Oz E Medicine - emergency medicine in Australia

There were a couple of very interesting presentations at the ACEM Winter Symposium in Darwin this week relating to Australian toxinology by A/Prof Geoff Isbister and Dr Bart Currie, and in particular, discussions surrounding antivenom usage.

Box jelly antivenom, whilst binding the venom in vitro, is NOT likely to be of benefit in actual poisonings as mortality cases usually occur within 20 minutes and for the antivenom to be effective in vivo, it would seem that it needs to be given BEFORE the envenomation.

Red back spider (Latrodectus sp) bites are well recognised for causing local severe pain (which appears to be neuropathic type pain and not well controlled by conventional analgesics), localised sweating, and systemic features, has been traditionally been managed in the ED with im red back antivenom, although recent studies have suggested that 2 vials iv is more likely to give demonstrable circulating antivenom, although similar response to pain (~60%) and reduction in systemic features.

Given the absence of detectable circulating redback antivenom when given im, and the similar response rates to iv doses, one hypothesis may be that the responses may be primarily placebo effect and this will need further studies to verify. Of course, anecdotally, there does usually seem to be a response and so if this is a placebo effect, then its a pretty good one!

Now for the Australian snake bite conundrum.

Bites from the Australian Brown Snakes are well recognised for causing:

• a possible initial hypotensive collapse and possible sudden death - often associated with intracranial haemorrhage which may have resulted from fall to ground, and head strike in an anticoagulated state due to the intravascular coagulation from the bite.
• profound coagulopathy due to the procoagulant in the venom causing a consumptive coagulapathy which once it has occurred, in particular, depletes factor V, factor VIII, and fibrinogen levels until the liver can restore these level some 8-14 hours later.
• a late onset neuropathy due to neurotoxins although there appears to be some controversy regarding this

A/Prof Geoff Isbister has shown that you ONLY NEED 1-2 vials of CSL antivenom to neutralise the venom from brown snake bites and 1 vial to neutralise venom from tiger snake bites, and furthermore, that there is NO POINT giving more antivenom to try to reverse the coagulopathy - this may need early FFP to achieve this although studies will need to be done to confirm this hypothesis. The main benefit of giving the antivenom appears to be in reducing the late neurotoxic effects - NOT the coagulopathy although having been given the antivenom, it lasts in the body a couple of weels or so, and may prevent a coagulapathy in a subsequent snake bite during this time period although this is speculative!

Furthermore, it has been shown that CSL tiger snake and brown snake antivenoms are actually polyvalent, and thus there is a push to have CSL just market them as a single brown snake/tiger snake antivenom, but this would need re-submission for marketing approval.

The possible conseqence of this, could be that in areas of Australia where the snake bites are almost entirely either brown snake or tiger snake such as in south-eastern Australia, the snake bite venom detection kits may become redundant!

An interesting question then arises in my mind:

Currently the practice with asymptomatic Australian Elapid snake bites managed with early pressure immobilisation is that once iv access and resuscitation equipment and antivenom is available, that the pressure immobilisation be removed in the ED under close observation, and if signs of envenomation occur such as coagulopathy or neurotoxicity (test by looking for ptosis on prolonged upward gaze of 30sec), then the pressure immobilisation is temporarily re-applied whilst antivenom is given.

The potential problem with this approach is that once you have allowed the coagulopathy to occur - assuming early pressure immobilisation prevents this - it is now too late to stop it using antivenom.

Thus, if you really believe the patient has been bitten by a brown snake, and likely to have been envenomated, and the risks of coagulopathy outweigh the risks of 1 vial of antivenom administration, then perhaps we should give that vial of antivenom BEFORE removing the pressure immobilisation - this of course may mean many more would get a vial of antivenom even though they may not be envenomated but it seems to me something to consider. Now, I am NOT a toxinology expert but it does seem to me the logical course to take.

Well it is all fascinating stuff - and maybe in the end, we can save the hospitals considerable amounts of money in VDK’s and antivenom, while the patients will hopefully have lower doses of antivenom and less serum sickness as a result - seems like a win-win situation to me - except there does not seems to be much incentive for CSL to play ball and help us achieve this.

eMJA has just published the new position statement by Australasian Society for Infectious Diseases (ASID) and the Swine Influenza Task Force of the Thoracic Society of Australia and New Zealand (TSANZ).

