EZ-IO Gains Popularity; Public Still Wary

From the St. Paul Pioneer Press, via JEMS:

ST. PAUL, Minn. — A new battery-powered drill is helping paramedics save lives, but it also might be scaring patients.

The handheld device makes injecting fluids and drugs quicker during many high-stress emergencies. It’s unfamiliar to patients and bystanders, though, so one emergency medical services official is hoping to spread the word about it.

“It’s important that people understand this, before a medic takes out this Black and Decker-looking thing and they wonder, ‘What in the hell are you doing?’” said Dr. R.J. Frascone, medical director of emergency medical services for Regions Hospital in St. Paul.

Regions EMS has been involved in early use and research of the so-called EZ-IO, which drills a needle through a soft spot below the knee and creates a port through which medics can inject and withdraw fluids. It’s typically used on patients in cardiac arrest or shock, and only then after medics are unable to manually thread needles into the veins in their hands or arms.

New Cyanide Antidote

From a press release from the University of Minnesota:

MINNEAPOLIS / ST. PAUL (December 26, 2007) – University of Minnesota Center for Drug Design and Minneapolis VA Medical Center researchers have discovered a new fast-acting antidote to cyanide poisoning. The antidote has potential to save lives of those who are exposed to the chemical – namely firefighters, industrial workers, and victims of terrorist attacks.

Current cyanide antidotes work slowly and are ineffective when administered after a certain point, said Steven Patterson, Ph.D., principal investigator and associate director of the University of the Minnesota Center for Drug Design.

Patterson is developing an antidote that was discovered by retired University of Minnesota Professor Herbert Nagasawa. This antidote works in less than three minutes – meeting the United States Department of Defense “three minute solution” standard. The research will be featured in the Dec. 27, 2007 issue of the Journal of Medicinal Chemistry.

“It’s much, much faster than current antidotes,” Patterson said. “The antidote is also effective over a wider time window. Giving emergency responders more time is important because it’s not likely that someone will be exposed to cyanide near a paramedic.”

The antidote was tested on animals and has been exceptionally effective, Patterson said. Researchers hope to begin human clinical trials during the next three years.

The antidote is also unique because it can be taken orally (current antidotes must be given intravenously) and may be administered up to an hour prior to cyanide exposure.

The new science of resuscitation is changing the way doctors think about heart attacks—and death itself.

From Newsweek:

Consider someone who has just died of a heart attack. His organs are intact, he hasn’t lost blood. All that’s happened is his heart has stopped beating—the definition of “clinical death”—and his brain has shut down to conserve oxygen. But what has actually died?

As recently as 1993, when Dr. Sherwin Nuland wrote the best seller “How We Die,” the conventional answer was that it was his cells that had died. The patient couldn’t be revived because the tissues of his brain and heart had suffered irreversible damage from lack of oxygen. This process was understood to begin after just four or five minutes. If the patient doesn’t receive cardiopulmonary resuscitation within that time, and if his heart can’t be restarted soon thereafter, he is unlikely to recover. That dogma went unquestioned until researchers actually looked at oxygen-starved heart cells under a microscope. What they saw amazed them, according to Dr. Lance Becker, an authority on emergency medicine at the University of Pennsylvania. “After one hour,” he says, “we couldn’t see evidence the cells had died. We thought we’d done something wrong.” In fact, cells cut off from their blood supply died only hours later.

But if the cells are still alive, why can’t doctors revive someone who has been dead for an hour? Because once the cells have been without oxygen for more than five minutes, they die when their oxygen supply is resumed. It was that “astounding” discovery, Becker says, that led him to his post as the director of Penn’s Center for Resuscitation Science, a newly created research institute operating on one of medicine’s newest frontiers: treating the dead.

Costomer Service in Healthcare

From the Physician Executive

Customer service skills (or bedside manner, as it used to be called) are distributed as a bell curve in any random population; some do better than others. But overall, as a profession, as a group of professions and as an industry, don’t we really do better than folks like Verizon and the cable company? On a risk-adjusted basis (adjusting for the fact that most patients are grumpy about even having to be a patient) we may, in fact, be stellar.

CMS Issues Information Regarding Physician 24/7 Coverage Rule

On December 14, CMS issued a survey and certification letter (S&C-08-07) to all state survey agencies providing guidance on enforcing the physician coverage notice requirements included in the Final Inpatient Prospective Payment System (PPS) rule, effective October 1, 2007.

Specifically, the rule requires hospitals that do not have a physician on-site 24 hours per day, 7 days per week to provide their patients with a written notice at the beginning of an outpatient visit or inpatient stay.  The notice not only must explain that a physician is not on-site at all times but also must indicate how the hospital will respond if the patient develops an emergency medical condition.

