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Monday, March 30, 2015

One in nine patients released from an emergency department after kidney stone treatment will face a repeat visit, according to a study published in Academic Emergency Medicine. (


Duke University researchers identified multiple factors that correlate with repeat ED visits for kidney stones, which may suggest ways for physicians and patients to improve care for a painful and costly condition.


Using administrative information generated from more than 128,000 initial ED visits in California for a kidney stone, researchers were able to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of a repeat visit.


Patients returned with symptoms that included uncontrolled pain, severe vomiting leading to dehydration, and infections that coincide with kidney stones. The researchers also found that repeat visits were more likely in areas where there are fewer urologists, indicating that access to specialized treatment might be able to prevent a return to the ED.


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Read more about kidney stones in our archive.


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Friday, March 27, 2015

Physician practices involved with new health care payment models intended to improve quality and reduce costs are discovering they need help managing data and figuring out how to respond to programs’ diversity and quality metrics of different payers, according to a new joint study by the RAND Corporation and the American Medical Association (AMA).


Researchers performed case studies on 81 people from 34 physician practices in diverse geographic markets between April and November 2014 to determine the effects that alternative health care payment models are having on physicians and medical practices in the United States. Researchers also spoke to leaders of 10 payers, nine hospitals or hospital systems, seven local medical societies, and five Medical Group Management Association chapters.


The report found the effect that alternative payment models have on practice stability ranged from neutral to positive. No practice had experienced financial hardship as a result of involvement in new payment models.


Researchers also found that most medical practices have shielded individual physicians from direct exposure to the new financial incentives that payers created. Practices are paid more for improved performance, but they generally use nonmonetary incentives to encourage physicians to change their decision-making.


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Read more about other payment models and related issues in our archive.


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Thursday, March 26, 2015

By Leon Gussow, MD


Extracorporeal membrane oxygenation had attendees at the recent North American Congress of Clinical Toxicology meeting buzzing about its use for treating poisoned patients. I knew little about ECMO so I contacted Scott Weingart, MD, the chief of emergency critical care at Stony Brook University Medical Center in New York, who said ECMO could be extremely valuable in treating certain severely ill poisoned patients because they are frequently young, otherwise healthy, and have “a heart too good to die.” My conversation with Dr. Weingart yielded these key points that may prompt you to think about ECMO.


Extracorporeal membrane oxygenation is an intervention that can support failing cardiac and respiratory function from a reversible cause until a specific end-point can be reached. It is often considered a bridge to recovery, buying time until, for example, a deteriorating patient with a myocardial infarction can be brought to the cath lab or a patient with a massive pulmonary embolus can undergo thrombectomy. ECMO may also maintain tissue perfusion and oxygenation in overdoses until the drug can be eliminated by the body’s natural metabolic and excretory processes, possibly enhanced by use of renal replacement therapy.


Hypoxic blood is removed from a large vessel such as the femoral vein, oxygenated mechanically, and returned to the venous circulation in veno-venous ECMO. This technique can maintain oxygen delivery to tissues while avoiding dangerously high ventilator pressures or high FiO2 in patients with severe acute respiratory distress syndrome. VV-ECMO also allows for pulsatile flow through the pulmonary vessels, letting the lungs continue their natural role as a filter for small emboli. It does not, however, provide any circulatory support.


On the other hand, hypoxic blood is removed from near the right atrium, oxygenated, and pumped back into the aorta during veno-arterial ECMO (VA-ECMO). This supports respiratory and circulatory functions.


Use of ECMO goes back almost half a century. Initially, it could be started only in the operating room because access to the great vessels near the heart required thoracotomy. Today, access can be secured via large peripheral vessels such as the femoral vein and artery. This technique can be facilitated using ultrasound guidance, and it builds on a skill set common to emergency physicians.


Early on, the machinery required was large, cumbersome, and difficult to manage. The original pumps operated on an occlusive roller mechanism that frequently broke down, and, more importantly, caused platelet dysfunction. Newer pumps use a magnetically suspended centrifugal design that is nonocclusive and maintains blood flow by producing pressure differentials. As technology improved, ECMO units have become easier to set up and are more portable and dependable than before.


