EATING DISORDERS – What to know and expert update.

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EATING DISORDERS

As summer approaches, we all want to have a great beach body, but for some, it can be a life-threatening obsession. Today’s TED explored Eating Disorders and we were lucky enough to have Dr Warren Ward, Director of RBWH Eating Disorder Service as a guest presenter and the venerable Dr Charles Denaro, Director of Internal Medicine, RBWH to offer his perspective of the management of these patients on the ward.

To put things in perspective, Dr Maya Aoude, Emergency Registrar, gave us “the skinny” on current state of affairs of presentations in the local RBWH context.

  • 32 patients over the last six months were seen at RBWH, ninety percent were female. 1 in 20 Australian suffer from an eating disorder.  There was some surprise from the local audience that the largest age demograph was in the 25-35 year age group. Dr Denaro and Dr Ward pointed out, the disease is chronic and that although the age of onset is around 14-20, it takes time to develop the physiological abnormalities that manifest in a need to present. Most are referred by their GP or community mental health.
  • About 50 % of all eating disorder admissions start out requiring medical admissions. Our network partners eluded that presentations to their EDs of patient with eating disorders requiring admissions are rare. The majority were voluntary patients

 

Anorexia Nervosa and Eating Disorders

Dr Ward took some time to offer some educational pearls and wisdom on the treatment of this group. Here are some of the key points as I saw them:

Three types of eating disorders

-> Anorexia Nervosa

-> Bulimia

-> Eating disorders associated with increased weight (binge eating disorder)

15 % of females in Australia will have an eating disorder in their lifetime

10-20% of anorexia nervosa patients will die – it has the highest mortality rate of all psychiatric illnesses. However it also has a 70% cure rate within 5 years, with a multidisciplinary team approach.

The biggest risk for patients with an eating disorder is unintentional death due to starvation.  Someone can feel well and have normal bloods, but can suddenly drop dead from an arrhythmia.

 

Indications of cardiac risk:

BMI < 14

No oral intake for 1 week

Purging several times per day

SBP < 90

HR <50 or >110

Postural hypotension

Electrolyte abnormalities

ECG changes

 

My pants don’t fit me, how did it let myself go … without eating??

Culture, genetics, female gender and abuse or disturbed attachments in the first five years of life all play a role in the development of anorexia.  And we can all can probably appreciate the effect of peer pressure and media on developing a negative self-image. The biggest cause however is dieting!!

 

Dr Ward showed two interesting studies:

1.) Eating attitudes and behaviours prior and post introduction of TV to a culture (Fiji)  previously without this media

http://www.ncbi.nlm.nih.gov/pubmed/12042229

-> 60 % increase in abnormal eating behaviour in adolescents who were exposed to TV compared to those that were not

2.) More interestingly, the Minnesota Starvation Experiment, Ancel Keys, just post war

-> Participants dropped 25 % of body weight

-> increases in depression and hypochondriasis and preoccupation with food

-> so dieting a major risk factor for developing anorexia nervosa

-> participants became obsessional and detailed in their thinking, lost libido

This means that behaviours of anorexia nervosa initially more likely to be related to biochemical effects of starvation syndrome, rather than underlying primary psychiatric problems.

 

SO WHAT CAN I DO??

Assessment of Eating Disorder Patients in ED

  • Should only really take 5-10 minutes despite being emotionally charged
  • History is the key -> the process of how they got to ED. They are here for a reason
    • If they are in ED, they are more than likely further down the slippery slope than we realise

-> episodes of fainting key indicator need admission

-> often will tell you “everything is ok” if asked generalised questions on welfare, but be honest when asked specific questions about eating 

-> Get collateral from family members and GP

-> Fainting, light-headedness, chest pain, palpitations, ankle swelling, weakness, fatigue, regular periods -> I send young, articulate, well-looking patients with non-specific symptoms like this home all the time!! Protection for you and your patient is to correlate with quick eating history

 

****LETHAL COMBINATION****

(No it’s not Mel Gibson and Danny Glover)

Patient and doctor denial of seriousness of condition

 

EXAM

Easy -> postural HR, BP, weight and height.

