To Give Steroids or Not: That is the Question

Steroid molecule. (Wikimedia Commons)

In Hamlet Act 3, scene 1, Shakespeare wrote; “To be, or not to be: that is the question”. Hamlets most famous soliloquy is both memorable and intriguing because he was contemplating profound ideas. Something you do every day, every shift and every hour while working…you contemplate decisions based on best practice, cutting-edge articles, and new research. One such question has haunted us for decades…to give or not to give steroids to septic patients.

Take a listen or read the August EMRAP article titled: Critical Care Mailbag: Steroids for Septic Patients by Anand Swaminathan MD and Scott Weingart MD for a fresh perspective.

On Jan 19th, 2018 the ADRENAL Trial results were published trying once and for all to answer the question of adjunctive steroids in septic shock. Take a look at this condensed version.

Rheumatoid arthritis (Wikimedia)

Who Knew? In 1948 the first patient with rheumatoid arthritis was treated with cortisone.  Between 1954 and 1958 six synthetic steroids were introduced for systemic anti-inflammatory therapy. By 1960 all of the toxic effects of chronic corticosteroid administration had been appreciated. In the 1970s the introduction of methotrexate helped restrict the dosages and indications for corticosteroids in the rheumatic diseases.

 

 

Go Fund Me: Give a Slice of CMES-Pi Success

 

The Techies Without Borders team thanks everyone who donated, sent words of encouragement and shared our Go Fund Me page on their social media. We raised $2000 USD in two weeks.

The funding supports installation of CMES-Pi units in Mbarara University of Science and Technology and Makerere University Hospital, Uganda; Mount St John’s Medical Centre, Antigua; Victoria Hospital, St. Lucia; Timmy Global Health (TGH) partner clinics in Quito, Santa Domingo, and Tena, Ecuador; and USB drives TGH’s Guangaji Clinic, Ecuador.

Who Knew? TWB slowly formed as two university professors, Dr. Manoj Thomas and Dr. Yan Li, along with their graduate students worked on social-driven educational IT projects for their studies. A mutual friend invited Manoj to meet her mom, Dr. Debra Stoner. Over dinner…Manoj and Deb formed a friendship based on mutual respect and their passions to bring education to those with limited access…CMES was born and in 2018 TWB incorporated as a 501c3 nonprofit corporation. We are committed for the long haul.

Testicular Torsion – A Convoluted Case

What do Chubby Checker and testicular torsion have in common? (Wikimedia photo)

The 14-year-old male patient complained of right lower quadrant pain which varied in intensity for 1 day. He denied nausea, vomiting or fever. The abdominal exam revealed bowel sounds and mild tenderness to palpation in the right lower quadrant without rebound. His abdominal ultrasound was inconclusive; the white blood cell count mildly elevated, and the urine microscopy normal. He was admitted for observation. Twelve hours later the patient developed a fever and severe groin pain. A genital exam revealed classic findings for testicular torsion. The testicle was not salvageable. Unfortunately, the patient was born monorchism and rendered sterile by the orchidectomy. The lesson from this case: always include a genital exam in patients with lower abdominal pain.

Can you rely on the history and physical exam to rule out testicular torsion? Is the testicle salvageable after 6 hours? Wrench yourself away from your music downloads and listen to the EM:RAP August podcast called Testicular Torsion by Rob Orman MD and Larry Mellick MD. Get an update and review on this twisted entity and you won’t spiral out of control when faced with the possibility.

Who Knew? “The Twist” is an American pop song written and originally released in 1959 by Hank Ballard and the Midnighters. It was made popular by Chubby Checker, an American rock n’ roll icon, who put his stamp on the song with the twist dance style.

So what do Chubby Checker and testicular torsion have in common? As Mr. Checker said, “Come on let’s twist again…”. Testicular torsion pain can come and go.

 

Potassium: An Element to Love

Photo courtesy of Wikimedia Commons.

Ever chase a patients potassium? Of course, you have…we all have nibbled our fingernails over the ever-changing potassium. So when do you worry? Here are a few questions to contemplate: true or false?

Hypokalemia is associated with hypomagnesemia.

Encourage repletion with potassium-rich foods rather than pills.

The total body deficit is always more than you think.

If the potassium is less than 3.0 meq/L and the QTc is approaching 500 msec, the patient should be admitted for repletion.

Tune into the August EMRAP podcast called: Electrolyte Emergencies – Part 1: All Things Potassium by Rob Orman MD and Corey Slovis MD for the answers.

Who Knew? Potassium was the first metal that was isolated by electrolysis by Sir Humphry Davy in 1807.

EMS in Nepal – Meet Dr. Sanjaya Karki

Dr. Sanjaya greets an opiod overdose patient transferred from a remote district in Nepal to Medicate Hospital, Kathmandu.

