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Emergency Medicine, Global Health, Stanford News

Day 4: Reaching beyond Kathmandu in treating Nepal earthquake victims

Day 4: Reaching beyond Kathmandu in treating Nepal earthquake victims

Paul Auerbach is in Nepal to aid victims of the recent earthquake and has been sending periodic reports.

The earthquake in Nepal caused immense damage to people and property not only in Kathmandu, but in a widespread area extending to Mt. Everest and in many other directions. Victims on Mt. Everest and in Kathmandu proper appropriately received a great deal of attention, but equally important has been the plight of persons trapped in villages remote from the big city. These communities are located in steep and isolated terrain, so that it is difficult to reach them by road, and sometimes even by helicopter. Part of the mission of International Medical Corps (IMC) and the other responding organizations has been to identify these areas of need and attempt to locate and treat the victims.

We continue to see improvement each day, and the number of volunteers from around the world is impressive

After a discussion with three health officials – the senior district health officer for Dhading, a pediatrician assigned to lead the district medical response to the earthquake, and the medical supervisor for the Dharding District Hospital, we were asked to consider finding a way to approach one of several villages that were reported to have urgent medical needs, but which had not yet been visited by rescuers and medical professionals. We selected Kumpur, a rugged 90-minute approach requiring a 4-wheel drive vehicle. We excluded others that required helicopter access, because these aircraft have been in short supply.

At the Dhading District Hospital, we witnessed arrival of a dozen earthquake victims choppered in from Darkha, which is at a high elevation in this region. They were suffering from trauma, with broken limbs and wounds in various stages of infection. The Nepalese doctors who volunteered their time by leaving Bangladesh to respond at the request of IMC, alongside a (literally) busload of surgeons and other medical professionals volunteering from India were skilled and swift in delivering treatment despite the limited resources and surge of patients.

The next day, we took a team into Kumpur and witnessed widespread destruction amid the beautiful surroundings. Many dwellings composed of mud and stone had collapsed, and the residents are now living in tents. With the monsoon season approaching, they will need assistance to rapidly create more suitable structures. They were busy clearing the remains of their homes and other structures, but always gave us a smile and a greeting. Their resilience and work ethic are amazing.

The health outpost has been rendered largely unusable, with large cracks in its side, holes in the wall, and instability in every direction. So, we worked mostly in the single safe room remaining and on the porch leading to the entryway. With a stellar support team, including two recently graduated doctors from Nepal, we were able to interview and examine many of the villagers, dealing with complaints both related to injuries sustained in the earthquake and medical conditions for which they sought advice.

As the days pass, fewer patients will present with acute earthquake-related injuries, and the medical care will shift to resumption of adequate primary care, surgeries related to orthopedic and soft tissue injuries, and aggressive detection and management of infectious diseases that might cause an epidemic. Public-health experts are on-scene, as are epidemiologists and other experts in sanitation systems, water disinfection, and so forth. Given the large geographic area affected by the earthquake and difficulty reaching many locations, the logistics are extremely important.

We continue to see improvement each day, and the number of volunteers from around the world is impressive. We hope for the best and appreciate all the support we’ve received from family and friends.

Paul Auerbach, MD, is a professor and chief of emergency medicine who works with the Stanford Emergency Medicine Program for Emergency Response (SEMPER).

Click here for a statement on Nepal from Michele Barry, MD, senior associate dean of global health and director of the Center for Innovation in Global Health (CIGH). Additional updates related to the Stanford relief efforts will be shared on the CIGH website in the coming days and weeks.

Previously: Day 2: “We have heard tales of miraculous survival” following Nepal earthquake and Day 1: Arriving in Nepal to aid earthquake victims

Emergency Medicine, Global Health, Stanford News

Day 2: “We have heard tales of miraculous survival” following Nepal earthquake

Day 2: "We have heard tales of miraculous survival" following Nepal earthquake

Paul Auerbach is in Nepal to aid victims of the recent earthquake and has been sending periodic reports.

Today in Kathmandu was quite different from yesterday. The city has certainly sprung back remarkably. Although its citizens face enormous challenges, the streets were nearly full with traffic, rubble was actively being cleared from obstructing piles, and people were walking and resuming commerce. There are an estimated 16 camps within the boundaries of Kathmandu, where people are either forced to seek housing or prefer to remain, certainly for sleeping at night, until homes can be replaced or cleared with respect to structural integrity. The camps are orderly and treated with dignity by the occupants and passers-by. We visited one this afternoon to perform a clinic, examining patients who wished to see a physician. Because the hospitals in Kathmandu received the injured soon after the earthquake, we mostly served persons with “routine” medical ailments. They were kind to us and appreciated the attention.

