Hematology

Topic 1 - Summary
1. Citation:

Tintinalli J, Peacock F, Wright M. “Emergency Medical Evaluation of Psychiatric Patients.” Annals of Emergency Medicine, 23:4, pages 859-862

2. Summary/Bottom Lines:
  • The purpose of the study was to analyze the accuracy and completeness of ED documentation and evaluation of Psychiatric patients, specifically in medical clearance.

  • A disturbing number of patients had been labeled “medically clear”, when they indeed had medical problems, 12 of which required acute intervention.

  • This paper possibly indicates a widespread phenomenon, and it’s shocking considering that the sorts of deficiencies are far out of proportion to non-psychiatric patients.

  • The “bottom line” is to stop using the term “medically clear”, but instead to include a list of diagnoses for psychiatric patients. 

3. Methods:
  • The study was a descriptive, retrospective chart review from January-June 1991 at a 900-bed community hospital.

  • Within the charts – namely, the Triage note, ED physician notes, and final discharge summaries – 42 variables were analyzed, and patients were divided into 2 groups: 1) Age <55, and 2) Age 55 and beyond.

  • The results revealed that 80% of patients who were labeled “Medically Clear” actually had medical conditions. Medical diagnosis was missed in 12 patients who had conditions which required acute medical attention, including:

    • Femur fracture
    • HIV encephalopathy
    • Multiple sclerosis
    • Caustic burn to the perineum
    • Hypertension (?)
    • GI Bleed
    • Organic dementia (?)
    • Arsenic poisoning
    • Polycythemia
    • Cardiac ischemia
    • Pneumonia
    • Staphylococcal septicemia

    Eight of the above 12 patients were labeled as “Medically Clear”.

    The missed diagnoses had no correlation between patient’s sex, psychiatric diagnosis, or psychiatric consult; there was a correlation to AGE, however. Patients less than 55 had a 4x greater likelihood of a missed diagnosis.

4. Limits:
  • This paper was written in 1991.
  • It only compiles data from one hospital.
  • The individual psychiatric chief complaints are not mentioned.
  • Each patient in the paper was voluntarily admitted, as opposed to many psychiatric which are uncooperative.
  • The disposition process at this hospital is not generalizable; namely, physicians cannot universally admit psychiatric patients without psychiatric consult, as occurred with several patients in this paper. 
5. Additional Info:

 

6. Author: Dr. Samuel Huddleston

 

Topic 2 - Summary
1. Citation: Johansson, Par I., Jakob Stensballe, Roberto Oliveri, Charles E. Wade, Sisse R. Ostrowski, and John B. Holcomb. "How I Treat Patients with Massive Hemorrhage." Blood 124.20 (2014): 3052-058
2. Summary/Bottom Lines:

This paper is essentially a case series on a novel method of managing massive hemorrhage in surgical, obstetric, and trauma patients requiring massive transfusion.  The authors evaluate two distinct but similar methods of coagulopathy evaluation via real-time viscoelastic hemostatic assays (VHA) and contend that these assays provide far more information which is more accurate than conventional coagulation tests (PT/INR, PTT) and then use the information to deliver a ratio/goal driven transfusion protocol.  Although the VHA utilization may take some time to be fully adopted, the wealth of information provided cannot be denied.  The concept of using transfusion package to deliver a fixed ratio driven resuscitation is something that can be implemented more readily.  

3. Methods:

This paper is more a description of their style of practice, although they reference an earlier published paper in Vox Sang in which they perform a before and after study to analyze the effects of the new transfusion practices on 30 and 90 day mortality rates, blood product use, and overall length of stay in the ICU or hospital. Their earlier published study demonstrates that the novel VHA guided transfusion practice using fixed ratio transfusion packages decreased mortality in a statistically significant manner.  

4. Limits:

Given the nature of the earlier published study in which the authors draw evidence for the practice described in this paper, the before and after study is limited by a number of factors. These factors include lack of randomization, lack of true controls, lack of consistency between the two time periods compared. However, given the nature of difficulty of randomizing patients in an emergent extremis situation and being able to blind physicians to the treatment, this study was well designed and powered to draw some conclusions. 

5. Additional Info:
  • Take home points:

    • The ideal transfusion ratio is unknown and has yet to be elucidated - more data is badly needed.

    • The ideal timing of PLT, FFP (or liquid plasma) also needs to be evaluated

    • Post-resucitative coagulopathy is complex and likely is both primary injury and iatrogenic in nature

    • The role of crystalloid and the ideal crystalloid in massive hemorrhage and resuscitation is limited and its timing requires further study

    • The current coagulation tests significantly underestimate the role of multiple factors in the coagulation cascade and may likely underestimate the overall coagulopathy presents in certain pt populations

    • VHAs produce a wealth of data that can better help clinicians evaluate coagulopathy with proper training in analysis of the data

    • Implementation of this combined real time VHA and transfusion package system is likely to take time and requiring significant effort from multiple parties in the hospital 

6. Author: Dr. Shashank Upadhyay