Dr. Steuerwald and Dr. Gerecht in front of Air Care 1 at UCMC

Dr. Steuerwald and Dr. Gerecht in front of Air Care 1 at UCMC

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

In most hospital-based clinical environments the answer to all of these questions in some form includes the use of PLASMA.

For the “transport resuscitationist” the question then becomes how do you manage these same patients in the prehospital environment? The “transport resuscitationist” asks why should the care of these critical patients be any different at the scene of an accident or during transport?

Earlier this year as a result of the hard work of many dedicated professionals at UC Health Air Care & Mobile Care and the University of Cincinnati Medical Center, each of Air Care’s 3 helicopters began transporting 2 units of type A plasma to complement its existing 2 units of pRBC’s and TXA.

In this podcast, we discuss some of the important logistics in bringing this advanced transport medicine to the patient. Additional details and resources are below.  Please feel free to contact EMS Fellow and Flight Physician Ryan Gerecht, MD, CMTE at ryan.gerecht@uc.edu with any questions.

Definitions:
  1. Plasma: the liquid, noncellular portion of whole blood, which contains coagulation factors, water, electrolytes, and fibrinogen.
  2. Fresh Frozen Plasma (FFP or FFP24): plasma that is separated and prepared from whole blood and then frozen within 8-24 hours of collection to allow long-term storage. Prior to administration, FFP must be thawed to a liquid state, which takes approximately 45 minutes.
Traditional obstacles to utilizing plasma in the prehospital environment:

1) As noted above, it takes approximately 45 minutes to thaw FFP for administration. This delay created in thawing FFP as well as the logistical obstacles of actually thawing plasma in a helicopter, limits its use in the emergency situations frequently encountered in the prehospital and transport environment.

2) Once thawed from its frozen state, plasma has a shelf-life of only 5 days. Thus for remote based air craft that may be a considerable distance from a blood bank, this requires a complex and costly courier system to constantly replenish and recirculate the plasma prior to expiration while ensuring such a valuable resource is not wasted.

The solution: Liquid Plasma or “never frozen plasma

Liquid plasma is plasma that is separated and prepared from whole blood in a liquid state and is never frozen. It is FDA approved and is stored at 1-6ºC for up to 40 days. Because liquid plasma is stored in a liquid state, it is ready for immediate administration, thus making it ideal for the transport environment.

In addition, research suggests that its hemostatic profile is as good if not better than thawed plasma.

See: Better Hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. By Matijevic et al. J Trauma Acute Care Surg. 2013 Jan;74(1): 84-90

Air Care Logistics:
  • 2 remote based helicopters with 2 units of type A liquid plasma + 2 units pRBC’s + TXA
  • 1 hospital based helicopter with 2 units of type A thawed plasma + 2 units pRBC’s + TXA
  • Plasma and pRBC’s are stored in a portable cooler with ice packs during transport. These coolers have been tested and approved by the blood bank to ensure that it maintains the appropriate temperature for several hours.
  • pRBC’s are already affixed with a temperature dot to monitor temperature of all blood products contained within the cooler.
  • At the helicopter base, the blood cooler is maintained in a blood bank calibrated refrigerator.
  • At the time of donation, plasma that is going to be made into liquid plasma has to be treated a little differently than plasma that is going to be frozen. Thus it requires some pre-planning on behalf of the blood bank.
  • Air Care & Mobile Care is the only department at University of Cincinnati Medical Center (UCMC) that uses liquid plasma.
  • Air Care buys liquid plasma from the blood bank for $65 per unit.
  • Liquid plasma is labeled with an imaged paper system for permanent tracking/record keeping by the blood bank.
  • The blood bank at UCMC keeps on hand 5-7 units of replacement liquid plasma for Air Care utilization 24/7.
Why type A plasma?

AB plasma is the universal donor; however, its supply is inherently scarce compared to other blood types. Further decreasing the supply of AB plasma is the utilization of only male plasma as part of TRALI reduction strategies.

On the other hand, Type A plasma is more plentiful & statistically more likely to match a recipient blood type.  The anti-B present in type A plasma is known not to be as strong an antibody as the anti-A present in type O or B plasma. Furthermore, the anti-B in type A plasma is thought to be diluted out in the recipients circulation and could be bound to the patients own soluble antigens since 80% of the population makes soluble A or B antigens. Thus to meet the growing plasma demands, major trauma centers around the US are switching to type A plasma.

