Years ago, this started as the “articles of the month” and was truly a monthly undertaking. In order to become more regular with the BroomeDocs podcast, I am going to try once again to make this a monthly endeavor, although that might mean fewer articles in each edition. For the people who skip right to the cheesy joke, that should just mean less scrolling and more jokes. For the people who actually read the summaries, I am sure less is more, even if I show up in your email box slightly more often. As always, be sure to check out the accompanying podcast.
Avoiding calls to neurosurgery?! Sign me up
Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. PMID: 35343931
Does anyone else feel like their job would be better if they had to make fewer phone calls to neurosurgery? The brain injury guidelines try to provide some advice on admission, repeat CT, and need for neurosurgical consultation in brain injuries. Patients are divided up into low risk (BIG1), medium risk (BIG2), and high risk (BIG3) based on clinical and radiographic characteristics, with a recommendation that BIG1 patients be discharged home after 6 hours of observation, BIG2 patients being admitted, but without a repeat CT or neurosurgical consultation, and BIG 3 patients getting the whole shebang. This study is a prospective observational look at the guidelines from 10 trauma centers in the US. Only 15% of patients were characterized as BIG1, and they had pretty good outcomes, with no patients having neurologic deterioration or need for neurosurgery, and only 1.3% having progression of their bleeding on repeat CT. BIG2 made up another 15% of the total cohort. 0.7% had neurologic deterioration, and although 7% had progression of the bleed on repeat CT, none of these patients required neurosurgical intervention. For BIG 3 patients, 16% deteriorated clinically, 21% had progression on repeat CT scan, and 20% had neurosurgical intervention. Knowing that 0 patients in the low and moderate risk groups needed neurosurgery is great, and would be enough to support use of these guidelines, if you could trust the numbers. My big issue is that the numbers are presented without any statistics, and with only 300 patients per group, the 95% confidence interval might still include a pretty high risk of needing surgery. Furthermore, not all patients received the gold standard test, so the rates of progression on a repeat CT are probably higher than reported here. However, I think it is a very good idea to consider resource utilization in this group. Assuming I can get our medicine (admitting) teams on board, I think this data supports decreasing neurosurgery consultations, even if we don’t go as far as they are recommending. Personally, for BIG1 patients I might suggest admission for 24 hours without repeat CT or neurosurgery consultation unless clinically indicated. For BIG2 patients, I would suggest admission and routine repeat CT, but no neurosurgical consultation unless there was a clinical change. And BIG 3 will continue to get the whole shebang. Do you think I am going to be able to convince our admitting teams to admit these patients without a neurosurgical blessing? Wish me luck.
Bottom line: In the first prospective look at the brain injury guidelines, no patients classified as low risk required neurosurgical intervention. This might help us limit resource utilization, by decreasing our use of routine repeat CT and neurosurgical consultation for no risk patients. However, this data has a number of issues, and probably is not strong enough on its own to justify complete implementation of these guidelines. (I am really hoping to get a modified version implemented.)
Maybe don’t try this at home?
Zwank MD, Kumasaka PG. A new technique for reduction of a posteriorly dislocated hip joint. Am J Emerg Med. 2023 Feb 8:S0735-6757(23)00066-9. doi: 10.1016/j.ajem.2023.01.053. PMID: 36781375
In my experience, especially since discovering the Captain Morgan technique, most posterior hip dislocations reduce relatively easily, but there remain that handful that seem near impossible. (I almost alway blame the person doing the sedation for not getting me enough muscle relaxation.) However, there are limits to human strength, and so these authors decided that hydraulics were the way to go. With the patient supine, they positioned a hydraulic patient lift at the end of the bed, stabilized the pelvis to the stretched with a band, and then used a strap looped under the patient’s knee and attached to the lift. (See the picture and video at the end.) The foot is held by the physician, who can then add internal or external rotation. Although I appreciate the innovation, I would be very concerned about the amount of force that one of these lifts could potentially generate, and the models I have seen are usually somewhat jerky on start-up. Thus, I am concerned that the risk of injury is much higher with this technique. (They say their hydraulic lift “increases traction in a gradual, regular manner”, so maybe it depends on the model of lift you have available. However, even with gradual traction, this technique loses all haptic feedback, which is important to know when things might be going wrong and when to stop.) As compared to jumping up on the stretcher, this technique is almost certainly safer for the doctor, but maybe not for the patient. I might be more comfortable if the patient wasn’t strapped to the stretcher, and the downward force was only applied after you position the patient with the lift. This paper really just describes the technique, but the authors tell us they have used it 5 times, and were successful 4 (which really doesn’t sound like an amazing success rate to me). Obviously, a case series of 5 patients is woefully inadequate for discussing possible harms.
