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  How Drug Abusers Fund Habit
Posted by: dbrosnahan - 06-21-2016, 12:46 AM - Forum: General Discussion - No Replies

In addition to prostitution and pawn shops, another mechanism to supply a drug abuser with cash is gift card exchanges. One patient who came to the ED seeking drug rehab. told me that she supplied her habit by shoplifting at Walmart and then returning the stolen item at another Walmart across town.  Walmart exchanges the item for a gift card which she then takes to MovieStop which exchanges gift cards for cash.

I asked this patient is this was a common practice. She said, "yes".

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  Suboxone vs. Methadone
Posted by: dbrosnahan - 06-21-2016, 12:15 AM - Forum: General Discussion - No Replies

Methadone and Suboxone are treatments for opioid dependence.  Patients with a history of heroin or prescription drug dependence can be referred to a treatment program that dispenses daily methadone and suboxone. The goal is for the patient to take the daily methadone and suboxone which will be gradually tapered until discontinued. However, that is not what usually happens with methadone.

Patients on methadone instead of being tapered off, can be tapered up to 120 or even 200 mg every day.  Can you even imagine how much narcotic that is every day.  It boggles the mind. And beware if the methadone patient misses their dose, or has nausea and vomiting and cannot tolerate it.  So, why do methadone clinics taper methadone up instead of down?  Because, the clinic patient can abuse heroin and prescription drugs on top of the methadone to get high. And it is surreptitious opioid abuse that is usually the reason why the methadone is increased and not decreased.

Suboxone is much more expense than methadone and approximately $15-35/day.  However, Suboxone (an agonist/antagonist) has the advantage of putting the patient into immediate opioid withdrawal if they take any prescription opioid or heroin afterwards.  Accordingly, in my experience, patients on suboxone are much more successful at recovering from opioid dependence and being weaned off suboxone.  Because of the history of methadone therapeutic failures, I warn and steer any patient away from methadone.  In my opinion, if an opioid dependent patient is serious about rehab, they will find a way to afford suboxone. However, I wish it wasn't so expensive.

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  EMTALA and the VA
Posted by: dbrosnahan - 06-20-2016, 11:49 PM - Forum: General Discussion - No Replies

The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable medical condition.  EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986. EMTALA is Section 1867(a) of the Social Security Act, within the section of the U.S. Code which governs Medicare.

Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.

The 2003 revisions provide: A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA. Other presentations outside the emergency room do not invoke EMTALA.  The 250-yard zone will continue to apply when defining the "hospital campus". Now, however, that sphere does not include non-medical businesses (shops and restaurants located close to the hospital), nor does it include physicians' offices or other medical entities that have a separate Medicare identity.  EMTALA does not apply to any off-campus facility, regardless of its provider-based status, unless it independently qualifies as a dedicated emergency department.

EMTALA sets up a universal health care system in the US where all persons, citizens or not will be evaluated regardless of citizenship status or insurance and treated for any and all emergency heath conditions.  These laws prevent patient dumping and discrimination by which ED's might selectively deny treatment to the uninsured. However, this law does not apply to the VA.  The VA does have an emergency department which they rename "Life Support Unit."  

VA claims that EMTALA does not apply to them because: 1. the Government can't sue the government? 2. the VA supposedly doesn't accept Medicare and EMTALA only applies to locations that provide emergency medical services that accept Medicare.  But many VA patients do have Medicare as a supplementary source of coverage.  Also, my brother-in-law is a federal lawyer and citizens can sue the government.  I am not sure why reason #1 is perpetuated.   Anyways, in my mind, I think that if we are going to have rules and be a nation of laws, we shouldn't have some entities above the law. The is part of the problem with America, we have different groups of people all playing by different rules.

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  Antimicrobial copper-alloy touch surfaces
Posted by: dbrosnahan - 06-13-2016, 06:25 PM - Forum: General Discussion - Replies (7)

Hospitals have almost unanimously instituted the use of stainless steel for touch surfaces such as doorknobs, IV poles, push plates, faucets, and hand rails, etc. It turns out that stainless steel and other iron-based alloys may be among the worst material to use because bacteria, fungus and viruses have been found to survive up to 30 days or more on such surfaces. 

Copper and copper-bases alloys such as bronze and brass are known to be antimicrobial and can kill bacteria, fungus, and viruses within 2 hours or less. Clinical trials using copper demonstrate over 90% reduction in bacterial colonization on surfaces compared to controls.  A 2013 multi-center US study demonstrated a 58% reduction in ICU infections after installing copper surfaces.