See: Emergency use of prethawed Group A plasma in trauma patients. By Zielinski et al. J Trauma Acute Care Surg. 2013;74(1):69-74

*** By protocol and at the request of our blood bank, Air Care does NOT transfuse type A liquid plasma on patients who weight < 50kg. The concern is that the anti-B antibodies present in type A plasma could have an adverse effect simply because there is not as much circulatory volume in these smaller adults / pediatric patients.***

Air Care & Mobile Care Transfusion Strategy

Air Care strives to achieve the following goals when resuscitating the acutely bleeding trauma patient.

  • 1:1 plasma and pRBC transfusion ratio
  • When possible transfuse plasma and pRBC simultaneously. If this is not possible secondary to limited IV/IO access then transfuse plasma first
  • Transfusion of blood products (plasma and pRBC) take precedence over TXA when IV/IO access is limited
  • Except in patients with concomitant TBI, resuscitation is guided by a permissive hypotension strategy.

See attached Air Care & Mobile Care Plasma Protocol

A special thank you to Dr. Bill Hinckley, Ms. Ruda Jenkins, Dr. Bryce Robinson, Dr. Patricia Carey, and Ms. Helen Hancock who together made plasma on Air Care a reality.

References:

ACMC Liquid Plasma Policy

____________________________________________

About the Authors
Steuerwald Small

Dr. Mike Steuerwald

 

Dr. Mike Steuerwald is an EMS Fellow in the University of Cincinnati Department of Emergency Medicine.  He is a graduate of the UC Department of Emergency Medicine Residency Training Program and former Resident Air Care Medical Director

Follow him on Twitter @MikeSteuerwald

Follow him on Google+

 

gerecht headshot

Dr. Ryan Gerecht

 

Dr. Ryan Gerecht is also an EMS Fellow in the University of Cincinnati Department of Emergency Medicine.  He is a graduate of the UC Department of Emergency Medicine Residency Training Program and former Resident Air Care Medical Director.  He is a past winner of the Jean Hollister EMS Award presented by SAEM (2013)

Follow him on Twitter @RGerecht

Follow him on Google +

Residents as Teachers with Dr. Palmer

In general, the best way to learn is to challenge yourself.  Teaching styles should take into account different learner types and levels

Learner levels:
  • Beginner: early 3rd year medical student
    • Can be an observer initially but transition these learners to the next stage
    • Keeps you on point as you have to really know what you are talking about
    • Incorporate them into your H+P
  • Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
  • Advanced: OMP (one minute preceptor) or SNAPPS model
What learners require from preceptors: empathy, enthusiasm, humor, respect, fairness, flexibility, consistency, dependability, support and warmth
     - You do not have to be all these things all the time but always try to start off strong
Learner Needs: space and time, concrete illustrations, control over pace, allow time for reflection, feedback, awareness of past experience level, contribute to care
Participation, repetition and reinforcement enhance learning
Constraints to teaching in the ED: lack of time, space, interest or resources
One Minute Preceptor Model: Start by laying groundwork for their presentation
  • Get a commitment: what do you think is going on, what lab test would you like to order, what is the disposition, etc
  • Probe for supporting evidence: why do you think this is going on, etc
  • Teach a general rule
  • Reinforce what was done well
  • Correct mistakes
SNAPPS: Learner Centered
  • Summarize H+P
  • Narrow differential diagnosis
  • Analyze differential diagnosis
  • Probe preceptor (ask questions)
  • Plan for management
  • Select a case related learning point

 


Complications of Bariatric Surgery with Dr. Watkins
Tachycardia = peritonitis in an obese patient, until proven otherwise
Bypass patients are always vitamin deficient. Always think Thiamine (B1) deficiency in a vomiting patient and just give a bypass patient Thiamine when they are in the ED
Do not give NSAIDS to bypass patients as this increases risk of stricture
Bariatric patients do not need a lot of PO contrast as their stomachs are small
Obese patients have lots of complications in every body system. There is a 95% improvement in their quality of life and 89% reduction in 5 year mortality after bariatric surgery
Roux-en-Y Gastric Bypass Source: U.S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Roux-en-Y_gastric_bypass.png

Roux-en-Y Gastric Bypass
Source: U.S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Roux-en-Y_gastric_bypass.png

Gastric Bypass: stomach is stapled into a small pouch and connected to distal intestine

