emergency medicine

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When Doctors Encounter Human Trafficking: What To Look For

(Ira Gelb/Flickr)

(Ira Gelb/Flickr)

It was 2 a.m. on a typically hectic Friday overnight shift in the emergency department.

A young woman, Kelly, checked into triage, accompanied by her older boyfriend Jim, who explained that Kelly had abdominal pain and some vaginal bleeding. Jim wanted her checked out and maybe some pain medicine to help her rest at home.

Kelly had no identification. She appeared younger than her stated age of 18. I also noticed track marks punctuating both of her arms — a sign of IV drug use. She immediately looked to Jim after answering all my questions.

If this sounds suspicious, that’s because it is. While clinicians are trained to address Kelly’s medical ailment, many of us fail to recognize the larger social cues right in front of us. It appears that Jim is in control of the situation. Kelly is young, maybe very young. As a clinician I must consider Kelly’s living situation, and her relationship with Jim.

As emergency care providers, it is standard practice for us to separate patients from their visitors long enough to at least ask about domestic violence. And for most of us, that would likely be the first concern in this case. But Kelly is actually a victim of human trafficking. Continue reading

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Anguished Reflections Of A College Crisis Counselor: A Student ‘On The Rooftop’

(Romain Caplanne/Flickr)

(Romain Caplanne/Flickr)

By John Rosario-Perez
Guest Contributor

John Rosario-Perez (Courtesy)

John Rosario-Perez (Courtesy)

We live and die for the weekend. Nowhere is this more true than on college campuses, where students are in hot pursuit of the pleasure principle. Chasing excess is a sport as well as a rite of passage. But the 72 hours from Friday night to Monday morning can also be among the most perilous, a portal to despair with no exit. A college crisis clinician for eight years, I encountered many students who suffered the weekend as exiles.

Over time I listened to dozens of anguished stories, so many that I could almost predict their twists and turns. Some were as lurid as a tabloid headline. Others landed faintly on the ear, a circuitous tale with multiple digressions before arriving at the dreaded destination — pain. Their narratives fell under many rubrics — crushed idealism, first love gone awry, dreams vanquished by failure. Betrayal.

To the casual observer, such confidences might seem transient and overblown, hysterical laments tied to youthful indiscretions. But to those overcome by despair, isolation can often feel permanent and unending, a life sentence without reprieve.

2 AM

Their calls often come in the middle of the night. By force of habit, I sleep restively, my ear cocked in anticipation of the mobile pager’s trill. Each time it summons me, I try to suppress a vague sense of dread and the panicked feeling that I don’t really know what to do despite my years of experience. A rush of adrenaline gives me a heightened sense of alertness and danger but also of being put on the spot.

Like so many other nights, I rouse myself from half-sleep and strain to collect myself in the dark. The phone lies on the bedside table, but my fingers, as reluctant as an arthritic’s, resist reaching for it. After speaking with the campus police, I dial a number.

“Hello. You called the crisis line?” I ask. “How can I help you?”

“It’s my roommate, Kevin. I’m not sure, but I think he’s suicidal,” a trembling voice says. “What should I do?” Continue reading

Calling 911 From Your Cellphone? Don’t Assume They’ll Know Exactly Where You Are

Trainer Kevin Lewis (Carey Goldberg/WBUR)

Training specialist Kevin Lewis of the Massachusetts 911 department at a call center training screen. (Carey Goldberg/WBUR)

One afternoon this fall, as Dr. Ian Sklaver was coaching his 13-year-old daughter’s soccer team, one of the players suddenly collapsed and stopped breathing. Her skin took on a blue pallor, and her pulse was thready, barely there.

Sklaver, who practices at Garden City Pediatrics in Beverly, Massachusetts, immediately started CPR and called 911. We need an ambulance, he told the dispatcher urgently, giving the name of the school he was at and the street it was on.

The dispatcher asked him a question or two, he recalls, “and then asked me the bewildering question of ‘What town are you in?’ And I told them, and then they reconnected me to another person to re-tell the same story again — which seemed to be taking a lot of time away from doing CPR.”

Fortunately, the player was fine — but Sklaver was left mystified.

He has Google Maps, Find-My-iPhone and other free apps, he said, “that can find me to the exact street address. And I call 911, the most important call one could potentially make,” and he’s asked what town he’s in.

Our goal is to bring the 911 system into the 21st century.

– David Furth, FCC

So — if apps like Google Maps and Uber seem to know just where your phone is, why doesn’t the 911 system?

The answer is sadly simple. The 911 system “is based on technology that was developed almost 40 years ago,” said Brian Fontes, CEO of the National Emergency Number Association, a nonprofit that focuses on 911 issues.