Roadside Medical Clinics: Bringing Care to Truckers

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Medgadget Reports:

Hard working members of the trucking community will now find convenient medical services on their way thanks to Roadside Medical Clinics, a company based in Alpharetta, Ga. The company plans to introduce its chain of roadside clinics coast to coast, offering its services “in various subscription packages for an average of $15 to $30 a month,” according to Bob Perry, Roadside Medical vice president, who is quoted in eTrucker.com.

Specialists Scarce in Hospital ERs

The Wall Street Journal (Health Blog) writing about the Washington Post

As visits to hospital emergency rooms rise, the shortage of medical specialists to treat the patients who show up there is growing, the Washington Post reports.

The dearth of specialists taking on-call duty for emergencies is delaying treatment as patients wait longer for a specialist to show up or are transferred to other hospitals. “It can mean death,” Linda Lawrence, president of the American College of Emergency Physicians told the Post. “Patients have died in transport, or waiting to find a neurosurgeon, or getting to a heart center for a cardiologist.”

House & Senate Pass Six Month Medicare Fix for 2008

From the EDPMA

Late on Tuesday, December 18, the United States Senate passed by voice vote (unanimous consent) the Medicare, Medicaid, and SCHIP Extension Act of 2007 (S. 2499).  The House took up the bill today, Wednesday, December 19, and late in the day passed the measure by a vote of 411-3.  The legislation now moves to the President’s desk for signature, and U.S. Department of Health and Human Services Secretary Michael Leavitt is reported to have indicated that the President will sign the bill into law. 

The legislation provides a 0.5 percent positive update for the 2008 Medicare Physician Fee Schedule for six months – from January 1 through June 30, 2008.  The fee schedule for July 1 through December 31, 2008 would be calculated as if the six month patch had not been enacted unless further congressional action occurred to stave off future cuts.   

Emergency Medicine Medicare Reimbursement for 2008

As noted above, the entire house of medicine was slated for a 10.1 percent across the board cut to the Medicare Physician Fee Schedule in 2008.  However, due to regulatory changes, emergency medicine is scheduled to take an additional reduction of approximately 2 percent in 2008.  The legislation passed this week in Congress averts the 10.1 percent cut to all Medicare physician payments, but does not directly avert the additional 2 percent reduction anticipated for emergency medicine.  A positive update, however, will reduce somewhat the impact of the expected reduction in payments. 

Eleven Nails

nails_in_head.jpgFrom ImpactED Nurse

“44-year-old man presented to his local emergency department wearing a baseball cap and complaining of headaches that had progressively worsened over the preceding 11 weeks. After we provided generous analgesia and performed simple investigations that failed to identify a diagnosis, the patient removed his cap to reveal an assortment of metallic objects embedded in his scalp. Plain radiographs showed 11 nails penetrating into his brain. A detailed history revealed a diagnosis of paranoid schizophrenia, and the patient confirmed that he had hammered a nail into his head each week for the past 11 weeks to rid him of evil. The nails were removed with the patient under general anesthesia, and he made an uncomplicated recovery with no neurological deficits.”

Does intraosseous equal intravenous- A pharmacokinetic study

From the American Journal of Emergency Medicine

Abstract

Study Objective

Despite the growing popularity of intraosseous infusion for adults in emergency medicine, to date there has been little research on the pharmacokinetics of intraosseously administered medications in humans. The objective of the study was to compare the pharmacokinetics of intraosseous vs intravenous administration of morphine sulfate in adults.

Methods

The study followed a prospective, randomized, crossover design. Each subject was equipped with an indwelling intraosseous access device and an intravenous line. Subjects were randomized to receive a 5-mg bolus of morphine sulfate infused intraosseously or intravenously, followed by the alternate administration route 24 hours later.

Serial venous blood samples (5 mL) were taken at baseline and at 13 time points over 8 hours postinfusion. Blood samples were analyzed for morphine concentration by radioimmunoassay. Pharmacokinetic parameters were calculated from the data, including maximum plasma concentration (Cmax), time to maximum concentration (Tmax), and area under plasma concentration-time curve (AUC), among others. Data were analyzed by analysis of variance.

Results

No statistically significant differences were observed between intraosseous and intravenous administration of morphine sulfate for nearly all of the pharmacokinetic parameters including Cmax (235 ± 107 vs 289 ± 197 ng/mL, mean ± SD, IO vs IV, respectively), Tmax (1.3 ± 0.5 vs 1.4 ± 0.5 minutes), and AUC(0-∞) (4372 ± 1785 vs 4410 ± 1930 ng min−1 mL−1). There was, however, a statistically significant difference in the volume of distribution in the central compartment, Vd (P = .0247), which in the opinion of the investigators was thought to be due to a minor deposition effect near the intraosseous port or in the bone marrow.

Conclusion

The results support the bioequivalence of intraosseous and intravenous administration of morphine sulfate in adults.