Archive for June 24th, 2009

OMNI Postings of 6/24/09

 

Q: Why are politicians proof of reincarnation?
A: You just can’t get that screwed up in one lifetime.


But I digress….

Today, for your enjoyment, we have attached a review article on the use of Antizol as antidotal therapy in methaol and ethylene glycol poisonings.  Indications, protocols, and dosages are discussed.
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1)  The average wait time in our nation’ ERs is 4 hours and 3 minutes.  That’s 2 minutes less than 2007.  But this wasn’t a priority item for the patients.  Patients’ top priorities are how well they were kept informed about delays, how well the staff cared about them as people, how well their pain was controlled, and if the waiting room was comfortable.  I guess whether or not they survived an AMI or a splenic rupture were matters of lesser concern.
http://omniphysicians.com/2009/06/24/er-wait-time-who-cares-not-the-patients/

2)  This abstract in J Trauma evaluated IOs in helicopter transports.  In 40 of 780 (5.1%) patients, an attempt was made to obtain intraosseous access with the bone injection gun. Intraosseous access was attempted more often in children than in adults (p < 0.01). The success rate was 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults (p = 1.0).  The numbers don’t sound encouraging, do they?  I would have intuited that the success rate would have been much higher.  Maybe we should ask the pilots to help out.
http://omniphysicians.com/2009/06/23/ioi-in-choppers/

3)  Drug-makers are pledging an $80 billion contribution to keep healthcare costs down.  It’s kinda like giving the schoolyard bully your football with the hope he won’t keep punching you in the stomach.
http://omniphysicians.com/2009/06/24/drug-makers-to-contribute-80-billion/

4)  This is a summary from WSJ about using progesterone for TBI and stroke.  Some studies are showing promising results.  The fact that 30% of the males had to wear Maxipads for the emainer of their lives was of little concern.
http://omniphysicians.com/2009/06/24/progesterone-for-tbi/

Paul R.

ER Wait Time? Who cares? Not the patients.

Link:  http://www.usatoday.com/news/health/2009-06-22-emergency-rooms_N.htm

USA Today, 6/22/09:  

In what might be a counterintuitive take on crowded emergency rooms, patients say the time spent waiting is not their top concern, according to a customer satisfaction survey last year of 1.4 million patients.Though decreasing the length of the visit would improve overall customer satisfaction, the report says, patients’ top priorities are how well they were kept informed about delays, how well the staff cared about them as people and how well their pain was controlled. It also mattered if the waiting room was comfortable.

 

The study was done by Press Ganey, a consultant for more than 10,000 health care facilities (more than 40% of the USA’s hospitals). For the fifth straight year, customer satisfaction showed a slight increase, to 83.7% from 83.1% in 2007.

 

The bad news in the report: The average time spent for each visit to an emergency room is 4 hours and 3 minutes, a two-minute decline from 2007. Lengthy stays also were highlighted in April by the Government Accountability Office, which found some waits for emergent patients — those who should see a doctor in one to 14 minutes — were more than twice as long as they should be.

 

The strain on emergency departments grew from 1996 to 2006 as 32% more patients sought care while the number of centers dropped from 4,019 to 3,833. Yet the increase in the number of patients seeking care shows the value Americans put on being treated in emergency rooms, says Nicholas Jouriles, president of the American College of Emergency Physicians.

“What I take away from the Press Ganey report is that people have to wait longer than they should, but they love the ER and want it to be an option in their health care,” Jouriles says.

 

Customer satisfaction declines the longer a patient waits: It’s 89.2% for waits of less than an hour, 81.4% for three to four hours, and 75.1% for six or more hours.

 

The report calls for addressing crowding in general and decreasing “boarding” in the emergency rooms and getting patients to the appropriate floor faster. (Boarders are patients waiting in the ER for admission to the hospital.) The GAO made the same recommendation, citing “competition between hospital admissions from the emergency department and scheduled admissions — for example, for elective surgeries, which may be more profitable.” Spreading out elective surgeries would help get boarders admitted during peak hours.

