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Saturday, July 23, 2022



BY LISA HOFFMAN

It is with a heavy heart that I tell you all that James R. Roberts, MD, died July 22. This is a loss for emergency medicine—he was a legend of the specialty, one of its earliest residents—but especially for Emergency Medicine News where he steered this ship for more than three decades with unparalleled expertise and genuine warmth.

This is a personal loss for me too; Jim was a great friend and mentor, supporting my work and my life, always going far beyond what was expected. He even sent my sons gifts every Christmas. He never met them, but he knew they are the most important people in the world to me, just like his daughter Martha and son Matthew were to him.

This is also a loss for everyone who was lucky enough to be his friend or colleague and for all of you who never met him but depended on his erudite, no-nonsense column every month. He wrote about everything, from fentanyl-laced heroin to urine dipstick testing (which was his most-read column of all time). Without fail, for more than 30 years, his InFocus column was always the most popular feature in EMN. I don’t think that was something Jim particularly cared about—he just wrote about what interested him and what he thought would be valuable to all of you.

I have to confess that sometimes he sent me columns that made me wonder if they would really appeal to emergency physicians, and every time—without exception—those were the columns that were best read. (See urine dipstick testing.) So much for my editorial intuition. But more to the point: He had a profound understanding not just of emergency medicine but what its physicians needed most.

He was also loyal beyond compare. More than 20 years ago, a former publisher was angry about something I had run in EMN, and Jim staunchly defended my decision. He was true blue and always saw the good in people. I never once heard him utter a harsh word against anyone, and that is no small thing to say about a person. I will forever be grateful for his support and the many acts of kindness he showed me over the 33 years I knew him. Everyone should have someone like Jim in her corner.

Jim was also modest, and this too is not an insignificant thing to say about someone. He had every right to have a monstrous ego given his accomplishments, but he always downplayed them and shared credit with others. You need only read what he wrote about his longtime friend and mentor David Wagner for evidence of that. (​https://bit.ly/3J7DIaL​.) I could write those same words about Jim. Like he said about Dave, I often say to myself, “WWJD?” In this case, the J stands for Jim.

It’s difficult to pick a single example of who Jim was, so I’ll go back to the first one, the week I started as the editor of EMN, way back in 1989. I called Jim to introduce myself, opening with, “Hello, Dr. Roberts, this is Lisa Hoffman, and I’m—” and he cut me off, and said, “Call me Jim.” That disarming comment was just the first of many things that endeared him to me.

Jim loved to have people follow him in the ED at Misericordia, and I spent a day there in 1990. I watched him expertly drain an abscess, diagnose congestive heart failure in five seconds flat, and teach a resident the finer points of intubation. He juggled a dozen cases at once, some medical, some not, calling over his shoulder to me at one point, “It’s like a Fellini movie in here every day!” You know how pregnant women fall in love with their obstetricians? That was me: It filled me with awe and admiration to see him work with such clinical acumen and deep concern for his patients.

A few years ago, he started talking about retiring from EMN, and I cut him off just like he had when I introduced myself all those years ago. “You can retire when I do,” I told him, which was not really what he wanted to hear, but frankly I didn’t care: I knew I couldn’t do this without him, and it is a woeful feeling that now I have to.

It is the end of an era for emergency medicine and Emergency Medicine News, and I hope you will join me in honoring Jim by saying something kind to that resident who hangs on your every word, telling your colleagues how much you appreciate them, or dropping me a note to publish in EMN about what Jim meant to you.

Goodbye, Jim. This day came many, many years before I wanted it to, but I am richer for having known you, and I will always be in your debt.

Ms. Hoffman is the managing editor of Emergency Medicine News. Write to her at [email protected].


Wednesday, July 13, 2022

BY TOM BELANGER, MD, &
MITCHELL LOUIS JUDGE LI, MD

 It would be an understatement to say emergency medicine is worried about corporate consolidation. The American Academy of Emergency Medicine and the American College of Emergency Physicians have written position statements, and many emergency physicians, prompted by Take Medicine Back, recently lent their voices in anonymous statements and virtual appearances to a Department of Justice and Federal Trade Commission request for information on merger enforcement. (AAEM. April 12, 2021; https://bit.ly/32ZbwTb; ACEP. April 18, 2022; https://bit.ly/3Oa6TeS; https://www.takemedicineback.org; Federal Trade Commission; https://bit.ly/3xIQCqm; ACEP. https://bit.ly/3y7s8J1.)

