The 3MG Trial

Didn’t even know this trial was being done till Simon Carley posted on it. It came just too late to be added to be talk on the Crashing Asthmatic but there you go.

Here’s my two cents on the trial

Goodacre, Steve, Judith Cohen, Mike Bradburn, Alasdair Gray, Jonathan Benger, and Timothy Coats. “Intravenous or Nebulised Magnesium Sulphate Versus Standard Therapy for Severe Acute Asthma (3Mg Trial): a Double-Blind, Randomised Controlled Trial.” The Lancet Respiratory Medicine 1, no. 4 (June 2013): 293–300. doi:10.1016/S2213-2600(13)70070-5.

METHODS

  • UK publicly funded
  • 34 EDs involved in the UK
  • acute severe asthma (remember it’s not that hard to get into that category)
  • specifically excluded those with life threatening features
  • centrally randomised and reasonable description of blinding
  • each pack had nebs and an infusion
  • IV Mag (2g) v 3 Mg Nebs v placebo
  • all dummys so it looked like everyone gets the same
  • treated as per SIGN and BTS guidelines, though I didn’t see details of how many salbutamol nebs they got etc…
  • two primary outcomes
    • hospital admission either at the time or within 7 days or
    • a change in breathlessness on a VAS

RESULTS

  • Big trial – 1000 folk, average age 35 or so. This is important as a trial this size is unlikely to be equaled.
  • about 75% admitted, no one died in the ED. 2 died overall (not sure why)
  • powered to detect a 10% difference in admission rates and there was only about an 6% difference favouring IV Mag. This didn’t reach stat significance of course.
  • Neb Mag didn’t seem to do much of anything
  • 7 of 1000 needed intubation emphasising how “severe” acute severe asthma is
  • Standard treatment with beta agonists and steroids was awesome as you can see in the placebo group.

MY THOUGHTS

  • to be honest this is hardly surprising. I’ve rarely, if ever, seen magnesium work like a magic drug. I’ve always given it cause it’s benign (which this trial reinforces) and there was some support for its use. That was enough for me. It’s hardly surprising that the trial was negative but I suspect the small improvement that is there is real but is just that – small. 
  • having never used nebulised Mag, I’m now not about to start.

UPDATE:

I had some correspondence from the author of this paper [free full text] regarding the ‘atrial calming’ effect of magnesium. I certainly gave lots of IV magnesium for patients in fast AF. Usually not for the ‘lone AF’ patients, but the sickies with pneumonias and deranged electrolytes. I’d never considered that the supposed rate control effect of magnesium might be useful in the asthmatic to help control the slightly ridiculous tachycardia you get if you’re doing it right.

As mentioned, the paper is free and well worth a read.

Standing Test for Long-QT syndrome

This was all brand new to me. I was reviewing a syncope patient left over from the night shift before. The hand over was: recent change in anti-hypertensives, now feeling weak and dizzy about 1 week. Syncopal episode at dinner table last night.

She’d been in the department overnight, got some fluids, bloods and an ECG. The ECG was said to be normal.

I went and chatted to the patient and yes indeed it did sound all very like postural hypotension. I went back and looked at the ECG and did my usual syncope ECG review looking for the following:

  • Brugada
  • HOCM
  • WPW
  • intervals – QT and PR

And there it was – a nice big QTc of 550ms staring at me.

I still suspect that postural hypotension was the main cause of her symptoms but it would be a tad on the risky side to call it that in the context of a long QT. K+ and Mg++ were on the low side (3.5 and 0.6) so she got a bit of both and admitted for ECG monitoring.

The interesting bit came in the discussio with admitting doctor who was (for once) interested, enthusiastic and asked about the standing test for Long QT. This was all news to me but effcetively people with a long QT syndrome (LQTS) have an abnormal response in QTc with standing.

In healthy people on standing the heart rate goes up with corresponing shortening of the QT interval. Due to the fact that heart rate goes up more than the QT comes down, the QTc actually goes up slightly,

In LQTS the QTc often goes up substantially.

This paper addresses this concept and while it’s in now waty perfect (ie it examined it in people known to have LQTS which undermines its use as a diagnostic test in undiagnosed QT problems) it suggests that in healthy people an increase in QTc on standing of about 10-15ms is allowed but in LTQS is likely to be in the range of 90-100 ms.

