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Mar 16, 2018 · How often are heart attack and stroke diagnoses missed in the emergency room?

(Credit: Medical News Today)

Every day, thousands of patients visit hospital emergency rooms with chest pain and worry that they’re having a heart attack. Or they have numbness in an arm and worry about a stroke. In some cases, patients aren’t worried but really should be.

Emergency physicians have the difficult task of deciding who actually has a problem and who is OK to go home. So how good a job are they doing?

It’s difficult to measure how often a problem isn’t diagnosed. After all, how does one know that a medical condition was present when the treating physician didn’t think it was?

In a study recently published Feb. 26 in JAMA Internal Medicine, two UCLA Department of Emergency Medicine physicians found a way to do it.

The physicians reviewed Medicare billing records to see how often patients admitted to the hospital for heart attacks, strokes, and other cardiovascular emergencies had been sent home from an ER days before their diagnosis. To account for coincidence, they looked further back in time before the emergencies could have begun to determine how often those same patients had visited the ER for other problems. The researchers deduced that the spike in discharges home from the ER was attributable to imminent heart attacks, strokes and other emergencies that went unrecognized.

The results are mostly reassuring, said lead author Dr. Daniel Waxman, an emergency medicine physician at Ronald Reagan UCLA Medical Center and associate clinical professor of emergency medicine at the David Geffen School of Medicine. Of more than 1.5 million Medicare patients diagnosed with a cardiovascular emergency from 2007 to 2014, researchers concluded that an actual emergency went unrecognized in fewer than one in 20 visits. They estimated that heart attacks were not diagnosed just 2.3% of the time, and strokes 4.1%.

Patients who were younger than 65, female or poor, or those with chronic medical conditions, were at increased risk of a missed diagnosis, although the differences with other patients were small in absolute terms. Nevertheless, the findings about increased risk raise important questions and suggest the need for further research and monitoring, Waxman said.

Despite the increasing use of advanced imaging and other diagnostic techniques, missed opportunities for diagnosis in the ER did not change much over the years that data were analyzed.

This “suggests that if we want to do better, we will need to do something qualitatively different from what we have done in the past,” Waxman, told MedicalResearch.com.

The National Academy of Medicine in 2015 issued a report saying that understanding diagnostic error was critical to patient safety but that little research had been conducted.

Waxman, also a policy researcher at the RAND Corp. in Santa Monica,  recommended that the statistical approach of the JAMA Internal Medicine study be extended to non-Medicare patient populations, health care settings other than emergency rooms and more common diseases conditions.

Waxman’s co-authors included Dr. David Schriger, vice chair of UCLA’s Department of Emergency Medicine, and Dr.  Hemal Kanzaria, an assistant clinical professor of emergency medicine at UC San Francisco.

Jan 19, 2018 · Have the flu? Know when to go. To the ER, that is.

Credit: williambrawley/Flickr

Flu-stricken patients are jamming emergency rooms across California and the country. Flu patients feel terrible. But at what point should they head to the hospital?

Many visit at the first sign of sniffling. Others wait until there’s no choice.

For guidance, we checked in with Dr. Mark Morocco, a supervising emergency physician at Ronald Reagan UCLA Medical Center in Westwood and a clinical professor of emergency medicine in the David Geffen School of Medicine.

If somebody thinks they have the flu, when is an emergency room visit justified?

Hospital emergency departments don’t turn away patients. Emergency rooms everywhere see and treat patients with the most severe symptoms or life-threatening conditions first. When flu is severe enough to keep you from normal health functions – like breathing comfortably, thinking clearly, eating, drinking fluids and getting to the bathroom – then a visit to the ER is needed. People with chronic conditions should call their doctor for advice at the first sign of illness.

What if a patient has been coughing and sneezing for days and having trouble sleeping?