Market consolidation harms workers through regional monopsonies, but labor market power is also affected by information asymmetry, which is when employers, especially large ones, have more information about a labor market than employees. (U.S. Department of the Treasury. March 7, 2022; https://bit.ly/3y6KXfl.)

A less competitive labor market stifles wage growth and reduces the quality of the services delivered. Improving access to information, which reduces information asymmetry, is an important way to contest an increasingly consolidated market, improving conditions for workers and consumers who in this case are doctors and patients.

Anonymous App
We built an application that collects anonymous emergency medicine employer reviews and analyzes the results so that doctors have as much information as possible. (https://www.takemedicineback.org/emrating.)

The application is free to use, and all emergency physicians and residents can leave a review and read others' reviews. It is completely anonymous, does not track IP addresses, and cannot identify users, so reviewers are protected.

Reviewers can answer a series of questions about employment in emergency medicine and enter comments. Questions are specific to attendings and residents and they can search for employers or residencies or add their own if theirs has not been entered.

Users may review the results and filter by employer (or residency) or employer type (or residency employment model). A net promoter score is calculated when enough data are available. Basic sentiment analysis is used to turn comments, which are not visible, into a sentiment score to allow users to get a softer feel for an employer.

The information is then incorporated into a Google Data Studio report that allows users to view geographical information and sort and filter data based on features. A resident, for instance, could create a map of residencies operated by democratic groups, hospital employees, contract management groups, or any combination of the three.

Hold Employers Accountable
We can see some trends emerging from the 199 reviews available when these data were pulled on June 1. The vast majority of the reviewers so far are attendings—190 versus nine residents.

A few employment types dominate the reviews so far. (Graph 1.) Most reviews appear to be from four types of employers: contract management groups, democratic groups, hospital employees, and academic institutions. It is clear, even without performing a deep analysis of the various employer types, that contract management groups are regarded quite unfavorably compared with other employers. (Graph 2.)
This is, however, a rough summary of the data. The application itself gives a much more granular breakdown.

We would like to encourage all emergency physicians—residents and attendings—to review their employers. The more data we share, the greater chance we have of overcoming our informational disadvantage against an increasingly consolidated market.

Not only is it our duty to hold our employers accountable, but providing information for another emergency physician to use may someday change where they work, live, and maybe even the course of their lives. We all deserve access to the best information available when making such important decisions.

Dr. Belanger is the secretary of the American College of Emergency Physicians Locum Tenens section and an emergency physician in McKinney, TX. Read his past articles at http://bit.ly/EMN-numbERs. Dr. Li is the chief medical officer of the AAEM Locum Group, the founder of Thrive Direct Care, PLLC, and a founder of Take Medicine Back (https://takemedicineback.org).

 ​Find graphs with data from the app in the August issue.

Friday, January 21, 2022

What EPs Should Know about Oral COVID Drugs

BY LEON GUSSOW, MD

Two new oral medications to treat COVID-19 received Emergency Use Authorization from the U.S. Food & Drug Administration early this year. Emergency physicians and medical toxicologists will soon be dealing with these drugs with which they have little or no experience.

Ritonavir/Nirmatrelvir
The most eagerly anticipated new oral treatment for COVID-19 is Pfizer’s formulation of ritonavir/nirmatrelvir (Paxlovid). The company reported that the drug reduces the risk of hospitalization or death by 89 percent if treatment is started within three days of symptom onset in high-risk outpatients with COVID-19. That sounds great, but keep in mind several important caveats, most importantly that Pfizer has not yet published the results of its clinical trial.

The claim from EPIC-HR (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients) of 89 percent reduction of hospitalization or death comes from a Pfizer press release describing results from the planned interim analysis of the data. (Nov. 5, 2021; https://bit.ly/3GIr53N.) The FDA issued an Emergency Use Authorization for the drug in December, and the agency apparently reviewed the data and was impressed by the results. Still, I find it somewhat discomforting to base clinical treatment on a press release rather than a real scientific publication.

