The Dope on SOAP charting

For some reason, SOAP charting seems to get people confused. It is an easy way to break down the information you are presenting if you do it right. The trick is to tell the story that allows the history to be separate from the observable findings. Why? Because what dispatchers and patients and families tell us, may or may not be what's actually going on.

S Subjective - things people tell you. 

• Called to scene for a...
• pt’s chief complaint is …
• pt’s s/o states...
• SAMPLE History
• OPQRST
• Medications/Allergies
• Medical History

O Objective - things you observe

• On arrival pt appears...
• Pt/Scene appearance
• AOX4 or AVPU
• Vital Signs
• DCAPBTLS

A Assement - what might be going on COPD vs CHF
chest pain protocol

• hypoglycemia
• hyperglycemia
• abdominal pain

P Plan - what you plan to do about it.

• o2 15L NRB, 12 lead, monitor, expedite transport, ALS ...

Little Things Mean A lot

One night when I had just started working in the big city ED, we had a ambulance come in the wee hours of the morning and the last hours of a long 12 hour shift.

 The call was for "leg pain" in a 48 year old female. When she rolled through the door, something didn't seem quite right. She appeared to be in excruciating pain, but EMS said her heart rate was brady at 54. Increasing pain should increase the heart rate. She also just didn't look well. I called for a 12 lead EKG before she was even off the gurney and started an IV and labs. 

A few minutes later, the ED doc held the EKG in his hand. "Who ordered an EKG for leg pain?" I explained my decision. Turns out she was in new onset of third degree heart block. 

We've had cases where nurses have caught heart attacks based on nothing more than a hunch. I've seen cases where present like a stroke and a blood sugar reveals that they were really just hypoglycemic. 

Little things, can protect you from missing the right diagnosis, the right course of action. 

Just had another case like this the other night. Call was for a 37 yoa male near syncope while playing pool in a bar. Hx of vertigo in the past but pt states "this is different." The Medic got the 12 lead = AFIB with RVR 170 - 190 with no prior history. If you think, "should I get a 12 lead/check a blood sugar" the answer is almost always yes.

Here's a good article on how doing little cheap things can reduce the risk of big failures. It's based on the new book Antifragile, which I haven't read yet - but based on this article, I think I'll check it out. 

"Thus the decision to withhold the 12-lead is in Taleb’s view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong."

Antifragile: Things That Gain from Disorder
Risk Assesment: From Streetwatch blog

Poor Tools Available For Fighting Seasonal Flu

Image Credit: Tamiflu

Influenza this year has reached epidemic proportions - now widespread in almost all 50 states and overwhelming hospital resources on the East Coast. 

Over at National Geographic, Carl Zimmer points out that, while the flu comes back and kills half a million people a year, it is pretty incompetent as far as epidemics go - unfortunately, our tools to respond are worse.

The fact that this year’s seasonal flu has overwhelmed us (shutting down some hospitals, in fact) doesn’t bode well for the inevitable moment some time in the future when we do come face to face with a much meaner flu strain.

The trouble lies not just in our creaky hospital system, but in the weapons we have on hand. There’s a flu vaccine, thank goodness, but it’s only about62% effective. Making matters worse, well under half of Americans get vaccinated each year. If you get sick, doctors don’t have a lot of options for treatments. 

Indeed, the other night I asked a provider if she wanted a flu swab. "Why," she said. "It doesn't change how we are going to treat it."

There are of course antiviral drugs on the market. Tamiflu being the most available drug. It is given out quite readily to anyone who demands it from their doctor and is even being used as prophylaxis after influenza exposure. 

How effective is Tamiflu? The joke around the hospital is that if you get the flu, it will be gone in two weeks. IF you take Tamiflu, it will be gone in 14 days. Actually, one study found that the duration of the disease symptoms is reduced on average of 20 hours. Moreover, in most otherwise healthy patient populations, using the drug caused little reduction in hospitalization or complications when compared with placebo in several studies.

So what's the harm? Well, there are side effects and adverse events that have been reported. Just about every drug -- including placebo if you coach for it -- has listed side effects of nausea, vomiting and abdominal pain. However, it is not often that you see this warning on a label:

Neuropsychiatric events: Patients with influenza, including those receiving
TAMIFLU, particularly pediatric patients, may be at an increased risk of
confusion or abnormal behavior early in their illness. Monitor for signs of
abnormal behavior. (5.2)

What kinds of confusion or abnormal behavior? Japanese cases involving abnormal behavior including a handful of deaths in pediatric patients lead regulators there to institute restrictions on prescribing the drug to those between the ages of 10 and 19 starting in 2007. 

