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Thursday, March 22, 2018


The patient was turning all shades of pale on his way to reverse Trendelenburg. From seashell, to ivory, to baby powder, to ghost. Our interaction had started innocently enough. Mr. E. said he had taken a few Motrin on top of his daily baby aspirin for a tight back. It began a bit later, he recounted, when he bent over to tie his shoe.

When I (Dr. Ballard) first laid eyes on him, I saw a gentle crimson rivulet meandering from the left nare into his whiskers, like a mustachioed Eleven from Stranger Things. The patient was attempting compression, pinching his nose rather than his vasculature. A blue foam clip was perched precariously on the tip of his nasal bridge, securely compressing superficial skin and tissues. "Ah, a quick fix," I thought while aerosolizing Afrin and lido into his nasopharynx.

Before I could leave the room, however, the initial treatment triggered a staccato of coughing, and Mr. E.'s bleeding quickly turned from rivulet to river. I hastily inserted a Rhino Rocket and rotated the ENT chair backwards as Mr. E passed out. I hustled to find a nurse as a helpful hospitalist remarked, "Your patient in Room 12 is about to code."

The Evidence

The following study is several years old, but has not yet widely diffused into practice (at least from our perspective). It looks at using an injectable form of tranexamic acid topically for epistaxis treatment. (Am J Emerg Med 2013;31[9]:1389.) We have never met an emergency physician who relishes treating epistaxis or a patient who likes nasal packing, so it seems like a study that should grab our interest. Of course, sending a patient home with packing is generally accepted as safe from a clinical perspective and usually avoids bounceback bleeding.

But from a patient perspective (speaking from personal experience after I [DB] received a stiff elbow to my nose playing basketball), packing is miserable. Packing makes it nearly impossible to breathe, sleep, smell, and speak (at least in a tone that is tolerable to those nearby.) Ideal epistaxis management should involve sending patients home without packing. Any technique that allows for this is superior to the wide array of nasal packing options.

The Zahed study compared a tranexamic acid (TXA) cohort with a "usual care" nasal packing group of ED patients with anterior nosebleed. Eligible patients were randomized to receive a 15-cm cotton pledget soaked in the injectable form of TXA (500 mg in 5 mL) that was left in place until bleeding arrested or cotton soaked with epinephrine (1:100,000) + lidocaine (2%) for 10 minutes, and then packing with several cotton pledgets covered with tetracycline. Nasal packing, when done, was removed after three days, and rescue cautery was permitted for both groups. The primary outcomes were time to arrest bleeding, ED length of stay, rebleeding at one week, and patient satisfaction on a visual analog scale (VAS) at time of discharge.

The 216 enrolled patients were similar in age, platelet count, and INR, though the TXA group had a much higher rate of prior bleeding (58.1% vs. 13.6%). The TXA group (n=107) had significantly faster time to ED discharge (95.3% within two hours versus 6.4%) and lower rates of rebleeding at 24 hours (4.7% vs. 12.8%) as well as in the 24 hours to one-week time frame (2.8% vs. 11%). The self-reported satisfaction rate was also higher with TXA (VAS 8.5 ± 1.7) compared with anterior nasal packing (VAS 4.4 ± 1.8). Neither group had any serious adverse events.

The manuscript is rather thin on certain details (it is not clear if rescue cautery was used), and the comparison group received cotton pledgets only (rather than an inflatable/expandable packing). The same research group recently replicated its findings in a population at higher risk for rebleeding (patients on aspirin or clopidogrel), and the cumulative results are compelling enough to justify a trial in day-to-day practice.

The Trial

Fortunately, Mr. E. in room 12 did not code, but he did require immediate resuscitation and soon became Mr. E. in Trauma A. His ghost-like doppelganger was replaced with a more perfused version of himself, so I initiated the TXA protocol. I removed the Rhino, and the pharmacist delivered the vial of injectable TXA to the bedside. I dripped it onto the cotton pledget and placed it in his nostril for 10 minutes: no bleeding, no repeat syncope. Mr. E. went home with routine nosebleed home care education and instructions to take an NSAID holiday. He did not return.