All subjects in the EPIC-HR trial were high risk and unvaccinated. It is not clear that any potential benefit would be as impressive in other populations. Word has it that an additional study of ritonavir/nirmatrelvir in 662 vaccinated volunteers showed a 70 percent reduction in hospitalizations and deaths over placebo, but these data have also not been published. EPIC-HR also enrolled patients from July 2021 to September 2021 before the Omicron variant was detected and a little before Delta was widespread. Pfizer apparently expects that ritonavir/nirmatrelvir will be effective against Omicron based on laboratory studies and the fact that the drug does not target the virus’s spike protein. Still, it would be nice to have published clinical confirmation.

The SARS-CoV-2 virus when it infects human cells induces synthesis of long protein chains that have to be cleaved at specific points to produce shorter proteins crucial to viral replication. Nirmatrelvir inhibits the main viral protease that enables this precise cleavage. The drug is metabolized by the CYP3A hepatic enzyme system. Ritonavir is another protease inhibitor long used in treating HIV/AIDS, but its role in Paxlovid is to inhibit CYP3A, prolonging the half-life and activity of nirmatrelvir. The combination is given as three tablets twice daily for five days.

Because ritonavir inhibits CYP3A, the potential for numerous significant drug interactions is a real concern. Use of ritonavir could increase concentrations of many other drugs metabolized by CYP3A. Conversely, nirmatrelvir levels may be reduced to subtherapeutic amounts in patients on drugs that induce CYP3A. Clinicians should be aware of these potential drug interactions, and frequently invite input from clinical pharmacists and medical toxicologists when prescribing Paxlovid. (See the table for potential drug interactions in the upcoming March issue.)

Molnupiravir
In contrast to Paxlovid, the initial Merck study on its COVID-19 drug molnupiravir (Lagevrio) has been posted online. (N Engl J Med. 2021 Dec 16; https://bit.ly/3rxwdkS.) This phase 3, double-blind, randomized, placebo-controlled trial evaluated the use of oral molnupiravir to treat nonhospitalized adults with mild to moderate COVID-19. All subjects had PCR-confirmed infection and began treatment within five days of first signs and symptoms.

The subjects were also considered high risk for progression to severe disease based on at least one of the following: BMI over 30, age over 60, diabetes mellitus, active cancer, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and cardiomyopathy. Exclusion criteria included ongoing hemodialysis, renal failure with a GFR less than 30, pregnancy, and previous vaccination for COVID-19. That last point is important: All the subjects in this study were unvaccinated. They received molnupiravir 800 mg bid for five days or placebo. The primary endpoints were hospitalization or death within 29 days of treatment initiation.

A total of 1433 subjects were randomized into the study, and a planned interim analysis was carried out after the first 775 patients were enrolled. The results initially looked promising. The interim analysis found that 7.3 percent of the group receiving molnupiravir reached a primary endpoint compared with 14.1 percent of the placebo group, a relative reduction of about 50 percent.

The final results from all 1433 study subjects were not as striking, with 9.7 percent of the placebo group reaching a primary endpoint v. 6.8 percent of the treated group, a relative reduction of 30 percent. It is not quite clear why these results were less positive than those from the interim analysis. The study took place from May 2021 to October 2021, so it is possible that few if any subjects from the interim analysis were infected with Delta variant, and that molnupiravir may be much less effective against the variants common now.

Notably, one death occurred in the treated subjects and nine in the placebo group during the 29 days after treatment was started. Adverse effects not directly related to COVID were generally nonspecific and included diarrhea, nausea, and dizziness.

It is important to realize that this trial was carried out among nonvaccinated subjects infected with mostly the Delta, Mu, and Gamma variants. Randomization also ended in early October 2021 before the Omicron variant was a concern. The results gave no indication of how effective the drug would be today, with new variants, or in vaccinated patients.

Monupiravir works by inducing multiple mutations as viral mRNA is copied in infected cells. There has been concern that this mechanism might accelerate development of more virulent or infectious mutations, but so far experience with the drug—although still quite limited—has not detected examples of this occurring.

Molnupiravir has been shown to induce mutations to mammalian DNA in cultures of hamster ovary cells (J Infect Dis. 2021:224[3]:415; https://bit.ly/3IbuAQA), but no data yet suggest this would be a problem with therapeutic use. In any event, the drug is not recommended for pregnant patients or those who might become pregnant during treatment.

Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Follow him on Twitter @poisonreview, and read his past columns at http://bit.ly/EMN-ToxRounds.

