Articles of the month (July 2018)

You will probably notice a new format to the articles of the month. I was getting sick of not being able to find papers that I knew I had previously commented upon. Having them listed as one 10 papers in the articles of the month made them very difficult to search for. Therefore, on bigger, more important papers, I have started writing stand alone blog posts. I will still include those papers in the articles of the month, but the summary will be truncated, with a link to the blog for all the details. The articles of the month will probably still contain extra articles, including papers that don’t warrant their own post and my usual “just for fun” kind of papers. Let me know what you think.

TXA is not magical?

Sprigg N, Flaherty K, Appleton JP, et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet (London, England). 2018; 391(10135):2107-2115. PMID: 29778325 [free full text]

This is an RCT looking at TXA in nontraumatic ICH. The bottom line is that, for now, the best evidence is that TXA does not help patients with nontraumatic ICH and we should not be using it. However, this data may warrant a further study to be sure.

The full write up can be found here.

Bougie is better

Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018; 319(21):2179-2189. PMID: 29800096

I love the bougie as a rescue technique for difficult airways, but many people use the bougie routinely on their first attempt. I discussed some previous retrospective data from this group in the March 2018 Articles of the Month. Now, they provide us with the best evidence to date, in the form of a RCT. The outcomes were clearly better with the bougie in this study. However, we should be cautious when applying the results, as it is a single-center study, and the degree to which providers are trained and comfortable with a bougie could significantly impact the generalizability of these results. That being said, I will probably change my practice and start using a bougie routinely for my first intubation attempt.

The full write up can be found here.

Interesting airway hack

Waldron S, Dobson A. A novel positioning technique to assist laryngoscopy in patients with a potentially difficult airway. European journal of anaesthesiology. 2010; 27(10):921. PMID: 20498607

This letter to the editor describes an interesting hack that might be useful in positioning patients for airway management. They use the IV fluid pressure infusion bag to position the head or shoulders. This allows you do pump the bag up to the exact height you might want, but also allows for rapid deflation to reposition if needed. Thanks to airway expert Dr. Yen Chow (@TBayEDGuy) for pointing this paper out, and sharing this video below demonstrating this technique. I have played with this a bit in the sim lab, and it works, but probably is a little too slow for me to use routinely as a positioning technique. However, considering the general lack of pillows in emergency departments, people might occasionally find this helpful as a replacement.

Medical management of peritonsillar abscess?

Souza DL, Cabrera D, Gilani WI, et al. Comparison of medical versus surgical management of peritonsillar abscess: A retrospective observational study. The Laryngoscope. 2016; 126(7):1529-34. PMID: 27010228

I have always been taught that abscesses need cold hard steel. However, it isn’t clear that is always the case. Needle aspiration is used first line in breast abscesses, and it may be equally efficacious for Bartholin’s abscesses. It also seems to be a common option in peri-tonisal abscess, but these authors ask whether aspirating the pus is even necessary. This is a chart review with good methods (predefined outcomes, multiple abstractors, rules for handling data), but the abstractors were not blinded to the study hypothesis. Of 297 patients with peritonsillar abscess, 97 (33%) were treated medically (antibiotics plus or minus steroids). Of the patients managed surgically, 77% had an incision and drainage and 22% needle aspiration. (All surgical patients also received antibiotics and 90% received steroids). There was no difference in terms of treatment failure between the two groups (3% surgical and 5% medical, p=0.3). However, like in so many observational trials, the two groups were fundamentally different. The surgical group was sicker, with more muffled voice, drooling, trismus, fever, and dysphagia. Therefore, it would be inappropriate to conclude that medical management and surgical management are equal. However, I think it is interesting to note that in a carefully selected population, medical management might be an option. I was surprised to hear this the first time I discussed it with a consultant. I was also surprised how many of these patients had a CT performed (63%) when this is usually a pretty easy clinical diagnosis. Personally, I don’t think imaging is necessary unless there is significant trismus or neck stiffness, indicating spread of the abscess beyond the tonsil.

Bottom line: Although probably not appropriate for all comers, some select patients with peritonsillar abscess might be managed non-surgically.  

Does ED physician speed affect patient experience?