Persistent coughing, sneezing, runny nose, sore throat, body aches, fever and headache from head or chest colds or flu-like illnesses can make you feel miserable. If- over-the-counter medications such as Tylenol (acetaminophen) or Motrin or Advil (ibuprofen) reduce your fever and body aches and you are able to drink fluids and urinate normally, you probably don’t need to go to the hospital emergency department. But it’s still best to NOT go to work or school. Cover your mouth with a tissue when you cough or sneeze, and wash your hands before touching or interacting with other people until you feel better – generally, about 5-10 days.

The symptoms of greatest concern are persistent vomiting that prevents consumption of water, decreased urination indicating dehydration, high fever that does not respond to over-the-counter medicines, shortness of breath and confusion.

Remember that the very young – under age 2 – and those who are over 65, pregnant or with chronic medical conditions have a higher risk and should contact their doctor for advice at the first sign of illness. The same is true for those with compromised immune symptoms, such as cancer or transplant patients.

What are my options if I have none of the most severe symptoms?

Most people underestimate how bad flu patients can feel – what I call stuck-in-bed bad.  But unless you have the symptoms described above, consider contacting your regular doctor first. Any physician can check you out, make sure there is no immediate threat beyond your discomfort, and prescribe medications if appropriate. Most patients do NOT need antibiotics.

Over-the-counter medications and plenty of fluids are most helpful. Chicken soup works basically the same as an IV; it is comforting but also easily replaces lost fluids and salt without the needle. Commercially available drinks like Gatorade work, too, but should be diluted to half-strength with water. Stay home until you are fever-free for 24 consecutive hours. That usually takes 5-10 days, although smokers and older patients can feel bad for longer.

What should patients and their loves ones be looking for?

Symptoms like cough can sometimes linger for weeks. But they are not dangerous unless accompanied by more serious symptoms – difficulty or painful breathing, shortness of breath, confusion, fever that doesn’t improve with over-the-counter medications, or a dry cough that suddenly changes to one that produces large amounts of green or yellow mucus. If this occurs or you suddenly get worse, see your regular doctor immediately or come to the emergency room. Left untreated, viral illness can become pneumonia.

Any tips for staying flu-free?

Avoid visiting those who have active flu or illness with fever, and wash your hands or use hand sanitizer if you touch someone who is sick. Flu vaccination is still the most effective way to prevent infection, despite what you may hear on TV. Even a partial-match vaccine might protect you from the worst flu symptoms. The vaccine takes two weeks to kick in, and there could be months left in this year’s flu season, so get one as soon as you can.

Mar 21, 2017 · Is medication alone a good alternative for treating appendicitis?

 

Challenging more than a century of medical tradition, a UCLA doctor is exploring whether antibiotics can be an effective alternative to surgery for treating appendicitis.

Dr. David Talan, an emergency medicine and infectious diseases specialist at the David Geffen School of Medicine at UCLA, is study director of a 1,500-patient, $12-million national clinic trial. It’s the largest randomized clinical trial comparing antibiotics to surgery for treating inflammation of the appendix.

“Routine appendectomy has served us well for a long time, so we should be skeptical of change,” Talan said in a Q&A with UCLA Newsroom. “But skepticism also demands that we carefully study and compare the relative efficacy of different treatment approaches.”

Patients may be able to avoid surgery altogether, Talan told the New York Times in 2015.

For 130 years, surgical removal has been the go-to option for an inflamed appendix, a short tube extending from the colon that is not essential to survival. Today, appendectomy is the most common emergency surgery, with approximately 300,000 performed in the U.S. each year.

Studies outside the U.S. and Talan’s own small study at county-run Olive View-UCLA Medical Center in Sylmar have shown antibiotics may be a safe alternative, with a quicker recovery time and reduced costs.  When caught early and treated with medication, an inflamed appendix “is not always a ticking time bomb that must be removed for fear of rupture and death,” Talan said

Talan emphasizes that more data are needed to determine the risks and benefits.

Participants in the clinical trial will be randomly selected for treatment with antibiotics or an appendectomy. Over a year or more, Talan and his colleagues will track patients for recurrence of appendicitis, length of hospital stays, treatment costs, pain, mobility and other measures.

“Traditional medical approaches are constantly being re-evaluated to determine their value to society,” Talan said. “Extensive data from a large-scale study will help patients and their physicians make more informed health care decisions.”

