Slate Magazine Challenges AP's Heroin Reporting

In our ED we seem to go through phases with the drugs of choice. These days it is heroin more than meth. Most of them get narcan and then try to leave AMA.

Slate Magazine has a great take on AP's "scare story reporting that new, cheap heroin is causing an increase in heroin deaths.

Drug scare stories are nothing new and are rarely based on any real documentation. Usually the source is local law enforcement and some questionable statistics.

In alarmist prose, the article asserts that the ultra-smack's purity ranges from 50 percent to 80 percent heroin, up from the 5 percent purity of the 1970s, and this potency is "contributing to a spike in overdose deaths across the nation." But reports of high-potency heroin being sold in the United States are anything but "recent." My source? The AP itself. Over the decades, the wire service has repeatedly reported on the sale of high-potency heroin on the streets.

Slate points out that AP's been reporting on high potency smack since the mid 1980s and while AP states new users are getting hooked due to cheaper prices -- AP's own reporting states that the price hasn't changed in over a decade. Moreover, Slate notes that the methodology for defining and comparing heroin ODs is pretty murky (if indeed any sort of methodology was involved.)

As it turns out, death by heroin alone is relatively uncommon, according to a 2008 study by the Florida Department of Law Enforcement and the Florida Medical Examiners Commission. The study (PDF) analyzed the cases of all 8,620 people 1) who died in the state during 2007; 2) whose death led to a medical examiner's report; and 3) who had one or more major drug (including alcohol) onboard when they died.

In only 17 of the 110 heroin-related deaths was heroin the only drug onboard. In most cases of heroin-related death, decedents take other drugs that depress the central nervous system—other opiates, alcohol, sedatives, etc. The dangers of "polydrug use," as some call it, have been well understood for some time. A survey of the medical literature published in Addiction in 1996 titled "Fatal Heroin 'Overdose': A Review" warns against attributing all deaths in which evidence of heroin is present as "heroin overdose."

The Guy Who Started the Autism/Vaccine Scare Gets His Due

A dozen years ago a research paper in the Lancet proposed a link between the MMR vaccine and increasing rates of Autism. The study was put forward by A Brit. Doc. named Andrew Wakefield.

Now Wakefield's losing is right to practice medicine in the UK.

There is no link of course and subsequent investigation have found that Wakefield was guilty of all sorts of ethical violations, not the least of which include making up data and conflict of interest. Good summary of the investigation that lead to Wakefield's downfall here at Brian Deer and in the Guardian.

Sadly, Wakefield's got a new career selling his bad science across the pond and will be little affected by the ruling.

Nurse, Interrupted ...

A new study from down under finds that interrupted nurses are more likely to make errors. Seems like we could assume that was true but nice to see it quantified.  It doesn't seem to matter how much experience you have, if you get interrupted, you increase your chance of making a mistake in medication preparation, aseptic technique and other critical jobs. From Medscape:

"Experimental studies suggest that interruptions produce negative impacts on memory by requiring individuals to switch attention from one task to another," write Johanna I. Westbrook, PhD, from the University of Sydney in Sydney, Australia, and colleagues. "Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task."  

For each interruption, there was a 12.1% increase in procedural failures and a 12.7% increase in clinical errors, with the association between interruptions and clinical errors independent of hospital and nurse characteristics. More than half (53.1%) of all administrations were interrupted (95% confidence interval [CI], 51.6% - 54.6%), and nearly three quarters of total drug administrations (74.4%; n = 3177) had at least 1 procedural failure (95% CI, 73.1% - 75.7%).  

Nurse experience did not protect against clinical errors and was actually associated with a higher rate of procedural failure. The frequency of the interruptions was associated with increased severity of the error. The estimated risk for a major error was 2.3% when there were no interruptions vs 4.7% when there were 4 interruptions (95% CI, 2.9% - 7.4%; P < .001). 

 "The converging evidence of the high rate of interruptions occurring during medication preparation and administration adds impetus to the need to develop and implement strategies to improve communication practices and to reduce unnecessary interruptions within ward environments. While it is clear that some interruptions are central to providing safe care, there is a need to better understand the reasons for such high interruption rates." 

 The question, however, is what can we do to reduce interruptions? In the emergency room especially, it's a difficult place for doctors and nurses to work without interruption. The patients are unstable and dynamic. Frequent updates are needed. So what do we do?

ICS SBAR SOAP CUS? Medical Communications...

Communications

Communication is one of the most important tools in the medical profession. The better the communication, the better care the patient is going to receive.

It is especially important for those in EMS. We are the eyes and ears of the doctors and definitives care. Moreover, what we are told prior to arrival is often wrong or inaccurate. It is our job to communicate with the patient, with each other and with higher levels of care. Failure to communicate effectively can lead to a failure in the patient's care.

