I’m good at intubating (the procedure by which a tube is passed through the vocal cords into the trachea to assist ventilation). I’m not the world’s expert, and I haven’t written a book about it, but I know what I’m about. I was trained by people who knew what they were doing, and I (and my patients) owe them a debt of gratitude. (Lotta I’s there, sorry).

Very occasionally, I get to help out my partners in Emergency Medicine practice when they’re in a bind with this procedure, and I do.  It’s always fun, and a little gratifying, to ‘get the tube’ when a colleague (and their patient) is in trouble.

As Ron White says, “I told you that story so I could tell you this one…”

Pride goeth before the fall.

I have come to learn that one of the worst sins of a physician is Pride. This is strictly different and separable from confidence, in that confidence is a normal and rational belief in ones self and abilities whereas Pride is based in ego, irrespective of confidence. Or logic, for that matter.

The worm turns, and I’m the one who cannot get the tube in the trachea. I’ve preoxygenated, sedated, RSI’d, and taken 3 tries. I’ve changed tubes, blades (the laryngoscope has differently sized and shaped blades), and patient positioning which are among the things that should be adjusted in the event of intubating failure. The good news? This patient can be oxygenated and ventilated easily with the bag valve mask. The bad? I’m now no closer to getting the airway secured with a cuffed tube than I was when I started.

This is where not having Pride came in: I asked for help. The Prideful EM doc (or the one in solo practice, and I respect the heck out of all of you) will keep trying, and will eventually help the patient and assuage their ego (or their situation) by getting The Tube. This can come at a cost to the patient in airway trauma or worse, and it’s desirable to avoid that.

My colleague physician came in, smiled, and helped my patient and me out of a bind. Colleague made it look ridiculously easy, with a first attempt intubation. Just like I’ve done before…

He was amazingly humble, and didn’t rub my nose in my failure to intubate. I truly hope I’ve been as nice to my colleagues in the same situation. Really, he was as nice as a human could have been while pulling chestnuts from a fire. Mine, to wit.

And I surprised myself by asking for help with a procedure I’m normally good at. No Pride, no Ego, just what’s good for the patient. I’m getting this Doc thing.

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…peddling the same tired phenomenon of magical thinking regarding the diagnostic miracle of highly sensitive troponins…

via Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA.

Nice! Go and read.

via @nickgenes on that Twitter thing…

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What would that new ED look like, from the following viewpoints :

• the patient
• the triage nurse (is there one?)
• the treating nurse
• the ED doc
• the consultant
• the hospital admissions team (billing)
• the OR
• the Tele units
• the Floor units
• ED discharge areas
• physical plant

I have a few ideas, but am frankly hamstrung by a lack of ‘out there’ imagination. Let’s hope you’re not similarly limited. Don’t feel like you need to answer all of these, but I’m interested in your ‘out of the box’ ideas…which you’ll get full (if ephemeral) credit for.

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Eli Lilly is withdrawing drotrecogin alfa (Xigris) from all markets worldwide after a major study failed to show a survival benefit for patients taking the drug.

…

Xigris should be discontinued immediately in patients currently receiving it and should not be started in new patients, the company said.

The trial with the bad news on Xigris was called PROWESS-SHOCK, a placebo-controlled study with 28-day mortality as the primary outcome and planned enrollment of nearly 1,700 patients.

via Medical News: Sepsis Drug Pulled from Market – in Product Alert, Prescriptions from MedPage Today.

At ACEP the reviewers of this study said it favored placebo over Xigris. Tough to market a very very expensive drug when not using it is better…

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These are trimmed from my tweets ( http://twitter.com/#!/gruntdoc ) and should you be interested, all the Scientific Assembly tweeters were using the hashtag #sa11.

My rough count for the ones I included here is 95. Some are more interesting than others. Enjoy.

