Well, that’s at least new

Tonight we had house alarm false #3 in about 6 weeks. Geez. Gift baskets for my neighbors.

To the alarm panel I go, and it tells me it’s a glassbreak downstairs. This isn’t good, as were I looking to break into the house I’d do it though the basement (and thus the glassbreaks, motion sensors, punjii-pits and laser traps).

So, to the bottom of the stair I go, and for the first time in my house I’m getting really spooked: someone is breathing heavily on the other end of the long room! I sweep the room behind me, and go to have a look, with the Voice of Doom in my right hand and a suddenly tremulous flashlight in the left. I clear the entire area, and nobody there, but the sound remains.

Then I hear a sharp noise behind me. I looked up to hear sound coming out of a glassbreak detector. Freaky. As I was about to curse the alarm manufacturer, hot water dripped on me.

Glassbreaks will alarm and make audible noise when you run water through them, turns out. The leak is in the dishwasher discharge on the floor above. Water and breaker are off to the dishwasher, and Monday will be calls to the trades.

Yes, by the way, this is the same ceiling the dishwasher dropped during the kitchen remodel several months ago. I have high hopes it’ll stay together and dry out well, though the dishwasher needs a different kind of union to the discharge piping.

I’m going to have the flashlight examined, too.

Farewell, Big Tex

ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

ACEP 2012 Tweets by me: Hoffman & Bukata

I went to the American College of Emergency Physicians Scientific Assembly held in Denver in October, 2012. I live tweeted some of the lectures I attended. Here they are.First, I’m going to combine the tweets from Hoffman and Bukata’s 2 lectures, as they’ll make more sense that way. Then pictures!

Storified by GruntDoc · Sat, Oct 13 2012 12:55:37

I’m going to start with my general Twitter disclaimer. I mean it.
Disclaimer: my tweets from #ACEP12 were paraphrasing, errors mine, don’t change practice based on reading tweets, do your homework.GruntDoc
And, off to the lectures:
HofKata: Trauma surgery is dooming their specialty going to the ER over and over for nothing surgical for them. #ACEP12GruntDoc
Referencing a European paper citing very very few went to the OR emergently from the ER to the OR, recommended calling TSS when the ER doc needs them, not a routine event.
(Will not catch on for a long time, Trauma needs their Activation Fee).
This following one had to do with ?whatever to do with those very tiny occult pneumothoraces we’re finding on trauma CT’s of the chest. Long, meandering discussion; sizes of the PTX weren’t defined, no criteria for getting a thoracostomy tube were made, just ‘did they get a chest tube or not’.
HofKata: discussion muddied as there is not a clear definition for want made the doc put in the tube to start with. #ACEP12GruntDoc
Not much was gotten from that article. Perhaps I missed the point.
HofKata: docs caught between doing what’s right for pt and right for doc; for doc getting test is right answer, not always for pt. #ACEP12GruntDoc
This next one tried to determine, in a ‘pan-scan’ for trauma ED, if there were some agreement on what trauma scans the ED attending and the Trauma Surgery attending could prospectively agree they didn’t need.

All the scans trauma wanted were gotten with a prospective form filled out by both about which scans they didn’t want. In the end the ED…

HofKata: wanted 30% fewer, and the TSS and EM in the end couldn’t decide about the value of the discovered incidentalomas. #ACEP12GruntDoc
They found a bunch of incidental things, and in the end couldn’t reconcile whether finding completely incidental things that didn’t affect management was worth the CT.
HofKata: factor VIIa is 10k for a 70kg pt in trauma and it didn’t help ( the non hemophiliac). Stop it. 97% uf use was off label. #ACEP12GruntDoc
HofKata: if you have 1 CT the likelihood is that you’ll have 5 in the next 5 years. Found a pt w 57 CTs. Wow. #ACEP12GruntDoc
The first CT is a gateway study to more, apparently.
HofKata: but when docs look at the same problem for themselves they typically choose less awful treatment, even if means pal care#ACEP12GruntDoc
Doctors will err on the side of survival in recommendations to patients, when they themselves often look at the data and decide they’d rather forgo some or all treatments and skip the unpleasant effects. Interesting.
HofKata: DC instructions. Pts have to understand, and they have to know when to come back. Ethical prob sending self limited prob #ACEP12GruntDoc
HofKata: to a referral, when its more cost for no benefit. #ACEP12GruntDoc
Bukata felt sending things like ankle sprains to PCP’s as a routine thing was ethically bad, as ‘it’s self limiting’ and costs the pt more for no benefit.
I disagree, many needs some Physical Therapy to have a more stable ankle that doesn’t recurrently sprain.