There are a couple models of communication that have become useful in Emergency Medicine. 

SBAR

Situation - What is going on. (Example. I have an elderly man with chest pain that started about 20 minutes ago.)

Background - History and relevant findings (he had a heart attack two years ago with stents placed. He took three nitro with no relief before calling 911)

Assessment - What's Happening (He may be having a heart attack. His 12 lead states acute mycardial infarction with ST elevation)

Recommendation - What needs to happen (He needs 02, IV, Cardiac monitor, ALS and rapid transport to a cath lab. I have a full set of vitals and a list of meds and allergies.)

We should be using the SBAR model every time we tell a new person about a patient. The first responder is going to use SBAR to communicate to the Ambulance crew, the Ambulance crew needs to communicate to the Paramedic and the Paramedic is going to use it to communicate to the hospital (via HEAR report) and to the doctor or nurse at bedside. SBAR is our tool in updating the team one where things stand and what needs to happen next. 

Here's an example of an SBAR given by a first responder to the arriving ambulance crew:

(S) "Martha here is having a hard time breathing and her son called 911 because she can only speak one word at a time. (B) She has a history of Congestive Heart Failure and had a heart attack two years ago. No history of lung disease. She's been feeling tired and weak for the past 4 days. (A) She can only breathe sitting straight up, her room air 02 sats are 90 %, she's pale and breathing rapidly. Her feet are swollen. Even with a oxygen mask she's only sat-ing at 93%. (R) We need to call ALS and get her to a hospital quickly. She'll need a 12 lead and to be placed on the monitor. Grab the stair chair and the lifepack. Her son is looking for a med and allergy list as well as a copy of her DNR."

Note that you don't have to convey every set of vitals or every part of the SAMPLE history. This is the MOST IMPORTANT STUFF in your clinical understanding. Other stuff can be communicated after the important stuff gets done. Don't be surprised if the patient gets asked the same questions more than once. Sometimes it is important to ask patients questions over and over again in different ways -- whether it is to assess their mentation, or to get a better picture of their medical history. For example, some people deny they have high blood pressure because it's controlled by their blood pressure medication. 

  

Don't confuse SBAR with SOAP charting. They are similar in that the separate information that is all jumbled together in our minds, but one is much more detailed -- even redundant. 

SOAP

Subjective - Stuff people have said -( the call was for a 43 year old woman not feeling well. Patient states she "feels tired and like she's going to throw up" Denies pain but says "it feels like there is an elephant sitting on my chest.")

Objective - Stuff you see and observe - (arrive to find cool, pale, sweating female with her hand on her chest. BP 186/40, HR 175 and irregular)

Assessment - What you think is happening - (patient maybe having an acute cardiac event.)

Plan - What you did and how it went- (IV, 02, 12 lead, ALS. pain relieved with 3 nitro. )

SOAP charting is for charting only and sometimes it is redundant. Sometimes what people tell you and what you yourself observe are the same things. Often in the world of EMS they are not. It is important to chart both. 

Incident Command

It is important for someone to be in charge on the scene of any emergency. Things are chaotic and often times well trained individuals can lack focus without direction. It is important for one person to step back and look at the big picture of what resources are needed, what is getting done and what needs to get done.  This all sounds more impressive than it is. For a small department like ours, incident command can be as simple as one person telling the other units where to park or to bring in a stair chair rather than a stretcher. Maybe if we used the term traffic control that would be less intimidating. In any case there are a few ways we can systematically integrate incident command principles into our everyday response.

First Person on scene - if someone responds to a call by private vehicle, that person is going to have a better idea of what is needed. As soon as possible they should give a quick seen size up report to other responding units and make sure the proper resources are enroute. (This is 384 on scene. I have an elderly man here having chest pain, not abdominal pain and we are going to need to get ALS enroute. He's upstairs in a small room, so 310 we'll need the stair chair and lifepack when you come in.) 

When other units arrive that first responder can remain incident command -- stepping back and letting others take over patient care -- or they can can remain primary caregiver. What they can't do is make assumptions. It has to be handed off to someone else. We can do this by protocol (senior officer assumes IC on arrival) or by verbally handing it off. (Ed, I'll do patient care and you can direct the other units as they arrive.) When we do this, we need to make sure that this shift is communicated effectively to everyone involved. (Okay, I'll take IC you keep doing patient care. Cathlamet 310 will be incident command.) 

Now if there is just one ambulance and three people, you don't need to call over the radio and say  "I'm in charge!" However, you still need to decide who is going to do what on scene.

Closed Loop Communication

So on scene, how should we communicate?

