UMEM Educational Pearls - Misc

Category: Misc

Title: Is added sugar the new smoking?

Posted: 2/10/2024 by Brian Corwell, MD (Updated: 2/23/2024)
Click here to contact Brian Corwell, MD

Ever see a commercial showing active fit people drinking sugar beverages? 

Ever wonder if exercise is protective from the effects of added sugar?

What are the health risks of added sugar?

How much is too much?

C. elegans, a roundworm, shares 40% of its genes with humans

     -Frequently used as a model for health and longevity research

In a 2021 study, researchers altered the diet of the roundworms and found that added sugar was linked to increased glycation end products, high levels of which are associated with an increased risk of CV disease, diabetes and Alzheimer’s disease.

Foods such as fruits are high in natural sugars. Added sugars however are “added” by manufactures to increase flavor.

In our diet, added sugars are everywhere from white bread to ketchup to your favorite Starbucks beverage.  

     -Sugar- sweetened beverages are the largest source of added sugars in the American diet.

In 2016 the FDA added a section on nutritional labels for added sugars.  

The CDC advises limitation of added sugars to 10% of total daily caloric intake. 

Added sugars (vs. natural sugars) are more likely to cause spikes in blood sugar and create an inflammatory state thereby increasing the risk of numerous medical problems.

A recent study from the Harvard school of public health investigated whether the benefits of physical activity outweigh the risks of CV disease associated with consumption of sugar-sweetened beverages.

Using 2 cohorts (100,000 people) over a 30-year period, those who consumed sugar-sweetened beverages more than twice a week had a higher risk of CV disease.

Those with daily consumption were at higher risk.

Even those that hit the recommended 150 minutes of weekly exercise were not protected.

Physical activity only reduced the risk of CV disease by approximately 50%. 

Though the study did not specifically look at sports and energy drinks, these beverages are large sources of added sugars.

For example, A 20-ounce Gatorade's Thirst Quencher contains 36g of sugar. 

Take home:  Added sugar, even in moderation, may have negative health consequences even in individuals who exercise regularly.



 

Point of Care Ultrasound has been shown to change medical management and decrease time to diagnosis. 

However, sometimes on a busy shift we may get an xray or radiological study prior to performing a POCUS exam due to time constraints.

A recent study looked at the time it takes to perform a bedside ultrasound.

The authors measured the duration of time from starting the exam through the ultrasound worklist to the timestamp on the last recorded image. 

They reviewed 2144 studies and found a median time of 6 minutes to perform a study. 

Of course the study is limited by the time it takes to find a machine, make sure it is functioning and other supplies such as gel. 

 

Conclusion: You can take 6 minutes to assist in your patient's clinical care.

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Category: Misc

Title: Care for Transgender and Gender Diverse Patients

Keywords: DEI, transgender, gender nonbinary, gender diverse (PubMed Search)

Posted: 6/17/2023 by Kevin Semelrath, MD
Click here to contact Kevin Semelrath, MD

Question

While transgender and gender diverse individuals make up a minority of the US population (approx 1.4 million individuals), they are unfortunately the victim of a large amount of discrimination in our society.  A seemingly overwhelming number of laws are being passed this year specifically targeting this group, including how they can access health care. As emergency physicians, it is our duty to not only understand and care for these patients with excellent and compassionate care, but advocate for them in places of power.

This is a qualitative study that looked at the experiences of transgender and gender nonbinary (TGN) patients seeking care in EDs in Arkansas.  They researchers performed structured interviews with 9 TGN patients who had received care in various EDs in the state.  It identified several themes in their experiences:

 1. Systems and structural issues- these included the patients' legal document and EHR gender prounouns not matching their gender identity, intake forms not having a place for patients' pronouns and chosen name, and confidentiality issues when calling patients from the waiting room using their deadname

2. Interactions with clinical staff- while many of the patients did have some positive interactions with the ED staff, there were several significant issues identified.  Patients experienced misgendering, either intentional or unintentional, as well as inappropriate questions about patient anatomy that was not related to the presenting complaint, and other harmful behavior such as being stared out by staff, and delays or refusal of care

3. Perceptions of clinical knowledge- many of the subjects reported having to educate the ED clinicans regarding transgender health care issues. This influenced their desire to return for care to those EDs

 

We are all responsible for treating all of our patients with dignity and respect, even if we don't fully understand their own journey. And remember pride started as a riot and became a revolution!

