Update 6/29/09 @ 12:36  This may all be a hoax.

NOPE. APPARENTLY THIS IS REAL.

British Media and News Reporting may actually not be related.

The shock findings of the Michael Jackson autopsy | The Sun |News
8st 1oz, no food just pills in his stomach, bald, bruised, his ribs broken by CPR, 4 needle wounds near his heart…

I don’t know if this is real or not, but it sounds … like I have some questions …(1 stone is 14 pounds)

There’s this:

SUFFERED several broken ribs as frantic rescuers pumped his chest after he collapsed in cardiac arrest.

That’s unfortunately normal.  No problems there.

And the (Emergency Medical) weirdness:

Four injection sites were found above or near to Jacko’s heart.

All appeared to result from attempts to pump adrenaline directly into the organ in a failed bit to restart it.

Three of the injections had penetrated the heart wall — causing damage — but a fourth missed and hit one of the 50-year-old star’s ribs.

What?  Intracardiac injections of epinephrine?  I thought that went out in the very early 80’s.  As for ‘causing damage’, needles do that, but the major problems with intracardiac epi are coronary artery lacerations (bad, but not the end of the earth, as the recipient was dead to start with and getting a return of circulation allows time to fix them) and intracardiac muscle injection, which causes intractable ventricular fibrillation, which is Bad.  Capital B Bad.  Usually Unrecoverable Bad.

Where does one even get epi with and intracardiac needle? I’ve been in the business for a good while and haven’t seen one since Paramedic school (82-83) and was then taught it was out of favor.

Nowadays if you don’t have an IV line during a code (it happens) you can squirt it down the endotracheal tube, or, failing that, an intraosseous IV line (shorter needle, not in the heart, works very well) through which all the resuscitation meds can be given.

Interesting.  Nothing to make of it now, but, who’s a) been watching too many Tarantino movies and b) did this?

(I doubt an emergency pericardiocentesis was the reason for the described wounds, as those if done without sonographic guidance are done from the top of the abdomen up, and with sono guidance would be through the chest wall, but with sono guidance you’d know if they needed it or not, and if there was a big pericardial effusion it’d have been in the report).

The article isn’t available yet.  Here’s the pre-publication take from Medwire news:

Crowded emergency departments pose increased risk for chest pain patients

By Mark Cowen

05 June 2009

Acad Emerg Med 2009: Not yet available online

MedWire News: Heart attack patients and those with other forms of chest pain are significantly more likely to experience serious complications after admission to hospital if they were initially treated in a crowded emergency department, US research shows.

“What shocked us is that these complications were not explained by what goes on in the emergency department,” said lead researcher Dr Jesse Pines, from the University of Pennsylvania in Philadelphia. “The adverse events occurred after the patient had been admitted to the hospital. Emergency department crowding is really more of a marker of a dysfunctional hospital.”

Hmm.  Delays are delays, but I’ll wait until I see the actual article to comment more.  My first question: are these different hospitals, or same ED with different censuses (which would be a better apple to apple comparison).

Don’t change where you go just yet.

» Lead Story » mouth to mouth regurgitation.

Pretty much why I’m glad mouth to mouth is fading from the CPR algorithms for first responders….

So typical a colleague remarked on it.

Per our Australasian colleagues:

The Australasian College for Emergency Medicine has reported the first case of a leech being safely removed from a human eye.

A 66-year-old woman from Sydney’s north was gardening in March last year when she flicked soil into her left eye.
…
Doctors at the Hospital removed the leech from beneath her upper eyelid using a 3 per cent saline solution.

Read the very short article to get the story.  Try not to think about a leech being stuck to your own eye.

Now you know.  Also, try not to think about having a leech stuck to your own eye.

Even in a profession, most days are just days at work.  EM is no different: I’ve had a longer than normal string of Just Days.  I was due from a karmic EM point of view.

Karma apparently has a sense of humor, giving me one of the best/busiest days in years.  I won’t go into the individual patients, but they were desperately ill, a lot of them.  Our consultants were terrific, doing their part selflessly, happily.

The Nurses, techs and sundry other professionals were on their games (nurses especially), and it was a pleasure working next to them.

I knew these days were there, still.

Yippee!

I take care of a of of patients with dialysis.  Certainly not all of them, and not even a big percentage of the ones in my county a year, but I do see one to several per shift.  I see dialysis patients, I mean.

I see their families, too.  They’re people, in that they run the gamut from normal to abby, from pleasant to un, from selfless to ish.

The other day I had diagnosed a patient with xxx, and offered an MRI of the same problem, mostly to facilitate the patients’ and consultants’ interaction.

“Oh, we have to get to our evening dialysis appointment” says family member, quickly echoed by the patient.

What?  You’d rather o to dialysis than get the MRI (which is amazingly insightful and probably borne of experience, but I’m not certain.  At any rate I’m not going to argue against it).

“Okay!” says a stunned me.

People who want to get to dialysis.  Sometimes in the ED we wonder if they exist.  They do.

Prologue « Ten out of Ten
…So I’ve come a long way, surviving this adolescent growth spurt, with most of my teen angst now behind me. But it’s funny how life works, just as you find one career obstacle safely in your rearview mirror, another one pops up unexpectedly in front of you. And once again I found myself in unfamiliar territory, flying by the seat of my pants, trying to make the right decisions. It’s a long story that I’ll break up over a series of upcoming posts.

