X PRIZE Foundation Aims to Put Virtual Physician in Every Pocket

From Medgadget:

The X PRIZE Foundation is planning a new contest to spur the development of an artificial intelligence powered physician. The $10 million AI Physician X PRIZE will go to “the first team to build an artificial intelligence system that can offer a medical diagnosis as good as or better than a diagnosis from a group of 10 board-certified doctors.” The vision for the AI physician is that it should be able to communicate in any language and be accessible from a cellphone. As more than 50% of the world’s population now has a cellphone, projected to increase to over 80% by 2013, the AI physician could truly become the world’s doctor.

Thrombolytic Therapy for Acute Ischemic Stroke beyond Three Hours

From the Journal of Emergency Medicine:

Ischemic cerebrovascular accidents remain a leading cause of morbidity and mortality. Thrombolytic therapy for acute ischemic stroke within 3h of symptom onset of highly select patients has been advocated by some groups since 1995, but trials have yielded inconsistent outcomes. One recent trial demonstrated significant improvement when the therapeutic window was extended to 4.5h.

Clinical Question: Does the intravenous systemic administration of tPA within 4.5h to select patients with acute ischemic stroke improve functional outcomes?

Evidence Review: All randomized controlled trials enrolling patients within 4.5h were identified, in addition to a meta-analysis of these trial data.

Results: The National Institute of Neurological Disorders and Stroke (NINDS) and European Cooperative Acute Stroke Study III (ECASS III) clinical trials demonstrated significantly improved outcomes at 3 months, with increased rates of intracranial hemorrhage, whereas ECASS II and the Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) study showed increased hemorrhagic complications without improving outcomes. Meta-analysis of trial data from all ECASS trials, NINDS, and ATLANTIS suggest that thrombolysis within 4.5h improves functional outcomes.

Conclusion: Ischemic stroke tPA treatment within 4.5h seems to improve functional outcomes and increases symptomatic intracranial hemorrhage rates without significantly increasing mortality.

Difficulties with Gum Elastic Bougie Intubation in an Academic Emergency Department

From the Journal of Emergency Medicine:

The difficulties with gum elastic bougie (GEB) use in the emergency department (ED) have never been studied prospectively.

Objectives: To determine the most common difficulties associated with endotracheal intubation using a GEB in the ED.

Methods: We conducted a prospective, observational study of GEB practices in our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000 patients. Laryngoscopists performing a GEB-assisted intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), reason for GEB use, and problems encountered. Data were analyzed using standard statistical methods and 95% confidence intervals.

Results: A GEB was used for 88 patients. The overall success rate was 70/88 (79.6%; 95% confidence interval [CI] 71.1–88.0%). The GEB failure rate of the first laryngoscopist was 25/88 (28.4%; 95% CI 21.0–40.3%), with the two most common reasons being: inability to insert the bougie past the hypopharynx in 13 (52%; 95% CI 32.4–71.6%) and inability to pass the endotracheal tube over the bougie in six (24%; 95% CI 7.3–40.7).

Conclusions: The GEB is a helpful rescue airway device, but emergency care providers should be aware that failure rates are relatively high at a teaching institution.

Emergency physicians and the choice of overtesting or lawsuits

From Kevin MD:

Emergency physicians are in a dilemma. Risk missing a diagnosis and be sued, or be criticized for overtesting.

Regular readers of this blog, along with many other physicians’, are familiar with the difficult choices facing doctors in the emergency department.

The Associated Press, continuing its excellent series on overtesting, discusses how lawsuit fears is a leading driver of unnecessary tests.

iPhone App for Nearest ED

From Boston.com:

Researchers from the Emergency Medicine Network at Massachusetts General Hospital today launched a free application for the iPhone that will tell you where the nearest hospital emergency rooms are in the United States, along with directions and other information designed to help people away from home.

The system relies on a database of 5,000 emergency departments. The iPhone app also prominently displays an option to call 911 for emergency medical services.

Supreme Court lets EMTALA case proceed

From Modern Healthcare:

The U.S. Supreme Court has denied an appeal by Providence Hospital, Southfield, Mich., to throw out a case in which a family is seeking to hold the 459-bed hospital responsible for the murder of their daughter in 2002 by the woman’s estranged husband, a discharged, mentally unstable patient.