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Category: Misc

Title: What do caregivers think of alternate EMS dispositions for pediatric patients?

Keywords: EMS, Alternate destinations, pediatric, EMS, reduce transport times (PubMed Search)

Posted: 5/17/2023 by Jenny Guyther, MD (Updated: 2/23/2024)
Click here to contact Jenny Guyther, MD

Pediatric patients represent up to 10% of EMS transports, but studies suggest that between 10-60% of these patients can be safely transported by alternate means.  Many EMS agencies have begun to implement alternate destination programs for adult patients - including transport to an urgent care center, using a taxi service instead of an ambulance, or utilizing telehealth services.  One of the first steps in being able to expand these program into the pediatric population involves determining the caregivers perspectives on the concept of not being taken directly to an emergency department when 911 is called.
 
This study conducted focus groups in English and Spanish which included a total of 38 participants in the Washington DC area.  Key take away points include:
1) The reasons for calling 911 for a non emergent reason were multifactorial and included lack of transportation, lack of health insurance, uncertainty about the severity of the patient's complaint and difficulty with after hours primary care access.
2) Most participants were not familiar with alternate EMS disposition programs.
3) Most caregivers preferred telemedicine over telecommunication.
4) Caregivers worried that there would be a delay in care if their child had a genuine medical emergency or decompensation.  They were also concerned that there would not be pediatric resources and expertise at the alternate destination requiring a second transport.  Also, there were concerns about the coordination between 911, clinics and EMS.  Concerns about transportation included vehicle cleanliness and hygiene and provision of appropriate car seats.
 
Bottom line: Alternate destination for EMS is possible with pediatric patients, but the programs need to take into consideration the above parental concerns in order to be successful. 

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Category: Misc

Title: Hydration, aging and mortality

Keywords: hydration, mortality (PubMed Search)

Posted: 1/28/2023 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

In a recent study in The Lancet, researchers at NIH attempted to test the hypothesis that optimal hydration may slow down the aging process. 

A large proportion of people do not consume the recommended fluid amounts. This has likely become worse with our masking during the pandemic.

Previous studies in a mouse model showed that water restriction, increasing serum sodium by 5 mmol/l, shortened the mouse lifespan by 6 months which corresponds to about 15 years of human life.

Population:  Data from Atherosclerosis Risk in Communities (ARIC) study: an ongoing population-based prospective cohort study in which 15,792 45-66 year-old black (African American) and white men and women were enrolled from four US communities in 1987–1989 and followed up for more than 25 years.

Variables:  15 biomarkers and serum sodium (as a proxy for the hydration habits of study participants).

They attempted to exclude people whose serum sodium could be affected by factors other than the amount of liquids they consume. After these exclusions, 11,255 participants remained in the datase.

Authors also calculated ones biologic age by sampling 15 biomarkers characterizing performance of multiple organ systems and processes: cardiovascular (systolic blood pressure), renal (eGFR, cystatin-C, urea nitrogen, creatinine, uric acid), respiratory (FEV), metabolic (glucose, cholesterol, HbA1c, glycated albumin, fructosamine), immune/inflammatory (CRP, albumin, beta 2-microglobulin).

Conclusions: The analysis showed that middle age serum sodium >142 mmol/l is associated with a 39% increased risk to develop chronic diseases (hazard ratio [HR] = 1.39, 95% confidence interval [CI]:1.18–1.63) and >144 mmol/l with 21% elevated risk of premature mortality (HR = 1.21, 95% CI:1.02–1.45). People with serum sodium >142 mmol/l had up to 50% higher odds to be older than their chronological age (OR = 1.50, 95% CI:1.14–1.96).

Limitations:  Observational study. No firm conclusions without intervention studies.

Summary: Serum sodium concentration exceeding 142 mmol/l is associated with increased risk to be biologically older, develop chronic diseases and die at younger age.

Take home:  Drink more water

 

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Category: Misc

Title: Dont act your age

Keywords: Aging, mortality, physical activity (PubMed Search)

Posted: 1/14/2023 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Humor me and imagine that your birth certificate vanished, and your age was based on the way you feel inside. How old would you say you are (subjective age) versus your actual age?