Neurological and psychological disorders were listed as possible side effects including impaired consciousness, abnormal behavior and hallucinations. Convulsions,  seizure like activity and neurological symptoms such  delirium, hallucinations, confusion, abnormal behavior, convulsions, and encephalitis. have been reported as well, but infrequently given the widespread use of the drug.

So do we have underreporting of adverse events due to all the other factors involved in a patient suffering from a viral illness, or are these neurological side effects just so rare that it is hard to establish a causal relationship.

Still, a busy flu season has renewed the hype and demand for the only drug out there indicated for seasonal flu. Moreover, the company that makes it still refuses to release full data from the trials - which is suspicious.

Further reading: (See: The Myth of Tamiflu: Five Things You Should Know ) and the British Medical Journal's Open Data Campaign. 

Toradol in the spotlight

Toradol is one of my favorite drugs to give in the Emergency room. It works great and is non-narcotic. 

Nightline and ABC news had a story out last night about the use of Toradol in college football locker rooms. Toradol is a NSAID pain reliever -- think of it as a prescription strength injectable super ibuprofen that works fast and relieves pain without the narcotic side effects. 

We use Toradol -- or Keterolac -- all the time in the emergency room. Kidney stone pain -- which some of my patients report as worse than child birth -- responds particularly well to Toradol. 

It is also a great medication to use after a orthopedic surgery to reduce postsurgical pain and inflammation and get patients up and out of bed. 

NSAID (Non-steriodal Anti-Inflamatory) drugs work by inhibiting the production of prostaglandin which is a key fuel for pain receptors. Prostaglandins works locally rather than systemically like a hormone, and they do different things in different parts of your body at different times. So it may be a pain and inflammation mediator at your knee, and it may be regulating platelet aggregation or reducing stomach acid someplace else. If you take a drug to inhibit prostaglandins all over your body, you could get several unintended side effects. 

The most common side effects seen from long term NSAID use are gastrointestinal and renal. These drugs are mostly cleared by the kidneys and prostaglandins have a role to play in kidney function. In fact we often check the kidney function tests of patients BEFORE we give Toradol in the hospital. You shouldn't give it to patients with fluid imbalances, congestive heart failure or impaired kidney function. 

Except for Aspirin, NSAIDs increase your risk for heart attack and stroke. This is because they increase platelet aggregation, making it more likely for you to form a clot. Aspirin, on the other hand, decreases platelet aggregation and thus protects us from heart attack and stroke. 

Do NSAIDs cause heart attacks? Here's what Richard N. Fogoros, M.D. has to say:

"So far, there is no evidence that any of the NSAIDs causeheart attacks in otherwise normal hearts. More likely, these drugs act by increasing the stickiness of platelets, so that in patients who have pre-existing coronary artery plaques that rupture, the platelets are somewhat more likely to occlude the artery in patients on NSAIDs than in patients not on NSAIDS. However, in patients who have plaques waiting to rupture, a heart attack is reasonably likely whether they are taking NSAIDs or not. Statistically, the risk is somewhat increased on NSAIDs. We must remember, however, that fundamentally the risk of heart attack is determined by the sum of many things - age, weight, exercise levels, blood pressure, lipid levels, diabetes, and smoking. The use of NSAIDs, apparently, tweaks that risk somewhat."

So, for the purposes of the lawsuit, this football player is alleging that he was perfectly healthy before he gets a shot of Toradol, then has a heart attack. That's going to be hard to prove in court. On the other hand, he may be able to prove that the team doc was using it without taking into consideration - or explaining - the potential risks of the drug. 

Moreover, prior risk factors for heart disease is something this person may or may not have been screened for. At this level of athletics, team doctors may be doing all sorts of baseline medical screening -- or they may just be doping the kids up assuming that they are perfect pictures of health when they walk through the door. 

If a healthy looking 20 year old came through with a kidney stone, I wouldn't hesitated to tell the doctor that he needs a little Toradol to make him feel better. That said, I've me some healthly looking 20 year olds with all sorts of medical history that was not obvious at first glance. 

Finally, I'd like to know is how often players were getting injected, and whether they were popping Advil on the side. 

Meanwhile, when you come in with your kidney stone, I'll be sure to have the Toradol ready.