American ER Doc Gone Walkabout Episode 028
I practiced in community hospital ED’s for the first roughly 35 years of my career. The switch to the world of Academics, about 5 years ago, was a bit of a shock to the system, and this year I decided to dive in a little further and see what a bunch of Academics do and what they talk about when they get together – so, off to SAEM 2014.
Day one, for me, was 8 hours of EBM. The last time I took a statistics course was in 1968 – we did the calculations with slide rules. Hand held calculators were still a couple years away (I bought my first one for $110 at a time when 12 hours in the ER earned me about $110), and desktop computers with 256 kb disk drives were still 15 years away. There seemed to be three groups in the (small) group of students in the seminar: really knowledgable folks (published in the field) who wanted to interact and share concepts with the presenters, educators and researchers who wanted to be sure that they really understood the concepts so that they could read the literature more critically, and a few who had little or no familiarity with the concepts and were really starting from near scratch.
It was worth working through the hours of math to just get a feel for how some articles, by using inappropriate statistical methods, can draw grossly improper conclusions: calculating a positive or negative predictive value from a case control study (PPV and NPV are dependent upon the prevalence of disease within the population – but a case control study arbitrarily chooses the number of control cases, therefore the prevalence of disease is artificial and a calculation of PPV and NPV is artificial and spurious). And, if one tries to convert a continuous variable into a dichotomous variable, the calculated likelihood ratios are wrong and imply a slope of the line from the origin of the graph to the chosen cut point, rather than using the slope of a line tangent to the ROC (receiver operating characteristic curve). If one does this (this article from the JAMA series on the rational clinical exam – looking at arthrocentesis WBC’s for septic joints – was used as an example), one can get a result where the pretest probability is thought to be doubled for a WBC near the cut point, whereas if one uses a proper LR (results) for a continuous variable (broken into intervals), one finds that the post test probability is actually lower than the pretest probability. 8 hours worth of such calculations and insights assured me that I’d never believe an article again, but might indeed someday understand an article.
As a community hospital ER Doc, my conference attendance was largely oriented to meetings with a practical bent: how to stop a nosebleed, how to diagnosis a STEMI and which specialist to call, what antibiotics to give or not give for Dengue, perhaps some business and billing stuff.
The realm of topics at SAEM was much more oriented to researchers (grant writing, where to look for funding, how to properly reference and write an article, etc.), administrators (how to love your hospital administration, how to get your ED waiting times below 17 hours), educators (how not to be boring, how to build power point slides, how to use the internet to find systematic reviews and to do systematic literature searches), with nary a practical word of advice in sight. Entire series of didactic sessions were devoted to career development for young investigators – convinced me that being a purely clinical ER Doc has its virtues: show up for a shift and your career is on track. If I ever tried to be a researcher, I’d first have to find where the lab is, and then when I got there, figure out where the loo is. Prominent in the short presentations were bench research topics: the pig who gave his life to help us diagnose more (is this possible) pulmonary emboli; the c5’ s49 gamma subunit of the hydromorphohumanokaiser variant of the 3rd order sub-branch of the corner store and its effect on single episodes of vomiting following the ingestion of toxic quantities of beer.
Among the lectures that I attended there were surprising numbers of references to “House” – always rather ambiguous references with equal dollops of awe at his diagnostic capabilities, disgust at his inability to discard any provisional diagnosis without some incredibly high tech diagnostic procedure (or, subtly uncovered, previously unknown, part of the clinical history), and ridicule of the unattainability of his acumen. Personally, I always aspire to his style of bedside manner and interpersonal relations.
The afternoon plenary session was a series of lectures devoted to potential effects of the Affordable Care Act (ACA) – I suspect known around the world as Obamacare (sorry Aussies, I’ve gotta talk about it) – on Emergency Medical clinical care and research. Rather remarkably (hold onto your heads, Aussies, so that they don’t explode), the talk started with a discussion of how we need to expand our billing and income from clinical emergency care in order to support education and research – which is drying up from the feds, and from many states, has long dried up – the term used was to “churn” the money back into research usage. Positive parts of recent legislation include establishment of a Division of Emergency Medicine Research within the NIH. But, we also have the silly rules like “the two midnight rule” (just guess what that’s all about – and try to get paid if you guess wrong).We were reminded that although, compared to civilized countries, we spend twice as much on medical “care”, our health outcomes are quite poor – perhaps related to the fact that our overall expenditures for health – public health, care for the disadvantaged, social support programs, mental health – are very small compared to the civilized world. But, we do have McDonald’s, American Idol, and, in Colorado – lots of pot.One entire toxicology session was devoted (somewhat hilariously) to THC in Colorado – and it’s derivatives. The lecturer is still fixated (many months after first hearing the story) on the “black mamba” intoxicated guy, still immobilized on a spine board, but running around our emergency department. We need to have darts loaded with haldol.
Paperwork does have it’s drawbacks (the disappearance of the rectal exam from American practice since we can no longer do bedside fecal occult bed testing – unless we’d like to take exams demonstrating our competence to read the little blue piece of paper – dude, even the color blind guys can tell blue from yellow!), and the practice of giving large doses of fentanyl rather than proper procedural sedation – to avoid doing all the paperwork. Oh well, it’s not unique to medicine: I recently took care of a pilot who shit all over himself and fainted while driving a very large passenger airplane (fortunately the autopilot worked well). Since he’d been having vomiting and diarrhea all night before he took off in the plane, I asked why he had tried to make a 6 hour flight. Apparently, the paperwork involved if you call in sick for a shift as a pilot is enough to make you think that shitting your pants in the pilot seat is not such a bad idea.