Studies have shown the best method is closed loop communication. In this system:

• A command is given for a task -- it's best if a person is assigned this task. If you give an open command out in the air, no one will do it, everyone will assume the other person is taking care of it. (Jack, we need 02 15 liters via mask)
• A response to the command is given to make sure it is understood. (Okay, I'm getting a nonrebreather mask for 02 at 15 liters)
• The loop is closed when the task is completed (Okay I've got oxygen going and it looks like Sats are improving.)

Assertive

The other thing that's required is assertive speech no soft speech. Soft speech is suggestive and respectful. Often we see soft speech in a situation where there are different ranks involved or one person with more experience than the other. In those situations the less experienced person may know something's wrong but they don't know how to come right out and say it. Instead, the try to hint at the looming danger. After a plane crashed when the co-pilot used "soft speech" and was unable to warn the pilot of error, airline training schools created "critical language" training. This involves the use of words that are designed to get the other team member's attention. 

Concerned - Uncomfortable - Scared

These words tell people to PAY ATTENTION to what they are saying. If you hear these yellow-flag words, it means for the team leader to stop and listen to me. Here's an example.

Team Leader: Okay, let's get this guy on the stretcher

EMT: I'm CONCERNED that this patient has neck pain and was in a car accident, yet we haven't put a C-collar on him.

The team leader doesn't listen to this first yellow flag so the EMT tries again:

EMT I'm UNCOMFORTABLE moving this patient without c-spine immobilization. 

If there is still no response from the team the EMT states:

EMT: I'm SCARED that we may injure this patient if we don't c-spine him.

Situational Awareness

This is away of reviewing what's been done and where things stand. It is a way of getting everyone on the same page. People need to know why they are doing what they are being asked to do.  Situational Awareness makes everyone move forward together and keeps things slow and calm. It also allows a forum for team members to give input on what to do next. Here's an example:

"Okay, we've got a good airway with an OPA and Jack is providing good ventilation with the bag valve mask. We have pulses after two shocks but the patient is not breathing. So let's keep bagging him and what else should we be doing. "

Questioning the Golden Hour for Ambulance Response

How fast should an ambulance go? In our rural area you are always at least 30 minutes from a hospital -- whether we go Code 3 in the Ambulance or put you on a helicopter. Still, we often drive sick patients to the hospital faster -- with lights and sirens blazing.

Of course, ambulances are not above traffic laws. We aren't supposed to fly through red lights or exceed the listed speed limit. Often running lights spook the other drivers into slowing to a crawl as they panic about getting off the road and out of the way. This is such a problem -- our lights and siren are such a hazard in some places -- that we turn them off to avoid making matters worse.

Moreover, Code 3 is dangerous. Accidents involving ambulances most often occur when responding with lights, siren and "turbo-diesel therapy." Medics are killed a rate three times higher than average workers mostly due to these accidents.

Yet time is muscle and speed saves lives right?

As reported this morning Slate Magazine, maybe not. New research indicates that the so called Golden Hour for the severely injured may not be as important as once thought. As Emergency doctors Pines and Meisel write:

Now a recent study in the Annals of Emergency Medicine casts further doubt to the concept of the golden hour for patients with severe injury. The authors studied more than 3,000 trauma patients—those with low blood pressures from bleeding, head injuries, and difficulty breathing—and looked at various time intervals after a 9-1-1 call. The times were compared with outcomes for the patients in the hospital. The result: shorter intervals did not appear to improve survival. These results are fascinating, in part because the principal question—how important is speed in the care of trauma patients before they get to the hospital?—has never been so elegantly explored. Previous efforts to measure the effect of ambulance time on survival have been plagued by the fundamental problem that medics may behave differently, like driving faster or spending more time working on patients, depending on the severity of the condition, making it impossible to tease out the effect of time on survival. While some of these biases remain, the authors of this study used sophisticated methods to account for many of these problems, allowing the reader to reasonably conclude that for ambulance care, a few minutes either way neither saves nor costs lives for patients with severe trauma.

 So what are we to think in all this? Do we need to "slow down with all due haste" as my dad used to say. Time does count when it comes to cells not getting oxygen. Time counts when a trauma center can prevent someone from bleeding out. However, we are increasingly able to do more in the field to buy time for transport.

I think application of Code 3 is required to come with some judgement -- not just as to the severity of the injury but also to whether seconds really count for this particular conditions.

Lots of parents reporting not giving kiddos tylenol because of the recall.

Baxter told to recall and destroy hospital IV pumps

The LA Times is reporting that medical manufacturing giant Baxter is being forced to "recall and destroy" Hospital IV pumps that we use at our hospital and at hospital across the nation. The pumps in question are known as Colleague Guardian pumps and the move is part of a larger effort by the FDA to crack down on IV pump safety issues.

The change comes after 710 deaths associated with malfunctioning infusion pumps used in homes and hospitals during the last five years, according to American Medical News. The agency has received 56,000 adverse-event reports regarding the devices during that time period and issued 87 recalls -- 14 of those in the FDA's highest-risk class I category. 

