Monday, May 29, 2017

An ED Model for Shared Decision Making

The Gist: Shared decision making (SDM) is increasingly common in the ED, yet most people, particularly trainees, are untrained in this area. A proposed framework in an Annals of Emergency Medicine article by Probst et al proposes a framework to guide clinicians (or train them) in the implementation of SDM in the busy ED and combats common misconceptions regarding SDM.
  1. Ask yourself: is this clinical scenario appropriate for SDM - is there clinical uncertainty or equipoise, is the patient capable of engaging in SDM, and is there time?
  2. Have the conversation - Acknowledge that a decision needs to be made and share information about the risks and benefits of each option. Explore the patient's values and circumstances to help come to a decision.
The Case:  The nurses give you a heads up the next patient to be seen is in a lot of pain.  You see a 25-year-old healthy male who is doing the “kidney stone dance” – pacing around the room while holding an emesis basin. He's had left flank pain for the past two hours, nausea, but has a reassuring abdominal exam with minimal tenderness.  His urinalysis shows red cells in the urine and he's feeling better after analgesia.  What's next - CT scan? Ultrasound? Discharge with neither?

An SDM in the Emergency Department Framework from the Probst et al Annals article

1.  Is this scenario appropriate for SDM? 
  • Is there more than one reasonable option at this time?
The current literature regarding renal colic in the ED supports multiple options as the next reasonable

step [1-5]. Non-contrast CT scan is the historic option; yet, recent evidence supports ultrasound as a reasonable next step, and an ultrasound-first diagnostic plan might decrease radiation exposure for this young patient [2]. Experts have also argued that renal colic can be diagnosed clinically, and imaging is not necessary in classic cases with low probability of dangerous alternative diagnoses [1]. The trade-offs between these options might be important to this patient; if he’s feeling better or concerned about lifetime radiation risk, he may not want to wait for a CT scan, and conversely, if he’s about to set off hiking the Appalachian Trail, he may want to know the location and size of his stone.  
Obviously, there are clinical reasons why some cases of suspected renal colic warrant CT scans – fever, concern for an alternate diagnosis, or solitary kidney [6].
  • Is the patient able to make his own medical decisions? 
While this patient may know little about the trade-offs involved in the clinical question, research has
shown that patients do want to be told about the risks of radiation prior to CT scans [7]. This patient isn't altered or otherwise incapacitated - he can participate in decision making.
  • Do you have time? Does your patient have time?
The latter question is easy to answer: unless he’s eloped because he’s feeling better, your patient
clearly has time to have this conversation. Whether you have time depends on the severity of other patients’ conditions and your ability to explain the trade-offs in a manner that he can understand. The more you practice this skill, the better you will be at it, and it’s worth noting that the results of your conversation may speed up his discharge, creating space for another patient and increasing throughput.

2.  Have the conversation (if the answers to the above questions are yes)
  • Acknowledge that a decision needs to be made - 
“I suspect that you have a kidney stone – kidney stones cause severe pain, vomiting, and blood in the urine, all of which you had. At this point, we have to decide if it makes sense to do some more imaging.”
  • Share Information in Regard to Management Options and the Potential Harms, Benefits, and Outcomes of Each - 
“For some people, we do a CT scan – the benefit of a CT is that we know exactly how big the stone is, which helps us know if you’re going to need a procedure from a urologist to get it out. Most people with kidney stones pass the stone by themselves, and the CT isn’t helpful. The downside of a CT is that it takes time and it exposes you to radiation – and we know that every time you get exposed to radiation it increases your future risk of cancer ever so slightly. Also, if your pain comes back and doesn’t go away, it might make more sense to get a CT later – and we wouldn’t want to have to do two CT scans. Most people who have one kidney stone will have another one in the next 10 years – so you could end up with multiple CT scans over your lifetime. The other option is an ultrasound: it gives us some information and sometimes we get a CT scan if we see a lot of swelling in your kidney, but it doesn't show us how big the stone. Because I can do the ultrasound right now, people often go home sooner when they have an ultrasound, if they don’t need a CT. If we decide on the ultrasound, it’s important that you have a doctor you can follow-up with if you are feeling worse.”
  • Explore Patient Values, Preferences, and Circumstances - Probing the patient about what's important to them is key - they may not disclose difficulties with transportation, their activities of daily living, or their travel plans.
“How are you feeling? Do you have a doctor you can see in the next week or so? Would you be able to get back to the ED if you had a problem? Kidney stones usually pass in a week or two – do you have any travel planned?”
  • Decide Together on the Best Option for the Patient, Given His or Her Values, Preferences, and Circumstances
If a patient has a preference, this part is easy – maybe they’re in a hurry, worried about the cost of a CT, or have had multiple CT scans, or maybe they have an upcoming trip and want certainty.
Many patients won't have a preference, and they may ask you for advice. Share your opinion but recognize that there is a huge power differential.

“If I had a kidney stone, and the pain medication worked, I wouldn’t be in a rush to get a CT scan – but might get one in a week or two if I still had alot of pain. If I had some reason that I felt like I needed more information right now, like I was going on a cruise, then I might get the scan.”

Presenting both sides in the explanation of your opinion empowers the patient to choose either the
option you endorsed or the other option without feeling like they are disagreeing with the expert.

1. Wang RC. Managing Urolithiasis. Annals of Emergency Medicine 2016;67(4):449–54.
2. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med 2014;371(12):1100–10.
3. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol 2016;:1–9.
4. Fiore M. A proposal algorithm for patients presenting to the Emergency Department with renal colic. Eur J Emerg Med 2016;23(6):456–8.
5. Xiang H, Chan M, Brown V, Huo YR, Chan L, Ridley L. Systematic review and meta-analysis of the diagnostic accuracy of low-dose computed tomography of the kidneys, ureters and bladder for urolithiasis. J Med Imaging Radiat Oncol 2017;:1–9.
6. Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European Urology 2015;:1–7.
7. Robey TE, Edwards K, Murphy MK. Barriers to computed tomography radiation risk communication in the emergency department: a qualitative analysis of patient and physician perspectives. Acad Emerg Med 2014;21(2):122–9.

Sunday, November 13, 2016

Slaying Prehistoric Practice - Killing off the Routine Pulse Check

The Gist: It's time to kill off the routine pulse check every two minutes. While some providers and systems have moved away from routine pulse checks, perfunctory cessation in compression to identify pulses happens as 'the norm' across the United States. Check the rhythm as indicated - without halting compressions if you have a monitor that is able to sense despite compressions or if there is a spike in end tidal capnography (etCO2) or another compelling reason such as gain on arterial line tracing, or during a brief, <10 second pause, if compressions interfere with rhythm analysis [1].

Most of us recognize that, to the best of our knowledge, interruptions in chest compression may be deleterious to return of spontaneous circulation and, theoretically, neurologic outcome [2]. We may even devise complicated ways of reducing time without compressions including mechanical compressions and hands-on defibrillation. These interventions are not evidence based and the yield is minimal. A more simple fix exists - stop checking for pulses routinely.  This isn't some novel wild idea.

