700 Club

[GeneralVeers]

Our Chief Learning Officer, Kevin Klauer (you may know him from EMRAP) stated in an e-mail this week that he's a proud member of the "700-club" meaning that he thinks it's okay to do 700 negative LPs to find one sub arachnoid hemorrhage.

My personal opinion is that this is nuts! So we do nearly 1000 invasive, painful procedures that take a lot of time and resources to find one possibly clinically relevant bleed? Count me out. We could do 1000 of almost any test (whole-body CT) and probably find 1-2 dangerous, life-threatening illnesses.

This latest research on the LP for headache puts the nail in the coffin of an archaic practice.

Thoughts?

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[xaelia]

Since when in our medical/medicolegal system have we valued population costs/risks above the expenses of CYA for the individual bad outcome? Other than higher marginal tax rates on increased revenue from RVUs, there's no incentive to practice cost-effective, responsible – higher-risk – medicine. LP away!

All seriousness aside, J. Hoffman still votes to LP because he's a purist when it comes to study design, and the follow-up gold standard in those 6-hour CT SAH studies is inadequate. The conclusions probably still reflect a reasonable true practice-changing paradigm, but it's still possible to defend LP if your assumptions for the base rate are higher.

 

[TrumpetDoc]

The recent paper is very compelling... And "prob spot on" but the design flaws do exist...and with a heavyweight like Hoffman against it, it's still SOC as usual for now.
I try hard to give some numbers to the patient in Kay terms. And tell them simply to be "sure" I have to do it... Otherwise, as little the chance may be, can't say for sure.
I'm about 50:50 who refute and who opt for it on avg.

 

[Birdstrike]

Our Chief Learning Officer, Kevin Klauer (you may know him from EMRAP) stated in an e-mail this week that he's a proud member of the "700-club" meaning that he thinks it's okay to do 700 negative LPs to find one sub arachnoid hemorrhage.

My personal opinion is that this is nuts! So we do nearly 1000 invasive, painful procedures that take a lot of time and resources to find one possibly clinically relevant bleed? Count me out. We could do 1000 of almost any test (whole-body CT) and probably find 1-2 dangerous, life-threatening illnesses.

This latest research on the LP for headache puts the nail in the coffin of an archaic practice.

Thoughts?

It's not a matter of being "In the 700 club" or not. It's a matter of knowing the facts and presenting them to the patient, and letting them decide if they want to be "in the 700 club" or not.

You do your CT. If negative, you simply give the patient the numbers,

"Sir, 699 out of 700 times this test will be normal. That means there's a 99.857% chance you are fine, that the LP will be normal and you will go home after having a negative test. There is a 0.143% the LP will show a bleed and will save your life. The LP does carry a small but significant risk of infection, bleeding, nerve damage and post-spinal headache.

I'm 99.85% sure you are fine. If you want to be 0.14% more certain, that is 100% certain that you don't have a life threatening bleed, we need to do the LP. The reality is that in this country, in this day and age I am held to a standard of 100%.

Going strictly 'by the book,' I must offer you the LP. If I don't recommend the LP, and you are the unlucky 1 in 700 and die from a bleed, that's certainly not good for you and it's not good for me since it will be obvious I left

ANY CHANCE

of you having a life threatening subarachnoid hemorrhage. Ultimately it is your decision, and it's my job to give you the facts so you can either give informed consent, or informed refusal."

Their choices are,

1-LP
2-Well informed, polite and completely non-confrontational informed refusal indicating the discussion you just had, and release of liability (I call it a "soft" AMA) indicating the above details, other options, option to return if they change their mind or worsen, and other AMA "et ceteras."

I have found that many patients, choose "99.85% OK" and no needle to the back, over having to buy an extra 0.1% certainty with a needle in the back.

It's also worth letting them know the possibility of a traumatic tap, which may expose them to procedure risk, yet leave them no more certain than with a CT alone.

Most patients appreciate the honesty. Plus, I think it's the right thing to do.

Half the time, when you start talking LP, all of a sudden the headache's "not so bad after all," and you get the, "Doc, I really just wanted a work note, ya know?"


Take home point?

Make sure the legal record makes it clear the patient opted out of the 700 Club, not you.

