Author Archives: tombartram

Are they laughing at me?

As the world becomes smaller and our populations more multicultural (Yes I am a “Lefty” Mr Burley)… so communication in our emergency departments becomes even more crucial.

Last week whilst working in the UK, I was involved in the care of a young refugee from Eastern Europe who had not a word of English at her disposal. I’m sure everyone has had a consultation where very little in the way of effective communication has taken place – you try charades, signing, talking loudly and clearly in English and smiles…. But in the end, all that time you put in to learning history taking skills at university  – useless.

Now, in the ED we are used to a lack of information…. (Indeed I think if I have more than 70% of information on which to base a decision I fall into a apoplexy of indecision)…and that is OK; if you know that’s all you’ve got. But it becomes incredibly frustrating when you want to do the best you can for a vulnerable patient and you know your missing vital information because you just can’t get the message through a language barrier.

Back to the patient…There are not many people who can effectively communicate in Baltic state languages in our department so I attempted (for the first time) using “Language Line”. For those that don’t know – this is a telephone service that allows you to contact a translator for any language in the world (except perhaps some dialects in the North-east of the UK!). Once you have you have your translator you then spend an incredibly long time passing the phone between yourself and the patient whilst the person on the other end translates ever more personal information (all in complete confidence – so we are told – and with patient consent).

This is great, a revolution. Instant understanding. Verbatim translation…..Except… those moments when – and you’ve no doubt know it – the patient and translator have an incredibly long conversation and perhaps share a laugh…… and you get a classic one word translation in response.

You wonder… What were they talking about? Were they laughing at me? Have I got some food left around my mouth? And you start to get a bit uncomfortable….

Probably more important you think –  have I missed something?

So, the translator and the patient have a rapport, they share a laugh (perhaps at my expense) but you get a history to write down and everyone’s happy…. Except the real history is often hidden in the nuance of communication – the way something is said, the unspoken words, the carefully selected words, the language.

And we do miss vital information….

A very interesting paper from South Africa by Penn et al. has attempted to characterise the information we miss in translation. But, hold onto your hats it’s Qualitative Research.

From the outset I will say that its not specific to the ED, but the findings are interesting and can be related to translation of all sorts.

What the authors did was record healthcare interviews performed “pas de trois” (their French term not mine), i.e. doctor-patient-translator. Using the interview transcripts they have then decided selected what they term “asides” – times when the translator and patient communicated between themselves and not involved the doctor. They have then taken these asides and classified them as “big talk” (topics like patient beliefs about illness, relationship issues, disclosure issues) or “small talk” (topics such as transport, weather, clarification requests).

Asides were rarely translated for the doctor (even when directly asked)…. And here’s the thing – these nuanced conversation pieces were judged to contained vital health related cues that were never triggered by the doctor in the rest of the consultation. For example, in one consultation a patient discloses information  regarding who has knowledge of her HIV status – and the fact that a partner might not know, which was never relayed to the doctor.

These were issues that gave insight into the patient’s true agenda but weren’t brought out in direct conversation only these non-interpreted “asides”. The treating doctor was left none-the-wiser. Being qualitative there are no hard outcome measures – just developing of these themes…however, this is all interesting stuff because it gives us 2 useful insights:

  1. That we must beware of the translated consultation – we are missing the point!!
  2. History taking (even in your mother tongue) is more than just about asking textbook questions – patients are constantly giving us social cues and clinically important information from each and every aside…. We had better be listen carefully.

So next time you’re in a translated consultation and the patient and translator laugh at you… They probably are laughing at you… But be sure to ask why…

@tombartram

The time bomb of doom: What I think about when I’m tending broad beans

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When I have downtime and I’m riding my bike or indeed tending to my Dads “prize winning” broad beans on the allotment; my mind unfortunately often wanders to recent cases in the ED that have gone bad.

I start to reflect on things I could have done better, or wonder if I could have affected patient outcomes for the better….

It’s the curse of the Emergency Physician.

This last week I have been pondering the dissecting thoracic aortic aneurysm (really type A dissections). Perhaps I’m practicing an area of unknown high incidence but I have come across 2 cases in recent months (normal incidence – by the way – 3/100,000) that have ended badly. Now, we all know that it’s a diagnosis that we find scary – the time bomb of doom – 1-2% of patients will die for each hour after onset of symptoms untreated. We know that symptoms aren’t reliable and you’ve gotta have a high index of suspicion (it is the “most undiagnosed serious condition” with up to 30% of diagnosis made at autopsy!).

