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Friday, April 1, 2016

Emergency Department Treatment of Infectious Patients with Chicken Soup: Does It Improve Outcome?

BY O.Y. VEY, MD, & C.N. CAMPBELL, RN

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Study objective:
The use of chicken soup in the symptomatic treatment of infectious disease is a well-known home remedy for the relief of symptoms and well-being advocated by mothers all over the world. We could find no published clinical trials, however, involving the use of chicken soup in the ED. Our goal was to see if the addition of chicken soup with standard treatment would improve patient's disposition and treatment outcome.

Methods: This non-controlled, non-blinded, non-randomized prospective study in a single center offered patients who presented to our ED with any complaints vaguely relating to an infectious disease treatment with chicken soup as part of their standard treatment. They were given a visual seven-point scale to report whether they were feeling better at disposition. Statistical analysis subsequently determined outcome improvement and patient satisfaction scores.

Results: Originally 1,989 patients were to be enrolled, but significant improvement in outcome was noted on early review of cases. The study was ended, and the use of chicken soup was added to standardized treatment protocols.

Conclusion: Mom was right. Chicken soup does improve all areas of measurement including patient improvement, satisfaction, and outcomes scores.

Decrease in Time to Defibrillation with the Use of a Remote Device

BY DR. HOWARD, DR. FINE, & DR. HOWARD


remote.JPG

Introduction: Time to defibrillation/cardioversion (shock) in ventricular dysthymias has been shown in multiple studies to be the rate determinate step in outcomes for cardiac arrest victims. Decrease in time to shock has been shown by other studies to improve outcome in cardiac arrest victims. Our study was proposed to see if we could decrease this time interval by using a remote-controlled handheld device to initiate shock by the code leader.

Conclusion: Our study showed a decrease in time-to-shock by the use of a remote-controlled handheld device to initiate electrical shock in cardiac arrest patients in ventricular dysrhythmias, Times were not statistically significant because several outlier times messed up the results. These prolonged times to shock were looked at individually, and it appeared that the inability to find the remote contributed to the most significant time delays for those outliers. Future research should focus on how to make this process more efficient. We suggest incorporating the shock button into an app on cellular phones.


Using the Long Outward Exhalation (LOX) Maneuver for Conversion of SVT in the Emergency Department

BY D. ELI, MD, K. OSHER, DO, & B. AGEL, MD​

We report a case of SVT that was successfully converted using a previously unreported technique for the cessation of SVT. An 18-year-old man presented to the ED with a fast heart rate. He denied any chest pain, lightheadedness, or shortness of breath. He also denied previous history of fast or irregular heart rate, family history, or recent ingestions of alcohol, sympathetic drugs, or tobacco.

The patient was alert, in no distress, and had a heart rate of 180 bpm and stable vital signs. His ECG showed a narrow complex regular tachycardia with a rate of 180. He was placed in a monitored room, a plain untoasted bagel was placed over his flips, and it was explained to him to use a long outward exhalation (LOX) for 15 seconds. This maneuver was tried twice without any success. After further discussion, we decided to place a piece of lox (salt-cured salmon) over the hole of the bagel. The patient was again instructed to take a long outward exhalation after placing the bagel and lox over his mouth. Conversion was almost immediate. Repeat ECG showed normal sinus rhythm with no changes. He was discharged home to follow-up with primary care in two to three days.

We hypothesized that exhaling through a plain bagel did not generate enough resistance to simulate a Valsalva maneuver, once but the lox applied to the outside of the bagel acted as a flutter valve, generating a 40 mm Hg pressure and 15 s strain, which has been shown to be needed for conversion. Further studies are needed to determine whether the LOX maneuver needs to be modified (i.e., toasting, cream cheese).


These April Fool's Day gems were brought to you by
Stuart Etengoff, DO, an emergency physician at Genesys Regional Medical Center in Grand Blanc, MI. He extends thanks to Stephen I. Rennard, MD, whose original research on chicken soup for URIs inspired him. (Chest 2000;118[4]:1150.)

In case you were wondering about the authors on these case reports, the first one was Dr. Oy Vey for the exclamation used by Jewish mothers everywhere when serving chicken soup to sick family members. C(hicken) N(oodle) Campbell stood for the soup. The authors of the second item were the last names often used by the Three Stooges when they played doctors on their show. The third case report used the words deli, kosher, and bagel as stand-ins for the doctors' names.


Friday, March 25, 2016

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Monday, February 22, 2016

BY ANDREW W. SEEFELD, MD

 

I was lying on the uncomfortable mattress in our on-call room, the box springs jabbing me in the back with a pillow wedged under my legs in a futile attempt to achieve some form of comfort, and I started thinking about my daughter, who was tucked in her bed and sleeping soundly. I thought of all the people in the neighboring towns who were asleep, hopefully dreaming of something nice, something comforting.

