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Preference: Emergency Medicine

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Brain cooling after injury not worth the risks

Cooling the brain and body soon after a severe traumatic brain injury does not improve patient outcomes as previously thought, and exposes patients to unnecessary harm, a landmark Australian trial has found.

The technique – using a combination of cold intravenous fluids and surface cooling wraps, followed by slow re-warming – has been shown to be neuroprotective in animal studies, and is used in selected patients with severe traumatic brain injury (TBI) in most Australian intensive care units.

The theory is that hypothermia limits secondary brain injury by attenuating inflammation and biochemical cascades set off by trauma.

However limited clinical trial evidence to date has failed to demonstrate that the potential benefits of hypothermia outweigh the known increased risks of bleeding, infection, decreased heart rate and blood pressure and pneumonia.

Now a major study led by researchers from Monash University in Melbourne has been credited with providing definitive evidence that the technique has no impact on patients’ long-term outcomes.

The brain cooling study

Led by Professor Jamie Cooper, director of the Australian and New Zealand Intensive Care Research Centre, the POLAR study randomized 500 traumatic brain injury patients recruited from emergency departments and ambulance services in six countries to either prophylactic hypothermia or normothermia. All other care was at the discretion of the treating physician.

Whereas a previous study (Eurotherm) only used hypothermia in patients with evidence of brain swelling, patients in the POLAR trial were randomised to hypothermia regardless of intracranial pressure. This was in order to ensure hypothermia commenced as soon as possible after injury, to maximise the likelihood of benefit.

The targeted temperature in the hypothermia group was 33-35⁰C for at least 72 hours and up to 7 days. For patients in the normothermia group, the targeted temperature was 37⁰C, with surface-cooling wraps used when required.

At six months follow-up, the study found no benefit to patients receiving hypothermia, as measured by their capacity to live independently. In both groups, 49% of patients had a favourable Glasgow Outcome Scale Extended Score.

Furthermore, hypothermia did not improve secondary outcomes including mortality.

The intervention was, however, associated with increased rates of pneumonia (55% vs 51.3%) and intracranial bleeding (18.1% vs 15.4%), the authors reported in JAMA.

Professor Cooper told doctorportal: “My view is that we should now cease using hypothermia for TBI patients in Australia”.

“From now on, patients should not have to endure the risks of hypothermia because we know there are no benefits.”

Why no effect?

The latest study showed it takes much longer to reach the target temperature in clinical practice than it does in lab rats – even when hypothermia management commences as early as possible. It took 2.5 hours on average to reach the initial target temperature of 35⁰C, and 10 hours to reach the final target temperature of 33⁰C.

The authors said the delay was largely due to the time required to exclude risk factors for bleeding, such as ruptured spleen or persistent hypotension, that would contraindicate hypothermia.

An accompanying editorial by doctors from the University of Edinburgh suggested this time lag might explain why hypothermia “failed in translation from the bench to the bedside”.

The editorialists agreed that the weight of evidence was now firmly against hypothermia initiation during the acute phases of TBI management.

Is there ever a place for hypothermia in TBI?

Professor Cooper said it’s time for an explicit warning that hypothermia has no place in the management of TBI, even when there is significant intracranial pressure.

Current guidelines by the Brain Trauma Foundation only recommend against short-term prophylactic hypothermia for diffuse TBI, and are silent on other indications.

Professor Cooper said there was now clear evidence that if intensive management of intracranial pressure was required, barbiturates were the standard of care – not hypothermia or decompressive craniectomy. In a 2011 study in the New England Journal of Medicine, Professor Cooper’s team found decompressive craniectomy was linked with poorer outcomes compared with standard care.

Professor Stephen Bernard, medical director of Ambulance Victoria told doctorportal: “I think the POLAR trial did in fact provide a definitive answer that there is no benefit in the provision of early, prophylactic therapeutic hypothermia in patients with isolated severe traumatic brain injury.”

He continued: “I understand that there is still some enthusiasm for hypothermia as a last resort for the management of intracranial hypertension after thiopentone infusion, but these patients have a dreadful outcome so it is uncertain whether this will ever be tested in a clinical trial.”

Professor Cooper said the study’s findings were far from expected.

“Few of the authors anticipated that such extensive hypothermia would have such little evidence of any measurable effect at all, other than the known complications,” he said.

Unconscionable to leave children on Nauru

The AMA’s paediatric representative Dr Paul Bauert has delivered a blunt message to the Federal Government – get the kids off Nauru.