In a few studies, those individuals reporting a younger subjective age had a lower risk of depression, greater mental well-being, better physical health, and a lower risk of dementia. These individuals also had improved episodic memory and executive functioning. Subjective age also predicts incident hospitalization.

Three longitudinal studies tracked more than 17,000 middle aged and elderly individuals.

Over a 20-year period, researchers tracked:  Subjective age, demographic factors, disease burden, functional limitations, depressive symptoms, and physical inactivity.

Researchers found that those who felt approximately 8, 11, and 13 years older than their actual age had an 18%, 29%, and 25% higher risk of mortality, respectively. They also had a greater disease burden even after controlling for demographic factors such as education, race and marital status. Multivariable analyses showed that disease burden, physical inactivity, functional limitations, and cognitive problems, but not depressive symptoms, accounted for the associations between subjective age and mortality.

This study provides evidence for an association between an older subjective age and a higher risk of mortality across adulthood. These findings support the role of subjective age as a biopsychosocial marker of aging. This may allow for early intervention for select individuals who may have a higher association with poor health outcomes.

Your subjective age can better predict your overall health than the date on your birth certificate.

 

 

 

 

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Category: Misc

Title: Stabilizing the healthcare system

Keywords: Health policy, healthcare (PubMed Search)

Posted: 1/7/2023 by Robert Flint, MD (Updated: 2/23/2024)
Click here to contact Robert Flint, MD

These two pieces from Becker’s Hospital Review demonstrate significant areas of weakness within the American healthcare system. Hospitals that care for underserved as well as medically and socially complicated patients should be afforded protection and financial security. Not only do they care for the most complex patients, they often educate the next generation of health care providers. 

 

The loss of small community or rural hospitals also has a major negative impact on the US health care system. For time sensitive conditions such as trauma, myocardial infarction or stroke these facilities are often the first, closest facility to initiate care or stabilization. The loss of these critical smaller hospitals also adds to the burden at already overwhelmed larger facilities. 

 

As medical providers, we are in a unique position to advocate for our patients, our co-workers and our communities. Join your professional societies (ACEP, AAEM, SAEM etc.), write your local and national representatives, find like minded colleagues, please get involved with the process any way you can.  As a nation we can not afford to lose large essential hospitals or small critical access, rural hospitals.

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Universal Human Rights

  • Human rights are rights inherent to all human beings, whether our nationality, place of residency, sex, national or ethnic origin, color, religion, language defines , or any other status 

  • The United Nations Human Rights Council (UNHRC) defines seven substantive rights: the right to life, freedom from torture, freedom from slavery, right to a fair trial, freedom of speech, freedom of thought, conscience and religion, and freedom of movement 

  • The right to life is the essential right that a human being has a right not to be killed by another human being. This has been central in debates on issues of abortion and euthanasia. 

  • Emergency care is an often overlooked, but essential component of the right to life in the highest attainable standard of health and universal health coverage (UHC - a WHO description used to describe access to care). Particularly for vulnerable and disadvantaged populations, emergency care is often the last chance for the health system to save a life.

  • The focus on vulnerable populations with little access to care and subsequent poor health outcomes has many similarities to the delivery of emergency care. Emergency conditions, such as traumatic injuries, disproportionately affect people in low- and middle-income countries. About 90% of the burden of death and disability from injuries occurs in low- and middle-income countries

  • COVID-19 emphatically highlighted how far countries (and differences in regulations between states in the US) are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. 

  •  Implementation of a rights-based framework for emergency care requires countries to enact legislation that ensures access to non-discriminatory emergency care and establish a regulatory body with appropriate oversight and authority to enforce these laws.



 

Approximately 1.4 million transgender and gender nonbinary patients live in the United States. Unfortunately, prior research has shown negative experiences with the health system are common after disclosing their trans/NB status. As a result, almost a ¼ report avoiding or delaying needed health care.

 

This qualitative study interviewed a subset of trans/NB individuals about their experiences visiting emergency departments. Several key themes emerged:

  • ED intake forms are commonly unequipped to reflect patients’ pronouns and chosen names. This leads to downstream misgendering and the use of deadnames.
  • Patients often fielded inappropriate questions and comments unrelated to their medical care
  • Many patients felt they had to educate clinicians regarding issues of trans health, rather than the other way around
  •  These negative experiences decreased the likelihood patients would return for needed medical care

 

Overall, the study found that clinicians have many opportunities to improve the care of transgender and nonbinary patients, including updating forms, using inclusive language, avoiding medically unnecessary questions, and providing training for staff on trans/NB health.

