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Emergency Medicine, Events, Imaging, Medical Education, Stanford News

Ultrasound has its day – and evangelists galore

Ultrasound has its day -  and evangelists galore

ULTRAfestUltrasound isn’t just for babies anymore.

“We use it for everything from head to toe and skin and organs,” emergency medicine instructor Laleh Gharahbaghian, MD, recently told writer Sara Wykes for an Inside Stanford Medicine story. “It’s become an essential tool at  the bedside we apply to immediately rule out — or rule in — medical conditions.”

That’s why Gharahbaghian and her colleagues are hosting ULTRAfest, a full day of ultrasound instruction open to all medical students on Oct. 18. Last year, more than 300 students from across the western United States attended.

Ultrasound uses sound waves that are too high pitched for our ears to detect. The waves bounce off material in the body, providing a glimpse inside.

ULTRAfest2What’s so great about ‘Sound (as Gharahbaghian calls it on her Twitter page)? It’s relatively cheap — new scanners start at $90,000 — non-invasive and portable. Ultrasound has also moved beyond mere diagnostics. For example, Stanford radiologist Pejman Ghanouni, MD, PhD, uses ultrasound to treat uterine fibroids.

Although the technology isn’t new, researchers are finding new uses for ultrasound. As detailed in that Inside Stanford Medicine piece:

More recently, the use of ultrasound has crossed into another part of the anatomy long thought to be immune to its imaging prowess: the lungs. In the air-filled environment of the lungs, the sound waves that are the basis of ultrasound have nothing to ping against. However, in lungs where disease has produced fluids, ultrasound has proven more accurate than a chest X-ray and faster than CT scan to diagnose common lung conditions, including pulmonary edema, pneumonia and pleural effusions.

Other doctors and medical students, including U-fest volunteer William White aren’t shy about touting ultrasound’s benefits: “I just fell in love with the technology, picking up a probe and looking into the body in real time.”

Previously: New technology enabling men to make more confident decisions about prostate cancer treatment, Listening to the stethoscope’s vitals, Plane crash creates unexpected learning environment for medical students 
Photos by Teresa Roman-Micek

Emergency Medicine, Health Policy, In the News, Patient Care, Research, Stanford News

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

ER sign - 560

One of the earliest – and most popular – parts of the Affordable Care Act allowed young adults to stay on their parents insurance until their 26th birthday. This week, Stanford researchers led by Tina Hernandez-Boussard, PhD, published a paper in the journal Health Affairs that tracked emergency room visits in California, New York and Florida for two age groups: 19 to 25 year olds – the group affected by the new requirement -  and 26 to 31 year olds for comparison. The researchers examined ER visits for the two years prior to the ACA requirement (2009 and 2010) and one year after the requirement went into effect (2011). Their findings showed that in 2011, 19- to 25-year-olds had slightly fewer ER visits – 2.7 per 1,000 people -compared to the older group.

The researchers calculated that the drop in ER use means more than 60,000 fewer visits for 19- to 26-year-olds across the three states  in 2011. They also found that the  largest relative decreases in ER use were among women and blacks.

post on Washington Post‘s Wonkblog covered the study and discussed further findings:

The researchers had another finding that seems just as important. While the total number of ER visits among the under-26 group was down, about the same number of people still went to the ER. The distinction here is that young adults with chronic conditions, who have greater care needs, probably now had better access to non-ER care settings, so their number of visits to the ER decreased. But the finding also suggests that healthy young adults, who might have shunned health insurance before, still continued to see the ER as a place for seeking out routine care, according to the study. Further, insurance likely makes those ER visits cheaper, which could actually increase how much people use the ER, the researchers wrote.

Hernandez-Boussard and her colleagues concluded in their paper, “As EDs face capacity challenges, it is important to consider how to meet the broad underlying needs of young adults through other channels and ensure the needed availability of these alternative health services.”

Previously: Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient”
Photo by Eric Staszczak/KOMU

Addiction, Emergency Medicine, Public Health, Research, Technology

Text messages after ER visit could reduce young adults’ binge drinking by more than 50 percent

Text messages after ER visit could reduce young adults' binge drinking by more than 50 percent

Bar_texting_0701414Researchers have demonstrated that text message programs can, among other things, help diabetes patients better manage their condition, assist smokers in kicking their nicotine habit, and encourage expecting mothers to get flu shots.