Bottom line: Be careful when trying to learn from case reports, and when MacGyvering equipment for use in patient care.
Video: https://ars.els-cdn.com/content/image/1-s2.0-S0735675723000669-mmc1.mp4
People are so obsessed with size
Landefeld KR, Koike S, Ran R, Semler MW, Barnes C, Stempek SB, Janz DR, Rice TW, Russell DW, Self WH, Vonderhaar D, West JR, Casey JD, Khan A. Effect of Laryngoscope Blade Size on First Pass Success of Tracheal Intubation in Critically Ill Adults. Crit Care Explor. 2023 Mar 6;5(3):e0855. doi: 10.1097/CCE.0000000000000855. PMID: 36895888
Do you have a strong opinion about laryngoscope blades? Do you just take whatever is handed to you? When it comes to the standard Macintosh blades, a common argument is that we are better off just using the size 4 blade for everyone, as the added length means it is more likely to reach the vallecula in a wider range of patient anatomy. However, in a patient that doesn’t require the additional length, the handle is further from the mouth, limiting your mechanical advantage when attempting to lift the jaw, and the slightly bigger size might also impair tube delivery. The theory from both sides seemed reasonable, which is why we love scientific data. This is a post-hoc analysis of a prospectively collected airway database of patients undergoing nonelective intubation in the ED or ICU. Of the original 979 patient database, 592 were intubated using DL with a Macintosh blade, 222 of which used a size 3 and 362 used a size 4. Overall, the numbers are better with a size 3 blade. First pass success was higher (81% vs 71%, aOR 0.56, 95% CI 0.37-0.85). Cormack-Lehane grade was on average better. That being said, the most important outcome, mortality, was worse (2.3% vs 0.6%), although not statistically and probably not related to blade size. I have heard this data talked about as if it is practice changing, but I am not sure. We use smaller blades in smaller patients, and smaller (non-obese) patients have always been easier to intubate with higher first pass success rates. So was this at all related to the size of the blade, or just pure confounding? Personally, I think it makes sense to grab a blade with approximately the right size, which means I am not in the “one size fits all” camp. But I am also prepared to rapidly move on if the blade I picked seems inappropriate once I make my first attempt. (I care less about ‘first pass success’ and more about ‘getting the patient intubated safely without hypoxia or other complications’.) I will note that this data is consistent with prior data (such as the MacSize-ICY study, Godet 2022, PMID: 35974189), but essentially all the data has the same risk of confounding.
Bottom line: This data is nowhere near as definitive as it seems when presented on Twitter, but I do think it makes sense to start with the blade estimated to be the best fit.
Yeah, we get it, video is better
Ruetzler K, Bustamante S, Schmidt MT, Almonacid-Cardenas F, Duncan A, Bauer A, Turan A, Skubas NJ, Sessler DI; Collaborative VLS Trial Group. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024 Mar 18:e240762. doi: 10.1001/jama.2024.0762. PMID: 38497992
We already have the DEVICE trial telling us that video laryngoscopy is better that direct, so I am not sure that a cluster RCT from an operating room setting is going to add that much. This is a cluster RCT with adult patients in the operating rooms in a single hospital, such that for 1 week at a time some ORs were to use video and the others direct. They only provided hyperangulated glidescopes and compared that to a standard Macintosh blade. The total number of intubation attempts was lower with video (OR 0.2, 95% CI 0.14-0.28). The overall success rate was excellent (and higher than most ED studies). First pass success was 98% with video and 92% with direct. Probably the most important caveat to this data is who is performing the intubation. A staff anesthesiologist only made the first attempt 2.7% of the time. The vast majority of the intubation attempts were by nurse anesthetists, residents, and students. I don’t think there is much doubt that video is easier for novices, and that isn’t really where this debate is focused. Remember also that “first pass success” is a very subjective surrogate outcome. They don’t present time to intubation, and they don’t present any clinical outcomes like hypoxia, so I don’t think this data is actually very useful.
Bottom line: This cluster RCT confirms better first pass success with video laryngoscopes, but doesn’t really say anything about clinical outcomes. If you have access to video, it makes sense to use it, but this data doesn’t settle the question of whether hospitals, especially in resource poor settings, need to be buying video laryngoscopes for every single intubation.