"There have been problems with every kind of infusion pump on the market, across the entire industry," said Jeffrey Shuren, MD, director of the agency's Center for Devices and Radiological Health. The initiative "represents a major shift in FDA's approach to medical device safety," Dr. Shuren said. "Instead of responding to problems one by one and manufacturer by manufacturer, we are taking comprehensive steps to prevent problems by fostering the development of safer, more effective infusion pumps industrywide."

The FDA said Baxter must "recall and destroy" all of its Colleague pumps, saying the action was based on "a long-standing failure" of the company to correct serious problems with them, the LA Times reported. Baxter issued a corrective action plan, however the FDA found it wanting, responding with the order for recall.


As the LA Times reported:

The agency called the plan "unacceptable" and said it would have allowed the company to keep a device with "known safety concerns" on the market until 2013. The FDA said it was not satisfied with Baxter's timetable for fixing Colleague, a pump the company stopped selling in 2005 because of various design flaws, battery failures and related software issues.

"The FDA has been working with Baxter since 1999 to correct numerous device flaws," the agency said in a statement. "Since then, Colleague pumps have been the subject of several Class I recalls for battery swelling, inadvertent power off, service data errors and other issues."

Based on a consent decree with FDA, Baxter hasn't sold the pumps directly since 2006, but they still remain on the market. 

Baxter is offering to exchange it's new Sigma smart pumps for the recalled pumps without charge. 

Personally I like Hospira's plum pumps, but I doubt we'd be able to get a hospital's worth for free ....

Care Trumps Patient Choice of Hospital

Over at JEMS, there's an article that speaks to an issue we've been dealing with here in Grays River. When Does Care Trump the Patient's Choice of Hospital?
It's a strange but familiar issue out here in rural Grays River Valley. We have two hospitals within our service area. They are in opposite directions, but one is closer by about 25 minutes. Moreover, Advanced Life Support is available going to the closer hospital and is often unavailable going to the larger hospital to the East. Bottom line, if you are sick, you are going to the closest hospital with ALS.
However, it's hard for our patients to understand that, most ask to go to the larger hospital that is farther away. Part of this is just because this is a great hospital (I work in the Emergency Room there). Many of our patients also have their doctor at that hospital, so there is a continuity of care component involved as well.
There is also the problem of tradition, which is huge in rural communities and resistant to changing circumstances.
In the "olden days" the ambulance would actually stop off at the nearby clinic so their doctor -- our MPD -- could step in an evaluate the patient. There used to be several volunteer paramedics in town that would hop on the ambulance just about any time day or night if needed. Even some of my EMTs still say "we should always take the patient where they want to go, because that's they way we've always done it."
Unfortunately things are changed. The MPD is no longer at the local clinic, and we no longer have a wealth of volunteer Paramedics available to hop on our truck and give ALS support. So should we continue to always honor the patient or family request for hospital? For stable patients, the answer is yes, however when a patient is unstable -- when heart or brain damage is likely -- the choice is not so clear. 

According to JEMS


"In some situations, it may actually be negligent to take a patient to the hospital of their choice, particularly when EMS protocols dictate otherwise,"  writes lawyer and paramedic Anne Maggiore in JEMS. "what about situations in which a patient or their family insists on transport to a hospital other than the one to which EMS protocol dictates transport? Usually this insistence is the result of some emotional attachment to a particular hospital facility (e.g., "I was born in that hospital"). This presents a difficult situation for EMS personnel. While not wanting to engage the patient, who's most likely very ill or injured, or their family in a debate over appropriate hospital destinations, it's nonetheless critical to try to make the patient understand the EMS service's legal obligation to transport to the appropriate facility. A life hanging in the balance may ultimately depend upon transport to a hospital that has what it takes to properly care for that patient. "

That's where it gets sticky for us here in Grays River. The closest hospital, the one where ALS is going to hop on board and help the patient more quickly also happens to be a smaller hospital with less specialty coverage. So we are going to have to really dial in our protocols as to what kind of patients are taken to which hospital. Acute CVA we may just put on a helicopter out in the field. 

Yet what if someone is having a STEMI? Do a prioritize ALS intercept, or just go BLS to the hospital with a cathlab? I'm currently writing a letter to be sent out to our coverage area trying to explain in advance how we make these decisions. We're also rewriting our protocols -- hopefully giving our EMTs more direction. 


"It's ultimately easier to defend an EMS decision to transport a patient to a higher level of care than it is to defend transport to a facility selected by family members. These same family members will later testify that they relied on the expertise of the EMS personnel to transport the patient to an appropriate facility. EMS protocols should be strictly adhered to, and if there's doubt about the proper facility, EMS should always contact medical control for assistance. "