The American Heart Association guidelines do not recommend any specific interval for pulse check after the first initial pulse check for healthcare providers [3].  Beginning in 2010,  however, the AHA guidelines begin discouraging routine pulse checks:
"Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred" [4].

It's really difficult to identify pulselessness in < 10 seconds
. Few people can determine the presence of pulselessness in 10 seconds. Dick et al performed a study of patients placed on cardiopulmonary bypass, and providers were blinded to the presence of pulsatile flow. Only two percent of experienced providers (n=209) were able to determine that a patient was pulseless in under 10 seconds [5].
Enforcement of time between compressions may be mitigated by having someone count down from 10 during the rhythm analysis. We often have the individual performing chest compressions do this and they are trained and reminded at the beginning of the resuscitation to resume compressions when they reach zero.

Pulse checks are inaccurate. A study by Tibaballs et al again had providers assess for a pulse in patients on bypass with and without pulsatile flow. They found 78% accuracy in identification of the presence or absence of a pulse [6]. While an accuracy of 78% may seem high, this means that approximately one in four times we are wrong. This means we may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions. Cardiac ultrasound and arterial line tracings demonstrate contractility and flow with superior diagnostic characteristics, although each has their limitations [7].

Why would we undertake a diagnostic strategy if we know it it is inaccurate and insensitive? Changing practice is difficult. In critical situations we default to what is familiar, what we know.  It is time to move away from the pulse check. We may still need to check for rhythm analysis at periodic intervals, and this is supported by the AHA guidelines. Some monitoring systems allow for this concurrently with compressions (filter out the baseline), while others do not. Many of us are also compelled to search for reversible causes of arrest with ultrasound, many of which do not require an interruption in compressions.

If you're curious about why we are so stubborn to let go of our practices, check out this post on unlearning practices we adore.

1. Soar J et al. "European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support." Resuscitation, October 2015, Pages 100 - 1472.
2. Eftestøl T, Sunde K, Steen PA.  Effects of Interrupting Precordial Compressions on the Calculated Probability of Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation.2002; 105: 2270-2273.
3. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support. Circulation. 132(18 suppl 2):S444-S464. 2015
4.Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
5. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000 Nov;28(11 Suppl):N183-
6. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010.
7. Gaspari R et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27

Unlearning - Yoga For Your Brain

The Gist:  Knowledge translation is a problem in medicine and, at the individual level, unlearning likely contributes to the knowledge translation gap.  It may also exist as part of the solution. Akin to yoga, unlearning requires flexibility, training or deliberate practice, and is enhanced by a community open to skepticism and growth.
  • Note: These musings are not evidence based but are more of a cognitive framework to understand why we have such difficulty individually changing practice.
For an introduction to unlearning, check out this post.  In brief, unlearning, while really an aspect of truly understanding and learning, is complicated.  Most of us find it relatively easy to stuff more information into our brains, a process we perceive as "learning."  Nasal cannula with oxygen at 15 liters per minute plus may help prolong safe apnea time and reduce hypoxia during intubation?  Cool, we can do that.  However, when we are told that something that we routinely do or believe may not necessary or even harmful, we often have more difficulty changing out behavior or "unlearning." Intubating patients with out of hospital cardiac arrest may not be helpful? Preposterous! Unlearning a bit of information is unnatural, it may feel awkward whereas learning, as it often does not put our knowledge or ego in jeopardy.

Flexibility - Unlearning requires cognitive flexibility. When we stretch our bodies, we reach a point where we feel a burn; our body telling us we are approaching our limit. We can push further safely, it just burns slightly more.  Unlearning is essentially the same and is often accompanied by “the burn.”  When we come across information counter to the way we practice, it stings. We may feel defensive. This is “the burn.”  We experience discomfort when we stretch our thinking beyond this. This may be, in part, because we are emotionally tied to our knowledge. We work hard for what we know.  We act quickly in emergency care and must have confidence in what we know, as emergent situations do not typically allow for debate or significant time to think.

  • A fix: When one feels “the burn” when confronted with new information that runs counter to our practice, recognize that this is a warning sign that knowledge may be changing.  Recognize that the sting comes from our ego, protecting what we know.  This does not mean that one should change practice whenever we come across a piece of novel information. Rather, we should we aware that in order to practice evidence based, up to date medicine, we may feel discomfort. When our beliefs are challenged, instead of becoming defensive, we should thoughtfully consider the information.
Training - Mastering a yoga pose requires training and deliberate practice. In order to unlearn ways of thinking, we must also engage in mental preparation and practice.  It is easy, particularly in emergency settings when adrenaline dominates, to think and execute in a perfunctory manner. We default to what we know and what is familiar.
Some fixes:

  • Early Exposure - The earlier we begin training, the more prepared we are. If one has an upcoming race, we may expect we will perform better if we begin preparing earlier rather than the week before the race. Similarly, when it comes to unlearning a habit or a way of thinking, the sooner we are exposed to the contrary argument, the more prepared we may be to unlearn.  This may serve as a preconditioning so that we may react less strongly upon repeat exposure. 
  • Repeat Exposure - Practice is central to most athletic endeavors. The more repetitions we do, the stronger we become.  The more we practice a yoga pose, the more likely we are to be successful, the more comfortable it will feel.  Unlearning is easier when we are exposed to the target bit of knowledge more frequently.  Spaced repetition exists as one of the most evidence-based means of learning and  this probably applies to unlearning. 
Community - Yoga and CrossFit are associated with strong communities, as are many team sports.  Communities may motivate us, hold us accountable, and push the bounds of our perceived capability.  Studies demonstrate that physicians practice similarly to the institution where they trained and show a wide array of geographic variation in practice patterns. A network of peers and colleagues, particularly outside of own’s main “system” or hospital, may increase our cognitive flexibility by exposing us to a wide array of practice pattern.  The Free Open Access Medical Education (FOAM) community may expose to novel and controversial information.

Unlearning in the Prehospital Arena: The Workout
Needle Decompression for Tension Pneumothorax (see this post or this podcast).  The second intercostal space at the midclavicular line (2nd ICS MCL) has been taught as the ideal spot for needle decompression.  This, however, is changing.  New recommendations are to use a catheter at least 8cm in length if needle decompression is attempted at the 2nd ICS MCL or decompress at the fourth or fifth intercostal space at the anterior axillary line (4/5th ICS AAL).
The chest wall is thick at the 2nd ICS MCL [1,2].  Radiographic studies of chest wall thickness demonstrate increased thickness at the 2nd ICS MCL compared with the 4/5th ICS AAL (4.78 cm vs 3.42 cm).  Even ATLS states that needle decompression in the 2nd ICS MCL will fail more than 50 percent of the time.  This is an intervention undertaken in extreme circumstances in critically ill patients.  A chance of failure of 1 in 2 is unacceptable.
The 2nd ICS MCL is difficult to identify [3,4].  The clavicle extends further than most people think. As a result, providers are less accurate in identifying the 2nd ICS MCL compared with the 4/5th ICS AAL.