I have updated the Ozemedicine wiki page on Tamiflu with the link and main recommendations.

Perhaps the main recommendation that many ED doctors may not have been doing to date is that ALL patients hospitalised with H1N1 09 should be given antiviral Rx (eg. Tamiflu) even if they have had the illness > 48 hours.

And, of course, it reinforces the recommendation that it should be given to pregnant patients as the benefits appear to outweigh the risks in this high risk group.

Lastly, ED doctors and nurses should perhaps be considered for long term prophylaxis:

“Long-term prophylaxis can be given to “first responder” health care workers for durations of up to 6 weeks for oseltamivir and 4 weeks for zanamivir. Use of antiviral prophylaxis for these groups should be in the context of agreement to use the national stockpile.”

Doctors can now prescribe Tamiflu for a patient with presumed H1N1 swine influenza within 48 hours of onset, and in addition write a letter to the pharmacy authorising free dispensing of Tamiflu for the number of household contacts.

See The Age report.

Interestingly, according to The Age, the approved pharmacies can only be found in the eastern, western, south-eastern and northern suburbs of Melbourne. Now let me get my compass out - hmmm… not sure what suburbs are being left out here, I think they have most of the compass well covered seeing that Port Phillip Bay occupies most of the region to the south of Melbourne.

A full list of pharmacies can be found here.

See Australian Prescriber (pdf).

Cilostazol (Pletal):

• a phosphodiesterase III inhibitor for Rx of intermittent claudication without rest pain or necrosis

Doripenem (Doribax):

• a new carbapenem with broad spectrum activity against Gram-negative or Gram-positive bacteria, but not against MRSA
• given by infusion 8 hourly
• half-life is ~1 hour in healthy adults and is not extensively metabolised

Sugammadex (Bridion):

• a modified gamma cyclodextrin designed to selective reverse the effects of the neuromuscular blockers rocuronium and vecuronium by forming a complex with them.
• dose of 4mg/kg was more effective and faster (3 minutes vs 50 minutes) than 70mcg/kg neostigmine at reversing profound NM blockade

New version of the Japanese encephalitis vaccine.

The headline in The Australian newspaper today is Melbourne, the swine flu capital of the world - based on prevalence of H1N1 influenza in Melbourne being twice that in Mexico, although confirmed cases are only 700-1000 compared with over 11,000 in USA and 5000 in Mexico.

It is likely to be true that this comparative prevalence is misleading as Victorian hospitals during the “CONTAIN” phase tended to be testing anyone remotely likely to have the flu.

The situation will presumably now change in the “SUSTAIN” phase where testing will only be carried out on a few patients and everyone else with a fever, cough and sore throat assumed to have it and treated with Tamiflu. Presumably there may not be any further true record keeping of actual cases given that Tamiflu is being give to contacts and cases, not even use of Tamiflu is a reliable indicator, nor will ED software recording systems.

In the meantime ED’s are being flooded by cases and contacts seeking Tamiflu while the government works out a more sensible distribution system.

Perhaps half our ED attendances now are flu-related, and it is likely that a significant proportion of ED staff will develop it given the sheer numbers of contacts and the known infectivity.

This will run the risk of staffing the ED becoming increasingly difficult as staff members are advised to remain in quarantine for 3 days if the develop symptoms and are taking Tamiflu.

And after some debacles in ED last night, despite starting Tamiflu prophylaxis, requiring a couple of hours of contact tracing of patients and staff, yours truly is now feeling a bit viraemic - hopefully it is is side effect of Tamiflu or psychological rather than true flu - we will have to see what tomorrow brings - may be it will mean quarantine and no work on the public holiday on Monday - now that will get a lot of people upset! Monday is going to be hell with the flu numbers rising further and the last thing ED needs is for consultants not to be available.

And, yes, I have had to cancel our anniversary restaurant dinner in the city tonight at my favorite French restaurant just in case they don’t want swine in the doors, and I have canceled a trip to the countryside tomorrow. Thanks guys!

