Published by
Stanford Medicine

Category

Emergency Medicine

Emergency Medicine, Medicine and Society, Patient Care, Public Safety, Stanford News

A young child, a falling cabinet, and a Life Flight rescue

A young child, a falling cabinet, and a Life Flight rescue

ticktockLife in the air rescue business is highly unpredictable. You can spend many hours idling away the time in an obscure, basement office. But when an emergency call comes, you literally don’t have a second to grab a pen on the way out the door.

So it was on one November day, when I did a ride-along with Stanford’s illustrious Life Flight air ambulance service, the oldest in California. The team graciously agreed to let me accompany them on a flight for a story for Stanford Medicine magazine, whose current issue is focused on the role of time in medicine. Life Flight, I figured, would give me a sense of the split-second timing that can sometimes make a difference between life and death in an emergency situation. I was scheduled to fly with the crew in late October, but instead I spent that day learning about the service in what proved to be a leisurely day with no calls.

On my second ride-along day, it appeared that history was about to repeat itself when, just as my shift was about to end, the emergency call came in at 3:39 p.m. I became an eye witness to the rescue of a toddler who suffered a serious head injury when a heavy, ill-secured cabinet at her preschool crashed down on her head during naptime. The story was so dramatic that it made the local news. The school was shut down several days later by local officials because of code violations.

Things could have gone poorly for little Aeshna, the 3-year-old victim of the accident, who was left dazed, not fully conscious and vomiting as a result of her injury – clear signs of head trauma. She could have suffered significant bleeding in the brain and permanent brain damage – a prospect that was a major concern for her parents and caregivers.

The two Life Flight nurses, who have a breathtaking array of skills, and their veteran U.S. Navy pilot made it to the scene at the Fremont, Ca. preschool across the bay within 23 minutes of the call and were able to bring Aeshna back to Stanford for quick assessment and treatment.

You can read the minute-by-minute scenario of Aeshna’s rescue in the the magazine, which came out last week.

Previously: Stanford Medicine magazine reports on time’s intersection with health, Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims, Stanford Life Flight celebrates 30 years and Ask Stanford Med: Answers to your questions about wildnerness medicine
Illustration by Lincoln Agnew

Aging, Cancer, Emergency Medicine, Medical Education, Pregnancy, Stanford News

Stanford Medicine magazine reports on time’s intersection with health

Stanford Medicine magazine reports on time's intersection with health

Why is it that giant tortoises typically live for 100 years but humans in the United States are lucky to make it past 80? And why does the life of an African killifish zip past in a matter of months?

I’ve often mused about the variability of life spans and I figure pretty much everyone else has too. But while editing the new issue of Stanford Medicine magazine’s special report on time and health, “Life time: The long and short of it,” I learned that serious scientists believe the limits are not set in stone.

“Ways of prolonging human life span are now within the realm of possibility,” says professor of genetics Anne Brunet, PhD, in “The Time of Your Life,” an article on the science of life spans. My first thought was, wow! Then I wondered if some day humans could live like the “immortal jellyfish,” which reverts back to its polyp state, matures and reverts again, ad infinitum. Now that would be interesting.

Also covered in the issue:

  • “Hacking the Biological Clock”: An article on attempts to co-opt the body’s timekeepers to treat cancer, ease jetlag and reverse learning disabilities.
  • “Time Lines”: A Q&A with bestselling author and physician Abraham Verghese, MD, on the timeless rituals of medicine. (The digital edition includes audio of an interview with Verghese.)
  • “Tick Tock”: A blow-by-blow account of the air-ambulance rescue of an injured toddler.
  • “Before I Go”: An essay about the nature of time from a young neurosurgeon who is now living with an advanced form of lung cancer. (The neurosurgeon, Paul Kalanithi, MD, is featured in the video above, and our digital edition also includes audio of an interview with him.)

