MRSA Update

More reasons to get immunized.

Apparently, in a recent CDC update in Annals of EM, there were more cases of necrotizing pneumonia associated with flu-like illnesses--10 in 2 months, with 6 deaths.

The deaths were notable for the speed of worsening and the age, worse in younger people rather than older.

Still rare, MRSA pneumonia may be more virulent as it is apparently able to kill the very cells (PMNs) that the body uses to neutralize it. Some of these cases were associated with a preceding MRSA skin infection.

0 for 3

I'm something of a black cloud.

3 times I've participated in resuscitations, 3 times the patients have shuffled off. It's been a watershed for me, the stepping forward, getting on the step ladder, and performing compressions. 90 percent of my thought is, 100 per minute, allow for full recoil, 100 per minute...10 percent is a sponge for death.

In the first resuscitation, we preserved dignity with our demeanor on his passing. Dignity in death, I now think, is not a function of tubes, or wires, or excreta, or the state of the body. It seems rather to be a state of the event. I've talked about the first loss before, a middle-aged man stabbed in the chest after bumming a ride. Twenty minutes out from the event, he arrived with a penetrating left chest wound; we opened the chest, plumbing for the heart, in the trauma bay. Heroic efforts would likely only have been successful if we had seen him get stabbed and immediately rushed him to help. Nevertheless, all that could be done, was.

I remember, after time had been called, the silence. The team set this. The team decided there was not space for idle chatter. I laid a hand on his knee before leaving, some attempt at communion. We didn't say a word following for what seemed like minutes. When we did talk, the chief's thought was to examine what we could've done better. He didn't speak of anything else for a good hour, and spent time just staring off even if others were talking.

There was a tacit understanding that the work we did was in the service of the patient and those to come which lent the event the dignity of respect. I hope it would've been seen that way by observers.

The third time, the dignity of passing was set by the observers. Death came sprinting down the long hallway of the ED in a wheelchair, nurses trailing behind, mouth open. She spewed up, yellow and frothy during CPR as we worked, knowing the futility. She had aspirated; her thin limbs spoke to her age, to long illness. Dry, papery skin and bones barely concealed underneath a patina of muscle. The success of CPR for non-responsive cancer patients is next to nil.

As I got down from the CPR step-ladder, her husband and son looked on. Both were seated, almost as if at a visitation; both were quietly crying. Not screaming. Not wailing. Not blaming. I can only guess what they were thinking, but their faces and attitudes bestowed upon their loved one all the dignity of her life until then. The resuscitation--messy, smelly, primal, and filled with the excreta of decay--was but a passing blemish. They were witnesses to her passing. The son and father accepted the gentle apologies and sympathies of the staff as they passed, and remained sitting as I left.

Dignity is in the spirit, in the mind, as well as in the body. Right thought and intention can overcome the bald shock of the body in death.

CA-MRSA, Bogeyman Extraordinaire

There's been a ton of news recently with regards to community-acquired MRSA--school closings, cancellation of sports events, deaths, rioting in the streets, mass panic. See this NY Times article.

The CDC has adroitly headlined recommendations on their website. One wonders how many hits they've gotten recently.

Wouldn't want to catch MRSA. It can kill you, you know. Keep your kids home from school. Keep them out of sports.

MRSA is now the most common cause of skin infections seen in the ED. It's a common question for med students--how would you treat CA-MRSA versus hospital-acquired MRSA, which is still much more common? The answer is a drug switch: Bactrim or clindamycin instead of vancomycin. Patients in contact isolation for MRSA are common. One of my first patients was a woman who likely turned septic and developed MRSA tracheobronchitis. Not so easy to treat; she was in the ICU for weeks. I've seen her since for a hysterectomy, and she seemed well. She had MRSA from her chronically open and weeping leg wounds. She was immobile.

Superbugs are scary, I admit. Clostridium dificile is scarier to me than MRSA because sepsis and invasive disease can just as easily be caused by bugs that are susceptible, and kill you anyway. So, MRSA is more difficult to treat--but the main problem with early invasive disease is recognizing it and treating it supportively until the correct antibiotic can be chosen. I therefore rate it as about the same on the scariness scale as susceptible staph infections, invasive strep infections like toxic shock syndrome, or meningitis--the kind that kills teenagers. Very scary. But not very common.