 

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IPV can occur once or over years by a current or former romantic partner.  Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner). 

IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined.   Think about how risky it is to NOT recognize IPV.

1:4 women and 1:10 men have been victims of IPV during their lifetime.

1:5 homicide victims are killed by an intimate partner.

Over 50% of female homicide victims are killed by a current or former intimate partner.  Patients who have been strangled are 4 times more likely to be killed within a year.

Your Spidey Sense should go off when:

  1. Stories Change
  2. History doesn’t match up with injuries
  3. Injuries in areas that are concealed, multiple injuries of varying ages, defensive wounds
  4. Major delays in seeking care
  5. Non-specific complaints - headache, gastric issues
  6. Multiple ED visits at odd hours
  7. Refusing the use of an interpreter by partner (why we always use an official interpreter)

 

Once patient is identified as a victim:

  1. Place victim in a safe, inaccessible by visitors, and hidden area
  2. Treat all medical issues
  3. Contact Social Work/SAFE/SANE examiner (some institutions will have IPV specific resources)
  4. Contact police if patient is willing to report
  5. Safe disposition
  6. If unable to ensure a safe disposition, be very careful about documentation provided in discharge paperwork and language used

 

 

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Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.

1. Social Determinants of Health: A meta-analysis in 2018 suggests that Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries such as America. Using patient centered language and taking time to explain diagnoses are CRITICAL in caring for immigrant populations particularly in the ED. Use of appropriate language services are also important.
 

2. Assess acute vs non-acute needs: A study done in pediatric migrant populations suggests that the severity of the reasons for visiting the ED and the hospitalization rates were not higher in the pediatric migrant population than in the general pediatric population. Some common non-urgent diagnoses include scabies, anemia, oral and dental disorders.

 

3. Create a safe environment: In a study done in 2013, up to 12% of undocumented immigrants that presented to the ED expressed fear of discovery and consequent deportation. On further assessment there was the belief that medical staff are required to report these patients to immigration. It is important to proactively address inaccurate beliefs to promote a safe trusting environment.

 

Resources in Baltimore/Maryland:

-CASA

-Esperanza Center

-International Rescue Committee

- John's Hopkins Centro Sol

- National Immigration Law Center

 

National Resources (US):

-Rural Health Information Hub

-National Resource Center for Refugees, Immigrants, and Migrants

 

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Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?

Background

This paper was written by some of the thought leaders in the Diversity, Equity and Inclusion realm in Emergency Medicine. Undergraduate medical education has minimal formal hours dedicated to LGBTQ+ health, and EM residency has even less. The authors wanted to assess EM resident comfort in caring for patients who identify as part of the LGBTQ+ community

Methodology

An anonymous service was sent out to CORD and was then disseminated to the residents of the 167 ACGME accredited EM residencies. It was a 24-question survey based on a similar one given to medical students. Overall, a total of 319 residents responded to the survey, with the vast majority identifying as heterosexual and cisgender

Results

The results seem at first to be contradictory. A majority of respondents (63.5%) were either comfortable or very comfortable in addressing the needs of LBGT patients. But when asked about specific behaviors related to providing care, there was more to the story. Only 17.3% of respondents always asked about sexual partner gender, 4.7% always asked about sexual orientation for an abdominal or genital complaint.

Perhaps more disturbing, the survey found that 10% of respondents had observed attending physicians make discriminatory or inappropriate comments about LGBT patients or staff, 2% of respondents were uncomfortable working alongside LGBT physicians, and 6% of respondents disagreed with the statement that LGBT patients deserve the same level of quality care as other patients.

Discussion

This study was published in 2019. Despite some amazing advancement in the LGBT community, we obviously still have a long way to go. This study shows the need for more formalized and routine education regarding LGBT population health issues at both the undergraduate and graduate medical education levels. It also demonstrates that LGBT physicians still experience discrimination in the workplace, even within our specialty. Be kind, be compassionate, be understanding.