The Verdict

So far, so good using the TXA approach to epistaxis. Between us, we have had several additional successes and one warfarin-epistaxis ED failure that required the patient discharge home with packing. The most difficult aspect of the approach (at least in our EDs) is coordinating with the pharmacy to attain the injectable TXA, but otherwise there is little downside to adding TXA to your nosebleed armamentarium. If I ever get cracked in the honker again and need epistaxis care, I'll be asking for TXA.

Dr. Vinson is an emergency physician at Kaiser Permanente Sacramento Medical Center, a chair of the CREST (Clinical Research on Emergency Services and Treatment) Network, and an adjunct investigator at the Kaiser Permanente Division of Research. He also hosts Lit Bits, a blog that follows the medical literature at Dr. Ballard is an emergency physician at San Rafael Kaiser, a chair of the KP CREST (Clinical Research on Emergency Services and Treatments) Network, and the medical director for Marin County Emergency Medical Services. He is also the creator of the Medically Clear podcast on iTunes or at Follow him on Twitter @dballard30. Read his past articles at

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Friday, February 23, 2018

The U.S. Food and Drug Administration issued an alert in February advising caution before prescribing the antibiotic clarithromycin (Biaxin) to patients with heart disease because of a potential increased risk of heart problems and death that can occur even years later.

The CLARICOR trial found an unexpected increase in deaths among patients with coronary heart disease who received a two-week course of clarithromycin that became apparent after patients had been followed for a year or longer. (
Int J Cardiol 2015;182:459.) The researchers from Copenhagen University Hospital, the University of Copenhagen, and Odense University Hospital, all in Denmark, found no clear explanation for how clarithromycin led to more deaths than placebo. Some observational studies also found an increase in deaths or other serious heart-related problems, while others did not. All the studies had limitations in how they were designed, the FDA said.

Two of the six observational studies in patients with or without coronary artery disease found evidence of long-term risks from clarithromycin, and four did not, but the prospective, placebo-controlled CLARICOR trial provided the strongest evidence of the increased risk compared with the observational study. Health care professionals
should consider these significant risks before prescribing clarithromycin to any patient, particularly patients with heart disease, even for short periods.

Adverse events should be reported to the FDA's MedWatch Safety Information and Adverse Event Reporting Program by submitting the form available at The full MedWatch Safety Alert is available at

Friday, February 16, 2018

A blood test that measures protein levels released from the brain into the blood may help predict which patients have intracranial lesions after concussions or mild traumatic brain injuries, according to the U.S. Food and Drug Administration, which approved the test this week. Developed by Banyan Biomarkers, the blood test measures ubiquitin c-terminal hydrolase L1 and glial fibrillary acidic protein and predicts which patients may have intracranial lesions visible by CT scan, possibly preventing unnecessary imaging and radiation exposure to patients, the FDA said.

The FDA evaluated data from a multicenter, prospective clinical study conducted by the U.S. Department of Defense and sponsored by Banyan of 1,947 blood samples from adults over 18 with suspected mild TBI or concussion and a Glasgow Coma Scale score of 9-13. Those samples were compared with CT scan results. The Banyan Brain Trauma Indicator was able to predict the presence of intracranial lesions on a CT scan 97.5 percent of the time and their absence 99.6 percent of the time. Results from the blood test are available within three to four hours, the FDA said.

The test was reviewed under the FDA's De Novo regulatory pathway for low- to moderate-risk devices that are novel and for which there is no similar device is marketed. (FDA, Feb. 14, 2018;

Nearly 50,000 people died from TBI in 2013, according to the U.S. Centers for Disease Control and Prevention. Approximately 2.8 million TBI-related emergency department visits, hospitalizations, and deaths were recorded in the United States that year. Seventy-five percent of TBIs each year are mild or concussions, and a majority of patients with concussion symptoms have a negative CT scan, according to the FDA.

The Department of Defense reported on its website that 15,501 members of the military experienced mild TBI in just the first three quarters of 2014, 83.5 percent of all military traumatic brain injuries. (U.S. DOD, Dec. 1, 2014; "A blood test to aid in concussion evaluation is an important tool for the American public and for our Service Members abroad who need access to quick and accurate tests," said Jeffrey Shuren, MD, the director of the FDA's Center for Devices and Radiological Health.