There is no digestion/absorption until later in the intestine, meaning that these patients have lots of vitamin deficiencies
Early complications: leak, GI bleed, wound infection, Pulmonary (PE, hypoventilation, sleep apnea)
  • Leak presents with abdominal pain, tachycardia, fever and dyspnea
    • Diagnose with gastrograffin UGI
  • GI bleed: usually managed conservatively if > 48 hours after surgery
  • Gastric Remnant distention: rare and potentially fatal if ruptures
    • Can be due to ileus or obstruction
    • Symptoms: pain, hiccups, shoulder pain, tachycardia, SOB
    • Needs immediate decompression
  • PE: pt’s at higher risk as they are hypercoagulable 2/2 high estrogen
Late complications: malnutrition, obstruction, stricture, fistula, marginal ulcer, cholelithiasis, nephrolithiasis, kidney stone, hernia, dumping syndrome, hypoglycemia
  • Internal hernia: increased risk after laparoscopic procedure
    • Incidence 3-5%, most common cause of SBO
    • Symptoms: postprandial crampy pain that can be preceded by symptoms of intermittent mild obstruction
    • CT: mesentary swirling
  • Marginal Ulcer: at site of gastrojenjunostomy
    • Present with epigastric pain and dysphagia
    • Jejunum does not have an acid buffer
    • Treat with PPI/sucralfate for 3-4 months
  • Dumping syndrome: due to high osmolar food bolus into the small intestine
    • Crampy pain, diarrhea, nausea, vomiting, flushing, hypotension, tachycardia, diaphoresis
Vitamin deficiencies after bypass: very common to have thiamine deficiency, anemia and Ca deficiency
Adjustable Gastric Banding Source: .S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Adjustable_gastric_banding.png

Adjustable Gastric Banding
Source: .S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Adjustable_gastric_banding.png

Gasric Sleeve: #1 surgery for weight loss
  • Take out 80% of the stomach
  • Appetite suppressive
  • Complications: leak, bleeding, volvulus, GERD, motility issues
Gastric Bands: Adjustable ring around stomach
Complications: upper pouch dilation, erosion, port problems
  • Dilated pouch: symptoms of severe GERD due to increased pressure
    • Diagnose with UGI
  • Erosion: this occurs when the band is too tight
    • Symptoms: weight regain, no restriction with maximal fill
    • This does not present with peritonitis as it seals itself
    • Treatment: band removal
    • Commonly associated with port infection
  • Issues with the port: saline leak, infection, tube disconnect
When is it safe to use BiPaP in these patients? After 1 week in Bypass surgery and after 1 month in sleeve patients, though overall this is very provider dependent

 

Clonidine Overdose with Dr. Axelson
Mechanism of action
  • Central alpha agonist: this leads to negative feedback to NE/E and hypotension
  • Peripheral alpha2 agonist
  • Leads to release an a beta-endorphin that acts as an agonist to opioid receptors
It can be tough to tell clinically clonidine vs opioid overdose
Should you give Narcan to clonidine overdose? Sure but it may not work because it only works on peripheral receptors so will only work early. You might see hypertension in children but this will usually autocorrect.