While addressing protest rallies, speaking to the media and handing over a petition to parliamentarians that has been signed by thousands of doctors, Dr Bauert repeated his insistence that it is unconscionable to leave children suffering on the Pacific island.  

Dr Bauert has treated asylum seeker patients on Nauru.

“This is the only situation I’ve come across where it is deliberate government policy which is causing the pain and suffering of these children,” he told reporters in Canberra in October.

“Many are damaged already, but we don’t want this damage to be permanent. They need to be assessed and treated as a matter of urgency.

“It’s a miracle we haven’t had a death already.

“I have reviewed many cases of these children myself. It is simply unconscionable that we are keeping these children and their families in a situation which we know is a critical threat to their health and wellbeing.

“The situation for children on Nauru is a humanitarian emergency requiring urgent intervention and removal of all these children and their families to medical treatment in Australia.”

On October 15, Dr Bauert and Sydney-based GP Dr Sara Townend delivered to Prime Minister Scott Morrison an open letter signed by almost 6,000 Australian doctors, urging children in detention on Nauru be transferred to Australia for medical and psychological treatment.

The number of signatories amounts to about five per cent of all registered doctors in Australia.

CHRIS JOHNSON

 

 

[Clinical Picture] Woe sushi: gastric anisakiasis

A 40-year-old man presented to our emergency department with acute upper abdominal pain 8 h after ingestion of sushi. During physical examination, he was found to have tenderness in the epigastric region. Abdominal CT showed diffuse thickening of the wall of the gastric body with surrounding fat stranding. Emergency gastroscopy identified a 15 mm long larva of the nematode Anisakis simplex penetrating the inflamed body of the stomach (figure). Disinfestation rapidly resolved the patient’s symptoms.

[Correspondence] World Restart a Heart initiative: all citizens of the world can save a life

Sudden cardiac arrest is the third leading cause of death in industrialised nations, resulting in more than 700 000 deaths in Europe and the USA annually.1 After cardiac arrest, the brain can survive for 3–5 min, which could be the minimum time that emergency medical services take to arrive. Consequently, the most important way to improve survival is the instigation of early bystander cardiopulmonary resuscitation (CPR).2 Bystander CPR increases survival by two to four times, which is much better than with any other intervention by emergency medical services or hospital staff.

AMA keeps up pressure over Nauru

Aggressive lobbying from the AMA has sparked a groundswell of support for the urgent removal of refugee families from Nauru.

While the Australian Government grapples with an onslaught of criticism over its handling of the worsening asylum seeker issue, AMA President Dr Tony Bartone continues to pressure the highest levels of power.

Following his recent letter to Prime Minister Scott Morrison, demanding a policy rethink and the urgent transfer of children and their families from Nauru, Dr Bartone has maintained the call through numerous media appearances as well as closed-door meetings.  

The Prime Minister initially dismissed the AMA’s call, but since being swamped with expressions of outrage from both inside and outside of his own party – all in the face of a potential by-election loss in Wentworth – he put on the table the prospect of refugees being resettled in New Zealand.

The New Zealand Government has repeatedly offered to take 150 asylum seekers from Nauru, but the offer has been continually met with rejection by the Australian Government.

Opposition Leader Bill Shorten has also received internal and community pressure over Labor’s position on asylum seekers, and so flagged a private member’s bill aimed at making medical transfers from Nauru much simpler.

This all happened in a week when Médecins Sans Frontières confirmed its people had been kicked off of Nauru, and also when the senior Australian doctor contracted by IHMS to provide medical care to the asylum seekers, Dr Nicole Montana, was removed.

Dr Bartone described the developments as “extremely concerning” and pointed to “crisis upon crisis” developing on the island.

“It highlights the confusion and chaos around the medical treatment being provided to a group of very vulnerable people and various stages of medical care required on their behalf,” he told ABC Radio.

“What we’re very clear about is that doctors working on Nauru, or any other processing centre, should be able to deliver the best care, the best appropriate care required by their patients.

“These people are under the care entrusted to the Australian Government, they are responsible for their health and wellbeing while in those centres, and they need to ensure that the provision of medical care is foremost unimpeded in that process.”

Dr Bartone said the AMA was continuing its advocacy on the issue and in addition to wanting all children and their families removed from Nauru, it is calling on the Government to allow an independent delegation of Australian medical professionals to visit the island.