The issue also includes a story about the danger-fraught birth of an unusual set of triplets and an excerpt from the new biography of Nobel Prize-winning Stanford biochemist Paul Berg, PhD, describing the sticky situation he found himself in graduate school.

Previously Stanford Medicine magazine traverses the immune system, Stanford Medicine magazine opens up the world of surgery and Mysteries of the heart: Stanford Medicine magazine answers cardiovascular questions.

Emergency Medicine, Research, Stanford News

Stanford study: Not all dog bites should be treated with antibiotics

Stanford study: Not all dog bites should be treated with antibiotics

8263808541_04a4c14c8d_zJust before the holidays, my husband whisked me off to urgent care because I received some nasty dog bites on both my hands. The incident involved surprise (our new foster dog seemed so sweet!), lightheadedness and nausea from shock, wonderfully caring medical staff, a few stitches, and a prescription for antibiotics.

I had never been bitten by an animal before, and the protocol was new to me. Sure, the wounds looked ugly, but I assumed they could just be stitched up, and I’d heal like the times I accidentally cut myself with a kitchen knife. Turns out, the risk of infection is deemed so high with animal bites that not only are prophylactic antibiotics prescribed as a matter of course, but the doctor was hesitant to use stitches, lest the closed wound become an inflamed pocket of harmful bacteria. After consulting with a plastic surgeon, her compromise was to “tack” it with three or four stitches, where ten or twelve would have been appropriate.

While this was a learning experience for me (in dog behavior as well as medical protocol!), doctors are well aware of bites’ potential for infection. However, new research shows that the protocol for dog bites should vary depending on the bite’s characteristics, and that routine prescriptions of antibiotics may not be necessary.

The study, conducted by Stanford medical student Meg Tabaka under supervision by James Quinn, MD, a professor of emergency medicine, followed nearly 500 patients who received treatment for dog bites over the past 4.5 years. Their incidence of infection was correlated with two characteristics: puncture wounds and closed wounds. Of the wounds that became infected in the sample, only 2.6 percent were neither punctures nor closed during treatment. The conclusion of the researchers is that puncture wounds and closed wounds are at high enough risk of infection to warrant prophylactic antibiotics. A potential implication is that in other types of wounds, antibiotics may not be necessary – that is, their benefits might not outweigh their risks.

Continue Reading »

Cardiovascular Medicine, Emergency Medicine, In the News, Research, Women's Health

New test could lead to increase of women diagnosed with heart attack

New test could lead to increase of women diagnosed with heart attack

12192161504_34544b2f38_zSimilar numbers of men and women come to the emergency room complaining of chest pain, and similar numbers of men and women die from heart disease each year (in fact, slightly more than half are women), so why are only half as many women being diagnosed with heart attacks?

A study recently published in the BMJ and funded by the British Heart Foundation suggests that the reason for the difference lies in the diagnostic methods: blood tests. Researchers at the University of Edinburgh found that if blood tests are administered with different criteria for each gender, women’s heart attack diagnoses are much higher. Better tests could limit under-diagnosis and prevent women from dying or suffering from future heart attacks. (And women are more likely than men to die after suffering an attack; twice as likely in the few weeks afterward!)

Blood diagnostic tests measure the presence of troponin, a protein released by the heart during an attack. Previous research showed that men produce up to twice as much troponin as women, so Anoop Shah, MD, and fellow authors hypothesized that if different thresholds of troponin levels were used for men and women, it would correct the disparity.

The researchers administered two tests on patients complaining of chest pain, once using methods that are standard around the world, and then again using a highly sensitive troponin test and gender-specific thresholds. MNT reports:

When using the standard blood test with a single diagnostic threshold, heart attacks were diagnosed in 19% of men and 11% of women. However, while the high-sensitivity blood tests yielded a similar number of diagnoses in men (21%), the number of heart attack diagnoses in women doubled to 22%.

