UMEM Educational Pearls - Misc

Point of Care Ultrasound has been shown to change medical management and decrease time to diagnosis. 

However, sometimes on a busy shift we may get an xray or radiological study prior to performing a POCUS exam due to time constraints.

A recent study looked at the time it takes to perform a bedside ultrasound.

The authors measured the duration of time from starting the exam through the ultrasound worklist to the timestamp on the last recorded image. 

They reviewed 2144 studies and found a median time of 6 minutes to perform a study. 

Of course the study is limited by the time it takes to find a machine, make sure it is functioning and other supplies such as gel. 

Conclusion: You can take 6 minutes to assist in your patient's clinical care.

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Takeaways

While transgender and gender diverse individuals make up a minority of the US population (approx 1.4 million individuals), they are unfortunately the victim of a large amount of discrimination in our society.  A seemingly overwhelming number of laws are being passed this year specifically targeting this group, including how they can access health care. As emergency physicians, it is our duty to not only understand and care for these patients with excellent and compassionate care, but advocate for them in places of power.

This is a qualitative study that looked at the experiences of transgender and gender nonbinary (TGN) patients seeking care in EDs in Arkansas.  They researchers performed structured interviews with 9 TGN patients who had received care in various EDs in the state.  It identified several themes in their experiences:

 1. Systems and structural issues- these included the patients' legal document and EHR gender prounouns not matching their gender identity, intake forms not having a place for patients' pronouns and chosen name, and confidentiality issues when calling patients from the waiting room using their deadname

2. Interactions with clinical staff- while many of the patients did have some positive interactions with the ED staff, there were several significant issues identified.  Patients experienced misgendering, either intentional or unintentional, as well as inappropriate questions about patient anatomy that was not related to the presenting complaint, and other harmful behavior such as being stared out by staff, and delays or refusal of care

3. Perceptions of clinical knowledge- many of the subjects reported having to educate the ED clinicans regarding transgender health care issues. This influenced their desire to return for care to those EDs

We are all responsible for treating all of our patients with dignity and respect, even if we don't fully understand their own journey. And remember pride started as a riot and became a revolution!

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In a recent study in The Lancet, researchers at NIH attempted to test the hypothesis that optimal hydration may slow down the aging process. 

A large proportion of people do not consume the recommended fluid amounts. This has likely become worse with our masking during the pandemic.

Previous studies in a mouse model showed that water restriction, increasing serum sodium by 5 mmol/l, shortened the mouse lifespan by 6 months which corresponds to about 15 years of human life.

Population:  Data from Atherosclerosis Risk in Communities (ARIC) study: an ongoing population-based prospective cohort study in which 15,792 45-66 year-old black (African American) and white men and women were enrolled from four US communities in 1987–1989 and followed up for more than 25 years.

Variables:  15 biomarkers and serum sodium (as a proxy for the hydration habits of study participants).

They attempted to exclude people whose serum sodium could be affected by factors other than the amount of liquids they consume. After these exclusions, 11,255 participants remained in the datase.

Authors also calculated ones biologic age by sampling 15 biomarkers characterizing performance of multiple organ systems and processes: cardiovascular (systolic blood pressure), renal (eGFR, cystatin-C, urea nitrogen, creatinine, uric acid), respiratory (FEV), metabolic (glucose, cholesterol, HbA1c, glycated albumin, fructosamine), immune/inflammatory (CRP, albumin, beta 2-microglobulin).

Conclusions: The analysis showed that middle age serum sodium >142 mmol/l is associated with a 39% increased risk to develop chronic diseases (hazard ratio [HR] = 1.39, 95% confidence interval [CI]:1.18–1.63) and >144 mmol/l with 21% elevated risk of premature mortality (HR = 1.21, 95% CI:1.02–1.45). People with serum sodium >142 mmol/l had up to 50% higher odds to be older than their chronological age (OR = 1.50, 95% CI:1.14–1.96).

Limitations:  Observational study. No firm conclusions without intervention studies.