Start here, and read the follow-ons.  It’s The Nightmare for independent EM groups.

Now Pass Your Papers Behind You « Ten out of Ten
Which part of this case do you suppose was the most exciting:

a) The part where her breathing was so labored she was dripping sweat and couldn’t talk?
b) The part where I intubated her?
c) The part where she had an accepting doc 39 minutes after hitting the door?

Exactly…

Parkland hospital streamlines emergency room procedures | News for Dallas, Texas | Dallas Morning News | Life/Travel: Health
Parkland hospital streamlines emergency room procedures

09:44 PM CST on Tuesday, February 10, 2009

By SHERRY JACOBSON / The Dallas Morning News
sjacobson@dallasnews.com

Parkland Memorial Hospital officials on Tuesday announced changes in emergency room procedures to improve care and reduce long waits.

Included is a new process for evaluating patients entering the ER, allowing them to confer immediately with a nurse or paramedic….

The new check-in process already is persuading patients to stay in the emergency room long enough to receive treatment.

Last month, Parkland said, 14 percent of ER patients left without seeing a physician, compared with the 24 percent who walked away in July.

A 14% LWBS rate would cost most ED groups their contract.  Astonishing this is tolerated.

ER doctors sue state, say emergency room system near collapse | L.A. Now | Los Angeles Times
Emergency room doctors filed a lawsuit today against the state, saying that California’s overstressed emergency healthcare system is on the verge of collapse unless they receive additional funding.

…

Emergency room physicians say they have been particularly hard hit by the state’s fiscal problems. Unlike other doctors, who can choose not to accept Medi-Cal patients, emergency rooms cannot deny treatment. They provide care for these patients but are reimbursed at rates they say are half the cost of the treatment. California’s reimbursement rate ranks 43rd in the country, state officials said.

Hmm.  I understand their frustration but wonder what they think they’re going to get from a state that’s essentially insolvent.

The Leap Non-Severity Scale at edwinleap.com
My scoring system for critical illness:

The Leap Non-severity scale:

Profanity:

3 Unable to speak profanity or make profane gestures.

Follow the link, there’s more.  And it’s funny (because it’s true)!

Genius.  Sheer, unadulterated genius.

Aggravated DocSurg: Four Horsemen of a Trauma Death

An excellent post on Trauma and why people dies traumatic deaths.

A couple of weeks ago a really dumb survey was published, which purported to show that a giant majority of EP’s thought police were using excessive force, and I agreed with California Medicine Man that it was at best ill-informed, and most likely wrong.

The original article didn’t go unnoticed by the Police:

Medical Diagnosis: We Suck! – Patrol Tactics Channel – POLICE Magazine
…
It appears to me that there’s a good number of doctors—say about 98% of those polled—out there who are in desperate need of some vertebrae transplants.

Physicians, heal thy selves.

Read the article, and the comments.  Interestingly, they assume it’s true (which I doubt), and the anecdotes about bad medicine flow.

A doctor I used to think had it together shows himself to be yet another ED basher, and a rather arrogant one to boot.

In a blog post today Dr. Centor unloads egregious tripe on me and my colleagues:

The second major concern is over use of technology in the emergency department.  Ask any practicing physician about testing in the ED.  Patients have too many imaging studies.  I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

Now clearly, ER physicians have a high exposure to malpractice claims.  When in doubt, they image.  The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.  We need a multispecialty panel to develop reasonable standards for technology use in the ED.

In case you missed it I’ll rephrase: there are too many imaging tests in the ED because EP’s are too lazy or stupid to do a history and a physical exam, so we just CT everybody.  Additionally, EM isn’t an actual specialty, so other specialties need to meet and tell them what to do.

The contempt he (and apparently his friends) hold the ED in is inexplicable though sadly common.  I’d like to have him explain the patronizing ‘I think we all know why these studies are done’ that’s not doublespeak for ‘they aren’t as smart as we internists are’.

First the monetary rebuttal to this load: as of 2006, ED care was 3.5% of the total healthcare budget.  Squeeze out all the negative imaging studies and it’d be less, but getting a margin out of 3.5% to make a dent in total healthcare expenditures would be difficult to say the least.

EP’s image patients after a history, a physical examination, and in order to rule out life threats while still focusing on the most likely diagnosis.  The statement “when in doubt, they image” is both dismissively arrogant and ill informed.  Are there a large number of scans done in EDs?  Yes.  I’ve called Dr. Centor on this bias hobby horse of his before, but he doesn’t want to hear it.

As for needing ‘multispecialty panels to develop reasonable standards for imaging in the ED’, he’s ignoring two very important things.  First, EM is an actual specialty with its own standards and unique fund of knowledge, since 1979.  From ACEP:

In 1979 emergency medicine was recognized as the 23rd medical specialty, a major milestone for ACEP and its members. The American Board of Emergency Medicine, the independent certifying body for the specialty, was also established and the first certification exam was given in 1980.

Second, EP’s do the studies they do because they have a higher diagnostic yield in the shortest amount of time.  A urologist would prefer an IVP for that hematuria and flank pain, but the CT will pick up the renal artery dissection a lot better than the IVP ever will.  EM is past needing specialists telling us their worms’-eye-view imaging recommendations, thanks just the same. 

Dr. Centor’s proposals about the ED are unwarranted from an economic perspective and unfounded from the medical.  Let’s hope nobody offers him that Health Czar post, and that if there is such a person they focus on actual problems and not peeves.