?
  • Several benzodiazepines are difficult to detect on urine drug screens – including Librium and Versed?
  • Levaquin, Cipro, dextromethorphan (common in OTC cough meds), rifampin, and verapamil can all cause false positive tests for opiates?
  • Standard urine toxicology screens do not usually detect Vicodin, Tramadol, Fentanyl and Percocet?
  • Ingestion of one poppy seed bagel can cause a false positive opiate test?
  • Most drugs are undetectable 3 days after use?

Links to some of the cited articles are here, here, and here.

By the way … if you came across this post in a web search on how to beat drug tests and now think you’ve got it made – don’t worry. There are plenty of other ways that doctors can tell whether or not you’re using drugs.

I’m not giving away all of our secrets.

Attack of the Superbugs

Thursday, August 19th, 2010

Antibiotics for viral infections are a big pet peeve of mine. No. Make that a huge pet peeve.

Some doctors prescribe antibiotics for coughs and stuffy noses because the patients want them. If you’re one of those patients who think that antibiotics make your coughs go away, or clear up your stuffy noses, or somehow make your sinus headaches vanish, or if you’re a doctor who prescribes antibiotics for these symptoms, this post is for you.

You’re killing people with your dumb demands and/or your inappropriate prescriptions.

MRSA stands for methicillin resistant staphylococcus aureus. There is regular staph aureus – that bug is pretty much fading into the sunset and being replaced by staph aureus on steroids. Because so many people are requesting/using antibiotics for non-bacterial infections, the bacteria in their systems learn how to beat the antibiotics – in effect, making the antibiotics useless. For example, in our area, Levaquin is frequently prescribed by many doctors for obvious viral infections. Then, when people have a urinary tract infection, almost half of the strains of E. coli – the most common urinary tract pathogen – in our town are resistant to Levaquin and Cipro and all the other drugs in that family that would normally kick E. coli‘s butt. We have had several patients who had simple UTIs turn into serious systemic infections because they were initially treated with Cipro or Levaquin for their urinary tract infection and the antibiotics didn’t help.

Now there’s a super duper bug that’s coming to a town near you. According to a recent article in Lancet Infectious Diseases, bacteria are now picking up a new gene called NDM-1 that makes the bacteria resistant to almost all antibiotics. Most of the bacterial with this gene were E. coli, but the gene can apparently can be relatively easily transferred to other bacteria. The only antibiotics that bacteria with this gene were sensitive to were tigecycline and colistin. Right now most of the isolates are in India and Pakistan, but it is only a matter of time before the super duper bugs have spread worldwide.

A 2007 JAMA article showed that MRSA infections were abundant (.pdf file). An editorial accompanying the JAMA article noted that “The estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000).” In addition, the editorial noted that if the predicted number of MRSA deaths was accurate, the 18,650 MRSA-related deaths in 2005 “would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States.”

Currently, a study by the CDC is claiming that the incidence of MRSA is declining (I wasn’t able to find the study on the CDC’s web site) by between 17 and 27 percent in the past few years.

Even if MRSA goes away – which it won’t – there are still other resistant bacteria out there that are going to become a greater part of our lives. According to this San Fransisco Chronicle article, there’s “extremely drug-resistant tuberculosis” (XXDR TB). Doctors don’t even know how to treat this disease – or if they even can treat it. Less resistant TB can cost $100,000 per year to cure. Patients with XXDR TB will probably just die.

The San Fransisco Chronicle article also notes that drug-resistant infections killed more than 65,000 people last year – more than prostate and breast cancer combined. In excess of 19,000 of the patients who died from drug-resistant infections had MRSA.

So how do we stop the spread of resistant bacteria? It’s actually pretty simple.

1. Patients need to stop requesting antibiotics for nasal congestion, coughs, bronchitis, and “sinus infections.” Doctors need to stop prescribing antibiotics for these diseases. Norway nearly eradicated MRSA just by restricting antibiotic use. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better.” The slogan on a packet of tissues in Norway says “Penicillin is not a cough medicine.” See another article on Norway’s approach to antibiotic resistance here.
If we can’t change the habits of doctors who prescribe antibiotics in this country, then antibiotics need to become controlled substances and regulated by the DEA. It is that serious of a problem.

2. Wash your hands. Patients, doctors, everybody. Wash … your … hands. One friend wrote me and asked whether or not you’ll be viewed as a “trouble patient” if you request that your doctor wash his or her hands after entering your room. My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator. If, on the other hand, you tell them “wash your hands you filthy friggin barnyard animal”, you’re asking for a loogie down your back when you’re not looking.

The video below kind of sums up the whole handwashing idea. I don’t watch TV, but apparently the green on the woman’s hands ends up killing her in the next episode.

Thanks to SeaSpray and to GrumpyRN for the ideas for this post.

Wash … your … hands

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