 

[dotcb]

Agree with Birdstrike - am a non-member of the 700 Club. I let the patient decide after informed discussion of risk, documented in the medical record.

 

[glorfindel]

Agree with Birdstrike - am a non-member of the 700 Club. I let the patient decide after informed discussion of risk, documented in the medical record.

This, for me too.

As an aside, a not-insignificant part of me rues the fact that I can't just decide on a clinical practice, and run with it. This "informed consent" stuff has to have a limit -- there's uncertainty in everything, and specifying a 0.143% chance that the LP will be "positive" suggests to the patient that we have more precise knowledge than we really have.

For instance, what if the study's numbers aren't exactly 1 in 700? What if the characteristics of the pt in front of you fail to match up exactly with the study population? What about the chances of a traumatic tap causing those "positive" results?

The two things I'm getting at:

1) we need a bit more freedom from the fear of legal liability for a bad outcome
2) we need to explore the boundaries and limits of the whole concept of 'informed consent.'

 

[GeneralVeers]

This conversation demonstrates the insanity of our system. We are testing for 1 in 1000, 1 in 10,000 and even rarer events. I argue we do more harm than good, in that we bankrupt the system, subject patients to potentially harmful tests and procedures, and produce false positives.

 

[gman33]

The informed consent thing drives me nuts at times.
Just tell the patient what you want to do and tell them to google it on their phone when you leave the room. That's what they are going to do anyway...

Telling someone there is a chance they will die, however small, and a bunch just stop listening.

Kind of like telling someone there is a chance they can get HIV from a blood transfusion.
For some, that is the end of logic.

For now, I hope we keep doing LPs.
I need to get my procedure numbers up.
After residency, not so much.

 

[emd123]

.

 

[emd123]

We need tort reform..

 

[Arcan57]

I would probably have this patient leave.

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

I refuse to subject myself or the nurses I work with to abusive behavior in any way.

We have decent systems for dealing with the mentally ill and intoxicated (namely restraints and chemical sedation), but d-ckishness NOS should not and cannot be tolerated. A patient (male) once threatened to slap one of the nurses in the face of she missed the IV. After I was done discussing the consequences of that action with him he was weeping. I'm not sure I've ever been more disgusted with a patient who didn't have a DSM diagnosis or was intoxicated.

 

[Khaos]

First, he is also my CLO. I have read the study and would like to point out that the 1 in 700 is actually much larger of a gap. The 1 in 700 is based on the idea that this is truly the patient's worst headache and other symptoms consistent with SAH. The paper itself stated that when looking back at records and such it is found that patients had similar complaints in the past and such and thus the numbers are skewed. How often do we offer LP's on patients we think are full of crap and want meds? Add up the patients that have "atypical headaches" to where they say it just isn't like the ones I've had before or are sitting their calmly, normal vital signs, state it is the worst HA of their life yet are crying and screaming when they get the IV stuck in their arms and you get much higher than 1 in 700.

How much bad have we done to find that one, which by the way I have yet to find by LP. HA's, infection, bleeding, patches, etc...

From now on when I speak to a patient I will explain that they have a 1 in 700 chance...I am certain most of them will refuse after being told they have a 0.1% and these odds are only slightly higher than slipping and dying in your bath tub (1 in 2000)

Hell, using PERC and Well's criteria only brings us at <2% and how many still use that? This is even better odds.

 

[emddo]

while i have no studies to back me up, i believe that I can clinically look at a patient after a thorough history and physical exam and determine whether or not they need an LP to r/o SAH after a negative CT. I would bet that I would be significantly better than 1/700. I've had several patients that have been handed off to me at shift change waiting for CT results with the disposition being "if negative, LP" that I have sat down with and had a meaningful discussion with, and as partners in care, have talked them out of a totally unnecessary procedure that the previous doc told them would be necessary, well knowing they would not be the one putting the needle in the back

 

[la gringa]

First, he is also my CLO. I have read the study and would like to point out that the 1 in 700 is actually much larger of a gap. The 1 in 700 is based on the idea that this is truly the patient's worst headache and other symptoms consistent with SAH. The paper itself stated that when looking back at records and such it is found that patients had similar complaints in the past and such and thus the numbers are skewed. How often do we offer LP's on patients we think are full of crap and want meds? Add up the patients that have "atypical headaches" to where they say it just isn't like the ones I've had before or are sitting their calmly, normal vital signs, state it is the worst HA of their life yet are crying and screaming when they get the IV stuck in their arms and you get much higher than 1 in 700.