The study's trial record is available at

Tuesday, November 7, 2017


The seat belt sign chimes again. Pinned between two strangers for hours, I silently wish for a brief reprieve—beverage service or a chance to hobble toward the back of the plane to stretch. But, no, the captain has turned on the seat belt sign again. She's the boss, and I trust her with my safety, regardless of how uncomfortable I might be.

Many analogies have been drawn between the seemingly different worlds of aviation and medicine over the years. Many have continued to look for similarities since Dr. Atul Gawande wrote The Checklist Manifesto. One of the best lectures I've heard was from fellow emergency physician Dr. Joe Novak who spoke at the ACEP Scientific Assembly about combat aviation paradigms" comparing our craft and our training to that of an Air Force fighter pilot. As a pilot and emergency physician, I think there are more comparisons yet to be made.

The aviation industry is plagued with bureaucracy. It makes sense to the lay passenger that the government ensures our safety. Colgan Air flight 3407 tragically crashed in Buffalo in 2009. This led Congress to raise the minimum number of hours required to fly as a co-pilot from 250 to 1,500 hours before being eligible for hire. The new requirements have led to a pilot shortage in our country, although this rule was developed with input from the Airline Pilots Association, a union with 52,000 members.

Medicine is no stranger to oversight. Joint Commission visits and an onslaught of quality metrics to report on is a never-ending plight for hospitals and physicians. Yet, unlike pilots, we have no voice. Sure, the American Medical Association and specialty colleges like the American College of Emergency Physicians exist to express concerns for physicians throughout our country, but the past decade of government turmoil brought down on physicians would suggest that having a few lobbyists looking out for us isn't enough.

Pilots would not follow a new operating procedure that made flying unsafe. Their union would speak up. The government dragged their feet when iPads became the new way to keep charts and airport information handy. The Federal Aviation Administration said they would need to do "more research" before agreeing that its use would be safe in flight. Pilots knew that this technology would save fuel and paper, reduce pilot workload, make flying safer, and save the pilot from dragging a 40-pound bag of charts through every airport. Many pilots still used the technology before given the official go-ahead. They are the experts, not the bureaucrats. They knew having charts readily accessible on an iPad when struggling to fly through difficult weather made the flight safer. So they did it. The FAA eventually saw the light, and now having an iPad in the cockpit is ubiquitous.

Pilots had work-hour restrictions long before medical residents did. Some experts doubt the ACGME requirements have resulted in increased safety at academic institutions, but aviation authorities certainly believe in their utility. The FAA (not the pilot experts) attempted to make the rules even more stringent in 1995, requiring increased periods of rest and less time in the cockpit each day. There can be too much of a good thing, and the pilots rang out! Union and industry pundits had a seat at the table. The increase in policymaking oversight was stifled. Every time it comes up again, it's a committee of pilots and doctors (experts in the physiology of flight) who have a voice. It is not a committee of congressmen on Capitol Hill.

Why don't physicians act in the same manner? Recently I was told by an administrator that nurses and providers (administrators never call us doctors anymore) couldn't have cell phones in patient care areas. I keep many resources on my phone. Paucis Verbis cards, Epocrates, Pedi-Stat, and other cell phone apps are integral to my practice of emergency medicine. The other option is to carry around a stack of outdated pocket cards, which would make a seasoned emergency physician look more like a third-year medical student with their overburdened white coats. I told her I would continue to use my phone. I am the expert in patient care. I know that having these resources helps me provide excellent, up-to-date care. Speak up! You are the expert.

North America is beginning to see a pilot shortage crisis. It is only expected to worsen. The experience required to be eligible for a co-pilot position increased sixfold in 2009. The typical debt incurred to become a pilot is well over $100,000 unless one joins the military. Once done with that, you suffer through endless low-paying jobs before you make it. Then, your first job at the regional airlines pays quite poorly, although slightly more per hour than you made during your residency. Eventually, you make a healthy salary after gaining experience and seniority. Sound familiar to the long road toward a career in medicine that you followed?