Also not a fan of these 9 page DC instructions we’re printing out.

HofKata: IO lines are great, and stop doing central lines because you can’t find a vein, use CL if need to measure things #ACEP12GruntDoc
HofKata: no need to give hydrocortisone if you use etomidate for induction. (Silly study). #ACEP12GruntDoc
HofKata: Tylenol w Motrin, and either alone. Point of treating fever comfort, not medical. No support to use both at the same time #ACEP12GruntDoc
HofKata: AAP specifically advises against using Tylenol then Motrin and alternating, confusing. Also, tells mom it’s a big deal. #ACEP12GruntDoc
treating pedi fever is about patient comfort, not treating disease. making a big deal out of fever treatment tells mom it’s very important, when it’s for comfort only.
HofKata: UTIs in small kids: can have asymptotic bacteruria and have a viral illnesses w fever and get dxd w uti. Cults have false+ #ACEP12GruntDoc
HofKata: 2-5% of kids have UTIs before puberty. Not happy about treating a ton. #ACEP12GruntDoc
Many of which were incidental findings, and the treatments can cause their own problems.
HofKata: study of 1,228 acute scrotii showed +creamasteric reflex w dxd torsion! 7% had NL or increased flow on US!? #ACEP12GruntDoc
Several people disliked my plural of scrotums being scrotii. I believe scrotae is the correct plural.
HofKata: test torsion, cont: advocates getting a iron consult for those w real sx’s and a negative w/u. Then cites anecdote. #ACEP12GruntDoc
uro(logy) got autocorrected here to iron, No idea why.
HofKata: study of Canadian hosp quick response teams. No difference. Things that seem reasonable often don’t work. #ACEP12GruntDoc
HofKata: several papers, PCR tests didn’t change abx rxing, CRP in URI resulted in 6 hour ED stays and no change in abx Rx, etc #ACEP12GruntDoc
Things being tried to tailor or eliminate antibiotic prescribing don’t. At least not in these studies.
HofKata: docs are reluctant to abandon disproven practices "ESP when lucrative". Most standards of care have never been studied. #ACEP12GruntDoc
HofKata: BNP for dyspnea in the ED. "Routine testing is of no benefit". Targeted okay. #ACEP12GruntDoc
HofKata: high sens Troponins: markedly higher positives, but 90% were causes other than AMI. (I don’t know want this). #ACEP12GruntDoc
Joe Lex ( @JoeLex5 ) commented on this later, ‘you mean low specificity troponins?”, rather than the as-spun high sensitivity. He’s right.
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
HofKata: stable angina, med mgmt vs stenting: medical therapy on top for everything x persistent pain. #aGruntDoc
HofKata: the US spends 150mil A DAY on angiosperm and stents, most never had a trial of med therapy. #ACEP12GruntDoc
Okay. for some reason the iPad autocorrect thought Angio meant angiosperm, which is weird. I don’t type well, things are flying by, and so I didn’t proofread that one before I hit send. (there were several comments later which I didn’t get, so didn’t play along)(It was busy in there, with all the tweeting and misspelling).
HofKata: shocker: STEMI pts needing transfer for PCI didn’t get transferred within 30 minutes. Median time was 64 minutes. #ACEP12GruntDoc
Bukata said they fixed this at his joint by having the same EMS crew that brought them in take them out, which was very fast, and with the right conversation EMS was all over it.
HofKata: if you can get to the cath lab in less than 4 hours its better than TPa. The 60 min rule for TPa is based on no evidence. #ACEP12GruntDoc
HofKata: then says he’d rather have TPa than stenting. (Weird). #ACEP12GruntDoc
The weird was mine. I don’t get that.
HofKata: 124k STEMI pts w CABG capability did cath then CABG 3%, without very rare. CABG grps did worse. #ACEP12GruntDoc
Wow, confusing tweet.
Issue was, is it safe to do caths in places that cannot do ‘rescue CABG”? In a study of 124K pt’s in centers with and without ‘rescue CABG’ ability, answer was yes, and in places that could do CABG it was done a whole lot more than places where it wasn’t; occasional pt had to be transferred to CABG place, but not many.
HofKata: ABCD2 score for stroke after TIA isn’t reliable. Another data dredging tool fails in real life. #ACEP12GruntDoc
HofKata: redefinition of Tia w MRI findings of infarct to stroke makes both groups look better: makes studies over time hard #ACEP12GruntDoc
Way more ‘strokes’ are now very minimal (what we used to call TIA’s) so the ‘stroke category looks better, and the TIA category looks smaller. Will confound studies looking both directions.