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I don’t claim to be a normal person, but I am always wary of patients (not intentionally, but, their “truths” can vary, they hide things, they’re never classic….) and my index of suspicion is always high….

BUT when you need some diagnostic imaging for your crazy, paranoid  hypotheses – it not always that easy to get a timely solution from our friendly radiologists.

What are the conventional options?

The Chest x-ray whilst much loved is awful as a rule-in or rule-out for dissecting thoracic aneurysm.  It will be completely normal in 20% of your patients and if your looking for mediastinal widening then you’ll only see that in 15%….as for the other myriad of “classic” signs we might as well get our euro millions lottery ticket.

The contrast CT, 79-100% sensitive, 87-99% specific – great, but not as “readily available” at the district hospital (where most EP’s) work as we might hope. The radiologist will argue that there is a high dose of radiation and no-one ever likes to use contrast. Meanwhile as we are debating and waiting for a slot in the scanner the time bomb is ticking.

And, Yes, there are also MR scan, transoesophageal echo and retrograde angiography, but I’m not convinced these diagnostics are available in many centres.

SO… what do I want in an ideal world? I would like bedside diagnostics that I can perform to help me expedite treatment rapidly…..So my big idea has been to use the ED ultrasound to perform Transthoracic echo (TTE) and measure the aortic root and get views of the arch to look for intimal flaps combined with standard descending aorta views. The question is – How confident can I be to use my ultrasound as a rule-out or rule-in for dissecting type A aneurysm?

Allow me to look over the literature:

The European Society of Cardiology have recommendations for aortic disease. They say that “TTE is an excellent modality for imaging aortic root dilatation…..not the ideal tool for visualizing all aortic segments”. In a related article from the Society they quote the “Literature of the past” i.e .1980’s and 1990’s, suggesting that for type A dissection TTE has a sensitivity of 78-100%, but as low as 57% in some series! They do point out that there have been no recent studies…. and certainly they would not use TTE as a rule-out. All very opinion based………

Luckily, to the rescue of evidence based practitioners, comes a diagnostic study published this year by an Italian team headed by Moreno Cecconi. They have asked a question similar to my own – “what is the current diagnostic value and the possible role of TTE in the management of patients with suspected aortic arch syndrome?”

270 patients (retrospectively collected data!?! And selection criteria not explained) all assessed by TTE as first line investigation and subsequently imaged by either CT/MR or transoesophageal echo…..Quoting: Sensitivity 87%, Specificity 91%, PPV 75%, NPV 95%.

In all honesty there are lots of problems with the methodology, and it’s from a dedicated cardiac centre  – not really generalisable for the average EP ultrasound operator – but it’s the only data we have using the latest generation of ultrasound technology. The authors are confident with their results and even go as far to say bedside TTE is “useful in establishing or excluding the differential diagnosis in the acutely unwell patient, particularly in the absence of aortic root dilatation”.

What conclusions can I draw from the limited evidence? Well, as with FAST and FASH etc, bedside TTE is another diagnostic modality in our armoury…. Its highly operator dependent but its quick and safe and can definitely guide your management. Would I rely on it to completely exclude a diagnosis of type A aortic dissection? Probably not… But I would measure the aortic root diameter and think hard about my next move…

Rare conditions with serious outcomes – its like being a goalkeeper facing a penalty in soccer – make a save and you’re a hero, drop the ball and you feel like a villian with the weight of the world on your shoulders… but the odds were always stacked against you. The magic wand of ultrasound – when used wisely – can be a significant arrow in your quiver of imaging diagnostics, but when the incidence is low and the risks are high, think hard before using TTE as a lone rule-out investigation…Its not an ideal world in the world of diagnostics…….

And that is what I think about when I’m tending broad beans.

@tombartram

The Ondansetron question

In your standard ED practice – do you give anti-emetics (specifically ondansetron) to children with gastroenteritis, hoping to improve the tolerance of oral rehydration?

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This has always been a debated topic, but has recently been given extra fuel by the issue of a drug safety warning by the FDA – Ondansetron: risk of abnormal heart rhythms…..

In the resource-rich world use of anti-emetics in gastroenteritis is questioned because we have resources available for NG and IV rehydration strategies and we also rarely see death in this cohort of patients. Still the burden of the attendance to ED’s huge, gastroenteritis in the UK accounts for more than 500,000 consultations and 7% of hospital admissions in children under 5years.