In addition, the researchers observed that participants whose heart attacks were only diagnosed by the high-sensitivity test with gender-specific diagnostic thresholds were also at a higher risk of dying or having another heart attack in the following 12 months.

This research included a little more than 1,000 subjects; the BHF is now funding a clinical trial on more than 26,000 patients to verify the results.

Photo by MattysFlicks

Emergency Medicine, Pediatrics, Pregnancy, Stanford News

Helping families navigate the NICU

Helping families navigate the NICU

Packard preemieEarly this morning, the baby girl that’s been growing inside me for 33 weeks decided to have a dance party in my belly. Not great timing, but it’s always a nice reminder to know she’s getting stronger every day and will soon be more than a pre-dawn percussionist in our lives. One of my biggest fears – as it is for many expecting parents – has been what might happen if I went into early labor or if something unexpected turns up when she’s born and she has to stay in the Neonatal Intensive Care Unit.

Those days, waiting for a baby to be well enough to come home from the NICU can be exhausting and confusing. And there’s often a lot to learn about the health issues many preemies suffer. So a new program at Stanford’s Lucile Packard Children’s Hospital, which admits 1,500 babies each year, aims to make that time a little less overwhelming.

The NICU Family Support Program was started last year and represents a new partnership between the hospital and the March of Dimes. The program is available at several hospitals nationwide and helps 90,000 families every year. Families gain access to print and online versions of educational materials to help them understand their babies’ health issues and treatments. A recent feature story describes the program’s holistic approach:

“We work very hard to take care of the whole family and not just the baby,” [hospital president Christopher] Dawes said in announcing the new partnership with the March of Dimes. “This program increases parents’ confidence and gives NICU staff the tools they need to support families and babies.”

. . .

“When you have a premature baby, you have to learn a whole new language. You are so inundated with terms, it’s easy to get mixed up,” said [mother of twin preemies Heather] Keller. “The March of Dimes website and written materials are a great reference that families can use throughout their journey. It’s accurate and written in a language that’s easy for families to understand, but is not complicated or condescending.”

In addition to the materials, the program offers iPads to NICU families, providing them with easy access to the March of Dimes materials and website without having to leave their babies’ bedsides.

The NICU Family Support Program is designed to help families become more involved in the care their young children receive. It’s an approach that can alleviate some of the burden parents of NICU patients feel at what is otherwise a harrowing time in their lives.

Previously: The year in the life of a preemie – and his parents, NICU trauma intervention shown to benefit mothers of preemies, Using the iPad to connect ill newborns, parents, Special care to protect newborns’ fragile brains and The emotional struggles of parents of preemies
Photo, of a Packard Children’s patient and his mom, by Doug Peck

Clinical Trials, Emergency Medicine, Neuroscience, Research

Clinical trial shows progesterone doesn’t improve recovery from head trauma

Clinical trial shows progesterone doesn't improve recovery from head trauma

800px-thumbnailResearchers had high hopes that progesterone, that multipurpose endogenous steroid, could stave off some of the worst effects of head injuries. A quick injection soon after a blunt trauma and  — wa-zam — marked improvement on the widely used Glasgow Outcome Scale, which measures brain injuries on a scale from death to low disability. Or so they thought.

Instead, a nationwide clinical trial was called off after early analyses showed no benefit. The findings were published last week in The New England Journal of Medicine.

“These results are plainly disappointing,” said lead investigator David Wright, MD, an emergency medicine physician at Emory University, in an Emory release.

Stanford, in partnership with Santa Clara Valley Medical Center and the Regional Medical Center of San Jose, enrolled approximately 80 patients in the study between 2008 and 2013, said James Quinn, MD, a Stanford emergency medicine physician. Quinn said there were many benefits to the study even though the results didn’t suggest an improvement.

“The patients all got great care,” Quinn said.  The care teams worked to ensure the care was standardized and top notch for study participants, he said. In addition, there’s still a possibility that progesterone administered closer to the time of injury might help patients. To adhere with study protocols, the teams had to wait one hour after the patient arrived at the emergency room before providing the progesterone or placebo, Quinn said.