I had just had a particularly tough trauma case. A young man in his early 20s was thrown from his car, and paramedics brought him in unconscious and unresponsive. After fervent efforts at resuscitation and all available resources exhausted, he was pronounced dead.

How could I sleep after that? Was everything done right? Was there something I missed? These questions plague all emergency physicians on tough cases, particularly in rural medical communities with limited access to care. I trained at UCLA/Los Angeles County where I had backup from all ancillary services, but it was just my team and me this time.

I had no other patients to see after that case, and I walked back to the on-call room and tried to get some rest. The phone rang within minutes, though, and the voice on the other end informed me a patient had just arrived with severe abdominal pain and looked "quite uncomfortable." I walked into the patient's room where a nurse was already placing an IV and drawing blood and the secretary was at the bedside registering him. I assessed the patient and determined he that he needed a CT scan of the abdomen to evaluate his complaints further, and the radiology technician was ready. Another nurse was getting pain medication and IV fluids, and the laboratory technician began analyzing the blood tests I had ordered. Everyone was doing what he needed to do to help the patient, and it was the middle of the night. We were working like an efficient machine, with all of the individual parts synchronized to generate a critical and time-sensitive product: a patient in less discomfort and a diagnosis with appropriate treatment.

Every time I experience such focused coordination, I realize how fortunate I am to work with skillful physicians, nurses, technicians, and hospital staff. They are ready and willing at any given moment to do whatever they can to help those who need help, heal those who need healing, and comfort those who need consoling, even in the middle of the night when most people are sleeping. Demand and often dependence on emergency departments increases, often during the night, as access to health care changes. Frequently, patients cannot wait until the morning to see their primary care providers. And if they could, they cannot get an appointment more often than not. Ear infections, sore throats, dental pain — we see it all — after business hours.

I chose emergency medicine because I love the unpredictable challenges, the quick decision-making, and the teamwork that is necessary to care for patients no matter the situation. I knew what I was getting into when I chose this field. I accepted the fact that I was entering a field where the word sleep would forever take on a different meaning. It meant I would sleep during the day if I could, so I would be awake and ready for whatever case presented to me on night shifts. Whether it is a patient who was awakened from his sleep with severe chest pain or a trauma patient brought in after being in a horrific motor vehicle accident, we are there, awake, and waiting to provide the required assistance.

So when you tuck your child into bed tonight, lie down on your mattress — hopefully more comfortable than the one I was lying on —remember that you are part of an emergency medicine team that will help whenever patients need us.

I can't think of anything that helps me sleep better at night.


Dr. Seefeld is an emergency physician at Speare Memorial Hospital in Plymouth, NH. 


Thursday, January 28, 2016

BY RUTH SORELLE, MPH

Picture a cartoon of large fish eating smaller fish until there is only one left.

That is what is happening across the United States as large management firms are acquiring small independent emergency medicine groups, a phenomenon complicated by a recent addition to the mix: Private equity or investment banking firms giving those larger groups the boost that enables them to buy more and more.

Tennessee-based management firm AmSurg, for example, spent $2.35 billion in stock and cash to acquire Sheridan Healthcare, which manages physician services, including those of emergency physicians, in May 2014, marking the organization's branching out into anesthesiology, radiology, and emergency medicine. AmSurg also offered this past October $5.3 billion to buy TeamHealth, a major provider of physician services, to no avail.

Then, this past December, AmSurg — through Sheridan — acquired Premier Emergency Medicine Specialists, a Phoenix -based emergency physician group, a purchase recommended by Edgemont Capital Partners, LP, an investment banking firm.

This kind of consolidation continues to occur in emergency medicine across the country, leaving independent democratic emergency physician groups adrift in a sea of big businesses, according to the American Academy of Emergency Medicine (AAEM).

Robert McNamara, MD, a professor and the chairman of emergency medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia, said he has spent the past few decades watching this with dismay. Now, AAEM, the group he helped found, is ready to move beyond advocacy, and is establishing the AAEM Physician Group based on the principles of the organization that stress group autonomy, fair pay, and transparency in financial transactions.

"There are limits to the effectiveness of advocacy at the local and national level," Dr. McNamara said. "We've been involved in legal actions and writing letters to administrators." But recent events in the marketplace spurred AAEM to establish an umbrella physician group that will allow small groups to continue with their current practices buttressed by the services usually provided by large management groups, said Dr. McNamara.