The lawsuit alleges that Providence violated the Emergency Medical Treatment and Active Labor Act, or EMTALA, by releasing Christopher Howard, a patient who a hospital psychiatrist recommended be put on suicide watch and moved to the facility’s secure psychiatric ward. The lawsuit alleges that Providence discharged Howard following several days of treatment after learning that his insurance would not cover the recommended care.

The Supreme Court ruling upheld the decision of a lower court to allow the lawsuit to proceed. The case’s outcome could substantially affect hospitals’ liability under EMTALA. A Providence spokeswoman declined to comment on the case.

Nervous about patient privacy, hospitals limit staff access to social media sites

From Hospitals and Health Networks:

Tweeting, Facebooking and blogging are easy ways to communicate and are becoming nearly ubiquitous in this age of portable computing. But for some hospital staff, they are becoming taboo activities.

Social networking can present dangers to patient privacy and other business practices. Neither the American Hospital Association nor the American Society for Healthcare Risk Management has official policies regarding social networking, leaving hospitals to decide individually how best to police work time usage.

The threat of privacy violations is real but it is unrealistic to expect hospitals to sever all access to these sites, says Robert Coffield, health care attorney with Flaherty, Sensabaugh & Bonasso, Charleston, W. Va. The challenge is training staff to use them properly while controlling their access. “Educating people to use social networking appropriately is difficult,” Coffield says. “Communication between hospital and patient is two-way, but it’s restricted from the hospital’s perspective to protect the patient.”

HealthGrades Evaluates Hospital Emergency Medicine for the First time

From FierceHealthcare, via Beth Cesta:

The quality of emergency medical care at the nation’s hospitals varies widely – both individually and by state – according to a new HealthGrades study released today that, for the first time, examines mortality rates for patients entering hospitals through emergency departments.

The first annual HealthGrades Emergency Medicine in American Hospitals Study examined more than 5 million Medicare records of patients admitted through the emergency department of 4,907 hospitals from 2006 to 2008 and identified hospitals that performed in the top 5% in the nation in emergency medicine.

Comparing the group of hospitals in the top 5% with all others, the study found that the group had a 39% lower risk-adjusted mortality rate. These top-performing hospitals improved their outcomes over the years 2006 through 2008 at a faster rate than all other hospitals, 16% compared with 10%.

Comparing tPA use for stroke in patients in their 80’s and 90’s

From Stroke:

Outcomes of Thrombolysis for Acute Ischemic Stroke in Octogenarians Versus Nonagenarians

Background and Purpose—Little is reported on the outcomes of nonagenarians who are treated with intravenous tissue plasminogen activator for acute ischemic stroke. It is uncertain whether nonagenarians have higher mortality and worse functional outcomes than octogenarians.

Conclusions—There is no significant difference in 90-day mortality, 30-day functional outcome, or rate of symptomatic intracerebral hemorrhage between nonagenarians and octogenarians treated with intravenous tissue plasminogen activator when comparing populations of similar baseline risk.

Intra-arrest cooling using intra-nasal cooling method (Rhinochill) for immediate induction of therapeutic hypothermia

From Critical Care:

Recent investigations have demonstrated improved neurological outcome after therapeutic hypothermia in patients after successful resuscitation. The time course and duration to achieve target temperature may be an important factor to influence patient’s outcome. To determine the safety and efficacy of intranasal cooling during ongoing resuscitation, for immediate induction of therapeutic hypothermia, the Pre-Resuscitation Intra-Nasal Cooling Effectiveness (PRINCE) study involved 200 patients in Europe, using a non-invasive nasal catheter that sprays evaporating coolant liquid into the nasal cavity. Here we demonstrate data from all German participating sites.

Using the intranasal cooling method, cooling was much faster and earlier in treated patients. Neurologically intact survival and discharge rates were higher in treated patients. Transnasal cooling for the induction of therapeutic hypothermia during prehospital resuscitation is feasible and highly effective in lowering brain temperature rapidly. The method offers the possibility for immediate introduction and realization of mild hypothermia in the field.