A recent JAMA article (not permalinked, may expire) placed the incidence of invasive CA-MRSA infections at 3 to 5 per 100,000 by examining 7 LARGE areas--for example, the whole state of Connecticut. Compare that to the incidence (i.e., only new cases) of diabetes, now at over 7 per 1000, or 200 times more common than invasive CA-MRSA infections. And diabetes is less scary but, over the long run, still loaded with significant morbidity and mortality. It is the leading cause of limb amputations in the US.

What about mortality? The mortality rate from what I can tell for CA-MRSA is 0.5 per 100,000 in the JAMA study above. Heart disease mortality, by contrast, was from 239 to over 430 per 100,000 depending on demographics in the year 2000.

It may well be that resistant infections turn out to be the defining adversary of our generation in health care. For now, though, I wonder if they don't just make good news. Even the CDC, who quotes the rising rates for MRSA infections overall, doesn't advocate the closing of schools. Even if you could eradicate MRSA from all surfaces, I have a feeling it just might be back as soon as the kids return.

So--Purell kills MRSA--wash your hands. And keep living. Because, like it or not, this bug--which lives on everyone's skin, for crying out loud--isn't leaving.

Belly pain, the black box of medicine

Up to 8% of all emergency room visits are for abdominal pain. Up to 50% of those will leave without a clear diagnosis.

Said one ED attending to another, 'what if we just had a belly pain team? Then that team could see all the belly pain patients on one shift, and you could rotate through it'.

Came the reply, 'if you wanted to kill yourself, that'd be a great idea'.

Frustration. Risk. Hallmarks of a belly pain patient. I remember opening the abdomen during anatomy. It was a mess. A mess contributed to by a cadaver that had megacolon (you can guess what that caused, I suppose), but a mess in any case. There are pouches (of Douglas, of Morrison), ligaments (of Treitz), ascensions (of the colon), flexures, anastomoses (my favorite, the superior and inferior pancreaticoduodenal), gutters, and lumens. There are systemic arteries and veins, and then the portal venous system that returns to the liver for metabolism from the digestive tract. There are spots for hemorrhage and infection inside the peritoneum (the lining of the gut) and behind the peritoneum. There's an omentum that hangs over it all like a beaded curtain.

So one can understand why the abdomen can be frustrating. There are also extra-abdominal causes of 'abdominal' pain, some of them catastrophic. In an elderly diabetic lady with indigestion and belly pain, an EKG is a sensible order to rule out a heart attack. Pulmonary embolism and pneumonia can both present with belly pain of one sort or another.

Obscure causes such as an abdominal migraine (the gut has more serotonin receptors than the brain) usually seen in children and errors in hemoglobin metabolism can cause belly pain. And, of course, the appendix.

Ah, the appendix. Still the most commonly missed diagnosis in the ED. So the question for a new belly pain patient could be phrased, 'why isn't this appendicitis?' It can flip up, as high as right below the rib cage, especially in pregnant women. It can migrate down and hide behind the bladder.

So here's to the 8% of my future life spent looking for the appendix.

Glow-In-The-Dark Pee

R the nurse was walking down the hall with an open urine cup, looking at it and smelling it. That doesn't happen too often. It looked like it was glowing; Mountain Dew straight out.

"You should put that under a Woods lamp (a black light)", I said. So we did, and gosh darn if it didn't glow like a kid's glowstick at Disneyland.

So what's the guy's story? He was an ingestion, unclear history, suicide attempt for two days...perhaps he decided to add antifreeze to his list. Antifreeze has a compound called fluorescein added for this exact reason, because antifreeze kills kidneys, tastes sweet, and tends to get ingested by kids and dogs. And alcoholics.
His blood alcohol level came back at an impressive 0.390, which is a personal best for me; this, actually, was really good news. Antifreeze is fun for two reasons--one for the fluorescent pee, two because the old school antidote is a lot of alcohol. The two are metabolized by the same pathway, but alcohol is a better substrate, so if you drink enough, you can prevent the antifreeze from being changed into it's toxic metabolite.

As with anything that's 'interesting', the guy's antifreeze level came back very low. Possible we just missed it and he had peed it all out. But, a Google search also turned up a wide variety of things that turn your pee fluorescent. In fact, there was an article in a pediatric journal that discussed a random sample of 30 pediatric urine tests, 21 of which were fluorescent underneath a Woods lamp. None of those patients had antifreeze poisoning.