-> Can add in a request to do a squat – de-conditioned patients find this hard to do

-> In patients with eating disorders, HR increases with standing/walking, as opposed to athletes who can maintain bradycardia with mild exertion

 

INVESTIGATIONS

Once again, pretty straight forward

-> ELFT (including phosphate), FBC, ECG

 

TREATMENT 

Fix what is not normal -> Na, K, Glucose, Phos preferentially IV -> they are more depleted and these parameters, particularly K likely to get worse with refeeding.

Myocardium de-conditions as well as skeletal muscle, just watch how much fluids you give them, especially if already puffy

DON’T FORGET THIAMINE, again IV

Start continuous NG feeds, 50mL/hr NGT of nutrison protein plus or liquid supplements in ED. Need 6300kJ/1500kCal per day.

Use the RBWH guidelines for assistance

Eating disorder admission guide

“WE DON’T NEGOTIATE WITH TERRORISTS”

Eating disorder patients are often high achievers as they are obsessional and detailed. They will provide a good arguments not to be admitted. Use the mental health act to keep them against their will and Guardianship act to treat their starvation syndrome. If you think they will leave, do a Request and Recommendation, even if they will agree to stay, even if PEC says not to. Use their guardians (parents are guardians in the event of them being assessed as incompetent to make decisions) and often do not need to use more aggressive measures to keep these patients.

Anorexia is a chronic disease, needing long-term help.

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Does a glass full of #FOAMed help the medicine go down?

(aka Social Media in medical education)

As we start a new registrar term at the RBH, DEMTEd takes a look back at the final session of 2013.2.

Does a Glass Full of #FOAM help the medicine go down? from Tranattack on Vimeo.

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Addendum

Profesor Brown, Editor of EMA announced during this session that the February Edition of EMA is the 25th anniversary edition with a focus on everything social media in the emergency department. Check out the online journal here (for ACEM memebrs) or here for the publishers page.

___________________

The final DEMTed of 2013 turned full circle, looking @ how we learn rather than what we learn. The session started with an overview of assisted education through SoMe (social media) and #FOAMed (free open access medical education) followed by a passionate debate on “The Textbook is at Death’s Door”.

Key Points

  1. Learning how to learn online now is easier than later                                            It will be exponentially more complex in a month, a year, a decade from now
  2. Reliability is an issue not limited to online media                                                    If you use google, then you know how to filter out the ‘bad apples’
  3. Use ALiEM’s 5 rules to enjoy longer lasting safe online education

Disclaimers                                                                                                                          I’m not a SoMe/#FOAM activist                                                                                                 I am millennial…therefore I am entitled (apparently)

What is Social Media?                                                                                                

There is no universal definition for Social Media. Some say it’s when an electronic medium has the ‘potential’ to collaborate, whereas others say it’s an electronic medium where users can easily show their opinion. For the purposes of this DEMTed we’ll call it an interactive online medium.

It’s important to be aware that none of the definitions requires users to actually contribute, the medium simply needs to have the ability to if one desires.

What is #FOAMed?                                                                                                               Free Open Access Medical Education

Let’s just put it out there. #FOAMed isn’t social media. Social media has helped evolve FOAM, help spread the word, and is part of it, but it’s not FOAMed. Instead, FOAMed is a concept – ‘any method of free online medical education’. Blogs, Podcasts, Twitter updates, email subscriptions, RSS feeds, it doesn’t matter what it is or how you use it, if its free and online, its FOAMed. That’s all you need to know about it for now.

The Art of Learning

  • SoMe helps gather information better
  • SoMe helps interpret/contextualise information easier

We all learn differently. But learning always starts by gathering information – be it from textbooks, ward rounds, lectures, meetings, or however else you gather information day-to-day. And the type of information that we choose to gather is decided on by a variety of recommendations (one of the consultants here reminisced that before the internet was a ‘thing’ the journal articles he read for ongoing education were limited to what the good Professor Brown recommended, if only the professor had a twitter account…)

We also learn by interpreting and contextualising the information that we gather. For this reason, concepts that we understand stay in our head longer than pure rote learning. This is also the reason why some of us learn better with study/discussion groups – because even though we might be reading the same text, we read differently between the lines. This is where FOAMed can offer a more efficient way of interpreting the information and making learning more efficient and more powerful.