How much bad have we done to find that one, which by the way I have yet to find by LP. HA's, infection, bleeding, patches, etc...

From now on when I speak to a patient I will explain that they have a 1 in 700 chance...I am certain most of them will refuse after being told they have a 0.1% and these odds are only slightly higher than slipping and dying in your bath tub (1 in 2000)

Hell, using PERC and Well's criteria only brings us at <2% and how many still use that? This is even better odds.

he is also my CLO, and i too have yet to have a positive LP. every SAH i have seen, ever, was not subtle on presentation nor CT.

i have had a few not totally negative LP's -- meaning RBC's 50-as high as 400 in tube 4 after a not terribly traumatic tap. consulted nsurg, did a CTA which was negative (one even showed a non-intracranial aneurysm) and was advised to dc the pt home.

i did so in all but 1 case - lady had persistent severe HA and noncon CT wasn't totally negative. she wasn't going home w/o further eval. went down like this:
- pt w/ new severe HA, looked legitimately uncomfortable. in my mind = start down the CT/LP pathway
- rads called a "possible small SAH" in a weird spot
- consult nsurg -- advise CTA AND LP
- both negative but LP was not TOTALLY negative (i believe 200 rbc's tube 4? not bad tube 1)
- still had to admit her!!

it perplexes me and i do not understand why we are not on the same page w/ neurosurgeons.... when they have to definitely manage our diagnosis.

 

[glorfindel]

hell, using perc and well's criteria only brings us at <2% and how many still use that? This is even better odds.

+1

 

[TrumpetDoc]

Wow lots of us in the same group it seems

Make sure to call the fail safe

 

[Arcan57]

From now on when I speak to a patient I will explain that they have a 1 in 700 chance...I am certain most of them will refuse after being told they have a 0.1% and these odds are only slightly higher than slipping and dying in your bath tub (1 in 2000)

Hell, using PERC and Well's criteria only brings us at <2% and how many still use that? This is even better odds.

To be fair, the mortality from SAH =/ PE. I don't think you're going to find anyone that's a proponent of a 2% miss rate for SAH.

 

[la gringa]

big big group, very big now in my hometown.

i like the TIA failsafe... hospitalists can't argue. easy dispo.

i do a ****-ton more LP's than i did in my prior gig though... still no + for SAH.

 

[TrumpetDoc]

big big group, very big now in my hometown.

i like the TIA failsafe... hospitalists can't argue. easy dispo.

i do a ****-ton more LP's than i did in my prior gig though... still no + for SAH.

Very true on all!
I've done soooo many LPs

I often wonder though how our fail safes will work with this new value based crap and resource utilization???

 

[GeneralVeers]

Very true on all!
I've done soooo many LPs

I often wonder though how our fail safes will work with this new value based crap and resource utilization???

Our failsafe program is slightly ridiculous.

- Testicular pain? Get ultrasound (duh!)
- Febrile infant <3 mo get LP (easy for them to say, harder to do)
- Low abdominal pain in a female? Get preg test (not sure who wouldn't do this...)
- Unusual or worst headache of life? Get CT and LP (again, easy for them to say, but tough on patients).

 

[EM_Rebuilder]

I saw the article, and the followup by Kevin.

I agree with the principles that Kevin lays out, that missing one of these in 700 is life changing and is unaccetable. The risks are also so small that I think they can be ignored. Post dural HA is not life threatening. As long as you use good technique, I think infection is nil.

On the flip side, I have always been a big proponent of talking to the patient, trying to give them facts, and really trying to include them on the decision....and documenting the discussion and needs to FU in detail. I will use this magic '700' in my next discussion about the subject. And, as others said, many (large majority) decline the procedure.

The problem, I think, is that many of us 'think SAH' way more often than needed, and I believe Kevin referenced this. I am very quilty of this as well. In the true 'sudden onset, thunderclap, worse HA of the life'... should we really talk those patients out of it? I think thats what Kevin is getting at. Most of the HAs we see, and think 'this could be SAH' do not fit the perfect bill. On those perfect bills, I still educate the patient but I tend to highly suggest we do indeed do the LP. MOST of the time, we see the chornic HA'er that has 'worse HA ever' all over the triage note.. or its the 18 year old with a 'severe sudden HA' and vaginal bleeding, etc. At least thats my experience?