Turns out niacin and other B vitamins turn your pee fluorescent, among other things, including certain other medications. I also wonder about food coloring, especially in children (perhaps why 21 of 30 randomly selected had fluorescent pee--have you seen what they eat?)

So the next time your friend drinks a pint of antifreeze, take him or her under a black light and hand them a fifth of tequila. And, again I'm reminded, even the classic cases, aren't.

Jaded

The slow progress from naive to bitter I expected, but the first patient who burned me I didn't see coming.

26-yo female came in with lower pelvic pain and bleeding that she truthfully attributed to endometritis, and had a long history of work-up for the same. I don't know about the literature, but I've seen a couple patients have significant pain from this condition, where implants of uterine lining in the pelvic cavity cause pain secondary to bleeding; though outside the uterus, they are hormonally responsive. It's not fun, partially because the pain and scarring isn't life threatening, so patients tend to feel their complaint is minimized.

The nurse, Robert, recognized her immediately and warned me that she was a 'frequent flier', and had been to the ED numerous times in the past six months. Her first request for pain medication was for Dilaudid, which I've seen used multiple times in my first ED but not at my second. It's considered overly strong. Too fast acting, too likely to cause respiratory depression. I'm sure the high is killer. I'm also sure that the pain relief is both quick and dramatic.

Most patients who are opiate-naive don't have a favorite yet; they may remember what they had last time, but they often mangle the name or just don't remember. The nurse was suspicious from the beginning that she was exaggerating her complaint to get more substantial pain relief.

The work-up, as expected, was negative for any of the more dangerous causes of bleeding and lower pelvic pain like an ectopic pregnancy or a ruptured ovarian cyst. I went to check on her, and sat down at the bedside. She was shaking, sitting curled up. She said she was frustrated by the pain she was still having and didn't feel like she was under control; we had offered a Percocet script to take with her and a dose of Toradol (similar to ibuprofen) before leaving, but that wasn't sufficient. She said she'd call for a ride if we could help her control her pain.

I walked back to the attending doc, who said he'd be willing to do that after she called for a ride. So I went back and told her and she said she'd call and picked up her phone. I went back and told the doc.

"Did she call?" he said.
"She was going to", I said.
"She can't have anything until she calls and her ride is on the way", he said. Then he looked at me. "Here's what's going to happen. She'll say she's getting a ride, get the shot, and take off. Then she'll drive herself into an abutment with narcotics in her system".

I didn't believe it. I thought she was genuine. Then I went back and talked to her again, and she said, 'Oh, did you want me to call? I wasn't clear'. The context made it suspicious. Maybe she was just gaming me into getting her high. The tricky part was that she did have genuine pathology; no one was arguing that. The argument was that she was way too into a shot of Dilaudid. By the time she finished her plea, called, and then 'couldn't get a ride', she would've had good relief from her oral pain meds.

So that plea, where she was shaking and frustrated and talked about how her pain had gotten worse after the pelvic exam, all calculated? Who knows? Perhaps all genuine but just accentuated. These are the drug seekers I have to get used to, the ones who are really sick. The most egregious are sickle cell patients, classically. They get so zonked out that they'll be close to respiratory arrest and still requesting meds. No one, however, will argue that a sickle cell crisis is faked. You try having your hemoglobin precipitate out in your peripheral arterial system.

The IV component can't be underestimated, either. Benadryl would never be considered a drug of abuse, but in the form of an IV push (given in one dose) it produces a high just because of the route.

I guess I'm a bit more cranky and jaded than before my shift started. I still believe pain must be treated, but, just as with every other complaint, the world is grey--or, in the case of the ED, a bit green.

What do this shack and a little girl have to do with an EKG?

So there's a foundation, Hearts for Kids, that helps kids in Africa get heart transplants. That's awesome. This picture, from their website, is where their patients live.

I don't know anything about them, I just found them with Google while I was searching for rheumatic fever. If you do a Google image search for the same, you'll see a lot of black and white pictures from the pre-antibiotic era of people who died from RF, including Mozart. Then I saw this picture. Not black and white. Full color. Hmmm.

RF is still on our diagnosis list of kids with fever and migratory rash; it can attack the heart most famously, or cause people to have similar symptoms to Huntington's disease, also known as Syddenham's chorea. During a grand rounds last week, a distinguished class of residents at a top program didn't recognize a video of it. That video was taken in Africa. To learn about it, I've had to use the Internet, textbooks, and slides, because I've never seen a case, and likely never will until I travel overseas.