 

“It is a difficult change, but the concept is a good one,” says Jim Scheulen, chief administrative officer of Johns Hopkins’ department of emergency medicine in Baltimore. “How would surgeons react to doing operations on Saturdays to help with this? It is easier said than done.”

 

Jouriles says boarders are the biggest problems facing ERs, not seekers of non-urgent care, who account for only 12% of ER patients. “Even though boarding occurs in the emergency department, it is really a systemwide problem. If we can solve the problem of boarding, we’ll fix the whole health care system.”

Drug-makers to contribute $80 billion

The Washington Post (6/23, Fletcher, Connolly) reports that President Obama “announced an offer by drug manufacturers to contribute $80 billion over the next decade to narrow the controversial gap in Medicare prescription drug coverage, a deal the president said moves the nation a step closer to comprehensive healthcare reform.” The President “was joined at the White House [Monday] by Barry Rand, head of the influential senior citizens’ advocacy group AARP, which endorsed the deal.” In his remarks, Obama “reiterated his vow to restructure the nation’s healthcare system to expand care and slow the increase in long-term expenses, despite mounting concerns about the initial costs and structure of various plans that have been put forward.”

Brain donation

Link:  http://www.nytimes.com/2009/06/23/health/23brai.html?_r=1&ref=health

June 23, 2009

A Chance for Clues to Brain Injury in Combat Blasts

By ALAN SCHWARZ

No direct impact caused Paul McQuigg’s brain injury in Iraq three years ago. And no wound from the incident visibly explains why Mr. McQuigg, now an office manager at a California Marine base, can get lost in his own neighborhood or arrive at the grocery store having forgotten why he left home.

But his blast injury — concussive brain trauma caused by an explosion’s invisible force waves — is no less real to him than a missing limb is to other veterans. Just how real could become clearer after he dies, when doctors slice up his brain to examine any damage.

Mr. McQuigg, 32, is one of 20 active and retired members of the military who recently agreed to donate their brain tissue upon death so that the effects of blast injuries — which, unlike most concussions, do not involve any direct contact with the head — can be better understood and treated.

The research will be conducted by the Sports Legacy Institute, a nonprofit organization based in Waltham, Mass., and by the Boston University Center for the Study of Traumatic Encephalopathy, whose recent examination of the brains of deceased football players has found damage linked to cognitive decline and depression.

Whether single, non-impact blasts in battle can cause the same damage as the years of repetitive head bashing seen in football is of particular interest to researchers. The damage, primarily toxic protein deposits and tangled brain fibers, cannot be detected through noninvasive procedures like M.R.I.’s and CT scans.

“We don’t know much about the medium- or long-term effects of head trauma experienced by our military,” said Robert Stern, co-director of the Boston University center as well as its Alzheimer’s Disease Clinical and Research Program. “We know that there are some immediate effects in terms of blast injury on cognition and behavior. But we do not yet know whether there are any long-term effects.”

“Does that single blow result in something that doesn’t go away,” he added, “or perhaps sets off a cascade of events that leads to a progressive degenerative brain disease?”

Mr. McQuigg may be finding out the cruelest way. In February 2006, he was on combat patrol when his Humvee was hit by a roadside bomb, knocking him unconscious, shattering his jaw and damaging his right eye. His helmet could not protect him from a severe concussion that doctors told him was caused solely by the bomb’s force waves, not direct impact.

Now he is experiencing headaches, short-term memory problems and trouble with balance that have only worsened.

“With prosthetics, you can replace an arm or a leg and can still throw a football with your kid,” said Mr. McQuigg, who works at Camp Pendleton, north of San Diego. “If you have a severe brain injury, you might not be able to live on your own.”

“And people don’t know what’s wrong with you,” he added. “People know if you’re missing an arm, something happened. If it happened to your brain, they can’t tell.”

An estimated 320,000 soldiers have experienced some form of traumatic brain injury during their service in Iraq or Afghanistan, according to a 2008 RAND Corp. study. Blast injuries have risen in prominence in recent years because improvements in armor and medical treatment allow soldiers to survive explosions, then experience any delayed effects.