"Seeing physician-owned groups selling out was the tipping point," he said. "The senior docs have sold out to the corporations and secured their futures and compromised the futures of graduating residents. To me, it's one of the most distressing things that has happened in emergency medicine. Doctors who have lived and breathed emergency medicine have turned around and said to the next generation, 'While it was good for us, we are going to sell you out to the companies.'"

 

EPs Burned Out

Pointing to a recent Medscape survey of satisfaction among physicians, Dr. McNamara said emergency physicians ranked second as the most dissatisfied and burned-out specialty. "Now we have the leadership of the specialty drifting back into corporate control," he said.

Mark Reiter, MD, MBA, the current president of AAEM, said his group is developing the umbrella group because "it is difficult for emergency medicine practices to remain independent. This will help them better compete in the marketplace. The big players have large sales and marketing budgets that help them obtain new contracts, often at the expense of democratic groups. A one- or two-hospital group is at a competitive disadvantage. Large groups talk about economies of scale that make them more appealing to hospital executives."

That ties into hospitals looking to consolidate because of the Affordable Care Act and other health care reform initiatives, he said. "We want to show that independent groups can be part of the bigger entity while maintaining their independence and the advantages of being a local independent democratic group. We think that local, independently owned and run groups are likely to understand and act in the best interests of the hospital and community. Independent groups are more likely to make decisions in the best interests of the emergency physicians that practice there and the patients they serve than a non-physician executive thousands of miles away," Dr. Reiter said.

 

Grow or Merge

Yet change is the standard in health care, said Jeff Swearingen, a founder and managing director of Edgemont Capital Partners, the health care investment banking firm that advised the Arizona-based Premier Emergency Medicine Specialists and the Ohio-based Premier Physician Services in their recent acquisitions by larger companies.

"The landscape is changing, with groups seeking to grow or merge with the thesis that scale is what matters in the current environment. When you see deals announced like Aetna acquiring Humana and Anthem acquiring Cigna, it's in part because they feel they're not big enough as stand-alone entities. Consolidation among managed care, hospital systems, and facility networks will create leverage. Unless physicians join together to combat that, they will be on the wrong end. Consolidation in emergency medicine was happening before the Affordable Care Act and has accelerated since," said Mr. Swearingen.

He said recruiting is a huge challenge, with an increasing need for board certified emergency physicians. "Twenty years ago, a rural facility's bylaws did not call for board certified emergency medicine physicians, but now all those facilities require that credential. Emergency room volume increases one to three percent each year. More volume and more facilities demanding boarded ER docs create challenges for recruiting. Small groups don't have the capability for a full-time recruiting effort. A service consolidator does," said Mr. Swearingen.

He said, though, operating on a larger scale in a region creates leverage with commercial players, and administrative needs contribute to that advantage. "IT systems and quality metrics are becoming more important as is the issue of readmissions."

Dealing with these challenges requires more money to invest in infrastructure and systems, he said. "Access to capital allows groups to take risk and invest in infrastructure and programs like post-discharge calls to encourage patients to fill their scripts and see their primary care doctors. These initiatives generally require financial and administrative resources not available to the average group. Frankly, a lot of physicians feel their job is becoming dominated by nonclinical challenges that take focus away from providing great care to patients. No one goes to medical school to negotiate payer contracts or implement a new IT system," Mr. Swearingen said.

 

AAEM as Partner

Dr. McNamara said those kinds of frustrations are among the reasons that AAEM wants to establish a physician group. "If you are a participant, you must adhere to set of principles in the group's mission statement. Our group is founded on being in a group practice, fairness, transparency, and open books. We are partnering with Physician Staffing Resources, a management services organization that supports 70 different emergency medicine groups. They are the business partners. AAEM is the lead in this, and there will be an agreement signed between us and the practicing physicians. They can use our name to recruit," he said.

Members appointed Dr. McNamara as the chief medical officer, and he said he will ensure that the members of the new group will meet the principles of practice, along with an oversight panel. They plan to market to physicians, hospitals, and existing groups that fit the requirement of the AAEM practice group. Dr. McNamara said AAEM wants to deliver "clout" and "the powers of a more nationally representative groups."

"Larger groups come in with established back office services, marketing, and extensive negotiation experience, and say that they can handle non-patient care activities much better. We would allow our groups to counter that by being part of a group that is involved in many states and emergency departments and have the benefit of being physician-owned, he said.

"It's a simple concept. Look at what is going on with physician satisfaction and the amount that [management] groups are taking out of their pockets. Twenty percent could be going back to the physicians. Emergency physicians will want this. They have been through the mill with corporate groups. The public would want it after the 60 Minutes show that found patients being admitted who didn't have to be. Doctors use their independent judgment in this scenario. The physician-patient [relationship] is now being infringed upon," he said.