Dr. Sanjaya Karki at Mediciti Hospital, Kathmandu Nepal, has been using the CMES thumb drive since 2016. He is a regular reader of this blog and uses the EMRAP cme to prepare lectures along with keeping his knowledge up-to-date. Dr. Karki is the Medical Director for the Department of Emergency Services at Mediciti. He did his MBBS and European official double masters in health and welfare and has done his MD in Emergency Medicine. Well known in Nepal and internationally for his innovation in EMS, he was honored and awarded the David Well Extreme Medicine Award, UK in 2014 and the EMS10 Innovators of The Year 2016 Award, USA.
Dr. Karki shares his insights about the fledgling EMS program in Nepal. “The EMS Helicopter emergency medical service is becoming more and more popular and productive in Nepal. Nowadays many voices are raised in order to streamline this service. The major topic at the government level should be to make a strategy and policies governing this important service.
Due to unavailability of road access in many places of Nepal, as well as no proper ground EMS service available across the nation, Helicoptor EMS will surely play a pivotal role in preventable deaths.”
Who Knew? Opioid Misuse Disorder is new to Nepal following on the heels of Cannabis and alcohol addiction. Read this article to find out more.

PreHospital Air Medical Plasma Trial (PAMPer)

Fresh frozen plasma (Wikimedia)

Fluid resuscitation, including type and amount, has been scrutinized for prehospital care of trauma patients. This recent multi-center study demonstrated remarkable results. The abstract is reproduced from the NEJM website:

The New England Journal of Medicine

Abstract

BACKGROUND

After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.

METHODS

To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days.

RESULTS

A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, −9.8 percentage points; 95% confidence interval, −18.6 to −1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan–Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients’ arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

CONCLUSIONS

In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427.)

Who Knew?

Two vampires walked into a bar.

The bartender said, “what will it be?”

The first vampire said, “I’ll have a blood.”

The second vampire said, “I’ll have a plasma.”

“Right”, the bartender replied, “one blood and one blood lite.”

 

 

Meet Dr. Samrat in Nepal

Dr. Samrat graduated from the Peoples’ Friendship University of Russia in Moscow and earned his post-graduate degree in General Practice and Emergency Medicine from Tribhuvan University Teaching Hospital in Kathmandu, Nepal.
After working in Patan Academy of Health Science and Kathmandu Model Hospital, he joined CIWEC Clinic and Hospital in Kathmandu a few years ago. CIWEC is a travel medicine facility that cares for patients with a variety of travel-related and general health issues. Dr. Samrat describes his practice: “We deal with common issues like common respiratory illness, gastrointestinal illness and also rare and complicated issues requiring prolonged hospital care or care in the intensive care unit. We look after both outpatients and inpatients.  We help people with their travel needs including vaccinations and recommendations for their specific travel plans.”
Despite having access at CIWEC to UpToDate, a point of care medical information site provided by his employee, he uses the CMES thumb drive to access up-to-date cme at home. He likes having this option because “…the CMES thumb drive has helped me a lot while dealing with these issues. This has also given opportunities to interact with colleagues for the improvement in the overall care of our patients.”
Who Knew? The national flag of Nepal (Nepali: नेपालको झण्डा) is the world’s only non-quadrilateral national flag. The flag is a simplified combination of two single pennons, known as a double pennon. Its crimson red is the color of the rhododendron, Nepal’s national flower, while the blue border is the color of peace.

Guatemala Gets a Slice of CMES-Pi

Dr. Manoj Thomas visited Timmy Global Healths partner Asociacion Pop Wuj Clinic in Xela, Guatemala this past March. Asociacion Pop Wuj is a collectively owned, non-profit, Spanish language school that promotes community development through a variety of programs including a daycare center, construction of safe stoves, reforestation and ecological education, a student scholarship program, and a comprehensive health and nutrition program.

Working with Dr. Carmen and Dr. Herman he set up a CMES-Pi at the Xela clinic. The regular access to up-to-date continuing medical education content for the staff is welcomed as travel to conferences is difficult and costly for the organization.

We welcome Asociacion Pop Wuj and there impressive work in the community.

The Pop Wuj team with Dr. Manoj Thomas (on right).

The Pop Wuj team tries out the CMES-Pi connectivity.

Emergency Severity Index: The Ups and Downs of Triage

Who’s next? (Wikimedia Commons)

Jessica Mason MD and Wendy Chan MD discuss the history and present methods of triage in the May EM:RAP podcast of Annals of Emergency Medicine: Emergency Severity Index.

How do you risk stratify in your emergency department? Do you use a three-step system of emergent, urgent or non-urgent? Or the five-step triage protocol with ESI 1 indicating a critical patient to an ESI 5 indicating nothing serious? Neither provide an ideal system, but what about front-end physician triage, split flow and vertical flow? Update your triage knowledge by listening to the podcast…it might make your day flow smoother.

Larreys Flying Ambulance (National Library of Medicine)

Who Knew? Baron Dominique Jean Larrey is credited with inventing triage during the Napoleonic Wars but did you know he invented the first ambulance? The horse-drawn “flying ambulances” could maneuver quickly across a battlefield delivering injured men to field hospitals.

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