Cautionary Tales

Here’s a list of what I think are the 5 most common reasons why Luddites see no point:

1. Reliability

The much revered peer review process has been the gold standard for centuries. But this all seems to have been by default. Prof Brown during the session suggested that there may be evidence to suggest that it isn’t any better, but makes editors feel better. At the end of the day, it’s up to you to decide on how you interpret the information. Do you believe the statistics, do you believe the rigorous scientific method applied and do you trust this ‘expert panel’ chosen for you, not by you?

The more interesting question is – do you use Google when learning? How can you trust it but not FOAMed (after all, isn’t googling something medically educational considered another aspect of the FOAMed concept)? The very fact that you go back to Google time and again doesn’t suggest that there is an inherent trust in the results. Instead, it reflects our sub/conscious ability to filter out the nonsense, to read around the debate and to use what we ‘think’ is reliable in our clinical practice. You’re FOAMing without knowing it! It’s not so bad is it? It’s important to apply these often subconscious principles when ‘googling’ to your approach with FOAMed.

2. Fad

The sacrifices of technologies’ short half-life have included the cd-rom book, Myspace, Digg, and Google wave. Will FOAMed be added to the list in a few years? Nothing is guaranteed in life, but given how social media is taking over how we communicate, it doesn’t seem like the bubble will burst any time soon. Knowing this, the longer you leave it, the more evolved FOAMed will become and steeper the learning curve will be when the time comes that you are required to use it.

3. Information Overload

To the uninitiated, online information can seem overwhelming. If that’s what you think about FOAM, you’re not far off – informative sites are like diamonds in the rough. The only difference is, once they’re found, they retain their value AND a greater number of people reap the rewards. This is where social media comes into its own: get a network of well informed and reliable online colleagues, keep up to date with what they’re reading, and find these gems.

4. Professionalism

We are taught early on what is acceptable and what isn’t, largely through trial and error. So what happens when a new way of communicating is developed? We saw this with the ‘reply all’ icon on an email. Adults have to learn through trial and error as much as kids do in order to calibrate to societies level of acceptability, but unlike kids, we have accountability to deal with. Rest assured, much of this trial-and-error has been done for you – the following is a guide to get your online learning going safely:

Live by #FOAM, Die by #FOAM

I won’t bore you by trying to emulate a great blog post http://academiclifeinem.com/5-rules-to-guide-your-approach-to-learning-in-social-media/ but the crux of the post includes:

  1. Approach with skepticism not cynicism
  2. Think about the context
  3. Innovative doesn’t mean rigorously tested
  4. Higher the risk = harder you think about changing YOUR practice
  5. Be inclusive (that means the patient too!)

Where to start?                                                                                                                   Try these sites on for size:

Life in the Fast Lane http://lifeinthefastlane.com/                                                            Academic Life in Emergency Medicine http://academiclifeinem.com/                            Boring EM http://boringem.org/                                                                                        Emcrit http://emcrit.org/                                                                                                  GMEP (Global Medical Education Project) https://gmep.org/

And you might be perplexed to see that the #FOAMed community is all inclusive, so these sites will have recommended reading if they think someone has done it better, differently or even the same!

Summary

  1. Embrace Online Learning (before it gets too hard)
  2. Make it work FOR you (and move to another site if it isn’t)
  3. Be cautious

Afterthought

Victoria Brazil, in her infinite wisdom, had two parting pearls;

  1. Experienced educators aren’t resistant to social media as a platform for education
  2. Be wary of something that’s free

And for those looking for the debate, unfortunately due to technical difficulties, we were unable to upload it.

Accelerated Diagnostic Protocols for Chest Pain

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This week DEMTEd took a look at troponins and chest pain workup using ‘accelerated diagnostic protocols’.