Mr. Swearingen said he sees similar opportunities in merged and acquired physician groups. "Physicians want to be part of something bigger that provides services and lets them practice medicine, he said. Much depends on the dynamics of a transaction. "Consolidators pay large cash amounts for the groups, integrate all back office functions, and sometimes individual groups are absorbed into something larger. You should go into it with your eyes open. Clearly there are sacrifices in any business relationship.

Mr. Swearingen said consolidators make an effort to preserve the group culture," and that Edgemont's clients are happy. "You always find people who, in hindsight, are negative about things or see one-half of the bargain that is struck," he said.

Not all emergency physicians are or need to be part of a consolidated group, he added, noting that there are 40,000 to 45,000 practicing emergency physicians in the United States. "Even TeamHealth and EmCare do not have a major market share. Consolidating all practicing emergency physicians into one or two groups is still a long way off. Consolidation will continue to happen, but there's still room in the market for independent groups," he said.

 

Equity Buyouts

Dr. Reiter said he is concerned with private equity groups buying out physician practices, which leads to the firms rolling smaller groups together. "We see a lot of times after that happens that compensation is significantly decreased, staffing is tightened, and physicians must see more patients per hour. There is more reliance on midlevel providers and a lot less incentive to recruit for excellence. The most qualified physicians are considered a liability because they are more expensive," he said, adding that that changes the focus to the bottom line instead of patients.

Drs. Reitman and McNamara said physicians should consider the AAEM Physician Group because it gives them a practice bound to the fairness principles of AAEM without loss of autonomy, which allows them to avoid the effects of feeling underrewarded for a demanding job. Physicians in the AAEM group will see what is paid in their name and understand how compensation is derived, and the group will recognize stressors in emergency medicine — shift work, stress, and aging, Dr. McNamara said.

Practices will be run locally and not strictly by the results of emergency department patient satisfaction surveys. The groups will not agree to termination without cause and will strive to restrain hospital administrative influence. Physicians will work for themselves, not a corporation or an individual. "You will not be sold out by the senior physicians," he said.

Hospitals, Drs. McNamara and Reiter said, should contract with the AAEM Physician Group because emergency physicians who are part of it will be happier in a physician-owned group that establishes a long relationship with hospitals. The AAEM Physician Group structures do not allow for a group to be sold to a corporation. All physicians in such group will be board certified and they will see the benefit in a well-run emergency department because physicians own the groups. Physician ownership also avoids violating prohibitions against the corporate practice of medicine and fee-splitting with lay owners.​

"There are numerous good, independent local physician-owned groups that exist and some sizeable ones that are acceptable with physician ownership. They are all at risk," said Dr. McNamara.


Friday, November 6, 2015
  •  All anesthetic drugs except ketamine are given on a per body weight basis.
  •  It was consistently observed for more than 23 years in more than 6,000 patients that 100-pound women and 250-pound men alike remain motionless (dissociated) with the same 50 mg ketamine IV two minutes prior to skin injection of local anesthesia.
  •  The ketamine dissociative effect, primarily at midbrain NMDA receptors, requires 98-99% saturation prior to stimulation.
  •  Midbrain size is unrelated to body weight.
  •  N.B. Precede with IV glycopyrrolate (preferred over atropine) to prevent ketamine salivation. It has less tachycardia.
  •  Ketamine side effects (i.e., emergence hallucinations, dysphoria, and intra-op hypertension, tachycardia) are prevented with a stable cerebral cortical level of propofol.
  •  Create a stable level with incremental, not bolus, propofol induction. Watch a video of this at http://bit.ly/1Mgijqp.
  •  Prescribe 50 mcg  kg-1 propofol repeated to loss of lid reflex c 25 mcg kg-1 basal infusion, increase or decrease prn to 60 <BIS <75 c baseline EMG as clinical picture dictates.
  •  Titration typically requires about two minutes. This results in cardiovascular and respiratory stability with blood pressure and airway maintained.
  •  Masseter tone typically remains intact with patent airway. Intervene if needed.
  •  Immediately after induction, give 50 mg IV ketamine, and wait two minutes.
  •  Inject skin prior to incision with 0.5% lidocaine c epinephrine.
  •  If movement occurs, wait an additional minute, and try again. If movement continues, re-bolus an additional 50 mg ketamine.
  •  Define 98-99% NMDA saturation with non-response to skin incision injection.
  •  Instill, not inject, 10-20 cc 0.25% bupivacaine in wound prior to closure.
  •  In event of cough or sneeze, bolus IV lidocaine 1 mg/pound to prevent laryngospasm. No high-pitched crowing noise is generally heard.