Emergency Medicine

Ambulance response time can vary widely across cities, depending on traffic patterns and the location of the emergency situation. As a volunteer medic in Jerusalem, Elli Beer witnessed firsthand how a few minutes can make a significant difference in saving a life. His frustration with poor ambulance response times led him to develop an all-volunteer rescue service called United Hatzalah.

In this recently posted TEDMED talk, Beer talks passionately about how a small neighborhood group dedicated to responding to nearby emergencies evolved into United Hatzalah’s network of 2,000 volunteers. Today, volunteers respond to incidents on “ambu-cycles,” motorcycles carrying the same equipment as a conventional ambulance but lacking the ability to transport patients, and have treated more than 200,000 people in the past year. Beer has rolled out the service in Brazil and Panama and plans to expand to India.

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims and On using social media to improve emergency-preparedness efforts

Emergency helicopter transport can be pricey and, as recent reports of aircraft crashes show, potentially dangerous. Such downsides have sparked some concerns that transporting trauma patients by air may not be worth the risk. So researchers at Stanford set out to investigate how often medical helicopters needed to help save critically injured patients’ lives in order to be considered cost-effective when compared with ambulances.

Researchers published their findings (subscription required) online this month in the Annals of Emergency Medicine. My colleague explains their results in a release:

The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective.

The study… does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

“What we aimed to do is reduce the uncertainty about the factors that drive the cost-effective use of this important critical care resource,” said the study’s lead author, M. Kit Delgado, MD, MS, an instructor in the Division of Emergency Medicine. “The goal is to continue to save the lives of those who need air transport, but spare flight personnel the additional risks of flying - and patients with minor injuries the additional cost - when helicopter transport is not likely to be cost-effective.” (Helicopter medical services generally bill patients’ insurance providers directly, but patients may have to pay some of the bill out of pocket, or, if they’re uninsured, possibly all of it.)

The findings only apply to situations and locations where patients could be taken by both ambulance and helicopter to a trauma center. Researchers said that in scenarios where ground transportation to a trauma center wasn’t feasible, then transport by helicopter was preferable.

Photo by Brett Neilson

The CommonHealth blog drew my attention today to the story of a group of students who jumped into action after the Boston Marathon bombings. As one of the pre-med students explains in the Times Higher Education piece, the incident - as horrific as it was - solidified her decision to go into medicine:

Near the marathon’s finish line, 50 Boston University pre-med undergraduates had been volunteering in the medical tent, filling out record forms and carrying supplies, when the bombs went off.

…

Some of the Boston University volunteers worked to clear the aisles as the floor of the tent ran red with blood. They saw the wounded, including children, arrive with missing limbs, and physicians fashion tourniquets from belts and shirts. One was ordered to set up a morgue.

“There was nothing in a classroom that could have prepared us for this,” [Yeon Woo Lee] said. “Some of the students in my group were barely 18. People stayed calm. Nobody panicked. It was scary, but I’m glad that I was there to help out and very proud.”

The experience for her and the others, she said, was horrifying and inspiring. “It was a terrible, terrible, terrible week with a lot of pain and suffering, but at the same time there’s nothing else in the world I would rather do now than go into the field that I chose to dedicate my life to,” Ms Lee added.

Previously: “We are not innocents:” What prepared medical professionals to treat Boston bombing victims

Those of you who have ever waited for hours (or what feels like hours) in an emergency room might appreciate this statistic: In the last eight months, the median door-to-doctor time for patients visiting Stanford’s emergency department dropped from 45 minutes to 18. So what happened? Credit the implementation of two new programs, Team Triage and Fast Track, that were “designed to provide speedier, more efficient service” in the ED. The current issue of Stanford Medicine News has more details:

First came Team Triage, inaugurated a year ago. In the same area as the waiting room, big bronze-colored letters that spell “triage nurse” are affixed to a dividing wall, behind which patients are evaluated by a team of doctors, nurses and ED technicians. Apart from trauma patients brought in by ambulance to receive the highest-priority care, everyone who comes into the ED passes through the Team Triage area. Minor injuries are classified as 4 or 5, the most critical as 1. “Most patients are 3s,” said Patrice Callagy, RN, patient care manager in the ED. “They might have abdominal pain or broken bones.” Team Triage also allows for earlier diagnosis of time-sensitive conditions, such as stroke.