International Medical Corps continues to grow its staff and operations to meet the evolving situation. Side by side with other entities that have responded, including large national emergency response teams, there will be increasing focus on the communities outside Kathmandu, where there is sparse medical care and distances to hospitals mean walks of hours. Some of these will need to be approached by helicopter because of distances, mud- and rockslides caused by the earthquakes that have obstructed roadways, and calls for urgent assistance. It’s anticipated that some teams may need to trek for days to reach certain villages. Much of the coming days’ and weeks’ activities will be intended to avoid the spread of infectious diseases.

We have heard tales of miraculous survival, sadly posed against the grief of many lost family members and friends. Driving through the city past enormous mounds of rubble that last week were sacred temples and monuments, it is striking to think about how much there is to be done worldwide to prepare for cataclysmic natural events. There will be many lessons learned from this catastrophe, and we should take them to heart. One of them is how much better is a world focused on mutual aid and skillful compassion than upon dominance and conflict.

Paul Auerbach, MD, is a professor and chief of emergency medicine who works with the Stanford Emergency Medicine Program for Emergency Response (SEMPER).

Click here for a statement on Nepal from Michele Barry, MD, senior associate dean of global health and director of the Center for Innovation in Global Health (CIGH). Additional updates related to the Stanford relief efforts will be shared on the CIGH website in the coming days and weeks.

Previously: Day 1: Arriving in Nepal to aid earthquake victims

Emergency Medicine, Global Health, Stanford News

Day 1: Arriving in Nepal to aid earthquake victims

Day 1: Arriving in Nepal to aid earthquake victims

17290207611_0062388d65_zUnder the auspices of International Medical Corps, I’ve just joined a team that will be growing to help meet the needs of Nepal following the recent devastating earthquake. It wasn’t easy to fly in, because the airport has a single main runway and isn’t large enough to park many large aircraft, and there is a great number of relief flights from all around the globe bringing people, equipment, and supplies. Our commercial flight was largely occupied by responders, including an official Japanese search and rescue team, as well as concerned and courageous people of Nepal returning to be with their families. Yesterday our plane originated out of Bangkok, was diverted twice to India, and then returned to Bangkok. We were fortunate to get an early start today and reach Kathmandu.

The scene is somewhat reminiscent of what we encountered five years ago in Haiti, with the main exception being that there is much more of a structured health-care system in Nepal than there was in Haiti, and so the national medical response has been significantly more robust. Still, there are more than 4,000 known victims, and likely many more to be discovered in areas surrounding Kathmandu that are difficult to reach. Furthermore, there will be at least quadruple that number of persons with significant injuries.

Having been to Kathmandu a few times on my way to the majestic Himalaya mountains to trek, including to Everest Base Camp (which was struck by a devastating avalanche caused by the earthquake), it was very sad to see the collapse of buildings – indeed large portions of certain neighborhoods – as well as ancient temples and iconic structures. Soon after leaving the airport, I witnessed resilient citizens sheltering under tents because their homes are destroyed or structurally unstable endure a fierce rainstorm with sheets of hail, causing some streets to flood and emphasizing the risk for spread of infectious disease, such as cholera, in the aftermath of the earthquake.

The local medical community has responded aggressively to this situation, and the health professionals have been working around the clock to tend to patients. The overall community led by volunteers is assessing its capabilities to support shelter, hygiene, provision of safe water and food, and integration of its capabilities with those that are coming in relief. The government is working hard to integrate its efforts with non-governmental agencies, other countries, and generous donors of all necessary aspects of the much needed relief effort.

Please keep the people of Nepal in your thoughts and prayers.

Paul Auerbach, MD, is a professor and chief of emergency medicine who works with the Stanford Emergency Medicine Program for Emergency Response (SEMPER).

Click here for a statement on Nepal from Michele Barry, MD, senior associate dean of global health and director of the Center for Innovation in Global Health (CIGH). Additional updates related to the Stanford relief efforts will be shared on the CIGH website in the coming days and weeks.