How are airlines fixing the pilot shortage? Many are beginning to create their own training programs. Train with them, and you are guaranteed a job—with less debt in the process. Remove financial barriers toward education, and more eligible pilots will come knocking. Airlines understand economics better than hospital systems and insurance companies. If you pay more, they will come. Bonuses and increased wages are also beginning to result in more aviators being willing to take on the financial burden of becoming an airline pilot.

Like the airlines, we are facing a physician shortage in our country. The debt incurred by undergraduate and medical education is staggering. Much like a pilot, one has the option of joining the military to decrease the burden of debt. Doctors who don't join the military must endure a decade of training with hundreds of thousands of dollars in debt. We accept this despite an ever-decreasing salary. In fact, it's difficult to imagine another profession where you get paid less the longer you work.

Perhaps we should follow the airlines' lead. What if hospital systems paid for residencies instead of Medicare and Medicaid funding them? What if I train with Kaiser, and then Kaiser pays my medical school costs and pays my salary during residency? I become a well-oiled Kaiser machine in the process who then signs a contract to work for a given number of years. Money talks. Paying board-certified physicians what they deserve and what they've previously made makes sense. No doctor should have to spend two decades paying off their loans.

Pilots don't have at-risk funds. What if 15 percent of a pilot's paycheck was held at ransom, given to them only if their passengers' satisfaction was in the 90th percentile and if they had on-time arrivals 95 percent of the time. That will not happen. Do you think that would lead to safe decision-making? No, it would result in airline accidents. It would result in death.

Pilots don't control the weather. They can't control the fact that the airlines they work for took away meals, peanuts, and that extra inch of leg room. The pilot instead focuses his energy on being a consummate professional and getting people safely to their destinations. Why aren't physicians more like pilots? We too cannot control the climate in our workplace. Sometimes, the ED gets busy. Wait times will rise when several critical patients arrive at once. That's OK. Period.

When saving a life, the patient with an ankle sprain can wait. Unfortunately, all too commonly contracts are being written with the premise that physicians must do X, Y, and Z to get the reimbursement that was, at one time, rightfully theirs.

It's time to take control of our aircraft. Thinking back to that uncomfortable flight, I had a lot to complain about. I was hungry. I was tired. I was bored. I got home three hours later than expected. But when I take a step back, I realize just how amazing it all was. I flew from coast to coast, over and around major thunderstorms, in a period of four hours. I just left my home in the Northwest, and this evening I'm having a family dinner in Alabama. I'm not using FaceTime to say hello to my mom; I'm using a hug. It's incredible. It's easy to be increasingly negative in a society that values speed, ease, and a burden-free world, but it's much easier to see just how good we have it when you look at the view from 40,000 feet. The emergency department is no different.

Why don't our colleagues, our government, and our administrators look at medicine in the same way? Yes, there was a delay in getting you to your room. Yes, the food is terrible or nonexistent. Yes, the gurney is less comfortable than a plush recliner. But at the end of the day, a trip to the emergency department is as incredible as a flight across the country, despite its inadequacies.

A patient is distressed. He has had pain for a week. A board-certified physician decreases his pain, listens to their worries, diagnoses his ailment, and advocates for his treatment. What might take weeks to work up in the outpatient world takes hours to work up in the ED. Where at people at one time died due to injury, now they arrive and have their lives saved in an immediate fashion by experts.

We are the captains of our ship. We know what is best for our patients and for health care. When a pilot decides to delay a flight due to dangerous lightning or a warning light in the cockpit, no passenger has the audacity to walk to the front of the plane to tell them to get going. The CEO of the airline doesn't patch into the radio to tell them to depart immediately because of the growing number of passengers sitting at the gate. Believe it or not, there is safety in paternalism! We trust the pilot to get us to our destination without harm. We acknowledge they have more experience than we do. If that means we must wait an extra hour or an extra day, we comply.