“And it was designed for a wired-only world where you have your wired phone tethered to a fixed address,” he explained. “Much has changed, obviously, over the years, and today roughly 75 or 80 percent of 911 calls come in from wireless devices.”

Back when cellphones were new, the 911 system could only map which tower had relayed a given call. In recent years, with GPS, the system has gotten much better at locating cellphone calls. But it is still behind commercial apps. Continue reading

Chest Pain Is Top Item On Nation’s $80 Billion ER Care Bill, Study Finds

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

If you’re feeling chest pain that you think might be a heart attack, there’s only one thing to do, medical experts say: Seek emergency care. Do not pass go, do not collect $200. Or rather, do not think about the roughly $1,000 your care will cost the hospital. Your life may be at stake.

But at a calmer moment less fraught with risk, you might want to contemplate the bigger picture of chest pain and emergency care, as sketched out by Dr. Jonathan Slutzman of UMass Medical School and colleagues at a recent national conference on emergency medicine. To wit: Your costs are part of a national Emergency Department care bill that totals nearly $80 billion, including nearly $5 billion for chest pain alone.

Every year, Americans log a total of about 130 million visits to emergency rooms, Dr. Slutzman said. Among those visits, according to his team’s analysis of millions of records, patients who come in for chest pain are the single biggest line item on the bill.

“Chest pain is one of the two most common reasons somebody comes into the Emergency Department,” he said. “It’s somewhere on the order of 5 percent of all visits,” which may not seem like very much until you realize it’s 5 percent of 130 million, and each chest-pain visit costs about $1,000.

The grand total: $4.7 billion. It’s so high because chest pain is both a high-volume diagnosis and the treatment is high-intensity, Slutzman said, usually including blood tests, X-rays, sometimes CT scans and sometimes stress tests. They add up.

So now that we see that prodigious price tag, what is to be done?

Emergency medical specialists are working on that problem, he said, in part by figuring out what the “best practices” are for evaluating chest pain. “This is on people’s radar screens,” he said, “to try and ‘rightsize’ our care,” meaning that “we can safely treat many patients while doing less.”

To which I naturally responded: “Yikes. I don’t really want the system to be trying to save money when I might be having a heart attack.”

Slutzman calmed me down. His No. 1 takeaway from the findings, he said, is that more patients should probably be evaluated as to whether they’re having a heart attack without having to stay overnight in a hospital. Chest pain patients tend to be almost reflexively kept in the hospital for at least one night of testing, he said, “and a big subset of those people don’t really need it. One big key is more rapid access to outpatient providers. If someone can see their doctor in one to two days and maybe get some additional testing then, they can be safely discharged.”

That calmed me down a bit. I do believe in staying out of the hospital whenever possible.

He calmed me still further with a story:

Historically, back in the late ’80s and early ’90s, if you walked into an Emergency Department with chest pain, you got admitted to a cardiac Intensive Care Unit, pretty much no matter what, because there was so much concern that they could be missing heart attack. There was a lot of fear of that.

And then, over time, we learned more and more. We could read our electrocardiograms — our EKGs — a little better, we could learn a little bit more about what the squiggles meant, and which ones were dangerous and which ones weren’t.

And then we got more blood tests that were a little bit more sensitive and a little bit more specific, and a little bit better at figuring out who was having a heart attack and who wasn’t. Continue reading

In NYC, More Severe Injuries After Painted Bike Lanes Installed, Study Finds

A study found that the severity of injuries among bicyclists hit by cars appeared to go up after New York City installed painted bike lanes. Here, the author of that report, Dr. Stephen Wall, finds a blocked NYC bike lane. (Courtesy of Stephen Wall)

A study found that the severity of injuries among bicyclists hit by cars appeared to go up after New York City installed painted bike lanes. Here, the author of that report, Dr. Stephen Wall, finds a blocked NYC bike lane. (Courtesy of Stephen Wall)

This may not surprise you if you’re a regular cyclist: Those painted bicycle lanes that are proliferating as the number of bike commuters rises? They don’t seem to make a dent in injuries and may even worsen their severity, according to a study presented in Boston this week at a national gathering of the American College of Emergency Physicians.

The study found that the severity of injuries among bicyclists hit by cars actually appeared to go up after New York City installed those painted bike lanes, at least among patients brought to Bellevue Hospital Centers’ emergency department.

Dr. Stephen Wall of New York University and Bellevue offers an immediate caveat, though: Bike lanes lead to increased volumes and may also lead to faster speeds.