It also probably helps that I am in Texas...

 

[GeneralVeers]

I saw the article, and the followup by Kevin.

I agree with the principles that Kevin lays out, that missing one of these in 700 is life changing and is unaccetable. The risks are also so small that I think they can be ignored. Post dural HA is not life threatening. As long as you use good technique, I think infection is nil..

Again, 1 in 700 is so small as to be almost insignificant. As I've stated before, why not just do a CT head/chest/abdomen on everyone who walks through the door? We'd certainly find something "life-changing" on at least 0.1% of them, and the risk of radiation of one CT is minimal.

The problem with out failsafe program is we CAN'T use clinical judgement. I'd agree that offering a tap on people with symptoms consistent with a SAH is reasonable. I maybe see 1-2 per year that have concerning symptoms and a negative CT.

But, our policy states "worst headache", "sudden onset headache" or "unusual headache". Almost every chronic migrainer I see will answer enough history questions correctly about their headache to fall into the "Get LP" category.

 

[glorfindel]

Again, 1 in 700 is so small as to be almost insignificant. As I've stated before, why not just do a CT head/chest/abdomen on everyone who walks through the door? We'd certainly find something "life-changing" on at least 0.1% of them, and the risk of radiation of one CT is minimal.

I agree with this.

In general, if we are going to make inroads on controlling costs, we're going to have to be very, very careful about any kind of "zero-miss" clinical conditions. That includes MI, SAH, etc. As soon as you say that "the miss rate should be zero", you're stating your preference for a fantasy-world of perfect happiness, unicorns, tooth-fairies, and costless, consequence-free medical care.

Of course we take particular care with high-risk conditions, but we have to use clinical judgment, as Veers says.

 

[Birdstrike]

I agree with this.

In general, if we are going to make inroads on controlling costs, we're going to have to be very, very careful about any kind of "zero-miss" clinical conditions. That includes MI, SAH, etc. As soon as you say that "the miss rate should be zero", you're stating your preference for a fantasy-world of perfect happiness, unicorns, tooth-fairies, and costless, consequence-free medical care.

Of course we take particular care with high-risk conditions, but we have to use clinical judgment, as Veers says.

What's not "zero-miss" nowadays? I swear to God we're f'ing doomed as a profession. Who else goes to work and their friggin 'boss screams in their face, "ZERO MISSES this year POINDEXTER! You here me? ZERO mistakes! ZERO!"

Bottom line: If you miss it, you're potentially liable. Period. It doesn't matter what the diagnosis is. This "zero-miss" stuff is more of a public policy mantra spewed by people who don't take care of patients and by hospital administrators that like to run around saying, "We're committed to being a 'ZERO MISS' heart hospital. Come have your heart cath'ed here! We're 'ZERO MISS'". It's a criminal level of unfair expectations as far as I'm concerned. How do you expect to defend yourself in a lawsuit where you met the standard of care yet still missed a ZERO MISS diagnosis?

How are we so stupid to accept this nonsense?

Lawyers, politicians and public health "experts" think everything is "zero miss". Doctors know 100% perfection is the pot of gold at the end of the rainbow, i.e., truly unachievable utopian perfection. I'd love to be PERFECT and 100% right, 100% of the time, but it's not possible.

There will be no cost controls, EVER, with this unrealistic standard we are expected to achieve. There will be no real tort reform (no fault) until politicians, lawyers, administrators and most importantly patients realize perfection is anything but an impossible and profoundly unfair expectation.

The lawyers won't give you 1 out of every 700 as a freebie if you miss it. They'll take that one and sue the **** out of you with no remorse. Or they'll sue you and say you did an unecessary LP. You cant win.

That being said, you can't LP everyone, CT everyone, or admit everyone.

You just have to do what you think is right for each patient and what allows you to sleep at night.

 

[Arcan57]

There are doctors who feel that some diagnoses can never be missed. They show up on the plaintiff's side and say things like 1:700 is an unacceptable miss rate. It's not just the suits that conspire against us, it's the idealists who started off passionate about something and wound up divorcing themselves from reality.