The pulse check.  If one were to survey cardiac arrest resuscitation across the United States, in and out of hospital,  we would probably see that the majority of people pause every two minutes for a “pulse check” despite decreased emphasis on the pulse check by the AHA guidelines over the past 10 years.  The guidelines recommend minimal interruptions for pulse check and detail the problematic sensitivity and specificity of pulse identification [6].  After the initial pulse check prior to CPR, the guidelines don’t actually specify any time frame for repeat pulse checks. Yet, many of us do.  Sure, we can pause for rhythm analysis; however, many systems and the European guidelines now recommend pulse assessment upon observation of an organized rhythm or increase in end tidal capnography [7].
Few people can determine the presence of pulselessness in 10 seconds. Dick et al of patients placed on cardiopulmonary bypass and providers blinded to whether or not the patient actually had a pulse. Only 2% of this cohort of experienced providers were able to identify a pulseless patient in 10 seconds [8]. With increased emphasis on compression fraction, this may result in a delay in resumption of compressions.
The accuracy of the pulse identification by providers is suboptimal, noted to be 78% in one study [9].  While an accuracy of 78% may seem high, this means that approximately one in four times we will be wrong. We may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions.
For more on this topic check out this post and/or this post.

Left Bundle Branch Block (LBBB) as a STEMI Equivalent (check out this post)- Prior to the 2013 iteration of the AHA guidelines for ST-elevation myocardial infarction (STEMI), new or presumed new LBBB existed as a “STEMI equivalent.”  This often activated the cath lab and STEMI teams.  In 2013, the AHA removed this from the guidelines yet these patients are often referred to the emergency department for “rule out MI.”
Further, STEMI may often be diagnosed on ECG, using the Sgarbossa or modified Sgarbossa criteria (link) [10].

Backboards - fortunately protocols in many states and systems have dispensed with long backboards.  Long thought to be protective, despite known harms, the American College of Emergency Physicians released a guideline in 2016 explicitly stating that long backboards should not be used as a therapeutic or precautionary measure. They cause harm and don’t help. [11]

Oxygen in Acute Coronary Syndromes - Aspirin, oxygen, and nitroglycerin have long been the initial interventions for patients with suspected ACS. Recent studies have found no clear benefit for oxygen in patients with normal oxygen saturations. Further, one study found oxygen was associated with markers of larger myocardial infarctions (although this is not a patient-oriented outcome) [12]. The AHA recommends oxygen is appropriate for patients who are hypoxemic (oxygen saturation < 90%) [6].

1.  Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16.
2. Advanced Trauma Life Support, 9th edition.
3. Ferrie EP et al. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005;22(11):788–9.
4. Inaba K et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers
6. Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
7. Resuscitation. 81(6):671-5. 2010.
8. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse?Crit Care Med. 2000 Nov;28(11 Suppl):N183-5
9. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation.
10. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 61(4):e78-e140. 2013
11. "EMS Management of Patients with Potential Spinal Injury." ACEP Board of Directors. Available at:
12. Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 131(24):2143-2150. 2015.

Saturday, May 28, 2016

Risky Business: Framing Statistics

The Gist: Medical literature frequently frames effect size using relative and absolute risks in ways that intentionally alter the appearance of an intervention, an example of framing bias. Effect sizes seem larger using relative risk and smaller using absolute risk [1,2].

Part of our 15 Minutes - 'Stats are the Dark Force?' residency lecture series
Risk from Lauren Westafer on Vimeo.

Perneger and colleagues surveyed physicians and patients about the efficacy of 4 new drugs. They were presented with the following scenarios:
While these numbers reflect the same data, patients and physicians selected that the drug that "reduced mortality by 1/3" was "clearly better" [3].  This indicates both parties are susceptible to the cognitive tricks statistics, particularly the way that relative risk make numbers appear larger and the ways absolute risk makes numbers appear smaller.  Authors can consistently switch between relative and absolute risk to maximize the appearance of benefit and minimize risks, as seen in the following abstract:

Perhap authors should be encouraged to report statistics consistently, using relative OR absolute rather than switching between the two to give the appearance of maximum benefit and minimal risk.

1. Barratt A. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. Canadian Medical Association Journal. 171(4):353-358. 2004
2. Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM. The framing effect of relative and absolute risk. Journal of general internal medicine. 1993;8(10):543-8.
3. Perneger TV, Agoritsas T. Doctors and patients' susceptibility to framing bias: a randomized trial. Journal of general internal medicine. 26(12):1411-7. 2011.

Saturday, May 21, 2016

P Values: Everything You Know Is Wrong

The Gist:  P values are probably the most “understood” statistic amongst clinicians yet are widely misunderstood.  P values should not be used alone to accept or reject something as “truth” but they may be thought of as representing the strength of evidence against the null hypothesis [1].

Part of our 15 Minutes - 'Stats are the Dark Force?' residency lecture series

P: Everything You Know Is Wrong from Lauren Westafer on Vimeo.

At various times in my life I, like many others, have believed the p value to represent one of the following (none of which are true):
    • Significance
      • Problem:  Significance is a loaded term.  A value of 0.05 has become synonymous with “statistical significance.”  Yet, this value is not magical and was chosen predominantly for convenience [3].  Further, the term “significant” may be confused with clinical importance, something a statistic cannot answer.
    • The probability that the null hypothesis is true.
      • Problem: The calculation of the p value includes the assumption that the null hypothesis is true.  Thus, a calculation that assumes the null hypothesis is true cannot, in fact, tell you that the null hypothesis is false.
    • The probability of getting a Type I Error 
      • Background: Type I Error is the incorrect rejection of a true null hypothesis (i.e. a false positive) and the probability of getting a Type I Error is represented by alpha. Alpha is often set at 0.05 so that there is a 5% chance you are wrong if you reject the null hypothesis. This is a PRE test calculation (set before the experiment)
      • Problem: Again, the calculation of the p value assumes the null hypothesis is true. The p value only tells us the probability of getting the data we did, it does NOT speak to the underlying truth of whatever is being tested (i.e. efficacy). The p value is also a POST test calculation.
      • The error rate associated with various p values varies, depending on the assumptions in the calculations, particularly prevalence. However, it's interesting to look at some of the estimates of false positive error rates often associated with various p values:  p=0.05 - false positive error rate of 23-50%; p=0.01 - false positive error rate of 7-15% [5].
P value is the probability of getting results as extreme or more extreme, assuming the null hypothesis is true. Originally, this statistic was intended to serve as a gauge for researchers to decided whether or not a study was worth investigating further [3].  
  • High P value - data are likely with a true null hypothesis [Weak evidence against the null hypothesis]
  • Low P value - data are UNlikely with a true null hypothesis [Stronger evidence against the null hypothesis]
Example:  A group is interested in evaluating needle decompression of tension pneumothorax and proposes the following:
    • Hypothesis - Longer angiocatheters are more effective than shorter catheters in decompression of tension pneumothorax.
    • Null hypothesis - There is no difference in effective decompression of tension pneumothorax using longer or shorter angiocatheters.
A group, Aho and colleagues, did this study and found a p value of 0.01 with 8 cm catheters compared with 5 cm catheters.  How do we interpret this p value?  
  • We would expect the same number of effective decompressions or more in 1% of cases due to random sampling error.  
  • The data are UNLIKELY with a true null hypothesis and this is decent strength evidence against the null hypothesis.
Limitations of the Letter “P”
    • Reliability.  P values depend on the statistical power of a study. A small study with little statistical power may have a p value greater than 0.05 and a large study may reveal that a trivial effect has statistical significance [2,4].  Thus, even if we are testing the same question, the p value may be "significant" or "nonsignificant" depending on the sample size.
    • P-hacking.  Definition:  "Exploiting –perhaps unconsciously - researcher degrees of freedom until p<.05" Alternatively: "Manipulation of statistics such that the desired outcome assumes "statistical significance", usually for the benefit of the study's sponsors" [7].
      • A recent study of abstracts between 1990-2015 showed 96% contained at least 1 p value < 0.05.  Are we that wildly successful in research? Or, are statistically nonsignificant results published less frequently (probably).  Or, do we try to find something in the data to report as significant, i.e. p-hack (likely).
P values are neither good nor bad. They serve a role that we have distorted and, according to the American Statistical Association: The widespread use of “statistical significance” (generally interpreted as “p ≤ 0.05”) as a license for making a claim of a scientific finding (or implied truth) leads to considerable distortion of the scientific process [1].  In sum, acknowledge what the p value is and is not and, by all means, do not p alone.