Now new findings published in the Annals of Emergency Medicine show that text messages can also be an effective tool for reducing binge drinking among young adults whose hazardous alcohol use has resulted in an emergency room visit. During a 12-week study, 765 patients who were treated in the emergency room and screened positive for a history of hazardous drinking were divided into three groups. The first group received text messages prompting them to respond to drinking-related queries and received text messages in return offering feedback aimed at either strengthening their low-risk drinking plan or promoting reflection on their drinking plan or decision not to set a low-risk goal. Another group received only text queries about their drinking, and the remaining individuals received no text messages.

A story published today on PsychCentral reports on the researchers’ results:

The group receiving both text message queries and feedback decreased their self-reported binge drinking days by 51 percent and decreased the number of self-reported drinks per day by 31 percent.

The groups that received only text messages or no text messages increased the number of binge drinking days.

“Illicit drugs and opiates grab all the headlines, but alcohol remains the fourth leading cause of preventable death in the U.S.,” said [Brian Suffoletto, MD, assistant professor in the Department of Emergency Medicine at the University of Pittsburgh School of Medicine].

“If we can intervene in a meaningful way in the health and habits of people when they are young, we could make a real dent in that tragic statistic. Alcohol may bring them to the ER, but we can do our part to keep them from becoming repeat visitors,” [he added].

Previously: CDC explores potential of using smartphones to collect public health data, Could better alcohol screening during doctor visits reduce underage drinking?, Personality-based approach can reduce teen drinking and The costs of college binge drinking
Photo by Anders Adermark

Cancer, Emergency Medicine, Research, Science, Stanford News

Small molecule may protect against radiation exposure, say Stanford scientists

Small molecule may protect against radiation exposure, say Stanford scientists

P1060359No one wants to imagine a nuclear accident. But, as Fukushima and Chernobyl showed, they do happen. Unfortunately there’s no truly effective way to protect people who have been exposed to large amounts of radiation (more than 10 gray, for those of you wondering; for you overachievers out there, 1 gray is the absorption of 1 joule of radiation energy per kilogram of matter).

Many of these people will die from what’s known as radiation-induced gastrointestinal syndrome when the rapidly dividing cells in their intestinal lining begin to die. As a result, the intestine loses its ability to regulate fluid loss and prevent the entry of pathogens into the body, causing severe diarrhea, electrolyte imbalance and sepsis.

Stanford radiation oncologist Amato Giaccia, PhD, and his colleagues wondered whether a cellular pathway that controls how cells respond to stress could be involved in the intestine’s response to radiation. Their study was featured today on the cover of Science Translational Medicine. As I explain in our release:

The researchers were studying a molecular pathway involved in the response of cells to conditions of low oxygen called hypoxia. Hypoxic cells produce proteins known as hypoxia-inducible factors, which help the cells survive the stressful conditions. (The HIF proteins – HIF1 and HIF2 – are normally degraded quickly when oxygen levels are normal.)

Hypoxia often occurs in fast-growing solid tumors as cells find themselves far from oxygen-delivering blood vessels, but it can also occur during times of inflammation, or in tissues like the intestine that experience natural gradations in oxygen levels. HIF proteins help the intestine absorb needed nutrients while blocking the entry of pathogens and maintaining healthy fluid exchange.

Giaacia and lead study author Cullen Taniguchi, MD, PhD, a postdoctoral scholar, wondered if increasing the levels of HIF proteins in intestinal epithelial cells could help the them survive damaging amounts of radiation. To test their theory, they used a small molecule called DMOG to block the naturally occurring degradation of HIF proteins in laboratory mice exposed to radiation. They found that administering DMOG to the mice significantly increased their survival – even when the molecule was given 24 hours after initial exposure.

The study suggests it may one day be possible to prevent or reduce the incidence of  radiation-induced gastrointestinal syndrome in humans.  It also provides an intriguing hint that it may be possible to mitigate some of the gastrointestinal side effects experienced by patients undergoing radiation therapy for cancer.

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Emergency Medicine, Stanford News, Videos

Stanford Life Flight celebrates 30 years

Stanford Life Flight celebrates 30 years

In May 1984, Stanford Life Flight’s first helicopter transport lifted a 70-year-old woman, critically injured in a car accident, over the Santa Cruz Mountains to Stanford Hospital. With that flight, Stanford became the first medical center in the Bay Area to have its own helicopter and air medical transport team. In its 30 year history, the air ambulance medical service has transported more than 15,000 patients going as far as 250 miles to California’s Northern and Central coasts, Central Valley and to Reno, Nev.

Priding themselves on their flight nurses’ extensive training and experience in caring for critically ill or injured patients, and on their accident-free flight track record, the men and women of Life Flight are an example of how combining compassionate care with advanced care capabilities saves lives. We celebrate their work in the hospital video above.