Also, in regards to the fail-safes I understand completely why a CMG would have them although why they feel they need them since they keep us ICs is another question. But how do they justify the "tap every <3 mo old"? That would have flown back in the 80s but I couldn't recommend it to the parents of a healthy 2mo 3 wk old with a URI with a straight face. Also, I can think of multiple cases of testicular pain that didn't need an U/S.

 

[GeneralVeers]

There are doctors who feel that some diagnoses can never be missed. They show up on the plaintiff's side and say things like 1:700 is an unacceptable miss rate. It's not just the suits that conspire against us, it's the idealists who started off passionate about something and wound up divorcing themselves from reality.

Hence a well-respected, brilliant member of our profession stating that we can't miss a 1 in 700 occurrence is damaging our profession, and putting us at higher risk instead of protecting us.

Also, in regards to the fail-safes I understand completely why a CMG would have them although why they feel they need them since they keep us ICs is another question. But how do they justify the "tap every <3 mo old"? That would have flown back in the 80s but I couldn't recommend it to the parents of a healthy 2mo 3 wk old with a URI with a straight face. Also, I can think of multiple cases of testicular pain that didn't need an U/S.

This is why I think the policy is poorly-conceived. I understand that they are trying to reduce lawsuits in high-risk complaints, but it leaves no clinician judgement and results in a lot of unnecessary tests and procedures.

 

[Birdstrike]

Remember, an LP is not a 100% sensitive diagnostic test either. It will likely catch your 1 in 700, but in a high volume ED across many providers over years, even a CT an LP could also miss a few SAHs.

Remember, after a certain time period, RBC sensitivity decreases and is never 100% to begin with. Early on (first few hrs after bleed), Xanthochromia sensitivity is less than 100% and rises, but never reaches 100%, even if lab detected (visual Xanthochromia is even lower).

Instead of 700 headache patients, say 70,000 over several years several EDs and many providers, you have 100 SAHs that need and get the LP. You still may miss a few.

"Zero miss" should be re-termed "zero myth".

To even accept usage of that term is to accept that anything but 100% accuracy is your failing and therefore, negligent.

But who am I? I'm certainly no one's CLO.

 

[la gringa]

the <3mo febrile infant was recently revised... whew. the peds folks don't tap the otherwise ok, over 1 mo anymore and haven't for a while.

 

[Mighty Mouse]

What's your strategy for patient you think is overall super low risk for SAH, neg head CT, feels better, consents to LP -- but then you can't successfully get fluid?

I always debate in my head -- if I felt it was important to get the tap, now what do I do if I can't seal the deal? Talk them into staying for IR to do it or let them go home?

 

[Arcan57]

What's your strategy for patient you think is overall super low risk for SAH, neg head CT, feels better, consents to LP -- but then you can't successfully get fluid?

I always debate in my head -- if I felt it was important to get the tap, now what do I do if I can't seal the deal? Talk them into staying for IR to do it or let them go home?

In general, if you thought it was important enough to try and puncture dura then you need to make sure dura is punctured. If not, then I would document very well why the patient refused further attempts despite offers of anxiolysis, etc. Or you could punt and get a CTA.

 

[Rendar5]

If that were the case, then I'd CTA them. If I think they're true super low risk, though, they dont' usually consent for LP. I actually had 2 cases like that. The first one had significant scar tissue and 4 completely separate attempts. well-documented that he declined further attempts.. the second one I had them consented and then decided against it when I examined their back: significant scoliosis, 1wk s/p back surgery (their Spinal Surgeon said the surgery itself wasn't a contraindication), and nonpalpable vertebrae in the region of the LP due to soft tissue swelling between the spinous processes.

 

[beanbean]

I'm also in the same group. I haven't had too many LPs. I find most patients back away from the LP if they really don't feel too bad. Those who really do have a SAH usually feel awful and know something is really wrong and they know they need the LP.

I have seen 2 patients who had the real deal but it wasn't seen on CT. One was brought in 3 days after a sentinel bleed for which she had been seen at two local ERs. Had a negative CT but no LP or CTA. Classic story of sudden onset headache; worst of her life; she died the next day.