Viskin, Sami, Pieter G Postema, Zahurul A Bhuiyan, Raphael Rosso, Jonathan M Kalman, Jitendra K Vohra, Milton E Guevara-Valdivia, et al. “The Response of the QT Interval to the Brief Tachycardia Provoked by Standing: a Bedside Test for Diagnosing Long QT Syndrome..” Journal of the American College of Cardiology 55, no. 18: 1955–1961. doi:10.1016/j.jacc.2009.12.015. PMID 20116193

 

METHODS

  • the normal response to standing after lying is an increase in HR. This would normally be accompanied by a shortedned QT. In LQTS this apparently isn’t the case
  • The intervention was standing and recording QT changes.
  • they did this on high risk LQTS (lots of features but no diagnosis as yet) and those who actually had it genetically documented. The controls were healthy relatives of those pts or volunteers (the vast majority)
  • took them off Beta blockers for a day then lay them flat 10 mins and stood them up for 5 mins with telemetry.
  • blinded investigator performed the measurement had a set part of the trace. Bazzett’s  formula was the main one used.
  • excluded the obviously normal and obviously prolonged

 

RESULTS

  • 68 LQTS; 82 controls
  • the baseline QTs were 380 v 450 – not diagnositcially different but borderline
  • the QT went down in all the normals but less than the RR interval therefore the QTc goes up slightly.
  • the QT of those with LQTS didn’t change at all. In some it went up. Or put another way the QTc of the control group went up 13ms while the LQTS patients the QTc went up 89ms

Not something I’m going to be doing every day, but it’s a fairly nice, bedside test that we can apply in the ED.

Full Capacity Protocols

[image via NetDance on Flickr. CC License]

Hospitals are busy places. We have no space, no beds, no staff and inevitably less money to make this all happen. This is the situation we have.

We’re fairly pragmatic folks so we find ways to manage the work more efficiently and try and do more as an out patient or involve things like ADPs (accelerated diagnostic protocols)

But when we get slammed and have more admitted patients than you have trolleys to put them on then the system grinds to a halt and you can’t assess treat and admit/discharge anyone new.

In Stony Brook in New York, the hospital (and that’s the important bit, not just the ED) decided that when the ED was choked that they could put some of the stable patients as extras in the hallways of the wards. You can imagine what the ward staff thought of that.

This is a brief paper reviewing their experience.

Viccellio, Asa, Carolyn Santora, Adam J Singer, Henry C Thode, and Mark C Henry. “The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: a 4-Year Experience..” Annals of Emergency Medicine 54, no. 4 (October 2009): 487–491. doi:10.1016/j.annemergmed.2009.03.005. PMID 19345442

This is a review of patient flow effectively and not a trial in any prospective sense. All they wanted to show was that this was happening and what the effects were.

It is not the highest quality science and does not claim to be.

RESULTS

  • 25% of those assigned to a hallway bed actually got a proper bed immediately
  • another 25% got a proper bed within an hour
  • the rest got a proper bed within 8 hrs.

THOUGHTS

Your hospital probably has more beds than they say they do. Spreading the crowding from one place to the whole hospital spreads the moral and professional responsibility to a hospital wide problem. It’s remarkable how that motivates resources.

Importantly it must be realised that this is no panacea for a poorly run hospital. In fact every time a hospital implements something like this it’s a sign that something is deeply wrong. However it can alleviate a crisis.

The Irish Association has a nice statement on FCPs. And indeed a nice EMJ paper on the same too.

EM docs are more burnt out than most but none of us are great…

The night shift insomnia that leaves me with about 4 hrs sleep a day has given me the chance to catch up with a bit of reading so here’s a paper for you.

This got a very amount of Twitter attention when it came out as it was a bit of a headline grabber:

Shanafelt, Tait D, Sonja Boone, Litjen Tan, Lotte N Dyrbye, Wayne Sotile, Daniel Satele, Colin P West, Jeff Sloan, and Michael R Oreskovich. “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population..” Archives of Internal Medicine (August 19, 2012): 1–9. doi:10.1001/archinternmed.2012.3199. PMID 22911330

First a quick run through of the study and then some thoughts

METHODS

  • this was a massive survey of the AMA register of doctors compared with the general population. It was done effectively by mass emailing
  • the survey used the “gold standard” of burnout: the Maslach Burnout Inventory
    • the only problem here is that it’s a bit of a cumbersome tool so they let the docs fill in the whole survey whereas Joe Bloggs only filled in what the authors state are the predictive bits of the survey. They say that doing this has been studied before and is kosher but there you go…

RESULTS

  • only a 26% (7000/27000) response rate in the docs. A response rate of somewhere closer to 70% is considered important as it’s giving a much more representative of the people you’re surveying. If you think about it could be only the pissed off, grumpy docs answering the survey. Or maybe even the opposite and only the calm and cool docs with lots of free time filled it out
  • bottom line was that a lot of docs feel overworked and burnt out. And this is higher than the general population
  • the people with the highest symptoms of burn out were the EM docs. By a clear country mile it seemed. We were much better than the surgeons in terms of work-life balance but despite this we were still burnt out.