Previously: Teen benefited by Stanford surgeon’s passion for trauma care

Emergency Medicine, Health Costs, Health Disparities, Pediatrics, Research, Stanford News

ER visits for U.S. newborns show racial disparities

ER visits for U.S. newborns show racial disparities

Haiti Earthquake“Baby’s first trip to the ER” is probably one photo that no one ever wants to put in a baby book. But a surprising number of newborns – 320,000 each year – visit an emergency department within their first month of life. For reasons that are likely a complex mix of socioeconomic and biological factors, black newborns across the U.S. are more than twice as likely to make the trip.

Henry Lee, MD, an assistant professor of pediatrics at Stanford, broke down the stats of how often newborns end up in the emergency department and looked at race, age and insurance status. In collaboration with researchers at the University of California-San Francisco, Lee analyzed data from nationwide emergency room visits collected by the National Center for Health Statistics. The study appears in the May issue of the journal Pediatric Emergency Care.

The researchers found that 14.4 percent of black babies visited the emergency department, compared to 7.7 percent of Hispanic babies and 6.7 percent of white newborns. Some trips to the ER are unavoidable, such as when a baby has an infection or isn’t gaining weight. But it’s likely that some of these visits could have been prevented.

All babies must get a checkup within several days of being born. But if the delivering doctor failed to counsel the new parents about checkups – or if the doctor missed a common problem, such as jaundice – then the new family might end up in the ER instead of at a clinic. In addition to representing a lack of continuity of care for the newborns, these visits drive up health-care costs.

Additional studies may tease apart the factors that cause black newborns to end up in the emergency room more often than other groups, and to find ways to reduce spending on health care while providing better services.

“Improving the quality of care for this higher-risk group could also help to improve disparities and outcomes as well,” Lee said.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Speed it up: Two programs help reduce length of stay for emergency-room visitors
Photo by Olav Saltbones / Norwegian Red Cross

Cardiovascular Medicine, Emergency Medicine, Patient Care, Pregnancy, Research, Stanford News

Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms

Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms

pregnantbelly2When a pregnant woman’s heart stops, two lives are threatened. Yet few caregivers know how to modify their cardiopulmonary resuscitation technique for the expectant mom and her fetus, and few hospitals are optimally prepared for such an event.

To fill the knowledge gap, the Society for Obstetric Anesthesia and Perinatology commissioned a Stanford-led team of experts from several medical disciplines to write a consensus statement of expert recommendations, publishing in the May issue of Anesthesia & Analgesia, that describes best practices for CPR on a pregnant patient. The new statement is one of many examples of Stanford leadership in helping to save the lives of pregnant women around the world; our experts have also helped to develop widely-adopted protocols for dealing with massive hemorrhage during delivery and for treatment of pre-eclampsia, for example.

I asked two Stanford scientists who helped prepare the statement, lead author Steven Lipman, MD, and senior author Brendan Carvalho, MD, for their perspectives on the challenges of resuscitation in pregnancy. Both are obstetric anesthesiologists at Lucile Packard Children’s Hospital Stanford, where Carvalho is chief of obstetric anesthesia.

“The good news is that cardiac arrest in pregnancy is very rare, and also that rates of survival are higher than for the non-pregnant population,” Lipman said. Only about one in every 20,000 women with access to modern obstetric care experiences cardiac arrest while pregnant. Higher survival among pregnant patients may be partly due, he said, to the fact that many maternal cardiac arrests are witnessed: They tend to occur during labor or delivery, when the woman is already in a hospital and being closely monitored by trained medical staff who can begin CPR right away.

But rarity creates challenges. Because maternal cardiac arrests happen infrequently, obstetric caregivers have less experience in performing resuscitation than people who work in other parts of the hospital, such as the emergency room or intensive care unit. And it’s impossible to conduct randomized clinical trials – usually considered the gold standard for evidence-based medicine – on these emergencies to determine what works best.

“Also, in pregnancy, there is an asymmetry between people’s expectations and the reality of the risk,” Lipman said. “People think, ‘Oh, I’m just having my baby, it’s just natural.’ But if you look at third-world countries with no developed medical infrastructure, the rates of maternal mortality are extremely high. Yes, it’s natural and people expect an easy delivery and a healthy baby, but the reality is that it can be a risky process, and people can become critically ill very quickly.”

The physiology of pregnancy also presents challenges for resuscitation. During the second half of pregnancy, when a pregnant woman lies flat on her back, the fetus and the enlarged uterus compress the large vein that returns most of the blood to her heart. This decreases the amount of blood available to the heart and makes it harder to provide effective chest compressions in CPR. And resuscitators also must think about how to balance the needs of the mother with those of the fetus.