An analysis found that 40 percent of the hospital’s patients were sick enough to have been admitted through the ED. It also showed that 12 to 13 percent of the ED’s patients were 4s and 5s, who did not require hospitalization. Yet their relatively minor medical issues meant that they were waiting the longest, starting with how long it took for them to see a doctor.

…

Enter Fast Track, a dedicated team composed of doctors, nurses and ED technicians whose job is to treat patients with less-severe health problems as rapidly as possible. “We treat you and let you get on with your life,” said [Grant Lipman, MD], Fast Track’s medical director. “You’re the least sick, so we’ll treat you the fastest.” The median length of stay for Fast Track patients is 65 minutes, well under the original goal of 90 minutes.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Windows ER?

Much has been written about the tragic events in Boston on Monday, but I have to draw attention to a New Yorker piece detailing how the doctors and nurses at area hospitals leapt into action to treat victims’ war-like injuries. Atul Gawande, MD, describes what happened at the hospitals that afternoon, and his take on why people there worked with such “grim efficiency”- and why, in turn, so many victims survived - is compelling:

…Something more significant occurred than professionals merely adhering to smart policies and procedures. What we saw unfold was the cultural legacy of the September 11th attacks and all that has followed in the decade-plus since. We are not innocents anymore.

A small percentage of patients admitted to hospital beds from emergency rooms — about 5 percent, according to recent studies — are then transferred to intensive care units due to an unexpected decline in their condition. What is striking about these so-called unplanned ICU transfers is that they account for 25 percent of all in-hospital deaths.

In a study (subscription required) published late last week in the Journal of Hospital Medicine, researchers led by M. Kit Delgado, MD, an emergency medicine physician at Stanford Hospital & Clinics, determined some of the risk factors for such transfers when they occur within 24 hours of patients being moved from the ER to a hospital bed. (About half of all unplanned ICU transfers happen within this time frame.)

The implications are that we need to figure out what is happening with patients with respiratory diseases in particular …

The researchers found, among other things, that the risk was higher during overnight nursing shifts. It was lower among female patients and in high-volume hospitals. But what really stood out was this: Respiratory conditions, such as pneumonia and chronic obstructive pulmonary disease, accounted for nearly half — 47 percent — of all conditions linked to the increased risk of unplanned ICU transfer.

About the study, Delgado told me:

The implications are that we need to figure out what is happening with patients with respiratory diseases in particular in terms of initial resuscitation, monitoring and determining the appropriate level of hospital care. We have found in previous research that these respiratory patients who experience an unplanned transfer to the ICU have higher mortality than those who are directly admitted. Perhaps with better initial resuscitation and closer monitoring, these unplanned transfers can be prevented, and lives can be saved.

The study was based on three years of admissions data at 13 Kaiser Permanente hospitals.

This image comes from a manga comic produced by Ian Roberts, MB, a professor of epidemiology and public heath at the London School of Hygiene and Tropical Medicine.

As the New York Times reported this week, Roberts created the comic to increase awareness among emergency physicians about recent scientific evidence showing the clot-boosting drug tranexamic acid can increase survival rates among trauma patients.

In the Times piece, Conor Rabinovitz, a die-hard manga fan and the 19-year-old son of Scope contributor Jonathan Rabinovitz, also offers his thoughts on the comic’s storyline.

Photo by Emma Vieceli

What doesn’t kill you makes you stronger, stand a little taller, right? Common Health blog begins a narrative post on one woman’s burst-appendix survival with a warning that I’ll repeat before going any further:

A perforated appendix can kill you. If you experience symptoms of appendicitis, particularly sharp pain in the lower right area of your abdomen, get prompt medical care.

Now, the story. WBUR’s news director, Martha Little, shares her experience with writer Carey Goldberg, who reports that treatment for appendicitis may be evolving from automatic emergency-room surgery to more nuanced and less invasive treatments. Little tells her story from the first instance of abdominal pain to entering a hospital. She writes:

I finally made it to the Brigham & Women’s emergency room, where I was told I would likely have the appendix taken out that night. But upon further examination, the surgeon and his resident told me that I could wait eight weeks for surgery, and meanwhile they would treat the infection with serious antibiotics.

Eight weeks!? “What,” I said, “would happen if the appendix burst?”

“It has already burst,” they said.

What? I thought people died when their appendix burst.

No, I was told. Not always.

The body, they explained, has a way of “walling off” the perforated appendix so that the infection doesn’t spread.