“I don’t want people to look at this data and say, ‘Oh, bike lanes are bad,’ ” Wall said. “They’re not. They’re definitely beneficial.”

But, he said, design flaws in the bike lanes may increase risks, and behaviors by drivers, cyclists and pedestrians can still cause problems. The findings, Wall says, show how important it is to analyze the designs of bike lanes and make sure they do prevent injuries, especially as the numbers of bikers rise.

Ideally, Wall said, police, hospitals and emergency services would all share and integrate their data to create a map of where injuries occur. When cities make choices on how to protect cyclists, they must be analyzed as well, to be sure money is spent wisely.

In New York City, he said, it’s becoming ever more clear that there are major problems — “hot spots” — at the exits of bridges and tunnels, and more barriers may be needed there. Boston may have a similar issue, he said; he’d like to examine the city’s data.

I immediately thought of this story from last week: “Scientist Killed In Bike Crash, But Her Thyroid Stem Cell Work Lives On.” The Beacon Street ghost bike in memory of Dr. Anita Kurmann is right at the bottom of the Massachusetts Avenue bridge and it’s a known danger spot for bikers.

From the study’s abstract: Continue reading

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Study: Thousands Of Injuries As Ziplines Proliferate, Younger Kids Most At Risk

In 2012 alone, there were over 3,600 zipline-related injuries, according to a recent report, or about 10 a day. (popejon2/Flickr)

In 2012 alone, there were over 3,600 zipline-related injuries, according to a recent report, or about 10 a day. (popejon2/Flickr)

Hannah Weyerhauser was 5 years old, playing on the zipline at her family’s house in New Hampshire, when she started complaining that her older cousins and siblings were going faster than she was. So her mother, Annie, gave Hannah an extra big push. But when Hannah sped to the end of the zipline, she stopped short, flew into the air, did a back flip, and landed on her neck.

“For a few minutes she was really pale and out of it,” said her mother, a Boston doctor (and a friend of mine). She called an ambulance, and paramedics put a collar on Hannah’s neck on the way to the local emergency department. Ultimately, the little girl was fine, although she probably had a minor concussion, her mother said. But Annie shudders as she thinks of what could have happened: “If she had fallen a little differently she could have broken her neck.”

Others are not so lucky. Increasingly, zipline disasters are making the news. A 12-year-old girl in North Carolina died after falling off a zipline at the YMCA’s Champ Cheerio in June. And last year, a 10-year-old boy died after a backyard zipline accident in Easton, Massachusetts, in which the tree holding the line fell on the child.

Indeed, injuries related to ziplines are rising as the lines proliferate, according to a new report: In 2012 alone, there were over 3,600 zipline-related injuries, or about 10 a day. The study, which researchers say is the first to characterize the epidemiology of zipline-related injuries using a nationally representative database, found that from 1997-2012, about 16,850 zipline-related injuries were treated in U.S. emergency departments.

Which states have zipline regulations (Source: Association for Challenge Course Technology)

Which states have zipline regulations (Source: Association for Challenge Course Technology)

The report on ziplines (first used over a century ago to transport supplies in the Indian Himalayas) found that most of the injuries resulted from falling off the zipline, and many involved young children. I asked one of the study authors, Tracy Mehan, manager of translational research with the Center for Injury Research and Policy at Nationwide Children’s Hospital in Ohio, a few questions about the report, published in the American Journal of Emergency Medicine.

Here, edited, is what she said.

Rachel Zimmerman: Are you surprised by this sharp increase in zipline injuries?

Tracy Mehan: The number of commercial ziplines grew from just 10 in 2001 to over 200 by 2012. When you include the number of amateur ziplines that can also be found in backyards and at places like outdoor education programs and camps, the number skyrockets to over 13,000. The increase in the number of injuries is likely due largely to the increase in number of ziplines and shows this is a growing trend. 

What are the most common types of injuries?

The majority of zipline-related injuries were the result of either a fall (77 percent) or a collision (13 percent) with either a tree, a stationary support structure or another person. The most frequent type of injuries were broken bones (46 percent), bruises (15 percent), strains/sprains (15 percent) and concussions/closed head injuries (7 percent). Approximately one in 10 patients (12 percent) were admitted to the hospital for their injury. Continue reading

Report: Dietary Supplements Send Thousands To The ER Annually

Dietary supplements can make you sick.

That’s the quick takeaway from a new report, published in The New England Journal of Medicine, that might make you think twice about the supplements.

Researchers at the Centers for Disease Control and Prevention conclude that about 23,000 emergency department visits each year in the United States can be attributed to “adverse events” due to dietary supplements. “Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults,” the study says.

