Anesthesia Tutorial of the Week

Learning resources on a variety of topics in anesthesiology and critical care.

A resource for CPOE

COPE.org

Witnessed collapse, two rescuer CPR, arrival of AED

This is another AHA instruction video.

Notice how long she fiddled around checking for air movement and getting a barrier device to give the two initial breaths. The healthy looking guy who collapsed probably had greater than 95% of his hemoglobin saturated with oxygen. Why not dispense with the rescue breaths? They only delayed the initiation of compressions.

But the sequence was performed in accordance with the AHA guidelines which can be accessed here.

At the University of Arizona for years they have been teaching it this way.

An updated science advisory released by the AHA last year said compression only CPR was an option for witnessed cardiac arrest.

The perfect megacode

AHA instructional video, V fib arrest, BLS transitioning to ACLS

Keep in mind the emerging controversy about rescue breathing in adult arrest of suspected cardiac origin.

Full text ACLS guidelines in Circulation here.

Stent placement for atherosclerotic renal artery stenosis

Not beneficial in terms of either renal function or blood pressure in this multicenter randomized trial. Stenting was associated with complications. According to an editorial note the study was underpowered.

Texas Heart Institute archived CME presentations

---can be accessed here.

Who thunk up hospital medicine?

Was it Robert Wachter or Myra Rosenbloom? You decide.

Background in Today's Hospitalist.

Tutorials in the Tetons, the 35th Annual Update in Cardiovascular Diseases

---is fast approaching. I've told you about it here and in several other posts. I'm signed up and ready to go. This is a rich learning experience for me, as well as my annual battery-charging.

The conference should be of benefit to anyone interested in evidence based cost effective cardiology, cutting edge advances and diagnostic skills. There will also be some updates on cardiovascular genetics, VTE and peripheral vascular disease. The course is appropriate for physicians (IM, FP, hospitalists, cardiologists), physician extenders, nurses and allied health care professionals.

Why attend?

This conference provides a unique opportunity to interact one on one with faculty. The quiet, spectacular beauty of the setting enhances the learning experience. Before the American College of Cardiology cut its CME conferences several years ago this was the College's most popular extramural activity, year after year, during its entire run. The PharmaScolds are trying to shut the meeting down, so this may be your last chance!

I'll be posting additional updates, but register as soon as possible, as accommodations have filled up fast in previous years. If you have questions about the conference I'd be glad to talk to you. Just let me know in the comments or via direct email.

Blogging colleagues, if you plan on attending let me know so we can arrange a confab over an adult beverage with a spectacular mountain view at the Blue Heron lounge.

The final course brochure and registration form is here.

Tamsulosin and the floppy iris

Research study and editorial in JAMA.

The confusing terminology of bronchiolitis syndromes

Do you know respiratory bronchiolitis-associated interstitial lung disease (RbILD) from bronchiolitis obliterans with organizing pneumonia (BOOP)? This review helps clarify the terminology.

Troponin measurement in the ER in patients with PE

The positive and negative predictive values for central pulmonary artery obstruction were good in this study:

Troponin values were elevated in 20 (19.2%) of 104 patients (95% confidence interval [CI], 11.6-26.8) with a mean cTnI concentration of 0.38 ± 0.44 μg/L. Elevated cTnI value had a significant correlation with main pulmonary arteries involvement using the modified Computed Tomography Obstruction Index score (P = .0001). Elevated ED cTnI value had 53.8% (95% CI, 37.6-66) sensitivity and 92.3% (95% CI, 87-96.4) specificity, 70% (95% CI, 49-86) PPV, and 85.7% (95% CI, 80.7-90) NPV for predicting main pulmonary artery obstruction on CT. Increased cTnI values were highly correlated to intensive care unit admission of patients with PE (RR, 12.83; 95% CI, 3.87-42.4).

The evidence in favor of cardiac biomarkers in the ER evaluation of suspected PE is mounting.

Salmonella infection and mycotic aneurysm

Don’t forget the association. It can be an aneurysm or a pseudoaneurysm, can occur as a new aneurysm or infection of a pre-existing one, and is associated with certain predisposing conditions. Serotype associations, according to the brief review, tend to be enteritidis and typhimurium. The article references several other reviews.

EMRs degrade the quality of clinical documentation

This article in the American Journal of Medicine explores some of the reasons. Repeated copying and pasting of other notes and template generated electronic clutter are two. Another underappreciated aspect is loss of the power of clinical narrative:

Another more insidious consequence of the copy-and-paste function has been the loss of the narrative. Because charts have become capacious warehouses of disorganized, irrelevant, or erroneous data, the story of the patient and the patient's illness is no longer easy to read or likely to be read. In a most compelling and perhaps unintended way, we are witnessing the “death” of the health record narrative, as many of us have known it. Others also speak of the loss of narrative in electronic health records, and with great concern because narratives form the basis of clinical decision making.