I understand the huge implications in missing a SAH but have also seen a patient who ended up with a epidural hematoma/paralysis s/p LP. We are damned if we do and damned if we don't.
I would really like to see the data lead us to CTA as the gold standard, not LP. Here's hoping...

I didn't know you guys were also with the same group. Perhaps we have met in Canton or Vegas!

 

[Birdstrike]

I'm also in the same group. I haven't had too many LPs. I find most patients back away from the LP if they really don't feel too bad. Those who really do have a SAH usually feel awful and know something is really wrong and they know they need the LP.

I have seen 2 patients who had the real deal but it wasn't seen on CT. One was brought in 3 days after a sentinel bleed for which she had been seen at two local ERs. Had a negative CT but no LP or CTA. Classic story of sudden onset headache; worst of her life; she died the next day.

I understand the huge implications in missing a SAH but have also seen a patient who ended up with a epidural hematoma/paralysis s/p LP. We are damned if we do and damned if we don't.
I would really like to see the data lead us to CTA as the gold standard, not LP. Here's hoping...

I didn't know you guys were also with the same group. Perhaps we have met in Canton or Vegas!

Paralyzed? At what level? How high did the hematoma go?

Considering the cord ends at the bottom of L1, it must have been a monster hematoma to cause paralysis. Were they anti-coagulated?

 

[Arcan57]

Paralyzed? At what level? How high did the hematoma go?

Considering the cord ends at the bottom of L1, it must have been a monster hematoma to cause paralysis. Were they anti-coagulated?

Plts of 2? A hemophiliac that didn't get factor?

 

[beanbean]

Anticoagulated. Horrible case from when I was an intern. I don't know the level but she ended up unable to walk and with bowel/bladder dysfunction.

 

[Birdstrike]

Anticoagulated. Horrible case from when I was an intern. I don't know the level but she ended up unable to walk and with bowel/bladder dysfunction.

Why did they tap someone anti-coagulated?

INR needs to be <1.4

(Actually, based on where this appears to be going, I think it might be best legally, if I don't know.)

 

[la gringa]

What's your strategy for patient you think is overall super low risk for SAH, neg head CT, feels better, consents to LP -- but then you can't successfully get fluid?

I always debate in my head -- if I felt it was important to get the tap, now what do I do if I can't seal the deal? Talk them into staying for IR to do it or let them go home?

we have IR during the day and on-call rads at night, thank goodness. takes a while but they will do it and i haven't had them not get one.

i HAVE had pts refuse further attempts. if i can't get it well... the nurses know me for rarely missing an LP!! ... then it's document x3... vaya con dios!

 

[glorfindel]

we have IR during the day and on-call rads at night, thank goodness.

I have IR during the day and at night I can ask the anesthesiologist to give it a shot. If he/she can't get it, I'll advise the patient to wait for IR in the AM.

If by that that time they're sick of being poked and want to leave, it's AMA (see other thread).

Once I decide to go after the csf, I won't stop until the CSF is extracted, or the patient refuses further attempts.

[EDIT: the nurses know me for giving ketamine to adults. Some love me for it, some hate me for it. ]

 

[Birdstrike]

Are you using a paramedian approach? If not learn it.

Watch an LP under fluoro. When doing an LP, your target is a sideways figure 8. When you use a median or midline approach, you are shooting for a tiny target, the waist of the sideways 8, between the spinous processes.

When you go paramedian (about 1 cm off the midline) you have a much, much bigger target. You are shooting for either circle of the sideways 8. As long as you target your needle tip back towards midline, you will end up in the same spot, and have a much higher success rate; close to 100%.

Watch an LP under fluoro, you'll laugh when you realize how small of a target you're shooting at. That's if you're doing your LPs midline/inter-spinous.

 

[Birdstrike]

.

 

[RustedFox]

Are you using a paramedian approach? If not learn it.

Watch an LP under fluoro. When doing an LP, your target is a sideways figure 8. When you use a median or midline approach, you are shooting for a tiny target, the waist of the sideways 8, between the spinous processes.

When you go paramedian (about 1 cm off the midline) you have a much, much bigger target. You are shooting for either circle of the sideways 8. As long as you target your needle tip back towards midline, you will end up in the same spot, and have a much higher success rate; close to 100%.

Watch an LP under fluoro, you'll laugh when you realize how small of a target you're shooting at. That's if you're doing your LPs midline/inter-spinous.