Chest pain assessment and troponin testing: the status quo

As of 2011, our guidelines in working up patients with possible acute coronary syndromes rely upon clinical assessment augmented with consecutive electrocardiograph and troponin assays.

The algorithm specifies a high sensitivity troponin, which is pretty controversial and impractical for those of us who can’t get them.

The timeline is also cumbersome in practice – we typically admit 4-6 patients a day to our short stay unit to work up possible ACS with intermediate risk as per the guidelines.

Slide1

The troponin in chest pain assessment

In the session today Dr Louise Cullen spent some time talking about the nuts and bolts of troponin testing. Here are some of the key points as I saw them:

  1. Troponin is released by myocardium in response to injury. It doesn’t come in any appreciable quantity from anywhere else.
  2. Troponin I and Troponin T are released from myocardium in equal amounts, but what happens after that may differ – some is free, some form complexes with other substances which are variably detected by different assays, and it may be that troponin T has a longer clearance t½ . This accounts for the differences in reference ranges between assays.
  3. The normal range has been generally defined by the 99th percentile, which means that of an unselected population, you might expect to see 1% of people having a troponin ‘elevated’ – by definition.
  4. The term ‘high-sensitivity’ troponin has (in practice for us in Oz) referred to a Roche assay for Troponin T (such as the test in current private practice). Unlike older troponin assays, most people have a troponin T above the detection limit of the test. So it generally returns a number, not just a “negative”. Interpreting that number when it is not very high has been problematic. Interestingly in the states the ‘high-sensitivity’ troponin assays have not been in general  use – they are not FDA approved. And of course at an institutional level Qld Health does not provide a hs troponin yet.There is a new high sensitivity troponin I assay which seems likely to percolate into our practice in the medium term. It’s worth mentioning as it seems to be as sensitive and considerably more specific that the hs-TnT that we are currently using, on the figures we were shown today, for ACS.
  5. The definition of MI has evolved. The cardiologists have categorised MI into 5 different types, only one of which is the pathophysiology I was probably supposed to learn in medical school (plaque rupture/thrombosis).The presence of an elevated biomarker (troponin) alone is not enough – to call it a Type I MI, for example, you need consistent symptoms, ECG changes and/or echo evidence.
  6. The above doesn’t change the fact that an elevated troponin confers a mortality risk in the person that has it, whether it’s due to ACS or not.

Of course, we mainly use a troponin in the context of working up a patient with undifferentiated chest pain. The ‘rule out’.

Accelerated Diagnostic Protocols for chest pain presentations

The assessment process detailed in the guidelines does confer a considerable cost burden to our patients (who are trapped in hospital) and to our health care system (providing the care and the tests).

In my patter to patients on presentation, I tell ‘em that we can rule out an MI with the ECG/blood tests and that we are looking at their future risk of a heart attack with the next test – in our institution a stress ECG.

Of course, once you get a 6 hour troponin back and start the final leg of your assessment, you’re looking at a length of stay of at least 8 hours, and often overnight depending on how you go about arranging.

The articles linked below describe an accelerated diagnostic protocol with (in one) high sensitivity troponin testing. The numbers and the process are pretty attractive and probably represent the next evolution of our practice. A TIMI score of 1 or less, no new ischaemic changes on ECG and normal hs-TnI at 0 and 2 hrs identifies a significant proportion of patients with a low risk of MACE  (<1%) who don’t look to need further testing.

By way of references check out a couple of papers on accelerated protocols (the future?) and the 2011 guideline summary (the past):

Validation of high-sensitivity troponin I in a 2-h diagnostic strategy to assess 30-day
outcomes in emergency-department patients with possible acute coronary syndrome.