In developing countries, the situation is starkly about mortality: diarrhoeal disease was the third leading cause of death in resource-poor (and middle-income) countries, causing 6.9% of deaths overall. In children under five years old, diarrhoeal disease is the second leading cause of death – 1.5 million deaths (figures from WHO).

Oral rehydration is still the mainstay of treatment of children with gastroenteritis throughout the world. Recently studies have showed that the addition of oral ondansetron can reduce vomiting episodes and facilitate oral rehydration (see Bestbet No.1442 for a succinct overview of the evidence). In the UK, NICE have produced guidance on childhood gastroenteritis (CG84), devoting a large section to a discussion on the evidence for and against ondansetron. In which they fall short of advocating its use (this was produced prior to the drug safety warning).

At the ICEM2012 recently, Hezi Waisman from Israel spoke of the efficacy and advantages of using ondansetron in children with gastroenteritis and was supportive of routine use. However debate was started when Baljit Cheema – a Paediatric Emergency Physician in South Africa – said that ondansetron had been withheld from formularies in ED’s in South Africa since the drug safety warning.

So what is the drug safety warning? Well, the information has come from the FDA who give this advice:

“The anti-nausea drug ondansetron (marketed as Zofran and in generic forms) should not be used in patients with congenital long QT syndrome, as they are at particular risk for developing torsade de pointes while taking the drug. Also at increased risk are patients with congestive heart failure or bradyarrhythmias, those predisposed to low potassium and magnesium levels, and those taking other drugs that can lead to QT prolongation. Accordingly, ECG monitoring is now recommended for such patients using ondansetron.”

The evidence cited by the FDA comes from 3 papers that have been published in anaesthetic journals. These papers have suggested that ondansetron can prolong the cardiac QT interval in some patients and extrapolated that this could be proarrythmic (patients with QTc >500ms are at risk of developing ventricular tachyarrythmia).

Looking closely at the cited evidence:

The first paper (Charbit et al) took a group of 85 patients under going anaesthetic (note that all inhalational anaesthetics and suxamethonium and patient temperature and known to prolong QT interval) then recorded ECG’s after the administration of ondansetron and droperidol (another anti-emetic known to prolong QT intervals). Patients were not randomized and there were no placebo groups. They found that in the ondansetron group showed a significant difference in (prolonged) QT interval after drug administration, however only 13% of these patients showed a QT >500ms and there were no other ECG abnormalities or adverse events during the study. Apart from the metholodical flaws in selection, it is unclear how this study relates to practice outside of the anaesthetic department as the sample had a baseline of 20% prevalence of prolonged QT prior to drug administration compared to the general population prevalence of 0.1% (thought to be due to anaesthetic drugs)….

The second paper (by the same team Charbit et al) is a well-designed, prospective cross-over trial in a healthy population, powered to detect a difference in QT length. This time they found again that ondansetron significantly (statistically) prolonged the QT interval. But no patient reached a QT of >500ms or indeed experience any arrhythmia or adverse event.

The final paper (by Nathan et al) is a retrospective chart based cohort study looking at all adverse events in children with known prolonged QT syndrome undergoing anaesthesia. There were 76 patients with 114 anaesthetic encounters. Only 2 adverse events (i.e. cardiac dysrrythmia requiring treatment) occurred but these were thought to be in close temporal proximity to administration of either reversal agent or ondansetron. Despite the fact that the adverse event rate was only 2.6% in a population known to already have prolonged QT and the fact that the events might or might not have been related to anti-emetic or reversal of anaesthetic or sympathetic drive during emergence from anaesthesia the authors conclude that ondansetron should be avoided…..

This is the evidence that has supported the FDA decision and, whilst I agree patient safety is paramount and all potential drug adverse effects should be flagged, I’m not sure that these 3 papers should induce clinical panic…

Now I want to write an impartial piece to generate discussion around the issue of ondansetron use in the ED, but as I write I am becoming a little distracted and bias – so I will sum up….

Gastroenteritis is a worldwide problem and leading cause of death amongst children under the age of 5years. The mainstay of treatment is oral rehydration, and ondansetron is clinically effective to aid this approach – increasing oral intake and reducing the use of IV therapy. In many countries the use of ondansetron is still debated (and specific to the UK not endorsed by NICE). Based on the evidence presented above the FDA has produced a drug warning that has resulted in some countries – notably a middle income country with a significant disease burden – withholding ondansetron use in children with gastroenteritis.

The question about ondansetron is actually opens a number of clinical, ethical and understanding of risk debates? What conclusions do you draw?

I’d be interested in your opinions.

Tom Bartram