CPC with Dr. Baxter and Dr. Mudd
44 yo M with chronic back pain and wrist arthritis presents with 2 weeks of N, V, D, minimal dyspnea on exertion and cough. Has a Hg 8.6, WBC 5, Cr 1.7, proteinuria. Most significant complaint was dyspnea on exertion, so the pt got an EKG and CXR that showed cardiomegaly. Diagnostic test of choice is echocardiogram which showed a large pericardial effusion with tamponade. He gets admitted to the hospital with ultimate diagnosis of Lupus.
SLE: there are 11 diagnostic criteria and if you have 4/11, you can diagnose with Lupus.
Pericarditis is one of the diagnostic criteria and pericarditis with effusion is common in Lupus but tamponade is rare.
Acute complications of lupus:
  • ACS: most common cause of death, Relative risk 6
  • Pulmonary: alveolar hemorrhage, ARDS, respiratory failure
  • Cricothyroid joint arthritis, angioedema
  • Cardiac tamponade
  • Renal failure
  • Infection
Somatoform Disorders with Dr. Betham
0.5-2% of patient encounters include some component of factitious symptoms
Somatization disorder: the patient has multiple unrelated complaints in several body systems.
  • Usually in young females
  • The pt is not aggressive
  • The pt is not consciously lying about their symptoms
  • There is no external gain
Malingering: patient consciously make up their symptoms for external gain
Factitious disorder: The patient consciously fabricates symptoms for primary gain (psychological gain in order to play the sick role)
Munchausen disease: 2 types
  • Classic peregrinating migrating
    • Commonly seen in males
    • Patients are aggressive and grandiose
    • Patient undergo lots of aggressive testing and have a poor prognosis
  • Common nonperegrinating
    • Commonly seen in females with some medical training
    • Patient is not aggressive
    • The patient has chronic health problems, high incidence of substance abuse and personality disorder
Management in the ED
  • Focus on objective data
  • Avoid risky tests and treatments
  • Be consistent
  • Establish limits
  • Focus on whats best for the pt
Digoxin Toxicity with Dr. Loftus
The pt presents with feeling “unwell”, vomiting and irregular heart rate. HR varies from 145 to 38 to 101 to 83 to 26. Labs show K 2.5, Cr 3.6, Ca 13.3
  • Digoxin works by blocking Na/K ATPase. This leads to increase in intracellular Na which inhibits Na/Ca exchanger and decreases intracellular Ca.
  • Hypokalemia and hypomagnisemia can worsen digoxin toxicity even with a normal level
  • Hyperkalemia is a marker of badness. K > 5.5 is an indication for digibind.
Stone heart theory: We used to believe that you cannot give Ca to dig toxic patients however that is no longer believed to be true. While Ca is not recommended to use in hyperK patients with dig toxicity, it is unlikely to be harmful
Digoxin toxicity can cause ANY arrhythmia
  • Scooped ST segment
  • PAT with AV block
  • Sinus bradycardia with SA block
  • Transcutaneous and transvenous pacing may be dangerous in these patients as digoxin creates an irritable myocardium and pacing can cause a higher risk of V. Fib

Indications for Digibind

  • Life threatening arrhythmia
  • K > 5.5
  • Renal failure
Bidirectional Ventricular Tachycardia - associated with digitalis toxicity.  From: Edward Burns. Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/bvt/

Bidirectional Ventricular Tachycardia – associated with digitalis toxicity.
From: Edward Burns. Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/bvt/

Ramsey Hunt Syndrome (aka Herpes Zoster Oticus) with Dr. Toth
This is a polycranial neuropathy secondary to VZV or HSV

  • Usually affects CN 7, 8, 9, 5, and 6 (in order of frequency)
  • 20% of the patients present with pain only without any cutaneous findings
  • Treatment: acyclovir and prednisone
  • Can give gabapentin for pain
  • Lidocaine eye drops for pain

MDM

by Mike Steuerwald,

Not much gets me as fired-up anymore as trying to optimize them. While I like to think that it’s because they are integral to our mission and are the ultimate weapon in our quest to go from “good to best”, it’s really just my borderline OCPD (just kidding…sort of).

Long story short, I spend a lot of time thinking about clinical and operational logistics in HEMS – it’s become my thing. My goal with this post is to share some of that thinking with others who might want to build off of our ideas in hopes that those colleagues (i.e. you) will share their ideas that they are really excited about with us at some point.

So in that stead, let me share our procedure kit idea with you…about 2 years ago we were fortunate to make the jump from BK-117 helos to EC-145s. During that transition, we completely revamped the way we carry and store our materials (i.e. our operational logistics). Part of this revamp included creation of procedure kits to store supplies needed to accomplish our core HEMS procedures. The ground rules were thus: (1) they had to be robust (2) they had to be uniform (3) they had to have everything you needed to do a procedure and nothing more (i.e. they had to reduce the cognitive load, not add to it).

So here is what we came up with. We built five kits that we vacuumed sealed using a food packaging system – goal #1 accomplished. The idea for doing this came from Jason Peng, one of our flight NPs. He was inspired by some observations he made while he was serving in the US Navy regarding how their materials came packaged.

Each kit has its own placard listing its purpose and all materials within (see goal #2). The placard also has a spot where the kit assembler can put their name and the kit’s expiration date (based on the soonest to expire component part).

The original five included: surgical cric (see video by Bill Hinckley posted a few months ago for much more on this), needle cric (see video posted by me a few months back for much more on this), finger thoracostomy, pericardiocentisis, and blind nasal intubation. If you take a look at my post on needle cric or Bill’s post on surg cric you will see what I mean regarding goal #3.

We have learned that these kits aren’t perfect in the couple years we have been making them. The names on the kits were a bit small to read and the placards were not color-coded…something newer iterations will fix. This tenant of operational hems logistics should not be overlooked – any system that cannot accept changes and evolve when improvements are concepted is doomed to fail.

In summary, if you think this is cool and you might want to make similar kits for your shop, I’m glad I was able to share this information with you. I hope to share more similar information soon.

Steuerwald Author Tag

Oral Boards Case with Dr. Blomkalns
The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling “sick”. His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4 (normal is less than 1.2). His K is 6 and Cr is 1.9. EKG shows LBBB.
Learning points on dig toxicity:
  • Can be acute or chronic
  • Acute presentation: unstable hypotension and bradycardia. PAT with slow ventricular rate is a common EKG finding.
  • Chronic presentation: AMS, fatigue, nausea
  • Common lab abnormalities: hyperkalemia, AKI
  • Treatment is digibind
  • Not all digoxin toxic patients get digibind. Be careful giving digibind to A.fib patients as this may put them in A.fib with RVR and make their hemodynamics worse.
  • Patients should be treated based on their K (> 5.5), EKG and symptoms. Do not treat based on dig level alone.
  • Stone heart phenomenon: in the past, folks used to be afraid of giving Ca to dig-toxic patients. This has been disproved and Ca is safe in these patients, though it will not work as digoxin binds to Na/K ATPase and does not work on Ca channels.
  • Dose of digibind (given in vials): 100/weight in kg
  • Dialysis does not work, however it does clear digoxin-digibind complex and is helpful in pt’s with renal failure
  • Do not get repeat digoxin level after giving digibind as it is useless.
Tox to know for oral boards:
  • Tylenol and NAC
  • Aspirin and alkalization
  • Toxic alcohols: ethylene glycol, methanol
  • Digoxin
  • Pediatric Fe ingestion
  • TCA
  • Beta blockers and Ca channel blockers
General tips for oral boards:
  • Updating family and calling PCP gives you extra points!
Oral Boards Case with Dr. Stettler
84 yo F with AMS. Presents hypotensive, tachycardic, febrile. Has a sacral decubitus with crepitus. Concern for necrotizing fasciitis. Pt should get aggressive fluid rescuscitation, at least 2 L. She then requires pressors for management of her septic shock, NE and vasopressin. Needs a surgery consult for debridement.
27 day old F that is “not acting right”. Has had decreased PO, lethargy for 1 day. Presents hypotensive, tachycardic, tachypneic, with temp 100.2. Has 2 seizures in the ED. Has hypoglycemia on labs as well as leukocytosis in CSF concerning for sepsis. Treat hypoglycemia and seizure aggresively as well as give antibiotics early. Do not delay for LP. Always consider nonaccidental trauma.
Sim Cases with Drs. Fernandez and Hill
Male with chest pain, shortness of breath and fatigue. Presents with HR in the 30s and BP 95/62. Has 3rd degree heart block on EKG. Troponin is 0.89 and BNP is 1008. You can give atropine, but this will not work. DDx is likely ischemia, so the pt likely needs the cath lab. The pt gets put on transcutaneous pacer, but that does not capture, so he needs a transvenous pacer. The line for this is similar to a trauma cath (dilator is already in the line) and then the pacer threads through the line. The control box for the pacer is precet for HR at 80 and current of 10. If you forget what settings to use, hit the red button and it gives you automatic settings. Thread the pacer to 15 cm and then inflate the balloon until you get capture. Deflate the balloon and then decrease current to the lowest value that gets capture.
Check out the following posts for more info on transvenous pacemaker placement:
Young male with racing heart rate. He drinks a lot of caffeine and has HR in 170s-180s on presentation with normal BP and mental status. EKG shows SVT. Try vagal maneuvers, which have success rate of 25%. If this doesn’t work, give adenosine 6 mg, followed by 12 mg x2 prn. Adenosine has to be given fast as it has a very short half life – consider stopcock method for administration or drawing the med up in the flush (ala ALIEM and Bryan Haynes). If adenosine doesn’t work, consider synchronized cardioversion or other medications: verapamil, BB, procainamide. It is ok to discharge these patients if they are healthy and remain in NSR.
Update on Drugs of Abuse with Dr. Mel Otten
  • Overdoses kill more people than MVCs
  • Heroin overdoses are increasing in number while cocaine overdoses are decreasing
  • Prescription drug abuse: clonazepam is the most abused, followed by xanax/oxycodone/hydrocodone.
  • Cocaine is very frequently adulterated
    • Levamisole: antihelminth used in horses and used to adulterate cocaine
      • Metabolized to a stimulant (Aminorex)
      • Causes agranulocytosis (low WBC and increased infection risk) and necrotozing vasculitis
  • Synthetic Drugs
    • Most act on cannabinoid and/or amphetamine receptors
    • Bath salts: synthetic KHAT, mephedrone
      • Addictive, easily available
      • Aka “plant food”
      • Similar in structure to methamphetamine
      • Stimulant with serotonin and NE activity
      • Toxicity: tissue injury if injected, tachyarrhythmia, MI, stroke, myocarditis
    • NBOME: causes hallucinations, seizures, AKI
    • Geranium: stimulant that causes HTN, MI, cerebral hemorrhage
    • Spice: super THC that acts on cannabinoid receptors
      • Desired effects: euphoria, anxiolysis, antidepressant
      • Side effects: paranoia, seizures, HA, agitation, hyperthermia, arrhythmia
  • Inhalants: can cause sudden death due to V.Fib
  • Krokodil: desomorphine – causes skin and soft tissue damage
Intralipid with Dr. Mel Otten
  • Is this the tox magic bullet?
  • First used in anesthesia to reverse local anesthetic cardiotoxicity
  • Reported in animal studies to reverse lipid soluble drugs
  • Mechanism of action: no one knows but there are a few theories:
    • Lipid sink: sequestration of toxins from tissue
    • Hemodilution
    • Cardiotonic: rapid inotropic effects
    • Metabolic: provides lipid substrate for metabolism
  • If it is going to work, it works very fast, within minutes
  • Adult dosing: 200 mL bolus of 20% lipid emulsion followed by infusion of 0.25 ml/kg/min
  • Current indications: overdose of local anesthetic, haldol, TCA, beta blocker, Ca channel blocker
Financial Planning with Dr. Shaw
“The power of compound interest the most powerful force in the universe”
- Albert Einstein (supposedly)
Investment options for college: education IRA, 529 plan, UGM640px-Piggybank
  • Education IRA
    • 2000/year with income qualifications
    • No restrictions on investments
    • Must be used by age 30
    • Only educational expenses allowed
    • Not tax deductible, so funded with post-tax dollars
  • 529 plan: prepaid tuition/savings
    • Educational expenses only
    • Can be transferrable
    • Contribution considered as gift, so there is an overall dollar limit
    • Tax treatment: investment earnings are not subject to tax but contribution is taxed
  • UGMA = trust
    • Legally belongs to the child
    • No tax advantage to the contributor
    • No restrictions on investments or spending
    • Child gets control at 21 years of age
    • Tax treatment: can count against your child for FAFSA purposes
    • Can’t be accessed if you get sued as it is in your child’s name
Retirement options: pension, social security, IRA, Roth IRA, 401k/403B
  • Pensions: these are exceedingly rare
    • You receive X dollars/years worked
    • Now you can have a defined contribution, meaning that you and your company put in X/year and get it when you retire
  • Social security: 2642/mo maximal benefit if you retire at full retirement age
  • IRA: can contribute up to 5500/year
    • Set up with variety of institutions
    • If retirement option available at work, can only tax deduct if AGI < 69,000
  • Roth IRA: 5500/year max
    • Eligible only if income is less than 129,000
    • Contribution is not tax deductible but there is no tax on investment EVER
  • 401k/403B
    • Set up by employer
    • You pick contribution amount and investment
    • Employer can match contribution
    • Contribution is tax deferred
    • Current limit is 17,500/year