  1. Wasserstein RL, Lazar NA. The ASA’s statement on p-values: context, process, and purpose. Am Stat. 2016;1305(April):00–00. doi:10.1080/00031305.2016.1154108.
  2. Goodman S. (2008) A dirty dozen: twelve p-value misconceptions. Seminars in hematology, 45(3), 135-40. PMID: 18582619 
  3. Fisher RA. Statistical Methods for Research Workers. Edinburgh, United Kingdom: Oliver&Boyd; 1925.
  4. Sainani KL. Putting P values in perspective. PM R. 2009;1(9):873–7. doi:10.1016/j.pmrj.2009.07.003.
  5. Sellke T, Bayarri MJ, Berger JO.  Calibration of p Values for Testing Precise Null Hypotheses.  The American Statistician, February 2001, Vol. 55, No. 1
  6. Chavalarias D, Wallach JD, Li AHT, Ioannidis JPA. Evolution of Reporting P Values in the Biomedical Literature, 1990-2015. Jama. 2016;315(11):1141. doi:10.1001/jama.2016.1952.
  7. PProf.  "P-Hacking."  Urban Dictionary. Accessed May 1, 2016.  Available at:

Tuesday, January 26, 2016

Percutaneous Chest Tubes: The Humane Choice

The Gist:  Small bore percutaneous catheters, often referred to as "pigtail" catheters, should be the initial means of treating many pneumothoraces and select other drainable thoracic pathologies as they cause less pain and capitalize on the commonly used seldinger technique [1-10].

Traditional tube thoracostomy is an invasive procedure.  For the past several years, international guidelines, individuals in the Free Open Access Medical education (FOAM) community, and various institutions have moved towards placing more pigtail catheters for urgent thoracic pathology.  Yet, this practice is still not ubiquitous.  I recently gave a talk on this to my program and, in the spirit of FOAM, have shared it:

Technique - Watch this video by Dr. Larry Mellick 
  • Seldinger style: uses a technique with which we are intimately familiar. The majority of emergency providers have likely done far more central lines than open tube thoracostomies. As such, a technique mentally and mechanically familiar to providers may be preferable.
  • Pearls for placement - Kulvatunyou and colleagues suggest "POW" pearls for placement.
    • P -Perpendicular: Ensure the finder needle is perpendicular to the rib during placement
    • O -Over the rib: Like chest tubes, pigtails go over the rib to avoid injury to the neurovascular bundle
    • W -Wary of wire kinking:  The wire may be prone to kinking, particularly upon dilation through the tough intercostal muscles.
  • Pneumothorax
    • Spontaneous pneumothorax: The British Thoracic Society has recommended small bore tubes over traditional chest tubes since 2010.
    • Traumatic pneumothorax:  Use of pigtail catheters have increased in many trauma communities, with success rates comparable to large bore chest tubes [8-11].
  • Effusions - pigtail catheters are frequently used to drain effusions, particularly simple effusions. Most of the primary literature on this topic has been conducted in children with parapneumonic effusions and has demonstrated that this technique is successful and safe [13].
  • Hemothorax/Complex fluid - Larger bore tubes (28F and larger) are typically used to drain hemothorax due to the feared complication of retained hemothorax.  A prospective review of 36, 14F pigtail catheters placed for hemothorax in trauma patients found no significant differences in complications or success between pigtails or chest tubes but wasn't powered to find important, infrequent complications [11].  An animal study found
The Good:
  • Less Painful - In addition to the procedure not requiring large, forceful separation of the and unsurprisingly, placing a smaller tube in the chest causes less pain, even 2 days after the procedure [10].
    • Pain in pigtail vs chest tube patients: Day 0 3.2  vs 7.7; p<0.001, Day 1 1.9 vs 6.2; p<0.001, Day 2 2.1 vs 5.5; p=0.04 (note: no power calculation performed)
  • Easy/Familiar Procedure - as above under "Seldinger technique"
  • May reduces some complications - The literature suggests that complications are typically at least equivalent between larger chest tubes and pigtails. More serious complications are difficult to quantify given the infrequency.
    • One study did show that infections were reduced in the pigtail group, possibly due to technique or a larger nidus for infection [2].
  • Outpatient treatment possible - In select patient groups with spontaneous pneumothorax and excellent follow up, a pigtail catheter may be connected to a heimlich valve and the patient may be discharged [7].
The Bad:
  • More predisposed to kinking - Due to the small, flexible tubing, these tubes may kink and obstruct the lumen.  The trauma literature suggests these complications may occur in 2-8% of cases [8-10].
  • Clogging - Drainage of some complex fluids (loculated effusion/hemothorax) may be more problematic through pigtail catheters as the small lumen may be easier obstructed with clot.
  • Time? The belief exists that open thoracostomy more expediently relieves pneumothorax compared with the percutaneous technique and is thus preferred in emergent, life-threatening situations. To date, there's no literature to support or refute this and the time a tube takes is likely provider dependent.
  • It's less cool - A certain pride and thrill exists with performing invasive procedures.  In discussions with individuals regarding barriers to uptake of the percutaneous technique the theme arose that performing this technique would demonstrate some sort of weakness by the provider. Note: this notion is not supported or addressed by the literature and is merely a thought about subconscious provider bias
1. Laws D et al. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58 Suppl 2:ii53-9.
2.  Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med. 2009 Oct;103(10):1436-40.
3. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002 Aug;18(4):265-7.
4. Gammie JS et al. The pigtail catheters for pleural drainages: a less invasive alternative to tube thoracostomy. JSLS. 1999 Jan-Mar;3(1):57–61.
5. Kuo HC, et al. Small-bore pigtail catheters for the treatment of primary spontaneous pneumothorax in young adolescents. Emerg Med J. 2013 Mar;30(3):e17.
6.  Repanshek ZD, Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Alternative Treatments of Pneumothorax. J Emerg Med. 2013 Feb;44(2):457-466.
7. Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009 Jun;16(6):513-8.
8. Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011 Nov;71(5):1104-7.
9. Rivera L, O’Reilly EB, Sise MJ, et al. Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. J Trauma. 2009 Feb;66(2):393–9
10.  Kulvatunyou N, et al. A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.
11. Kulvatunyou N, Joseph B, Friese RS, et al. 14 French pigtail catheters placed by surgeons to drain blood on trauma patients. J Trauma Acute Care Surg. 2012;73(6):1423–1427. 
12. Russo RM, Zakaluzny SA, Neff LP, et al. A pilot study of chest tube versus pigtail catheter drainage of acute hemothorax in swine. J Trauma Acute Care Surg. 2015;79(6):1038–1043. 
13.  Liu YH, et al. Ultrasound-guided pigtail catheters for drainage of various pleural diseases. Am J Emerg Med. 2010 Oct;28(8):915-21
14. Inaba K, Lustenberger T, Recinos G. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. The journal of trauma and acute care surgery. 72(2):422-7. 2012.