The study had a unique design, in part because emergency trauma patients can often not provide consent. Instead, the research team publicized the study before starting and gave participants the opportunity to opt out when they were able.

Quinn also made note of an observation made by he and his colleagues:  Although nationwide most injuries stemmed from vehicle crashes, the Stanford-led teams saw an abundance of bicycle accidents.

Previously: For prolonged seizures, a quick shot often does the trick, study finds, Stanford Medicine story on surviving brain injury wins health journalism award and Estradiol — but not Premarin — prevents neurodegeneration in women at heightened dementia risk
Photo by U.S. Navy

Emergency Medicine, Medical Education, Patient Care, SMS Unplugged

Role reversal: How I went from med student to ED patient in under two minutes

Role reversal: How I went from med student to ED patient in under two minutes

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

emergency sign - smallAs part of the second-year clinical skills course, each member of my class is required to complete two 8-hour Emergency Department (ED) shifts. I had my first ED shift last week, and when I walked in, I introduced myself as a second-year medical student who needed to practice IV placements, EKGs, and any other procedures that happened to come my way. Three hours later, when I walked out of the ED, staff knew me not as a medical student, but as a recently discharged patient, grasping paperwork with my official diagnosis: “syncope and collapse.”

It was 30 minutes into my ED shift, while I was watching a pelvic exam (ironic, given my post a couple weeks ago), when I began to feel a little dizzy. I’ve fainted twice before – once in high school after getting my blood drawn, and once when watching a C-section at a clinic in India – so I recognized the signs: feeling a little hot, starting to see black dots, slightly swaying. I tried to fight off the sensation by breathing slowly, but I could tell it wasn’t working. At the earliest possible opportunity, I turned to the attending in the room, saying, “Is it okay if I leave? I’m feeling lightheaded.”

I barely waited to hear her response before I bolted out of the room and found the closest stool to sit on. Bad call. The stool had no back to it, and next thing I knew, I was on the ground. When I opened my eyes, there were at least five  nurses around me, one whom matter-of-factly said, “Honey, you just became a patient.” Another nurse quietly slipped my hospital badge off my jacket, returning two minutes later with a medical bracelet that she fastened around my wrist.

My memory of those early moments is a little shaky, but I do remember saying over and over again, “I’m so sorry, I’m so sorry.” I felt awful that I had come to the ED to learn from the patients, physicians, and staff – without being a burden – but had ended up being another patient for whom they had to provide care. The nurses and attendings immediately normalized the situation, telling me repeatedly that this is a common occurrence in the ED and that many of them had had this happen to them as well. Their assurances made me feel so much better.

The efficiency of the events that followed totally impressed me. The nurse helping me to the bed did the fastest history on me I’ve ever heard, all while hooking me up to a BP cuff and a pulse oximeter. Did I have allergies? (Nope.) Did I  have diabetes? (Nope.) When was the last time I ate? (That morning). Any other medical conditions that I’m being treated for? (Nope.) Any family history of cardiac conditions? (Nope.)

The attending who was with me when I initially felt lightheaded came in at that point and asked, “Has this happened to you before?” and when I told her about the C-section, joked, “ObGyn probably isn’t your favorite thing, huh?” She then laid out the plan for what would happen next: an EKG, a glucose stick, and a blood test, to check for cardiac abnormalities, low blood sugar, and anemia, respectively. Within 30 minutes, all three of these had been done, and I even got a bonus ultrasound thrown in by someone who was practicing recognizing cardiac pathology (not that I had any). Noticing my scrubs and med student badge, this person took the time to show me each ultrasound image, pointing out the various heart chambers, valves, and the location where my IVC entered my right atrium.