Monday, January 3, 2022

Starting a Ketamine Clinic: Another Option for EPs

BY SAMUEL KO, MD, MBA

I have been working as an emergency physician for the past decade, but I took a leap four years ago into the world of side gigs by starting a ketamine infusion clinic in Palm Springs, CA.

The seed was planted years ago when I came across an early article about the off-label use of ketamine for depression. (Biol Psychiatry. 2000;47[4]:351.) I was curious and did a deep dive into the research and stayed on top of the latest studies and meta-analyses, which showed continued support for its efficacy in treatment-resistant depression. (J Affect Disord. 2020;277:831.)

I never imagined I would own my own clinic. Surprisingly, it’s one of the best decisions I have made in my career. I was able to transition out of night shifts and holidays. I now decide what time to start and end my clinic hours. Most importantly, my patients get rapid improvement compared with traditional antidepressants that can take months to take effect.

About Depression
Ketamine was invented in 1962 by Calvin Stevens, PhD, while consulting for Parke-Davis Research Laboratory. It was approved by the FDA in 1970 as a dissociative anesthetic agent, and is on the World Health Organization's list of essential medications.

Ketamine is used in the ED for procedural sedation, acute pain control, severe agitation, delayed sequence intubation, and even as a third-line agent for status epilepticus.

Interestingly, research is showing that sub-dissociative ketamine doses infused over 40 minutes can be effective for treatment-resistant depression. Improvement can last days to weeks after one infusion, but benefits seem to accumulate with multiple infusions (typically six infusions over two to three weeks).

It’s not ideal to give multiple treatments for depression in a busy ED, but that can be done in an outpatient clinic. Ketamine infusions are also not routinely covered by insurance, and out-of-pocket-costs can be significant for many patients. Janssen Pharmaceuticals, which is owned by Johnson & Johnson, released intranasal esketamine, which was approved by the FDA in 2019 for depression, and it is reimbursed by insurance companies.

A recently published systematic review and meta-analysis showed that intravenous racemic ketamine is more effective than esketamine for depression. (J Affect Disord. 2021;278:542.) Insurance companies will likely realize that it will save them money in the long run to cover IV ketamine treatments.

Current State of EM
Emergency physicians have always been on the cutting edge of medicine. We are trained in administering ketamine as well as vital sign monitoring and addressing potential side effects. We are also adept at handling any potential acute airway and cardiovascular issues as well as psychiatric emergencies.

I believe ketamine clinics can be an opportunity for emergency physicians who are curious about starting a side gig while taking more control over their future. By collaborating with psychiatrists and other mental health professionals, EPs are uniquely positioned to meet the increased demand from patients suffering from depression. That could also be a solution to the projection that emergency medicine will have an oversupply of 8000 physicians by 2030 (Ann Emerg Med. 2021;78[6]:726; https://bit.ly/3lVrGYu) and concerns about graduating residents being unable to find jobs because of COVID-19. (AAMC. Feb. 25, 2021; https://bit.ly/2P2M3Vz.)

The Downside
Starting a ketamine clinic has challenges. One of the benefits of emergency medicine is being able to clock in and out for shifts and be done. Owning your own medical practice will mean thinking about it all the time. This option is not for those who don’t want to devote extra time to their clinic.

You’ll likely also be criticized by your colleagues who may say that you are profiteering on the backs of suffering patients and peddling snake oil and that you are not a psychiatrist and only they should provide ketamine infusions. They may even accuse you of getting patients addicted to ketamine. And much more.

This venture is definitely not for you if you haven’t yet developed a thick skin in medicine. You’ll also have to get involved in the business aspects of medicine, such as marketing, accounting, and hiring. Some of this can be outsourced, but you’ll need to be willing to learn the basics.

Initial Steps
But a ketamine clinic just might be for you if you are entrepreneurial, proactive, and looking for a change. The first few steps will involve writing a business plan, finding a location, getting business licenses and malpractice insurance, and ordering medications and supplies. It took me about two years before physically opening to learn the nuts and bolts of starting a ketamine clinic. It then took two years after opening to establish a patient base. I continued working part time in the ED while the patient volumes grew at the clinic to keep my finances stable.

None of us is taught how to open up a private practice in medical school or residency, so I had to do a ton of research to launch the clinic. I made a free checklist you can download at www.ketaminestartup.com to get things started if you’re interested.

