Winter Symposium 2009 Report
Times are a changing. In the past there were lots of drug reps at Conferences and stands with the makers of medical devices. Stands at this year's ACEM Winter Symposium included a locum agency, three departments of health, and one for TASERs.
At the TASER stand, I was reminded of the days when tobacco companies denied that cigarettes caused lung cancer. A man in a suit, with an American accent politely and repeatedly informed me that there was no case where the TASER was definitely found to have killed someone.
While I was there, two gentlemen from the Queensland police came to speak to him. Donald Dawes, who is a FACEP and Police Officer, presented a paper prepared by Jeffery Ho on " The introduction of the Conducted Electric Weapon into a Hospital Setting". He declared an interest in that he was a consultant to TASER international. TASER works by making muscles contract and also causes pain. So it can be used as "pain compliance". When TASER is first deployed in an area, it is discharged a lot, but then you get "Red Dot Compliance". That is where you point it at people, and the red dot illuminates on them, and they comply. In 12 months at HCMC (a level 1 trauma centre) they had 18803 calls to security for immediate need of help. Previously security had extendable batons and pepper spray and hand cuffs. In the year following introduction of TASER they used it in some way in 27 of the 18000. Visual introduction: 24, Red Dot: 20, Brandish: 4, Probe Deployment: 3. They showed reduced staff injury and reduced lost days as a result.
A trial of IM sedation for violent and behavioral disturbance in the ED
This hospital only had an Australian standard 5 per thousand VABD patients. They are in the middle of a trial of IM Droperidol or Midazolam (DORM). Before the trial 82% of VABD had IV sedation but in the trial it is 100%IM. They are finding a shorter time to security "all Clear" with the IM DORM, less adverse events, and the staff prefer it.
The Rivers early goal directed therapy trial had a high mortality by Australian standards even in the improved treatment group. Nevertheless, it became incorporated into many guides as the standard of care, along with measurement of mixed venous O2 sat. THen the Wall Street Journal pointed out that the author took out a patent on the oxymetric central line before he published the study. Now the ARISE study in Australia will try to sort out if it makes a difference here. The big thing that is proven is that early antibiotics saves lives. After that, the consensus is: Do ABG for lactate and Base Excess; Art line; Central line; MAP > 70, norad; CVVH for severe acidocis or renal failure; Early enteral feeding. And it is best to use a protocol and do it early.
Indigenous patients have more renal failure (and diabetes and obesity). Indigenous peritoneal dialysis patients get more peritonitis due to overcrowded housing (average 16 per household), and grafts don't survive due to sepsis. Renal failure is an independent risk factor for cardiovascular disease and death and hospitalisation. We should all be keeping our cannulae clear of the cephalic vein in our renal patients so the shunt doesn't block up with scars when they end up with one. Nebulised B agonists are useful for decreasing K for hours.
Paediatrics now that there is pneumococcal vaccine
There is no evidence that giving steroids in meningitis alters mortality. The risk of bacteremia in a well looking child (after the neonatal period), is probably now so small that it does not justify investigation and treatment; rather, it is better to do good, early follow up. For UTIs <3month males, <12month females, and those with a know abnormal urinary tract are the ones at risk.
The NT Aboriginal intervention
Several speakers addressed this from different points of view. Originally the AMA called for an inquiry into why indigenous health and education standards were so poor. Then the AMA passed a "no confidence" motion in NT governments health management. This led to the "Little children are scared" report, and then the federal government intervention.
The background is overcrowding (average 16 per household), household smokers and poor hygiene leading to recurrent chest infections then bronchiectasis. This disease of poverty affects 2% of indigenous children and is very, very uncommon in non indigenous. Also diarrhoea, skin infections, malnutrition, growth retardation and post strep illnesses are frequent diseases of childhood.
The "Boiling Frog" syndrome was said to be at work. Regular workers stop noticing how bad it is, but external visitors are horrified. Infections, malnutrition and growth retardation and post strep diseases are the frequent diseases of childhood.
So has the intervention helped? On the one hand, it has brought a significant police presence to communities which the communities appreciate. And the most vulnerable, abused women certainly benefit from having half their income quarantined for food and clothes. The voluntary health checks led to audiology, ENT, dental and paediatric referrals.
But there were lots of issues between teams. The racial discrimination act was suspended to enable the intervention. So those who were not vulnerable have indignity and a new layer of paper work applied to going shopping. Most of the houses built have been for government managers and law. And a new policy of reporting under 16 year olds who are sexually active is causing harm and unworkable. Young teen pregnancies had been vastly reduced, but that will go backwards if health workers don't break.
Drinks at the Governor's
The welcome reception was held on a lawn at Parliament House, overlooking the harbor. Like the rest of the conference, it was warm, friendly and beautiful.
Access Block NT Style
This is story of access block NT style. Access block in the ED at Alice Springs Hospital (ASH) is a daily part of life. A 19 bed department, it routinely has over 50% of its beds holding patients awaiting wards beds. A maximum of 3 further trolleys can be accommodated within the maid ED. At times, selected patients are placed in a nearby, out of sight, corridor, or even on trolleys in the waiting room, curtained off! Stays in ED can measure 3 days or more.
Tennant Creek Hospital (TCH) is staffed by a couple of locum junior doctors. A patient needed ventilation and ICY. Two senior ED registrars were sent form Alice Springs to Tennant Creek. The patient was intubated and transferred to Royal Darwin Hospital as ASH ICU was full. The plane and the two registrars then were stuck in Darwin as the pilot had run out of flying hours. One of those female doctors has a small baby at home. The other was meant to be on duty at ASH ED at 0730 the next morning. The doctors returned to Alice Springs at 1230 the next day and the plane flew back the following day. Total distance travelled: over 3000km.
Access block is a pervasive and serious problem: on this occasion the consequences were costlier than usual.
Dr Paul Helliwell
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