By 2 PM, my tests were all back, everything was normal, and I was able to laugh about the entire situation: Somehow, I had come into the ED hoping to practice blood draws and EKGs but came out having them done to me instead. Just another day in the life of a med student.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by zoomar

 

Emergency Medicine, Global Health, Stanford News, Videos

Improving global emergency medicine to save lives

Improving global emergency medicine to save lives

In July 2013, Stanford physician S. V. Mahadevan, MD, and colleagues conducted a study at the largest children’s hospital in Karachi, Pakistan to understand the kinds of medical emergencies that doctors treated at the facility. “What we found was astonishing,” he says in this Stanford+Connect video. “By fourteen days 10 percent of [the 1266 children enrolled in the study] were dead.” Mahadevan saw more children die during the one week he spent in the Pakistan hospital than in his entire 22-year-career in the United States.

Despite such dire statistics, there is hope. Mahadevan, founder of Stanford Emergency Medicine International, explains in the video how important early interventions can be made in the chain of survival to save thousands of lives in low-resource countries. Watch the full lecture to learn more about his efforts to establish Nepal’s first ambulance service, India’s first paramedic training program and his ongoing work to improve emergency care in Cambodia.

Previously: Stanford undergrad uncovers importance of traditional midwives in India, Providing medical, educational and technological tools in Zimbabwe and Saving lives with low-cost, global health solutions

Addiction, Emergency Medicine, Health Policy, Research, Stanford News

Assessing the opioid overdose epidemic

Assessing the opioid overdose epidemic

Vicodin bottle Flickr Sharyn MorrowIn recent years, doctors and policy-makers have become aware of the dangers of prescription opioid medications like methadone, oxycodone and hydrocodone (which is sold as OxyContin or Vicodin). In a study published in this month’s JAMA Internal Medicine, Stanford medical student Michael Yokell and Stanford surgeon Nancy Wang, MD, took a new approach to quantifying those dangers.

Many previous studies of the toll of opioids looked at death certificate data and examined trends among deaths due to opioid overdoses, including street drugs like heroin and prescription painkillers. The new study looked at emergency department admissions and found that more than two thirds of ER visits due to overdoses were related to prescription opioids, while heroin overdoses accounted for 16 percent. Moreover, only about 2 percent of cases that made it to the ER died, but more than half the patients needed further hospitalization.

The study also found that those admitted to the emergency room because of opioid overdoses are more likely to have conditions such as chronic breathing problems, heart problems or mental health issues. Yokell explained that it’s important for doctors to be aware of the possibility of overdose and consider prescribing alternatives or discuss the risk of overdose with patients.

Beyond providing better access to emergency medical care and treatments for patients, an important next step to resolving the problem of opioid misuse is to establish or improve statewide prescription monitoring programs. For example, California has a prescription drug-monitoring database called CURES, but not all doctors actively use the program. “We can do a better job of making that database more widely used by physicians in the state.  We need more doctors to sign up and use it. It’s a valuable resource,” said Yokell.

Additionally, many people get access to prescription opioids via fraudulent prescriptions or from dealers that have illegally obtained the drugs – sometimes from breaking into and raiding pharmacies. “It’s important to keep in mind that good prescribing practices are one component of an effective strategy. There are many other ways for people to get their hands on [prescription opioids] and use them inappropriately.”

Although fixing things on the prescription side is important for managing the opioid overdose epidemic, Yokell notes that it’s not enough. Cases that make it to the ER are likely to survive, but Yokell noted that the fear of criminal charges often results in people avoiding medical care for overdoses caused by opioids and that getting this group better access to emergency services and treatment could improve outcomes. Paramedics and doctors have access to the drug naxolone, marketed as Narcan, which is safe and effective treatment for opioid overdose. But “people don’t call 911, so they are dying,” Yokell told me.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Increasing access to an anti-overdose drug and A focus on addiction, the country’s leading cause of accidental death
Photo by Sharyn Morrow

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

Stanford Medicine Resources: