Tag: Emergency Medicine

EpiPen cost soars 400%: Implications for EMS and the ED

I had a patient last week brought into the Pediatric ED for an allergic reaction. The child had known allergies, and by the EMR, had been prescribed an EpiPen by the Pediatrician – but mom said she didn’t have one at home to use. “We have insurance, but when I tried to fill the prescription, they wanted $620! I just can’t afford that,” she apologetically told me. I sat there in disbelief, assuming she had crappy insurance.

Flash forward three days later when the news hits the mainstream media:

“EpiPen price hike has parents of kids with allergies scrambling”

“Why did Mylan hike EpiPen prices 400%? Because they could”


Prehospital Implications

AEMTs and Paramedics, better check that drug box twice for your 1:1000 epi vials because you’ll be using them more often for anaphylaxis as parents and patients increasingly forgo the EpiPen. With a $400-$650 price tag (with insurance), and a 1 year expiration date, can you blame them? I certainly don’t.  So brush up on your local protocols, and stay vigilant. For a good review on anaphylaxis, check out this post.

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Emergency Department (ED) Implications

As with prehospital providers, we too need to be ready with the IM epinephrine.  It’s always been recommended after EpiPen administration for patients to come to the ED  to be observed for 4-6 hours in case they need a redose of epinephrine.  As patients increasingly skip that first dose, we should expect more potential for respiratory distress and need for difficult airway management.


EpiPen Alternative

Thanks to the Facebook Group EM Docs, I learned of AdrenaClick, a reasonable alternative we can prescribe for patients with severe allergies.  The mechanism of delivery is slightly different than the EpiPen (two caps to remove instead of one), but given that it’s 1/4 the cost – it’s what I’ll be prescribing moving forward.  AdrenaClick has a good training video on their website with detailed instructions for use.  With a coupon from GoodRx, AdrenaClick is available for as low as $141.67 at Wal-Mart.  It’s still more than the original $57 cost of an EpiPen when acquired by Mylan, but better than current EpiPen prices.

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If you want to learn more about the skyrocketing prices of the EpiPen and the not-so-coincidental tie to congressional mandates requiring EpiPens (like AEDs) in schools, check out this article on Bloomberg.

<Disclaimer> And, of course, I do not endorse the efficacy of, nor am I paid by AdrenaClick. They just happen to be the only other comparable epi auto-injector on the market right now.  <Disclaimer />

~Steph

 

Celebrate the Small Stuff: Surviving the Marathon of Medical Training

In just two short months, thousands of newly minted young physicians will be walking into new hospitals, new jobs, and new responsibility. They’ll notice something unfamiliar tickling their calves on that first day – a long white coat having replaced the short one, which in our case went up in flames just days earlier. They’ll be excited and terrified, nervous and naïve.

A doctor’s “intern year” has become something of a legend in pop-culture, portrayed as twelve months of rude awakenings, sleep deprivation and verbal abuse, +/- a love triangle or two. Having been there, done that and proudly owning the t-shirt, I can say the reality couldn’t be further from the truth – at least it doesn’t have to be.*

To all the newbies out there – yes, there will be long hours and sleepless nights. You’ll occasionally go a full week without seeing your loved ones and eat whatever/whenever you can. Med school will seem a lifetime ago when you’re being asked at 3am what to do for a dying person, and you’ll wonder why they never taught you all the things that matter. But Steph and I have stumbled across the solution to all of that.

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Champagne celebration for med school graduation | Photo credit: Amy McClure

We celebrate the small stuff.

Sure we popped champagne like we’d just won a Grand Prix on graduation day, but we’ve also raised a glass to finishing tough rotations, making a clutch diagnosis and running our first double cardiac arrest. We’ve made a ritual of rare Sunday mornings off together with a supply of cinnamon buns always available, just in case. Sometimes we just celebrate because it’s Tuesday and we can. By making a big deal of small victories, the roadblocks become surmountable.

 

Don’t get me wrong – residency is tough. In the past month, three of my patients have died, and I’ve told four others they have cancer. But for every bad day I have had there have been a dozen that left me thinking, “I have the best job in the world.”

I encourage all the newbies out there to approach this next chapter the same way. And remember: when the champagne runs out, there’s always more coffee.

 

*Note: does not apply to general surgery residents. Your life will suck.


How do you like to celebrate the small stuff?

~Amir

 

Understanding the Origins of the Cincinnati Prehospital Stroke Scale

We all learned it in EMT-B class.  The Cincinnati Prehospital Stroke Scale (CPSS) is the core assessment tool for EMS providers to evaluate possible stroke patients in the field.  But, have you ever wondered where it came from?  Why does it have 3 parts? Why test speech and not eyesight?  What part of the brain is really injured? Let’s take a deeper dive.

What is the CPSS?