Asplin says its harder to collect from high deductible/HSA pts than from self pay. Seems odd. Asplin

1% of population accounts for 30% of all spending in a given year, 5% account for HALF. 20% spend nothing. There’s your problem.Asplin

Understatement: there’s a gap between the vision and the reality of the Medical Home. Asplin

ER docs make the most expensive routine decision in healthcare: admit or home? We have little to no control over readmissions. Asplin

(David Seaberg, ACEP President): ED docs are 4% of total us docs, give 40+% of acute care visits, and cost 2% of the budget. Value.

Hoffman: everything from 1974 ACLS course we know know is wrong. Interesting how we can change received knowledge quickly.

Hoffman: our fascination with dead people (CPR) is not good, being dead is a bad prognostic sign.

CPR before shock doesn’t help. So, don’t delay a shock to do CPR (was a theory that ‘some circulation before shock’ is better).

Bukata: individual risk factors for mi don’t matter for that one pt in front of you: populations yes, individuals, not so much

Hoffman: easy to find a rule with data trolling, and these rules typically fall apart the more they’re studied. Clin judgement better

Hoffman: VAS scales are for research because they’re repeatable in research, not because they’re reliable.

Bukata: surgeons used to ask “what’s the white count”, now they ask “what’s the ct show”? Silly

CXR before 100d of life increased CA risk 1-2%.

[W]ith anesthetics for dig blocks Hoffman: again, epi in digits isn’t going to make fingers fall off

Herbert/Swadron on Cardio lit:

LBBB&MI: dogma is lytics w CP; they don’t rule in more than those without an LBBB. Clinically having the big one? Treat w lytics.

Soon to appear: ultra sensitive Troponins (not what you have now, which is a sensitive Troponin). Very sensitve, but only 14% specific

(with the new ultrasensitive troponins): How about short interval Troponin testing? Need a rate of rise >50% for mi, 9/10 positives are false positives

CT coronary angio: high rad exp (500 cxrs); lack of clear outcome meas; too much Ca, can’t do; need a HR <70.

More stents and cabg with the CTA, it’s an anatomical study and cards tends to fix the plaques.

Strehlow from Stanford. Cutting edge care for CHF. Hyper/normo vs hypo are the two big therapeutic groupings.

CHF: bedside sono shows “lung rockets”, fluid filled alveoli transmitting sound. Distinct from artifact in that they’re full length.

CHF BiPap NNT 6 to save a life. That’s a good intervention. CPAP and BiPap normally considered equivalent.

High dose nitrate drop safe in normo/ hypertensive CHF (big doses, too, like 450 mcgs/min).

Morphine not recommended in decomp CHF. Increased intubations and ICU admits. Not a potent venodilator

Ntg infusion for decomp CHF : start at 100, titrTe up q5 until better, map down by 30%.

Ace inhibitors. Low dose. Per lecturer, acute use during hospitalization does not increase renal failure or cause hypotension

Nesiritide doesn’t help. No diff from placebo in NEJM 7,000+ pt study just out.

Hypotensive CHF pts. They’re the ones with really high mortality. Dobutamine increases CO, but also increases dysrhythmias and no pos effect on mortality.

As an aside, “business casual ” apparently has no working definition. ER docs are a ‘comfortable’ group, and it shows.

Bukata: abx for lower resp cough. Don’t help. It’s a 3 week dz, abx don’t help. Don’t call it bronchitis, call it a “chest cold”

Bukata. Albuterol inh helps bronchitis only if they actually have bronchospasm, not for everyone.

Hoffman. Codeine doesn’t help as a cough suppressant in yet more studies. (would work in a big dose, but side effects preclude).

Bukata. Oral ketoralac is a black and decker stomach wrecker. IM ketoralac is no better than 800ibuprofen in 3 identical studies.

Bukata: scribes. Feels scribe is too narrow a term, should be ‘personal assistant’ (and I agree).

Bukata: scribes increase billing, are valuable for a lot of things beyond the chart, but they didn’t increase throughput.

Hoffman/Bukata Handoffs should be face to face with the patient and both docs. Better care (which is a guess) and better pt sat.

Hoffman/Bukata mandatory flu vaccine (in a NH) showed less pt deaths. For mandatory vax. Flu in US kills same # as breast CA.

