EBOLA Update: Is Witholding Care Even Acceptable ?

Ebola

A horrible situation for patients. Withholding care when care is requested is a crime, especially when necessary safety precautions can be taken. Not doing it because of fear is tantamount to medical negligence.

Some U.S. hospitals weigh withholding care to Ebola patients (REUTERS)
The Ebola crisis is forcing the American healthcare system to consider the previously unthinkable: withholding some medical interventions because they are too dangerous to doctors and nurses and unlikely to help a patient.

Reference: http://www.reuters.com/article/2014/10/22/us-health-ebola-usa-interventions-idUSKCN0IB2OM20141022

EBOLA Update: United States Requiring Travellers from Affected States to Register Details

Ebola

The U.S. has put in place plans for travellers to have their details recorded upon arrival on U.S. soil. This still falls short of temporary border controls, a hot button issue for the President.

U.S. Plans 21-Day Watch of Travelers From Ebola-Hit Nations (NY Times)
The new federal rules take effect next Monday. All travelers who have visited Guinea, Liberia or Sierra Leone will be required to provide home and email addresses, telephone numbers and other contact details for themselves and at least one friend or relative.

Reference:

http://www.nytimes.com/2014/10/23/health/us-to-monitor-travelers-from-ebola-hit-nations-for-21-days.html?_r=0

Donate to Médecins Sans Frontières

ebolafunds

msf-names_finalAll of the World Health Organisations (WHO) fundings and goals are tied into what member countries think is the best use of the limited funds, and into programmes that will bear the greatest outcome. Non profits like Doctors without Borders however are already working on the ground and saving lives. If you have the time, and some cash – donate to them instead. These guys are doing some amazing work on the ground and in the process risking their lives. Do give a little, because a little goes a long way in developing nations in West Africa. Click on the image on the left to go to the donate page.

Worsening Ebola Crisis in Sierra Leone

EBOLASL

To be honest, the Ebola crisis in Western Africa looks far from over. The WHO declaring Nigeria a success story seems like a premature celebration. This disease is ravaging the western front on the continent and its spread is far from being controlled. We need to do more. Our reluctance to help those desperate for medical aide in Africa will hurt everyone as Ebola spreads unchecked.

 

Small Victories and Negativity

teatro vuoto

Today there was a trivial victory in the morning. It was almost instantly followed by negativity from the usual lot. I laughed a little, and the day went off as planned. The big mistake I was making was faking the niceness and well meaning nature when dealing with the negativity. Then I happened to come across this quote and it has changed my perspective forever. Now I laugh and do whatever it takes to make myself happy. Do I forget those who put me down? Of course not. Do I wish them well? Of course not. It would be surely foolish of me to wish well of people who do not do the same for me. Good will is the fuel of the soul, it has to be put to use or all you have is an inefficient machine, generating wasteful heat.

 

nice ahf feat

Playing NICE with the Acute Heart Failure Guidance

These are the current NICE guidance for patients presenting with Acute Heart Failure(AHF). The problem with these guidelines is the definition of AHF. No mention of whether AHF is the same as ADHF (decompensated) but I’m guessing they are commenting on patients who present early with mild symptoms of heart failure. But for arguments sake, because Emergency Physicians are hammers and this looks like a nice enough nail, I thought I’d dress up as hammer and discuss this.

Diuretics as the main stay again?Then there is also the negative wording with regards to nitrates and NIV.

Haven’t we been through this already?

Patients with AHF are symptomatic because of pulmonary and or systemic congestion and end organ dysfunction from decreased cardiac output.

Furosemide will reduce preload via diuresis, but most of these patients are already clinically dry. Besides the fact that you need to have a functioning kidney to ultrafiltrate out the fluid, loop diuretics have a long duration of action (i.e. 2hours and longer), it is not an easily titratable drug as compared to nitrates. It is hard to ignore the continuous fear of hypokalemia and its complications from high dose loop diuretics.

NIV with PEEP saves lives. The data is there. This should not even come up in 2014.

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The Best Resources for the ARISE Study

As promised, the Australians have killed EGDT in Sepsis. Just to make sure some points aren’t lost here, the following is accepted as standard practice:
1. there is no debate on the definition of sepsis as per Rivers
2. even in the control groups (called standard care here) antibiotics were given
3. The use of fluids and vasopressors were also used in standard care.

So what is this whole ARISE thing you are so excited about ?
1. This trial was huge 1600 patients
2. the EGDT group as per Rivers were more aggressive with fluids , packed cells and pressors (and by a lot when compared)
3. The EGDT group was allowed to use SCVO2 which was not allowed in the control group.
4. There was no significant difference in
a. survival time
b. in-hospital mortality
c. 90 day mortality
d. duration of organ support
e. length of hospital stay.

At this juncture we already have 2 large RCT’s – ARISE and PROCESS both of which clearly show the regimented approach to treating sepsis as having no difference in outcomes.

However it is important to note that Rivers et al did a great service in highlighting the need to identify sepsis early and treat. What these 2 new trials show is that there might not be a benefit in being so aggressive in managing patients in sepsis in particular patients with septics shock .

Links:
PROCESS – http://www.nejm.org/doi/pdf/10.1056/nejmoa1401602
ARISE – http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404380
this is the link for rivers et al response to the PROCESS trial. http://www.survivingsepsis.org/…/SSC-Responds-Process-Trial…

hangover cat

Laziness is a Virtue

Of course it is. It’s the most important of all. Right after not giving a f-. Kids however should remember that if you get caught being lazy, and when you are getting yelled at by your supervisor, don’t look to me. I’m doing my own thing.

Open Top Car

The Problem With Maria

I’m not going to pretend that I’m not hurt or angry, but I will however go on with life. Its been a hard few weeks, learning lessons about trust and friendship but I feel that I’m much better off now than I was before. I’ve learnt in the last few weeks that I need to put myself, and those closest around me, first before work. These things you only realise after the proverbial shit, actually hits the fan.