Dengue high alert!

It is dengue season alright here on the equator. A huge spike in cases over the last month has prompted the authorities to not only step up mosquito eradication drives but hospitals also have been bracing themselves for more than a fare share of dengue shock syndrome.
Good guidelines have been sent out by health authorities and here's an edited and condensed version for those who need to brush up or are new to dengue:

Dengue haemorrhagic fever guide

Remember to watch the platelet counts daily and look out for subtle signs of shock and bleeding.

4 new laws

Now here's an update if I ever saw one.
The intuitive chap who wrote "House of God" has new laws for your perusal!

4 new laws

Salt water is anti-freeze... right?

Here's a pic of intravenous "fluid" on one of my retrievals not near the equator.
Little did I know that normal saline can indeed freeze ... and so can sodium lactate!
Apparently the ambient temp of -23C (in the day!) was indeed too much for these bottles. Thankfully fluid wasn't required this time.
There you go - a once useless fact that now isn't.


Fight the bugs!

The new sepsis guidelines are out and every emergency doc worth their salt needs to know the ins and outs. Speaking of salts - the hypertonic saline debate has finally been put to rest - don't bother with it.
The energizer bunny that is Scott Weingart has already done a comprehensive summary here for those without the time to read the whole thing:
Full pdf file is here for sharing.

Boxing tip

Nice tip from academiclifeinem

Reduction of these #s is generally badly done in ED. Care must be taken to straighten out the lumbricals and ensure the cast is set before you send the patient off.
Here is the video for reduction techniques:

Reducing metacarpal fractures

Adding to the pile of evidence on low risk chest pain

The combination of a normal ECG, negative highly sensitive troponin measurement, and TIMI score of zero have an extremely low risk for short-term major adverse cardiac events.
http://emj.bmj.com/content/30/1/15

Own the Resus room!

Inspiring talk by Dr.Cliff Reid. He is dual trained and works in retrieval. Nice summary of skills required to ensure smooth transitions for your critical patients.
Thanks to Mohan for this vid.


Own the Resus Room - 320 from mohan tiru on Vimeo.

P wave flirting...

Awesome run down by Dr Amal Mattu on AV-Dissociation and Complete Heart Block. They are NOT the same and can happen together. This will clear your head about "bizarre" rhythms.




For more of his vids or older cases, go to www.ekg.umem.org

Know your rashes!

Good stuff from experienced ACEM examiners.

Rash

Feeling trapped?

Great paediatric compartment syndrome summary by the good fellow at Paed EM Morsels.
Remember the 3 As if nothing else.

Compartment syndrome

Spot the pathologies - CT head

Here's an axial CT head slice showing a few different signs. The history is just - fall. If you spot more than we have - feel free to comment below.



Thinking about thinking


I showed a few of my residents this chest x-ray and asked for their x-ray diagnoses. Pulmonary congestion and congestive cardiac failure was the first thing to come to their minds. However, when I told them that this chest x-ray belonged to a teenager, they became less certain and started coming up with other possibilities, over-reading the x-ray. Confabulation I say.

Truth is, this teen actually had acute heart failure from myocarditis. The diagnosis was only made in the ED after several hours. Patient presented atypically (chief complaint of vomiting and tummy pain), denied any chest symptoms or dypsnoea, though palor and mild tachypnea was present at rest. Vital signs were 'arguably' normal though mild tachycardia was seen. Heart lung examination were normal at presentation. The labs did not make sense at first to the managing team, and it was only after careful analytical thinking was the diagnosis made and ultimately confirmed with bedside ultrasound.

And there lies the crux. When we are faced with a dilemma or diagnostic uncertainty, we often fall back to familiar territory. MICU consult called it sepsis with shock, HAGMA, AKI and possibly hepatic origin given raised right hemidiaphragm and abnormal liver function test. This diagnosis was particularly difficult to shake off, even though additional tests reduced the likelihood and perhaps even refuted the diagnosis (absence of fever, normal white counts, normal pro-calcitonin levels etc).

So what happened was a case study in cognitive biases (a.k.a cognitive dispositions to respond or CDRs). The ED has been called a 'natural laboratory of errors'. There is a lot going on to annoy the emergency physician in his or her work; time pressures, information overload, undifferentiated patients and constant disturbances just to name a few. Not to mention cognitive biases and those that took place in this case; triage cueing, anchoring, diagnostic momentum, confirmation bias and framing effect.

To sort through all this we need to think about how we think, otherwise known as metacognition. Knowing that the cognitive process of clinical decision making is in effect dual process theory, where most of our snap decisions occur using the intuitive and heuristic based system 1 thinking. This is quick, useful for most daily work and usually successful, but is prone to cognitive errors. Stepping back and using the more structured and analytical system 2 thinking is better at times like this, because it forces us to consider opposites, form alternative hypotheses and take into account biases.

And that's what we did. By considering cardiogenic shock instead of septic shock. Pieces of the puzzle started to fall in place and that led to our conclusive bedside ultrasound. An enlarged heart with global hypokinesis and extremely poor ejection fraction was what we found. The patient was right sited and received the correct therapy and support.

Scott Weingart and his famous blog emcrit.org showcased literature for the resuscitationist in a recent episode. I would suggest all to read it and the related articles. In it you will find a mention to Pat Croskerry, a Professor of Emergency Medicine practicing in Nova Scotia, Canada. His awesome writings about cognitive processes, diagnostic errors and clinical decision making is what inspired this post. Happy reading !