Thursday, January 7, 2016

We Don't Know the Midclavicular Line

The Gist:  Needle decompression for tension pneumothorax should be taught at the fourth or fifth intercostal space at the anterior axillary line (4/5ICS AAL). 

  • Note: This post will not detail critiques that needle decompression may be overused or the needle vs thoracostomy debate.

Historical teaching instructs providers to place a needle in the second ICS at the mid-clavicular line (2ICS MCL) for tension pneumothorax [1,2]. Free Open Access Medical Education (FOAM) sources such as Emergency Medicine Ireland have preached the more lateral approach for years; yet this teaching has not spread widely (outside of military circles where there seems to be better adoption). Change is difficult, particularly when it involves re-educating thousands of providers and it seems like this is the primary driver behind the 2ICS MCL remaining as the typical site for needle decompression..  However, several potential problems exist with the mid-clavicular approach that warrant consideration for assuming 4/5ICS AAL as the primary initial placement for needle decompression.

A: Where I see most needles placed, B: 2ICS MCL, C: 5ICS AAL
We may not be able to reach the pleura [3-5].  The chest wall may be particularly thick at the 2ICS MCL, particularly as the average BMI in many nations grows.  Researchers have looked at this question for years through a couple of means - measuring the depth at the 2ICS MCL on CT scans of trauma patients compared with alternative sites. The 2ICS MCL is generally 1.3 cm thicker than 5ICS AAL. 
  • This discrepancy was not solely seen in the morbidly obese.  In fact, it was seen consistently across all four BMI quartiles tested, and at the traditional insertion site, needle decompression would have been extremely difficult with any eccentric placement using a standard needle in all but the lowest BMI quartile [3].
How often would the needle fail?  A systematic review and meta-analysis in Injury 2015 by Laan et al looked at 17 studies, generally cadaveric or radiographic, and found that a standard 5 cm catheter used for needle decompression at the 2ICS MCL would fail 38% (24–54%) of the time compared with only 13% (8–22%) at ICS4/5-AAL (p= .01) [5].
  • The British Thoracic Society Guidelines (2010) even remark “a standard 14 gauge (4.5 cm) cannula may not be long enough to penetrate the parietal pleura..with up to one-third of patients having a chest wall thickness >5 cm in the second interspace.”
  • In some places, the failure rate may be even higher secondary to obesity [5].
What about a longer needle?  Many catheters used for needle decompression are 5 cm in length; however, some have access to 8 cm angiocatheters.  A analysis by Clemency and colleagues found that in order to achieve a success rate of 95%, we would need a catheter at lease 6.4 cm in length [8].  Similarly, Laan and colleagues conducted a pre-post retrospective study in an EMS system that switched from using 5 cm catheters to 8 cm catheters with an increase in success rate (48% vs 83%) [6].  For a life saving, last ditch effort, I'm not sure that 95% success rate is adequate when alternatives exist.

We don’t identify this site well [10,11].  A 2005 paper by Ferrie and colleagues had 25 emergency physicians name the correct side for needle thoracentesis and label this site with a pen on a male volunteer (erased between providers).  Nearly all participants were ATLS certified within the past 10 years.  
  • 88% (n=22) named the correct site (one additional person did name the 5ICS AAL).
  • Only 15 of the 25 participants (60%) could correctly identify the 2ICS MCL [10].   
In another study, Inaba and colleagues trained 25 US Navy corpsmen on needle decompression, using both the 2ICS MCL and the 5ICS AAL. The corpsmen then performed needle decompression at both sites on randomly selected cadavers, bilaterally.  
  • Mean distance from the correct location: 3.1 cm 2ICS MCL vs 1.2 cm 5ICS AAL
  • Correct placement (ICS +/- 5 cm):  15/50 (30%) 2ICS MCL vs 41/50 (82%) 5ICS AAL
  • Limitations: This study had multiple outcomes and no power analysis was performed [11]
I think much of this is because we underestimate the length of the clavicle.  It's easier when you can see the chest wall bones but we don't have this advantage in the clinical setting.  On a person, the midclavicular line often seems fairly lateral.  

Important structures surround the 2ICS MCL.  As mentioned above, we seem to have a tough time finding the 2ICS MCL [8,9]. There are important structures in this vicinity, particularly if the tendency is to go more medial than the actual midclavicular line, including the internal mammary artery and contents of the superior mediastinum.  Naturally, should an individual placing a needle in the 4/5ICS AAL go too caudal the possibility exists for the needle to enter the liver or spleen but the study by Inaba and colleagues suggest we may be better able to identify this space [9].

Given the literature, it seems that at this time should a needle be placed aiming for the 2ICS MCL for needle decompression and fail, this is a failure of education and changing our knowledge base rather than a patient-based failure. We should know better.