The clinical trial is scheduled for completion in 2021.

Jun 26, 2016 · Better pain relief speeds recovery after colorectal surgery

As we’ve seen from the much-reported rise in abuse of prescription opioids, use of the painkillers can be fatal when not properly managed.

But even under the careful supervision of a physician, opioid use can cause a less severe problem – opioid-induced constipation, leading to delays in a patient’s discharge after surgery.

Now, UCLA physicians from several departments have collaborated on a new regimen to manage pain using fewer opioids while speeding recovery of patients before, during and after colorectal surgery. It’s part of a larger enhanced recovery program for these surgery patients at Ronald Reagan UCLA Medical Center.

“We always strive to keep patients as comfortable as possible when they’re in the hospital, and allow them to return home to their families as soon as possible after surgery,” said Dr. Aman Mahajan, chair of the Department of Anesthesiology and Perioperative Medicine at the David Geffen School of Medicine at UCLA.

The pain-management protocol took shape after surgeons realized that some patients were staying in the hospital longer than average after surgery on the colon, small intestine or rectum because they were slow to recover bowel function.

Physicians identified the chief culprits as morphine, Dilaudid and other narcotics that help manage post-operative pain but may result in opioid-induced constipation.

Surgeons and anesthesiologists – led by Dr. Anne Lin, an assistant professor specializing in colon and rectal surgery, and Dr. Maxime Cannesson, vice chair for perioperative medicine – developed a plan to reduce the prescription of opioids through the use of local anesthetics in combination with an ultrasound-guided nerve block, and acetaminophen.

The result: In a pilot study, patients on this pain management regimen recovered bowel function up to two days earlier than patients who received the usual medications.

The enhanced recovery program – which includes pain management techniques as well as many other elements – has now expanded beyond the pilot phase.

Get more information on the program on the Department of Anesthesiology & Perioperative Medicine website.

 

Apr 28, 2016 · Airway tubes can be vital. Maybe we can secure them more effectively

Modern medicine demands a constant quest for more efficient and safer ways to deliver care.

An endotracheal tuAirway-tube3be – a device inserted into a patient’s mouth and guided into the windpipe to maintain an open airway and when patients cannot breathe on their own – is typically kept in place with tape wrapped around it and attached to the patient’s face. If the tube is pulled out accidentally, a patient may suffer from lack of oxygen or other complications.

UCLA anesthesiologists have found that a special device created to keep the breathing tube in position is far more effective and secure than tape.

Their research, published recently in the journal Anesthesia & Analgesia, has the potential to improve the safety and security of endotracheal tubes for patients in the operating room, emergency room and intensive care unit, said Dr. Nir Hoftman, a clinical professor of anesthesiology at David Geffen School of Medicine at UCLA, and one of the study’s authors. Study results are featured on the department’s website.

The anesthesiologists studied a group of patients who needed to be intubated for elective surgery, and who gave their permission to participate.  After the breathing tube was properly positioned in the windpipe and secured with tape, the physicians applied a controlled amount of force in an attempt to dislodge it. The tape was then removed and the tube fitted with the new plastic device, called the Haider Tube-Guardâ, which is inserted in the patient’s mouth and includes a clamp to secure the tube. Then the same amount of controlled force was applied.

The results: In 29 of 30 patients, there was clinically significant movement of tubes secured by tape, with nine tubes deemed at high risk of being dislodged. That compares with only one instance of significant tube movement when the tube guard device was used, and no instance of the tube deemed at high risk of being dislodged.

Dr. Hoftman said using the tube guard was “like putting a key in a lock. Once it’s turned, you can’t pull it out.”

The manufacturer provided devices to UCLA anesthesiologists for the purpose of independently conducted research. There was no compensation to patients or commercial funding for the study.

UCLA Health is planning additional tests and evaluating potential wider use of the device, which has U.S. Food and Drug Administration approval.

The soft plastic device – which serves as a bite block as well as a tube holder – was developed by an orthopedic spine surgeon from Riverside, Calif.