Daily documentation of the patient's trajectory, in prose, even when stripped of overt emotional content, is not just educational. It is humanizing.

I have yet to encounter an electronically generated note that effectively tells a patient’s story.

Fact checking for Atul Gawande

As much as I liked Gawande's New Yorker article I'm having increasing reservations about the accuracy of his assertions, as I suggested here. I think the comment thread from Thursday's post deserves reposting:

Clinton said...
Just some fact-checking.
St. Louis County's Medicare $/beneficiary = 8,306.

Not sure if Wikipedia is a great reference, especially lacking an independent citation, but St. Louis does not show up as #3 (that spot belongs to Starr County, TX.)

Hidalgo County hits the list at #22, while St. Louis doesn't even hit the lowest 100 list. Something isn't quite right with Gawande's statistics. Maybe he is going off of a different set of measures than lowest income per capita or median household income?

http://www.dartmouthatlas.org/interactive_map.shtm
http://en.wikipedia.org/wiki/Lowest-income_counties_in_the_United_States

R. W. Donnell said...
Clinton,
The figure you cite is identical to his. That's for St. Louis County, as he said. The problem is, St. Louis County is not among the poorest regions in the nation by any metric or any stretch of the imagination. The City of St. Louis (which is, I repeat, NOT in St. Louis County) may be. He doesn't seem to have any idea of what the cost per enrollee is for the City of St. Louis, but that's what he needs to cite if he wants to make his point about poverty and Medicare expenses.

My guess would be that the cost would be high in the City of St Louis. I think care is pretty fragmented and under served. Most of the hospitals (aside from ones affiliated with the two med schools) have moved to the burbs, so the picture there is pretty atypical.

I don't consider Wikipedia a very authoritative source but I know St. Louis is a city without a county from personal familiarity with the area.

Raises even more questions about his fact checking.

Oh, those greedy cardiologists

I'm all over health care variation and non-evidence based medicine (N-EBM) these days. They're hot topics because of their close ties with the current health care reform debate.

If you want some entertainment on the subject, and can stomach a little demagoguery and name calling about greedy cardiologists and pigs running the AMA by all means check out this post by Doug Bremner, M.D. If you want something factual look elsewhere.

Bremner's post is so over the top and patently absurd one wonders whether it even merits a serious response, but, evidently, some people take Bremner's blog seriously. Besides, all I have to do to smack it down is cite some simple facts, so here goes.

He starts with this:

I just found a way to save 25 billion dollars a year for President Barack Obama’s healthcare plans. That is to cut out angioplasty, for which multiple studies, including one in the June 11 edition of the New England Journal of Medicine. The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Wrong, wrong, wrong, Dr. Bremner.

First, I'll give him the benefit of the doubt and assume he's not really talking about angioplasty but rather coronary stenting. Angioplasty as the principal coronary intervention is seldom performed anymore. In the NEJM study he cited almost all the PCI patients underwent some form of stenting.

Concerning stenting, most are not done in patients addressed in that NEJM study or the other landmark trial with similar findings, the COURAGE trial. In fact, patients with stable angina represent less than a third of those who get stents nowadays.

Let's pick apart Bremner's statement a bit more---

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack----

Huh? Cardiologists have known for over a decade that revascularization doesn't prevent heart attacks. No one is promoting it for that indication. Where does Dr. Bremner get his “information?”

Let's parse it a bit more (my italics):

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Nonsense. The COURAGE trial certainly did stop doctors from performing them in patients with stable angina, almost immediately:

ResultsThere was a significant increase in anti-ischemia medication use prior to catheterization referral following the COURAGE trial (mean = 1.31 [SD 0.83] medications pre-COURAGE, mean = 1.54 [SD 0.84] medications post-COURAGE, P = 0.012). Among 217 patients with coronary disease on catheterization, treatment with medication rather than percutaneous or surgical revascularization increased after COURAGE (11.1% pre-COURAGE vs 23.0% post-COURAGE, P = 0.03). There was also a significant decrease in referral volume following the COURAGE trial (3.12 referrals/day pre-COURAGE vs 2.51 referrals/day post-COURAGE, P = 0.034).