  1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.
  2. Advanced Trauma Life Support, 9th ed. 
  3. Inaba K, Ives C, McClure K, Branco BC, Eckstein M, ShatzD, Martin MJ, Reddy S, Demetriades D. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9): 813Y818.
  4. Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. JTrauma. 2011;71(5):1099Y1103; discussion 103.
  5. Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16. 
  6.  Laan D, Berns KS, Habermann EB. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. 2015. doi:10.1097/TA.0000000000000889.
  7. Hecker M, Hegenscheid K, Völzke H, et al. Needle decompression of tension pneumothorax. J Trauma Acute Care Surg. 2016;80(1):119–124. doi:10.1097/TA.0000000000000878.
  8. Carter TE, et al. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? West J Emerg Med, 2013; 14(6): 650–2
  9. Clemency BM, Tanski CT, Rosenberg M, May PR, Consiglio JD, Lindstrom HA. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehospital and disaster medicine. 30(3):249-53. 2015.
  10. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005;22(11):788–789.
  11. Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers.

Wednesday, June 3, 2015

GCS: Saying What We Mean

The Gist:  The Glasgow Coma Scale (GCS) is widely used, yet complicated by clunkiness and poor inter-rater reliability (explanation of kappa).  The Simplified Motor Score (SMS) is easier to use and equivalent, although this is prone to similar limitations.  Until a better means of communicating mental status comes, it may be best to communicate what the patient is doing (opening eyes to voice, moaning incomprehensibly, localizing pain). See this ScanCrit post.

The Case: A 29 year old male involved in a MVC with multiple traumatic injuries resulting in a prolonged ICU course at Janus General had a tracheostomy placed for respiratory failure.  The patient was responding appropriately to questions, following commands, opening his eyes spontaneous and lacked any signs of confusion or delirium, mouthing words, but was awaiting tracheostomy exchange for a fenestrated trach with a Passy-Muir valve.  What's the patient's GCS? Does this patient's GCS reflect their mental status?
  • Documented at as 10NT, 11T, and 15 by various providers.  The arguments behind each: 10NT - cannot test verbal, 11T -one point for showing up, 15 -patient oriented, and saying appropriate words, just without phonation.
In medicine, we communicate through abbreviations, codes, and numbers. When we see heart rate or blood pressure values we can place these numbers in the context of our knowledge of the patient’s peers. These numbers become actionable.  

Other critical components to the physical exam and evaluation are less easily quantified.  The mental status, for example, is a key component to evaluating a patient.  The GCS was developed to communicate the mental status of a head injured individual among providers during continuing care in a neurosurgical unit [1].  It is often used to track neurologic status when transferring care or over time.  A particular GCS in the prehospital setting may also qualify a patient for a trauma activation in some settings. 

Limitations: Unfortunately, unlike other vital signs, scores don't have explicit meaning.  The total GCS is often reported, yet this 13 point scale (3-15) actually has 120 different possible combinations.  A patient with a GCS of 10 may be completely oriented but totally paralyzed or be moaning incomprehensibly with their eyes own and a withdrawal reflex present.  Further, the sum of the GCS does not equal the parts, with regard to mortality. Healey et al used the National Trauma Database to model mortality predictions based on GCS and found that the same total sum score could be associated with double the mortality (ex: from 27% to 52%) depending on the individual components. Further, the mortality associated with scores is not linear [3].  So a GCS of 11, for instance may mean very different things for two different patients.

Yet, even if the numbers did mean something, the GCS has been found to have abysmal inter-rater reliability.  In one study, 19 emergency physicians rated 131 patients within five minutes of each other found a concordant GCS 32% of the time (Spearson's rho 75, weighted kappa 0.40) [4].   Even in the rather protected setting of case based written scenarios, emergency providers the overall GCS accuracy was 33.1% (95% CI, 30.2-36.0) [5].  In a written mock scenario, EMS personnel (n=178) generated an accurate GCS one-quarter of time without a scoring aid and a shocking 57% with the use of a scoring aid [7].

Alternatives: Given the inaccuracy of the GCS, Thompson et al set out to determine whether the performance of the SMS, a truncated version of the GCS was equivalent to the GCS in a retrospective cohort of out of hospital head injured patients. In the SMS, points are awarded for obeying commands (2), localizing pain (1), and withdrawing to pain or worse (0). They found that the predictive nature of the SMS paralleled that of the GCS, although the GCS seemed to predict mortality slightly better,  0.90 using GCS (0.88-0.01) vs 0.87 using SMS (0.86-0.88) [7].

So, what do we do?
Trashing the GCS is simply not an option for most of us; yet, score cards don't seem to do us any favors.  For example, during a trauma activation, the expectation (at least at Janus General) is to communicate to the room the patient’s GCS.  This may seem to convey more neurologic information than the actual exam discriminates. Recognizing the limitations to the GCS is important in discerning both what we do with this information and how we communicate what we mean, whether it's in documentation, to other providers, or family members.

  • Describe the exam.  With the knowledge of the subjectivity and poor reliability of the GCS, one may give the breakdown of points rather than a simple total GCS and describe the neurologic examination.  Documenting descriptors in medical records this may aid other teams in tracking the patient's exam.  
  • We may also engage in interdisciplinary discussions about use of simplified scoring systems such as the SMS or about the ways we communicate and document neurologic exams. 
1. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427–30. doi:10.1016/j.annemergmed.2011.06.009.
2. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow Coma Scale and Simplified Motor Score in predicting traumatic brain injury outcomes. 2013;27(March):293–300. 
3. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671–678; discussion 678–680. 
4. Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med. 2004;43(February):215–223. 
5. Bledsoe BE, Casey MJ, Feldman J, et al. Glasgow Coma Scale Scoring is Often Inaccurate. Prehosp Disaster Med. 2014. doi:10.1017/S1049023X14001289.
6. Feldman A, Hart KW, Lindsell CJ et al. Randomized controlled trial of a scoring aid to improve glascow coma scale scoring by emergency medical services providers. Ann Emerg Med. 2015 Mar;65(3):325-329.e2.
7. Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58(5):417–25. 

Friday, May 15, 2015

FOAM on the Spot - A Needle in a Haystack?

At the SAEM conference, I had the privilege of partaking in a didactic with Dr. Anand Swaminathan, Dr. Ryan Radecki, and Dr. Matt Astin entitled, "FOAM on the Spot - Integration of Online Resources into Real-Time Education and Patient Care."

The cornucopia of free open access medical education (FOAM) resources may be overwhelming and I get frequent requests for guidance sorting through the cornucopia of FOAM.  People often have the question, "I remember hearing about this technique but I can't recall which site and want to review it..."  As such, I've posted a recording of my portion of the didactic here.

The Gist:
  • Filter FOAM by searching relevant information - FOAMsearch [1].
    • Customized Google search engine of 300+ blogs related to EM/critical care plus journal articles.
  • Engage in the community of personal librarians - Twitter (a few pearls on Twitter)
    • Tag others when you have a question
    • Participate in discussions and "be the librarian" for others.
  • Use a system to stay organized and collate resources - AgileMD.
    • Pro - Can collate several FOAM blogs, PV cards from Academic Life in Emergency Medicine, WikEM, and podcast notes all in one application on a smart phone/tablet.
    • Con - Presently can only build a "library" from a limited number of resources.
As a rather junior individual, selfishly, always welcome constructive feedback on my talks. This is my experiment in crowdsourcing feedback from the FOAM community to become a better presenter.