Why couldn’t the government have pre-empted the Tamiflu distribution need and not dumped it on such a valuable resource as our ED’s?

There are guidelines on use of Tamiflu on the wiki here, including emergency preparation of suspension form from capsules.

and for some perspective, check out Google’s new flu trend charting tool.

As briefly discussed in the previous blog, ED nurses and doctors will need individual access at the bed side and while on the move if clinical systems such as electronic prescribing and full electronic medical records are going to be workable in our environments.

A few specs that would be workable for a carry-around device:

• light enough eg. 800g or less
• small enough to hold easily in one hand and use the other to interface, and fit into a large scrubs pocket
• LCD screen big enough for optimum usability in the ED - perhaps a 7″ 800×480 pixel display is optimum for a hand held device (larger resolutions make font size too small unless using a 10″ display)
• touch screen works with gloved fingers as well as a stylus pen (ie. dual mode), and preferably has iPhone’s multi-touch gesturing technology styles - ie. use 2 fingers at a time to allow zooming in and zooming out, etc
• preferably the ability to run Win32 programs as despite the recent rise in Apple products, Windows is still where its at for product development
• if running Windows Vista then 2Gb RAM, otherwise 1Gb RAM may be adequate
• 16-32Gb solid state HDD that can cope with movement, is more robust and can provide longer battery life
• Kensington-like security system to allow attachment of a lanyard
• easy to disinefect
• built-in camera and ring flash to act as bar code reader to identify patient’s arm bands and perhaps drugs for prescribing as well as to allow rapid clinical photography at the bedside to document injuries or patient ID (as in the recent burns victims from the bushfires). It could also be used to video events where this may have relevance - in otherwords - a Citrix-based system is NOT likely to be the solution, particularly when the new touch technology becomes available - see at bottom of this blog.
• built-in WiFi wireless networking
• long battery life - preferably at least 8 hours, and short recharging times
• a good keyboard type interface for typing notes whether physical or virtual
• hand-writing recognition when used with stylus pen
• perhaps built-in VOIP phone capability with bluetooth headphone/mic set
• perhaps speech recognition to dictate notes
• usual software such as browser, media player, MS Office document viewers and editors

The Apple iPhone is a cute pocketable device which has a nice new multi-touch interface and potentially can be individually “owned” by employees which has some advantages in addition to being a web browser, email client and a mobile phone.

BUT it has some major limitations when it comes to data entry for clinical systems including:

• its small user interface of only 480×320 pixels which makes viewing 50 patients in the ED or getting a sense of a department map not that user-friendly, although not impossible.
• its proprietary Apple software developing system which will limit application development
• the absence of a keyboard will make data entry frustrating for many users
• battery life - with fairly constant wifi access and LCD use, they may struggle to last an 8 hour shift
• although you can run Windows programs via Citrix servers using Citrix Receiver, unless the Windows program is designed with iPhone in mind, it is unlikely to be a nice user experience - OK for browsing perhaps but maybe not for data entry

The new Panasonic Toughbooks have a potential role in the ED with the larger screen sizes but still they weigh over 1kg and this will significantly limit constant hand held use.

• CF-U1 UMPC is 1.06kg and has a 16Gb SSHD, 5.6″ 1024×600 LCD touch screen PLUS built-in keyboard, measures 150(H) x 184(W) x 57(D) and can be fitted with bar code reader or RFID reader to enable recognition of staff member using it



• CF-08 Wireless Display is a 1.2kg 10.4″ 1024×768 touch screen thin client display (no hard drive) with 14 hour battery life but which requires a system such as Citrix servers to allow software to be viewed on the screen. There is no keyboard or mouse but requires a stylus pen to use the touchscreen. This screen will have a role in Citrix environments but is heavier and bigger again - measures 267(H)x208(W)x36(D).



• note, the other new Panasonic models weigh over 3kg - maybe OK in an ambulance or to roll around on a trolley for ward rounds, but not really for hand held usage

Likewise the Medical Clinical Assistant with 10.4″ touch screen display, barcode reader and RFID reader, but it weighs 1.47kg.