Preventing poison ivy? Why is there so much I never learned?
Stibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol. 2000 Jul;39(7):515-8. doi: 10.1046/j.1365-4362.2000.00003.x. PMID: 10940115
This won’t really be applicable in the ED, but might be a useful first aid tip for your families. (I also know I have some readers who spend the summers as camp doctors, who probably already know this?) Can we prevent poison ivy dermatitis? This study enrolled medical student “volunteers”, with each participant acting as their own control. Each participant had 4 2.5cm square areas of their skin exposed to crushed poison ivy, and then returned 2 hours later to test 3 different agents (with the 4th being left as control): Goop (a commercial automotive grease), Tecnu (an over the counter product specifically sold to prevent poison ivy), and Dial ultra dish soap. The subsequent rash was then graded at 4 and 7 days. No product completely eliminated symptoms, but all of the active options decreased symptoms by more than half. The cost per ounce of therapy was $0.007 for both soap and automotive grease, and $1.25 for Tecnu. This was an unblinded study using a relatively subjective grading scale, so there is a high risk of bias, but I don’t think you are going to see a better study. I certainly wouldn’t expose myself to poison ivy on purpose, but it looks like any surfactant product is probably effective when applied within a few hours of exposure, and liquid dish soap is probably the cheapest and most readily available.
Bottom line: Surfactant agents appear to be moderately effective in reducing symptoms from poison Ivy exposure.
More medicine I never knew: an easy test to see scabies burrows?
Rauwerdink D, Balak D. Burrow Ink Test for Scabies. N Engl J Med. 2023 Aug 17;389(7):e12. doi: 10.1056/NEJMicm2216654. Epub 2023 Aug 12. PMID: 37578077
Another quick skin related tip. Had anyone else heard of this “burrow ink test” for scabies? Apparently you put ink over the affected area (some sources describe using the skin markers that used to come in procedure kits but that I haven’t seen in years, others just describe using a ballpoint pen). The ink will seep into the burrow, and then after wiping off the excess the burrow will be easily visible. There is no critical appraisal to be done here, as this is literally just a picture. I don’t know the likelihood ratios. But I had never heard of this technique, and it seemed like a potentially helpful tip
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When does 10 mcg not equal 10 mcg? Apparently with norepinephrine??
Wieruszewski PM, Leone M, Kaas-Hansen BS, Dugar S, Legrand M, McKenzie CA, Bissell Turpin BD, Messina A, Nasa P, Schorr CA, De Waele JJ, Khanna AK. Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force. Crit Care Med. 2024 Apr 1;52(4):521-530. doi: 10.1097/CCM.0000000000006176. PMID: 38240498
Brought to my attention through EMCrit, I have to admit I had no idea that this was an issue. Apparently not all norepinephrine (or for my Aussie co-host noradrenaline) is created equal? The base medication of norepinephrine is not soluble, and therefore can only be used intravenously when combined with an acidic salt. However, the weight of the medication obviously varies depending on the salt that you combine with the medicine. 1 mg of norepinephrine tartrate has 0.5 mg of actual norepinephrine, whereas 1 mg of norepinephrine bitartrate (which my hospital stocks) has 0.53 mg, and 1 mg or norepinephrine hydrochloride has 0.82 mg. In other words, the amount of norepinephrine you are giving can vary by almost double depending on the salt you are using. As long as you are titrating to the patient in front of you, this doesn’t really matter clinically, but if you are switching between hospitals, comparing doses to those used in studies, using the norepinephrine dose in a score (like the SOFA score), or if your hospital sets an arbitrary max dose (they shouldn’t), this conversion could really matter.
This paper discusses a number of other ways that this distinction muddles prior research. Ultimately, this task force suggests that we should uniformly discuss norepinephrine dosing (and, in fact, all medication dosing) in terms of the weight of the base molecule, not the total weight of the salt. Based on this picture I took a few years back, it looks like we might already do that in Canada:
Bottom line: This probably doesn’t have huge impacts on clinical care, but if you are in a place that sets an arbitrary maximum dose of norepinephrine, it would be good to check what units your hospital is using.