Hoffman/Bukata from 1998 to 2007 trauma ct/MRI increased 3x, dx no more life threats, increased LOS 126 min. For no benefit.

Hoffman/Bukata Massive Transfusion Protocol works if you live long enough to get all the products.

Hoffman/Bukata the worse the pt looks clinically, believe a negative FAST exam less. Don’t stop there.

Hoffman/Bukata often we have to ‘give permission’ to older pts to take narcs. Raised drugs are evil, have to let them know it’s okay.

Hoffman/Bukata10-30% of pts thought to be having a CVA don’t. Good news? Pts w stroke mimics aren’t harmed w TPa. Cold comfort. (Hoffman/Bukata more on TPa. Their numbers are low enough you’d miss a bleed,so it’s not actually safe to TPa stroke mimics, try not to)

Hoffman/Bukata if your doing the ABCD2 score for Tia risk strat, you can stop. It doesn’t work, again. Stuff you find by data dredging never pans out.

Hoffman/Bukata foleys in the ED. ED worst place to put them in, done for nursing convenience often (which is wrong).

Hoffman/Bukata. Flomax does not actually help pts pass ureteral stones (paper favored placebo).

Hoffman/Bukata. Perc rule for PE misses 1/6 for PE. too complex a dx to devolve to a rule.

Swadron/Hebert ACLS now has tox chapters, and made recs on rattlesnake bites. This is not the ACLS we remember.

Swadron/Hebert BLS main emphasis is on good quality CPR and early defibrillation. Recurrent theme in ACLS.

Who is America’s most famous doctor? Ken Jeong, IM Chapel Hill. (very funny actor).

Swadron/Hebert new guidelines increase depth of compression from 4.5cm to 5cm. Really. Official change. Silly.

Swadron/Hebert don’t stop CPR. Just keep going, the ‘hold CPR’ order should be really rare.

Swadron/Hebert. Venous cutdowns are now passé, do the IO. Super easy, quick, effective, safe. Oh, and if they’re awake squirt some lido in first.

Swadron/Hebert. Cuffed ET tube isn’t required, the supra glottis devices (King, LMA) are fine. Leave it in if you’re ventilating.

Swadron/Hebert Continuous waveform capnography is good for airway placement (is predictive; if pts co2 is less than 10 no metabolism)

Swadron/Hebert. PEA arrests now do not get routine Atropine. (hard to harm dead people, but not required).

Swadron/Hebert Transcutaneous pacing no longer first. Now drugs first, then to IV pacing.

Swadron/Hebert. To determine the subset Epi helps will require a RCT of 10k pts to find the ones it really helps

Swadron/Hebert Isuprel is back! )My paramedic training will carry me through!) For bradycardia.

Swadron/Hebert Narrow complex tach that’s unstable, can try Adenosine rather than electricity first.

Swadron/Hebert. Stable WCT it’s acceptable to try adenosine, as if it’s svt w aberrancy it’ll convert, if not, no harm no foul.

EM: thriving through the work aversion of others.

Moak: Koker Criteria: Fever, nonweightbearing, WBC >12k, sed rate > 40 needs an arthrocentesis.

Somand: 5Joint Comission recs for handoffs: interactive, up to date, read back, opportunity for questions, limit interruptions.

Hendey: Nursemaids elbow: hyper pronation, not the twist and bend. Actually has 3 RCTs that show better first pass success.

Hendey: knee effusion with enough mechanism, need to do enough knee exam to make sure there’s an endpoint; if not w/u for dislocation

Hendey: tendinitis is probably a misnomer, more likely micro tears, etc, current term is tendonopathy. Rx is REST.

Slovis: Top articles for 2011. Tried to focus on the ones that are practice changing.

Slovis: Benzos vs Droperidol for emergent sedation in ED 10mg Versed vs 10mg Droperidol. Droperidol much more effective and safe

Slovis: ACLS changes. “I advocate using new drugs early, before they develop side effects”. Heh.

Slovis: [coronary ct angio] would come with a warranty, 5 years after a clean Ccta pts had 0.0% cardiac dz

Slovis: triple r/o CTA is the equivalent of 100,000 cxrs. Wow.