 

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Title: Mammalian meat allergy (alpha-gal syndrome) following tick bites

Author: Dan Gingold, MD, MPH

Development of IgE antibodies to the oligosaccharide galactose-alpha-1-3-galactose (alpha-gal) appears to be responsible for an acquired allergy to non-primate mammalian meat (i.e., beef and pork) and derived productsAntigen in the salivary apparatus of certain ticks (gross!!) can sensitize an IgE-mediated response to alpha-gal which is present in mammalian meat. 

 
Symptoms are similar to other IgE-mediated hypersensitivity reactions, and can cause a delayed-onset reaction with hives, GI upset, or anaphylaxis after ingestion of red meat. Treatment with standard anti-histamines and epinephrine is effectiveIndividuals with no prior history of meat sensitivity can develop the syndrome at any age, often after exposure to the outdoors in tick-endemic areasSkin and blood allergy testing can confirm the diagnosis. Symptoms can persist for years, but can recede over time if not exposed to further tick bites.

 
In the US, the primary tick responsible is Lone Star Tick (Amblyomma americanum), found primarily in the Eastern, Southeastern, and Midwestern US. Other tick species in Europe, Australia, and Asia have been found to induce the syndrome as well. Interestingly, there is a cross-reactivity with the monoclonal antibody Cetuximab (used to treat colorectal and head and neck cancers), an allergic reaction to which can also induce similar alpha-gal meat sensitivity.

Having first been described in 2009, the syndrome often goes unrecognized; increased physician awareness can inform the evaluation, diagnosis, and education of patients presenting to the ED with undifferentiated allergic reaction.

 
 

 

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Category: Misc

Title: CT Radiation doses

Keywords: CT, head, radiation (PubMed Search)

Posted: 4/13/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

 
  • A recent retrospective study examined CT radiation doses in different types of facilities

 

  • Mean patient age: 12 years
  • Authors reviewed radiation doses for nearly 240,000 CT scans in over 500 facilities
  •  
  • The facilities were categorized into 4 groups: 

 

  • 1) academic pediatric,
  • 2) non-academic pediatric,
  • 3) academic adult, 
  • 4) non-academic adult

 

Most (65%) scans were performed at nonacademic adult centers

 

  • Radiation doses were significantly higher at adult facilities vs. pediatric facilities
  • Also, radiation doses were higher at non-academic vs. academic facilities
  • For example, the largest children received twice the radiation dose for abdomen-pelvis CT scans performed at nonacademic adult facilities compared with academic pediatric facilities
    • 11.9 mGy vs. 5.8 mGy
  • Academic pediatric facilities use lower radiation doses than do nonacademic pediatric or adult facilities for all head CT examinations and for the majority of chest and abdomen-pelvis

 

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Category: Misc

Title: Acute Pain Management in Dental Pain

Keywords: dental pain, ibuprofen, acetaminophen (PubMed Search)

Posted: 4/6/2018 by Michael Bond, MD (Emailed: 4/7/2018)
Click here to contact Michael Bond, MD

Question

Bottom Line:
 
A recent review in the Journal of the American Dental Association found that Ibuprofen 400mg plus acetaminophen 1000mg was the best regimen for the relief of postoperative dental pain when compared to any opioid-containing regimen.

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Category: Misc

Title: Non-Musculoskeletal Causes of Neck Pain

Keywords: Neck pain (PubMed Search)

Posted: 7/16/2016 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Non-Musculoskeletal Causes of Neck Pain

Neck pain is a common complaint of people presenting to the ED. Most of the cases will be musculoskeleteal in origin and will respond to conservative therapy with NSAIDs or acetominophen. However, other non-musculoskeletal causes of pain could be lurky behind this benign complaint.

Don't forget to consider:

  1. Early mengingitis (84% of patients with meningitis will complain of neck stiffness)
  2. Myocardial infarction/angina. Women are known to have atypical symptoms and might just have dull pain in their neck. Be sure to ask about whether exertion increases the pain.
  3. Epidural Abscess- fever and neuro symptoms are often missing early on. Make sure to ask about risk factors for spinal epidural abscess.
  4. Vertebral Artery Discection - most common identifiable cause of stroke in your people.  <50% are associated with trauma and <8% of patients have connective tissue disorder. Patients are at increased risk if they have had
    1. Cervical trauma (remember seen in < 50% of cases)
    2. Recent infection
    3. Hypertension
    4. h/o migraines

 



Category: Misc

Title: Diverticulitis

Keywords: Diverticulitis, antibiotics. (PubMed Search)

Posted: 1/30/2016 by Michael Bond, MD (Updated: 1/31/2016)
Click here to contact Michael Bond, MD

Diverticulitis

It seems like the standard treatment course for patients with suspected diverticulitis in the ED is to obtain a CT of the Abdomen and pelvis and then to start antibiotics. A CT scan is really only needed if you suspect that they have an abscess, micro perforation, are not responding to conventional treatment, or you suspect an alternative diagnosis.