Summary: Serum sodium concentration exceeding 142 mmol/l is associated with increased risk to be biologically older, develop chronic diseases and die at younger age.

Take home:  Drink more water

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Humor me and imagine that your birth certificate vanished, and your age was based on the way you feel inside. How old would you say you are (subjective age) versus your actual age?

In a few studies, those individuals reporting a younger subjective age had a lower risk of depression, greater mental well-being, better physical health, and a lower risk of dementia. These individuals also had improved episodic memory and executive functioning. Subjective age also predicts incident hospitalization.

Three longitudinal studies tracked more than 17,000 middle aged and elderly individuals.

Over a 20-year period, researchers tracked:  Subjective age, demographic factors, disease burden, functional limitations, depressive symptoms, and physical inactivity.

Researchers found that those who felt approximately 8, 11, and 13 years older than their actual age had an 18%, 29%, and 25% higher risk of mortality, respectively. They also had a greater disease burden even after controlling for demographic factors such as education, race and marital status. Multivariable analyses showed that disease burden, physical inactivity, functional limitations, and cognitive problems, but not depressive symptoms, accounted for the associations between subjective age and mortality.

This study provides evidence for an association between an older subjective age and a higher risk of mortality across adulthood. These findings support the role of subjective age as a biopsychosocial marker of aging. This may allow for early intervention for select individuals who may have a higher association with poor health outcomes.

Your subjective age can better predict your overall health than the date on your birth certificate.

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These two pieces from Becker’s Hospital Review demonstrate significant areas of weakness within the American healthcare system. Hospitals that care for underserved as well as medically and socially complicated patients should be afforded protection and financial security. Not only do they care for the most complex patients, they often educate the next generation of health care providers. 

The loss of small community or rural hospitals also has a major negative impact on the US health care system. For time sensitive conditions such as trauma, myocardial infarction or stroke these facilities are often the first, closest facility to initiate care or stabilization. The loss of these critical smaller hospitals also adds to the burden at already overwhelmed larger facilities. 

As medical providers, we are in a unique position to advocate for our patients, our co-workers and our communities. Join your professional societies (ACEP, AAEM, SAEM etc.), write your local and national representatives, find like minded colleagues, please get involved with the process any way you can.  As a nation we can not afford to lose large essential hospitals or small critical access, rural hospitals.

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Universal Human Rights

• Human rights are rights inherent to all human beings, whether our nationality, place of residency, sex, national or ethnic origin, color, religion, language defines , or any other status 

• The United Nations Human Rights Council (UNHRC) defines seven substantive rights: the right to life, freedom from torture, freedom from slavery, right to a fair trial, freedom of speech, freedom of thought, conscience and religion, and freedom of movement 

• The right to life is the essential right that a human being has a right not to be killed by another human being. This has been central in debates on issues of abortion and euthanasia. 

• Emergency care is an often overlooked, but essential component of the right to life in the highest attainable standard of health and universal health coverage (UHC - a WHO description used to describe access to care). Particularly for vulnerable and disadvantaged populations, emergency care is often the last chance for the health system to save a life.

• The focus on vulnerable populations with little access to care and subsequent poor health outcomes has many similarities to the delivery of emergency care. Emergency conditions, such as traumatic injuries, disproportionately affect people in low- and middle-income countries. About 90% of the burden of death and disability from injuries occurs in low- and middle-income countries

• COVID-19 emphatically highlighted how far countries (and differences in regulations between states in the US) are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. 

•  Implementation of a rights-based framework for emergency care requires countries to enact legislation that ensures access to non-discriminatory emergency care and establish a regulatory body with appropriate oversight and authority to enforce these laws.

Approximately 1.4 million transgender and gender nonbinary patients live in the United States. Unfortunately, prior research has shown negative experiences with the health system are common after disclosing their trans/NB status. As a result, almost a ¼ report avoiding or delaying needed health care.