“We need a solution in this area. We need a solution which brings to a head this ongoing crisis. We’re talking about the lives of children, in particular, many in very, very serious states of urgent medical care requirement, and we really do need to know that every day that goes by is another day of suffering for these children in particular,” he said.

“What we’re saying is the Government and the appropriate department there is remaining steadfast with the lack of transparency in the approaches, in the information sharing. The information flow is very, very slow, very, very guarded, and very, very piecemeal when it does come our way. This is unacceptable obviously.”

The AMA President has met with Shadow Immigration Minister Shayne Neumann and has said Labor’s proposal is pragmatic – in the absence of anything meaningful coming from the Government – and the AMA was backing it.

“This approach, this legislation, will seek to both reduce the bureaucratic process in this transfer, increase the transparency, increase the medical decision-making powers, and increase the independent medical oversight of the whole medical treatment process on the facilities… and ensure that vulnerable children, in particular, but anyone who requires urgent medical attention is afforded that care, appropriate care, before they get too far down the track,” Dr Bartone said.

“What we know is that if the Minister has the final decision, that needs to be independently verified by a second medical doctor within 24 hours of that decision. That both speeds up the process of the decision-making capacity and it would be a very, very brave Minister who would refuse the advice of two treating doctors, independent, and then have to report back to Parliament in a transparent way to the Australian public that that decision was not proceeded with.”

A number of the Government’s own MPs publicly broke ranks this week to demand action and the urgent removal of children from Nauru.

A host of other medical and health groups, as well as the Law Council of Australia, have backed the AMA’s call for the immediate removal of asylum seeker children and their families off Nauru.

CHRIS JOHNSON

 

Related story:

ausmed/ama-demands-urgent-fix-humanitarian-emergency-nauru

 

 

Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study [Research]

BACKGROUND:

Emergency department visits as a first point of contact for people with mental illness may reflect poor access to timely outpatient mental health care. We sought to determine the extent to which immigrants use the emergency department as an entryway into mental health services.

METHODS:

We used linked health and demographic administrative data sets to design a population-based cohort study. We included youth (aged 10–24 yr) with an incident mental health emergency department visit from 2010 to 2014 in Ontario, Canada (n = 118 851). The main outcome measure was an emergency department visit for mental health reasons without prior mental health care from a physician on an outpatient basis. The main predictor of interest was immigrant status (refugee, non-refugee immigrant and non-immigrant). Immigrant-specific predictors included time since migration, and region and country of origin. We used Poisson models to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS:

The cohort included 2194 (1.8%) refugee, 6680 (5.6%) non-refugee immigrant and 109 977 (92.5%) nonimmigrant youth. Rates of first mental health contact in the emergency department were higher among refugee (61.3%) and non-refugee immigrant youth (57.6%) than non-immigrant youth (51.3%) (refugee aRR 1.17, 95% CI 1.13–1.21; non-refugee immigrant aRR 1.10, 95% CI 1.08–1.13). Compared with non-refugee immigrants, refugees had a higher rate of first mental health contact in the emergency department (aRR 1.06, 95% CI 1.02–1.11). We also observed higher rates among recent versus longer-term immigrants (aRR 1.10, 95% CI 1.05–1.16) and immigrants from Central America (aRR 1.17, 95% CI 1.08–1.26) and Africa (aRR 1.15, 95% CI 1.06–1.24) versus from North America and Western Europe.

INTERPRETATION:

Immigrant youth are more likely to present with a first mental health crisis to the emergency department than non-immigrants, with variability by region of origin and time since migration. Immigrants may face barriers to access and use of outpatient mental health services from a physician. Efforts are needed to reduce stigma and identify mental health problems early, before crisis, among immigrant populations.

Paying for performance

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Assessing the quality of care in general practice can mislead if it is not based on observations of that care. Asking doctors what they have done and judging quality on the basis of medical records is not good enough. 

The perils of judging what happens in the clinical setting on the basis of what doctors record is obvious in a study of a health care funding agency, in this case the NHS, ceasing to pay doctors for providing additional services it regarded as so desirable that for which it had previously provided incentive payments. 

A paper in the September 5 issue of the New England Journal of Medicine by five authors from the National Institute for Health and Care Excellence in the UK [N Engl J Med 2018; 379:948-957 or  www.nejm.org/doi/full/10.1056/NEJMsa180149] used electronic medical records from 2010 to 2017 in UK general practices to assess the effects of removing, in 2014, 12 incentives linked to 12 indicators and compared the outcomes for six indicators where the incentives were maintained.

