Fabrizio Elia

Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation

PURPOSE Ultrasound (US) is a useful tool for peripheral vein cannulation in patients with difficult venous access. However, few data about the survival of US-guided peripheral catheters in acute care setting exist. Some studies showed that the survival rate of standard-length catheters (SC) is poor especially in obese patients. The use of longer than normal catheters could provide a solution to low survival rate. The aim of the present study was to compare US-guided peripheral SCs vs US-guided peripheral long catheters inserted with Seldinger technique (LC) in acute hospitalized patients with difficult venous access. METHODS This was a prospective, randomized controlled trial. A total of 100 consecutively admitted subjects in an urban High Dependency Unit were randomized to obtain US-guided intravenous access using either SC or LC after 3 failed blind attempts. Primary outcome was catheter failure rate. RESULTS Success rate was 86% in the SC groups and 84% in the LC group (P=.77). Time requested to positioning venous access resulted to be shorter for SC as opposed to LC (9.5 vs 16.8 minutes, respectively; P=.001). Catheter failure was observed in 45% of patients in the SC group and in 14% of patients in the LC group (relative risk, 3.2; P<.001). CONCLUSIONS Both SC and LC US-guided cannulations have a high success rate in patients with difficult venous access. Notwithstanding a higher time to cannulation, LC US-guided procedure is associated with a lower risk of catheter failure compared with SC US-guided procedure.

Lung ultrasound in the reexpansion of pulmonary atelectasis

A 60-year-old man was admitted to our hospital complaining of dyspnea and productive cough that had been present for 24 h. One year prior, the patient had been diagnosed with amyotrophic lateral sclerosis. On admission, he was bedridden, had a tracheotomy, was ventilatordependent and fed by enteral nutrition by means of a gastrostomy tube. The vital signs were: blood pressure 120/80 mmHg, heart rate 110 beats/min, temperature 37 C. Percutaneous oxygen saturation was 85% on 80% ventilator-delivered oxygen. Physical examination revealed decreased breath sounds over the right lung and rales compatible with the presence of bronchial secretions over the left lung. A Chest x-ray study showed an opacification of the lower half of the right lung fields with mild homolateral mediastinal displacement suggesting pulmonary atelectasis (Fig. 1). Electrocardiography was unremarkable. Blood gas analysis revealed hypocapnic respiratory failure. Other laboratory tests were normal except for a mild leucocytosis. The emergency physician performed a lung ultrasound (US), which confirmed the presence of a right pulmonary atelectasis appearing as an area of pulmonary parenchyma with a tissue-like pattern and abolished lung sliding in the presence of lung pulse (Fig. 2, Online Resource 1). In order to remove secretions, a bronchoscopy was performed while simultaneously checking for adequate pulmonary reexpansion with US imaging. As airway clearing progressed, the US study showed the appearance of an air bronchogram near the hilar pulmonary structures (Fig. 3, Online Resource 2), gradually advancing toward the peripheral parenchyma (Fig. 4, Online Resource 3) till pulmonary reexpansion was completed, as evidenced by the appearance of lung sliding and the disappearance of the tissue-like pattern (Fig. 5, Online Resource 4). After the procedure, the oxygen saturation was 95% on 40% ventilator-delivered oxygen. The physical examination revealed bilateral breath sounds.

Acute liver injury after intravenous amiodarone: A case report☆

Acute hepatotoxicity is a rare but potentially fatal complication of amiodarone use. Although oral long-term use of the drug is frequently complicated by an asymptomatic rise in serum aminotransferase concentrations, acute hepatotoxicity during intravenous loading is much less frequent and potentially fatal. We report a case of liver injury after intravenous administration in a patient with atrial fibrillation.

''First, know thyself'': cognition and error in medicine

Although error is an integral part of the world of medicine, physicians have always been little inclined to take into account their own mistakes and the extraordinary technological progress observed in the last decades does not seem to have resulted in a significant reduction in the percentage of diagnostic errors. The failure in the reduction in diagnostic errors, notwithstanding the considerable investment in human and economic resources, has paved the way to new strategies which were made available by the development of cognitive psychology, the branch of psychology that aims at understanding the mechanisms of human reasoning. This new approach led us to realize that we are not fully rational agents able to take decisions on the basis of logical and probabilistically appropriate evaluations. In us, two different and mostly independent modes of reasoning coexist: a fast or non-analytical reasoning, which tends to be largely automatic and fast-reactive, and a slow or analytical reasoning, which permits to give rationally founded answers. One of the features of the fast mode of reasoning is the employment of standardized rules, termed “heuristics.” Heuristics lead physicians to correct choices in a large percentage of cases. Unfortunately, cases exist wherein the heuristic triggered fails to fit the target problem, so that the fast mode of reasoning can lead us to unreflectively perform actions exposing us and others to variable degrees of risk. Cognitive errors arise as a result of these cases. Our review illustrates how cognitive errors can cause diagnostic problems in clinical practice.