A talk on sepsis, with emphasis on the PROCESS trial, discussed the question: does EGDT not work, or have we learned enough from EGDT that current sepsis care, even if not following formal EGDT guidelines, has learned so much from EGDT that it works well. I favor, as did the PROCESS investigators, option B – we’ve learned to do a good job even without inserting a CVC and measuring ScvO2 in every patient.
Sometimes the research boys can get a little “Ivory Towerish”: a talk on bedside internet resources for clinical care downplayed resources such as UpToDate because it wasn’t transparent in how it identified and evaluated references and how thoroughly it had evaluated all the source materials. So suggested going back to the original sources with explicit statements, etc, etc …………..you get the idea. Gimme a break, I have a hard time getting enough time to check drug dosages and interactions, a harder time reviewing diagnostic criteria for unusual disease in UpToDate. Looking through a Cochrane review (after I go through the 29 steps to get access to it through the Universities paid subscription) to decide for myself whether the Z statistic really gives a good summary of the 69 articles reviewed – it’s not gonna happen. (When we went through the class exercises, I almost always got most of the same articles using UpToDate as the pinhead guys did using sophisticated techniques). OK, research it is, not bedside.
A talk on new directions in stroke focused largely on “wake up” stokes and the question of whether sufficient numbers of these strokes occurred near the time of awakening to have benefit and safety if treated with thrombolytics. Articles comparing MRI DWI and FLAIR imaging suggest that some large portion of these could be safely treated and clinical trials are ongoing. (If I had heard this talk a couple months ago, I might have had more sense of urgency when I woke up with a brainstem stroke syndrome, might have asked my ER Doc to treat me with TPA, might have been treated for my “stroke mimic” basilar migraine, and would have a less than 1 in 50 chance of typing this with one hand because of my hemiparesis from the ICH from the unnecessary lytic. Since the migrainous deficit would have abated shortly after the TPA was given, I would have been convinced that TPA had saved me from a life of bicycling with one eye closed.) A brief side comment, which I hadn’t heard before, is that some countries (notably Japan) use smaller doses (0.6 mg/kg) of TPA than is usual in the US – with consequent lower ICH rates. Presumably Genentech is unlikely to be enthusiastic about funding a study of this dosing in order to sell less of its product.
Another portion of the session looked at the importance of treating (the question of whether thrombolysis actually worked was not discussed, and was considered to be a question “asked and answered”) strokes that involved items not on the usual stroke score. For instance, ability to walk, and fine motor function are not part of the NIHSS – but, are quite disabling for most people. Other items that get you only 2 points, and may not qualify you for treatment, have effects that outweigh the score – hemianopsia is likely to eliminate work or reading, and aphasia or dysarthria can destroy human interaction. Even if not included in guidelines, such deficits should prompt consideration of treatment.
Finally, there is “dizzy”. In the days before CT, we considered it an achievement to separate spinning from losing consciousness. And, if it was vertigo, if there was a cranial nerve deficit it was central, otherwise it was labyrinthine. Quite simple. Then it started to get complicated. The latest iteration of separating central (i.e. stroke) from peripheral (labyrinthine) vertigo is HINTS. If you haven’t read it, you should: , and be sure to watch more than a few videos of how to do the head impulse, and other, tests. The nystagmus part of the testing is pretty easy. The skew deviation ocular testing is subtle, but isn’t too hard to do. But, head impulse – there’s a challenge. You’ve got to be vigorous and quick doing it. It looks brutal, though patients don’t seem to mind it. But, the finding that you’re looking for (a quick correction movement of the eye to return to the lost fixation point after the quick movement of the head) happens fast, lasts only an instant, and is tough to see. I’ve been wandering around my department looking for dizzy patients to practice on, and I’m getting so that I’m a bit more confident that I can find it – that quick little correction movement – or, when I don’t find it, can be reasonably confident that it is not present – thus suggesting a central cause of vertigo. Talking with the stroke neurologists at the University, I get varying responses to the question of reliability of finding the pertinent abnormality on exam: sure, no problem identifying the abnormality – hmm, not so sure – gotta be kidding, nobody could possibly see that. So, I talked with “the man” Dr Newman-Toker after today’s talk – he described examining large numbers of patients with his mentor, some famous neuro-ophtho guy, looking over his shoulder while he got it wrong repeatedly before finally being confident that he could get it right. Well, I still think it’s a test worth trying to learn to do – it seems to be helpful in deciding who to work up as a stroke. But, it takes practice and experience, and like being able to hear soft aortic insufficiency murmurs, may be a skill that not all competent ER Docs can master. But, be sure, if you decide to image, get an MRI – CT’s can be terribly misleading in acute syndromes especially in the posterior fossa.
Wow, these academics can sure burn you out. They didn’t even leave a couple hours to go skiing between sessions.
Next time: More Notes from SAEM 2014
American ER doc