Goldberg writes:

Here’s the good news for patients like Martha: The appendix is surrounded by other structures, mostly the intestine, and so, as she was told, the seepage can get “walled off.” One theory, [Douglas Smink, MD, MPH, program director of the general surgery residency program at Brigham & Women’s Hospital ] said, is that a somewhat mobile layer of visceral fat called the omentum — nicknamed “the policeman of the abdomen” — could be drawn toward areas of inflammation to contain infection. So a patient can end up with a pus-filled abscess outside the appendix, covered partially by the omentum.

Still, why not just operate and get rid of the problem? It’s not so simple. An area rife with inflammation is hard for surgeons to work with, Dr. Smink said, and an appendectomy could end up turning into removal of part of the intestine and colon as well.

So the idea is to give the patient antibiotics to fight the infection, wait as the inflammation subsides and then do an “interval appendectomy,” after the waiting interval.

Some reserach has shown that for some cases of uncomplicated appendicitis, with the appendix still intact, antibiotic treatment may be an effective alternative to surgery.

Previously: A new lifestyle, Can you catch appendicitis? and Study shoes smart phones may speed up diagnosis

Thanks for the great questions about health and safety in the wilderness. I enjoyed reading them and hope these responses will help you better prepare for your adventures this summer.

@sarahwhelchel asks: What’s the craziest situation you’ve ever had to deal with in the wilderness?

This is not “crazy,” but it was memorable. I was hiking near a lake when I was approached by a young boy out fishing with his friends. He came up to me in distress and it was quickly obvious that he had a problem. There was a big treble hook anchored in his nose, with one barbed prong embedded pretty far up inside a nostril and the other two hanging outside his nose. He was pretty agitated, so from a distance I asked him if it was “hurting real bad.” He shouted, “No.” Then he got closer he said, “It don’t hurt that much, but I sure would ‘preciate it if you could take off the worm.” I looked closer up his nose and there it was, wiggling around. I tried not to smile, but I couldn’t help it. I had one of his friends help me stabilize the hook to keep it from moving too much, and then I reached up with a tiny blade and scraped the crawler off the barb. The kid was a tough little fellow and let me push the point of the hook through his nose so that I could cut it off and extract the hook. Afterwards, I asked him to tell me the truth - what was the worst part? He was emphatic: it was the worm!

@rdicker asks: I pack all the basic first-aid stuff for hiking. What is the most common serious injury people don’t prepare for?

I can’t say for sure the most common serious injury for which people don’t prepare. But I can provide a list some things that are tragic because they could have been avoided with proper preventive measures. These include:

• Drowning because a person wasn’t wearing a life jacket or didn’t have a personal flotation device
• Being struck by lightning because a person failed to seek shelter during a thunderstorm
• Suffering an attack by a wild animal because of intentionally approaching the creature
• Falling over a cliff or waterfall after ignoring a posted warning sign
• Sustaining a head injury because of failing to wear a helmet while rock climbing or mountain biking
• Being bitten by a rattlesnake after trying to handle a venomous reptile
• Suffering a serious burn after tripping into a campfire while intoxicated
• Breaking a leg because the person didn’t bring a hiking pole to maintain balance on a rocky, uneven trail
• Developing disabling blisters because boots were not properly broken in or were too tight

Continue Reading »

Epiphanies and transformative experiences make great copy; these kinds of stories write themselves. They’re also pretty rare. But I recently found one in the tale of Nataly Kuznetsov, right, a nursing resident in Stanford Hospital & Clinics‘ Emergency Department.

Kuznetsov was 23 when she got in a horrible motorcycle accident. As I write in my story:

The motorcycle smashed into the driver’s side, sending Kuznetsov flying about 100 feet. She landed along the side of the northbound lane.

Her right femur had shattered into about 10 pieces. Some pieces had shorn through her skin. She was bleeding profusely from her leg. “The bone was basically completely blown,” she said. “My right leg was 4 inches shorter than my left one, just from the impact. You should see my X-rays. They’re phenomenal.”

She was airlifted to Stanford Hospital, where, after two weeks, she realized she wanted to be a nurse. She explains in the story:

What I’ve realized is just how much of an impact nurses have on patients’ lives. … They’re the ones who are next to you. They’re the ones who are looking after you. They’re the ones who are holding your hand. They’re the ones who are going to let you cry next to them.

Previously: Nursing: The need to make a difference and Nursing is not all science
Photo by Norbert von der Groeben