ConclusionsThe COURAGE trial immediately impacted the management of stable angina. Catheterization referral volume decreased, medication use increased, and the use of medical therapy rather than revascularization increased among patients with coronary disease.

And, there was this from Heartwire:

Use of coronary stents, including drug-eluting stents (DES), "dropped sharply" in April, the Wall Street Journal reports, citing a marketplace report conducted by Millennium Research Group in 140 US hospitals [1].

According to Journal reporter Keith J Winstein, doctors did roughly 71 200 stenting procedures in April: 10% less than in March and 15% less than the previous year. Physicians believe that drop, writes Winstein, is "an unusually quick response" to the COURAGE trial, presented at the ACC 2007 meeting in March. In COURAGE, stents (primarily bare-metal stents) were no better than optimal medical therapy at preventing future death or MI in people with stable coronary artery disease.

So here's the bomb in Bremner's post:

But I’ll give the reason why they still perform 1.2 million of these procedures every year. It is pretty simple really. Greed.

The moral preening and finger pointing that goes on in our profession is astounding.

Evidence, please, Dr. Bremner.

Perhaps the most concerning problem with Dr. Bremner's post is that he conflates stenting for stable angina with it's real evidence based use, which is in patinets with acute coronary syndromes. Emergent PCI for patients experiencing acute STEMI has been shown over and over again to save lives, save ejection fractions and get people back to work. Let's hope some misguided folks in Washington don't deprive them of it. I personally believe the doctors taking care of patients who know what they're doing should be the ones responsible for critical appraisal of best evidence, not some policy wonks from afar. See why?

Antithrombotic agents and the risk of cerebral microbleeds

Antiplatelet agents, but not anticoagulants, were associated with cerebral microbleeds in this study. While that may seem surprising at first glance it actually makes sense. Intracranial microbleed is a disease of the elderly, and is related to amyloid angiopathy in the case of lobar bleeds and hypertensive or atherosclerotic small vessel disease in the case of subtentorial bleeds. Following a tiny break in a blood vessel your first defense against such hemorrhage is the platelet plug, not the coagulation proteins. Although warfarin is known to be associated with spontaneous intracranial hemorrhage this study challenges our thinking about antithrombotic therapy in the elderly.

Amyloid angiopathy and associated hemorrhage are related in a complex way to the APO E genotype.

Medscape CME here.

Atul Gawande answers objections

H/T to DB for pointing me to this follow up article by Atul Gawande concerning his earlier New Yorker piece on health care costs.

Here he elaborates and provides more data in response to objections and questions concerning his original article. He also re-emphasizes that it’s all about organization and leadership and gives another example, Scott and White Hospital in Temple, Texas which is part of an integrated medical group in many ways like Mayo Clinic. Despite having, purportedly, more physicians per capita than any other community in the U.S., Temple Texas has high quality scores and low costs.

One quibble. In answering the point about McAllen’s poverty as a possible driver of utilization he says:

By any measure, McAllen’s poverty and poor health fails to account for its differences from El Paso. St. Louis is located in another county that is just as poor as McAllen (it is the third-poorest county in the U.S.). Its cost per Medicare enrollee? $8,306.

St. Louis is not located in a county. It is an independent city. The surrounding St. Louis County, particularly its western aspect, is very wealthy. This leaves me wondering how well he checked his other “facts.” It is not clear whether his figure of $8,306 per enrollee represents St. Louis or St. Louis County. The demographics and culture are as different as night and day. (I grew up in the area).

Reasons for practice variation

In view of the reaction to Atul Gawande’s recent New Yorker article I thought it would be interesting to explore some of the many reasons for practice variation. A popular perception is that it’s a lot about greed, and Gawande provided some extreme anecdotes which suggest, on first glance, that this is the case. Objective evidence, however, suggests otherwise. Here’s a run down.

Physicians with risk averse personality profiles order more tests.

Malpractice fear drives referrals to specialists.

Internists have higher utilization than FPs according to multiple studies, attributable to being more risk averse.

I have found no study looking at greed as a driver of utilization.

QT prolongation in hospitalized patients

The horribly ill patients who are typically admitted to the hospital often have electrolyte disturbances or other conditions that may prolong the QT interval. This calls for special vigilance in drug therapy, as the list of QT prolonging drugs is daunting. This brief article from The Hospitalist has some pointers. You could just about make the case for doing an electrocardiogram on all hospitalized patients.

The electrocardiogram in pulmonary embolism

---has very poor sensitivity and only fair specificity. A new study shows that positive electrocardiographic findings indicative of right ventricular strain are additive to the prognostic information gained from echocardiography. The two techniques are complementary.