Researchers analyzed data on dietary supplement-related emergency department visits over a 10-year period, from Jan. 1, 2004, through Dec. 31, 2013, from 63 hospitals. Of the more than 23,000 ER visits, researchers report that 2,154 patients were then hospitalized for further treatment. (The new analysis did not include patients who may have died en route to the hospital.)

The backdrop to all this is that supplement sales are dramatically on the rise:

The estimated number of supplement products increased from 4,000 in
1994 to more than 55,000 in 2012 (the most recent year for which data are publicly available), and approximately half of all adults in the United States report having used at least one dietary supplement in the past month. In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, one third of the out-of-pocket expenditures for prescription drugs.

I asked the study’s lead author, Dr. Andrew Geller with the CDC, what consumers should make of the study. Here’s what he said, via email:

People may not realize that dietary supplements can cause any adverse effects, but each year thousands of people are treated in emergency departments for symptoms attributed to dietary supplements.

Young adults taking products to lose weight or increase energy should keep in mind that some of these products can have effects on their heart, and they should not take these products in excess. If you have a heart condition, talk to your doctor before starting a weight loss or energy supplement.

Older adults should be mindful of possible choking or other swallowing problems from taking supplements. They should avoid taking several pills at once, avoid extra large pills or capsules, and swallow supplements with plenty of water or other fluid. Tell your physician you are having difficulty swallowing pills and ask him/her or your pharmacist for other options or if you can cut the supplement in half.

Patients should always tell their doctors if they are taking dietary supplements, and which ones.

All medicines and dietary supplements should be stored up, away and out of sight of young children.

Pieter Cohen — an internist at Cambridge Health Alliance and asistant professor at Harvard Medical School who studies dietary supplements and has been critical of the federal law governing them — said the new study may trigger some long-needed changes.

“This study is the most important research published since the passage of DSHEA [the Dietary Supplement Health and Education Act of 1994] and sends a clear message: Not only does the regulatory framework make no sense, it’s posing imminent threats to the public’s health,” Cohen says. “The publication of this new CDC study will hopefully be a watershed in regulating supplements in the U.S.”

He adds that the current regulations “are based on the premise that all supplement ingredients are safe.” But, he says, “with the new CDC study we learn that these products are anything but safe. In fact, the CDC found that supplements lead to tens of thousands of emergency room visits and thousands of hospitalizations each year.” Continue reading

After A Death, Crackdown On Drowsy Teen Drivers Led To Fewer Crashes, Study Finds

(KaritoGlam/Flickr)

(KaritoGlam/Flickr)

By Marina Renton
CommonHealth Intern

It was to be Maj. Robert Raneri’s last day of work before his wedding the following week. On June 26, 2002, Raneri, a member of Army Reserves, left his home in Nashua, New Hampshire for the Devens Reserve Forces Training Area in Ayer, Massachusetts. But he never arrived.

Raneri was killed by a 19-year-old drowsy driver who admitted to having stayed up through the night playing video games. Shortly after Raneri’s death, his fiancée, Maj. Amy Huther, learned she was pregnant with his child.

In accordance with Massachusetts law at the time, the teen driver faced misdemeanor charges, leading to five years probation, a 10-year license suspension and 140 hours of mandated community service, The Boston Globe reported in 2004.

Drowsy Driving

But the tragedy brought attention to the problem of drowsy driving and, in 2007, led to new rules that govern the way young drivers grow into their adult licenses: the graduated driver-licensing program.

Those rules (amendments to already existing law) included stiffer nighttime driving penalties, driver’s education on drowsy driving and tougher penalties for negligent or reckless driving. And it seems the strict new rules have worked, dramatically decreasing the number of drowsy driving accidents involving teenagers, according to a new study out this month in the journal Health Affairs.

Indeed, the results are striking: Among junior operators (ages 16-17), the overall rate of car accidents fell by 18.6 percent, the rate of night crashes decreased by almost 29 percent, and there was an almost 40 percent decrease in car crashes resulting in a fatal or incapacitating injury, researchers report. The study focused on data from one year before and five years after the implementation of the new amendments.

Legal Crackdown

This is the first study of its kind to look at the effects of individual components of a driver licensing law, such as more exacting penalties, the authors state.

Dr. Charles Czeisler, chief of the Division of Sleep and Circadian Disorders at Brigham and Women’s Hospital in Boston and co-author of the study, said in an interview that researchers are “confident that these features of the law were critical in the decline in the teen fatal and incapacitating injuries as well as the overall crash rate that we observed.”