1. Raine T, Thoma B, Chan TM, Lin M. A custom search engine for emergency medicine and critical care. Emerg Med Australas. 2015;(March):n/a–n/a. doi:10.1111/1742-6723.12404.

Monday, December 29, 2014

Medicine's Third: Polypharmacy

The Gist: Polypharmacy, the concurrent use of multiple medications (5+) or use of unnecessary medications, is problematic in medicine.  Consider “medication related problem” on the differential diagnosis and review the patient’s medications.  When prescribing a medication, consider the unwanted reactions and tailor therapy, recalling that medications frequently have subtle or additive effects that may be especially problematic in the elderly. When in doubt, send a communication to a patient's PCP.

The Case: A 58 y/o with a history of hypertension and diabetes presented with weakness, vomiting, and fatigue.  A basic chemistry panel returned with a creatinine of 3.8 mg/dL (last value, 0.9 mg/dL).  While initially it seemed as though the gentleman had prerenal acute kidney injury from vomiting, the patient revealed he had been taking both ibuprofen and naproxen for worsening arthritis, in addition to his prescribed ace-inhibitor and thiazide diuretic.  See another case in this post on medication reconciliation.

Newton's Third Law states:
"For every action there is an equal and opposite reaction.” 

We ponder this frequently looking at collisions or calculating billiard shots but I think this principle can be translated to medicine. In the medical realm we prescribe therapies for the primary action of that medication/intervention.  Yet, unintended consequences abound.  Despite the comically long “disclaimers” of side effects on advertisements, the additive effects, unintended as they may be, are often disguised in a patient’s presenting complaint.  Further, patients are often prescribed medication to mask the side effects of another medication. Struck by this during medical school, I created my own version:
Westafer’s Third Law of Medicine:
 “For every medication action there is an unequal and unintended reaction.” 

This came up recently in a discussion on Twitter regarding a new medication for hyperkalemia, targeted to combat the side effect of elevated potassium in patients on ACE-inhibitors, ZS-9. A medication for a medication side effect (with likely more broad application in reality).

Although prescriptions from the emergency department (ED) are likely a minority of offenders with regard to the volume of inappropriate medications, awareness of the role that medications may play in the patient’s complaint. Studies show that adverse drug events (ADEs) may be responsible for 10-12% of ED visits among patients > 65 years old, although the definition of adverse drug event and determination of causality vary based on the study [1-3].   A more recent Canadian database review demonstrated a lower prevalence of ADEs generating ED visits, 0.8%, but the methods leave something to be desired [4].

A small study by Chin and colleagues identified ED prescriptions for analgesia, notably NSAIDs, muscle relaxants, and narcotics, as an area for future intervention [5].  Interestingly, this paper was published prior to the massive spike in opioid prescriptions; thus, this area may be even more crucial presently [6].  

Polypharmacy, particularly in the elderly, is associated with an increase in the prevalence of falls, mortality, hospital admission, and hospital length of stay.  The elderly are more susceptible to many of these effects as clearance and metabolism change with age, and elderly patients tend to be on more medications. 

Drug-drug interaction - A medication alters the activity of another.  Example: warfarin + ciprofloxacin -> supratherapeutic INR and may lead to increased bleeding.
Drug-disease interaction - Medications that should be avoided in patients with specific medical conditions.  
  • Example: Use of aspirin 325 mg or non-steroid anti-inflammatories in patients with peptic ulcer disease.
Adverse effects - Many medications have more pronounced adverse effects in elderly patients, often because the pharmacokinetics, such as renal excretion, are altered and may predispose patients to acute kidney injury, delirium, or orthostatic hypotension.  Check out this podcast for more.
  • Example: Anticholinergic properties are abundant in medications, including antidepressants, antihistamines, and antipsychotics.  In the elderly these effects are more pronounced and are associated with hallucinations, impaired memory, tachycardia, falls, constipation, etc.
Unnecessary - Medications are frequently initiated and then continued without re-examination for appropriateness. A study of Veterans Association hospital discharges of patients age >65 y/o classified as "frail" found that 44% had at least one unnecessary medication at discharge [8]. These medications contribute to increase cost and may play a role in further drug interactions or adverse effects. 
  • Example: A H2 blocker such as ranitidine may be prescribed for prophylaxis but the anticholinergic effects can contribute to diminished cognition, constipation, etc (see above).
Under-recognized  A prospective observational study by Hohl and colleagues of ED patients > 65 y/o in Canada found ADEs in 8.3%-12.3%, depending on the breadth of the definition of ADEs.  A prospective study by Hohl et al found that many ADEs in the ED were not attributed as medication related, particularly in the older population [9]. 

ED Interventions
  • Consider the Third Law of Medication when pondering the differential diagnosis.  For example, geriatric fall patients should probably be screened for polypharmacy (What medications is the patient on?  Can the problem be explained by a medication?) and while prescribing medications (Is the medication truly necessary? Will it interact with any of their medications?  Does the patient need a bowel regimen or other precautions?)
  • Medication review in the ED.  The ED encounter can serve as an opportunity for an outsider to glance at the patients medications to gain a sense as to whether something may be dangerous or warrant further discussion with their primary physician.
  • Judicious prescription of medications.  In the ED, we often write for short courses of medication and may be lulled into the sense that these prescriptions don't matter, yet they may carry an unintended reaction.  Be familiar with medications that are common offenders.
    • The Beers' List has a long list of medications to avoid in the elderly, but often these aren't the biggest offenders (also note the STOPP criteria). The most common medications associated with ADEs, implicated in 67% of hospital admissions according to a national survey database, were: 
      • warfarin (33.3%)
      • insulins(13.9%)
      • oral antiplatelet agents (13.3%)
      • oral hypoglycemic agents (10.7) [1,4]
  • Targeted feedback to general practitioners regarding potentially problematic medications.  Many health systems and electronic medical records have easy ways to send messages to primary care physicians.  In the ED haste, these communications frequently take a back seat but may be important.  Yet, the ACEP Geriatric ED guidelines recommend referral to PCP for any concern for polypharmacy (>5 medications) or presence of any high risk medication [10].
  • ED pharmacists. Many study authors have called for increasing the role of ED pharmacists in identifying ADE related to medications [2].
1.Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:(21)2002-12. 
2. Banerjee A, Mbamalu D, Ebrahimi S, Khan AA, Chan TF. The prevalence of polypharmacy in elderly attenders to an emergency department - a problem with a need for an effective solution. Int J Emerg Med. 2011;4(1):22.
3. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:(11)755-65.
4.Bayoumi I, Dolovich L, Hutchison B, Holbrook A. Medication-related emergency department visits and hospitalizations among older adults. Can Fam Physician. 2014;60:(4)e217-22. 
5. Chin MH, Wang LC, Jin L, et al. Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department. Acad Emerg Med. 2007;6(12):1232–1242.
6. Ruscitto A, Smith BH, Guthrie B. Changes in opioid and other analgesic use 1995-2010: Repeated cross-sectional analysis of dispensed prescribing for a large geographical population in Scotland.Eur J Pain. 2015 Jan;19(1):59-66. 
7. Robitaille C, Lord V, Dankoff J, et al. Emergency Physician Recognition of Adverse Drug-related Events in Elder Patients Presenting to an Emergency Department. 2005;12(3). 
8.Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53:(9)1518-23. 
9. Hohl CM, Zed PJ, Brubacher JR, Loewen PS, Purssell RA. Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems? YMEM. 2009;55(6):493–502.e4. 
10.American College of Emergency Physicians. Geriatric emergency department guidelines 2013