A victim of the Occam’s razor

In November 2011, a 31-year-old man was admitted to our hospital with fever and acute renal failure. Two months before, he had been diagnosed with methicillin-resistant Staphylococcus aureus aortic valve endocarditis requiring valve replacement. Heart surgery was performed without complications, and antibiotic therapy was started. 40 days after surgery, he became febrile and a diagnosis of prosthetic valve endocarditis was suspected. A transesophageal echocardiogram did not reveal new signs of endocarditis. Blood cultures were negative. The initial antibiotic therapy was empirically changed, and gentamicin was administered. After 2 weeks the patient developed acute anuric renal failure. At this time he was transferred to our hospital. On arrival the patient was febrile. Physical examination showed neither new cardiac abnormalities nor signs of systemic embolization. Blood test yielded a leucocytosis, renal failure and mild elevation of procalcitonin levels. CT scan of his head, chest and abdomen were negative for septic emboli. Transesophageal echocardiogram revealed the aortic prosthesis to be functioning normally in the absence of clear vegetations. Blood cultures were negative. Although there was no evidence of sources of infection, fever was considered to be of infectious origin, and the renal failure was attributed to aminoglycoside nephrotoxicity. Gentamicin was discontinued, antibiotic therapy was changed again, and hemodialysis was started. Over the following days, the patient had one episode of severe hemoptysis associated with respiratory failure and blood loss. A CT scan of the chest showed diffuse interstitial and alveolar infiltrates suggestive of alveolar hemorrhage. At this point, a diagnosis of a pulmonary renal syndrome was suspected. Autoimmune tests were performed showing high titers of anti-glomerular basement membrane (anti-GBM) antibodies. A diagnosis of Goodpasture syndrome was made. The patient was administered prednisone and rituximab (preferred to other immunosuppressive drugs to minimize the risk of infection) and underwent a series of 19 plasma-exchange treatments. Clinical conditions improved, no further episodes of hemoptysis occurred, and, at the time of discharge, antiGBM antibodies were undetectable. However, the patient became dependent on chronic hemodialysis. Goodpasture syndrome is an autoimmune disease characterized by pulmonary hemorrhage, glomerulonephritis and the presence of circulating anti-GBM antibodies. Infection may be an initiating event or a precipitating factor for relapse. Identifying Goodpasture syndrome following an infectious event is challenging and high procalcitonin values may be observed even in the absence of infection [1]. In presence of a typical presentation including alveolar hemorrhage and renal failure, the evidence of circulating anti-GBM antibodies may confirm the diagnosis. Life-saving treatment includes plasma-exchange to remove circulating antibodies and immunosuppressive medications to stop the production of the antibodies. F. Elia (&) F. Pagnozzi B. Laface F. Apra High Dependency Unit, San Giovanni Bosco Hospital, Piazza Donatore del Sangue 3, 10154 Turin, Italy e-mail: fabrizioelia@yahoo.it

Understanding and improving decisions in clinical medicine (I): Reasoning, heuristics, and error

In considering ourselves as agents who think and make decisions, it is natural to rely on a logic-plus-error model. According to this view, the human mind is essentially a logical machine providing coherent inferences and choices unless disturbing factors interfere and lead us astray. One key point of this idea is that, in principle, were the sources of error subtracted, logical reasoning would flow undeterred, and mistakes would vanish. The logic-plus-error model has been strongly influential in medicine. One often presupposes that healthcare professionals, too, would reason according to valid logical rules quite naturally, if only their judgment was not distorted by the effects of sleep deprivation, the reality of emotional stress, the concerns of defensive medicine, or sheer work overload. As to interventions to improve practice, the ensuing policy amounts to a combination of the following: strengthen consequential behavior by training (e.g., teaching some statistics) and institutional control (e.g., enforcing guidelines), and try to lessen the impact of disturbing factors (e.g., by more effective technology and organization). Clever measures consistent with this view have achieved some significant degree of success. After all, there is little doubt that fatigue, poor planning, and other exogenous causes of burden can indeed hinder accomplishment in a variety of clinical tasks. Despite this, the logic-plus-error view is fundamentally untenable. Research on human cognition indicates that, typically, the same kind of mental processes produce a large amount of valid judgments along with patterns of biased reasoning in specific conditions. Such processes are known as heuristics, and they are qualitatively different from formal logical principles. In short, the human mind is much more a heuristic, rather than a logical, machine [1, 2].

Cervicofacial Emphysema and Pneumomediastinum Complicating a Dental Procedure

A 41-year-old woman with a history of left peripheral facial paralysis after parotidectomy underwent a surgical extraction of her right lower secondmolar tooth at a dental clinic. The procedure was performed using an air-turbine drill. During the surgical intervention, hemifacial swelling appeared and the patient complained of neck discomfort in the absence of swallowing and breathing difficulties. She was urgently transported to our hospital by Emergency Medical Services. On arrival, her vital signs were all normal. Examination revealed neck and right hemifacial swelling (Figure 1A), and palpable crepitus was detected over the head, neck, and upper chest. No signs of airway obstruction were observed. A computed tomography scan was performed and showed cervicofacial and mediastinal emphysema (Figures 2 and 3, respectively). Our patient was admitted for respiratory monitoring. Antibiotics and analgesics were administered. Her hospital course was unremarkable; no complications appeared, and after 1 week, the swelling had nearly completely resolved (Figure 1B).