For a quick review, the CPSS is comprised of three individual tests, each of which get interpreted as either normal or abnormal by the EMS provider.   The tests as well as interpretation are summarized in the table below.

Components of the Cincinnati Prehospital Stroke Scale

Adopted from Kothari, et al, 1996 

Test

Normal

Abnormal

1

 

Facial Droop

 

Patient smiles or shows teeth Both side of face move equally One side of the face does not move as well as the other (or not at all)

2

 

Arm Drift

 

Patient extends arms out, closes eyes, and holds in place x 10 seconds Both arms move the same, or both arms stay in position One arm does not move or drifts downward compared to the other

3

 

Speech

 

Patient repeats “You can’t teach an old dog new tricks” Patient repeats back correct words with no slurring of words Patient can’t speak, says the wrong words, or slurs words

The CPSS is positive if any one of the three tests is deemed abnormal.  In studies comparing Physicians vs EMS providers when performing the CPSS, when performed by an EMS provider, if the patient scored positive for one component, the sensitivity was 59%, meaning just over half of the patients who indeed had a stroke were identified by the EMS provider as having a stroke.  The specificity was 89%, meaning that 89% of people who had a positive CPSS (1/3 components) indeed had a stroke.  In other words, they caught just over half of the true strokes, but they also obtained a positive CPSS on some patients that didn’t have a stroke. The best example is a patient who is intoxicated.  They likely have slurred speech, and therefore a positive CPSS, but aren’t actually having a stroke.  Most tests in medicine are like this, you miss some, and you catch some that don’t really have the disease.  We call these false negatives and false positives.  Oh, and did I mentioned that EMT-Bs scored just as reliably as the Paramedics in the study?

The CPSS intentionally misses some strokes

To understand what the CPSS is looking for, it’s important to know a bit about the history of how it was created and why.  The CPSS was developed at the University of Cincinnati Medical Center in 1997.  tPA had just been approved by the FDA in June 1996.  The CPSS is derived from the NIH Stroke Scale (NIHSS).  You can read more about it here, but simply put, it’s a 15 part assessment where the patient gets scored according to their symptoms.  The NIHSS was developed to identify neurological deficits that correspond to specific geographic tissue damage in the brain.  MDCalc offers a great online calculator for helping determine a patient’s NIH Stroke Scale score.  The NIHSS was condensed down, with some categories eliminated and some combined, to make the CPSS simple and easy to use, but also to help identify those patients who would be potential candidates for tPA.   Not all strokes are created equal, and not all strokes are elligible for tPA, even if identified within the 4.5 hour time window.  Strokes of the anterior cerebral artery and middle cerebral artery are better tPA candidates that other types of stroke.  The CPSS focuses on identifying those strokes, but not posterior strokes for example.

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The future of the CPSS and prehospital stroke identification

As I mentioned, the CPSS is not designed to detect things like posterior circulation strokes that affect the cerebellum, the balance center of the brain.  Historically, efforts focused on early identification of tPA candidates.  As new surgical and pharmacological advancements develop for other types of stroke, there’s a greater emphasis on early identification of all strokes.  As such, there’s a lot of research going on right now studying new or modified prehospital stroke assessment tools.  One front-runner is the B-FAST, which adds one more test to the CPSS to test for balance, and potentially identify posterior circulation strokes.  The posterior circulation (basilar artery in the diagram above) supplies blood flow to the cerebellum, the balance center of the brain.

B – Balance, tested by having the patient walk

F – Face, same as CPSS

A – Arms, same as CPSS

S – Speech, same as CPSS

T – Time, to remind us that time is brain

If you want to impress with your turnover on your next stroke patient, be sure to test for balance disturbances by (carefully) ambulating your patient.  If the patient stumbles or can’t walk without assistance, that’s a pertinent positive.  In the original Cincinnati study by Kothari, the CPSS missed 13 patients with stroke, but 10 of those were posterior circulation strokes, notoriously difficult to diagnose clinically, and often missed by even the best Emergency Medicine physicians.


 

As always, feel free to share any tips you have on helping assess for stroke in the field.

~Steph

Some references:
Kothari R1, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med. 1997 Oct;4(10):986-90.
Kothari RU1, Pancioli A, Liu T, Brott T, Broderick J. Ann Cincinnati Prehospital Stroke Scale: reproducibility and validity. Emerg Med. 1999 Apr;33(4):373-8.

Caring for criminals: How to provide good medical care to people who have done bad things

As an Emergency Medicine Physician and EMS provider, I get a lot of questions about my job.  #1 “What’s the worst thing you’ve ever seen?”  #2 is “How do you stay motivated and not let it get to you?” And #3 is what I’ll address in this post, “How do you take care of murderers, rapists and other people who have done horrible things?”