2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker

Acute Coronary Syndromes treatment algorithm

 

Resus of blunt abdo trauma

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Abdominal  trauma session today in the emergency Thursday Ed video conference – and with the sort of resuscitation we can see in any facility, not just a trauma centre……

A 24 yr old footballer arrives by private transport after being injured in a tackle on Saturday afternoon. Blunt abdominal trauma – a shoulder to his LUQ. Looks pale and sweaty at triage and clearly has lots of pain. Rapidly moved to monitored area and his initial obs are pulse 140, BP 60/-. He becomes unresponsive and you can’t find a pulse……

 1. How should you approach resuscitation in arrest from blunt abdominal trauma?

Lots of discussion here with some scepticism about the utility of chest compression and some of the other elements of BLS/ALS in hypovolaemic arrest after trauma.

There are some obvious broad priorities

very rapid fluid resuscitation (ideally with something approaching a 1:1:1 ratio of red cell units : FFP : platelets, but obviously you are initially giving crystalloid pending the arrival of blood products) until an output regained (but not much further)

and

emergent laparotomy in absolutely the most rapid way you can make it happen

In our audience there was discussion around the additional priority of not missing other treatable causes (ie tension pneumothorax).

The role of chest compression and adrenaline is less clear, and in the audience there was a 50:50 divide on whether it was beneficial or harmful – which matches the views of trauma resuscitation authorities, with some prominent figures in the “don’t do it” camp. And it is easy to see why – using chest compression to generate intrathoracic positive pressure doesn’t have much beneficial effect with IVC/SVC and heart are empty.

Daryl Wall (Trauma surgeon) was along and emphasised the importance of haemorrhage control. The Surgical staff in hospital overnight in a hospital like RBH should be able to start a laparotomy, apply packs and pressure to have some chance to control haemorrhage while awaiting the support of more experienced supervision. The other option that may be available is thoracotomy and aortic cross clamp.

I would have to watch that on youtube first. Or maybe old ER re-runs.

2. What about interventional radiology in trauma care and abdominal injuries?

It is possible to consider sending some patients to the angiography suite (or a hybrid theatre – ie a suite in theatre) for DSA and intervention.

They have to be somewhat stable, and it is more efficient to go into the procedure with a CT which gives a head start to the radiologist on what to catheterise and embolise. Apart from isolated pelvic injuries, most abdominal trauma patients with instability and ongoing bleeding will be laparotomized by the surgeons first and interventional radiology is considered for ongoing haemorrhage.

3. What are the indications for “Trauma Pan-Scan” and is it performed too often?

Most “pan-scans” for trauma are a collection of CTs including following regions:
Head and c-spine – non contrast
Neck/Chest/Abdomen/Pelvis – Arterial phase
Abdomen/Pelvis – Portal phase
Face, Thoracolumbar spine – reconstructed from above

The upside to doing this is that it finds most (but not all – esp abdominal hollow viscus) injuries.

The downsides:

– Radiation, with estimates of around 24 mSv given possibly leading to an additional risk of 1 cancer in every 1000 patients scanned (scanning around 400 patients a year this way at RBH). The real lifetime risk from this imaging is hard to pin down, cause it’s dubiously extrapolated from Hiroshima etc
– Queues of people waiting for the CT scanner
– Queues of people waiting for reports from the radiologists looking at 1200 images

Once you have a mechanism of an appropriate nature and a patient that is unable to be evaluated (ie altered mental status or intubated), the decision is easy – do it.

In patients with physical findings or symptoms that indicate the scans above it’s also easy

Controversy (apparently) arises when you have a mechanism but an alert and overtly uninjured patient with no symptoms or signs. There are some fairly-easy-to-poke-holes-in studies that push the routine panscan on mechanism.

I don’t find it that controversial at all – If they are able to be evaluated and truly asymptomatic with an absolutely normal exam, I don’t believe you will find anything on abdominal CT that needs them to go to theatre before they develop symptoms. (Cue someone with a case series of patients that contradict that).
Back to our critical or even arrested patient. We would be in a bit of trouble in a non-trauma centre (mind you his chances of survival are slim anywhere). Unless I had just seen a surgeon wander through the foyer on the way to the ward I reckon I would start out with a default plan of fluid resuscitation and lights and sirens to a trauma centre.

And another thing

Just as an aside, we see a crook looking patient every year or so with no or a less prominent trauma mechanism and splenic rupture in the context of (undiagnosed) infectious mononucleosis.