Slovis: V1&2, Posterior MI look for R>S,mdepressed ST and a normal looking T wave.

Slovis: aVR ST elev w depressions elsewhere, think non-STEMI left man occlusion. (I blogged a case of this)

Slovis: CT for SAH. If done with a 64 slice or greater scanner, and done within 6 hrs of HA onset, it found 100% of the SAHs (Slovis: CT for SAH cont: just one study, needs to be duplicated, don’t change your practice yet)

Slovis: CURB scale for pneumonia. Confusion, Uremia, Resp rate and BP; if score 3 or greater admit.

Next up is Gregory Henry on the rapid neuro exam. I like this lecturer because I see in him a fellow curmudgeon.

Henry: 90% of the nervous system: hear ‘em talk, watch ‘em walk, look at their eyes. And most of us dont watch the walk.

Henry: LBP; rate and prog do sx’s, bowel and bladder fn, and warnings. Always invite back if they get worse.

Henry: make sure you document dorsiflexion of the extensor hallicus longus (L5) as part of your exam. Sens of inner thigh, etc

Henry: Rule: never diagnose a new migrane after the age of 50.

Henry: All causes of monocular diplopia can be found on examination (usually dislocated lens), etc.

Henry: fourth nerve palsy is either DM with a tiny stroke or an arteritis

Henry: saying II-XII intact is usually BS, just say what you saw.

Henry: dizzy is not a medical term, we have to divide it into one of four groups. Central v peripheral, syncope, multisensory deficit syndrome, psych.

Henry: syncope. No diff btwn near and full syncope. look into drugs, etc

Henry: ask dizzy pts if they’re thinking of self harm. Will be surprised at number of dizzy w psych overlay.

Hedayati: Pacers and ICDs. (this ones for @doctorwes).

Hedayati: on an over penetrated CXR and with a digital system, there are little radio graphic tags to tell us the manufacturer!

Hedayati: what does the magnet do with a modern pacer? It turns off the sensing and makes its pacing asynchronous.

Hedayati: failure to capture, pacer fail, or metabolic prob, meds, mi, etc. not always a mechanical problem.

Hedayati: runaway pacer: true emergency, highest recorded rate is 750! Heroic proc time, cut the wires, then be prepared to pace

Hedayati: JAMA 2011 has article tha 22% of ICD pts got them outside of recommended guidelines. Oopsie.

Hedayati: magnet on an ICD stops VF/VT sensing and therapy ( but pacing for bradycardia is unaffected ).

Hedayati: ICD with a magnet on will emit an audible tone! If they need cardio version, lecturer recommends putting magnet on ICD before (external) shock

Hedayati: super obese might need two stacked magnets to turn off their pacer/ICD.

And with that, I end the ACEP program coverage I’m going to do. Thanks for reading, and now I will go back to my 3 tweets a week…

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I plan to live-tweet my conferences tomorrow, so if you’re interested follow along on Twitter @gruntdoc. Last year I had more than 200, and some people liked them. We shall see, some lectures, and lecturers, are more quotable than others.

Yes, people watching here.

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Gastroenterologist Michael Kirsch put up a post on his blog that was then reposted over at ACP Hospitalist asking where the threshold for admitting a patient to the hospital should be.

He asserts that there should be more collaboration between medical colleagues to determine whether or not a patient needs to be hospitalized…

via To Admit or Not to Admit? That is the Question. | WhiteCoat’s Call Room.

Another WhiteCoat tour de force.

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When you run out of EMS bays (and we have several), you’re having a bad day.

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The Community Health Program was started in 2008 after MedStar officials discovered that 21 patients were using a big chunk of ambulance and emergency department resources. Those patients triggered more than 800 ambulance calls and cost the system more than $962,000 in charges, most of which were never collected because the patients lacked health insurance.

Nine of the 21 were selected for the program. They experienced a 77 percent reduction in their need for services during a 30-day test.

via In Fort Worth, MedStar’s Community Health Program cutting costs, improving patients’ well-being ….

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