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Emergency Medicine, Global Health, Patient Care, Stanford News, Videos

SEMPER team reflects on relief work after Typhoon Haiyan

SEMPER team reflects on relief work after Typhoon Haiyan

As previously reported on Scope, the Stanford Emergency Medicine Program for Emergency Response sent 1o medical professionals to the Philippines last year to relieve Typhoon Haiyan victims. “There was so much medical need that it was necessary to split up SEMPER into two teams: One team went to Guiuan and the other was in Talcoban,” said Linda Jordan, PA-C, who was among those providing services. Setting up makeshift clinics, the Stanford affiliates teamed with Filipino doctors and nurses to provide primary care and help people suffering from traumatic illness, infected wounds and severe injuries who had not been treated in the immediate aftermath of the storm.

In the recently posted video above, members of the SEMPER team reflect on their experiences from the ground and what they took away. “You start to see qualities in people that you work with and I think you realize that you can stretch beyond what you’re doing,” said Julie Pacioppi, RN.

Previously: “I’m glad that we were there”: Stanford emergency-response team returns home from the PhilippinesOn the ground in post-typhoon Philippines, Post-typhoon Philippines: “It is all becoming real and sinking in” and Stanford emergency-response team heads to the Philippines

Cancer, Emergency Medicine, Medicine and Society

An emergency medicine physician’s take on honoring your emotions

But how do you really feel? Over on KevinMD.com, Anoop Kumar, MD, reflects on his personal and professional experiences with cancer. The emergency physician cares for people with acute complications from cancer and related treatments. In the post, Kumar describes his journey through the death of his grandmother when he was in seventh grade, the bursting of a dam of emotional supression later on, and the continued leaking of grief as he confronts his confusion, sadness and loss around the event.

Inspired by a 2010 article in The Guardian, Kumar urges readers dealing with hardship to “be positive. Or be negative. Or be confused. But whatever you are, be yourself.”

Previously: Becoming Doctors: Stanford med students reflect and share experiences through podcasts

Emergency Medicine, Health Disparities, Research, Stanford News

Insurance status might perversely affect the kind of trauma care you get: Stanford study

Insurance status might perversely affect the kind of trauma care you get: Stanford study

trauma centerGiven how much my health insurance checks eat into my income, I shouldn’t need to worry about the kind of trauma care I’d get if I were ever in a car accident (knock on wood). But should I?

A new School of Medicine study reveals that even insured patients might be at risk for getting poor trauma care for severe injuries – possibly at greater risk than uninsured patients.

Why? Simply because emergency doctors at hospitals lacking a trauma center decide to keep them there instead of sending them to a hospital with more expertise.

Ironically, insured trauma patients are admitted at non-trauma hospitals at higher rates than uninsured patients are, researchers find. Ergo, insured patients may end up missing out on critical resources that trauma centers are equipped with for severe injuries.

Our press release on the study published online today reports on the researchers’ findings from analyzing more than 4,500 nationwide reported trauma cases.

Why would non-trauma hospitals want to hold on to insured patients? One possible reason is that sometimes emergency doctors fail to recognize conditions that need extra care, lead author M. Kit Delgado, MD, suggests. Hospitals may also be used to taking care of certain severe injuries on their own.

But there might also be other reasons. As Delgado elaborates in the release:

Doctors working in the trenches most often strive to do what’s best for patients. But these findings are concerning and suggest that non-trauma centers are considering admitting some patients with life-threatening injuries based on whether or not they can be paid, when research has shown these patients fare better if transferred to a trauma center.

Delgado carried out the research when he was an emergency medicine instructor at Stanford. He is currently an emergency care research scholar at University of Pennsylvania.

Calling the finding “very disturbing,” Nancy Wang, MD, senior author – and an emergency physician herself – says researchers must call attention to such disparities in trauma care. She and colleagues previously discovered disparities in access to trauma care at California hospitals between children with and without insurance.

“I believe in health care as a right,” Wang wrote to me. “I never believed that there would be disparities in access to emergency trauma care based on insurance status.”

The authors suggest closer monitoring of emergency room encounters and splitting costs between hospitals and trauma centers as potential ways to curb such practices.

In follow-up studies, they also hope to figure out how much patients know about their options, and whether their preferences are being taken into account. As Delgado says in the press release, “People who have insurance may not realize that they could do better if they are transferred.”

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims
Photo by Seattle Municipal Archives

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