I believe it is time for us to act more like pilots. If you don't need an MRI scan of your head, I shouldn't order it just to make you happy. If I spend an hour in the critical care bay, I shouldn't get reprimanded by administration for decreased throughput. They should thank me for saving a life and for doing what I was trained to do. They shouldn't chastise me or lessen my pay because someone with a cold waited for three hours. My skill as an emergency physician should not be tethered to a wait time on a billboard. The government shouldn't judge me by how well I treat someone's pain. Increased workload and alert fatigue through our EMRs (our version of the cockpit) has become unsafe and overly complicated, and it has diminished the human aspect of medicine that many of us sought when we chose our profession. Why should I be forced to spend more time in front of a computer screen under the guise of meaningful use when it has never been proven to be meaningful?

Many people love to talk about physician burnout. This is simply a synonym for its true meaning: physician disempowerment. Let's call it what it is. It's time we speak up. It's time we take the controls of the craft we spent so many years learning. It's time we have a seat at the controls. It's time we unionize, just like pilots have.

Dr. Miller is a clinical instructor with the University of Washington and an attending emergency physician practicing in Boise, Idaho. He also works as a critical care air transport physician and EMS director with the Idaho Air National Guard.

Wednesday, October 4, 2017


When I first heard of the shooting in Las Vegas a few days ago, it sounded as if only a few people were injured. I was preparing for bed, but as soon as I realized the scope of the incident, I went immediately to the emergency department. I ran several red lights as ambulances do, exceeded speed limits by a factor of 2+, and was quickly waved through police barricades when I showed my hospital ID.

I would like to say that I heroically saved dozens of lives by performing numerous invasive bloody procedures, but that was not the case. Most of the serious cases were already handled when I got there. We had one DOA, and all the others are expected to survive, but many will have permanent injuries.

When I arrived, I was immediately struck by how quiet it was. Nothing moved me more than how patients with horrific injuries heroically suffered in silence while the staff worked diligently to care for all. They knew we would get to them as soon as possible and in order of priority. None of the providers yelled or so much as raised their voices. They walked briskly, but never ran. With the exception of one neurosurgeon who did not want to be bothered, specialists and ancillary services responded quickly and efficiently.

It was truly an inspirational scene, once you could get beyond the depravity of what just happened.

The worst cases I saw were an 18-year-old girl with a spinal injury who will be permanently paralyzed, and a young man whose hip was pulverized and femoral artery lacerated. He may keep his leg, but probably will never walk well again.

I didn't perform any dramatic invasive procedures, but I would like to think that coordinating complex evaluations among the surgeons, technicians, and nurses was just as life-saving.

I offered many reassurances to patients as honestly as I could. I touched many foreheads, gently placed my cheek on a few, and gave hugs to others, including family members. It was all graciously and emotionally received.

It was deeply moving to see the help offered to others by non-medical people. Bystanders used makeshift stretchers to carry people out of harm's way, drivers allowed bloodied victims to pile into their nice cars for transport to the hospital, and pickup trucks were also used to transport more serious victims. Long lines, up to six hours, formed with those waiting to give blood. Many delivered food and drink to the donors.

Out of evil and chaos came goodness and beauty.

I believe there is a God, but even if you don't and even if you are correct, there is God-like charity in all of us should we choose to practice it.

I felt emotionally detached from it all, until the following day, at which time I must admit, I needed a few moments alone.

We may never know what motivated the perpetrator, but he was obviously a tortured soul. I believe that almost all human beings are innately good. Children raised in loving and supportive environments, even with disparate financial resources, will almost always become loving and contributing adults. Providing children with a moral compass, regardless of religious beliefs, is an important part of the same process.

Beyond raising children, we can all play a part in this. Please consider donating your time to charities, especially those working with underprivileged children. Also, set up affordable automatic monthly donations to the charities of your choice. Remote Area Medical (, Safe Nest (, and Three Square, a service feeding poor children (, are among my favorites.

Savor your relationships with family and friends and those things you enjoy. In less than a second, it can all be taken away from you.

Spread goodwill and generosity to others, every day, even in small ways. Be kind to others, even when they don't deserve it.

Dr. Del Vecchio is an emergency physician in Las Vegas and a retired U.S. Navy captain and flight surgeon.​