It’s an unfortunately common scenario: high-speed MVC, multiple vehicles, one DOA (dead on arrival), two adults in critical condition, being flown by helicopter as the highest level trauma alert, alcohol involved.  And all too often, Paramedics, Nurses and Physicians have to take care of everyone involved, including the intoxicated driver that caused the mayhem.  How do you have compassion, empathy and care for someone that by all evidence just killed someone in a completely preventable way?  I’ve been in Emergency Medicine for 11 years, and I still struggle with this.  It’s never easy, but I’ve found a few strategies to help cope.

1. Don’t Ask, Don’t Tell

A few months back I was taking care of an ICU patient that I knew was a prisoner in a maximum security prison due to the vigilant watch by 2-3 armed security guards at all times.  Clearly he had done something bad, but for me, knowing exactly what would only potentially worsen the medical care I could give him, not improve it.  So I didn’t ask, I didn’t Google.  Unfortunately someone else did, and shared it with the whole team.

Turns out he beheaded a total stranger, a husband and a father of two, because he didn’t have cash in his wallet when he tried to rob him.  Once I learned that, I couldn’t unknow it.  I struggled to walk in his room each morning with a smiling face and open, non-judging mind.  For the human in me, it was a battle I had to consciously fight.  My advice to anyone who might care for inmates or anyone in police custody, don’t ask, and encourage the whole team not to ask.  And if you find out, don’t tell.  99% of the time it’s not relevant to patient care, and can only cause you (and everyone else on the team) to make mistakes.

2. Be an Advocate

Incarcerated people have difficulty accessing medical care.  Although prisons and jails have a medical clinic, studies show that prisoners get less frequent and timely care for both chronic and acute conditions.  A 2009 report published in the American Journal of Public Health, unearthed some worrisome stats:

  • “Among inmates with a persistent medical problem, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local jail inmates had received no medical examination since incarceration.

  • Prior to incarceration, slightly more than 1 in 7 inmates were taking a prescription medication for an active medical problem routinely requiring medication (as defined in the Methods section). Of these, 3314 federal (20.9%), 43 679 state (24.3%), and 28 473 local jail inmates (36.5%) stopped the medication following incarceration.

  • Only a small portion of prison inmates (3.9% of federal and 6.4% of state inmates) with an active medical problem for which laboratory monitoring is routinely indicated had not undergone at least 1 blood test since incarceration. However, most local jail inmates with such a condition (60.1% [SE = 1.8%]) had not undergone a blood test.

  • Following serious injury, 650 federal inmates (7.7%), 12 997 state inmates (12.0%), and 3183 local jail inmates (24.7%) were not seen by medical personnel.

Incarcerated persons have to “prove” to prison staff they are truly sick and need to go to the Emergency Department.  Yes, many prisoners fake or exaggerate symptoms for the secondary gain of getting a break from behind bars: better eye candy, different food, and maybe some good pain medication.  But, 38-43% of inmates have chronic medical conditions, which by all evidence, may not be properly addressed and managed by the prison clinic.  When these patients present to the ED, I play it safe and assume they have been sick a few days longer than a regular person, as they probably had to fight to make their case to prison staff.  Guilty or innocent, these patients all need an advocate for their medical care.  I take pride in being that person, which allows me to keep my personal judgements out of the encounter.

3. We are guilty, too

Last week I took care of a woman addicted to IV heroin.  By all accounts, she was pitiful looking – shivering, sweating, unable to sit still.  She was also curt, demanding and liked to cuss at us.  The medical student with me asked how someone could make such poor choices and then be so demanding.  I didn’t disagree, and I found myself starting to judge.  I had to redirect my thoughts and remember that prescription opioids can be a gateway to heroin for many people.  Heroin is 1/10th the cost of prescription drugs bought on the street.  People get hurt or have surgery, and we (doctors, NPs and PAs) prescribe them pain medication.  When people can’t afford their prescription drug addictions, they turn to the cheaper alternative.  And who writes the most prescriptions for these drugs?  Us. We contribute to this, so we need to accept treating it.

handcuffs

That’s my limited advice.  It’s still a daily struggle, with some days easier than others.  Do you have any tips to offer on how to approach this difficult patient population?  If so, I’d love to hear them.  I encourage you to comment below.

~Steph

Advice on Switching Careers: How I made my decision to move from Marketing to Medicine

I’ve had a few people ask me to write about this, so here goes.  First off, my story is just that – mine and potentially not entirely applicable to others looking to change careers, but nonetheless I’m going to attempt to pull out the pearls and advice that I can.  Here’s the step by step process I took to a total career and life change, from President of a boutique Interactive Advertising Agency, to Emergency Medicine Physician, in the span of 7.5 years.