I did this tonight; paramedian approach. Wow. In there like swimwear.

Thanks for the tip, amigo.

 

[deleted206819]

Are you using a paramedian approach? If not learn it.

Watch an LP under fluoro. When doing an LP, your target is a sideways figure 8. When you use a median or midline approach, you are shooting for a tiny target, the waist of the sideways 8, between the spinous processes.

When you go paramedian (about 1 cm off the midline) you have a much, much bigger target. You are shooting for either circle of the sideways 8. As long as you target your needle tip back towards midline, you will end up in the same spot, and have a much higher success rate; close to 100%.

Watch an LP under fluoro, you'll laugh when you realize how small of a target you're shooting at. That's if you're doing your LPs midline/inter-spinous.

Birdstrike,

Something like this?

 

[RustedFox]

Birdstrike,

Something like this?

Pretty much exactly how I did it. I didn't have to angle 45 degrees; much less than that. Just 1cm off the midline, and aim back towards the center. There wasn't that frustrating "crunch" of bone as I had to "walk" the needle up or down.

 

[pinipig523]

Pretty much exactly how I did it. I didn't have to angle 45 degrees; much less than that. Just 1cm off the midline, and aim back towards the center. There wasn't that frustrating "crunch" of bone as I had to "walk" the needle up or down.

So you were 1cm off midline... were you at the level of a spinous process or were you in between superior and inferior spinous processes?

 

[RustedFox]

So you were 1cm off midline... were you at the level of a spinous process or were you in between superior and inferior spinous processes?

Between.

I picked my spot as if I were to do it the "old way", then just moved "down" (that is, towards the bed, as gravity would have you fall... my patient was in the lateral decubitus position, with a pretty good "curl up into a ball, now" response). 1cm. Felt around with my fingers (thankfully, the patient had a reasonable body habitus). That diagram above is actually really sharp. Angled back towards midline and "juuust" superior.

Gal said to me - "That was waaaay easier than my epidural. Do you have an office?" She tweaked more during the skin wheal than she did at any other time.

Night and day. I'm a believer.

 

[Birdstrike]

Birdstrike,

Something like this?

Yes.

 

[WilcoWorld]

Wow. I can't believe I haven't heard of this before.

Looks like there might be data to support it too (from the 2011 Pakistani Armed Forces Medical Journal - unblinded, stat. sig. not reported):
The success rate of median approach was found to be 84%, with the first attempt success rate of 48%. Paresthesia was felt by 38% of patients and incidence of bloody tap was 6%. Length of needle required most of the time was between 4-6 cms. The success rate of paramedian approach was found to be 96%, with first attempt success rate of 70%. Paresthesia was felt by 20% of patients and incidence of bloody tap was 12%. Most of the time length of needle required was between 6-8 cms.

 

[pinipig523]

Don't mean to rehash an old (but great) thread...

1. This "700 club"... at what point are they CT-ing the patient to determine no CT evidence of SAH? At <6h or >12h or random?

2. If a patient presented to you 2 weeks into their headache and it is the worst ever - still think SAH? I mean.... unless it's a slow leak, a SAH 2 weeks out, you should've clotted off your ventricles or died I assume... right?

 

[WilcoWorld]

Don't mean to rehash an old (but great) thread...

1. This "700 club"... at what point are they CT-ing the patient to determine no CT evidence of SAH? At <6h or >12h or random?

2. If a patient presented to you 2 weeks into their headache and it is the worst ever - still think SAH? I mean.... unless it's a slow leak, a SAH 2 weeks out, you should've clotted off your ventricles or died I assume... right?

If it was a "sentinel bleed", then no. They'd probably look like a million bucks. However, at 2 weeks you probably wouldn't see xanthochromia, so you're hosed either way.

 

[SpaceLeftBlank]

We need tort reform..

We have tort reform in my state. You would think it would put an end to defensive medicine, but it doesn't. I have learned to be very careful about what questions I ask of my primary-care doctor, because he's becoming increasingly more liable to order additional tests in response, and I think it's mostly because he knows I'm a lawyer (and I represent physicians in malpractice cases!). Especially when my wife (who's a physician herself) expressed skepticism about whether I really needed the most recent one.