If you build it, will they come (back)?

This is a review of 2.5 years worth of lower back pain.  Basically, every single patient with an ICD-9 code had their chart reviewed to ask the question, “If you got an MRI in the ED, are you less likely to return?”

They specifically did not look at yield, rather, just whether or not patients initially thought to have plain, old back pain came back.
The answer, contrary to those of us who think more is more, is no.   Repeat visits for those that had an MRI was 4.3%, repeat visits for those without an MRI at initial visit- 4.6%
However, it does give you some insight into who returns – they were more likely male (5.9% vs 2.8%) – further demonstrating that males are in fact the weaker sex.  They were more likely English speaking (4.9% vs 2.1%) and, speaking of which, non-English speakers were less likely to have an MRI (12.2% vs 7.4%), and self-pay patients were also less likely to have an MRI (9.8% vs 5.1%).   Its unclear if this further demonstrates a touch of bias on the provider side, if English-speaking patients speak up more about wanting diagnostics, or if non-English speakers just go to another hospital since this was a single center study.
As a secondary measure, they also looked at disposition for these patients.  Only 16% were discharged after MRI (vs 82% of those without MRI), 74% of those MRI’ed were placed in observation status (vs 11% of those not), 9% of those MRI’ed were admitted vs 3%, and 4% of those not MRI’ed left prior to completing treatment. Now, for some fancy math.
of the 797 patients who received an MRI over this time period, if only 11% were placed in obs status (rather than 74%), that is only 88 patients rather than 591 patients placed in obs status. that’s 503 patients with an unnecessarily padded bill. At $35.8013 per RVU, were talking tens of thousands of dollars billed that’s wasted.
Or, to put it another way, if you are in an area with a good payor mix, why not just obs & MRI them all?
"Palliative" is not a dirty word, Improving Outcomes

“The Treatment of Pain is Very Important.”

Back to pain being the 5th vital sign, or so this study may have us believe. This study included an independent investigator essentially sneaking into the patient room to tell half the patients that “the treatment of pain is very important and be sure to tell the staff when you have pain.”

77.6% of the control vs 88.8% of the intervention group reported being provided with the above “pain advice” and the intervention group had an absolute and relative increase in satisfaction of 6.3% vs 14.2%, respectively. 91.3% of patients who were “very satisfied” had received this advice vs 76.3% of patients who were not “very satisfied” having received “pain advice.”

I think that ultimately, the aforementioned increase in patient satisfaction goes with giving clear instructions, and being clear with your projected management and expectations. I imagine that having a third party (such as Dr McDreamy) come over and say, “the treatment of pain is very important and be sure to tell the staff when you have pain,” will undoubtedly boost patient satisfaction. Likewise, I also question if it buys a bit (too much?) into “pain is the 5th vital sign” that got us into our current opiate frenzy in the first place. Regardless, there is potential for this to be a useful word choice in the quest for improved Press Ganey scores.

Improving Outcomes, Improving Throughput, Mythbusting

Had an abscess packed? Call now!

It’s a generally accepted FOAM principle that packing an abscess is of no benefit, but now we can add one more reason onto why we should not do this:

An impressively high rate of recurrence!

In this study of 272 patients with roughly 83% of patients having the unpleasant packing experience (!!) the adjusted OR for recurrence: 4.64. (coincidentally, there was also an 83% 1 week follow up and 71% follow up at either 1 or 3 months). Overall recurrence rate was about 28% within 3 months. The only two variables associated with a recurrence? A prior abscess within the last 2 months, and a prior abscess within the last 3-6 months.

So… Not HIV status, not the presence of diabetes… Nope. Just the lack of the providers FOAM knowledge base about wound packing will bump up your likelihood of recurrence. Perhaps they had larger abscesses, but given that abscess size and amount of erythema was not significantly correlated with recurrence, I doubt it.

Per the authors: “The reasons for this latter observation is unclear; however, other studies have shown that this practice may not improve outcomes and can lead to increased pain… Interestingly, packing was associated with increased recurrence, warranting further investigation of this practice.”

Or we could just stop doing it altogether. Cant you just see a late night TV ad? If you’ve had an abscess packed, then had another one within three months, call us now! You may be entitled to a settlement! Operators are standing by!

Improving Outcomes, Mythbusting

Epinephrine- Still safe for the digits.

We are just going to cut to the chase on this one.

“No study reported digital necrosis or gangrene attributable to epinephrine, either in healthy patients or in patients with risk for poor peripheral circulation. In total, at least 2797 digital nerve blocks with epinephrine have been performed without any complications… Epinephrine 1:100,000-200,000 (5-10 μg/mL) is safe to use in digital nerve blocks in healthy patients. Physiological studies show epinephrine-induced vasoconstriction to be transient. There are no reported cases of epinephrine-induced harm to patients with risk for poor peripheral circulation despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A lack of reported complications suggests that the risk of epinephrine-induced vasoconstriction to digits may be overstated.”

’nuff said.

Improving Outcomes

Poison Ivy- Short vs long course of steroids?