Understanding and improving decisions in clinical medicine (II): making sense of reasoning in practice

The most refined logical model for clinical reasoning is the combination of Bayes’ theorem and expected utility theory. Briefly put, it implies that the probabilities of an exhaustive list of initial diagnostic hypotheses be updated through the collection of data, and that treatment for a condition becomes justified when the probability of such condition exceeds the threshold where expected clinical benefit outweighs potential harm [1]. The theoretical virtues of this model as a benchmark of rational thinking are not in question, in our opinion. In a ‘‘logic-plus-error’’ view of human reasoning [2], one would go further and rely on this model as a major tool for understanding and improving actual decision making in medicine. Yet, as tempting as it may be, this approach provides insufficient guidance to address many pressing issues arising from clinical practice. As an illustrative example, we will discuss a recent report concerning the case of a 35-year-old woman with a chronic history of diarrhea and malabsorption associated with severe gastrointestinal dysmotility that was left with no diagnostic explanation for approximately 20 years [3]. The key to the resolution of this case was the serendipitous detection of blepharoptosis, a clinical sign that had been present for a long time, but never appreciated. A thorough revision of the case in light of this finding (with a stronger emphasis on neurological signs), eventually allowed the clinicians to identify a rare genetic disorder, named mitochondrial neuro-gastrointestinal encephalomyopathy (MNGIE), known from the scientific literature since the 1990s. In this case, the patient suffered from a chronic problem of malabsorption without a satisfactory interpretation. After two decades, a rare condition with a dismal prognosis turned out to be involved. Is the rarity of this disease sufficient to explain the belated diagnosis? How did the physicians handle this case over the years? What prevented them from achieving a diagnosis? And what eventually allowed the correct conclusion to emerge? While there is no easy route to a definite answer to these questions, we mean to point out that a cognitive science approach to clinical reasoning offers a better framework for analysis than a logic-plus-error view.

The clinical eye

In September 2011, a 35-year-old woman was admitted to our hospital with abdominal pain, nausea and vomiting. She reported a history of chronic weight loss, vomiting and diarrhea since adolescence. Her symptoms had been worsening over the past few months, with the onset of leg swelling and intermittent paresthesia affecting both feet. The patient denied other symptoms such as fever, shortness of breath, night sweats or joint pain. She was not on any medication and her family history was unremarkable. She did not report any recent travels. She had recently undergone psychiatric consultation on the suspicion of anorexia nervosa. On arrival the patient appeared cachectic (body mass index: 14 kg/m). All vital signs were normal. On examination, the abdomen was distended and mildly tender with reduced bowel sounds. Moderate swelling of both ankles was observed. Neurological examination showed generalized muscle weakness. Psychiatric assessment was normal. No rash, lymphadenopathy or joint swelling was detected. Routine blood tests revealed mild microcytic anemia and low albumin levels.

A plea to respect medical mistakes

the assignment. It was a compelling coming out that allowed us to create a favourable environment for discussion, and to strengthen the view that everyone, without exceptions, can make mistakes, regardless of age, experience and professional role. In our view, it is essential to rethink about the issue of medical errors, and above all to engage physicians at the beginning of their careers and junior doctors to create a new cultural climate: a cultural climate able to accept the uncertainty that runs through so many medical decisions, able to accept mistakes as an intrinsic part of our job, to discuss them once made, and to support (without necessarily blaming) those committing them. Only in this context it is conceivable to have a safer system to identify potential mistakes at an early stage, to reduce their adverse effects, and to prevent further occurrences. The interest in medical education, in all its aspects, has significantly increased in the last few years [3], and making room for this subject in the context of medical education could be extremely important. “You learn by your mistakes,” it is a sentence that is often heard. It is true, but only so long as we learn to face our mistakes and learn from them. This is a plea to all doctors of good will to create a new medical culture tolerant towards mistakes and more friendly towards whoever made a mistake. Please let us go beyond the old medical culture based on a shame-and-blame approach to medical errors. “Physicians and nurses need to accept the notion that error is an inevitable accompaniment of the human condition, even among conscientious professionals with high standards.” [1] This is what Lucian Laepe, physician and professor at Harvard School of Public Health, said. Error is a big part of the doctors’ and nurses’ job as well as a big part of the job of any professionals in fields other than medicine. Nevertheless, it remains a real taboo for health professionals. It is hard for physicians to talk about mistakes, and it is even harder to recognise one’s own mistakes. It is virtually a cultural issue whose origins are difficult to explain in a few lines. “Never ever, ever make a mistake, but you worry about the details, about how that’s going to happen.” This is the message that, all too often, early career doctors receive, as Brian Goldman very clearly highlighted in a famous TED talk [2]. In a recent educational event aimed at young doctors, each participant was asked to describe a significant mistake drawn from his/her own experience, and to share it with the other colleagues (Fig. 1). In spite of the initial reluctance, everyone, from the youngest to oldest, was able to complete