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Wednesday, August 10, 2016
Monday, August 8, 2016
BY PETER GOLDMAN, MD
Victims of life-threatening asthma attacks above all initially need supplemental oxygen, then nebulized or aerosolized albuterol. Dr. David Inwald, a UK pediatric intensivist, wrote in his BMJ article, "Oxygen Treatment for Acute Severe Asthma," that "the important point is that asthmatic patients are still dying during acute attacks, and the use of oxygen before, during, and after nebulised B2 agonist therapy in primary care and in the community is rational and could save lives." (2001;323:98.)
That prompted an innovation to fulfill his call.
During severe attacks, asthmatics are unable to negotiate an inhaler when it is used alone, and they are unable to make a seal around the spacer's mouthpiece when it is used with a spacer. Either way, albuterol inhalation is much reduced. And if the oxygen mask is already on the victim's face, it must be removed to (attempt to) provide the albuterol, depriving the victim of oxygen while trying. The pictured combination assembly solves this problem, allowing lay responder administration of oxygen and albuterol (as taught individually to lay responders by the American Red Cross, et al.) simultaneously without the need for any coordination or cooperation by the victim. This can make the difference while awaiting an EMS response.
A typical first aid oxygen unit's oxygen flow rate into its mask is 6.5 LPM continuous flow, approximately 108 ml/sec. A typical inspiratory time for severe asthma is one second at a typical respiratory rate of 30. In that one second with a good mask seal, inspiratory volumes above 108 ml would necessarily draw in albuterol contents from the spacer chamber after drawing in the oxygen. Inspiratory volume is proportional to body mass (5-8 ml/ kg for healthy breathing at rest), so a 100 kg patient will draw in the chamber contents faster than a 25 kg victim, though the smaller patient will still inhale all the contents with subsequent inhalations because the mask remains continuously on the face.
Either way, it is very expeditious and complete. The few victims who inhale less than 108 ml because of small size or extreme severity still at least get supplemental oxygen with each inhalation.
If, in spite of this more efficient treatment, the victim still goes into respiratory arrest, the spacer chamber/inhaler can be removed from the mask port, the one-way valve put back in, and oxygen-enriched rescue breathing can then be provided through the CPR mask. The ergonomics of this response is very simple and fast, especially if the spacer chamber and albuterol inhaler are pre-assembled and stocked with the first aid oxygen unit. If the victim does not, in fact, have asthma, the oxygen and albuterol are very unlikely to have an untoward effect for other conditions (and may still be of benefit).
The combination described — three devices and two drugs — falls under the regulatory oversight of the Office of Combination Products of the FDA, and it has yet to be determined if updated clearances by the manufacturers will be required for them to promote and advertise the described as an indication for use of their component as part of the combination. Respironics has clearance to market their Diamond spacer chamber with albuterol MDI plugged into the back end and their LiteTouch delivery mask plugged into the front end for use by those who cannot make and maintain a seal around the mouthpiece of the spacer when the mask is not used. The only effective difference between this and the proposed is oxygen flowing into the delivery mask.
Meanwhile, physicians are able to use "off-label" drugs and devices per their discretion and experience, as allowed by the FDA. Comments welcome.
Dr. Goldman is the inventor of Lif-O-Gen Automated First Aid Oxygen (http://lifogen.com) and the training and development coordinator for Lif-O-Gen Automated Blended Training (http://automatedoxygentraining.com), providing six free training certificates for each unit purchased from any distributor. He is also a former consultant to the First Aid Oxygen division of Allied Healthcare Products, Inc., a former director of emergency services at Malcolm Grow U.S. Air Force Medical Center at Andrews Air Force Base, and the first medical director of the American Safety & Health Institute. Watch a 45-second video on how to use the unit at http://bit.ly/1TT96x7.
Watch a short video of Dr. Goldman demonstrating how to attach the Lif-O-Gen to an oxygen mask.
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
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
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;118:1150.)
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.
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.