Just in case you read read a CT report which tells you your patient with acute pain, free fluid and shock has ascites, as I have, a word to the wise – be somewhat sceptical of the ability to differentiate intraperitoneal blood and ascites based on density at CT.

Disasters

0400 Wednesday night shift

You sip your coffee international roast beverage fatigue management supplement and the phone rings…..

“Hey, it’s Rob, an IC paramedic from QAS. There’s been an explosion in the valley!! It looks like we have a large number of critically injured young people outside a club  on Wickham street – its looks like a mixture of blast trauma and burns at this stage. Can you send a team to the scene?!!!”

You call your consultant who advised you go straight to scene and she will meet you there………….

 

Who coordinates our emergency medical systems and medical response in incidents and disasters?

QEMS is the Qld Emergency Medical System.

The QEMS Coordination Centre (QCC) functions from a joint facility in Spring Hill between QAS and Qld Health’s Retrieval Services Queensland (RSQ) division.

QCC operates 24hrs a day
RSQ provides

  • Coordination, clinical governance, credentialing, oversight, quality control
  • Nursing Coordinators
  • Medical Coordinators (RSQ staff or CMS contracted)
  • >20,000 Retrievals/Transfers per year (25% Paeds/Neonate or high risk obstetric)

You arrive on scene and are fronted with multiple burnt, screaming patient. Some mobilizing. Some not moving.  A well meaning but not immediately useful crowd is in attendance.

OK, you are now – hopefully briefly – the only doctor on site at a disaster. What do you do now???

sieve

Sieve and Sort

The basic concept is to (capital T) Triage to “do the most for the most”. Deal with life threats to enable rapid Triage/Treatment/Transport.

When there are multiple casualties initial assessment can take place with the Adult Triage Sieve.

The sieve can be applied by an experienced paramedic or doctor on scene, and is designed to RAPIDLY triage to 4 groups ((1) Immediate, (2) Urgent, (3) Delayed and Dead).

260436_132_sort-triage-fix_1_After using the sieve to triage and moving disaster patients to a casualty clearing station, the Revised Trauma Score can be used to sort.

By using GCS, respiratory rate and systolic BP a score is calculated, priority can be assigned and casualties can be distributed to appropriate receiving hospitals in an appropriate distribution.

 

 

 

You conclude you have 12 reds and yellows with up to 15 greens and start to think about the best way to move people to definitive care….

 Well, this is pretty easy when the site of the incident is close to the hospitals that can provide definitive care. It is possible to summarise the attributes of road, fixed and rotary wing transportation as below:

  ROAD ROTARY WING FIXED WING
SPEED 0-140km/hr 200-280km/hr 300-800km/hr
RANGE 500km 1000km 3000km
ALTITUDE 0ft 0-10,000ft 0-35,000ft
COST Cheap 4 X FW Expensive
CLIMATE LIMITATION Rare Frequent Minimal
WINCH No Yes No
Secondary T/F needed No No Yes
Vibration Subtle Marked Minimal
Noise Subtle Extreme Marked
Procedural space Limited Extremely Limited Limited
Turbulence Nil Rare Significant
Flexible landing sites Yes Yes No
Response times Instant Fast (2-10min) Slow (15-30min)

 

 

 

Your boss arrives to take over the scene and sends you back to prepare ‘the hospital’!!!

Disaster Concepts/Phases

  • ALERT
  • STANDBY
  • RESPOND
  • STANDDOWN

 Major Incident Medical Management and Support Approach (MIMMS)

C – Command and Control

  • Emergency operations room
  • Hierarchy
  • Delegation and Roles
  • Identification

S – Safety

  • PPE
  • Toxins
  • Media/Crowds/Violence

C – Communications

  • Vertical vs Horizontal
  • Devices – radio, phone, PA (probably on bypass)

 A – Assessment

T – Triage

  • Red, Yellow, Green vs ATS

T – Treatment

  • Teams to be consultant lead by specialty

T – Transport

  • T/F of critically Ill vs Transport of walking well