When I was a teenager, two friends & I worked for the Parks & Recreation Department in our town. We did things like manage the softball & baseball fields, water town greens, cut grass, etc. Both of my friends, every summer, managed to get some ugly cases of poison ivy. I always remember one of them requiring “the long course” of steroids because “it always came back with only a few days of prednisone.”

This has always sort of stuck with me since I started practicing. Poison Ivy & the like are generally the only time I will write for a steroid taper. I recently reviewed the evidence, and low and behold, found this:

This study compared long taper vs short term fixed dosing for patients greater than 14 years old with “severe” cases of poison ivy defined as having a clear exposure, a rash consistent with poison ivy, PLUS one of the following: 1) rash >20% of body surface area 2) rash on hands, feet, face, or genitals, or 3) involvement of two or more body areas. 27 patients were allocated to the short treatment arm (5 days of 40mg prednisone), and 28 patients allocated to a long taper (30mg x 2 days, 20mg x 2 days, 10mg x 2 days, 5mg x 4 days). One patient in the short treatment arm discontinued treatment due to weight gain, while 3 in the long term taper were lost to follow up and 2 discontinued treatment due to improvement of rash.

While not statistically significant, the mean time to improvement favored the long taper (2.93 days vs 4.42 days), as did mean time to resolution (11.7 days vs 14.63 days), and rate of side effects (3 vs 0). The rate of seeking additional medication to use was statistically significant, favoring long taper treatment with 5 patients using additional meds, vs 15 patients in the short course treatment arm (22.7% vs 55.6%). In the short course, these additional medications ranged from an additional oral steroid prescription in 11 cases (vs 2 additional steroid prescriptions for the long course), as well as calamine lotion, antihistamines, topical hydrocortisone, and other OTC lotions. The NNT with longer tapers to avoid having to take additional medications– 3.

My thoughts: If you’re going to get poison ivy, isn’t it usually on your hands or involve more than 2 body areas? Based on their definition of “severe,” the authors essentially recommend to give oral steroids to the majority of patients with poison ivy who present to the ED. While this seems odd on first glance, then again, almost half of the patients in the short course of steroids bounced back and required an additional oral steroid prescription, so the authors are probably on to something. The numbers are small, but compelling enough that unless patients really put up a fight about having steroids, I would just give them a tapered dose. If they are adamant about only having as short a course as possible, giving them two prescriptions with the second being the taper would seem reasonable.

Oh, and if you’re looking for preventative therapy, Tecnu has the most efficacy (70% protection after exposure), with Goop and Dial being the most cost effective ($0.07 per ounce for both vs $1.25 for Tecnu, with protection after exposure rates of 62% and 56% respectively), though results were not statistically significant from each other, but were statistically significant above placebo.

Happy & Safe Fourth.

Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 9 of Christmas: Midlevel EM Sono Training

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the ninth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Simply put, for traumatic injuries, nerve blocks are the best source of pain control. If your only option of providing pain control for a femur fracture is to make the patient limp from your favorite opiate or giving tylenol, you have failed as a provider to keep up with current trends and literature. EM is all about having options in your toolbox.

Why are we not using nerve blocks? Can we train mid-levels to do these safely to provide a higher level of care and provide more job satisfaction?

I have seen patients with rib fractures go to observation for pain control and have been stonewalled in attempts to perform a block, either by myself or in consultation with anesthesia. This is despite evidence showing that nerve blocks work wonderfully during the EDs attempt at initial pain control, and with even better when a catheter is placed for continuous infusion. Nerve blocks for rib fractures also decrease mortality.  In case you were wondering, lidoderm patches wont work.

So, can we perform an ED based study showing mid-levels can safely use ED ultrasound for blocks? We can already safely do sono guided liver biopsies, soft tissue foreign bodies, hip injections, transrectal prostate biopsies, and we can even be remotely guided for lung sono. Its time for an ED study demonstrating we can safely do this in the ED.

Improving Throughput, Twelve Trials of Christmas!

Day 8 of Christmas- Dexamethasone for Allergic Reactions

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the eighth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

We’ve seen that two dose dexamethasone is as effective for pediatric asthma exacerbations as prednisone. In fact, there are fewer missed school days for children and adults return to work sooner with two days of decadron rather than 5 days of prednisone with similar relapse rates.  There is decent evidence here and here that a single intramuscular dose of dexamethasone for young asthmatics (<8 yrs, mean age 36 months) is sufficient.  To wit, 40% of children missed >30% of the oral prednisone dose vs receiving all of the IM dexamethasone dose despite parental efforts, with 70% of parents in both the oral prednisone and the IM dexamethasone group would choose IM dexamethasone to treat their child’s next asthma exacerbation.

With all of this information, why not apply it to allergic reactions? We know that biphasic reactions are rare and rarely life threatening. One or two doses of decadron plus an epiPen to go with over the counter diphenhydramine for mild breakthrough pruritis should likely do the trick. Easy trial to do, yet amazingly no literature for dexamethasone in allergic reactions.