Studies show that silver is a bit more antimicrobial than copper but it is also much more expensive. Copper has also been demonstrated to be hypoallergenic unlike nickel.

http://www.jstor.org/stable/10.1086/670207
http://www.ncbi.nlm.nih.gov/m/pubmed/23571364/

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  "You sound sick. You should go to the ER"
Posted by: dbrosnahan - 06-08-2016, 07:24 AM - Forum: General Discussion - No Replies

The ED is the place for sicker patients. However, are primary care physicians being slowly squeezed out of acute medicine?  Many PMD no longer admit their own patients, they don't have access to many stat labs (CLIA), and many are offering fewer acute care treatments than ever before.  Many PMD offices can't start an IV or give IV fluids or give a jet neb.

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  Doxepin for Itch
Posted by: dbrosnahan - 06-08-2016, 06:52 AM - Forum: General Discussion - No Replies

Doxepin is a tricyclic antidepresent that happens to be a very potent H1/H2 blocker up to 8000 times more powerful than diphenhydramine. Doxepin can be used for allergic urticaria and atopic dermatitis.  the starting dose is 25-50 mg before bed.  I occasionally use doxepin together with hydroxyzine for severe urticarial, severe chronic eczema, or psoriasis. Has anyone used this drug for an acute allergic reaction?

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  Vicks VapoRub for Onychomycosis
Posted by: dbrosnahan - 06-08-2016, 06:21 AM - Forum: General Discussion - No Replies

http://www.ncbi.nlm.nih.gov/pubmed/21209346

A dermatologist friend of mine told me about this treatment for toenail fungus.  He says the treatment works better if you wrap the toes in plastic wrap each night to increase penetration.

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  Sulfate Deficiency?
Posted by: dbrosnahan - 06-02-2016, 12:37 AM - Forum: General Discussion - Replies (2)

     During the 1980's environmemtalist who today are warning about global warming were decrying acid rain.  The consequence of the "acid rain" movement was to significantly reduce the amount of sulfate in coal, oil and gasoline as well as their combustion products. Billions of dollars were spent on this policy and the consequences to soil sulfate levels according to the graphic are pronounced. 

Scientific studies demonstrate that if sulfate is not in the soil, it is not incorporated into the plants. Sulfate is not legally required and not routinely added to soil either.  BigAg finds using NH4NO3 is cheaper than NH4SO4 because they get twice the nitrogen per pound. Also, using Alum as a flocculant in drinking water actually decreases overall sulfate content of water.  All the sulfate coagulates and precipitates out of solution and may be the mechanism of how Alum serves as an adjuvant in vaccines. 

Over the last 100 years, we have seen an explosion of chronic inflammatory illnesses from lupus to crohns disease, asthma, and even hypertension, diabetes, and heart disease.  Some argue that these inflammatory disorders were always there but we are seeing more of them today because people are living longer today and we are recognizing them better.

All these modern chronic inflammatory diseases have something in common. They all are associated with elevated homocysteine levels.  Accordingly, homocysyeine is considered a nonspecific marker of inflammation.  But, thats just it.  Homocysteine is not nonspecific. Homocysteine is a very specific biochemical intermediate in the sulfur and DNA repair pathway.  Could it be that elevated homocysteine is pointing us directly to what the problem is-- Sulfate deficiency?

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  Phentolamine Alternative
Posted by: dbrosnahan - 05-30-2016, 04:39 AM - Forum: General Discussion - No Replies

A patient came to the ED with allergic reaction. They attempted to use an EPI-pen but mistakenly injected epinephrine into their thumb.  The patient presented with mild blanching of their thumb including the base of the thumb, snuffbox area, and thenar eminence. Although there are only a few cases of significant morbidity from epinephrine injection to a digit, the treatment usually involves infiltration of the digit with phentolamine, an alpha-1 blocker. Phentolamine is also indicted in the case of infiltration of a vasopressor from an peripheral IV or central line.  Unfortunately, there is currently a phentolamine shortage. Also, the pharmacy are reporting that this medicine is very expensive. The alternatives to phentolamine for IV extravasation or from epinephrine autoinjector are:

1. Watchful waiting.
2. Apply topical nitroglycernin 2%, apply a 1-inch strip to the site of ischemia q8 hrs prn; monitor for hypotension.
3. Dilute 1 mg terbutaline in 10 ml NS.  Inject locally across symptomatic sites.

http://www.pharmacyjoe.com/episode-6-alt...avasation/

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  EM Literature Websites
Posted by: dbrosnahan - 05-29-2016, 08:24 AM - Forum: Medical Literature - No Replies

http://www.uptodate.com/contents/whats-n...y-medicine

http://www.emlitofnote.com/

http://www.jwatch.org/emergency-medicine

http://emed.wustl.edu/education/Emergenc...chive.aspx

http://emjclub.com/ (podcast)

http://www.annemergmed.com/content/journalclub

http://emergency.med.ubc.ca/research/jou...-articles/

https://wikem.org/wiki/WikEM:Journal_Club_(Main)

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