STEP 1: Recognize you need a change

Sometimes the need for change is obvious – if you find yourself counting down the clock to the end of your workday, then something is likely wrong.  What’s harder is recognizing the need for a career change when it’s less obvious – when you like the job you have, but you have more passion for something else.  That was the case with me.  I’d been fortunate enough to have great success in my last career.  I was well-paid for doing interesting work with cool people.  But, I had been volunteering with the rescue squad for 3 years and had gone back to school to get my Advanced Life Support (ALS) certification.  I felt alive and intellectually stimulated in the course. I was finally getting to learn the deeper pathophysiology behind what I’d been seeing in my patients for the last 3 years.  And, instead of volunteering the required 48 hours per month with my rescue squad, I was logging somewhere just over 100 hours per month.  I was about to cross a threshold where I was spending just as much time pursuing my passion for Emergency Medicine as I was in my professional field of Interactive Marketing.  That’s when I first had the idea of a career switch.  That was October 2007.

STEP 2: Mull it over

A career change isn’t the kind of thing you should decide on a whim.  So, do yourself and those around you a favor and take some time to digest the idea.  One of the smartest things I did was asked my friends what they thought, “Could you see me as a doctor?” “Do you think I’d miss marketing & technology?” “When do I seem most happy?”  If you have great friends & family like I do, they’ll have noticed this and be willing to share.  For the record, my parents did ask me the night of my EMT-B graduation (December 2004), “Are you sure you don’t want to go to medical school?”

That said, be prepared that this is the stage where the naysayers also come out.  I can’t tell you how many people said to me something along the lines of, “So I guess you don’t want marriage and kids then, huh?”  To which I wanted to reply, “No, I’m pretty sure I didn’t say that.”  The implication is reasonable though, and certainly something I took into consideration.  At the time I was 27 and single with no kids.  If I was accepted to medical school, would I ever have time to date?  Even if I met the right person, would I be able to balance marriage, babies and a life as a Med Student/Resident?

But at the same time, was I going to put my dreams and my life on hold waiting for a theoretical knight on a white horse that might never arrive?  I saw myself 10 years later without my knight or my dream career in medicine.  I most certainly didn’t want to come up empty handed on both counts.

What about the financial implications?  Here’s where it helped that I was single with no kids.  Supporting just myself, I’d been able to save a decent lump of money while working.  I was in a position to quit working and go back to school full-time (more on that in a bit).  And if it meant going back to eating Ramen Noodles, it was just me who would have to suffer.

STEP 3: Gather Information

Having not been a pre-med major, I had no idea what the rules were for medical school.  For example, would they even accept someone over the age of 30?  What prerequisite courses are required?  Does it matter that I majored in Computer Science, Marketing & Spanish and not Chemistry or Biology?  What’s on this MCAT thing? Every career field will have some of these rules, written and unwritten.  You need to know what you’re up against.

Do yourself a favor and do what I did.  Make some appointments to meet with the people that matter.  I had two major challenges: 1) identify and take all of the prerequisite courses and 2) understand admission requirements for medical school and assess my competitiveness.  So, I knew I needed to talk to someone at an undergraduate university and at a medical school.  Because I wanted to stay local, I set up appointments with the Dean of Sciences at Old Dominion University (ODU) and the Dean of Admissions at Eastern Virginia Medical School (EVMS).  Getting the appointments was much easier than I had anticipated.  I simply filled out contact forms on the websites for each school; they emailed me back within 48 hours.  That was November 2007.

Also, this is a great time to network.  On a side note, coming out of undergrad I was very hesitant to play the Networking game.  I naively wanted to feel like I achieved everything I had on my own, without “cheating.”  After working for a few years, I learned that success is actually a combination of three things: hard work, luck and help from those around you.  Your neighbor may have gone to college with the Hiring Manager for the job you have your eyes on.  Ask your Facebook friends if they know the people in charge at the place you want to go.  Did you know you can search Facebook for people who work at specific companies?  Simply type in “Friends who work at ________” and you might be surprised to find that someone you know works at the company or school where you need an “in.”  Here’s an example from my page of “Friends who work at Google.”

Facebook example

The last thing I did as a part of my information gathering was organize what I had learned about the situation.  A pro and con list if you will.  It looked something like this:

PROCONlist

STEP 4: Pull the trigger

This was actually the easiest step for me.  By the time I reached the end of my Information Gathering stage, my decision was essentially made for me.  So many people have barriers to making a big career change – no money for classes, family commitments, you name it – I had none of those things.  I knew and still know so many people that would kill to be able to pursue a new life dream but can’t. Most of my CONS were just related to money.  I couldn’t NOT do it.

STEP 5: Enjoy the ride

While med school was downright miserable at sometimes, ok many times, one thing I can say about this whole journey is that it’s been an amazing experience to help me grow as a person.  I’ve learned a ton about myself, what motivates me, what I can survive.  And, I feel true to my soul having pursued what at many points felt like an impossible dream.  Oh, and the icing on the cake, I met and married my best friend.

~Steph