Saturday, November 22, 2014

Misrepresented: EBM

The Gist: Evidence based medicine (EBM) is misunderstood; it's not a randomized control trial (RCT) or "the literature." Rather, EBM is the intersection of the best available evidence, clinical expertise, and patient values [1-2]. Avoid BARF (Brainless Application of Research Findings), with tips from Emergency Medicine Cases

We have a cultural problem.  Clinicians are increasingly called upon to practice EBM.  Yet, the term EBM does not sit well on the palate of many physicians.  Conversations involving a mention of EBM have resulted in some of the following refrains...
"See, my patients are different..." 
"We'll never get an RCT on that..." 
"The culture is different here, I don't want to get sued." 
"Patients don't understand, but they do hold the power with satisfaction scores." 
"It's cookbook medicine."
With these words and reactionary body language, the dialogue quickly shuts down - by both parties.  First, this is a shame.  We should learn from one another but there seems to be a "hard stop" between many who champion EBM and those who find EBM off-putting. Second, this is a misunderstanding.  EBM is not an RCT.  In fact, EBM is not the best statistical methods or the rationing of care. EBM is not nihilism.  

EBM is the intersection of the best available evidence, clinical expertise, and patient values:
"the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research" [1].
Why, then, the misunderstanding? 
Here are some thoughts...

Misrepresentation. EBM is often used to refer to literature or studies, rather than to the application of research and evidence to particular patients and situations, using one's clinical experience (example and discussion: "EBM is Crap").  As a result, EBM may be misunderstood as a cost-cutting venture or a cookbook for medicine [3]. I have been complicit in perpetuating this misrepresentation of EBM.   As a novice physician-in-training with limited clinical experience, I draw predominantly upon the literature base.  I have unknowingly quoted the literature, thereby proudly proclaiming my practice of EBM, while unconsciously dismissing the other components of EBM.  
  • A remedy:  Remind ourselves and others that the evidence is part of the trifecta of EBM, along with the patient's values and clinical expertise.  We can be clear in what we mean by EBM and refrain from referring to a body of literature as EBM. 
Zeal. A religiosity exists amongst many champions of EBM, or people who believe they are championing EBM.  We tout our pyramids of evidence and may scoff at a lack of evidence or rigorous trials.  This may be off-putting as not all fields are amenable to RCTs and patient populations vary.  Moreover, there's a human tendency to form a reactionary attitude when someone exerts a strong identity [4].  Hence, EBM zeal may engender an anti-EBM attitude and cause people to be wary of solid practice changing evidence.
  • A remedy:  While championing good research and employing the best available evidence, we can balance our enthusiasm with important caveats and understand the importance for tailored approaches for patients.  Gentle education about EBM rather than diatribes may aid individuals in understanding the values of EBM beyond evidence.
Fear.  People like to be right.  We may reflexively become defensive when we are (possibly) wrong. EBM or "literature" can be used in an antagonizing way and, subconsciously, a way to exert a feeling of superiority.  "You haven't read that study?"
  • A remedy: Understand that unlearning in medicine is difficult.  Aggressive assertions may push people further away.  Think of it as a Kubler-Ross like grief cycle, as explained in this post.  This may help us become more cognitively flexible, understand the reticence of others, and perhaps make our points more effectively.  

Confusion.  Historically, researchers, clinicians, physicians in training, and allied health professionals have limited understanding of fundamental statistics [5,6].  As such, we may not understand what we're reading or how it applies to our patient population.  We may have difficulty understanding why something we believed was proper at one time is no longer the case.  Often, this is because the research was, in fact, initially wrong or misleading [7]. 
  • A remedy: Read.  This podcast proffers tips on getting started; however, even the most seemingly rigorous papers published in high impact journals are subject to bias (publication bias and otherwise), which can be difficult to parse through.  For example, the oseltamivir (tamiflu) recommendations from Cochrane changed after they were allotted access to data, demonstrating the profound impact of publication bias [Jefferson et al].  More on this here.
Time. The number of journal articles needed to read (NNR) to obtain valid and relevant information is typically cited as 20-200, an insurmountable task [8].  The process of trolling through the literature is time consuming and may be overwhelming.  Frustration can turn into apathy, confusion, and mistrust.
There are legitimate issues with EBM.  Evidence is often subject to the biases of industry and legislative bodies.  Guidelines or recommendations billed as "EBM" may be hijacked by individuals with conflicts of interest or other agendas. Further, the grading of evidence isn't always objective or consistent, as seen by the grading of evidence for thromboylitics in acute ischemic stroke listed in the ACEP clinical policy.   In addition, guidelines harness EBM and disseminate the body of evidence to practitioners.  For example, the 2008 AHA/ACC guidelines are based largely on low levels of evidence and expert opinion,  many of whom have financial conflicts of interest.  Only 11% of the recommendations were based on high quality evidence [9].  

So, while EBM has imperfections in concept, representation, and implementation, the model incorporates the primary things we, as providers, care about - the evidence, the patient, and clinical experience.  Let's understand what EBM means and apply the term and principles appropriately.

1. Sackett DL, Rosenberg WM, Gray JAM, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71–72. 
2. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725
3. Straus SE, McAlister FA. Evidence-based medicine: a commentary on common criticisms. CMAJ. 2000;163(7):837–41. 
4.  Maalouf A.  In the Name of Identity: Violence and the Need to Belong. New York: Penguin Books, 2000.
5.  Windish D, Huot S, Green M. Medicine residents’ understanding of the biostatistics and results in the medical literature. Jama. 2007;298(9). 
6.  Mavros MN, Alexiou VG, Vardakas KZ, Falagas ME. Understanding of statistical terms routinely used in meta-analyses: an international survey among researchers. PLoS One. 2013;8(1):e47229. 
7.Ioannidis JP a. How many contemporary medical practices are worse than doing nothing or doing less? Mayo Clin Proc. 2013;88(8):779–81.
8. McKibbon KA, Wilczynski NL, Haynes RB. What do evidence-based secondary journals tell us about the publication of clinically important articles in primary care journals? BMC Med. 2004;2:33. 
9.  Tricoci P1, Allen JM, Kramer JM, et al.  Scientific evidence underlying the ACC/AHA clinical practice guidelinesJAMA. 2009 Feb 25;301(8):831-41.