Like young drivers everywhere, Massachusetts teens don’t have the same privileges as adult drivers. They aren’t allowed to drive at certain times of night; they can’t have friends in the car right away; and they have to drive with a parent or other adult in the car when they’re first starting out. Continue reading

Most States Don’t Require CPR Training For High Schoolers — Should They?

(Ken Schwarz/Flickr)

(Ken Schwarz/Flickr)

By Marina Renton
CommonHealth intern

I walked into health class one day to find slack-jawed mannequin heads atop foam torsos lined up in rows on the classroom floor. Interspersed among the adult mannequins were infant dummies — fully formed, but equally eerie.

That macabre scene began the first aid unit of 11th-grade health, which included the memorable experience of giving the mannequins chest compressions to the rhythm of “Stayin’ Alive,” using both hands for the adults and only two fingers for the infants.

I learned cardiopulmonary resuscitation at a Massachusetts public high school, but it wasn’t a legally mandated part of the curriculum. Twenty-one states — including Washington, Texas, Alabama and Iowa — have passed laws that make CPR training a high school graduation requirement. Massachusetts is not one of them.

Someone ‘has to take up the torch and really advocate for it.’

– Dr. Farrah Mateen

But maybe it should be. A commentary just out in the Mayo Clinic Proceedings argues that the potential benefits of requiring CPR training in high school — from saving lives to getting a taste of selfless service — are so great that every state should do it.

Why don’t they? The answer isn’t that states are necessarily facing resistance to the laws. It’s that the laws just aren’t a priority, says commentary co-author Dr. Farrah Mateen, an assistant professor of neurology at Harvard Medical School and a neurologist at Massachusetts General Hospital.

In other states, legislation has been advanced by champions of the cause, Mateen said. Continue reading

Viewpoint: Doctors Respond To Home Births That End Up In Hospital

By Shirie Leng, M.D. and Cindy Ku, M.D.

As physicians we are concerned about a recent post on CommonHealth — “What to Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)” — that focuses on planned home births that end up in the hospital.

While we respect the right of women to labor and deliver in the environment of their choosing, requiring medical intervention in childbirth is neither shameful nor a moral failing. Life-threatening complications which, 100 years ago, would have meant a death sentence for mothers and babies, are now treatable and even preventable in the modern hospital maternity ward. Suggesting that women are unduly traumatized by transfer to and treatment in a medical facility does a disservice to the obstetricians, nurses, anesthesiologists, and neonatologists who work so hard to save these lives.

Here’s an example of the kind of case that could possibly result from a home birth that goes awry. While on a routine morning on the obstetrics unit, the usual routine was interrupted by a phone call from the emergency room. A laboring mother was in distress and needed an emergency caesarean, and she was about to arrive into the trauma OR. Since caesareans are not normally performed in the emergency room trauma room, everyone dropped their plans and hurriedly prepared the trauma OR. One minute later a petite young woman on a stretcher crashed through the door along with the obstetrician. “Get the baby out of me!” she screamed, writhing and crying in agony as the team transferred her to the operating table. Between her moans and her desperate outbursts, she could barely understand the questions as the anesthesiologist tried to ascertain three things: did she have heart or lung problems, did she have allergies, and did she have any potential problems with her airway?

 (meme_mutation/flickr)

(meme_mutation/flickr)

We had no other information to go by – no laboratory data, no history, not even her name. All we knew was the baby was in breech position (legs down, not head down) and was in distress. We had five seconds to decide how we would help to save the two lives in front of us. We told her as gently as we could (though it likely didn’t register with her at all) that she needed to breathe in oxygen for herself and her unborn child, that she would be unconscious for about an hour, and we would see her and her baby in the recovery room. Vaginal delivery is not the standard of care for breech presentations because of the significantly elevated risk of shoulder entrapment in the birth canal and stillbirth. Months after this case we all still wonder how we could have done better and what would’ve happened if she hadn’t arrived in time.

Thankfully, our team — the obstetricians, anesthesiologists, nurses and neonatologists — worked together successfully and both mother and child did well. We don’t know for sure if this case began as a home birth, but it does represent the sorts of difficulties that we medical staffs wrestle with when a home birth becomes complicated and ends up at the hospital.

Childbirth always brings with it an element of danger. While everything usually goes right, when it goes wrong it usually does so quickly and seriously. To expect the idealized experience in every case is to deny reality. In 1900, when women were having the arguably blissful natural birth experience home birthers seek, the maternal mortality rate was more than 800 deaths per 100,000 births. According to the CDC, in 1997 that number was 7 per 100,000. This statistic, an upwards of 99 percent decrease in mortality rate, was not achieved by midwives and doulas with the latest technology in birthing balls and labor tubs. It was achieved through advances in science and medicine. Continue reading