Sunday Morning – 05.23.21

I’ve finished looking at the newspaper. Afterwards, I started browsing my RSS feed and for some inexplicable reason I read an article on whole bowel irrigation at https://emcrit.org/toxhound/the-purge/.

Memo to My Life Underwriting Colleagues:

Retire before you get to this point in your career. Reading articles like this will not facilitate advancement in your chosen profession. Get out. Get a life.

Rocky Mountain Spotted Fever (RMSF)

RMSF is the most common fatal rickettsial illness in the United States.

Overall hospitalization rates are noted be at 23.4% based on aggregated reviews of case reports (Openshaw 2010.

Case fatality rate is estimated to be 5-10% overall (Biggs 2016). If treatment is delayed, case-fatality rates of 40-50% have been described for patients treated on day 8 or 9 of their illness.

Case fatality rate is highest in those over the age of 70 (Amsden 2005).

Without treatment, the case fatality rate is over 25% (Lacz 2006).

Citation: Muhammad Durrani, “Emerging Tick-Borne Illnesses: Not Just Lyme Disease Part 4 RMSF”, REBEL EM blog, November 5, 2020. Available at: https://rebelem.com/emerging-tick-borne-illnesses-not-just-lyme-disease-part-4-rmsf/.

The CFR for untreated RMSF surprised me.

And yet another reason besides bears to stay out of the woods.

Remind me to tell some of my favorite tick stories when we can all gather unmasked to enjoy some food and drink.

Benzodiazepines Implicated in High Rate of ED Visits Across US

Seven out of eight emergency department (ED) visits attributed to adverse events from benzodiazepines involve self-harm or nonmedical use of these drugs, and more than 80% involve concurrent use of alcohol, illicit drugs, or other substances, new research shows.

Although benzodiazepines are typically not problematic in terms of acute overdoses when used alone, patients often don’t take them as prescribed or use them with other substances in a self-harm attempt, author Daniel S. Budnitz, MD, MPH, director of the Medication Safety Program, Centers for Disease Control and Prevention (CDC), told Medscape Medical News.

“Clinicians need to be aware of what other substances patients might be taking when they’re being prescribed a benzodiazepine,” Budnitz added.

The study was published online February 19 in the American Journal of Preventive Medicine.

Benzodiazepines Implicated in High Rate of ED Visits Across US – Medscape – Feb 25, 2020 – https://www.medscape.com/viewarticle/925686#vp_1

Ten Commandments of Emergency Medicine Revisited

#2 Remember naloxone, glucose, and thiamine (NGT)
Original: Consider or give naloxone, glucose and thiamine
The number of patients presenting with opioid intoxication is growing, and the gentle reversal of patients without severe respiratory depression with naloxone is in the art of medicine – consider starting with 0.4mg and titrate to effect.

In contrast to empiric administration of glucose in the altered or ill patient, rapid assessment of glucose level with point-of-care testing is recommended.

Thiamine deficiency may be less prevalent than previously thought in intoxicated patients, but we now know that giving 100mg of IV thiamine can benefit other malnourished patients, including those with calorie-malnourishment from cancer, gastric bypass, hyperemesis gravidarum, and eating disorders. Personally, I use the ‘T’ of ‘NGT’ to remind myself not to miss alcohol withdrawal.

Ten Commandments of Emergency Medicine Revisitedhttps://journalfeed.org/article-a-day/2021/ten-commandments-of-em-revisited

Why does this matter? I hear you thinking we underwrite life insurance, we’re not doctors. So true. But if we think like doctors we will get better at what we do by recognizing the subtleties buried within the medical charts we read. Here’s what my eyes/brain picked up.

The bold in the excerpt above are mine to illustrate how the mind of a mortality risk expert works. In Emergency Department records pay attention to the initial treatments provided which in some cases hints to a serious condition impacting mortality. Naloxone and opioids are obvious. But would you have associated the administration of IV thiamine to malnutrition or alcohol withdrawal? I thought so.

So read and research widely. You’ll always find little jewels to improve your skills and to impress your friends with. Or in my case to make Dr. Lee think his old man knows more than he actually does.

Kaiser San Jose Covid Outbreak

Hospital officials initially reported an outbreak of 44 infections traced back to the apparently impromptu Christmas celebration, but this would be the first fatality associated with the informal Dec. 25 visit. All 44, including the employee who died, had been working in the emergency department that day, according to NBC Bay Area, which also described the outbreak’s first victim as a woman who worked as a registration clerk in the department.

Coronavirus: 1 employee dead after outbreak infects dozens at Kaiser San Jose — https://www.mercurynews.com/2021/01/04/coronavirus-1-employee-dead-after-outbreak-infects-dozens-at-kaiser-san-jose/

COVID-19 in the Elderly (case study and literature review)

Summary

Age is a risk factor for increased morbidity and mortality in COVID-19 infections.

Elderly men have increased mortality compared to elderly women.

Elderly patients can present differently. Delirium can be the primary symptom of COVID-19 infection, as can persistent hypoxia.

Consider COVID-19 in the setting of altered mental status and geriatric falls.

Elderly patients in the ED who live in nursing homes should undergo COVID-19 testing.

Elderly individuals with COVID-19 tend to have increased lesions and lobar involvement on chest CT.

Laboratory diagnostics may differ based on age, and the geriatric population may have lymphopenia, higher CRP values, and increased D-dimer on testing.

COVID-19 in the Elderly — http://www.emdocs.net/covid-19-in-the-elderly/?utm_source=feedly&utm_medium=rss&utm_campaign=covid-19-in-the-elderly

The full article takes some time to read but it’s well worth it if you are into the clinical stuff.

Mugged at Thanksgiving!

A mug every four years to commemorate milestones in a physician’s career.

Just another Saturday morning except this day starts the second half of a long four day Thanksgiving holiday break. We have given our thanks for the things we are grateful for. Today I’m asking all who read this post to give thanks for all of our front line healthcare workers for whom there is no break from work. We have many dedicated people who are spending the holiday away from their families while most of us are spending time with our families. These brave souls are putting their own health and safety on the line for the rest of us.

  • Thanksgiving – 3:00-11:00 PM
  • Friday Nov. 27 – 1:00-9:00 PM
  • Saturday Nov. 28 – 1:00-9:00 PM
  • Sunday Nov. 29 – 6:00 AM-2:00 PM
  • Is it too hard to wear a mask?

I’m getting better at writing effective click-bait blog post titles.

Anorexia Nervosa – More Dangerous Than You Think

This article is written by an Emergency Medicine doctor for other Emergency Medicine doctors as a quick primer on recognizing and diagnosing anorexia.  While those of us in the life insurance business are not diagnosticians  you will definitely benefit from this short ten minute article on the next case you encounter where Momma Bear is applying for $2,000,000 on her skinny 15 year old daughter who can’t seem to gain weight no matter how much the kid eats.

AN is a common, severe psychiatric illness. It is often present with co-morbid psychiatric illnesses. There is a high mortality rate, 5.6% per decade. It is notoriously difficult to treat with psychotherapy and pharmacotherapy.

Anorexia Nervosa – More Dangerous Than You Think