According to an NEJM article, rheumatic fever in the US has decreased precipitously. From being a more common topic than stroke in the era from 1967 to 1976, it is now rare, and a search of all medical journals in the US yields only eight articles between 1997 and 2006. But in places like that in the picture above--that is, the 80% of the world without access to prompt antibiosis for strep throat--there are 470,000 new cases of ARF each year.

What got me on this topic? EKGs, actually. Wolff-Parkinson-White syndrome is a sub-set of supraventricular tachycardias, or fast heart rhythms. It is a characteristic, classic finding on an EKG; there is a bit of an early rise in the QRS complex called the delta wave, and it represents a track of heart muscle that goes around the normal pathway of conduction. It typically does not cause problems (story to the patient) but can proceed to ventricular fibrillation (story to students) if you block the normal pathway.



Our hearts have a built in delay to allow for filling of the ventricles. Because the WPW pathway bypasses that system, if it becomes ascendant, it conducts directly from the atria to the ventricles at a rate of anywhere from 150-300 beats per minute. That is sometimes called 'badness'. If the patient is unstable, the best treatment is to shock them (electrical cardioversion). If they are stable but fast, a variety of drugs can be used; I learned that adenosine, which is usually used even in the field by paramedics for narrow-complex tachycardias should not be used for WPW, but some texts seem to suggest it is acceptable. I'll have to read more to figure out the differences.

WPW was first described by a few physicians, as often happens, but Paul Dudley White, who worked at Harvard at the turn of the century, described it in 1908. It is interesting to note why he became a physician, and to wonder why he decided to focus on the heart. He, like countless others at the turn of the century, before the advent of penicillin, lost a sister to acute rheumatic fever at the age of 12.

Tired

My speech doesn't slur so much as pause, catch. I'm still processing the last thought as I ask for the next.

Slow, and careful. Musn't miss.

Light is a soft glow at the edge of vision. Sounds encroach. Monitors pace thought, insistent, racing.

Moments magnify. As if the previous one isn't gone yet, new one already here.

My stray thoughts are of sheets, and food. Heavy, sweet food.

Standing in the middle of this river, current stronger than it appears. How tempting to float rather than wade.

To be the responsible one at 4 am.

And, finally, the morning air.

Genius Parade, part 1

At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.

Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.

Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.

Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.

Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?

Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.

After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.

So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?

His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.

And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.

Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.

During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.

Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.

Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.

I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?

In the meantime, I'll try to be less of an idiot, if only for the sake of others.

'stop if you see brain'

Probably you saw the photo before you started reading. Probably the correct response, if there is one, is 'dear Lord', or an expression of your choice to that effect.

That's about right. That's what I say to myself too. A couple shifts ago I spent five hours on scalp lacerations, including history, eval, and then repair.

The first one was a bit silly; poor anxious girl had banged her head on the visor of her car after running into a post at 5 miles an hour and was more upset about what dad was going to say than the lac in her forehead. Aside from poor anesthesia, probably secondary to her anxiety, it was a quick repair.

The second was a stoic swiss farmer who had fallen off an ATV and hit god knows what; he had four inches of a jagged tear. The ED was busy. I went in to clean and evaluate it.

"Any pain here?" I asked, tapping on his exposed skull. His exposed skull. When I went in, the attending said, go ahead and clean it out well. Stop if you see a fracture or exposed brain. Always good advice, stopping when you see exposed brain.

The ED was still busy. Attending came in, looked, and said, 'OK, well I'd close with a couple sub-Q for approximation and then staple it. Let me know when you're done.' Twenty-three staples and five sub-Q dissolveable stitches later, it was a nice Frankenstein scar down the right side of his forehead. But it wasn't bleeding. And the bits of hay and dirt were gone.

Despite myself, it was an amazingly satisfying complaint. The guy needed help, but there was no way he was going to surgery. The perfect wound care challenge for the ED. And now, when I walk into a room with a lac and they say, 'have you done this before?', I have a lot more confidence in saying, 'yup'.

Wow. I can actually deliver care, instead of just going in and talking to someone. Gotta love this job. A small part of me still whistles internally as one would witnessing any dramatic incident from afar; the part that drives me at work steps up and sees what needs to be done. So much still beyond my experience, obviously. But there's getting to be more and more I can handle.

BTW, please don't ride your ATV without a helmet. Thanks. Remember how lucky the patient in this story was. His CT was normal.