THOUGHTS

I think this is vitally important stuff.

Emergency Medicine is like a puppy – it’s for life not just for Christmas but it seems increasingly both from my own anecdotal experience and now represented in study form in various settings that we’re going to have real difficulty keeping docs in the specialty.

In the US there are comparatively huge numbers of trained Emergency Physicians compared with the UK/Irish model. These guys work shift patterns often for their entire career. They are well paid and work reasonable hours (I was quoted that 30 hrs a week was an average for an EP in the US – can anyone corroborate this?) Despite their resonable work life balance these guys are really burnt out.

Now the UK/Irish model is a service delivered by trainees and non-board certified EPs, (the “sickest looked after by the thickest” as some have joked) these guys are paid less and work more hours than fully trained EPs, of whom we have vanishingly few. Just imagine how much more burn out might apply to those docs who deliver hands on emergency care day in, day out (or night in, night out)…

As I enter my ninth year since graduation from med school with no clear end in sight to my training (largely my own fault I’ll admit) the importance of work-life balance and the threat of burn out becomes more and more apparent. Workforce planning is one of the biggest problems (along with overcrowding) that EM has to face in this part of the world, but if we are to address it in any way we must address sustainability and burn out.

update:

Graham Walker did a survey for EM News on burnout that’s worth a read

http://mobile.journals.lww.com/em-news/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2013&issue=03000&article=00008

Keeping up with the literature

Today I think I’m finally giving up on my old system.

The old system was email subscriptions to the table of contents (TOC) of about 30 different journals that i filed under a gmail label and reviewed roughly monthly. If I saw a title or abstract that interested me then I’d pull the pdf and read it at my leisure. I now have over 1500 pdfs that I’ve read over the past 4 or 5 years.

This was an incredibly time-sucking task that often didn’t help me that much in finding the stuff I want to read.

So I think, given the proliferation of alternative sources of literature review out there I’m going to ease off on tracking the journals a bit. Let me outline my new alternatives.

Emergency Medical Abstracts

  • 40 papers a month by two of the sharpest minds in Emergency Medicine  These guys taught me how to read a paper. After listening to the “tape” I comb through the 40 papers in the abstracts and pull the pdfs of the ones that really catch my eye
  • NB this is a subscription service that I get for free through my EMRA membership [Ed. this is the best $50 you will ever spend in emergency medicine...]. Can be pricy if you’re a non-trainee

Emergency Medicine Update [#FOAMed]

  • Yosef Leibman does a stellar review of the non-mainline journals and pulls out some real crackers. I pull the pdfs on only the ones I really want to get the detail of. 

R&R in the Fast Lane [#FOAMed]

  • Somewhat infrequent but a great place to find out what your peers have been reading

Journal Watch

  • Another subscription service – I  just use the free version to get the titles of the papers

Keeping up with Emergency Medicine [#FOAMed]

  • another great podcast of journal reviews. 

EM Literature of Note [#FOAMed]

  • Ryan started his site around the time I started mine and after a while I did less and less of the critical review stuff because… well… he’s just so much better at it than I am. He also finds lots of papers that you won’t find in the main EM journals

St Emlyns Twitter Journal Club [#FOAMed]

  • there’s been a twitter journal club for a while ran mainly by @silv24 but this one comes from the Virchester crew and is EM specific

Resus.me [#FOAMed]

  • Cliff is doing the hard work at 4am to find the papers we should be reading. Cheers Cliff!

Twitter [#FOAMed]

  • rarely a day goes by that I’m not following a link on Twitter to pub med and downloading a pdf to read later. This is a truly invaluable source

These are just a selection of the resources I’ve been using over the past couple of years but which I’ll be relying on from now on.

The problem with this is that you have to trust your filter. It’s almost like a pseudo-publication bias. If people only read papers that have been tweeted then lots of important stuff (that may be contradictory to your position) will not get read.

Of course this problem exists already in that all of us have a tendency to read (and remember) stuff that interests us.

Feel free to chime in with comments and suggestions in the comments.