Lenz K, McRae A, Wang D, et al. Slow or swift, your patients’ experience won’t drift: absence of correlation between physician productivity and the patient experience. CJEM. 2017; 19(5):372-380. PMID: 27819217

This is an interesting study. It is a retrospective observational study using a database of patient satisfaction surveys and comparing the results to physician productivity (the average number of patients seen per hour). This is a Canadian satisfaction survey, but I have no experience with it. Survey response rate is 45%, so like most surveys, there will be significant response bias. They looked at 3794 surveys tied to 130 emergency physicians. Physicians saw between 1.25 and 4.5 patients per hour (although the vast majority were between 1.5 and 2.5 patients per hour). There were no statistical correlations between physician productivity and satisfaction in any of 6 domains (staff care, discharge communication, respect, medication communication, pain management, and wait time/crowding). There are a number of methodological limitations to the study, including it being retrospective, using a post hoc power calculation, and significant response bias. The big problem is all the complex data hidden in the correlation. A very good doctor might be able see more patients an hour and provide good care, but if the doctor currently seeing 1.5 patients an hour suddenly tried to see 3 an hour, would their patients remain satisfied? I also wonder about system effects that contribute to both issues. Most days, the difference in my ability to see 2 patients an hour or 3 lies not in my desire or abilities, but in the availability of beds, nursing times, lab functionality, timely radiology reports, and a little luck. My guess is that it is more important to focus on those systemic issues than on individual doctors, with the possible exception of extreme outliers.

Bottom line: Not sure I have one here. What do you think?

Once again: tamsulosin doesn’t help with kidney stones

Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA internal medicine. 2018. PMID: 29913020

Yet another negative trial of tamsulosin for kidney stones, and this one doesn’t even have positive subgroups for people to be excited about. I think it is now pretty clear that tamsulosin isn’t helping our patients. When you consider that every intervention has harms and costs, I think it is pretty clear we shouldn’t be using it at this point.

The full write up can be found here.

IV fluids DO NOT cause cerebral edema in pediatric DKA

Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. The New England journal of medicine. 2018; 378(24):2275-2287. PMID: 29897851

This is probably the most important paper of the month. It is a RCT looking at fluid type and rate in the management of pediatric DKA. Before this study, I thought that it was probably a myth that fluid choice impacted cerebral edema in pediatric DKA. This study seems to support that belief. There was no difference in any outcome. If anything, the slower rates looked worse.

The full write up can be found here.

Best medical care in the world

Reilly BM. The Best Medical Care in the World. The New England journal of medicine. 2018; 378(18):1741-1743. PMID: 29719189 [free full text]

This one has left me at a loss for words. (Rare, I know). It is a short essay about an unbelievably bad patient journey that everyone should probably just take the time to read. I have two clinical lessons from this story.  The first, which we all know but is so hard to implement, is that patients with psychiatric conditions are high risk for misdiagnosis. Empathy and a true understanding of their story is essential. Second is a reminder of the power of anchoring. Every patient deserves a full assessment, but all too often we allow this to be short changed by a diagnosis that is already written on the chart.

Best ever cure for hiccups

Peleg R, Peleg A. Case report: sexual intercourse as potential treatment for intractable hiccups. Canadian family physician. 2000; 46:1631-2. PMID: 10955182 [free full text]

This is a case report of a 40 year old man who developed hiccups after a trigger point injection, and they had lasted for 4 days. He had intercourse with his wife, hiccuping “throughout the sexual interlude”, but at the moment of climax the hiccups disappeared and never returned. This sound better than being scared or trying to drink upside down. If sex works for kidney stones, why not hiccups? (Casey has made the very astute observation that the pair of authors on this paper share the same last name. Make what insinuations you will.)

Dexter G. Singular Case of Hiccough Caused by Masturbation The Boston Medical and Surgical Journal. 1845; 32(10):195-197.

I can’t really do justice to this article in a summary. It reads as a very weird combination between a letter to an adult magazine and a confession to assault, with some reminders of how much medicine has changed over the years sprinkled in. It is another case report about hiccups in an 18 year old female. Of course, the first attempt at cure was to “bleed her freely”. Surprisingly, that didn’t work. They probably just didn’t get the dose correct, because I am pretty sure that with a large enough volume of blood removed, hiccups would certainly stop. The case progresses disturbingly, and I will provide the doctor’s description of his cure: “I pressed my hand firmly upon the upper part of the genitals, and the convulsions subsided directly, and she lay perfectly quiet.” This piece could have potentially stood as a humorous reminder of the history of medicine, but the freeness with which this physician describes his patient as “revolting” and “depraved” quickly moved this from comedy to horror. I am not sure how Casey and I will be able to discuss this without getting ourselves in trouble, but I am sure there are some lessons to learn somewhere in here.

Cheesy Joke of the Month

Why can’t a nose be 12 inches long?

Because then it would be a foot.