Monday, August 28, 2006

Pressure ulcers; Out of hospital cessation of CPR; PCEP

Back from vacation, back at work, and already wondering how I can miss my baby boy so much after 9 measly hours.

Several things:

There has been a randomized controlled trial comparing morphine with hydromorphone for acute pain in emergency departments.  I'm having trouble getting the full text of the article due to strange happenings at Science Direct (full text of the issue has not been posted although the full-text of the subsequent issue has already been put's weird) but will get to it as soon as I can.  So few truly randomized, head to head trials comparing opioids in real patients in real pain using drugs I really use every day come out that it's always exciting to see if anything can be gleaned.  So stay tuned.

JAMA has a systematic review of interventions to prevent pressure ulcers.  Can you guess the conclusions?  Lack of quality trials, heterogeneous methods and outcomes limit comparison, etc. etc.  These, though, were the major clinical findings:

Effective strategies that addressed impaired mobility included the use of support surfaces, mattress overlays on operating tables, and specialized foam and specialized sheepskin overlays. While repositioning is a mainstay in most pressure ulcer prevention protocols, there is insufficient evidence to recommend specific turning regimens for patients with impaired mobility. In patients with nutritional impairments, dietary supplements may be beneficial. The incremental benefit of specific topical agents over simple moisturizers for patients with impaired skin health is unclear.

The NEJM recently published a report about out of hospital termination of cardiopulmonary resuscitation (that is, emergency medical personnel declaring a person dead and stopping resuscitative efforts in the field and bringing the deceased patient to a morgue and not an emergency department).  The study is actually a validation study of a rule (protocol) to predict who should have resuscitative efforts discontinued in the field, not a study of actually implementing cessation of resuscitation in a community.  The article follows ~1400 adults who arrested in the community and received resuscitative efforts and looks to see if the protocol rule accurately predicted those patients who didn't survive (such that, if implemented, people who would survive would not have resuscitation inappropriately terminated in the field).  The major elements of the rule is that 1) the arrest was not witnessed by emergency personnel and 2) the automatic external defibrillator device delivered no shocks ( i.e. the patient never had a 'shockable rhythm' like ventricular fibrillation).  These elements (along with a couple others) predicted accurately ~99.5% of deaths.  I'm not going to go into more details here about the actual protocol or the findings other than they appear to be quite robust.  What I want to mention is that this is one of several such protocols which are being developed and that in the not too distant future communities may begin implementing policies using these rules which will likely decrease the number of severely neurologically devastated people, headed to an inevitable death, ending up in emergency rooms and ICUs.  I am curious to see the public's reaction to this.  Surely a less than 1% chance of success/survival meets any reasonable definition of futility--no surgeon would operate if s/he thought the patient's chance of benefitting from the surgery was 0.5%--but things are different when it's CPR....

The most recent Journal of General Internal Medicine has an article looking at the long-term impact of the Harvard Medical School Program in Palliative Care Education and Practice (PCEP).  Long term here means up to 18 months.  Generally they found that they made sustained behavioral changes in their participants.  So congratulations & it's good to see such positive, sustained results.

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