EPIC-SR
Hammond J, Fountaine RJ, Yunis C, Fleishaker D, Almas M, Bao W, Wisemandle W, Baniecki ML, Hendrick VM, Kalfov V, Simón-Campos JA, Pypstra R, Rusnak JM. Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. N Engl J Med. 2024 Apr 4;390(13):1186-1195. doi: 10.1056/NEJMoa2309003. PMID: 38598573
We have known this trial was negative for more than 2 years. It really shouldn’t change practice, because we already knew the results. However, in an effort to push more product, Pfizer sat on this data (despite releasing the simultaneous positive study immediately), and for some reason the medical community fell for it and bought tens of billions of dollars worth of the drug. EPIC-SR is a double blind placebo controlled RCT of paxlovid. The population is somewhat complicated, partly because they changed it partway through the trial, but essentially it was vaccinated patients with high risk comorbidities or unvaccinated patients without comorbidities. The trial is negative, with no difference in their primary outcome of symptom alleviation, and also no statistical difference in important outcomes like hospitalization and death. No trial thus far has looked at the effects of treatment on long term symptoms, so we cannot comment there. No trial is perfect, but considering the massive financial conflicts of interest here that would bias in favour of paxlovid, you should believe these negative results. You can be strict in your interpretation, and not prescribe paxlovid just in the EPIC-SR population, but given that the initial trial was also heavily biased by financial conflict of interest, has not been replicated, and has multiple limitations, my take is that we never should have started using this drug in the first place. I consider it an experimental agent waiting on high quality independent data.
Bottom line: There may be a few exceptions, but for the most part paxlovid just shouldn’t be prescribed (and COVID shouldn’t be tested for anymore.) Specifically, this study covers anyone with at least 2 COVID vaccines, or who is unvaccinated but does not have comorbidities.
The Problematic Term “Provider”
Scarff JR. What’s in a Name? The Problematic Term “Provider”. Fed Pract. 2021 Oct;38(10):446-448. doi: 10.12788/fp.0188. PMID: 34733063
In the tradition of including potentially controversial papers, how do you feel about the term “provider”? I am a strong believer that language matters, and that the subtle impacts of language are often overlooked. (I will also admit that this is an area that I constantly struggle with, as my brain likes to spit out the terminology of my youth, long after I have been informed of the problems with my language.) This author has a major problem with the term “provider”. He discusses a surprising history, where apparently the first ever use of this term was to replace the word “doctor” among Jewish pediatricians in 1930s Germany, and therefore undermine their authority and societal sway. Later, this term has strong ties to a commercialized American healthcare system, with a focus on healthcare as a commodity to be “provided”. In that context, it is not difficult to see his concerns. He believes healthcare is more than something we “provide”. Our jobs are fundamentally different from others who provide commercial services; we are not like shopkeepers or landlords. The Latin roots of “doctor” are “to teach, or to instruct”, and we should not lose sight of that etymology. (Similarly, I refuse to call patients “clients” despite a strong push for that terminology from some circles.) He is also concerned, given the range of individuals incorporated under the term “provider”, including “chiropractors, nurse practitioners, nurse-midwives, clinical social workers, and physician assistants”, the single use term could mislead or confuse patients. Although most people don’t think deeply about the influence of our language, you can imagine how some groups might strongly push the use of the term “provider” for their own gain. Aside from reading this article, I know nothing about the history of this term, and I don’t know if any of his concerns manifest in clinical practice, but I find his arguments relatively convincing. I would love to hear from people with more insight into the history or impact of the term “provider”, or any other medical terminology that may be problematic.
Bottom line: I think it is important to consider the history, context, and impact of the language we choose. I am interested to see how controversial this essay is.
It appears that others have picked up on the problems with this language. Shortly after writing this summary, I encountered this quote in a novel I am reading, as part of a larger paragraph on the commoditization of medicine: “We’re no longer physicians – we’re merely providers, rushing through cases with incomplete information, sacrificing the essence of being a doctor.” From Shadow in the Ward by Ari Gray.
Cheesy Joke of the Month
My horse will only come out of its stable when it gets dark.
It’s becoming a night mare.
One thought on “Research Roundup and BroomeDocs Podcast (May 2024)”
Unfortunately, we don’t have a good umbrella term so I used “provider” in multiple research papers on OB emergencies in low income areas. It is a perfectly reasonable alternative to ” physicians, midwives, nurses and community health workers” which would be the alternative ) or maybe God forbid “PMNCHPs”. When getting a history in the USA I can use a verb form “who do you see for health care?” But a better noun alternative would be appreciated.