Dr. Ko is the CEO of a ketamine clinic (www.resetketamine.com) and a creator of an online course on how to start a ketamine clinic. (www.ketaminestartup.com.) Follow him on Twitter @drsamko.

Tuesday, November 16, 2021

​A Smackdown for Epinephrine Skin Necrosis

BY BLAKE BRIGGS, MD

My aversion to medical myths started long before residency. I distinctly recall as a third-year medical student on my EM rotation when an attending showed me how to perform a digital block but instructed me to avoid using lidocaine with epinephrine due to the “theoretical” risk of digital necrosis. When I asked what “theoretical” meant, he replied, “It has probably never happened, but I would hate to be the first!”

The dogmatic belief that 1:100,000 epinephrine causes necrosis to distal appendages on the human body has unfortunately been drilled into practicing physicians and young, impressionable students for decades. The thought is that locally injected epinephrine will cause necrosis of the toes, fingers, ears, and even nose due to sudden vasoconstriction, leading to local ischemia.

Why do we care? Subcutaneously injected epinephrine has notable benefits. It has been shown to increase lidocaine’s duration of action in local injection, especially digital nerve blocks. (J Hand Surg Am. 2014;39[4]:744; Plast Reconstr Surg. 2006;118[2]:429.) It also reduces bleeding at wound sites, making it especially useful in highly vascularized areas (e.g., scalp lacerations).

A comprehensive literature review reported that only 21 case reports between 1889 and 1949 described finger necrosis when epinephrine was used. The concentration of epinephrine was not known in 17 of the cases. (J Emerg Med. 2015;49[5]:799.)

It is incredible how pervasive myths can be. The digital necrosis myth is particularly interesting because literally no cases have been reported since 1949. This was the same year the Soviet Union detonated its first atomic bomb, West and East Germany were established as separate countries, and electron microscopy was developed. But many students and young physicians are still taught this dogmatic fear in 2021.

Follow the Data
Today epinephrine formulations currently available include 1:100,000 and 1:200,000. A few physiologic studies have been performed, and normal perfusion was present after an hour, though perfusion might have decreased for 10-60 minutes in the affected digit. No decrease in local capillary pH or blood gas was seen. (J Hand Surg Eur. 2008;33[4]:515.)

Seven retrospective studies (ranging from 43 to 200,000 patients per study) and two prospective studies (23 and 1340 cases in each) demonstrated no cases of digital necrosis in the fingers, toes, and feet. (J Emerg Med. 2015;49[5]:799.)

Let’s assume the worst. What if a patient had a high concentration of epinephrine injected into the digit? Thankfully, data are available on this too. Fitzcharles, et al., in 2007 reviewed 59 cases of EpiPen autoinjector discharge with a 1:1000 concentration injection into the finger. These cases were unintentional, usually sustained by a child or loved one playing with another person’s EpiPen. More than half of the cases did not receive any locally injected phentolamine (the preferred reversal agent) yet suffered no ischemia. (Hand [NY]. 2007;2[1]:5; https://bit.ly/3Fhaunz.)

Another review of 365 epinephrine autoinjector injections to the hand were reviewed in 2010, finding that no patients suffered permanent damage. Four patients suffered “ischemia” and received phentolamine treatment, but we are unsure how the reports defined ischemia given that no permanent damage occurred. (Ann Emerg Med. 2010;56[3]:270.)

Perhaps most damning to this dogmatic belief is whether a dilute, subcutaneous injection of epinephrine really causes harm given the lack of evidence that highly concentrated epinephrine (1:1000) causes digital necrosis. It simply curtails the myth even more if a patient can safely be exposed to 100 times the dose of epinephrine that we would normally use in a standard digital nerve block or local anesthetization.

This is not much of a clinical controversy but more a clinical dogma smackdown. Decrease your patient’s pain and improve the visualization in your field by using subcutaneous epinephrine mixed with lidocaine. If a student asks you about the “theoretical” risk of necrosis, you should reply that it certainly was theoretical … in 1949.

Special thanks to one of our readers, Tom Benzoni, DO, for suggesting I write about this topic.

Dr. Briggs is an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host, and editor-in-chief of EM Board Bombs (https://www.emboardbombs.com), a multiplatform educational tool designed to provide board prep and focus on what you need to know for the practice of emergency medicine. Follow him on Twitter @blakebriggsmd.