This next one it a review of IST-3, the never-ceasing desire to give TPa to every stroke no matter the time elapsed.
HofKata: IST-3 showed in a no blinded study using untrained family members as evaluators showed a tiny trend to improvement. #ACEP12GruntDoc
HofKata: IST-3 the first 300 pts evaluated by neurologists showed the tpa out to 6 hrs is much worse. #ACEP12 scathing editorials yesterdayGruntDoc
Family members, who knew whether or not their loved one got the TPa were asked by postal mail to evaluate their loved ones’ recovery, trended better for those who got TPa. Bizarre study bias built it. To say they were unimpressed would be an understatement.
HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12GruntDoc
“@gruntdoc: HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12” surprise surpriseJennie
HofKata: Geriatric and dizzy with a normal neuro exam will not have ICH. Based on a paper from 1998 w 4 pts found to have cblr bld. #ACEP12GruntDoc
There’s a practice that’ll be hard to change.
HofKata: no decent studies on ischemic stroke leaving BP up or the older lowering. Unless going to give TPa. #ACEP12GruntDoc
HofKata: kids w brain rumors typically represent w recurrent headaches, etc. authors rec scanning in kids w recurrent ha. #ACEP12GruntDoc
Means, don’t scan a kid on first HA or first week of HA.
HofKata:Canadian SAH CT study w 3rd gen scanner didn’t LP 50% of the pts in study. Gold std was pos CT. 30% lost to f/u. LP for SAH #ACEP12GruntDoc
HofKata: says Dr Newman who presented this paper yesterday as not needing LP is incorrect. #ACEP12GruntDoc
This could be ACEP’s first Pay Per View smackdown, Hoffman vs. Newman on this Canadian CT for SAH study.
HofKata: accumulating evidence quinolones can cause neuro sx’s. still safe drug as denominator is vast, but be aware. #ACEP12GruntDoc
HofKata: giving reglan over 15 vs 2 mins decreased the akathasia. 7% vs 26%. #ACEP12GruntDoc
Turkish study, makes sense.
HofKata: CO poisoning. Hyperbaric didn’t help, showed no benefit over high flow o2. Small study. #ACEP12GruntDoc
HofKata: studied on neurosurgeon, 1/2 sit vs stand on first postop visit. Again, pts like the seated visit. #ACEP12GruntDoc
Shocker here was that this was timed, it was these NS pt’s first post-surgical visit, and they lasted about a minute and 10 seconds. Wow.
HofKata: 8% of German studies eligibility criteria weren’t included in the paper,13 published modified info. Can’t extrapolate1/2 .#ACEP12GruntDoc
HofKata: 2/2 those findings to groups that were excluded. Theme is that funded studies seem to play fast and loose w reporting. #ACEP12GruntDoc
Throws a lot of what’s published into doubt, and when they don’t report excluded groups we assume their results are applicable for the general population, which isn’t correct.
What about the deep dive into the study information that’s given to the FDA from drug companies, that’s easily digestible, right?
HofKata: Cochrane authors report that it would take 2 FTEs 14 months to analyze, and found things never addressed in the papers. #ACEP12GruntDoc
The papers mean the studies that get publishe in journals. Not getting the whole story.
HofKata: Cochrane cont: the US FDA wouldn’t give the data, had to get from AUS. puts a lot of the publications in doubt. #ACEP12GruntDoc
Interesting.
This was about the new ‘high sensitivity’ troponins that are about to come out, for what reasons none of us in EM can discern, as it absolutely isn’t helpful…
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
Thanks, but I just tweet it. The glory goes to the lecturers, some were phenomenal. “@fayazg99: @gruntdoc fantastic stuff!” #ACEP12GruntDoc
Great coverage! RT @gruntdoc: That ends the lectures for me for today. Hope you enjoyed my coverage.Doc Gurley
@docgurley Awww, shucks ma’am. *tips hat*.GruntDoc
Meeting the social media twitter and blog greats at #ACEP12 @emcrit @gruntdoc @drrwinters @movinmeat @EMDocBrett http://pic.twitter.com/D6dLKId3Alexei Wagner
@JoeLex5 s 3 rules of emergency medicine:1) the nurse can hurt you way more than you can hurt themGruntDoc
@JoeLex5 s 3 rules of emergency medicine:2) you will never waken someone with narcan that you will like more awake than asleepGruntDoc
@JoeLex5 s 3 rules of emergency medicine:3) the LP target is always 1cm deeper than you think.GruntDoc
@JoeLex5 s 3 rules of emergency medicine:4) bonus: if you really don’t want someone to elope, hide their shoes.GruntDoc
“@gruntdoc: All the twitterers from #ACEP12 in one place. The rest of you are safe. For now. http://pic.twitter.com/j8i2uwb0” Wish I was there….realEDdoc