Previously: Stanford emergency-response team heads to the Philippines, Treating the injured amid the apocalypse of Haiti, Reports from Stanford medical team in Haiti and Stanford sends medical team to Haiti
Related: Stanford’s SEMPER team provides relief to Typhoon Haiyan survivors and Report from Haiti: ‘None of us had ever seen anything like it’
Photo by Domenico

Emergency Medicine, Medicine and Society, Public Health, Public Safety, Research

Study: ER statistics could be used to help reduce gun violence

Study: ER statistics could be used to help reduce gun violence

ER shot

Emergency room doctors treat many patients who have been involved in violent assaults. New research shows that these patients are far more likely than other ER patients with otherwise similar demographics to seek treatment for gun-related injuries in the near future.

These findings “could help injury researchers, emergency department physicians, and social service agencies focus their intervention efforts to prevent future firearm incidents and other violent incidents among high-risk youth populations,” explains a University of Michigan press release published Monday.

The study, published in Pediatrics, followed nearly 600 drug-using youth in Flint, Mich. for two years after they were admitted to the emergency room. Nearly 60 percent of those admitted for assault-injury care became involved in a violent incident involving a firearm within the next two years, and of those, the majority did so within six months after the initial visit. Between two people with highly similar demographic factors, someone admitted for assault is 40 percent more likely to be involved in gun violence than someone admitted for a cold.

The results also calculated the statistical correlations of various markers, such as race, gender, drug abuse, PTSD, possession of a firearm, and tendency toward retaliation (see the release for the details). ERs that track such markers could identify the highest-risk youth and help them receive targeted treatment. The release quotes Patrick M. Carter, MD, an assistant professor of emergency medicine at UM, member of the UM Injury Center, and first author of the study, saying the results “support using the ER as the site for intervention, especially during the ‘teachable moment’ that immediately follows an initial assault or fight.”

Previously: Pediatricians’ role in gun control: Recommendations from the American Academy of Pediatrics, Emergency-room interventions may reduce alcohol-based violence among teens and Emergency room as soup kitchen
Photo by Military Health

Emergency Medicine, Health Costs, In the News, Research, Stanford News

Thinking twice before doing blood transfusions improves outcomes, reduces costs

Thinking twice before doing blood transfusions improves outcomes, reduces costs

7413610060_317879301e_zStanford Hospital has figured out that doing fewer blood transfusions saves lives – and millions of dollars annually. In two studies headed by Stanford’s Lawrence Goodnough, MD, professor of pathology and hematology, doctors were gently nudged by a computer program to think twice before performing a blood transfusion. The impressive results were discussed in a Nature news feature published Tuesday:

The number of red-blood-cell transfusions dropped by 24% between 2009 and 2013, representing an annual savings of $1.6 million in purchasing costs alone. And as transfusion rates fell, so did mortality, average length of stay and the number patients who needed to be readmitted within 30 days of a transfusion. By simply asking doctors to think twice about transfusions, the hospital had not only reduced costs, but also improved patient outcomes.

Transfusions are common procedures in industrialized countries, but scientists are finding that they’re overused. More research needs to be done to determine when, exactly, transfusions cross the line between helpful and harmful. They do save lives, but probably only for the most critically ill patients.

Decades of established practice and protocol are hard to change, though. Clinicians acting in the moment refer to their experience, not to guidelines. That’s one reason Stanford’s simple computer innovation is so important. Goodnough, quoted in Nature, speculates about why it succeeded: Not only did alerts remind doctors about the guidelines and provide links to the relevant literature, they forced them to slow down and think instead of running with the default. The alerts may have provided an opening for more individualized discussion among caregivers:

‘Maybe the intern, who was ordering the blood because they were told to, goes back to the team and says, “I have to give a reason”, and then they discuss it,’ Goodnough says. The clinicians might decide to order the blood anyway, of course. Or they might stop, consider the evidence, and come to agree with what Goodnough believes is its clear message. ‘The safest blood transfusion,’ he says, ‘is the one not given.’

Check out the article for more on the history of blood transfusions, other research into their optimal use, and new practices being pioneered around the world.

Previously: Fewer transfusions means better patient outcomes, lower mortality, Stanford Hospital trims use of blood supplies, Stanford test a landmark in the blood banking industry and Should the US create a national blood transfusion reporting system?
Related: Against the flow: What’s behind the decline in blood transfusions?
Photo by Banc de Sang i Teixits

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.

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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

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