This qualitative study interviewed a subset of trans/NB individuals about their experiences visiting emergency departments. Several key themes emerged:

• ED intake forms are commonly unequipped to reflect patients’ pronouns and chosen names. This leads to downstream misgendering and the use of deadnames.
• Patients often fielded inappropriate questions and comments unrelated to their medical care
• Many patients felt they had to educate clinicians regarding issues of trans health, rather than the other way around
•  These negative experiences decreased the likelihood patients would return for needed medical care

Overall, the study found that clinicians have many opportunities to improve the care of transgender and nonbinary patients, including updating forms, using inclusive language, avoiding medically unnecessary questions, and providing training for staff on trans/NB health.

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IPV can occur once or over years by a current or former romantic partner.  Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner). 

IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined.   Think about how risky it is to NOT recognize IPV.

1:4 women and 1:10 men have been victims of IPV during their lifetime.

1:5 homicide victims are killed by an intimate partner.

Over 50% of female homicide victims are killed by a current or former intimate partner.  Patients who have been strangled are 4 times more likely to be killed within a year.

Your Spidey Sense should go off when:

1. Stories Change
2. History doesn’t match up with injuries
3. Injuries in areas that are concealed, multiple injuries of varying ages, defensive wounds
4. Major delays in seeking care
5. Non-specific complaints - headache, gastric issues
6. Multiple ED visits at odd hours
7. Refusing the use of an interpreter by partner (why we always use an official interpreter)

Once patient is identified as a victim:

1. Place victim in a safe, inaccessible by visitors, and hidden area
2. Treat all medical issues
3. Contact Social Work/SAFE/SANE examiner (some institutions will have IPV specific resources)
4. Contact police if patient is willing to report
5. Safe disposition
6. If unable to ensure a safe disposition, be very careful about documentation provided in discharge paperwork and language used

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Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.

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Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?

Background

This paper was written by some of the thought leaders in the Diversity, Equity and Inclusion realm in Emergency Medicine. Undergraduate medical education has minimal formal hours dedicated to LGBTQ+ health, and EM residency has even less. The authors wanted to assess EM resident comfort in caring for patients who identify as part of the LGBTQ+ community

Methodology

An anonymous service was sent out to CORD and was then disseminated to the residents of the 167 ACGME accredited EM residencies. It was a 24-question survey based on a similar one given to medical students. Overall, a total of 319 residents responded to the survey, with the vast majority identifying as heterosexual and cisgender

Results

The results seem at first to be contradictory. A majority of respondents (63.5%) were either comfortable or very comfortable in addressing the needs of LBGT patients. But when asked about specific behaviors related to providing care, there was more to the story. Only 17.3% of respondents always asked about sexual partner gender, 4.7% always asked about sexual orientation for an abdominal or genital complaint.

Perhaps more disturbing, the survey found that 10% of respondents had observed attending physicians make discriminatory or inappropriate comments about LGBT patients or staff, 2% of respondents were uncomfortable working alongside LGBT physicians, and 6% of respondents disagreed with the statement that LGBT patients deserve the same level of quality care as other patients.

Discussion

This study was published in 2019. Despite some amazing advancement in the LGBT community, we obviously still have a long way to go. This study shows the need for more formalized and routine education regarding LGBT population health issues at both the undergraduate and graduate medical education levels. It also demonstrates that LGBT physicians still experience discrimination in the workplace, even within our specialty. Be kind, be compassionate, be understanding.