The study was set in 2,819 English general practices with more than 20 million registered patients. There were big drops – 62 per cent – in records of indicators ‘related to lifestyle counselling for patients with hypertension’ when the incentives were withdrawn.  

The authors noted that reductions in the documentation of clinical processes varied widely among conditions – from a 6 per cent reduction for smoking counselling to a 30 per cent decrease in documenting BMI of 30 per cent among patients with mental illnesses.

The authors observe: “Several studies show that what is gained on incentive introduction is essentially lost on incentive withdrawal.”

But – and here’s the rub – what was gained?  The authors note: “The uncertainty about whether changes in the documentation [my italics] of care represent true changes in patient care.”

We do not know to what extent the reduced documentation of the incentivised clinical behaviours reflected reduced clinical care.

Other than the automatically updated markers (like lab tests) in the records, frequencies of other interventions were measured purely on their action being documented.

It is quite possible that the desired actions were still taking place at a similar rate, but were simply not documented. Ask any busy clinician about how record keeping can diminish when the day is long or when there’s an emergency. It is hardly surprising that documentary markers decrease after removal of incentive.

An example of the disconnect between the record and the action given in the paper is that of prescription of long-term contraceptives. Although the records suggested a fall in prescriptions after the withdrawal of the incentive, actual use assessed from other sources increased.

I hold to the view, based on long observation, including a five-year stint chairing a district health board in Sydney, that our health system would grind to a halt were it not for the altruism of health professionals, including doctors. Yes, getting the right mechanism for paying for health care matters intensely, and doctors are well paid, but creating the conditions where doctors can express and apply more altruism in the system may offer the best yield in clinical care. Worth an experiment, anyway.

Recently I read Out of the Wreckage: A New Politics for an Age of Crisis by British journalist George Monbiot. It is an exciting and optimistic book despite the prevailing uncertainties in many democracies.

A major thesis is that the distinctive human attribute which has led humanity to its current zenith, and which Monbiot considers to be critical to our approach to the future, is altruism – by which he means people looking out for others and caring for them. You can assess the strength of his argument for yourself or watch him on YouTube www.youtube.com/watch?v=uE63Y7srr_Y

If you consider that more needs to be done in improving health care, proceed cautiously with the idea of incentive payments.

Do not be beguiled in assessing their effectiveness by the documentation of process. Rather, measure their effects on actual care and outcomes. And when considering what doctors and other health professionals do day by day and how this might be strengthened, remember that altruism – doing caring things without concern about reward – still ranks highly on the scale of what motivates them.  This is why they do what they do. Make it easier for them.

World doctors condemn torture in Uganda

The World Medical Association has rebuked the Government of Uganda, followed reports detainees in the East African nation are being tortured and denied access to specialised medical care.

Dr Yoshitake Yokokura, WMA President, has written to Uganda’s Prime Minister Ruhakana Rugunda to express the WMA’s revulsion at what he described as “the pervasive practice of torture” in Ugandan detention places.

The letter sets out details of the violence and rape that the Uganda Human Rights Commission discovered when it visited detention centres. 

It also reinforces the call from the Uganda Medical Association to respect the rights of patients and to protect doctors documenting and denouncing torture in Uganda.

The letter states: “Torture and other cruel or degrading treatments are one of the gravest violations of international human rights law. It destroys the dignity, the essence of the human being. As physicians, we are revolted by the devastating consequences of this practice for victims, their families and society as a whole, with severe physical and mental injuries.”

The letter calls on Uganda’s Prime Minister to take immediate and effectives measures to prevent and stop such intolerable shaming practices and to be an inspiring model for other countries.

“We have received appalling reports about a number of detainees in Uganda being tortured while under arrest and then denied access to medical attention, even when the Uganda Medical Association has offered to help them,” Dr Yokokura said.

“Such activities are especially disappointing, since Uganda is one of only 10 African countries with anti-torture legislation and is a signatory to the United Nations Torture Convention.

“Torture is unconditionally prohibited by the United Nation Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment that Uganda ratified in 1987, hereby establishing its consent to be bound by the provisions of the Convention.

“No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political
instability or any other public emergency, may be invoked as a justification of torture.”

The letter concludes: “We call on you to act as a matter of priority to ensure effective access to comprehensive health care to those in need and to allow and ensure that physicians can follow their ethical duties to provide medical care in an undisturbed and professional manner without intimidation and repression.”