Blast injuries result from waves of air pressure that can travel several times as fast as hurricane winds. Those waves can not only throw a soldier dozens of feet in the air into other objects — causing a conventional concussion as the brain crashes inside the skull — but may also subject brain tissue to sudden pressure variations that can cause similar damage.

Repeated brain trauma among some football players and boxers has been linked to the subsequent appearance of toxic proteins and neurofibrillary tangles in the brain — a disease known as chronic traumatic encephalopathy, or C.T.E. Many athletes who were found after death to have had the disease experienced memory loss, depression and oncoming dementia as early as their 30s, decades before afflictions like Alzheimer’s appear in the general population.

Just as researchers at the Boston University center and elsewhere have linked some athletes’ later-life emotional problems to their on-field brain trauma, the research on military personnel will try to determine whether some soldiers with post-traumatic stress disorder — a psychological diagnosis — actually retain physical brain damage caused by battlefield blasts. Some signs of P.T.S.D., particularly depression, erratic behavior and the inability to concentrate, appear similar to those experienced by concussed athletes.

Such a link could have effects beyond medicine. Disability benefits for veterans can vary depending on whether an injury is considered psychological or physical. And veterans with P.T.S.D. alone do not receive the Purple Heart, the medal given to soldiers wounded or killed in enemy action, because it is not a physical wound.

Dr. Stern, at Boston University, said that blast injuries could be seen as this generation’s version of exposure to Agent Orange, the herbicide used in the Vietnam War.

“During exposure to Agent Orange, it wasn’t known what long-term effects there would be, but through scientific study, long-term study of veterans, those effects have been more clearly understood,” he said. “We need to know if these individuals with blast injuries are going to require long-term care and treatment.”

The Boston University center and the Sports Legacy Institute will compare findings from the brains of military personnel with those from their athlete program, which has signed up more than 120 donors in less than a year, and other brain banks around the world. The two centers, not the military, are paying for the registry, storage and examination of brain tissue.

But Col. Michael S. Jaffee, national director of the Defense and Veterans Brain Injury Center, said the Defense Department supported the spirit of the research and could assist in approaching active and retired soldiers to register for brain donation.

“Having a brain bank to allow us to study what these brains look like will help us correlate this with other emerging research findings,” said Colonel Jaffee, who is a physician.

But he cautioned: “Whenever we’re talking about organ donation for the sake of science, we’re dealing with a lot of sensitive and cultural issues. We ask people to consider and realize that asking family and individuals to remove the brain from the body, many cultures and traditions may not find that acceptable. So it’s always a challenge to balance the benefits, which are real and will come, with a way to maintain the dignity and respect of people who have made the ultimate sacrifice.”

Benefits of the research on military personnel could extend to the general population, said Dr. Daniel P. Perl, director of neuropathology at the Mount Sinai School of Medicine in New York. Even though civilians are rarely subjected to anything close to the devastating waves that burst from battle explosions, the characteristics of blast injuries could lend insight into brain damage caused by single impacts in automobile accidents, for example.

If protein deposits and tangles appear in the hippocampus area of the brain, for instance, then they would affect short-term memory; appearance in the frontal lobes could impair executive function, and in the cerebellum coordination and balance. The researchers will also be looking at possible genetic factors.

“I wouldn’t be surprised if there was a great deal of overlap between examples of this from the sports arena and the military, but we don’t know,” Dr. Perl said. “The forces are different and presumably the mechanisms are somewhat different. If this research and the examinations are done right, they have the potential to contribute significantly. It could tell us what happens, which we’re not going to get otherwise.”

 

Progesterone for TBI?

The Wall Street Journal (6/23, D3, Burton) reports that “several potential treatments for brain injury and stroke have failed in recent clinical studies, but one improbable therapy — the hormone progesterone — continues to show promise in warding off brain damage from head trauma and stroke.” Now, “the National Institutes of Health are expected Tuesday to begin funding a study evaluating the hormone in more than 1,100 emergency patients with moderate to severe head trauma.” The “study will get under way at 17 hospitals in 15 states around the US and is expected to last up to five years.” According to the Journal, “it will be the pivotal study of whether the naturally occurring hormone progesterone, injected into patients within hours of severe accidents, can lower deaths and reduce paralysis and cognitive damage.”