Anchoring and its impact on clinical decision making


Anchoring is a cognitive bias, arising from reliance on the first piece of info, whether true or not, when making decisions. This occurs on a regular basis, during clinical practice and most times it goes unnoticed.

Case Illustration: True Story
A middle aged Indian gentleman has had about 6-7 prior attendances to our ED over the last 4 years and has been diagnosed with ‘gastritis’.  He had an OGD done in 2011 but defaulted follow up OGD. He has now presented to the ED 3 days in a row, each time with severe epigastric pain (pain score 10) radiating to the back. On the first two occasions, he was treated symptomatically as for ‘gastritis’ and discharged with meds & appt when symptoms improved. Now he presents for the 3rd time, in obvious pain and distress. FBC was done on the first 2 occasions showing mildly raised white counts, LFT and lipase were also repeated both normal. Does he now have severe ‘gastritis’?

Looking back over the past 4 years, he had been having episodic presentations of epigastric pain and remained well in-between. The usual presentation seemed acute (a specific time was often documented), pain occasionally radiated to the back and it usually resolved after some antacids or PPI or analgesia. Endoscopy in 2011 reported ‘mild corpus gastritis’ (that’s endoscopy speak for “hey I see a bit of redness better call it something than have a normal report”).

So, no more blood tests for Mr Painful. He gets a ED bedside ultrasound. Lo and behold, clear as day to the beginner sonographer, one sees multiple gall stones, thickened gallbladder walls and pericholecystic fluid (see attached picture). He gets proper analgesia, antibiotics and an admission to appropriate unit.



In hindsight Mr Painful got 4 years of misdiagnosis, lots of suffering, an unnecessary endoscopy (lucky he skipped on the repeat) and a final climatic admission. Isn’t biliary colic a more likely consideration given the presentation? Knowing the natural history it always resolves after some time and whatever meds. Leave ‘gastritis’ to the endoscopists; it should be a diagnosis or exclusion for us ED folk. Examples of other common misdiagnosis of gastritis (true cases) had been: acute aortic dissection, appendicitis, inferior AMI.

How to avoid anchoring?
It’s tough. Studies have shown that even when told to avoid anchoring and that a given fact may be falsehood, study groups have consistently shown higher rates of making decisions based on the anchor. One way is to be like Gregory House and have a narcissistic personality (don’t trust anyone, don’t believe anything).  Unfortunately that’s hard to pull off and you don’t have a Lisa Cuddy as your CMB to develop a love relationship with. Therefore, always think differently; have differential diagnosis at hand and don’t be afraid to challenge what is established or held in common belief.

What To Do when a child dies in the ED

AAP Recommendations

This prescient clinical report provides pediatric clinicians with a guide to actively help parents and siblings after the death of a child. The following are among the many practical suggestions:
  • Expect that grief after the loss of a child is intense and long lasting.
  • Acknowledge the family's grief. Parents and other family members often experience more pain when the death of a child is not acknowledged. Grieving parents report that they remember painful feelings associated with a friend, family member, or physician who does not contact them.
  • Find an opportunity to meet with the parents. A telephone call to the parents may be helpful, but a face-to-face visit with the parents is best. A simple statement to parents might be, "I'm so sorry to hear about _____'s death. What a terrible loss for you and your family."
  • Don't attempt to alleviate grief by providing advice; it is usually ineffective and could be detrimental.
  • Help siblings with the grieving process. Siblings are often "forgotten mourners" when parents are dealing with their own grief. A pediatrician who knows the family is in a position to help siblings according to the child's developmental age (see Pediatrics 2000; 105:445).
  • Community-based self-help groups can provide immediate and ongoing support to a family. A useful website for parents is www.bereavedparentsusa.org.
  • Refer parents or siblings experiencing a complicated grief process to a mental health therapist. Complicated grief is often associated with a preexisting psychiatric condition or a troubled relationship with the child before his or her death.
Here is the reference

Mixology

Risks of mixing NRG drinks with ETOH

Original article

Kiss me mummy

Evidence from case reports and case series suggests that the mother’s kiss technique is a useful and safe first-line option for the removal of foreign bodies from the nasal cavities of children.

Kiss this link

Special K please...

A standardized medication protocol with ketamine simplifies RSI and allows efficient airway management of critically injured trauma patients in the ED of a teaching hospital. - http://journals.lww.com/jtrauma/Abstract/2012/12000/A_standardized_rapid_sequence_intubation_protocol.9.aspx

Sedation is NOT analgesia!

Just a reminder to trainees and docs alike that reducing and manipulating is no soft feat.
A case like one shown below requires not just sedation but much analgesia.
Apart from being humane, the synergistic effect also reduces your sedative dose and hence a less riskier sedation.
For those interested: describe and interpret.


A headache to diagnose

It is sometimes difficult to ascertain what is a benign history and what is not. Here is a great read to revise the different forms of presentations of headaches.

NICE headache guideline

ST segment differentials




Dr Amal Mattu demonstrates how not all ST elevation is infarction.
For more of his vids or older cases, go to website at www.ekg.umem.org

Supra what?

Great case from EMDutch.com. Also has a great arrhythmia pathway from ESC.
A-clear-case-of-avnrt-or-isnt-it?