During the A/H1N1 flu pandemic in 2009, VV-ECMO was used as a bridge to recovery for many patients with severe ARDS. The surprisingly low mortality rate in these extremely sick patients created renewed interest in all aspects of the modality.


ECMO may be indicated in patients with a reversible cause of pulmonary or cardiac failure that has not responded to conventional therapy. It is now generally considered a last-gasp intervention for patients who seem destined to die without it, but continued research and experience may find that results improve in certain situations when ECMO is initiated at an earlier stage.


VV-ECMO has been used to treat children with lung injury from inhalation of hydrocarbon products. VA-ECMO has potential use in patients poisoned with cardiotoxic agents such as calcium channel blockers, beta blockers, venlafaxine, or bupropion who are suffering from hypotension and shock that has not responded to standard therapy with fluids and inotropes. Supporting failing cardiac function in these patients can not only buy time while the body’s natural processes eliminate the toxin and promote systemic distribution of specific antidotes.


It is important to remember that drugs such as calcium channel blockers can cause hypotension from cardiogenic shock or vasodilation. Because VA-ECMO is not indicated in the latter, it is prudent to obtain an echocardiogram before initiating the procedure to confirm myocardial dysfunction.


Uncontrolled coagulopathy and severe intracranial bleeding are considered absolute contraindications to ECMO. The presence of a significant irreversible process such as hypoxic brain injury or terminal metastatic cancer may also make heroic measures futile.


Bleeding at access sites occurs in up to a third of patients, intracranial hemorrhage in about six percent. The relatively large size of the catheter required for arterial access can result in ischemia of the lower extremity. Because oxygenated blood is returned directly to the aorta without being filtered through the lungs in VA-ECMO, patients are at risk for systemic emboli.


An excellent article by de Lange, et al. comprehensively reviewed the literature to date about use of ECMO in poisoned patients. (Clin Toxicol 2013;51[5]:385.) It includes 81 references and a list of published reports of patients treated with ECMO for toxic exposure.


An excellent resource for all things ECMO in emergency critical care is the website of the ED-ECMO project ( by Joe Bellezzo, MD, and Zack Shinar, MD, from San Diego, and Dr. Weingart. The site includes a discussion of basic concepts, protocols, video tutorials, and an up-to-date list of relevant medical literature. It also has a blog and podcast. Anyone interested in the potential of ECMO for treating poisoned patients will want to follow this site.


Physicians still have relatively little experience treating toxicology patients with ECMO. The National Poison Data System reported that 14 patients in their database were treated with ECMO in 2010. That had increased to 29 by 2013. This is still just a handful, but that will continue to grow as the modality becomes more commonly used in emergency and critical care.


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Wednesday, March 25, 2015

Poor communication may lead some patients with chest pain to be admitted to the hospital even when their risk for a heart attack is low, according to a small study in Annals of Emergency Medicine. (


Researchers surveyed 425 pairs of physicians and patients shortly after the patients were admitted to the hospital for acute coronary syndrome. The patients’ average age was 58, and the group was roughly half men and half women. Slightly more than half had annual incomes of $50,000 or less, and about 40 percent had no education beyond high school.


Patients reported that their physicians spoke to them about their chances of having a heart attack in 65 percent of cases, but the physicians said they discussed this in only 46 percent of cases.


The study’s authors had to rely on subjects’ ability to correctly recall conversations about the diagnosis and risks. Regardless, the findings speak to the need for a communication breakdown to be repaired, said Dr. Daniel Munoz in a Medscape article.


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Tuesday, March 24, 2015

Female medical students answered medical questions correctly more often than their male counterparts, but expressed less certainty about their answers, according to a study published in Annals of Internal Medicine. (


Researchers analyzed the responses of 1,021 users (617 men and 404 women) who answered at least 50 questions. Gender was determined based on name, and ambiguous names were omitted.


Women's answers were accurate 61.4 percent of the time, compared with 60.3 percent of men's, but women selected "I'm sure" significantly less often than men did (39.5 percent vs. 44.4 percent, respectively).


Recognizing an association between accuracy and confidence in medical trainees may help reduce diagnostic errors caused by overconfidence, wrote the three male medical students who conducted the study.


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