BUT really, a smaller, lighter option with 800×480 display, preferably with multi-touch technology as with the iPhone would be nicer - perhaps the hopefully soon to be released Apple “iTablet”, but in the meantime, what else is on offer:

Ultra Mobile PC’s (UMPCs):

Microsoft have introduced a new system for Ultra-Mobile Personal Computers (UMPC’s) which is optimised for touch technology - Origami Experience to run under Windows Vista. This appears to bring a bit of the iPhone interface look to Windows based devices but designed to run on a display of 800×480 which may be more optimal for nurses and doctors on the move - now will the clinical software vendors make the most of this interface?

The hardware manufacturers have introduced a multitude of devices which are capable of running this software, and importantly their weight tends to be around the 800g region - but who will make the best option for doctors and nurses in the ED? Examples include:

• HTC Shift sliding tablet style which includes keyboard but only 2 hours battery.
• eo TufTab



• other UMPC’s listed on Tegatech

The use of any of these technologies raises more problems to solve:

• theft
• binding them to trolleys won’t be the solution - there is not enough geographic space in ED’s for that.
• I could imagine a UMPC attached to a lanyard around a nurse’s neck and placed into a large pocket sewn onto scrubs when not in use which would reduce theft and solve the problem of user logons as each staff member could have their own dedicated device
• damage from dropping or liquids
• ease of disinfection
• traditional keyboards and buttons are particularly problematic
• software maintenance
• how often are your PC’s needing to have their hard drives re-imaged or replaced currently?
• re-charging batteries for use throughout a shift - how to manage this?
• wireless networking security
• capital costs and maintenance/replacement costs - where is all that on-going budget requirement going to come from?

Coming soon:

Microsoft believe that in 3-4 years we will be using revolutionary touch screen technology as demonstrated in this video:

Microsoft no more keyboards

and Microsoft’s tablet PC iPhone-like technology on the way which shows how we might use it in clinical education and bedside instruction - demonstrates that the future is NOT likely to be Citrix server based but fat client rich user interfaces - that said, in the interim, Citrix servers may have a limited place for certain applications:

tablet PC

and the future UMPC:

future UMPC

The good news is that new designs and form factors are evolving rapidly, we may yet get what we need - but it might take a few more years and then will the software be ready for the new form factors? Will we be ready to leverage their capabilities? We need to be the champions of ensuring new technologies are used appropriately to optimise our ability to care for our patients and become more effective ED’s, rather than passively accept what software vendors and governments giving us what THEY think we need.

It’s well and truly time we moved away from the 1990’s government proposition that ED information systems are primarily for data collection - we need to make sure they are primarily there to create efficient and effective patient care.

This blog is a rather frivolous take on how the media is reporting the swine flu in Australia this week.

On the weekend, we had the front page of the Melbourne newspapers “reassuring” the population that “there is nothing to worry about - it appears the swine flu virus is fairly tame - similar to seasonal influenza which normally kills 2500 Australians each flu season”

Somehow, I don’t think that was reassuring, thanks guys!

And the Herald Sun newspaper for the 27th May has the heading “Mass pig flu vaccination plan for Victoria” and goes onto state:

“Parents are taking about 300 children every day to the Royal Children’s Hospital, prompting a plea for calm.” - I’m thinking this might be exaggeration, but nevertheless, a failure of the public reassurance.

“Up to three special pig flu clinics will be opened at hospitals in a move to ease the burden on emergency departments inundated by concerned parents.” — hmmm … parents bringing their pigs into ED now? I knew we had an obesity problem, but surely this is not politically correct!

“Authorities fear there will be hundreds more cases by the end of the week.” - I’m not sure there will be that many - the government has advised not to swab non-direct contacts so how are we going to know who is a contact if the virus has been let loose already? At least this should keep the number of confirmed cases down.

On the other side of the coin, the ABC tried to calm people down with some advice for the West Australians:

“Swine flu hype overdone: Professor”

“An infectious diseases expert says West Australians have no reason to worry about swine flu despite the state recording its first confirmed case of the virus.” - good luck with that line - Victoria only had 1 case a few days ago and now expect to have hundreds by the end of the week!

“It’s really one which if you can stay home for two or three days you’re not going to infect others and you’re going to not have a serious illness and after that you can go back to work again.” - and I thought influenza was infective for 7 days according to the experts.