8 Pound, 9 Ounce Baby Born on 10/11/12 at 13:14 | CNSNews.com

That’s all the story you need to read, right there.

8 Pound, 9 Ounce Baby Born on 10/11/12 at 13:14

Des Moines baby a numerologist’s delight

via 8 Pound, 9 Ounce Baby Born on 10/11/12 at 13:14 | CNSNews.com.

The most entertaining celebrity political endorsement of the century

I’m not endorsing the candidate, just the ad.

 

Steve Martin is terrific.

An Elegantly Icky Solution

Entertaining and medical!

I’d love to shield the identify of the patient in this story. But I can’t, and you’ll understand why in a minute. It’s not that I’m worried about a HIPAA violation or a law suit. After all, the patient was my mother-in-law. She and my father-in-law – Pop Pop – have moved in with us . . . so they aren’t going to sue anybody. And while I hesitate to embarrass my soft-spoken “Mom Mom” with the details of this tale, I have to tell this story straight. Here goes.

via An Elegantly Icky Solution.

Sounds like something we need to try earlier.

Movin’ Meat: Are low acuity patients congesting the ER?

Big big Kudos to MovinMeat for bringing data to an argument that seemed doomed to opinion-lock.


I have pointed out in the past that my BS-meter starts pinging when people start claiming that the ER is only caring for emergent patients and that non-emergency cases are rare. So this set me off, of course. My perception — and that of many of us in the trenches — is that we are absolutely beset by non-emergencies and that the ER is viewed by many as the "convenience clinic," if not the "vicodin clinic." But is this true? How can we quantify this?

via Movin' Meat: Are low acuity patients congesting the ER?.

It’s a terrific post. It’s worth your time.