Investment options: stocks vs bonds

  • Stocks: unit of ownership in a company
    • Make money from appreciation and/or dividends
    • Foreign stocks are useful as their market does not always correlate with US market
    • Over long haul, usually increase in value
  • Bonds = IOUs
    • You lend me 100,000 over 10 years and I will pay you 400/month and then return 100,000 at the end of 10 years
    • Safer than stocks
    • Sources of risk
      • Inflation
      • Interest rate
      • Credit risk: issuer goes bankrupt
How to buy stocks/bonds: individually through a broker or through a mutual fund
  • 2 types of mutual funds:
    • Actively managed: fund hires a manager
      • Costly, 1-2%/year
    • Passively managed: index fund
      • Fund duplicates return on index
      • Index fund outperforms actively managed fund 75% of the time
  • Market crashes are terrifying. Do not sell your stocks. Sit and do nothing and stick to your plan
    • Upside of market crash is that stocks are on sale!
Alternative minimum tax: applies if you have lots of kids, high medical/dental expenses and high state and federal tax
     – not indexed for inflation
     – if you make > 100 K/year, you need to check if you have to do this
Bottom line: start investing now as every dollar you invest will compound over 20-30 years
MDM

by Tim Loftus, MD

Heilman, J.   http://upload.wikimedia.org/wikipedia/commons/c/c1/SubarachnoidP.png http://creativecommons.org/licenses/by-sa/3.0/deed.en

Heilman, J.

http://upload.wikimedia.org/wikipedia/commons/c/c1/SubarachnoidP.png

http://creativecommons.org/licenses/by-sa/3.0/deed.en

Perry et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ 2011; 343:d4277.                                                                                                               

Study Objective: To determine sensitivity of head CT within 6 hours in ED patients presenting for possible SAH

Design: Multicenter prospective cohort study at 11 tertiary care centers in Canada from 2000-2009

Main Results:

  • 3132 patients enrolled
  • 240 total cases of SAH (7.7% study prevalence)
  • Overall sensitivity of CT for SAH was 92.9%
  • Overall specificity was 100%
  • Negative Predictive Value was 99.4%
  • Positive Predictive Value was 100%
  • 953 patients (30.4%) were scanned within 6 hours

o   121 (12.7%) found to have SAH

o   All cases identified by head CT (100% sensitivity + 100% specificity) 

Table 3: Sensitivity of Computed Tomography for SAH in patients with acute headache (recreated from original text)
LR (95% CI) Predictive Value (95% CI)
Time from HA onset to Scan # of Pts % Sens % Spec Positive Negative Positive Negative
All patients 3132 92.9 (89-95.5) 100 Infinity 0.07 (0.05 – 0.11) 100 99.4
≤ 6 hours 953 100 100 Infinity 0.00 (0.00 – 0.02) 100 100
> 6 hours 2179 85.7 (78.3 – 90.9) 100 Infinity 0.14 (0.14 – 0.17) 100 99.2

 

Authors’ Conclusions

Modern multi-detector thin slice head CT is highly sensitive for detecting SAH if performed within 6 hours of headache onset and interpreted by qualified radiologist.

“These findings are robust enough to inform the clinical decision […] whether to perform lumbar puncture after negative results on CT.”

Why Should You Care?
  • Headache approximates 2% of presenting complaints to the ED, and SAH is identified in approximately 1% of those patients with headache in the ED.
  • Overall mortality of SAH is high, estimated at 25-50% of patients dying within 6 months
  • If not fatal, SAH leaves approximately 33% of survivors with some appreciable neurological deficit affecting their ADLs.
Summary of the Discussion:

Many thanks to Dr’s Knight, McDonough, Hooker, and Adeoye who actively participated in the discussion and provided valuable insight. Many excellent points were raised, and although a verbatim post might do the contributors justice, it will not benefit those of us wary of the scroll feature.

Although this study raised some interesting points, as of right now the ASA/AHA currently recommend the CT/LP approach to diagnosing aSAH (Class 1 Recommendation, Level B Evidence, Stroke 2012). Heck, if Ope and his cronies cannot diagnose what may or may not be an aneurysm, then what is left for the rest of us? As was stated, if SAH is suspected clinically, then those patients should probably continue to get LP’s to assist in diagnosis or exclusion.

An interesting discussion ensued about the acceptable miss rate for SAH – and other neurologic catastrophes – being essentially zero. Thus, although a “bad” test might still look good for a disease of such low prevalence, it remains essentially indefensible not to complete the currently recommended evaluation if the head CT was non-diagnostic.

Also, to satisfy you methodology wonks, thanks to Dr. Benoit for pointing out that this was indeed a prospective study with the time cut-off decided a priori!

References:

  • Perry et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ 2011; 343:d4277.
  • Connolly, et al. AHA/ASA Guideline.  Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. Stroke.  43. 1711-1737. doi: 10.1161/​STR.0b013e3182587839