“It’s a new disease so it’s not one we’ve seen before, a new form of flu we haven’t seen before, but it’s only severe in very occasional cases and always in people who’ve got some underlying health reason.” - well at least he’s trying to be reassuring.

Bring on the pig flu clinics!

and I am keeping a timeline of the pandemic here just in case the survivors need it as a reference for the future

now is it too late to put in for long service leave this winter?

Various Australian State governments are in the process of attempting to convince the now rather skeptical doctors and nurses that electronic prescribing will make life better.

The key to success largely rests with an efficient user interface and ready access to computer interfaces so that while an ED resuscitation nurse is scribing what drugs and infusions are being given as well as checking to see when the next dose should be given, the ED doctor can be writing an order and checking results and at the same time the inpatient medical team can be writing up their inpatient prescriptions for that patient.

It then becomes obvious that in busy areas, particularly with multiple teams concurrently managing a patient as in the ED, computer terminal access rapidly becomes a point of frustration.

No longer can an ED nurse present an IV fluid chart to a doctor and ask him to write the next IV order up - no, the doctor will need to find a computer terminal, log on, find the patient, go to the electronic prescribing section for IV fluid orders, scroll through a lookup table to find Normal saline, tab to another field to enter the desired administration rate, then cope with potential pop up warning boxes that tell him the patient’s sodium level is 129, are you sure you want to give this, then log off and go back to his other patient who hopefully is still alive.

Life in the ED is much more complicated than people would appreciate - the complexities and inefficiencies introduced by the new patient management system further reflect this and forewarn of problems with the introduction of electronic prescribing in the ED.

BUT, there is hope on the horizon. Perhaps the new technologies similar to Apple’s iPhone (but in larger screen format such as the expected Apple iTablet) may make using and accessing electronic prescribing more efficient with several possibilities becoming available:

• Citrix Receiver on the iPhone:
• Citrix has announced their new product Citrix Receiver for iPhone which allows iPhone users to run any program running on a hospital’s Citrix server (eg. presumably Cerner’s ePrescribing software and Symphony ED software) and the only data transferred between the iPhone and the hospital wireless system are the user’s screen taps, gestures, keyboard input, and the screen updates.
• the BIG question is, how well will these software systems interact with the user in an iPhone or iTablet?
• new cross-platform software development tools
• development of software for Mac systems has been somewhat of a niche market given the dominance of Windows, but now Embarcadero (who bought Borland/Inprise/Codegear’s Delphi software development suite) have announced a road map for their Project X which would allow cross-platform database development which not only will allow software to be built efficiently for deployment on Windows, MacOS or Linux operating systems, but will also include the new user interface experiences of Touch technologies
• in addition, they have also created a MacOS route for Windows .NET developers with their Delphi Prism software.

If the major software vendors are not interested in making clinical software interfaces that are efficient for the end users, I am sure there will soon be a flood of competing products that will - 1995 technology is just not good enough in a 2009 world.

ps.. I do not own an iPhone, nor a Mac computer, nor do I run Citrix, but I do program in Delphi Win 32 - arguably the best native Window’s database programming tool available.

Given the relevance of this to hospital employees such as ED physicians, I thought it would be useful to many to post this news.

It seems the Rudd government aim to slash salary packaging of superannuation by half in the coming budget - see here.

It may be prudent then to ensure you maximise your salary packaging of superannuation for this current year while the stock market is low, but then I’m not a financial adviser, just a messenger.

Doctors at more than 100 hospitals in the state could not access patient records or vital test results for up to 36 hours last weekend after a power failure crippled NSW Health’s computerised database.

If you are going to centralised database systems, there needs to be 24×7 availability with appropriate contingency and redundancy systems in place.

This is a major issue when full electronic prescribing and medical records systems are introduced as they are planned to be in Victoria. Centralising systems just adds an extra but far more reaching risk to hospital IT systems. The potential benefits of centralised systems may outweigh the risks, but only if those risks are managed well.

And, as the recent past has shown, Victoria is far from immune to major, prolonged power outages, whether it be heat-wave induced, or otherwise.

See report here.