However, what should the conventional treatment be? Several recent studies from Sweden, Iceland and the Netherlands have shown that patients treated with antibiotics did not fair any better then patients who were just observed. There was no difference in time to resolution of symptoms, complications, recurrence rate, or duration of hospitalization.  

Several national societies (Dutch, Danish, German, and Italian) now recommend withholding antibiotics in patients free of risk factors who have uncomplicated disease, but these patients will need close follow up.

TAKE HOME POINT: Patients with diverticulitis can be treated supportively and probably do not require antibiotics unless you suspect they have complicated disease or are immunosuppressed.

 

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Category: Misc

Title: New UMEM Pearls App!

Keywords: app pearls apple google (PubMed Search)

Posted: 10/7/2014 by Kevin Hamilton
Click here to contact Kevin Hamilton

We are proud to announce the release of our new UMEM Pearls App, now available in the Apple App Store and the Google Play Marketplace! You will now be able to pull down pearl content for offline viewing, in addition to having all of the pearls in searchable format available on your mobile devices.

Click either of the following links on your mobile device to download your Pearls App today!

Get it on Google Play!

 

Get it on Apple App Store!



Category: Misc

Title: Drowning

Keywords: Drowning, rescue (PubMed Search)

Posted: 5/24/2014 by Brian Corwell, MD (Updated: 2/23/2024)
Click here to contact Brian Corwell, MD

Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

 

The Instinctive Drowning Response—so named by Francesco A. Pia, Ph.D., is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind. To get an idea of just how quiet and undramatic from the surface drowning can be, consider this: It is the No. 2 cause of accidental death in children, ages 15 and under (just behind vehicle accidents)—of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In some of those drownings, the adult will actually watch the child do it, having no idea it is happening.* Drowning does not look like drowning—Dr. Pia, in an article in the Coast Guard’s On Scenemagazine, described the Instinctive Drowning Response like this:

  1. “Except in rare circumstances, drowning people are physiologically unable to call out for help. The respiratory system was designed for breathing. Speech is the secondary or overlaid function. Breathing must be fulfilled before speech occurs.
  2. Drowning people’s mouths alternately sink below and reappear above the surface of the water. The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.
  3. Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.
  4. Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.
  5. From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs.”

This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble—they are experiencing aquatic distress. Not always present before the Instinctive Drowning Response, aquatic distress doesn’t last long—but unlike true drowning, these victims can still assist in their own rescue. They can grab lifelines, throw rings, etc.

Look for these other signs of drowning when persons are in the water:

  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs—vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back
  • Appear to be climbing an invisible ladder

So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.

 

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Category: Misc

Title: Cause of Post-Operative Fever

Keywords: Postoperative, fever, cause (PubMed Search)

Posted: 1/18/2014 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Post Operative Fever is extremely common, and with the increase in same day surgery this is a common complaint presenting to the ED.  The mnemonic "5Ws" are often taught to remember the causes. They are:

  • Wind - Pneumonia, aspiration, pulmonary embolism, and atelectasis
  • Water - urinary tract infection
  • Walking - Deep Venous Thrombosis or pulmonary embolism
  • Wound - surgical wound infection
  • Wonder drugs - Drug fever, or infection due to indwelling lines, or a reaction to blood products

Though many surgical textbooks report that atelectasis is the most common cause of early post-operative fever,  some even claiming that it is responsible for over 90% of febrile episodes in the first 48 hours after surgery; a recent review in CHEST (reference below) showed that there is no evidence to support this. We often see atelectasis in medical patients too, and few if any of them have fever.  The CHEST review found that there was no clear evidence that atelectasis causes fever at all.

Pearl:  Temperature >38.9C should raise concern for a true infection, where lower temperatures can be due to pulmonary embolism, DVT, drug fever, etc….
 

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