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• A recent retrospective study examined CT radiation doses in different types of facilities

• Mean patient age: 12 years
• Authors reviewed radiation doses for nearly 240,000 CT scans in over 500 facilities
•  
• The facilities were categorized into 4 groups: 

• 1) academic pediatric,
• 2) non-academic pediatric,
• 3) academic adult, 
• 4) non-academic adult

Most (65%) scans were performed at nonacademic adult centers

• Radiation doses were significantly higher at adult facilities vs. pediatric facilities
• Also, radiation doses were higher at non-academic vs. academic facilities
• For example, the largest children received twice the radiation dose for abdomen-pelvis CT scans performed at nonacademic adult facilities compared with academic pediatric facilities
  • 11.9 mGy vs. 5.8 mGy
• Academic pediatric facilities use lower radiation doses than do nonacademic pediatric or adult facilities for all head CT examinations and for the majority of chest and abdomen-pelvis

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Takeaways

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Non-Musculoskeletal Causes of Neck Pain

Neck pain is a common complaint of people presenting to the ED. Most of the cases will be musculoskeleteal in origin and will respond to conservative therapy with NSAIDs or acetominophen. However, other non-musculoskeletal causes of pain could be lurky behind this benign complaint.

Don't forget to consider:

1. Early mengingitis (84% of patients with meningitis will complain of neck stiffness)
2. Myocardial infarction/angina. Women are known to have atypical symptoms and might just have dull pain in their neck. Be sure to ask about whether exertion increases the pain.
3. Epidural Abscess- fever and neuro symptoms are often missing early on. Make sure to ask about risk factors for spinal epidural abscess.
4. Vertebral Artery Discection - most common identifiable cause of stroke in your people.  <50% are associated with trauma and <8% of patients have connective tissue disorder. Patients are at increased risk if they have had
   1. Cervical trauma (remember seen in < 50% of cases)
   2. Recent infection
   3. Hypertension
   4. h/o migraines

Diverticulitis

It seems like the standard treatment course for patients with suspected diverticulitis in the ED is to obtain a CT of the Abdomen and pelvis and then to start antibiotics. A CT scan is really only needed if you suspect that they have an abscess, micro perforation, are not responding to conventional treatment, or you suspect an alternative diagnosis.

However, what should the conventional treatment be? Several recent studies from Sweden, Iceland and the Netherlands have shown that patients treated with antibiotics did not fair any better then patients who were just observed. There was no difference in time to resolution of symptoms, complications, recurrence rate, or duration of hospitalization.  

Several national societies (Dutch, Danish, German, and Italian) now recommend withholding antibiotics in patients free of risk factors who have uncomplicated disease, but these patients will need close follow up.

TAKE HOME POINT: Patients with diverticulitis can be treated supportively and probably do not require antibiotics unless you suspect they have complicated disease or are immunosuppressed.

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We are proud to announce the release of our new UMEM Pearls App, now available in the Apple App Store and the Google Play Marketplace! You will now be able to pull down pearl content for offline viewing, in addition to having all of the pearls in searchable format available on your mobile devices.

Click either of the following links on your mobile device to download your Pearls App today!

Get it on Google Play!

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Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

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Post Operative Fever is extremely common, and with the increase in same day surgery this is a common complaint presenting to the ED.  The mnemonic "5Ws" are often taught to remember the causes. They are:

• Wind - Pneumonia, aspiration, pulmonary embolism, and atelectasis
• Water - urinary tract infection
• Walking - Deep Venous Thrombosis or pulmonary embolism
• Wound - surgical wound infection
• Wonder drugs - Drug fever, or infection due to indwelling lines, or a reaction to blood products

Though many surgical textbooks report that atelectasis is the most common cause of early post-operative fever,  some even claiming that it is responsible for over 90% of febrile episodes in the first 48 hours after surgery; a recent review in CHEST (reference below) showed that there is no evidence to support this. We often see atelectasis in medical patients too, and few if any of them have fever.  The CHEST review found that there was no clear evidence that atelectasis causes fever at all.

Pearl:  Temperature >38.9C should raise concern for a true infection, where lower temperatures can be due to pulmonary embolism, DVT, drug fever, etc….
 

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• If less than 24 hours since injury, consider diagnostic angiography and  intra-arterial TPA, and heparin infusion, Prostacyclin infusion.
• Angiography and Bone Scan can be used to prognosticate clinical course.
• Consider Hyperbaric Oxygen Therapy for moderate to severe frostbite- multiple case reports of significant improvement with HBOT even if delayed by several days. 

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